Every finding on record at River Walk Care Center

Based on interview and record review, the facility failed to ensure the physicians orders were followed for one of three sampled residents (Resident 1) when the diet order was not updated correctly during an order update for Resident 1. This failure resulted in Resident 1 not receiving a controlled carbohydrate diet (CCHO- commonly used for diabetics) for approximately three months.Findings:During a review of Resident 1's Care Plan (CP) dated 12/18/25, the CP indicated, Nutrition Status.at risk for weight loss, dehydration, skin breakdown and altered nutritional status r/t (related to) .DM2 (type 2 diabetes) .Interventions.Diet as ordered. Renal (diet for residents with chronic kidney disease) CCHO diet.date initiated: 12/18/25.During a review of the Physician Orders (PO) dated 4/28/26 at 1:33 p.m., the PO indicated, Order Summary: Renal diet regular texture.thin consistency.During a review of the PO dated 4/28/26 at 1:34 p.m., the PO indicated, Order Summary Renal.CCHO diet regular texture, regular consistency.discontinue.4/28/26 1:33 p.m .language clarification.During a review of Resident 1's Progress Notes (PN) dated 4/29/26 at 10:22 a.m., the PN indicated, No change in diet was made, template revision only.During a review of Order Listing Report (OLR) dated 7/16/26, the OLR indicated, (Resident 1) was on a Renal diet.During an interview on 7/16/26 at 11:08 a.m. with Resident 1, Resident 1 stated she was not receiving a diabetic (medical condition where your body cannot properly process sugar from the food you eat) diet.During an interview on 7/16/26 at 3 p.m. with Director of Nursing (DON), DON stated Resident 1 was not on a CCHO diet because the template was revised and the CCHO was accidentally dropped. DON stated Resident 1 should have been on a CCHO diet as ordered by the physician.During a review of the policy and procedure (P&P) titled Therapeutic Diet Orders undated, the P&P indicated, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician.therapeutic diets are provided only when ordered by the attending physician.dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on interview and record review, the facility failed to ensure their policy and procedure was followed when one of three sampled residents (Resident 1) did not have a discharge care plan developed. This failure had the potential for Resident 1 to have unmet discharge needs.Findings:During a review of Resident 1's IDT (Interdisciplinary Team-collaborative group of professionals from different disciplines who work together interdependently to provide comprehensive patient-centered care) Care Conference Meeting (IDTCCM), dated 2/27/26 at 2:15 p.m., the IDTCCM indicated, An IDT meeting was held to discuss the resident's progress.At this time, therapy recommends that the resident is not appropriate for discharge due to decreased activity tolerance and the need for continued strengthening and endurance training to ensure a safe transition home.The care plan will be updated accordingly to reflect ongoing therapy services, transfer training, and continued discharge planning.During a review of Resident 1's Progress Notes (PN) dated 3/19/26 at 2:18 p.m., the PN indicated, At 1230, resident d/c (discharge) to home.During a concurrent interview and record review on 5/5/26 at 12:17 p.m. with Social Service Director (SSD), Resident 1's Care Plans were reviewed. SSD was unable to provide a discharge care plan for Resident 1. SSD stated there was no discharge care plan developed for Resident 1. SSD stated a discharge care plan should be developed when it was time for the resident to discharge.During an interview on 5/5/26 at 1:17 p.m. with Administrator, Administrator stated there should have been a discharge care plan developed per policy.During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Resident-Initiated undated, the P&P indicated, For resident-initiated discharges, the medical record contains.a discharge care plan.The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated.

Based interview and record review, the facility failed to follow its own policy and procedure (P&P) for one of three sampled (Resident 1) when written request for Resident 1's clinical records was not provided in a timely manner. This failure resulted in violation of Resident 1's rights and not providing Resident 1's clinical records approximately 29 days after the request date.Findings:During a concurrent interview and record review on 4/2/26 at 12:57 p.m. with Assistant Director of Nurses (ADON) and Medical Records Director (MRD), MRD stated on 2/26/26 a written request for Resident 1's clinical record was received. MRD stated Resident 1's clinical record was not released until 3/27/26 (approximately 29 days after the request date). ADON and MRD reviewed the facility's P&P titled, Release of Medical Records. ADON and MRD confirmed the facility P&P was not followed when written request for Resident 1's clinical record was not released within 2 working days.During a review of facility's P&P titled, Release of Medical Records, dated 2025, the P&P indicated, Access Rights to Medical Information are as Follows: 1.The resident or his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made.

Based on interview and record review, the facility failed to implement their care plan (a comprehensive, personalized document created by an interdisciplinary team [IDT - a collaborative group of healthcare professionals, including nurses, doctors, therapists, social workers, and the resident/family, who work together to create and implement personalized care plans] to guide a resident's medical, nursing, and rehabilitative care) intervention for monitoring five of 13 sampled residents (Resident 27, Resident 67, Resident 36, Resident 42, and Resident 3). This failure had the potential to result in resident harm/injury, and/or failure to provide appropriate interventions for Resident 27, Resident 67, Resident 36, Resident 42, and Resident 3 safety.Findings:During a review of Resident 27's Care Plan Report (CP), dated 11/13/23, the CP indicated, Resident 27 was at risk for unavoidable falls with major injury. On 11/3/25, an intervention was implemented for one-to-one monitoring (dedicated 24-hour staff for the purpose of resident monitoring).During a review of Resident 67's CP, dated 1/13/25, the CP indicated, Resident 67 had multiple falls including falls with injury. On 1/25/25, an intervention was implemented to place Resident 67 on one to one monitoring.During a review of Resident 36's CP, dated 6/8/25, the CP indicated, Resident 36 was a high risk for falls. On 12/16/25, an intervention was implemented to place Resident 36 on one to one monitoring.During a review of Resident 42 's CP, dated 1/30/26, the CP indicated, Resident 42 was an elopement risk (any instance where a resident leaves a safe, designated care environment without authorization, knowledge, or supervision of staff)/wanderer (a person who travels aimlessly). On 11/22/23, an intervention was implemented to monitor Resident 42 location every 15 minutes.During a review of Resident 3 's CP, dated 5/6/25, the CP indicated, Resident 3 was at risk for falls. On 10/28/25, an intervention was implemented for Resident 3 to be monitored every 15 minutes.During a review of the facility document titled FALL PROGRAM (FP), undated, the FP indicated facility staff are to be Resident 27, Resident 67, Resident 36) on one-to-one monitoring. The FP indicated the are to facility staff to monitor Resident 3 and Resident 42 every 15 minutes. During a concurrent interview and record review on 2/25/26 at 3:16 p.m. with Director of Staff Development (DSD), the facility forms titled Resident with Behaviors Monitoring (RBM), was reviewed. The RBM indicated Resident 27, Resident 26, Resident 42, Resident 67, and Resident 3 required narrative notes needed to be taken every 15 minutes on the RBM to indicate what the residents were doing at that time. DSD stated the forms were supposed to be filled out every 15 minutes by the morning shift (6:30 a.m. to 2:45 p.m.), the evening shift (2:30 p.m. to 10:45 p.m.), and the night shift (10:30 p.m. to 6:45 a.m.). DSD stated once the day was completed the RBM was to be turned into her office for record keeping and review. DSD confirmed the RBM indicated the following:1.For Resident 27:1/1/26 - there was no documentation for the morning shift and night shift1/2/26 - there was no documentation for the night shift.1/3/26 - there was no documentation for the evening and night shift.1/4/26 - there was no documentation for the evening and night shift1/6/26 - there was No documentation for all three shifts1/8/26 - there was no documentation for the evening shift1/9/26 - there was no documentation for the evening and night shift1/12/26 - there was no documentation for the night shift1/13/26 - there was no documentation for the morning and evening shift1/14/26 - there was no documentation for the night shift.1/17/26 - there was no documentation for the morning shift1/20/26 - there was no documentation for the evening shift1/21/26 - there was no documentation for the morning shift1/22/26 - there was no documentation for the night shift1/23/26 - there was no documentation for the night shift 1/24/26 - documentation was not complete for the morning shift1/25/26 - documentation was not complete for the evening shift2/19/26 - there was no documentation for the evening shift2/20/26 - there was no documentation for the morning shift2/22/26 - there was no documentation for the night shift2/23/26 - documentation was not complete for the evening shift 2. For Resident 67: 1/1/26 - there was no documentation for the night shift and documentation for the evening shift was not complete 1/2/26 - there was no documentation for the night shift1/3/26 - there was no documentation for the evening shift1/4/26 - there was no documentation for the evening and night shift 1/6/26 - there was no documentation for the evening shift and documentation for the morning and evening shifts were not complete1/7/26 - documentation for the morning shift was not complete1/10/26 - documentation for the evening shift was not complete1/11/26 - there was no documentation for the night shift1/13/26 - there was no documentation for the morning shift1/14/26 - there was no documentation for the night shift1/17/26 - there was no documentation for the night shift1/21/26 - there was no documentation for the morning shift1/22/26 - there was no documentation for the night shift1/23/26 - there was no documentation for the night shift1/25/26 - there was no documentation for the night shift1/28/26 to 1/31/26 - there was no documentation for all three shifts 2/1/26 to 2/6/26 - there was no documentation for all three shifts 2/18/26 - there was no documentation for the morning shift2/19/26 - there was no documentation for the evening shift2/22/26 - there was no documentation for the night shift 3. For Resident 36 1/1/26 - there was no documentation for the evening and night shift 1/2/26 - there was no documentation for the evening and night shift 1/3/26 to 1/6/26 - there was no documentation for all three shifts 1/7/26 - there was no documentation for the evening and night shift1/8/26 - there was no documentation for the evening and night shift1/9/26 - there was no documentation for the night shift1/11/26 and 1/12/26 - there was no documentation for all three shifts1/13/26 - there was no documentation for the morning and night shift. The documentation for the evening shift was not completed1/14/26 to 1/16/26 - there was no documentation for all three shifts1/17/26 - there was no documentation for the night shift1/18/26 - there was no documentation for all three shifts1/19/26 - there was no documentation for the morning and night shift1/21/26 - there was no documentation for the night shift1/23/26 - there was no documentation for the evening and night shift1/24/26 - there was no documentation for the morning and night shift1/25/26 and 1/26/26 - there was no documentation for all three shifts1/27/26 - there was no documentation for the morning and night shift1/28/26 - there was no documentation for all three shifts2/1/26 to 2/3/26 - there was no documentation for all three shifts2/4/26 - there was no documentation for the morning and night shift2/6/26 and 2/7/26 - there was no documentation for all three shifts2/8/26 and 2/9/26 - there was no documentation for the evening and night shift2/10/26 - there was no documentation for the morning and night shift2/14/16 - there was no documentation for the evening and night shift2/15/26 and 2/16/26 - there was no documentation for all three shifts2/17/26 - there was no documentation for the evening and night shift. Documentation for the morning shift was not completed2/18/26 - there was no documentation for all three shifts2/19/26 - there was no documentation for the morning and night shift2/20/26 and 2/21/26 - there was no documentation for the evening and night shift2/22/26 - there was no documentation for all three shifts2/23/26 - there was no documentation for the night shift and documentation for the day shift was not completed2/24/26 - there was no documentation for the night shift 4. For Resident 421/1/26 to 1/7/26 - there was no documentation for all three shifts1/8/26, 1/9/26, and 1/10/26 - there was no documentation for the morning and night shift1/11/26 and 1/12/26 - there was no documentation for all three shifts1/13/26 - there was no documentation for the morning and night shift. Documentation for the evening shift was not complete 1/14/26 to 1/16/26 - there was no documentation for all three shifts1/17/26 - there was no documentation for the morning shift and the night shift1/18/26 - there was no documentation for all three shifts 1/19/26 - there was no documentation for the morning and night shift1/20/26 - there was no documentation for all three shifts1/21/26 - there was no documentation for the night shift1/22/26 - there was no documentation for all three shifts1/23/26 - there was no documentation for the evening and night shift1/24/26 - there was no documentation for the morning and night shift1/25/26 - there was no documentation for the morning and night shift1/26/26 - there was no documentation for all three shifts1/27/26 and 1/28/26 - there was no documentation for the morning and night shift 1/29/26 to 1/31/26 - there was no documentation for all three shifts2/1/26 to 2/13/26 - there was no documentation for all three shifts2/14/26 - there was no documentation for the morning and night shift. Documentation for the evening shift was not complete2/15/26 and 2/16/26 - there was no documentation for all three shifts2/17/26 - there was no documentation for the evening and night shift2/18/26 and 2/19/26 - there was no documentation for all three shifts2/20/26 - there was no documentation for the evening and night shift2/21/26 and 2/22/26 - there was no documentation for all three shifts2/23/26 - there was no documentation for the evening and night shift. Documentation for the morning shift was not complete5. For Resident 3 1/1/26 - there was no documentation for the night shift1/2/26 - there was no documentation for the evening and night shift1/3/26 and 1/4/26 - there is no documentation for all three shifts1/5/26 to 1/7/26 - there is no documentation for the evening and night shift1/8/26 - there was no documentation for the night shift1/9/26 - there was no documentation for the night shift1/10/26 and 1/11/26 - there was no documentation for all three shifts1/12/26 - there was no documentation for the night shift1/13/26 - there was no documentation for the evening and night shift. Documentation for the morning shift was not complete1/14/26 and 1/15/26 - there was no documentation for the evening and night shift1/16/26 - there was no documentation for all three shifts1/17/26 and 1/18/26 - there was no documentation for the night shift1/19/26 and 1/20/26 - there was no documentation for the evening and night shift1/21/26 - there was no documentation for the night shift1/22/26 - there was no documentation for all three shifts1/23/26 and 1/24/26 - there was no documentation for all three shifts1/23/26 and 1/24/26 - there was no documentation for the evening and night shift1/25/26 and 1/26/26 - there was no documentation for the night shift1/27/26 and 1/28/26 - there [NAME] no documentation for the evening and night shift1/29/26 - there was no documentation for all three shifts1/31/26 - there was no documentation for the night shift2/1/26 and 2/2/26 - there was no documentation for the evening and night shift2/3/26 - there was no documentation for the morning and night shift2/4/26 - there was no documentation for all three shifts2/5/26 - there was no documentation for the morning and night shift2/6/26 to 2/8/26 - there was no documentation for the evening and night shift2/9/26 and 2/10/26 - there was no documentation for all three shifts2/11/26 - there was no documentation for the evening and night shift2/13/26 to 2/15/26 - there was no documentation for the evening and night shift2/16/26 - there was no documentation for the night shift2/17/26 - there was no documentation for the evening and night shift2/18/26 - there was no documentation for the night shift2/19/26 - there was no documentation for the night shift2/20/26 - there was no documentation for the evening and night shift2/21/26 - there was no documentation for all three shifts2/22/26 to 2/24/26 - there was no documentation for the evening and night shiftDuring an interview on 2/25/26 at 4:09 p.m. with Director of Nursing (DON), DON stated the RBM forms are used to determine if resident centered interventions are successful and/or if there is more to be done to ensure safety. DON stated she and Assistant Director of Nursing (ADON) look at the RBM forms weekly. DON stated the RBM forms from last week were looked at.During an interview on 2/26/26 at 3:48 p.m. with DON, DON stated the purpose of the RBM forms is to decrease or prevent whatever resident action is of concern listed on the care plan. DON stated the RBM forms are used to rationalize or modify interventions for the residents. DON stated, The expectation is the [facility] staff are to be filling out the [RBM] forms as expected so that a decision can be made on future interventions and action [for the residents].During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident centered approach to safety addresses safety and accident hazards for individualized residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following . Ensuring that interventions are implemented correctly and consistently . Evaluating the effectiveness of interventions . Evaluating the effectiveness of new or revised interventions. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. These risk factors and environmental hazards include . Falls . unsafe wandering.

Based on observation, interview, and record review, the facility failed to follow standard practice for infection control when: 1. Two of eight sampled staff members (Certified Nursing Assistant [CNA] 1 and Physical Therapy Assistant [PTA] 1) did not apply appropriate personal protective equipment (PPE- gowns, gloves, face masks, face shields or other equipment designed to protect the wearer from injury or the spread of infection or illness) prior to providing high contact care (involving direct contact with a resident) to a resident on enhanced barrier precautions (EBP- an infection control practice that utilizes the use of gown and gloves during high contact care activities to stop the spread of multi-drug resistant organisms [MDRO]).2. Facility failed to implement their policy and procedure on Handling Soiled Linen, for one of 29 sampled residents (Resident 65). These failures had the potential to spread infection and cause illness to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 2/24/26 at 8:42 a.m. with CNA 1 and PTA 1 in Resident 33's room, CNA 1 and PTA 1 were providing high contact resident care to Resident 33. CNA 1 and PTA 1 were not wearing a gown. Resident 33 had a gauze dressing applied to the right lower leg. CNA 1 stated Resident 33 had a wound to her right lower leg. PTA 1 and CNA 1 stated they were unsure if Resident 33 was on EBP. During a concurrent observation and interview on 2/24/26 at 8:46 a.m. with CNA 1, outside of Resident 33' room, an EBP sign was on Resident 33's door and there was an orange dot next to Resident 33's name. CNA 1 stated the orange dot next to Resident 33's name indicated that Resident 33 was on EBP. CNA 1 stated she should have looked at the sign and used a gown prior to providing care to Resident 33. During an interview on 2/26/26 at 9:13 a.m. with Infection Preventionist (IP), IP stated residents with wounds that require a dressing change are placed on EBP. IP stated it was her expectation for staff to wear a gown and gloves while providing care to residents on EBP. During a review of Resident 33's Physician Orders (PO), dated 2/3/26, the PO indicated, Enhanced Barrier Precautions (EBP)-Staff to utilize gowns and gloves for high-contact resident care activities due to a colonized MDRO. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated March 2024, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care.a. Gloves and gown are applied prior to performing the high contact resident care activity.5. EBPs are indicated.for residents with wounds and/or indwelling medical devices regardless of MDRO. 2.During a review of Resident 65's Care Plan Report (CP), dated 10/7/24, the CP indicated, Resident 65 is incontinent (unable to control bowel and/or bladder) of bowel and bladder. During an observation on 2/24/26 at 12:08 p.m. in Resident 65 room, CNA 3 was changing Resident 65's bed linen. CNA 3 placed Resident 65's bowel movement covered sheets onto the floor at her bedside leading out toward the entry door while he was providing care. During an interview on 2/24/26 at 12:11 p.m. with CNA 3, CNA 3 stated Resident 65's bowel movement soiled bed linens were placed on the floor while he was providing care, but he should not have done that because it could spread infection. During an interview on 2/24/26 at 12:21 p.m. with IP, IP stated resident soiled bed linen should be rolled off the mattress and placed directly into a designated container. IP stated soiled bed linen should not be placed on the floor. IP stated the reason soiled linen should not be placed on the floor is due to staff, visitors, and/or other residents can step on that area and spread infection. During a review of the facility's policy and procedure (P&P) titled, Handling Soiled Linen, undated, the P&P indicated, It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. Linen can become contaminated with pathogens (tiny organisms that can cause sickness and disease) from contact with intact skin, body substances, or from environmental contaminants. Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen. All used linen should be handled using standard precautions (basic methods to control infection such as washing hands, wearing gloves and other appropriate protective equipment) . and treated as potentially contaminated . Linen should not be allowed to touch the uniform or floor and should be handled as little as possible . Used or soiled linen shall be collected at the bedside . and placed in a linen bag or designated linen receptacle. When task is complete, the bag shall be closed securely and placed in the soiled linen utility room.

Based on interview and record review, the facility failed to monitor refrigerator/freezer temperatures used to store residents' food. This failure had the potential to spread foodborne illnesses to residents.Findings:During a concurrent interview and record review on 2/23/25 at 9:26 a.m. with Dietary Supervisor (DS), the facility document titled, Refrigerator and Freezer Temperature Log (RFTL), was reviewed. The RFTL indicated, the refrigerator/freezer temperatures where to be taken in the a.m. and the p.m. The RFTL indicated, the following: On 12/31/25 - there was no temperature taken in the a.m.On 11/29/25 - there was no temperature taken in the in the p.m.On 10/31/25 - there was no temperature taken in the a.m. DS stated the temperatures should have been taken but were not. During a review of the facility's policy and procedure (P&P) titled, COLD STORAGE TEMPERATURE MONITORING AND RECORD KEEPING, undated, the P&P indicated, Food and Nutrition staff shall review and record temperature of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. Food (and) Nutrition Services staff will check the inside temperature of refrigerators and freezers. Food (and) Nutrition Services staff will record and initial the temperatures on the Healthcare Menu Direct, LLC.'s Cold Storage Temperature Log . at the beginning of the AM and PM shifts.

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 5) was provided with meal at a palatable (pleasant to taste) and safe temperature. This failure had the potential for food borne illnesses to affect all residents eating from the facility kitchen and/or result in meals not being palatable leading to potential unintended weight loss.Findings:During a concurrent observation and interview on 2/25/26 at 12:55 p.m. with Dietary Supervisor (DS), the last lunch meal tray was served, and food temperatures were taken. DS observed and confirmed the following food temperatures: Fish temperature was at 116 degrees Fahrenheit ( F- a unit of measurement). DS stated the temperature was supposed to be at 140 FBroccoli temperature was at 113 F. DS stated the temperature was supposed to be at 140 FRice temperature was at 128 F. DS stated the temperature was supposed to be at 140 FCucumber salad was at 70 F. DS stated the temperature was supposed to be below 68 FMilk was at 52 F. DS stated the milk was supposed to be 40 F or lowerDuring a review of Resident 5's Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition is. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests the cognition is intact. A score of 99 suggest the resident was unable to complete the interview and therefore unable to determine the resident's cognition), dated 2/21/26 the BIMS indicated Resident 5's score was 15 During an interview on 2/26/26 at 8:44 a.m. with Resident 5, Resident 5 stated he attended resident council (group of residents who meet to discuss facility/resident concerns) meetings on a regular basis. Resident 5 stated the facility kitchen had been sending out meals that were not heated or chilled correctly for approximately the last three months. Resident 5 stated, The hot food is cold, and the cold food is hot.During a review of the facility's policy and procedure (P&P) titled, MEAL SERVICE, UNDATED, the P&P indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appointment temperatures. Hot food serving temperature must be at or above minimum holding temperature of 140 F. The temperatures of the food should be periodically monitored throughout the meal service to ensure proper hot and cold temperature. Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. Recommended Temp (temperature) at Delivery to Resident . Cold entree . (at or lower than) 50 F . Salads . (at or lower than) 45 F . Milk/cold beverage . (at or lower than) 45 F . Hot entree . (at or higher than) 120 F . Vegetables . (at or higher than) 120 F.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of 25 sampled residents' (Resident 92) medical record contained accurate documentation. This failure resulted in inaccurate medical documentation and had the potential to result in inaccurate monitoring of wound progression, inappropriate treatment, and wound treatment complications. 2. Ensure one of 6 sampled residents (Resident 92) had a physician order prior to changing a wound treatment. This failure had the potential to result in inappropriate treatment and wound treatment complications.3. Ensure one of 4 sampled residents (Resident 10) had a physician order to discontinue weekly/monthly weights. This failure had the potential for Resident 10's weight gain or loss to go unmonitored.Findings:1.During a concurrent observation and interview on 2/23/26 at 10:06 a.m. with Resident 92, in Resident 92's room, Resident 92 was sitting in his wheelchair, and both of his lower legs were wrapped with Kerlix gauze (cotton medical dressing/wrap that was designed to absorb moderate to heavy wound drainage) dated 2/22/26. During a concurrent observation and interview on 2/24/26 at 8:38 a.m. with Resident 92, in Resident 92's room, Resident 92 was sitting in a chair, both of his lower legs were covered with pink foam dressings (highly absorbent bandage) dated 2/23/26. Resident 92 stated he had a reaction to the gauze dressing that made his skin itch. Resident 92 stated the treatment nurse applied a different wound dressing. During an observation on 2/25/26 at 10:40 a.m. in Resident 92's room, Resident 92 was sitting on his bed, both of his lower legs were covered with pink foam dressings dated 2/24/26. During a concurrent interview and record review on 2/25/26 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 92's Physician Orders (PO) dated 2/20/26 were reviewed. The PO indicated, Resident 92 was to have daily wound treatment to both of his lower legs that consisted of cleaning wounds with normal saline [NS, a sterile solution of salt dissolved in water that is gentle and non-irritating for wound care], pat dry, apply silver med gel [brand name, a water based gel mixed with silver ions (active ingredient) used to manage infections and keep a moist wound bed] to wound bed, cover with Adaptec [mesh dressing designed to protect the wound bed and prevent bandages from sticking to healthy tissue], layer with ABD pad [abdominal pad, highly absorbent cotton filled dressing], wrap with Kerlix every day shift. LVN 1 stated Resident 92's current wound treatment order was NS, Silver med gel, Adaptec, ABD pad and Kerlix wrap. During a concurrent interview and record review on 2/25/26 at 11:09 a.m. with LVN 1, Resident 92's Treatment Administration Record (TAR), dated February 2026 was reviewed. The TAR indicated, on 2/23/26 and 2/24/26, Resident 92's wounds to his bilateral legs were cleaned with NS, patted dry, silver med gel, Adaptec, and ABD pad applied and wrapped with Kerlix gauze. LVN 1 stated she had changed Resident 92's dressing to a foam dressing on 2/23/26 and 2/24/26. LVN 1 stated she had not placed a new treatment order in Resident 92's chart. LVN 1 stated she should not have documented under the current order in the TAR if it was not the treatment being provided. LVN 1 stated she should have obtained a new physician order. LVN 1 stated this was inaccurate documentation. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, the P&P indicated, All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record.2. The following information is to be documented in the resident's medical record.c. Treatments or services performed.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 2. During a concurrent observation and interview on 2/23/26 at 10:06 a.m. with Resident 92, in Resident 92's room, Resident 92 was sitting in a wheelchair with bilateral (both) lower legs wrapped with Kerlix gauze (white cotton medical dressing/wrap that was designed to absorb moderate to heavy wound drainage) dated 2/22/26. During a concurrent observation and interview on 2/24/26 at 8:38 a.m. with Resident 92, in Resident 92's room, Resident 92 was sitting in a chair, his bilateral lower legs were covered with pink foam dressings (highly absorbent bandage) dated 2/23/26. Resident 92 stated he had a reaction to the Kerlix gauze dressing that made his skin itch. Resident 92 stated the treatment nurse applied a different dressing. During an observation on 2/25/26 at 10:40 a.m. in Resident 92's room, Resident 92 was sitting on his bed, his bilateral lower legs were covered with pink foam dressings, dated 2/24/26. During a concurrent interview and record review on 2/25/26 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 92's Physician Orders (PO) dated 2/20/26 was reviewed. The PO indicated, Resident 92 was to have daily wound treatment to his bilateral lower legs that consisted of cleaning wounds with normal saline [NS, a sterile solution of salt dissolved in water that is gentle and non-irritating for wound care], pat dry, apply silver med gel [brand name, a water based gel mixed with silver ions (active ingredient) used to manage infections and keep a moist wound bed] to wound bed, cover with Adaptec [mesh dressing designed to protect the wound bed and prevent bandages from sticking to healthy tissue], layer with ABD pad [abdominal pad, highly absorbent cotton filled dressing], wrap with Kerlix every day shift. LVN 1 stated Resident 92's current wound treatment order was NS, Silver med gel, Adaptec, ABD pad and kerlix wrap. During an interview on 2/25/26 at 11:09 a.m. with LVN 1, LVN 1 stated she had changed Resident 92's wound treatment to a foam dressing on 2/23/26 and 2/24/26 due to Resident 92's request. LVN 1 stated there were no POs in Resident 92's chart to change Resident 92's wound treatment to a foam dressing. LVN 1 stated she should have obtained a PO for the foam dressings. During a review of the facility's policy and procedure (P&P) titled, Dressings, Dry/Clean, dated September 2013, the P&P indicated, The purpose of this procedure is to provide guidelines for the application of dry clean dressings.1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan, current orders, and diagnosis. 3. During review of Resident 10's Electronic Medical Record (eMAR) on 2/26/26, the eMAR indicated, Resident 10's last recorded weekly/monthly weight was 7/14/25, with a recorded weight of 104 pounds (unit of weight). During a review of Resident 10's Order Summary Report (OSR), dated 2/26/26, the OSR indicated, Resident 10 was admitted to hospice (compassionate care for near end of life within a facility) on 1/8/26 with a diagnosis of Parkinson's disease (incurable, disorder, tremors, stiffness, and slow movement). During a review of Resident 10's Physician Order Sheet (POS), dated 12/30/26, the POS indicated, No weekly weights only monthly - daughter has agreed to monthly weights. During a concurrent interview and record review on 2/26/26 at 3:34 p.m., with Director of Nursing (DON), Resident 10's eMAR was reviewed. The eMAR indicated Resident 10's last daily weight 7/14/25. DON stated, The weights were not completed after July, 2025 there's no Physician order to discontinue the weights. During a review of the facility's policy and procedure (P&P) titled, Physician Services, dated 2001, the P&P indicated, The medical care of each resident is supervised by a licensed physician . 1. A physician must recommend in writing that an individual be admitted to the facility . 2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) . 3. Supervising the medical care of residents includes (but not limited to): b. monitoring changes in resident's medical status. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 2001, the P&P indicated, Resident weights are monitored for undesirable or unintended weight loss or gain . Weight Assessment 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any changes of 5% or more since the last weight assessment is retaken the next day for confirmation.

Based on observation, interview and record review the facility failed to follow the steps in checking the placement of G-Tube (surgical tube place in stomach delivering nutrient supplement) prior to administering two medications for one of four sampled Residents (Resident 79). This failure the had potential for Resident 79 to have discomfort and aspiration (food or liquid enters the airway).Findings:During a review of Resident 79's Order Summary (OS), dated 1/1/25, the OS indicated, Every shift check tube placement. By gastric [stomach] aspiration of contents. Report residuals > [greater than] 100 cc [cubic centimeters-unit of measurement].During a review of Resident 79's OS, dated 1/1/25, the OS indicated, Every shift for Diet Flush with 15 cc [cubic centimeter/milliliter] of water before and after each medication.During a concurrent observation and interview on 2/25/26 at 12:35 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 79's room, LVN 2 did not check stomach residual prior to administering Resident 79's two crushed medications. LVN 2 did not give 15 ml (millimeters- unit of measurement) in-between medication one and medication two. LVN 2 stated she did not check residual after checking placement of the G-tube. LVN 2 stated she did not give the 15 ml of water between the two medications after they were administered. During an interview on 2/25/26 at 3:36 p.m. with Director of Nursing (DON), DON stated it is basic nursing to flush between medications, and it is an expectation for her staff.During a review of the facility policy and procedure (P &P) titled, Enteral Tube Feeding via Syringe (Bolus), dated November 2018, the P & P indicated, When correct tube placement has been verified, flush tubing with at least 30 ml warm water (or prescribe amount).

Based on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Psychotropic Medication [medication that affects brain activity, resulting in changes in mood, behavior, thoughts, and perception] Use for one of two sampled residents (Resident 45) when psychotropic medication was administered to Resident 45 for 50 days without IDT (Interdisciplinary team- a collaborative group of healthcare professionals, including nurses, doctors, therapists, social workers, and the resident/family, who work together to create and implement personalized care plans) approval and consent. This failure had the potential for Resident 45 receiving a larger dose of medication than what the facility determined was appropriate causing potential for harm and/or serious side effects. Findings:During a review of Resident 45's admission RECORD (AR), dated 2/26/26, the AR indicated Resident 45 was admitted to the facility on [DATE] with diagnosis of muscle weakness, history of falling, unspecified dementia (progressive state of decline in mental abilities) and depression (common, serious mental health condition characterized by a persistent feeling of sadness, emptiness, or a loss of interest in activities).During a review of Resident 45's Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition is. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests the cognition is intact. A score of 99 suggest the resident was unable to complete the interview and therefore unable to determine the resident's cognition), dated 1/30/26, the BIMS indicated, Resident 45 had a score of 4. During an interview on 2/23/26 at 10:05 a.m. with Resident 45, Resident 45 was alert but confused and could not provide any responses that made sense.During a concurrent interview and record review on 2/26/26 at 10:34 a.m. with Social Services Director (SSD), Resident 45's Electronic Medical Record (EMR), was reviewed. SSD stated according to the EMR Resident 45 was started on Trazadone (medication for depression) 25 mg (milligram - a unit of measurement) on 9/11/23 for depression manifested by inability to sleep. SSD stated Resident 45 was placed on 50 mg of Trazadone in September 2024. SSD stated on 5/26/25 Resident 45 had a gradual dose reduction (GDR- a structured decreasing of medication dosage to determine if a residents symptoms, conditions, or risks can be managed with a lower dose, or if the medication can be discontinued) of his Trazadone down to 25 mg and remained on 25 mg dosage until 7/26/25. SSD stated Resident 45 was sent to the acute hospital on 7/21/25 with his Trazadone order remaining at 25 mg a day, but when he returned on 7/26/25 he was placed back onto 50 mg a day due to possible error in medication reconciliation (the safety-focused process of comparing a resident's actual, current medication list against their new, ordered medications at every care transition) from hospital to facility. SSD stated the facility IDT did not meet to discuss Resident 45 increase in Trazadone until 18 days later (8/13/25) and consent for the 50 mg of Trazadone was not obtained until 9/15/25 (50 days after Trazadone medication was increased).During a review of Resident 45's Psychiatric (relating to mental illness or its treatment) F/U (follow up) Note (PFUN), dated 5/26/25, the PFUN indicated, Resident 45 had a psychiatric consult in which a recommendation was made to decrease his Trazadone 50 mg every night to 25 mg every night.During a review of Resident 45's Order Summary Report (OSR), dated 7/21/25, the OSR indicated, Resident 45 was on Trazadone 25 mg a day.During a review of Resident 45's Hospital Course, under the section Discharge Plan (DP), dated 7/22/25, the DP indicated, Resident 45 would be discharged from the acute hospital soon with, trazadone 50 mg tablet . (give) 25 mg (every night).During a review of Resident 45's MEDICATION RECONCILLIATION FORM (MRF), dated 7/26/25, the MRF indicated, the facility wrote Resident 45's order for Trazadone to be 50 mg every night and not 25 mg.During a review of Resident 45's IDT - Psychotropic Medication Quarterly (PMQ), dated 8/13/25, the PMQ indicated, the facility IDT met to discuss Resident 45's order for Trazadone 50 mg every night. The PMQ indicated, IDT recommends continuing current medication as a GDR may hinder his [Resident 45] quality of life and overall emotional well-being.During a review of Resident 45's Interim Medication Regimen Review (IMRR), dated 7/28/25, the IMRR indicated, the facility pharmacy reviewed Resident 45's medication and recommended a consent be obtained for Resident 45's Trazadone 50 mg every night.During a review of Resident 45's Psychoactive Medication Evaluation and Consent (PMEC), dated 9/15/25, the PMEC indicated, on 9/15/25 the facility obtained a consent for Resident 45's Trazadone 50 mg every night (50 days after the medication was started).During an interview on 2/26/26 at 3:33 p.m. with Director of Nursing (DON), DON stated the error in not obtaining consent for Resident 45's Trazadone was discovered in September 2025. DON stated the facility did not follow their policy and procedure for psychotropic medication on obtaining IDT and consent.During a review of the facility's P&P titled, Psychotropic Medication Use, dated 2/2025, the P&P indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes . determining adequate indications for use . establishing appropriate dose . and duration .Psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff.When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident's . physical, behavioral, mental, and psychosocial status .Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include . admission or readmission . an irregularity identified during drug regimen review . Diagnosis alone does not necessarily warrant the use of psychotropic medication. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal . the indications and rationale for the recommendation . the potential risk and benefits . the resident's/representative right to accept or decline the treatment.

Based on interview and record review, the facility failed to re-assess and monitor one of three sampled resident (Resident 1) with bruising to the right forearm. This failure had the potential Resident 1's bruise to the right forearm to worsen.Findings:During a review of the clinical record for Resident 1, the admission note dated 1/15/26 indicated Resident 1 was admitted with discoloration (bruising) to bilateral (both) forearms. The skin re-assessment note dated 1/16/26 indicated, resident (Resident 1) presenting with bruising to RFA (right forearm) measuring approximately 6cm (centimeters) x5cm. Treatment Record (TR) for the month of 1/26 indicated Resident 1's bruise to right forearm was not re-assessed after monitoring order was completed on 1/23/26. During a concurrent interview and record review on 2/9/26 at 11:24 a.m. with Treatment Nurse (TN), Resident 1's clinical records were reviewed. TN confirmed Resident 1 was admitted on [DATE] with bruise to right forearm. TN stated it was the facility practice to re-assess skin bruises after monitoring order is completed to ensure bruise is not something new and make sure it's not getting worse. TN reviewed Resident 1's TR record for 1/26 and confirmed bruise to right forearm was not re-assessed after monitoring order was completed on 1/23/26. TN confirmed Resident 1's bruise to right forearm was still present after 1/23/26 and should have been re-assessed. TN stated, yes that was my mistake, it should have continued to be monitored. During a review of the facility's Policy and Procedures (P&P) titled, Skin Assessment, undated, the P&P indicated, 1. A full body, or head to toe, skin assessment will be conducted by licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter.

Based on observation, interview, and record review, the facility failed to ensure:1. Expired food was disposed of;2. Food was labeled and dated in the refrigerator and freezer once opened;3. Frozen food items were stored properly and;4. Steam table was kept free of debris.These failures had the potential for residents to consume expired food items and the potential for food borne illness.Findings:During a concurrent observation and interview on 10/27/25 at 9:07 a.m. with Dietary Supervisor (DS), in the dry food storage room, there was a package of 12 hamburger buns on the shelf labeled with the date 10/15/25 (12 days earlier). DS stated the hamburger buns should have been used within five to seven days from the date on the label. During a concurrent observation and interview on 10/27/25 at 9:10 a.m. with DS, in the walk-in refrigerator, there were nine bowls of apple crisp, 11 containers of vanilla pudding, 13 plastic containers of mixed fruit and 11 containers of chocolate pudding on trays that contained no label. There was a plastic food storage container that was labeled lunch dessert 8/10/25 in permanent marker that contained 10 liters of orange juice. In a plastic food storage container, there was sliced cheese that contained no label or date. There was a container of tomato soup that was dated 10/23/25 (4 days earlier). There was a 1/2 gallon of buttermilk that had an expiration date of 10/15/25. DS stated all food items should be labeled and dated when placed in the refrigerator. DS 1 stated the orange juice was made in the morning and should have been labeled and dated at the time it was made. DS stated the tomato soup should not have been in the refrigerator for more than three days and should have been thrown away. DS stated the buttermilk should have been thrown away when it expired.During a concurrent observation and interview on 10/27/25 at 9:20 a.m. with DS, in the walk-in freezer, there was a box of chopped spinach and beef steaks that had been opened, and the contents left open to air. The spinach and beef steaks did not contain an open date. There was a box of broccoli that did not have an open date. DS stated the boxes should have been closed after being used and should have contained an open date.During a concurrent observation and interview on 10/27/25 at 10:30 a.m. with Registered Dietitian (RD), in the kitchen. The steam table (used to keep food hot while serving the meal trays) contained hot water in each of the five compartments. There was food debris on the covers of the compartments, between the compartments and in the compartments. RD stated the steam table should have been wiped down. RD stated the steam table was to be wiped down at least once a day and as needed and the steam table covers should be washed once a day.During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods undated, the P&P indicated, Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines.(Exception: milk is to be used by its stamped expiration date). All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service.leftovers will be covered, labeled, and dated.During a review of the facility's P&P titled, Dry Goods Storage Guidelines dated 2023, the P&P indicated, Bread.unopened on shelf.5-7- days.Buttermilk.follow expiration date or 1 week.During a review of the facility's P&P titled, Refrigerated Storage Guide undated, the P&P indicated, Buttermilk.follow expiration date or 1 week.During a review of the facility's P&P titled, Kitchen Sanitation undated, the P&P indicated, All utensils, counters, shelves and equipment shall be kept clean.

Based on interview and record review, the facility failed to implement the care plan (specific healthcare goals, interventions, and monitoring strategies) for one of two sampled residents (Resident 1) when the bowel and bladder retraining (scheduled toileting) was not implemented for Resident 1 who was at high risk for falls and had a history of falls related to toileting needs. This failure resulted in Resident 1 going to the bathroom on 8/20/25, independently, falling and sustaining an acute (new) left femoral neck fracture (break in the bone that connects the head of the femur (ball of the hip joint) to the shaft of the femur) extending to the lesser trochanter (attachment point for hip flexor muscles) and requiring hospitalization and surgical repair.Findings:During a review of Resident 1's admission Record (AR) undated, the AR indicated Resident 1 was admitted on [DATE], with diagnoses including difficulty in walking and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 6/8/25.the MDS indicated, Cognitive (mental processes of thinking, knowing, remembering, and understanding) Patterns.BIMS (brief interview for mental status) Summary Score.03 (indicating severe cognitive impairment).Functional Abilities.toilet transfer (the ability to get on and off a toilet).01 (dependent-helper does all of the effort) Bladder and Bowel.Urinary Continence (ability to control movements of the bladder).3 (Always incontinent-no episodes of continent voiding).Bowel continence (ability to control movements of the bowel).2 (Frequently incontinent-2 or more episodes of bowel incontinence, but at least one continent bowel movement).During a review of Resident 1's Care Plan (CP- at-risk care plan) dated 6/8/25, the CP indicated, (Resident name) is high risk for falls r/t (related to) confusion (lack of understanding).poor safety awareness.multiple falls.attempts to transfer and ambulate (walk) unassisted, takes self to bathroom.Interventions/Tasks.Offer toileting assistance after meals, at bedtime, q (every) 2hour and as needed per facility protocol.Date initiated.7/27/25During a review of Resident 1's Evaluation Scoring Report (ESR-fall risk evaluation) dated 10/8/2025, the ESR indicated, 7/27/25.High Fall Risk (at risk to move downward, typically rapidly, freely without control from a higher to lower level) .7/28/25.High Fall Risk.8/6/25.High Fall Risk.8/18/25.High Fall Risk.8/20/25.High Fall Risk.1. During a review of Resident 1's Progress Notes (PN) dated 7/27/25 at 12:00 a.m., the PN indicated, When entering resident's room, resident was found on the floor at the end of his bed. Resident stated that he slipped when going to the restroom.During a review of Resident 1's CP dated 7/27//25, the CP indicated, Resident had an unwitnessed fall; sustained no injury on 7/27/25. Attempted to go to bathroom unassisted; no injury.interventions/tasks.offer toileting (assist in using the toilet) Q (every) 2 hr (hours) and PRN (as needed) (toileting offered but not documented) .2. During a review of Resident 1's PN dated 7/28/25 at 6 a.m., the PN indicated, Resident was found lying on his back on the floor at the right side of bed, next to his side table and trash can.Resident stated he got up to use the bathroom, when he was done, he walked back to bed but he slipped and fell on his back. During a review of Resident 1's CP dated 7/28/25, the CP indicated, Resident had an unwitnessed fall on 7/28/25 with scratch and bump to mid back attempting to go to bathroom unassisted.Interventions/tasks.remind resident to use call light and ask for assistance as needed.3. During a review of Resident 1's PN dated 8/6/25 at 6:45 p.m., the PN indicated, At approx. (approximately) 6:45 p.m. CNA (certified nursing assistant) informed this CN (charge nurse) resident was found in resident restroom sitting on his buttocks on the floor. CNA asked resident what happened resident replied, I miss the toilet and fell on my a**.During a review of Resident 1's CP dated 8/6/25, the CP indicated, (Resident name) had an actual fall with no injury 8/6/25 in the bathroom.Interventions/Tasks.Bowel and Bladder retraining (resident physically taken to the restroom and intervention documented) . There was no evidence the facility implemented bowel and bladder retraining.4. During a review of Resident 1's PN dated 8/18/25 at 11:36 a.m., the PN indicated, Resident stated he fell this morning when preparing for the day. Resident sated he was going to the restroom without his assistive device this morning to get himself ready, when he lost balance and grabbed into the restroom's handrail and hit his (R) (right) ribon (rib on) [sic] the corner of the sink.During a review of Resident 1's CP dated 8/18/25, the CP indicated, (Resident 1) had an alleged fall on 8/18/25.Interventions.Continue interventions on the at-risk plan.5. During a review of Resident 1's PN dated 8/20/25 at 10:00 a.m., the PN indicated, Resident was found laying [sic] on his back on the floor facing the entrance door of the room. According to staff who witnessed the fall, resident was coming out of the restroom when he lost his balance and hang his hand on the corner of the neighbor's bed, turned around before slipping on the ground.Resident stated he got out of the restroom and slipped.During a review of Resident 1's CP dated 8/20/25, the CP indicated, (Resident 1) had an actual witnessed fall on 8/20/25 attempting to ambulate without assistance from bathroom.Interventions/Tasks.Send to acute (hospital) for evaluation and treatment as indicated.During a review of Resident 1's PN dated 8/20/25 at 8:43 p.m., the PN indicated, At approximately 1135 this writer assessed resident for pain and any delayed injuries due to fall. Resident reported experiencing pain in the (L) (left) leg and requested for pain pill.Notified (physician name) for breakthrough (medications that treats serious medical condition) RX (prescription) or possible send out to acute (hospital). MD (Doctor of Medicine) declined to give any more pain management and order received to send to (hospital name) for further eval, pain control and to rule out possible fracture.During a review of Resident 1's PN dated 8/20/25 at 8:49 p.m., the PN indicated, .At 7:30pm, this writer called (the hospital) again and got an update on resident who obtained a fracture on (L) hip and will be admitted .During a review of Resident 1's Imaging Report (IR-completed at the hospital) dated 8/20/25, the IR indicated Acute left femoral neck fracture extending to the lesser trochanter.During a review of Resident 1's History and Physical (H&P-completed at the hospital) dated 8/20/25, the H&P indicated, (Resident 1) is coming from a skilled nursing facility and has been evaluated in the past for recurrent falls.While he was at the skilled nursing facility, he states he tried to use the restroom on his own and had a fall. CT (computed tomography scan-imaging procedure that uses x-ray to create detailed images of internal organs, bones, and blood vessels) hip shows acute left femoral neck fracture extending to the lesser trochanter.Plan for surgical evaluation tomorrow.During a review Resident 1's Consultation Report (CR-completed at the hospital) dated 8/20/25, CR indicated, Reason for consultation narrative: left hip pain.patient is a.male who had a ground-level fall yesterday.He denies any pain except for the left side of his lower extremity.Plan.Patient is a.male with a rather vertical pattern of the femoral neck fracture. He has a subcapital (head of the bone) fracture that extends to the top of the lesser trochanter. Given that this is intracapsular (occurring within a capsule) and displaced (moved from its proper place), we recommend a hip hemiarthroplasty (surgical procedure to replace half of a joint).During a review of Resident 1's Discharge Summary (DS) dated 8/24/25 (four days after being admitted from the skilled nursing facility to the hospital), the DS indicated, Date of admission: [DATE].for left hip fracture status post (Resident 1's current condition) mechanical fall (fall caused by external, environmental factors) status post left hip hemiarthroplasty. Hip CT showed acute left femoral neck fracture extending to the lesser trochanter.patient had left hemiarthroplasty.During an interview on 9/5/25 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had prior falls, would not call for assistance, and would take himself to the bathroom independently.During an interview on 10/6/25 at 1:13 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 at the time of the fall (8/20/25). CNA 2 stated she was unaware Resident 1 was a fall risk and Resident 1 was on bowel and bladder retraining. CNA 2 stated Resident 1 would attempt to get up by himself and go to the bathroom, and she was unaware of any prior falls.During an interview on 10/6/25 at 2:33 p.m. with CNA 3, CNA 3 stated Resident 1 was a fall risk, and would go to the bathroom independently. CNA 3 stated she was not aware Resident 1 was on bowel and bladder retraining. CNA 3 stated when a resident was on bowel and bladder retraining it should show on the POC (point of care-used by CNAs to document and includes the Kardex that provides information on how to care for the resident) for the CNAs to document each time the resident was taken to the bathroom.During an interview on 10/6/25 at 2:39 p.m. with CNA 4, CNA 4 stated Resident 1 was a fall risk, and he was not on bowel and bladder retraining at the time of the fall (8/20/25).During an interview on 10/6/25 at 10:20 a.m. with Director of Nursing (DON), DON stated Resident 1 was placed on bowel and bladder retraining on 8/7/25 (13 days prior to the fall) due to Resident 1 falling on 7/27/25, 7/28/25, 8/6/25 when taking himself to the bathroom. DON stated when a resident was on bowel and bladder retraining the CNAs were required to physically take the resident to the bathroom and document it. DON stated the CNAs were made aware of the bowel and bladder retraining through the POC Kardex. DON stated the bowel and bladder retraining was appearing on the POC Kardex, but the task was not triggering for the CNAs to document each time Resident 1 was taken to the bathroom. DON During an interview on 10/14/25 at 3:38 p.m. with DON, DON stated at the time of the 8/20/25 fall the bowel and bladder retraining should have been ongoing. DON stated after 14 days the data collected was used to evaluate the effectiveness of the retraining and determine how Resident 1 was doing on bowel and bladder retraining. DON stated the bowel and bladder retraining was not implemented correctly on the POC prior to the 8/20/25 fall.During a review of the facility's policy and procedure (P&P) tilted, Care Plans, Comprehensive Person-Centered dated 3/22, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.the comprehensive, person-centered care plan.includes measurable objectives and timeframes.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.the interdisciplinary team (group of professionals from different fields who collaborate to work toward a common goal, sharing expertise and knowledge to provide comprehensive care or solve a problem) reviews and updates the care plan.when there has been a significant change in the resident's condition.During a review of the facility's policy and procedure titled Falls and Fall Risk, Managing dated 3/2018, the P&P indicated, Resident conditions that may contribute to the risk of falls include.delirium (state of confusion) and other cognitive impairment.if a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on interview and record review, the facility failed to notify the physician when one of two sampled residents (Resident 1) had blue discoloration to his left foot. This failure resulted in the facility being unaware of Resident 1's nondisplaced (bone fragments are in their original position) fracture (break in the bone) proximal (closer to the center) aspect proximal phalanx (toe bone) left first digit and a delay in care.Findings:During a review of the Progress Notes (PN) dated 8/11/25 at 10:26 p.m. (documented by Licensed Vocational Nurse (LVN) 3), the PN indicated, Resident is being monitored for s/s (signs and symptoms) of edema (swelling that occurs when fluid builds up in the body's tissues) to BLEs (bilateral lower extremities), will encourage resident to elevate legs. Denies pain and discomfort at this time. Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/12/25 at 12:03 p.m. (documented by LVN 2), the PN indicated, Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/12/25 at 8:26 p.m. (documented by LVN 2), the PN indicated, Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/13/25 at 3:12 a.m., the PN indicated, .blueish discoloration to the left foot. Will cont. (continue) to observe and evaluate for acute changes.During a review of the PN dated 8/13/25 at 12:38 p.m. (documented by LVN 1), the PN indicated, Edema noted to bilateral extremities and reddish in color. Discoloration also noted to toes on LLE (left lower extremity).During a review of the PN dated 8/13/25 at 5:49 p.m., the PN indicated, Resident's daughter in to visit. Requesting resident be sent to (hospital name) for evaluation of lower extremity edema and discoloration. MD notified and received order to send to ER (emergency room) for further evaluation and treatment as indicated.During a review of the Imaging Report (IR-from the acute hospital) dated 8/13/25, the IR indicated, .suspicious for nondisplaced (bone fragments that are in their original position) fracture (break in the bone) proximal (closer to the center) aspect proximal phalanx (toe bone) left first digit.During a review of Resident 1's emergency room Note (ERN) dated 8/13/25 at 6:39 p.m., the ERN indicated, Patient does have 2+ (swelling where the affected area retains fluid and leaves a visible indentation when pressed) bilateral lower extremity edema. Along with bruising on the right third toe and left 2-43 (sic) toe.Patient's foot x-ray that showed a nondisplaced proximal left great toe fracture.During an interview on 8/21/25 at 12:43 p.m. with LVN 1, LVN 1 stated the discoloration to Resident 1's left foot was noticed a couple of days before she returned to work from her days off. LVN 1 stated Resident 1 was monitored at the time it was discovered and then sent to the hospital.During a concurrent interview and record review, on 8/21/25 at 1:15 p.m. with Assistant Director of Nursing (ADON), Resident 1's PN's were reviewed. ADON stated bluish discoloration was documented to Resident 1's left foot on 8/11/25, 8/12/25 and 8/13/25. ADON was unable to provide documentation the physician was notified of the discoloration until 8/13/25. ADON stated when the discoloration was noted the physician should have been notified.During an interview on 8/21/25 at 2:20 p.m. with LVN 2, LVN 2 stated she did not recall notifying the physician of the discoloration to Resident 1's foot. LVN 2 stated when the discoloration was discovered the physician should have been notified. During an interview on 8/21/25 at 2:34 pm with LVN 3, LVN 3 stated she was aware of the discoloration to Resident 1's foot on 8/11/25 and did not notify the physician.During a review of the facility's policy and procedure (P&P) titled, Notification of Changes dated 2024, the P&P indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include.significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.clinical complications.

Based on interview and record review, the facility failed to follow Physicians Order (PO) for one of three sampled residents (Resident 1) when a follow up wound clinic appointment was not scheduled. This failure had the potential for Resident 1's wound to worsen. Findings: During a review of Resident 1's Discharge Activity Instructions ([NAME]), dated 4/29/25, the [NAME] indicted, Follow up at [clinic name] Wound Healing Clinic to resume grafix (skin graft) and wound vac (machine used for wound healing) therapy. During an interview on 5/28/25 at 1:30 p.m. with Wound Nurse (WN), WN stated Resident 1 was admitted on [DATE] from the hospital with multiple wounds including unstageable (depth and stage cannot be determined) to right buttocks and stage 3 (full-thickness loss of skin. Dead and black tissue may be visible) to left buttock and sacrum. WN stated she was not aware of Resident 1 having a follow up order at the wound clinic. During a concurrent interview and record review on 5/28/25 at 1:39 p.m. with Registered Nurse (RN), Resident 1's Order Summary Report (OSR), dated 5/1/25 was reviewed. The OSR indicated, order date 4/29/25 Follow up at [clinic name] Wound Healing Clinic to resume grafix and wound vac therapy. RN was unable to find documented evidence a follow up appointment was scheduled at the wound clinic for Resident 1. During a concurrent interview and record review on 5/28/25 at 1:59 p.m. with the Director of Nurses (DON), Resident 1's clinical record was reviewed. DON confirmed Resident 1 had a discharge order for a follow-up appointment at the wound clinic. DON was unable to find documented evidence a follow-up appointment was scheduled at the wound clinic for Resident 1. DON stated it was the facility practice to treat hospital discharge orders as physicians order. DON stated a follow up appointment at the wound clinic should have been made for Resident 1. During a review of the facility's policy and procedure (P&P) titled, Medication Orders dated 2025, the P&P indicated, c. Written Transfer Orders (sent with a resident by a hospital or other health care facility)-Implement a transfer order without further validation.

Based on interview and record review, the facility failed to follow its policy and procedure for a change of condition for one of three sampled residents (Resident 1) when a S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR-document used to notify the physician of a change of condition) was not completed, and Resident 1 was not monitored for a change of condition when experiencing a dislocated hip. This failure had the potential for staff to be unaware of Resident 1's worsening condition and the potential for a delay in care. Findings: During a review of Resident 1's Progress Notes (PN) dated 1/27/25 at 1:58 p.m., the PN indicated, Xray results received. The prosthetic (artificial body part) head is dislocated (joint that is no longer in proper alignment) superior (above another structure) to the acetabular cup (a prosthetic implant used in total hip replacement surgery to replace the natural acetabulum). No evidence of acute fracture or dislocation. [Physician name] made aware. New orders: Refer to [Physician name] . During a review of Resident 1's PN dated 1/29/25 (two days after the facility was aware of the dislocation) at 2:28 p.m., the PN indicated, T.O. (telephone order) noted by (Physician name) to send resident to ER (emergency room ) (Hospital name) for eval (evaluation) and treat as indicated to Rt (right) hip per family request. Resident and daughter R/P (responsible party) aware. During a review of Resident 1's PN dated 1/29/25 at 2:51 p.m., the PN indicated, Radiology Result.Resident c/o (complain of) pain d/t (due to) dislocation of prosthetic head of left hip arthroplasty (damaged parts of a joint are removed and replaced with artificial components). Resident has sustained no falls or trauma. Resident and family stated that resident has history of spontaneous dislocation, but it normally resets itself. Due to continued pain and dislocation, received order to send to ER for further eval and treatment. During a review of Resident 1's PN dated 1/30/25 at 7:36 a.m., the PN indicated, This nurse called (hospital name) for update. Resident was admitted to med (medical) surg (surgical) for left hip dislocation. Pending orthopedic surgeon (physician that treats disorders of the bones, joints, ligaments, tendons and muscles) consult. During a concurrent interview and record review on 4/22/25 at 2:31 p.m. with Director of Nursing (DON), Resident 1's PN's were reviewed. DON was unable to provide a completed SBAR and monitoring for Resident 1 regarding the dislocation. DON stated there should have been an SBAR completed when notifying the physician of the change of condition and Resident 1 should have been monitored for any changes. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status dated 2/2021, the P&P indicated, Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.The nurse will record in the resident's medial record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a detailed discharge summary. This failure had the potential for Resident 1 to be unaware of how to care for his wounds and the potential for the wounds to worsen. Findings: During a review of Resident 1's Order Summary Report (OSR-physicians orders) dated 12/1/24, the OSR indicated, L (left) back of heel diabetic ulcer (open sores or wounds on the feet of people with diabetes [high blood sugar]) 1.3 cm (centimeters-a unit of measurement) x 1.1 cm cleanse with wound cleaner, pay [sic] dry and swab with betadine.start date 8/21/24.unstageable pressure injury (pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin] where the depth and extent of the tissue damage cannot be determined) to L inner heel cleanse with wound cleaner and swab with betadine.start date 11/19/24.unstageable pressure injury to L medial foot cleanse with wound cleanser and swab with betadine.start date 11/19/24. During a review of Resident 1's Progress Note Details (PND-completed by the wound doctor) dated 12/5/24 (5 days before discharge), the PND indicated Wound Assessment(s).wound #3 left heel is a deep tissue pressure injury (injury where damage occurs deep within the soft tissues).and has received a status of not healed.wound #8 left Achilles (tendon that connects the calf muscles to the heel bone) is a diabetic ulcer (open sores or wounds on the feet of people with diabetes, usually on the bottom of the foot) and has received a status of not healed.wound #9 left, medial foot is a pressure ulcer and has received a status of not healed. During a review of Resident 1's Discharge Summary/Instructions (DSI) dated 12/10/24 at 10:52 a.m., the DSI indicated, Date of Discharge.12/11/24.skin condition.blank (no wounds were identified) .wound care supplies.blank (indicated no supplies were being used) .wound care instructions (if needed) .blank (indicating no wound care was needed) .patient/representative signature.blank (no signature) . During a concurrent interview and record review, on 4/22/25 at 2:31 p.m. with Director of Nursing (DON), DON reviewed Resident 1's DSI dated 12/10/24. DON stated at the time of Resident 1's discharge, Resident 1 was being treated for three wounds. DON stated the DSI did not contain any documentation regarding Resident 1's wounds or the wound care he was to receive. DON stated when Resident 1 was discharged the DSI should have contained the wound documentation, wound treatments and the resident or the person caring for him should have been educated on the wounds and signed the DSI prior to Resident 1 discharged . During an interview on 4/29/25 at 1:47 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident is for discharge home with wounds, the physician orders for the wound care should be discussed with the resident or the person that will be taking care of them and they are provided discharge instructions that are signed prior to discharging the facility. During a review of the facility's policy and procedure (P&P) titled Transfer or Discharge, Resident Initiated dated 10/22, the P&P indicated, Information Conveyed to Receiving Provider.All special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices.

Based on interview and record review, the facility failed to ensure physician's orders were followed for one of three sampled residents (Resident 1) when: 1. The physician was not notified when blood sugar results were greater than 400; 2. Antibiotics were not administered for osteomyelitis (bone infection). These failures had the potential for Resident 1 to experience adverse side effects such as delayed wound healing and the potential for wounds to worsen. Findings: 1. During a review of Resident 1's Order Summary Report (OSR-physician orders) dated 1/1/25, the OSR indicated, Humulin R (medication used to control high blood sugar).inject as per sliding scale: if 70-200 = 0 (units); 201-250 = 2; 251-300 = 4; 301-350 = 6; 351-400 = 8, subcutaneously (under the skin) three times a day for diabetes mellitus (chronic metabolic disorder characterized by high blood sugar levels, due to a deficiency in insulin production or the body's inability to effectively use insulin) hold if BS (blood sugar) < (less than) 70 or > (greater than) 400. Notify MD. During a review of Resident 1's OSR dated 2/1/25, the OSR indicated, Humulin R. inject as per sliding scale: if 70-150 = 0 (units); 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units, 351-400 = 10 units; 401+ = 12 units, subcutaneously three times a day for diabetes mellitus fingerstick prior to administration. Hold if BS <100. Notify MD if BS <70 or > 400. During a review of Resident 1's OSR dated 3/1/25, the OSR indicated, Novolin R.inject as per sliding scale: if 0-150 = 0; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units, 351-400 = 10 units; 401+ = 12 units, subcutaneously before meals for DM2 (diabetes mellitus type 2) fingerstick prior to administration. Hold if BS <100. Notify MD if BS <70 or > 400. During a concurrent interview and record review on 4/22/25 at 2:31 p.m. with Director of Nursing (DON), Resident 1's Medication Administration Record (MAR)'s dated 1/2025, 2/2025 and 3/2025, were reviewed. Resident 1's blood sugars were as follows: 1/20/25 6:06 a.m. 415 2/1/25 4:30 p.m. 445 2/13/25 4:30 p.m. 401 2/14/25 4:30 p.m. 456 2/16/25 6:00 a.m. 510 3/7/25 4:30 p.m. 413. DON was unable to provide documentation the physician was notified of the blood sugars greater than 400. DON stated the physician should have been notified when the blood sugar result was greater than 400. 2. During a review of Resident 1's OSR dated 1/1/25-1/31/25, the OSR indicated, ceftriaxone (medication used to treat infection) .use 2 gram intravenously (administered through the vein) every 24 hours for infection related to other chronic osteomyelitis, left ankle and foot.until 2/4/25. During a concurrent interview and record review on 4/22/25 at 2:33 p.m. with DON, Resident 1's 1/2025 MAR was reviewed. The MAR indicated Resident 1 did not receive ceftriaxone on 1/21, 1/22 and 1/28. DON was unable to provide documentation the medication was administered. DON stated when medication was administered the nurse was expected to document it in the medical record. DON stated if it was not documented there was no way to know if Resident 1 received the medication. During a review of the facility's policy and procedure (P&P) titled Diabetes - clinical protocol dated 11/2020, the P&P indicated, The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan.The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration. During a review of the facility's policy and procedure (P&P) titled Administering Medications dated 4/19, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview, and record review, the facility failed to ensure the therapeutic menu was followed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being served the incorrect dessert. Findings: During a review of Resident 1's Order Summary Report (OSR-physician orders) dated 4/1/25, the OSR indicated, CCHO (consistent carbohydrate diet for diabetes [condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels])/NAS (no added salt) diet. During a review of the Cooks Spreadsheet (CS) dated 4/22/25, the CS indicated, the CCHO diet was to be served vanilla mousse no chocolate chips. During a concurrent observation and interview on 4/22/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1's lunch tray was sitting on the over bed table. The lunch tray contained vanilla mousse pudding with chocolate chips. CNA 1 stated Resident 1 was provided pudding with chocolate chips. During an interview on 4/30/25 at 3:16 p.m. with Dietary Services Supervisor (DSS), DSS stated Resident 1 was on a CCHO/NAS diet and should not have been served the vanilla mousse with chocolate chips. During a review of the facility's policy and procedure (P&P) titled, Menu planning dated 2023, the P&P indicated, 1. The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. 2. Menus are written for regular and therapeutic diets in compliance with the diet manual.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided: 1. A restorative nursing program (program where restorative nursing assistants [RNA]-assist residents with performing exercises to maintain their ability to perform daily activities and tasks, impacting their quality of life and overall well-being and independence) from February 2024-December 2024. 2. Physical therapy (PT-exercises, massages and various treatments used to relieve pain, help you move better or strengthen weakened muscles) and Occupational therapy (OT-focuses on everyday tasks and activities that people value and need to do, such as self-care, work, play, and social participation) as ordered by the physician in August 2024 and December 2024. These failures resulted in a decline in Resident 1's bed mobility (ability to move around in bed, including scooting, rolling, and moving from lying to sitting and back) which can lead to a decline in Resident 1's ability to participate in daily activities of living (ADL's) and the potential for developing pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's Admission Record (AR) dated 3/26/25, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function).Type 2 diabetes mellitus without complications (condition in which the body has trouble controlling blood sugar and using it for energy).Personal history of transient ischemic attack (TIA-episode of nervous system (complex network of cells, tissues, and organs that controls and coordinates all bodily functions) dysfunction due to inadequate blood supply). During a review of Resident 1's Quarterly Minimum Data Set (MDS-resident assessment tool) dated 2/28/25, the MDS indicated, Brief Interview for Mental Status (BIMS-used to identify cognitive impairment) .08 (moderately impaired cognition-the ways people think, process information, and make judgments). 1. During a review of Resident 1's PT Discharge Summary (PDS) dated 2/27/24, the PDS indicated, Discharge Recommendations: discharge to restorative.Restorative Program Established/Trained = Restorative Bed Mobility Program.Prognosis (outcome of a disease) to Maintain CLOF (current level of function-how well a resident is currently able to perform everyday tasks and activities in their daily life) = good with consistent staff follow-through. During a review of Resident 1's Admission MDS dated [DATE], the MDS indicated, Restorative Nursing Programs.Number of days.0 (look back period 5/16/24-5/22/24) During a review of Resident 1's Quarterly MDS dated [DATE], the MDS indicated, Restorative Nursing Programs.Number of days.0 (look back period 8/15/24-8/21/24) During a review of Resident 1's PT Evaluation & Plan of Treatment (PEPT) dated 10/17/24 (approximately eight months after RNA program was recommended on 2/27/24), the PEPT indicated, Current Referral.Pt (patient) presents to therapy with significant deficits in bed mobility and functional transfers (safe and effective movement from one surface or position to another), as well as increased risk for falls (to move downward, typically rapidly and freely without control, from a higher to a lower level), immobility and further deconditioning (decline that occurs due to prolonged inactivity or reduced physical activity). During an interview on 3/24/25 at 11:17 a.m. with Director of Rehabilitation (DOR-a healthcare leader who plans, administers, and directs the operation of the rehabilitation program), DOR stated Resident 1 received PT services from 2/8/24-2/26/24 and when Resident 1 was discharged from PT services, there was an RNA (Restorative Nursing Assistant) program recommended by the physical therapist. DOR stated the facility's practice was for the PT to provide the nursing department the RNA program recommendations, nursing department was to input the physician orders and schedule the RNA program. DOR stated the RNA program recommended on 2/27/24 for Resident 1 was a bed mobility program designed to keep Resident 1 active, avoid general decline (like bed mobility and transfers) and help to minimize, decrease or prevent pressure ulcers. During a concurrent interview and record review on 3/24/25 at 12:21 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's clinical record was reviewed. LVN 1 stated when PT recommended Resident 1 for an RNA program on 2/27/24, it was the responsibility of the PT to enter the RNA program physician orders into the clinical record and it was her (LVN 1) responsibility to schedule the RNA program. LVN 1 was unable to provide documentation indicating the RNA program was provided to Resident 1 (2/27/24). LVN 1 stated there was no physician order for RNA program in the clinical record nor was there a record of the RNA program being provided. During a concurrent interview and record review on 3/25/25 at 3:24 p.m. with DOR, Resident 1's clinical record was reviewed. DOR was unable to locate the physician orders for the RNA program to be provided when Resident 1 was discharged from PT on 2/27/24. DOR stated the physician orders should have been entered in the clinical record by nursing and Resident 1 should have been provided the RNA program recommended on 2/27/24 to prevent/minimize resident from developing a pressure ulcer. During an interview on 3/26/25 at 12:14 p.m. with RNA, RNA stated she could not recall Resident 1 being provided an RNA program (2/27/24-12/2024). During a concurrent interview and record review on 4/1/25 at 3:55 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON was unable to provide documentation indicating RNA program was provided and there was no care plan (outlines specific healthcare needs, goals, and interventions for an individual resident) developed for RNA program. DON stated the RNA program was not provided when PT recommended it on 2/27/24. During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Services dated 7/2017, the P&P indicated, Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative (restore to a good condition or a useful and constructive activity) services.resident may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative services.restorative goals and objectives are individualized and are resident-centered, and outlined in the residents plan of care. 2. During a review of Resident 1's Order Summary Report (OSR-Physician's orders) dated 8/31/24, the OSR indicated, Occupational therapy evaluation and treatment as indicated.start date 8/29/24.Physical therapy evaluation and treatment as indicated.start date 8/29/24. During a review of Resident 1's OSR dated 12/31/24, the OSR indicated, Occupational therapy evaluation and treatment as indicated.order date 12/31/24.Physical therapy evaluation and treatment as indicated.order date 12/31/24. During a review of Resident 1's Quarterly MDS dated [DATE], the MDS indicated, .Functional Abilities and Goals.Functional Limitation in Range of Motion (ROM- extent and direction to which a joint can move).No impairment.roll left and right.02.sit to lying.03 (Partial/moderate assistance-helper does more than half the effort) .lying to sitting on side of bed.03. During a review of Resident 1's OT evaluation & Plan of Treatment (OTPT) dated 8/30/24, the OTPT indicated, Patient Goals: I wanted to get stronger as pt (patient) stated.Patient demonstrates good rehab (rehabilitation-restoring function) potential as evidence by ability to follow multi-step directions and motivated to participate. Focus on Plan of Treatment = Restoration.Reason for skilled services (specialized form of nursing) .patient presents with impairments in mobility and strength resulting in limitations and/or participation restrictions in the areas of self-care and general tasks and demands which requires skilled (treatment provided by licensed therapist) OT services to increase independence with ADLs (activities of daily living) and increase functional activity tolerance. During a review of Resident 1's Quarterly MDS dated [DATE] (three months after OT evaluation was completed and after the last MDS [8/21/24]), the MDS indicated, Functional Abilities and Goals .Functional Limitation in Range of Motion. 2 (impairment on both sides [a decline from MDS 8/21/24]) lower extremities (hip, knee, ankle, foot).roll left and right.01 (dependent -helper does all of the effort [a decline from MDS 8/21/24]).sit to lying.88 (not attempted due to medical condition or safety concerns).lying to sitting on side of bed.88. During a review of Resident 1's Significant change MDS dated [DATE] (three months after prior assessment 11/21/24), the MDS indicated, Functional Abilities and Goals.Functional Limitation in Range of Motion. 2 (impairment on both sides) lower extremities (hip, knee, ankle, foot).roll left and right.01 (dependent -helper does all of the effort).sit to lying.01.lying to sitting on side of bed.01. During a concurrent interview and record review on 3/25/25 at 3:24 p.m. with DOR, Resident 1's clinical record was reviewed. DOR stated Resident 1 had developed foot drop (condition where it is difficult or impossible to lift the front part of the foot, causing it to drag on the ground while walking, often due to nerve or muscle weakness) due to a TIA. During an interview on 3/26/25 at 11:38 a.m. with DON, DON stated she was made aware of Resident 1's decline during the investigation and stated physician orders were received on 8/29/24 and 12/31/24 for Resident 1 to be evaluated and treated by PT and OT to assess Resident 1 for a change in function and the need for therapy (PT/OT). DON stated Resident 1 did not receive a PT evaluation on 8/29/24 or 12/31/24 nor did she receive the PT and OT treatments that were ordered on 8/29/24 and 12/31/24. DON stated when Resident 1 was noted with a decline the nurses should have made her or therapy aware so the facility could get to the root cause of what was happening and intervene. DON stated somewhere between nursing and therapy communication fell between the cracks and nothing was put into place when Resident 1 declined and there should have been. During an interview on 3/27/25 at 10:36 a.m. with DOR, DOR stated Resident 1 had physician orders for PT and OT evaluations and treatment on 8/29/24 and 12/31/24. DOR stated Resident 1 received an OT evaluation on 8/31/24 but did not receive OT treatment or PT evaluation and treatment. DOR stated when the OT evaluation was completed a need for treatment was identified but due to Resident 1's insurance (provides financial protection against healthcare costs) not covering therapy treatment services, only the OT evaluation was completed. DOR stated Resident 1 was dropped from OT therapy on 8/31/24 and no PT services were provided. DOR stated RNA program should have been established to continue the bed mobility program and it would have prevented some of the decline in Resident 1's bed mobility. During a review of the facility's policy and procedure (P&P) titled, Functional Impairment - Clinical Protocol dated 3/2018, the P&P indicated, Upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident/patient's stay, the physician and staff will assess the resident/patient's function along with their physical condition.The staff and physician will identify individuals with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living (ADLs).The staff and physician will collaborate to identify a rehabilitative or restorative care plan to help improve function and quality of life and meet a resident/patient's goals and needs and attain other desired outcomes such as discharge to the community.Based on a review of available information (including results of the evaluation), the physician will determine if a resident/patient meets the criteria for skilled therapy services.The staff will monitor and document the resident/patient's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait, etc.) and will discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care.The physician will identify the subsequent relevance of therapy services, based on reviewing the resident/patient's progress relative to his/her care goals (e.g., functional stabilization or improvement) and the status of conditions and the current treatment regimen that have been identified as affecting his/her function.

Based on interview and record review, the facility failed to follow its policy and procedure on Care Plans, Comprehensive Person-Centered for one of three sampled residents (Resident 341) to reduce the risk of falls and minimize injuries. This failure resulted in Resident 341 falling multiple times in six months and sustaining a fracture (broken bone) to his left hip and left shoulder requiring surgical repair. Findings: During a review of Resident 341 Admission Record (AR) dated 4/2/24, the AR indicated, Resident 341 was admitted on [DATE]. Resident 341 diagnosis including metabolic encephalopathy (brain dysfunction caused by a chemical im-balance in the blood that affects the brain) difficulty in walking, and muscle weakness (generalized). During a review of Resident 341 Minimum Data Set (MDS- a resident assessment tool) dated 04/2/24, the MDS indicated, Resident 341 had significant cognitive impairment (problem with a person's ability to think, learn, remember, use judgement, and make decisions) with a Brief Interview for Mental Status (BIMS-assesses mental processes) score of 7 (score of 0-7 [significant impairment]). During a review of Resident 341 Fall Risk Evaluation (FRE) dated 4/4/24, the FRE indicated, Fall Risk Evaluation Score: 11.High Fall Risk. During a review of Resident 341 MDS dated [DATE], the MDS indicated, Resident 341 required partial /moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfer and toilet transfer. A. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with Director of Nursing (DON), Resident 341 Progress Notes (PN), dated 7/12/24 was reviewed. The PN indicated, IDT (group of professionals with different areas of expertise who work together to achieve a common goal).On 7/11/24 @ (at) 1:45 p.m. licensed nurse was notified by CNA (Certified Nursing Assistant) that (Resident 341) was observed on the floor in tv (television) room in front of sofa and w/c (wheelchair) was beside him.Recommendations: 72-hour nursing post fall review.72-hour neuro (neurological- to assess the function of the brain) checks, pharmacy IMRR (Interim Medication Regimen Review).rehabilitation post fall review.New Fall interventions: Physical Therapy (PT) to review (Resident 341) wheelchair brake management. There was no updated care plan noted on this fall incident (7/11/24). DON confirmed the findings and stated the care plan should have been updated after the fall incident. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 IMRR dated 7/12/2024, was reviewed. The IMRR indicated, Type of Review: Change of Condition.Fall.Recommendation.BMP (basic metabolic panel-a common blood test that can be used to screen for, diagnose, or monitor health conditions).TSH (thyroid stimulating hormone-blood test that measures the amount of TSH in the blood).BP (blood pressure).HR (heart rate).Check orthostatic (blood pressure taken when standing up from a sitting or lying position) BPS (blood pressures) Q (every) Shift X (times) 3 days. Notify MD (Doctor of Medicine) if resident experiences orthostasis (drop in blood pressure when standing). There was no evidence of the recommendations being implemented. DON confirmed the findings and stated the IMRR recommendations should have been implemented. B. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 Care Plan (CP) dated 7/18/24 was reviewed. The CP indicated, (Resident 341) had an unwitnessed fall with no injury on 7/18/24.Interventions.Monitoring for 72 hrs (hours) for any delayed injuries.Pharmacy IMMR.Rehab (Rehabilitation post fall evaluation) .Staff advised to do frequent (frequency not indicated) rounds on resident. There was no IDT noted and no evidence of the frequent rounds being implemented. DON confirmed the findings and stated there should have been an IDT conducted and DON was unable to provide evidence of frequent rounding. C. During a review of Resident 341 IDT-Interdisciplinary Post Event Note (IDT) dated 8/23/24 was reviewed. The IDT indicated, Two staff members notified this writer that resident was on his buttock on the ground floor of his restroom with noted urine on the floor.Date and Time of Event 8/22/24 7:45 p.m .New Interventions.neuro-check.Rehab (rehabilitation) Referral.Care Plan Revision. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 CP dated 8/23/24 was reviewed. The CP indicated, Resident sustained an unwitnessed fall w/o (without) injury on 8/22/24.Continue s/p (status post-shorthand term used to describe a patient's condition after a specific event or procedure) neuro check monitoring.monitor for any delay injuries & or pain.Notify MD of any changes. There were no new interventions implemented after the fall. The interventions indicated were the same as the fall incident on 7/18/24. DON confirmed the findings and stated the facility should initiate new interventions after the fall incident on 8/22/24. D. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 IDT dated 9/18/24 was reviewed. The IDT indicated, On 9/16/24 @ 2145 (9:45 pm) license nurse was notified of an observed fall and rushed to his side. He (Resident 341) was asked what happened and stated in that he did not know, and his back and head were hurting.CNA stated (Resident 341) was walking out of his room, his shoes were unbuckled, he started stumbling and lost his balance and before the CNA could intervene (Resident 341) fell and hit his head on the tile.Date and time of event 9:45 p.m.Injury Present.Yes.Indicate Injury.Resident noted to have two staples to his R (right) upper eyebrow, report also determined a contusion (bruise) to right elbow.New Interventions.Neuro-Check.Medication Review.Rehab referral. There was no CP developed or new interventions implemented after the fall incident on 9/16/24. DON confirmed the findings and stated there should have been a care plan developed and new interventions implemented after the fall incident on 9/16/24. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 IMRR, dated 9/23/24 (Medication review from fall incident on 9/16/24) was reviewed. The IMRR indicated, Type of Review: Change of condition.Fall.Recommendation.BMP.BP.HR.Check orthostatic BPS Q Shift X3 days. Notify MD if resident experiences orthostasis. There was no evidence of the recommendations being implemented. DON confirmed the findings and stated the IMRR recommendations should have been implemented. E. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 CP dated 9/22/24 was reviewed. The CP indicated, Resident had an unwitnessed fall with no suspected injuries on 9/22/24.Interventions.Assist resident to the restroom as needed.Maintain bed at a low safe position.provide pain management as needed.report abnormal vital signs and any complications to MD. There was no IDT completed after this fall incident on 9/22/24. DON confirmed the findings and stated there should have been an IDT completed after the fall incident on 9/22/24. F. During a concurrent interview and record review on 9/14/24 at 12:44 p.m. with DON, Resident 341 Change in Condition Evaluation (COCE) dated 9/28/24 was reviewed. The COCE indicated, The change in condition.Falls.9/28/24.Resident attempts to self-transfer from bed to chair and chair to bed. Resident should be monitored for attempting to transfer without assistance. The CP was not revised, there were no new interventions implemented and there was no IDT completed after the fall incident on 9/28/24. DON confirmed the findings. G. During a review of Resident 341 PN dated 10/4/24, the PN indicated, IDT.On 10/1/24 @ 9 p.m. this nurse heard a low cry for help. (Resident 341) was observed laying on the ground floor on his right side near the entrance to (Resident 341) room. He was wearing sweatpants that were around his knees and he was not wearing any shoes.@ 2300 (11 pm) (Resident 341) was receiving care and cried out in pain.was reassessed and observed guarding his left arm.Dr (Doctor). notified and directed he be sent to the ER (emergency room ) due to SP (status post) fall with pain to left upper extremity.Contacted ER.who stated that he is admitted with a fracture to the left femur (bone of the thigh) and left shoulder. During a review of Resident 341 History and Physical Report (H&P) (completed at hospital 1) dated 10/2/24, the H&P indicated, Patient is .year-old male with.history of recurrent fall who presented to the emergency room via EMS (emergency medical services) from SNF (skilled nursing facility) for unwitnessed fall.Assessment and Plan.Left shoulder displacement (not in alignment) & hip fracture.Recurrent unwitnessed fall. During a review of Resident 341 Imaging Report (IR) (completed at hospital 1) dated 10/2/24, the IR indicated, Patient fell today with injury to the left hip, left hip pain.Findings: acute (severe and sudden in onset) impacted (lodged or wedged) left sub-capital (fracture in the neck of the thigh bone) hip fracture. During a review of Resident 341 IR (completed at hospital 1) dated 10/2/24, the IR indicated, Left shoulder pain today.Impression: Impacted comminuted (bone broken into more than two pieces) fractures proximal (near the center) humerus (the bone of the upper arm). During a review of Resident 341's Consultation (CS) (completed at hospital 1) dated 10/2/24, the CS indicated, X-ray of the left shoulder was obtained. It revealed a fracture of the upper shaft of the left humerus with little impaction and mild displacement. X-ray of the left hip revealed subcapital fracture.Recommendations: Left hip surgical procedure was discussed. I explained that I will put a screw and the plate. During an interview on 10/14/24 at 12:44 p.m. with DON, DON stated after a fall incident It was the responsibility of the nurse to put in a short-term care plan and then within one business day an IDT should be held to discuss the root cause of the fall and determine an intervention to address the cause of the fall. DON stated a new intervention should be implemented after each fall and the recommendations from the IMRR should be implemented. During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/22, the P&P indicated, Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.When possible interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met. During a review of the facility's policy and procedure (P&P) titled Falls-Clinical Protocol dated 3/18, the P&P indicated, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling.and also reconsider the current interventions.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 1) was safely moved in bed by one Certified Nursing Assistant (CNA) while providing care. This failure resulted in Resident 1 rolling out of the bed, falling to the floor, and sustaining a fracture (broken bone) to the collar bone. Findings: During a review of Resident 1's Care Plan titled Activity of Daily Living (ADL), dated 9/26/21, the CP indicated, Bed mobility; extensive (resident involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) assistance. There was no documentation under approaches/plan the resident required two-person assistance with bed mobility. During a review of Resident 1 ' s CP dated, 11/12/22, the CP indicated, a CP for high risk for falls related to gait/balance, vision/hearing problems. The goals for this care plan indicated the resident will be free from falls. Interventions include: The resident needs a safe environment with (Specify: even floors free from spills and/or clutter; glare-free light, a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on the walls, and personal items within reach). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated, High Risk for Falls. 5. Motor control c. Poor balance. 5.a Notes: Res [Resident] is non ambulatory (not able to walk around). 2 person assist with transfers. During a review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment tool), dated 12/21/22, the MDS indicated under Brief Interview of Mental Status (BIMS - an assessment to determine a resident's cognition status) a score of 8 (moderately impaired cognition), and indicated under Section G (Functional Status- Activity of Daily Living Assistance), Resident 1 required extensive assistance with bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed) which means the resident is involved in the activity, with staff providing weight-bearing support and two-person physical assistance. During a review of the facility document, untitled, dated 1/23/23, indicated, On 1/21/2023 @ [at] 2127 [9:27 p.m.] [Resident 1] was being changed by [CNA 1] and while [Resident 1] was on her right side she rolled from the bed [to the floor]. [Resident 1] was assessed for any injury and then transferred from the floor back on to the bed. No s/s (sign and symptoms) of fx [fracture] noted. [Resident 1] verbalized feeling pain from the initial fall but denies pain afterwards . Physician has ordered follow-up with orthopedist (medical specialty focusing on injuries and diseases affecting bones, muscles, joints, and soft tissue). During a review of Resident 1's Xray Report, dated 1/23/23, the Xray report indicated, Right shoulder, findings Bones: Non-displaced (in which the bone cracks or breaks but retains its proper alignment) acute [not chronic]/subacute [rather recent onset or somewhat rapid change] fracture distal [further away from the center of the body] portion clavical [collar bone]. During a review of Resident 1 ' s Progress Notes (PN) dated 1/24/23, at 11:28 a.m. the PN indicated, [Resident 1] was being changed by CNA [1] and while resident was on the right-side resident rolled off the bed. [Resident 1] was assessed for any injury and then transferred from floor back on to the bed. During a concurrent interview and record review, on 3/27/23, at 9:10 a.m. with Minimum Data Set Coordinator (MDSC) 1, Resident 1's Late Loss ADL's, [activity of daily living] were reviewed. The Late Loss ADL (self-performance for bed mobility, transfer, eating and toileting) documentation indicates the amount of assistance a resident requires. The Late Loss ADL indicated the following for Resident 1's bed mobility: A. 1/21/23, [1:12 a.m.] - bed mobility score of 3 (extensive assistance required) - Resident involved in activity, staff provided weight bearing support (allowing the person to help support their weight), 2 - one-person physical assist. B. 1/21/23, [2:18 p.m.] - bed mobility score of 3 - Resident involved in activity, staff provided weight bearing support, 2 - one-person physical assist. C. 1/21/23, [10:40 a.m.] - bed mobility score of 2 (limited assistance required) - Resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight -bearing assistance, 2 - One-person physical assist. MDSC stated, the above is what the CNAs documented about the assistance Resident 1 required. During a concurrent observation and interview on, 1/25/23, 2:43 p.m. with Resident 1, Resident 1 was noted to have bruising approximately 6 centimeters (cm - unit of measurement) by 6 cm to her right shoulder. Resident 1 stated, I had a bad fall, I think they were changing me. They put me on my side, the next thing I knew I was on the floor. During an interview on 1/25/23, at 2:52 p.m. with CNA 1, CNA 1 stated, When I was changing her [Resident 1] I turned her onto her side to change her. Resident 1 was lying on her left side in the bed with her back to [CNA 1] who was standing on the right side of the resident's bed. She [Resident 1] started rolling by herself. She rolled off the bed. The resident rolled onto her right shoulder on the floor. CNA 1 stated, he was standing on the right side of the bed and the resident was on her left side. During an interview on 3/23/23, at 10:57 a.m. with CNA 1, CNA 1 stated, [Resident 1] was just a one-person assist from the beginning when I started working with her. CNA 1 [since 9/12/2022]. I was never told otherwise she was two-person assist with bed mobility. Usually when we would change her in bed, she's one-person assist. CNA 1 stated, he usually did not ask for assistance, we [staff] do it, one-person assist when changing her in bed. During an interview on 3/27/23, at 9:10 a.m. with MDS Coordinator (MDSC 1), MDSC 1 confirmed Resident 1 should have been a two-person assist with bed mobility based on the MDS section G. During an interview on 4/18/23, at 11:13 a.m. with CNA 1, CNA 1 stated, Resident 1 was a resident of the facility when the CNA started working at the facility (since 9/12/22). CNA 1 stated, No they did not tell me she was two-persons assist. During an interview on 5/8/23, at 3:15 p.m. with CNA 1, CNA 1 stated, Resident 1 had one side rail up on the right side of the bed on the day of the fall and no side rail on the left side of the bed. During a review of the facility policy and procedure titled Fall Prevention Program dated 6/1/22, indicated under Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Indicated under Policy Explanation and Compliance Guidelines: .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant (CNA 1) physically hit Resident 1 resulting in injuries to the resident's face, back of head, right hand and both arms. Findings: During a review of Resident 1's Face Sheet (FS), dated 12/27/2022, the FS indicated, Resident 1 was a [AGE] year-old male with a history of hypo-osmolality (low nutrients in the blood) and hyponatremia (low sodium), hypertension (high blood pressure), Schizophrenia (effects one ability to think), and a history of COVID - 19 (contagious respiratory infection), depression (mood disorder). During a review of the Minimum Data Set assessment (MDS - a comprehensive assessment tool) dated 11/16/2022, the MDS Section C, which assesses a resident's cognitive ability indicated the resident's Brief Interview for Mental Status (BIMs- an assessment to determine a resident's cognitive status) score was Seven which indicated the resident had severe cognitive impairment. The MDS assessment Section E which assesses a resident's behavior indicated Resident 1 had no behaviors. During a review of the facility document titled, Body assessment dated [DATE], at 10:45 PM, indicated, swelling to left periorbital area [left eye].swelling to nasal bridge, bruise, back of scalp 1 cm (centimeter - unit of measurement) x 1.5 cm.generalized bruising and ecchymosis (discoloration of the skin resulting from bleeding underneath) to BUE [bilateral upper extremities].1 cm skin tear to left back of hand.right back of hand 0.5 cm skin tear. During a review of the facility document, untitled, dated 12/29/2022, the document indicated, On 12/24/22, @ [at] 2245 [10:45 PM], the (licensed Vocational Nurse [LVN] 1) was at nursing station charting and was summoned by one of the CNA's [Certified Nurse Assistant 2] in 600 hall to see the resident . Upon observing [Resident 1] it appeared resident has swelling and redness to left periorbital (around the eye) area and bridge of the nose. [Resident 1] also had a skin tear to back of the right hand measuring 0.5 cm (centimeter- unit of measurement) and back of left hand measuring 1 cm. [Resident 1] also observed to have a laceration (a cut) on back of head measuring 1 cm x 0.5 cm. Generalized bruising noted to bilateral forearms. When [Resident 1] was asked what happened he stated that [NAME] Garcia beat the hell out of him. During an attempted interview on, 12/28/2022, at 3:12 PM, with CNA 1, CNA 1 stated, He was advised to wait for legal counsel . He was advised not to talk to anyone. During an interview on, 1/28/2023, at 10 AM, with Resident 2, Resident 2 stated, he heard what sounded like a belt whipping sound. Resident 2 was in the bedroom with Resident 2 at the time of the incident. During an interview on, 1/28/2023, at 2:12 PM, with LVN 1, LVN 1 stated, on 12/24/2022 at approximately 10:45 PM, when CNA 2 called LVN 1 to check the condition of Resident 1. LVN 1 proceeded to go down the hall to Resident 1's bedroom. LVN 1 observed Resident 1 was seated in his wheelchair outside his bedroom. LVN 1 stated, Resident 1 appeared to have bruising to his left eye and the left side of his nose. There was bruising to the back of both upper hands. LVN 1 stated, she noticed a laceration (cut) to the back of Resident 1's head. LVN 1 stated, when the police department arrived at the facility she remained in the room. Resident 1 informed the police that [NAME] Garcia used his fist on his face, and had a towel wrapped around his hand when he was hitting the resident's face. During an interview on, 2/2/2023, at 2:38 PM, with CNA 2, CNA 2 stated, it was around 10:30 PM, on 12/24/2022. Resident 1 was outside his bedroom CNA 2 went up to the resident and asked him to put his mask on. CNA 2 did not notice any injuries to the resident at this time. CNA 2 stated, she went into another room to assist a resident across the hall from Resident 1's bedroom. CNA 2 stated, it was around 10:45 PM she heard yelling, she heard someone say, Are you ready to be changed dumb ass. CNA 2 stated, she went outside to check. CNA 2 stated, she looked into Resident 1's bedroom and CNA 1 was in the room with Residents 1. CNA 1 was using one hand to hold on to Resident 1's wheelchair and the other hand was in the closet. She went back to the across the hallway from Resident 1's. CNA 2 stated she saw CNA 1 later exit Resident 1' bedroom and put linen into the dirty laundry hamper outside Resident 1's bedroom. CNA 2 stated, two to three minutes later she saw Resident 1 exit his bedroom. CNA 2 stated, she looked and glanced a second time at Resident 1, because Resident 1 face was so red, CNA 2 stated, WOW because the resident's face was so red, and Resident 1 had a cut under the left eye. The right side of Resident 1's face had a lump near the cheek, his hands were scratched up. CNA 1 stated, she ran to the nurses' station to get help. During a review of the Police Department Report dated 12/25/2022, the following was noted: [CNA 2] stated on 12/24/2022 at approximately 2240 hours (10:40 PM), [LVN 1] was working at the facility, beginning her shift. [LVN 1] stated at approximately 2245 (10:45 PM) hours, she was advised by a CNA, who she identified as [CNA 2], to come check on a [Resident 1], referring to [Resident 1], regarding an injury. [LVN 1] stated upon observing [Resident 1], she observed his left eye to have redness and was swollen, his nose to be red with a small laceration, and observed on his left hand in between his index finger and thumb had a small laceration. [LVN 1] stated all these injuries appeared to be fresh. [LVN 1] stated, she asked [Resident 1] what had happened, to which he stated a subject who he identified as [NAME] Garcia had 'beat the hell out of him.' [LVN 1] stated she asked [Resident 1] to elaborate on what he meant, to which [Resident 1] became agitated, [LVN 1] stated [Resident 1] stated, 'Do you know what it is to get your ass beat?' . [LVN 1] stated [Resident 1] then proceeded to the exit [facility] west exit, where she observed the back of his head to have a small laceration . [LVN 1] stated her supervisor, [Director of Nursing], asked her which CNA was in charge of the area where [Resident 1] was located, [LVN 1] stated it was [CNA 1]. [CNA 2] stated at approximately 2230 hours (10:30 PM), she came into work at the [facility]. [CNA 2] stated during this time, she was checking on her residents that stay in the in the west part of the hospital, including [Resident 1]. [CNA 1] stated she observed [Resident 1] in the nearby area and did not observe him to be injured, nor show any kind of distress. [CNA 2] stated at approximately 2240 (10:40 PM) hours, while she was checking on her residents in the hospital [nursing home], she observed a commotion coming from [Resident 1] room . [CNA 2] stated after she heard a commotion coming from the room, she looked in the room's direction, in which she stated she saw [Resident 1] in his wheelchair on the northeast end of the room, where [CNA 1] was holding [Resident 1's] wheelchair, leaning on its back two wheels up against the wall with his right hand and was digging through a nearby cabinet with his left hand. [CNA 2] stated during this time, she overheard [CNA 1] asking [Resident 1] in an aggressive manner, 'Are you wet? Do you need me to change your smelly ass?' [CNA 2] stated [CNA 1] observed her looking in his direction, to which [CNA 1] then closed the curtain, preventing her from looking in his immediate direction. [CNA 2] stated immediately after, she was no longer able to see [CNA 1] and [Resident 1] . [CNA 2] stated while [CNA 1] was outside, she then observed [Resident 1] step out of the room . [CNA 1] stated during that time, she observed [Resident 1] to have visible injuries to his face, and [Resident 1] appeared to be startled. [CNA 2] stated she asked [Resident 1] what had happened, to which [Resident] stated a subject who [Resident 1] identified as Garcia 'beat the s .t out of him.' [CNA 2] stated, [Resident 1] went back to his room as [CNA 1] walked back into the [Facility]. [CNA 2] stated, she observed [CNA 1] enter 603, collect [Resident 1's] dirty clothes, and store them outside of the room. [CNA 2] stated while [CNA 1] was exiting the [Facility], he stated to her, 'I know you're not going to say anything, but that m .f .r is going to get me caught up. He's putting my life in jeopardy. I hate that asshole.' [Resident 1] stated, 'I got beat up'.: [Officer] asked [Resident 1] if his body was still in pain, to which [Resident 1] stated it was . [Officer] asked [Resident 1] if he was able to provide a name for the subject who caused him injury, to which [Resident] stated it was '[NAME] Garcia. [Officer] asked [Resident 1] to describe the subject he identified as [NAME] Garcia, to which [Resident 1] stated he was a big guy, tall, works at the [Facility], was possibly Caucasian, and sees him on a frequent basis. [Officer] asked [Resident 1] if he observed the subject who had injured him and if he would be able to identify him, to which he stated he would. [Officer] asked [Resident 1] how the subject he identified as [NAME] had hurt him, to which [Resident 1] stated, his hands to punch his face . [Resident 1] stated he instructed Garcia to stop, to which he said no.[Resident 1] continued to state his face hurt during my investigation. On 12/25/2022 at approximately 1940 hours [7:40 PM], I contacted [CNA 1] regarding the incident from the day prior.[CNA 1] stated [Resident 1] is known to get irate when he does not get a cigarette, suing the incident as an example. [CNA 1] was placed into custody and escorted to the back of my patrol unit.I read [CNA 1] his rights per [NAME] in which he stated he understood and did not wish to speak without a lawyer. Narrative: On 01/03/[2023] [Officer] was assigned .I was briefed on this investigation as well as recent development regarding the passing away of [Resident 1]. At approximately 0918 hours [9:18 AM] made contact with [Resident 1's] next of kin. she was not made aware of the assault.I advised. of the requirement of an autopsy to rule out any trauma as an attribute to. [Resident 1's] death. On 01/06/[23] .Upon competition of the autopsy by [Coroner] noted there was evidence of trauma to the [Resident 1's] left eye, blood on the exterior of the rear of the decedents scalp. During a review of the facility policy and procedure (P&P) titled, Abuse Prevention/Prohibition, 11/2018, indicated, The Facility does not condone any form of resident abuse, neglect, misappropriation of the resident property, exploitation and/or mistreatment, and develops Facility policies, procedures, training programs, and systems in order to promote an environmental free form abuse and mistreatment.'Abuse' is defined as the willful infliction of injury.physical, or chemical restraint not required to treat the residents' symptoms, intimidation, or punishment with resulting physical harm, pain.'Physical Abuse' is defined as hitting, slapping, pinching, and/or kicking.Staff Training.Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include.Aggressive and/or catastrophic reactions of residents.Resistance to care.Outbursts or yelling out.

Based on observation, interview, and record review, the facility failed to immediately assess and notify the Attending Physician (AP) for one of two sampled residents (Resident 1) after a fall. This resulted in a delay in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During an interview on 12/22/21, at 10:05 AM, with Administrator and Director of Nursing (DON), Administrator stated on 12/12/21 Resident 1 had complained of right leg pain, Resident 1's AP was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator stated he did not know how Resident 1 had sustained a right [CONDITION(S)] until after the facility investigation. Administrator stated on 12/10/21, Resident 1 was found by Restorative Nursing Assistant (RNA), on the floor lying on his floor mat. RNA called for assistance, the Certified Nursing Assistant (CNA) responded, saw Resident 1 on the floor, thought he was sleeping, picked him up and placed him in bed. Administrator stated RNA and CNA did not report the fall to the on-duty Licensed Vocational Nurse (LVN). No body assessment was conducted on 12/10/21 after the fall. During an interview on 12/22/21, at 11:15 AM, with Director of Staff Development (DSD), DSD stated it was the facility's practice for staff to notify the LVN of all falls. DSD stated, They [staff] need to tell right away, they should never move them [resident], they need to wait for LVN to assess, and then help get them on the bed only if the LVN says so. During a concurrent observation and interview, on 12/22/21, at 11:34 AM, with LVN 1, in Resident 1's room, Resident 1 was observed lying in bed with eyes closed. LVN 1 stated Resident 1 was readmitted from the hospital after having a right hip surgery. LVN 1 stated on 12/12/21, Resident 1 had refused care, kept saying No it hurts. LVN 1 stated Resident 1 was very confused and was hard to determine the location of his pain but kept guarding his knee. LVN 1 stated Resident 1 was found on the floor on 12/10/21, but the fall was never reported and believes Resident 1's right [CONDITION(S)] was from the fall. LVN 1 stated anytime a resident is found on the floor, we [LVN] need to go do a body assessment, do COC [change of condition], and notify MD [medical doctor]. During a concurrent interview and record review, on 12/22/2021, at 11:34 AM, with LVN 1, after reviewing the clinical record of Resident 1 she validated on the day of the incident (12/10/21) there was no documented evidence a physical assessment of Resident 1 was completed and validated the LVN assigned did not notify the AP on 12/10/21 of the fall. During an interview on 12/22/21, at 12 PM, with RNA, RNA stated on 12/10/21 at approximately 2:45 PM, she was passing out the afternoon snacks when she saw Resident 1 lying on his right side on the floor next to his bed, his face was towards the closet. RNA stated CNA responded to her call for help and moved on to passing the rest of the afternoon snacks to other residents when CNA stated, yeah I got this. RNA stated she assumed CNA had notified the LVN of Resident 1's fall. RNA stated, For any fall, we always let the nurse know. Nurse must assess first before we can do anything. We don't move the resident at all unless the nurse says it's ok. During an interview on 12/22/21, at 12:09 PM, with Director of Nursing (DON), DON stated CNA should have reported the fall right away. During an interview on 12/23/21, at 10:40 PM, with LVN 2, LVN 2 stated it was the facility practice for LVNs to be notified of any fall. LVN 2 stated after a fall, the resident is assessed, MD is notified, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 2 stated, LVN is always made aware. Assessment is to be done right away. During an interview on 12/23/21, at 10:55 PM, with CNA, CNA stated, he had arrived to work on 12/10/21 for PM shift, when he heard RNA calling for assistance in Resident 1's room. CNA stated, When I got to his [Resident 1] room, he was lying on his right side, on the floor, curled up like he was sleeping. CNA stated he called Resident 1 by his name and asked for Resident 1 to stand up. CNA stated Resident 1 stood up and helped him back into bed. CNA stated, I totally spaced out when it (fall) happened, and I didn't tell the nurse. I should have told the nurse right away. During a review of Resident 1's Right Hip x-ray dated 12/12/21, the result indicated a right [CONDITION(S)]. During a review of Resident 1's Interdisciplinary Team (IDT) note dated 12/14/21, at 11:50 AM, the IDT indicated An investigation was completed and it was identified through staff interviews that on 12/10/21 @ [at] apx.[approximately] 2:45 p.m. a CNA observed [Resident 1] on the floor in his room. She immediately notified another CNA who stated that he would take care of it. The CNA stated that he saw [Resident 1] sleeping on the floor by his bed, assisted him up and back in to [sic] bed. He further stated that he did not notify the nurse of the fall. During a review of the hospital's Operative Report, dated 12/15/21, the report indicated, Resident 1 had sustained a displaced fracture (misaligned broken bone) of the right hip which required an open reduction internal fixation with trocanteric fixation nail Synthes implant (surgery which places screws to fix the broken bone). During a review of the facility's P&P titled, Falls-Clinical Protocol, dated 3/18, the P&P indicated, Assessment and Recognition 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for changes in normal range of motion, weight bearing, etc,;. 5. The staff will evaluate and document falls that occur while the individual is in the facility: for example, when and where they happen, any observations of the events, etc. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/17, the P&P indicated, 1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a(an): a. accident or incident involving the resident; d. significant change in the resident's physical/emotional/mental condition.