Every finding on record at Ridgeview Terrace of Life Care

Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow Transmission Based Precautions (TBP) for 2 residents (Resident #6 and #61) of 6 residents reviewed for TBP.The findings include: Review of a facility policy titled Transmission-based Precautions and Isolation Procedures, revised 12/23/2025, revealed .The facility will implement .[TBP] .ensure the mitigation of infection spread .ensure standards of infection prevention and control are followed . Further review revealed .[TBP] must be used when a resident develops signs and symptoms of a transmissible infection . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Malnutrition, and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Further review revealed the resident was coded for assistance with Activities of Daily Living (ADLs). Review of a comprehensive care plan for Resident #6 initiated 7/25/2026, revealed appropriate goals and interventions for care areas including ADL care, nutrition risk, and respiratory care. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), Muscle Weakness, and Bacteremia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #61 scored a 12 on the BIMS assessment, which indicated moderate cognitive impairment. Further review revealed the resident required staff assistance with ADLs. Review of a comprehensive care plan for Resident #61 initiated 4/27/2026, revealed appropriate goals and interventions for care areas including ADL assistance, TBP, and risk for nutritional problems. Review of a physician's order for Resident #61 dated 8/17/2026, revealed . Isolation: Enteric Precautions Diagnosis: poss [possible] c-diff [clostridium Difficile] [bacterial infection known for causing serious diarrheal infections] . During an observation on 8/17/2026 at 2:20 PM, revealed Resident #6 and #61 shared room [ROOM NUMBER]. Further review revealed Resident #6 and #61's room door had signage for TBP- Enteric Precautions displayed. During an observation on 8/17/2026 at 2:30 PM, revealed Certified Nursing Assistant (CNA) A taking Resident #61's vital signs in room [ROOM NUMBER]. CNA A was not wearing Personal Protective Equipment (PPE). Further observation revealed CNA B who was also in room [ROOM NUMBER] was not wearing PPE. During a interviews on 8/17/2026 at 2:49 PM, CNA A and CNA B both confirmed they were not wearing appropriate PPE to provide care in room [ROOM NUMBER]. During an interview on 8/17/2026 at 3:00 PM, with the Director of Nursing (DON) and the Administrator, the DON confirmed that CNAs A and B failed to follow TBP by not wearing appropriate PPE while providing care in room [ROOM NUMBER].

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record review, and interview, the facility failed to ensure MDS assessments were accurate for 3 residents (Resident #2, Resident #9, and Resident #45) of 20 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Active Diagnosis in the Last 7 Days .Check all that apply .I0110 .Special Treatments, Procedures, and Programs .Check all of the following treatments, procedures, and programs that were performed .while a Resident .Performed while a resident of this facility and within the last 14 days . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and re-admitted to facility on 7/9/2026, with diagnoses including Delusional Disorders, Obsessive-Compulsive Behavior, Hallucinations, Anxiety Disorder, and Major Depressive Disorder. Review of the Medicare-5 day MDS assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Further review revealed Resident #2 was coded for receiving Dialysis within the previous 14 days on the MDS. During a medical record review and interview on 8/19/2026 at 9:30 AM, Registered Nurse (RN) MDS Coordinator B reviewed Resident #2's Medicare-5 day MDS assessment dated [DATE]. The RN MDS Coordinator B confirmed Resident #2 had not received Dialysis during admission in the facility and further confirmed the Medicare-5 day MDS assessment was inaccurate and should not have included Dialysis. During an interview on 8/19/2026 at 1:50 PM, the Director of Nursing (DON) confirmed the Medicare-5 day MDS assessment dated [DATE] was not coded correctly for Resident #2 concerning Dialysis services and the expectation was for the MDS coordinator to accurately assess and code the MDS assessment. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Vascular Dementia with Behavioral Disturbance, Generalized Anxiety Disorder and Delusional Disorder. Review of a quarterly MDS dated [DATE], revealed Resident #8 scored an 8 on the BIMS assessment, which indicated severe cognitive impairment. Further review revealed .is resident currently considered by the state level II PASRR ] Pre-admission Screening and Resident Review] process to have serious mental illness and/or intellectual disability or a related condition .No . Review of a Notice of PASRR Level II Outcome dated 11/15/2024, revealed .The Individual [Resident #9] meets criteria for having a diagnosis of .Serious mental illness . Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia/Hemiparesis following Cerebral Infarction, Delusional Disorder, Anxiety Disorder and Bipolar Disorder. Review of an annual MDS assessment dated [DATE], revealed Resident #45 scored a 15 on the BIMS assessment, which indicated the resident was cognitively intact. Further review revealed .is resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition .No . Review of a Notice of PASRR Level II Outcome dated 3/21/2024, revealed .The Individual [Resident #45] meets criteria for having a diagnosis of .Serious mental illness . During a medical record review and interview on 8/19/2026 at 1:36 PM, RN MDS Coordinator A reviewed the annual MDS assessment dated [DATE] for Resident #9 and the annual MDS assessment dated [DATE] for Resident #45. RN MDS Coordinator A confirmed the annual MDS assessment for Resident #9 dated 6/16/2026 and the annual MDS assessment dated [DATE] for Resident #45 was inaccurate.

Based on Long-Term Care Facility Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record review, and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) screen was accurate after mental health diagnoses were identified for 1 (Resident #37) of 6 residents reviewed for PASRR.The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 dated 10/1/2025, revealed .facilities are responsible for accurately reflecting active diagnoses within the assessment process and ensuring coordination with PASRR requirements when residents have serious mental illness, intellectual disability, or related conditions . Review of the Level 1 PASRR for Resident #37 dated 5/30/2024 (prior to admission to the facility), revealed .no mental health diagnosis is known or suspected . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Depression and Delusional Disorders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had Depression and Psychotic Disorder. During an interview on 8/19/2026 at 1:49 PM, the Assistant Director of Nursing (ADON) confirmed Resident #37 PASRR level 1 dated 5/30/2024 was not accurate and did not include the residents' current mental health diagnoses. The ADON further confirmed the diagnoses should have been added and a new PASRR level 1 screen submitted for determination of level 2 services. During an interview on 8/19/2026 at 1:49 PM, the Director of Nursing (DON) confirmed Resident #37 current PASRR was not accurate and did not include the residents' current mental health diagnoses.

Based on facility policy review, observation, and interview, the facility failed to ensure a dietary aide wore an appropriate beard covering during food service in 1 of 1 kitchen.The findings include: Review of the facility's policy titled Associate Conduct and Dress Code, dated 10/3/2019 and revised 5/5/2026, revealed .Dietary staff must wear hair restraints .to prevent hair from contacting food .all facial hair including mustaches and beards should be trimmed and covered . During an observation on 8/17/2026 at 11:34 AM, revealed Dietary Aide A assisting with residents' food tray assembly on the tray line. Dietary Aide A did not have a covering on his facial hair.During an interview on 8/17/2026 at 11:38, the Dietary Manager confirmed Dietary Aides should wear appropriate hair and beard coverings while in the kitchen and working on the tray line and confirmed Dietary Aide A did not have the facial hair covered.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, observations, and interviews, the facility failed to accurately complete an MDS assessment for 1 resident (Resident #76) of 18 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual dated 10/2024, revealed .discharge assessment .must be completed when the resident is discharged from the facility .SECTION A .discharge status .this item documents the location to which the resident is being discharged at the time of discharge .steps for assessment .review the medical record including the discharge plan and discharge orders for documentation of discharge location .coding instructions for A0310G .Code 1 if type of discharge is a planned discharge .Code 2 if type of discharge is an unplanned discharge . Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Dementia, Peripheral Vascular Disease, and Delusional Disorder. Review of the comprehensive care plan for Resident #76 dated 2/6/2025, revealed .discharge plan .wishes to return home/ALF [Assisted Living Facility] . Review of a Progress Note for Resident #76 dated 2/6/2025, revealed .previously lived at .ALF, and family is seeking .with alternate ALF placement .begin d/c [discharge] planning . Review of a Progress Note for Resident #76 dated 2/28/2025, revealed .Spoke with resident's son .r/t [related to] d/c to ALF .Son stated he planned to take resident to .ALF on Tuesday 3/4/25 . Review of a Progress Note for Resident #76 dated 3/4/2025, revealed .Discharge Summary .Resident discharged from facility to go to ALF with her son .in personal vehicle . Review of a Discharge Return Not Anticipated MDS assessment dated [DATE], revealed Resident #76 was coded as an unplanned discharge. During an interview on 5/29/2025 at 1:05 PM, with Registered Nurse (RN - D) confirmed the MDS assessment dated [DATE] was coded inaccurately as unplanned discharge. RN D confirmed that Resident #76's discharge from facility had been a planned discharge. During an interview on 5/29/2025 at 3:30 PM, the Director of Nursing confirmed Resident #76's MDS assessment dated [DATE] had been coded inaccurately.

Based on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan for 1 resident (Resident #68 ) of 18 residents reviewed for care plans. The findings include: Review of the facility 's policy titled, Person Centered Care Planning, dated 9/5/2024, revealed .The facility .develops a person-centered care plan that addresses the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment .to attain or maintain .highest practicable well-being and prevent further decline .to meet those needs .developed and implemented to ensure consistency .across all shifts . Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Dementia with Behavioral Disturbance, and Hallucinations. Review of the comprehensive care plan for Resident #68 dated 5/14/2025, revealed .EATING: The resident is able to feed self after tray set up with encouragement from staff & minimal assistance . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 scored 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Further review revealed the resident was dependent upon staff with eating. During an interview on 5/27/2025 at 11:45 AM, Certified Nursing Assistant (CNA) B stated Resident #68 was dependent upon staff with eating. During an interview on 5/29/2025 at 9:35 AM, CNA A stated Resident #68 was dependent upon staff with eating. During an interview on 5/29/2025 at 9:40 AM, Certified Occupational Therapy Assistant (COTA) C stated she worked with Resident #68 on self-feeding and the resident was not able to perform the activity on her own due to her cognitive decline. During an observation on 5/29/2025 at 12:28 PM, revealed CNA A set up Resident #68's meal tray and began assisting the resident with the meal. During an interview on 5/29/2025 at 1:05 PM, with Registered Nurse (RN) D and the RN MDS Coordinator revealed Resident #68's care plan had not been revised to reflect the resident was dependent on staff with eating. During an interview on 5/29/2025 at 3:35 PM, the Director of Nursing stated Resident #68's care plan had not been revised to show the resident had total dependence upon staff with eating.

Based on facility policy review, observation, and interview, the facility failed to follow the facility's policy and meet safety and sanitation requirements for food items stored in 2 residents' personal refrigerators (Resident #13 and Resident #37) of 6 residents' personal refrigerators observed. The findings include: Review of the facility's policy titled, Resident Refrigerators, with a revised date of 4/30/2025, revealed .Facility staff will check individual food items weekly for expiration dates .food will be labeled and dated to monitor for food safety .Food items in unmarked or unlabeled containers should be labeled with contents, and the date the food item was stored .food .with visible signs of contamination should be discarded immediately . During the initial tour of the facility on 5/27/2025, from 9:10 AM - 1:00 PM, Residents' #13 and Resident #37 were noted to have personal refrigerators in their rooms. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Kidney Disease, Anxiety Disorder, and Depression. During an observation on 5/29/2025 at 10:48 AM, in Resident #13's room revealed the resident's room contained a personal refrigerator. Contents in the refrigerator contained a plastic container which held sliced tomatoes. The container was unlabeled and undated. Upon opening the container, the tomatoes were covered by a white film and a foul odor was present. Continued observation revealed a clear glass jar with a blue metal lid which was not labeled or dated. The contents of the jar contained a dark pink liquid, eggs without their shell, and brown square cubes. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Anxiety Disorder, Depression, Chronic Pain, and Parkinson's Disease with Dyskinesia. During an observation on 5/29/2025 at 10:51 AM, in Resident #37's room revealed the residents room contained a personal refrigerator. The contents of the refrigerator contained a plastic bag which contained a fried pie and was unlabeled and undated. Continued observation revealed a disposable foam container which contained baked food items, undated and unlabeled. During an interview on 5/29/2025 at 11:30 AM, the Director of Nursing (DON) stated it was the responsibility of the housekeeping staff to clean, maintain, and perform and record daily temperature checks of the residents' personal refrigerators. During an interview and observation on 5/29/2025 at 11:50AM, the Regional [NAME] President and Regional Director of Nursing confirmed the food items in Resident #13's and #37's personal refrigerators were not stored according to the facility's policy.

Based on facility policy review, medical record review, observations, and interview the facility staff failed to perform hand hygiene prior to distributing meal service to 5 residents (Residents #70, #277, #71, #25, and #16) of 18 residents observed on the secured unit during lunch service. The findings include: Review of the facility's policy titled, Hand Hygiene, revised 6/13/2023, revealed .facility has adopted .core infection prevention .for safe healthcare delivery in all settings .hand hygiene procedures are to be followed by staff involved in direct resident contact .associates perform hand hygiene .in following situations .Before and after contact with the resident . Review of the facility's policy titled, Resident Dining Services, revised 4/29/2025, revealed .ensure food is served in accordance with professional standards for food service safety .associates involved in dining/food services will perform hand hygiene prior to distributing trays to the residents . 1. The facility staff failed to perform adequate hand hygiene while serving lunch meal trays for Residents #70, #277, #71, #25, and #16. 1a. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Dementia, Delusional Disorders, and Atrial Fibrillation. Review of the comprehensive care plan for Resident #70 revised 3/10/2025, revealed .ADL [Activities of Daily Living] Assistance .needed to maintain or attain highest level of function .assist with ADLS as needed . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #70 scored a 6 on the Brief Interview of Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Further review revealed the resident required setup assistance with eating. During an observation on 5/27/2025 at 12:35 PM, Certified Nursing Assistant (CNA) A placed the lunch meal tray in front of Resident #70, setup the meal tray for the resident to eat. CNA A did not wash or sanitize the hands after serving Resident #70's lunch meal tray. 1b. Review of the medical record revealed Resident #277 was admitted to the facility on [DATE] with diagnoses including Fracture of Superior Rim of Right Pubis, Anemia, and Heart Failure. Review of the comprehensive care plan for Resident #277 revised 5/19/2025, revealed .resident has an ADL self-care performance r/t Dementia .EATING .resident requires supervision . Review of an admission MDS assessment dated [DATE], revealed Resident #277 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed the resident required supervision with eating. During an observation on 5/27/2025 at 12:36 PM, CNA A placed the lunch meal tray in front of Resident #277, setup the meal tray for the resident to eat. CNA A did not wash or sanitize the hands after serving Resident #277's lunch meal tray. 1c. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Hypertension. Review of the comprehensive care plan for Resident #71 revised 4/7/2025, revealed .ADL Assistance .needed to maintain or attain .highest level of function .Assist with .ADLS as needed . Review of a quarterly MDS assessment dated [DATE], revealed Resident #71 scored a 6 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident required setup assistance with eating. During an observation on 5/27/2025 at 12:38 PM, CNA A placed the lunch meal tray in front of Resident #71, setup the meal tray for the resident to eat. CNA A did not wash or sanitize the hands after serving Resident #71's lunch meal tray. 1d. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Depression, and Dysphagia. Review of the comprehensive care plan for Resident #25 revised 5/16/2025, revealed .functional care plan .has limited physical mobility r/t [related to] Weakness . Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 4 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed the resident was dependent upon staff assistance for feeding. During an observation on 5/27/2025 at 12:42 PM, CNA A placed the lunch meal tray in front of Resident #25, setup the meal tray for the resident to eat. CNA A did not wash or sanitize the hands after serving Resident #25's lunch meal tray. 1e. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertension, and Depression. Review of the comprehensive care plan for Resident #16 revised 4/7/2025, revealed .ADL .resident is at risk for ADL . requires assistance related to Dementia . Review of an annual MDS assessment dated [DATE], revealed Resident #16 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed the resident was able to feed self after setup of tray. During an observation on 5/27/2025 at 12:45 PM, CNA A placed the lunch meal tray in front of Resident #16, setup the meal tray for the resident to eat. CNA A did not wah or sanitize the hands after serving Resident #16's lunch meal tray. During an interview on 5/27/2025 at 12:50 PM, CNA A confirmed that she had not performed hand hygiene after serving Residents #70, #277, #71, #25, and #16 the lunch meal tray. CNA A confirmed that she should have washed or sanitized her hands after passing each resident's meal tray. During an interview on 5/29/2025 at 1:40 PM, the Director of Nursing (DON) confirmed staff should wash or sanitize hands between passing each resident's meal trays. The DON confirmed CNA A did not perform hand hygiene after serving Residents #70, #277, #71, #25, and #16 lunch meal tray.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 1 resident (#12) of 79 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Dignity, dated 8/3/2021, showed .Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff .or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth .The resident has a right to a dignified existence .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .The facility must protect and promote the rights of the resident . Review of the facility's policy titled, Preservation of Resident's Rights, dated 8/7/2021, showed .The Social Services staff promote and advocate the preservation of residents' rights .All associates are responsible for the preservation of resident's rights .Each resident has the right to be treated with dignity and respect .The Social Services staff ensure that signs are not posted unless they are related to precautionary measures (e.g. [example], oxygen in use or isolation). Signs that reveal personal and medical information re [are] not posted in an area accessible to other residents, visitors, or family . Review of the medical record showed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #12 had severe cognitive impairment. During observations on 4/11/2022 at 12:17 PM, 4/11/2022 at 12:59 PM, 4/12/2022 at 5:45 AM, and 4/12/2022 at 7:38 AM, there was 1 sign posted on the wall on the left side of the bed that read, Caregivers who assist w/ [with] eating meals .please alternate 1 bite/1 sip .small bites/sips .encourage 'hard' swallow (effortful) .positioning .as close to 90 [degrees] as possible .Thank You!! [smiley face] .[named staff member] .SLP [Speech Language Pathologist] . The sign was visible to anyone who entered the room. During an interview on 4/13/2022 at 9:08 AM, the Social Services Director stated it was the expectation of the facility that no signs are posted that contain resident medical or personal information unless requested by the resident or family. During an observation and interview on 4/13/2022 at 9:11 AM, in Resident #12's room, the Social Services Director confirmed the sign was present and visible to anyone who entered the room. The Social Services Director confirmed the sign contained medical information and Resident #12's dignity was not maintained. During an interview on 4/13/2022 at 9:20 AM, the Director of Nursing (DON) stated it was the expectation of the facility that signage only be posted when requested by the resident or the resident's representative. During an interview on 4/13/2022 at 9:30 AM, the Speech Therapist confirmed that she posted the sign in Resident #12's room to communicate safety techniques for reducing aspiration to staff that assisted the resident with feeding. Further interview confirmed Resident #12 and Resident #12's family had not requested the sign to be posted.

Based on facility policy review, the facility investigation, medical record review, and interview the facility failed to report a resident-to-resident alleged abuse for 1 resident (Resident #31) out of 24 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect, dated 8/10/2021, revealed .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse .are reported not later than 2 hours after allegation is made, if the events that cause the allegation involve abuse .to the administrator of the facility and to other officials (including to the State Survey Agency .) . Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse progress note dated 11/15/2021 timed 11:30 AM by Licensed Practical Nurse (LPN #3), revealed Resident #14 .was up in w/c [wheelchair] .[Resident #31] was in front of her [Resident #14] she told him [Resident #31] to move he [Resident #31] didn't so .[Resident #14] slapped him [Resident #31] on the left hand .separated immediately 15 min [minute] check started family notified dr [doctor] .notified order noted for psych [psychiatric] eval [evaluate] and treat as indicated . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had moderate cognitive impairment. The resident required extensive to total assistance of 1-2 staff members for transfers, mobility, toileting, and supervision with locomotion and eating. The MDS showed no documented behaviors. Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's investigation dated 11/15/2021, revealed no injury noted to Resident #31. The skin assessment completed for Resident #31 showed no bruising or redness to left hand. Resident #14, the alleged perpetrator, was placed on 15-minute check awaiting psych evaluation. The facility Interdisciplinary Team (IDT) identified other residents in the facility with the potential for anger outbursts they felt could lead to aggression with other residents. Care plans were updated and the staff were aware of the interventions. Staff were re-educated on the abuse/neglect policy. Review of an annual MDS assessment dated [DATE], revealed Resident #31 was cognitively intact. The resident required extensive to total assistance of 1-2 staff members for transfers, mobility, toileting, and feeding. During an interview on 4/13/2022 at 12:15 PM, Resident #31 revealed he was blind and another resident hit him on his left hand in November 2021 (unable to recall exact date/time). stated . it did not hurt, and she has not done it again . During an interview on 4/13/2022 at 1:50 PM, LPN #3 revealed Resident #14 was coming out of her room and Resident #31 was propelling self in hallway in front of Resident #14's door. Resident #14 told Resident #31 to move. Resident #14 wheeled out the door, Resident #31 was in front of Resident #14's wheelchair. Resident #31's hand was on the hemi tray (plastic support device attached to wheelchair), Resident #14 accidently grazed Resident #31's hand with her hand as she was bringing her hands down to self propel her wheelchair. Resident #14 did not intend to hurt Resident #31. LPN #3 assessed Resident #31's left hand for injury and none was noted. LPN #3 futher stated they were in-serviced on abuse and what to do if abuse occurs. During continued interview LPN #3 explained she had documented in the nurses note that Resident #14 slapped him (Resident #31) on the hand, but should have worded it as touched or grazed hand while she (Resident #14) was self propelling in wheelchair. LPN #3 stated her description did not accurately reflect the incident. During an interview on 4/13/2022 at 1:33 PM, the Administrator confirmed the alleged abuse between the two residents was not reported to the State Survey Agency. Further interview revealed after investigation she felt like it was an accidental encounter.

Based on medical record review and interview the facility failed to ensure a [CONDITION(S)] contract was in place for 1 resident (Resident #1) of 1 resident reviewed for [CONDITION(S)]. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Receives [CONDITION(S)] at [named [CONDITION(S)] center] .send to [CONDITION(S)] on Monday, Wednesday, and Friday . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 8 indicating Resident #1 had moderate cognitive impairment. Continued review showed the resident was receiving [CONDITION(S)]. Review of the Pre/Post [CONDITION(S)] Communication forms dated 4/2021-4/2022, showed ongoing communication was being maintained with the [CONDITION(S)] center. During an interview on 4/13/2022 at 9:55 AM, the Administrator confirmed Resident #1 received [CONDITION(S)] at (named [CONDITION(S)] center) and a contract had not been established with the [CONDITION(S)] center.

Based on facility policy review, medical record review, and interview the facility failed to follow a Psychiatric recommendation and Physician's Order for 1 resident (Resident #47) of 19 resident's reviewed for physician orders. The findings include: Review of the facility policy titled, Physician Order, revised 3/17/2022 showed .A physician, physician assistant or nurse practitioner [NP] must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines .Any orders written by a consulting physician must be reviewed and signed by the resident's attending physician . Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #47 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive Care Plan dated 3/1/2022 showed Resident #47 was dependent upon staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan showed the resident had behavioral problems, was resistive to care, and had the potential to be verbally aggressive related to Dementia. The care plan showed the resident was at risk for changes in moods and behaviors and used [CONDITION(S)] medications related to Depression and [CONDITION(S)] with interventions including administer [CONDITION(S)] medications as ordered. Review of the Physician's Orders dated 3/1/2022-3/31/2022 showed [MEDICATION(S)] (anti-psychotic medication) 25 milligram (mg) in the morning and 50 mg at bedtime. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Psychiatric Periodic Evaluation dated 3/14/2022, showed the resident was evaluated for management of Dementia with Behavioral Disturbance and Agitation. Continued review showed the Psychiatric NP recommended an increase in the [MEDICATION(S)] to 75 mg twice daily due to severe agitation and delusions. Further review showed the recommendation was reviewed and initialed by the attending physician and noted okay on 3/24/2022. During review of the resident's medical record and interview on 4/12/2022 at 1:57 PM, with Licensed Practical Nurse (LPN) #1, the LPN stated the resident was known to have occasions of verbally and physically aggressive behaviors. Review of the resident's medical record with the LPN showed a psychiatric note dated 3/14/2022 a recommendation for an increase in [MEDICATION(S)] to 75 mg twice daily due to continued severe agitation and delusions. The physician noted okay and initialed the document on 3/24/2022 which indicated the physician was in agreement for the increased dosage of [MEDICATION(S)]. Review of the 3/2022 and 4/2022 MAR's with LPN #1 showed the increased dose of [MEDICATION(S)] had not been increased or transcribed to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/12/2022 at 2:32 PM and on 4/13/2022 at 8:45 AM, the Director of Nursing (DON) stated the Psychiatric Note dated 3/14/2022 which recommended an increase of the resident's [MEDICATION(S)] to 75 mg twice daily had been reviewed, noted and initialed by the physician on 3/24/2022 which indicated the physician was in agreement to the increase dosage of [MEDICATION(S)]. The DON stated the increased dose of [MEDICATION(S)] to 75 mg twice daily was missed by the nurse and had not been transcribed to the resident's MAR. The DON further confirmed Resident #47 did not receive the increased dose of [MEDICATION(S)] as recommended by the Psychiatric NP and as ordered by the Physician.

Based on facility policy review, record review, and interview, the facility failed to designate an employee of the facility to assume responsibility for collaborating and coordinating care between the nursing home and the hospice entity, and failed to obtain the most recent hospice plan of care for 1 resident (Resident #19) of 5 residents reviewed for hospice services. The findings include: Review of the facility's policy titled, Area of Focus: Hospice, undated, showed, .The facility must designate a member of the interdisciplinary team .to ensure .the resident receives quality care in collaboration with the facility staff and the hospice staff. Review of the facility's policy titled, Hospice Coordination of Care, last reviewed 5/7/2021, showed, .interdisciplinary team member is responsible .Collaborating with hospice representatives and coordinating LTC [long term care] facility staff participation in the hospice care planning process .Obtaining the following information from the hospice .most recent hospice plan of care specific to each resident .Each LTC facility providing hospice care .must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a comprehensive Care Plan, last reviewed 2/23/2022, showed .resident has a terminal prognosis .Current patient with [name of hospice entity] . During an interview on 4/12/2022 at 1:31 PM, Licensed Practical Nurse (LPN) #2 confirmed there was no hospice care plan in Resident #19's medical record. During an interview on 4/12/2022 at 2:03 PM, the Social Services Director stated she was not responsible for coordination of care between the facility and the hospice entity. She also stated the Admissions Coordinator was responsible for acquiring the hospice plan of care if a resident was admitted to the facility with hospice services, and the MDS coordinator was responsible for the coordination of care between the facility and the hospice entity. During an interview on 4/12/2022 at 2:12 PM, the MDS Coordinator stated she was not the contact person at the facility responsible for coordination of care between the hospice entity and the facility. During an interview on 4/12/2022 at 2:17 PM, the Admissions Coordinator stated the hospice entity was responsible to ensure the facility had an updated hospice plan of care for Resident #19. She also stated she was not the coordinator at the facility for communication between the hospice entity and the facility. During an interview on 4/12/2022 at 2:27 PM, the Director of Nursing confirmed the Social Services Director was the contact person at the facility responsible for the coordination of care between the facility and the hospice entity. She also confirmed there was not a hospice plan of care in Resident #19's medical record.

Based on facility policy review, observation, and interview, the facility failed to ensure opened medications were labeled and dated in 1 of 2 medication carts viewed for medication storage (A/B Hall Medication Cart). The findings include: Review of the facility policy titled, Storage and Expiration Dating of Medication, Biologicals, revised 1/1/2022, showed .Once any medication .is opened .Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) . During an observation on 4/12/2022 at 1:24 PM, of the A/B halls medication cart showed 1 multiple dose bottle of [MEDICATION(S)] (a nasal steroid medication) 50 micrograms (mcg) nasal spray, opened and undated; 1 multiple dose bottle of [MEDICATION(S)] (an allergy nasal antihistamine) 205.5 mcg/0.137 milliliters (ml) nasal spray opened and undated; 1 multiple dose bottle liquid loperamide (a diarrhea medication) 1 milligram (mg)/ 7.5 ml (floor stock), over 3/4 empty, opened and undated; 1 multiple dose bottle of geri-lanta (antacid/anti-gas supplement), over 1/2 full, opened and undated; 1 multiple dose bottle of [MEDICATION(S)] [MEDICATION(S)] (a medication used to treat heartburn, diarrhea, nausea, and upset stomach), over 1/2 full, opened and undated; and 1 multiple dose bottle of geri-tussin (a liquid medication used to treat chest congestion) 100 mg/5 ml, a full bottle, opened and undated. During an interview on 4/12/2022 at 1:24 PM, Licensed Practical Nurse #2 stated medications should be dated when opened. During an interview on 4/12/2022 at 1:31 PM, the Director of Nursing stated it was her expectation that medications be dated when opened.

Based on the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, medical record reviews, and interviews the facility failed to correctly code Minimum Data Set (MDS) assessments for 3 residents (Resident #12, Resident #19, and Resident #75) of 22 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 showed .Review the medical record including the discharge plan .discharge orders for documentation of discharge location .Nutritional Approaches .FEEDING TUBE .Presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system. Examples include .percutaneous endoscopic gastrostomy (PEG) tubes .Review the medical record to determine if any of the listed nutritional approaches were performed during the 7-day look-back period .Check all nutritional approaches performed .within the 7-day look-back period .Proportion of Total Calories the Resident Received through Parental or Tube Feeding .Review intake records to determine actual intake through .tube feeding routes .Calculate proportion of total calories received through these routes .Code residents identified as being in a hospice program for terminally ill persons where .services is provided for the palliation and management of terminal illness and related conditions . Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised on 12/22/2021, showed .The resident needs total assistance with tube feeding and water flushes. Provide TF [tube feeding] and free water flushes per MD [Medical Doctor] orders . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] [a tube feeding formula] 1.5 at 30 ml [milliters]/hr [hour] x [for] 17 hours via pump via peg. Flush with 40 ml/hr water via pump via peg x 17 hrs . The order start date was 12/9/2021. Review of the Nutrition/Dietary Note dated 1/20/2022, showed .diet is reg [regular] mech [mechanical] soft and she consumes 56% [percent]. cont [continue] with tube feeding [MEDICATION(S)] 1.5 at 30 cc's [cubic centimeters equalivant to milliliters] per hour from 3p [3:00 PM] to 8a [8:00 am] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed .Nutrition Approaches .Check all of the following nutritional approaches that were performed during the last 7 days .Feeding tube - nasogastric or abdominal (PEG) .Not checked (No) . Further review showed the section of the assessment that addressed .Proportion of total calories the resident received through .tube feeding . was not completed. During an interview on 4/12/2022 at 1:19 PM, the MDS Coordinator stated Resident #12 had a PEG tube and received tube feeding at the time of the 1/21/2022 quarterly MDS assessment. The MDS coordinator confirmed Resident #12's PEG tube and tube feeding was not coded on the quarterly MDS assessment dated [DATE]. Further interview confirmed the quarterly MDS assessment dated [DATE] was not accurate. Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], showed hospice services were not identified. During an interview on 4/12/2022 at 2:03 PM, the MDS Coordinator stated Resident #19 was admitted to the facility on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Psychosocial Note dated 2/2/2022, showed .seeking STC [short term care] with d/c [discharge] plans to return home . Review of the discharge MDS assessment dated [DATE], showed discharge return not anticipated. Resident #75 discharged to acute hospital. Review of the Physicians order dated 2/5/2022, showed discharge home. Review of a skilled note dated 2/5/2022, showed .Discharge orders received. Resident voiced understanding. Prescriptions given to resident. Left facility . Review of the Discharge Summary Information dated 2/5/2022, showed Resident #75 was discharged home by private vehicle. Resident #75 requested to be discharged home. During an interview on 4/13/2022 at 12:25 PM, the MDS coordinator confirmed the discharge MDS assessment was inaccurate, and Resident #75 was discharged home, not to the hospital.

Based on medical record review and interview the facility failed to report a laboratory test result timely for 1 resident (Resident #2) of 7 residents reviewed. The findings include: Review of the medical record showed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had severe cognitive impairment and had received an antibiotic (medication used to treat an infection) one day. Review of the Care Plan dated 3/10/2020, showed a history of UTI, potential for UTI with interventions in place to monitor for signs and symptoms. Care plan dated 3/1/2021 showed a UTI with treatment with [MEDICATION(S)] (medication to treat UTI) BID (twice a day). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the laboratory data report dated 2/17/2021, revealed Escherichia coli (bacteria found in the urine). Review of the medical record showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/17/2021 at 2:00 PM, the Director of Nursing (DON) confirmed the facility had identified the delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the facility received the lab results on 2/18/2021 and treatment was not started until 3/1/2021. During an interview on 5/17/2021 at 4:07 PM, the Medical Director confirmed he was notified by the facility about the delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .thought he gave a verbal order, and the order did not get placed into the computer on 2/18/2021 . The Medical Director stated he was in the facility on 3/1/2021 making rounds and he wrote on the lab culture result, .if not treated give [MEDICATION(S)] BID x 7 days . The nurse was informed, and the order was placed in the computer on 3/1/2021. During an interview on 5/19/2021 at 12:15 PM, the Medical Director confirmed Resident #2 did not have any adverse effects from the delay of treatment.

Based on facility policy review, review of controlled drug records, observation and interview, the facility failed to ensure controlled medications were accurately recorded for 2 residents (#48 and #73) of 9 residents reviewed for [MEDICATION NAME] useage (anxiety medication) during medication storage review. The findings include: Review of facility policy Controlled Drugs, undated revealed .A 'controlled drugs proof of use sheet' is accurately maintained on all residents requiring controlled medications .appropriate storage, recording, and use of controlled drugs are maintained on all units .when controlled keys change hands during a shift, controlled drugs are recounted and both nurses sign the change of shift count record .if the count is incorrect, notify the supervisor and pharmacist .Note: The nurse remains on duty until the count is reconciled or the supervisor has given permission to leave . Observation, controlled drug record review, and interview with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #2 on 7/18/18 at 8:15 AM, at the 100 hall medication cart, revealed Resident #48's controlled drug record documented the pharmacy dispensed 28 tablets of [MEDICATION NAME] 0.5 milligrams (mg) on 7/17/18 for Resident #48. Continued review revealed the facility documented 30 tablets had been received from the pharmacy. The count was off by 2 tablets. Review of Resident #73's controlled drug record revealed the pharmacy dispensed 60 tablets of [MEDICATION NAME] 0.5 mg on 6/19/18 for Resident #73. Continued review revealed the facility began the medication count at 30 tablets instead of 60 tablets. The count was off by 30 tablets. The ADON and LPN #2 confirmed Resident #48 and Resident #73's Controlled Drug Records for [MEDICATION NAME] count were incorrect. Interview with the ADON on 7/18/18 at 8:15 AM, at the 100 hall medication cart, confirmed the facility failed to ensure controlled medications were accurately recorded and failed to follow the facility policy.

Based on facility policy review, observation and interview, the facility failed to ensure medications remained under the direct observation of the person administering, during medication administration for the 21 residents in the secure unit. The findings include: Review of facility policy General Dose Preparation and Medication Administration, dated 5 2010, revealed .Facility staff should not leave medications or chemicals unattended . Observation of Licensed Practical Nurse (LPN) #1 on 7/16/18 at 4:10 PM, revealed LPN #1 removed the following medications: [REDACTED]. Further observation revealed LPN #1 dispensed medications from the packaging into the medication cup. Continued observation revealed LPN #1 left the medications unattended on top of the medication cart as she walked down the hall to open a closet door for a staff member. Continued observation revealed LPN #1 had her back to the medication cart as she walked down the hall. Further observation revealed Resident #15 and Resident #22 wandered near the unattended medications. Interview with LPN #1 on 7/16/18 at 4:15 PM, at the medication cart in the secure unit, confirmed LPN #1 walked away from the cart with medication in a cup unsecured while residents were wandering around the cart. Continued interview confirmed LPN #1 failed to follow facility policy. Interview with the Assistant Director of Nursing on 7/17/18 at 3:20 PM, in the Assistant Director of Nursing's office, confirmed the facility failed to ensure medications remained under the direct observation of the person administering during medication administration and failed to follow the facility policy.

Based on facility policy review, observation and interview, the facility failed to ensure resident food was labeled and failed to ensure staff beverages were not stored in 1 resident nourishment refrigerator of 2 nourishment refrigerators observed. The findings include: Review of the facility policy For Guests: Keeping Food Safe for the Residents in Ridgeview Terrace of Life Care undated, revealed .Storage of Food .b. Food requiring refrigerated storage must be placed in a container that is covered securely. It must contain a label that has the name of resident, what the item is, the date it was stored & (and) the 'use by date' .e. During rounds, any food found not to be stored properly will be discarded .9. When to Discard Food .c. If there is no date on the food item . Observation of the resident nourishment refrigerator on 7/17/18 at 2:47 PM, on the secure unit revealed a partially eaten hamburger in a paper bag. Further observation revealed the food was not labeled with a resident's name, date it was stored, or a use by date. Continued observation revealed an opened bottle of a soft drink which belonged to a staff member. Interview with Licensed Practical Nurse #3 on 7/17/18 at 2:47 PM, in the secure unit nurses' station confirmed the food was not labeled and confirmed the soft drink belonged to a staff member. Interview with the Director of Food and Nutrition on 7/17/18 at 2:48 PM, in the secure unit nurses' station confirmed resident food items are expected to be labeled with the resident's name and the date the food item was placed in the refrigerator. Continued interview confirmed staff food items or drinks were not to be stored in the resident nourishment refrigerator and the facility failed to follow facility policy.

Based on review of facility policy, medical record review and interview, the facility failed to notify the resident's representative of a significant change in condition for 1 resident (#102) of 38 residents reviewed. The findings included: Review of the facility policy Changes in Resident's Condition or Status, revealed .Nursing services will be responsible for notifying the resident, his/her next of kin, or representative .when .There is a significant change in the resident's physical, mental, or emotional status . Medical record review revealed Resident #102 was admitted to the facility 1/14/15 with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes dated 5/10/16 3:27 PM, revealed .congested with audible rhonchi required suctioning with O2 (oxygen) sat (saturation) of 82 (percent) on RA (room air) elevated temp (temperature) refused to eat placed on O2 at 3L (liters) sat up to 91 (percent) only after suctioning MD notified of condition . Medical record review of the Progress Notes dated 5/10/16 10:35 PM revealed .MD ordered [MEDICATION NAME] 875mg (milligrams) po (by mouth) BID (twice a day), [MEDICATION NAME] inhalation solution .q (every) 6 hours, and CXR (chest xray) . Medical record review of the Progress Notes dated 5/11/16 revealed .appx (approximately) 2 pm niece at facility upset because resident wasn't feeling well .obtained order to send to (hospital) . Interview with Licensed Practical Nurse (LPN) #2 on 7/27/16 at 9:40 AM, by telephone, confirmed the facility did not notify the family when new orders had been received for Resident #102 on 5/10/16. Interview with the Assistant Director of Nursing (ADON) on 7/27/16 at 2:30 PM, in the staff development office confirmed the family had not been notified of the change in Resident #102's condition.

Based on medical record review, review of facility provided documentation (investigation), and interview, the facility failed to ensure a safety device was turned on to alert staff of unassisted transfers for one resident (#1) of five residents reviewed. The facility's failure to ensure the bed alarm was turned on for resident #1 resulted in a fall and a left orbital floor fracture (facial bone under the left eye) and soft tissue injury to the left orbit (facial tissue near the left eye) (Actual Harm). The findings included: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nursing Assessments dated [DATE] and 16, 2011, revealed the resident had short-term memory loss. Medical record review of a Fall Risk Evaluation dated [DATE], revealed a resident who scores ten or higher is at risk (of falls); the resident scored six. Medical record review of nurse's notes dated [DATE], 10, 17, 18, and 23, 2011, revealed the resident was "confused." Medical record review of two Rehabilitation Multidisciplinary Screening Tools, both dated [DATE], revealed the following: (Screening #1) "...Comments: Nursing staff came to rehab gym this morning to get wc (wheelchair) for patient secondary to instability with gait and poor endurance-putting (resident) at increased risk for falls when staff was trying to assist (resident) to dining room...Cognition: poor memory, poor historian...Transfers: sit to stand with CGA (care giver assist); bed to WC with CGA...Balance and Falls:...high risk for falls...Other: visual deficits...(Screening #2) "...Comments: Pt (patient) presents with poor endurance, decreased strength in UE's (upper extremities) and LE's (lower extremities), decreased balance and coordination, poor safety awareness with transfers, decreased ability to perform ADLs (Activities of Daily Living) and transfers safely...Dressing/Grooming/Bathing/Hygiene: needs assistance...Transfers: needs assistance...Ambulation: needs assistance...Balance and Falls: falls risk due to confusion..." Medical record review of a Physical Therapy Plan of Treatment dated [DATE], revealed "...gait instability with increased risk for fall...poor endurance...poor balance...difficulties with gait and transfers...high fall risk category..." Medical record review of a nurse's note dated [DATE], revealed "...resident in bathroom...lost balance...confused...(family) stated has low vision and can only see peripheral vision. Medical record review of a Rehabilitation Multidisciplinary Screening Tool dated [DATE], revealed "...Cognition: poor safety awareness; Dementia; anxious...Transfers: sit to stand minimal assist for safety...Other: impaired vision..." Medical record review of a nurse's note dated [DATE], revealed "...restless...very unsteady...redirected to bed several times..." Medical record review of a Physical Therapy Plan of Treatment dated [DATE], revealed "...high risk for falls...Dementia...has experienced LOB (loss of balance)...decreased strength...poor balance...difficulty with gait...difficulty with transfers...high fall risk category..." Medical record review of two nurse's notes dated [DATE], revealed the following: 3:30 p.m. "...confused, mental function varies throughout the day...very forgetful...somewhat anxious, wants another person to be with her every second..." 10:00 p.m. "...increased confusion...continuously ask staff to stay in room..." Medical record review of a Physician's Telephone Order dated [DATE], revealed "Bed Alarm." Medical record review of a nurse's note dated [DATE], revealed "...bed alarm placed on bed for poor safety awareness..." Medical record review of a nurse's note dated [DATE], revealed "...keeps getting up by self and walking to bed or bathroom, counseled many times by staff without success..." (One day after bed alarm placed) Medical record review of a nurse's note dated [DATE], revealed "...anxious, wants staff to stay in room every second...short-term memory problem..." Medical record review of a nurse's note dated [DATE], at 9:40 p.m., revealed "...order received for BNP (brain natriuretic peptide- a heart failure blood test) and after lab draw give 20 mg (milligrams) Lasix (diuretic to increase the rate and amount of urination) IM (intramuscular-injection into the muscle) x (times) 1 (one) dose..." Continued review revealed the lab was drawn and the Lasix was given at 11:00 p.m. Medical record review of a nurse's note dated [DATE], at 12:00 a.m., revealed "...upon entering resident's room I observed resident lying on side in front of closet with a small amount of blood coming from the head...I called out for help and instructed for someone to call 911...resident was unconscious upon entering the room...resident was rolled over to back with c-spine held in place...blood pressure and pulse were obtained...resident awake and was agitated and temperature and respirations were not obtained..." Continued review revealed 911 was called and EMS (Emergency Medical Services) arrived at the facility at 12:09 a.m., and departed from the facility to the emergency room with the resident at 12:25 a.m. Further review revealed "12:00 a.m., Addendum. Resident had a bed alarm and it was not turned on at the time of the incident." Review of a facility investigation dated [DATE], at 12:00 a.m., revealed "...Summary of Investigative Facts: resident was found lying on floor in room...admitted to hospital with hip fracture...Follow-Up:...Add-patient did not have hip fracture..." Continued review of the facility investigation revealed a witness statement by LPN #2 dated [DATE], revealed "...family had been here to visit...(family) assisted resident to bed and did not turn on bed alarm..." Medical record review of a CT of the Brain (Computed Tomography, a radiologic imaging that uses computer processing to generate an image of tissue density in slices through the patient's body) dated [DATE], revealed "...Clinical History: fall, laceration to the left cheek, swollen left eye, headache...Impression: Findings of soft tissue injury about the left orbit (socket of the eye). There is also a fracture of the left orbital floor (fracture of the bone at the floor of the eye socket)..." Medical record review of a CT of Facial Bones dated [DATE], revealed, "... Clinical History: fall, laceration to the left cheek, swollen left eye, headache...Impression: Minimally displaced fracture of the left orbital floor..." Medical record review of a Hospital Discharge Summary dated [DATE], revealed "...sent over from (nursing home) after (resident) fell there...sustained a prominent hematoma (localized swelling filled with blood resulting from a break in a blood vessel) to the left periorbital region (around the left socket of the eye)...left hip and leg was externally rotated and in the emergency room thought (resident) had a left hip fracture, but...radiologist determined that there was no fracture...because of the fall and the mental status changes, CT of the brain was also done and was negative for any intracranial finding, though there was incidental finding of the soft tissue injury to the left orbit and a fracture to the left orbital floor...CT of the facial bones was done to follow up on this and confirmed a minimally displaced fracture to the left orbital floor and, of course, the soft tissue swelling around that area..." Continued review revealed the resident was admitted to the hospital's Intensive Care Unit (ICU) on [DATE], improved, and was discharged back to the nursing home on [DATE]. Medical record review of a Physician's Progress Note dated [DATE], revealed "...sent to the hospital...[DATE] after a fall...had a loss of consciousness with the fall...did have an orbital floor fracture..." Medical record review of a nurse's note revealed the resident expired on [DATE], at 10:15 p.m. Interview with Physical Therapist (PT) #1 on [DATE], at 3:25 p.m., in the Conference Room confirmed the resident was a fall risk due to confusion, poor vision, poor strength, poor muscular endurance, Dementia, and confusion. Continued interview confirmed the Rehab staff worked with the resident from admission throughout the resident's stay. Further interview confirmed the resident remained unchanged and was a fall risk due to confusion, poor vision, poor strength, poor muscular endurance, Dementia, and confusion. Interview by telephone on [DATE], at 3:40 p.m., with Licensed Practical Nurse (LPN) #1, confirmed the resident was confused and LPN #1 was concerned the resident was going to fall. Continued interview confirmed LPN #1 stated "(Resident) was unsteady and I knew it was just a matter of time before (resident) fell , that's why I called the doctor and got the order for the bed alarm." Continued interview confirmed a bed alarm had been ordered and placed due to the resident's poor safety awareness to alert staff of unassisted transfers. Continued interview confirmed LPN #1 entered the room on [DATE], at 12:00 a.m., found the resident lying on the floor from a fall; the resident was bleeding from a laceration on the left side of the head near the left eye, and was unconscious. Continued interview confirmed upon rolling the resident over onto the resident's back, pressure was applied to the laceration, the bleeding was controlled, and the resident regained consciousness. Further interview confirmed the bed alarm was not sounding at the time of the fall and was not turned on. Interview with LPN #2 on [DATE], at 4:00 p.m., in the Conference Room confirmed LPN #1 called out for help upon finding the resident lying in the floor from the fall on [DATE], at 12:00 a.m. Continued interview confirmed the bed alarm in place for the resident was a pressure pad alarm. Continued interview confirmed the bed alarm was not sounding at the time of the fall and was not turned on. Continued interview confirmed a family member had been visiting with the resident, had put the resident to bed, and didn't turn the bed alarm on. Continued interview confirmed LPN #2 observed the family member leaving the facility at 10:00 p.m., on [DATE]. Continued interview confirmed LPN #2 failed to check on the resident or the bed alarm upon observing the family member leave the facility. Continued interview confirmed the Certified Nursing Assistants (CNAs) and Nurses (Licensed Practical Nurses and/or Registered Nurses) are required to make rounds (check on residents) at least every two hours. Further interview with LPN #2 confirmed the facility failed to check the resident's bed alarm at least every two hours and failed to ensure the bed alarm was turned on at the time of the fall. Interview by telephone on [DATE], at 5:05 p.m., with Family Member #1, confirmed Family Member #1 assisted the resident to bed on [DATE], between 7:45 p.m., and 8:00 p.m. Continued interview confirmed Family Member #1 was unaware the resident had an alarm and stated, "They (nursing home staff) never told me or showed me anything about a bed alarm." Continued interview confirmed on [DATE], at 8:30 p.m., Family Member #1 asked LPN #2 to give the resident's bedtime medications. Continued interview confirmed LPN #2 entered the room at 9:00 p.m., gave the resident's bedtime medications, and immediately left the room without checking anything on the resident's bed. Interview with LPN #2 on [DATE], at 5:15 p.m., in the Conference Room confirmed LPN #2 went into the resident's room on [DATE], at 9:00 p.m., and 11:00 p.m. and administered the medications to the resident (bedtime medications at 9:00 p.m., and Lasix at 11:00 p.m.). Continued interview confirmed the resident was in the bed and LPN #2 failed to ensure the bed alarm was turned on before leaving the room. Interview with CNA #1 on [DATE], at 5:45 p.m., in the Conference Room confirmed CNA #1 did not recall checking the resident's alarm after family member #1 put the resident to bed on [DATE]. Interview with CNA #2 on [DATE], at 6:00 p.m., in the Conference Room confirmed Family Member #1 was in the resident's room and assisted the resident to bed on the evening of [DATE]. CNA #2 confirmed checking on the resident's roommate, but did not check on the resident. Continued interview confirmed CNA #2 stated "(resident's name) was sleeping; I did not check the resident or bed alarm because (Family Member #1) was with the resident." Interview with CNA #3 on [DATE], at 6:15 p.m., in the Conference Room confirmed CNA #3 did not recall checking the resident's alarm on [DATE]. Interview with the Assistant Director of Nursing (ADON) on [DATE], at 6:35 p.m., in the ADON's Office confirmed the facility staff was unaware the resident had a fracture and stated "We thought (resident) had a hip fracture, but it was negative; we didn't know there was a fracture." Continued interview confirmed the facility failed to review hospital documentation thoroughly and the unassisted transfer out of bed resulted in a fracture. C/O .