Every finding on record at Springfield Villa

Based on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times when staff failed to air dry dishes, failed to wear hair/beard nets appropriately, failed to ensure the hood above the cooking area was clean, and when staff did not ensure a proper air gap for drain hoses/pipes. These failures had the potential to affect all residents. The facility census was 118.1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following:-Items must be allowed to drain and to air-dry before being stacked or stored;-Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow.Review of the facility's policy titled General Dish Room Sanitation, dated May 2015, showed the following:-All items are to be air dried. No moisture can be found on any stacked item;-If a fan is used to cause air flow, it cannot be directed at the clean dishes;-All items must be stored inverted, covered, or stacked with top of dish/tray inverted.Observation on 04/13/26, beginning at approximately 9:00 A.M., showed the following:-Wet dishes stacked on the tray:-A total of 30 small, clear juice cups stacked upside down on a tray with no liner or possible air flow, trapping water inside the cups;-A total of 69 small, white bowls stacked upside down on a tray with no liner or possible air flow, trapping water inside the bowls. Observation on 04/17/26, at approximately 9:35 A.M., showed the following:-A total of 19 plastic soup bowls stacked upside down on a tray with no liner or possible air flow, trapping water inside the bowls;-A total of 30 small, clear juice cups stacked upside down on a tray with no liner or possible air flow, trapping water inside the cups. During an interview on 04/17/26, at approximately 11:45 A.M., Dietary Aide (DA) J said the following:-Dishes should be air dried before being put away;-None of the dishes should be wet when they are stacked;-He tried to make sure dishes are dried before putting any of them away.During an interview on 04/17/26, at approximately 1:45 P.M., DA F said dishes were not to be stacked wet.During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager (DM) said he/she did know that dishes could not be stacked while still wet.During an interview on 04/17/26, at approximately 2:35 P.M., the Director of Nursing (DON) said the following:-Dishes are not supposed to be stacked while still wet and have no air flow;-This can cause bacteria to grow on the surface;-All dishes need to be completely air dried and then they can be put away.During an interview on 04/17/26, at approximately 5:35 P.M., the Administrator said the following:-Dishes should never be stacked when they are still wet;-He/she understands that bacteria growth could occur.2. Review of the FDA 2022 Food Code showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens, and unwrapped single-service and single-use articlesReview of the facility's policy titled Dietary Personnel Guidelines, dated May 2015, showed hairnets or bouffant disposable caps should be always worn and should cover the entire head.Observation on 04/13/26, at approximately 1:15 P.M., showed the following:-The Administrator entered the kitchen without a hairnet or beard net;-He/she walked through the kitchen and into the Dietary Manager's office and shut the door;-At approximately 1:20 P.M., the Administrator walked back through the kitchen to exit the kitchen;-Each time he/she went through the kitchen, he/she was in close proximity to where food was served out daily by walking past the front-side of the steam table.Observation on 04/15/26, at approximately 11:00 A.M., showed DA J was in the kitchen putting away clean dishes and had no beard covering on his/her facial hair.During an interview on 04/17/26, at approximately 11:45 A.M., DA J said the following:-He/she knew to wear a beard covering;-He/she forgot today.During an interview on 04/17/26, at approximately 2:00 P.M., [NAME] G said the following:-He/she does not go without a hairnet;-If he/she sees another staff not wearing one, he/she will remind the person and then it is taken care of.During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager said the following:-Anyone in the kitchen is required to wear hairnets, including beard coverings;-If someone comes into the kitchen, that is not kitchen staff, they should not pass the markings at the door, without a hairnet.During an interview on 04/17/26, at approximately 2:35 P.M., the DON said anyone going into the kitchen needs to wear a hairnet.During an interview on 04/17/26, at approximately 5:35 P.M., the Administrator said the following:-Staff are required to always wear hairnets and beard coverings when in the kitchen;-Anyone working with food needs to have hair coverings.3. Review of the facility policy titled Stoves, Guidelines for Hood Filter Over Stove, dated May 2015, showed the following:-The screen will be cleaned monthly, and interior/exterior of exhaust hood will be cleaned monthly;-Remove screens from over stove and wash screens in a heavy-duty degreaser;-Use a brush to scrub the screens, dip in hot sanitized water, rinse;-Remove and let screens air dry;-Cleaning the screens is done weekly;-Spray the interior of the hood with a degreasing agent;-Wash interior of the hood with detergent solution to remove the degreaser, rinse thoroughly;-The outside of the hood is cleaned daily with a clean cloth.Observation on 04/13/26, beginning at approximately 9:00 A.M., showed the following:-The hood over the gas stove was covered in a thick, greasy buildup, that was mixed with cobwebs or lint;-The top rim, edging the hood was covered in the grease and cobweb/lint buildup, and food splatters.During an interview on 04/17/26, at approximately 1:20 P.M., [NAME] G said the following:-He/she will clean the stove and oven and other appliances but does not clean the hood on a regular basis;-This should be done by the dishwasher.During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager said the following:-He/she had removed the screens and cleaned them before, but it had been too long since the hood had been cleaned;-He/she did not know how long it had been since the hood had been cleaned. 4. Review of the FDA 2022 Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing, fixure, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).Review showed the facility did not provide a policy regarding air gaps.Observation on 04/13/26, beginning at approximately 9:00 A.M., showed the following:-A drainpipe, approximately 6 to 8 wide, coming out of the floor and located behind the ice machine (left of the counter where the sink is located) with no air gap with the pipes over it; -There were drainpipes coming out of the ice machine and the sink, that went directly to the drainpipe;-The drain from the ice machine and the drain from the sink both lay directly on top of the drainpipe, with no air gap in between;-All the pipes were covered in a black, slimy substance, from where they touch to approximately 3-4 inches onto the pipes.Observation on 04/13/26, at approximately 1:05 P.M., showed in the vending machine room, a counter-top ice machine sat on the right edge. The drainpipe came out the back of the ice machine, going into a drain pan. The drain pan was the shape of a loaf pan, approximately 5 inches by 6 inches and made of metal and connected to the side of the cabinet, where the ice machine sat. The drainpipe lay directly in the drain pan, which was overflowing. The drainpipe sat in approximately 2 inches of stagnant water and touching the side of the drain pan, with no air gap in between.During an interview on 04/17/26, at approximately 2:00 P.M., [NAME] G said there was supposed to be an air gap for all pipes, where they are close to each other.During an interview on 04/17/26, at approximately 2:20 P.M., the DM said he/she did not know about the required air gap.During an interview on 04/17/26, at approximately 3:20 P.M., the Maintenance Director said the following:-The pipes behind the counters or going into the drains are cleaned monthly;-Staff noticed there was no air gap, but they thought the pipes were correct.During an interview on 04/17/26, at approximately 5:35 P.M., the Administrator said the following:-It was brought to his/her attention that there was no air gap, as required, for the ice machines and one of the kitchen sinks;-He/she had assumed that the pipes were okay and was not aware of any potential problems;-He/she understood that there is a possibility of bacterial growth occurring.

Based on interview and record review, the facility failed to have a policy in place that addressed the quantity of emergency water to be kept on-site and failed have a supply of emergency water on-site. The facility census was 118.Review of the facility's policy entitled, Emergency Water, undated, showed the following:-To ensure safe water for residents, staff, and visitors during a crisis, our facility maintains:-An emergency water supply that is suitable and accessible;-An emergency water supply consistent with applicable regulatory requirements; and-Methods for water treatment when supplies are low;-A corporation provides emergency water supply in the event it is needed. Review of the facility policy titled Emergency Water Source, undated, showed the following:-Verbal communication is acceptable;-Specific companies are contracted to provide 500 gallons of bottled water per day in the instance of an emergency;-The purpose of the guideline is to ensure that there will be adequate water supply on hand to supply residents with water for their personal and hygienic needs;-In the event of a water supply shortage, water will be brought in and dispensed as needed. Water will be boiled or treated according to the Department of Health recommendations, as needed for ingestion or other usage;-Local water can be obtained immediately by individual transport, from the local grocery stores, local pharmacies, gas stations, and any area store that sells water;-The nearby corporate facilities will transport needed water by van or individual vehicles, immediately upon phone calls requesting water assistance;-The facility will determine the amount of water based on information from the Centers for Disease Control (CDC) and World Health Organization (WHO), which recommends 1-2 gallons of potable water per resident and employee per day;-The amount of bottled water needed will depend on the option of boiling and treating water in the facility;-The amount of 1-3 (average 2) gallons of potable water will be considered to ensure water for drinking, cooking and treatments (i.e.: if the facility has 60 residents and 20 employees a day, with the average of 2 gallons for both, this will require 160 gallons of potable water a day, approximately);-The facility should have agreements with outside vendors to provide the determined amount of water in an emergency water supply outage;-Services will be provided within 1-2 hours after request is made, but will depend on the road conditions and access to the facility;-Services will be provided until the emergency has been resolved. 1. During an interview on 04/13/26, at approximately 9:45 A.M., the Dietary Manager said the following:-He/she was unsure where the emergency water is located;-He/she said it may be kept at a storage building for all facilities. During an interview on 04/17/26, at approximately 1:20 P.M., Dietary Aide (DA) E said he/she did not know where any emergency water might be kept. During an interview on 04/17/26, at approximately 1:45 P.M., DA F said he/she did not know where any emergency water was located and had never seen any. During an interview on 04/17/26, at approximately 2:00 P.M., [NAME] G said he/she had not seen any emergency water anywhere at the facility but felt like they used to have some stored, somewhere, but could not remember. During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager said the following:-He/she was sure the facility used to have some, but was no longer familiar with where it may be kept;-He/she was uncertain if the facility has emergency water any longer kept on-site;-If they are keeping emergency water, he/she is uncertain where it is located or how much is required. During interviews on 04/13/26, at 8:45 A.M., and on 04/17/26, at 4:57 P.M., the Director of Nursing (DON) said the facility did not keep a supply of emergency water onsite. The facility had contracts in place for the delivery of emergency water. During interviews on 04/13/26, at 8:45 A.M., and on 04/17/26, at 5:20 P.M., the Administrator said the facility did not keep a supply of emergency water on site. The facility had contracts in place for the delivery of emergency water. The facility should have a supply of emergency water stored on site.

Based on record review and interview, the facility failed to implement policies to prevent possible abuse when staff failed to maintain documentation for a criminal background check (CBC) for one staff member (Certified Medication Technician (CMT) N). The facility census was 118.Review of the facility's policy entitled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following:-It is the policy to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license, and criminal background check;-A criminal background check will be conducted on all prospective employees using either the Family Care Safety Registry (FCSR - a database that includes a CBC check) or the facility's contracted independent investigation and consulting company. 1. Review of the CMT N's personnel file showed the following:-Hire date of 08/15/24;-Staff did not have documentation of a CBC completed. During an interview on 04/17/26, at 2:55 P.M., the Receptionist/Human Resources staff said he/she was responsible for completing the background, EDL, and Nurse Aide Registry checks prior to hiring an employee. He/she took over this duty from the previous facility administrator last year, after CMT N was hired. During an interview on 04/17/26, at 3:52 P.M., the Director of Nursing (DON) said the Receptionist/Human Resources staff was currently responsible for completing background checks for potential employees before they are hired. Orientation was not scheduled until the CBC results were received. During an interview on 04/17/26, at 2:52 P.M., the Administrator said they were unable to locate the documentation pertaining to a CBC for CMT N. The receptionist/human resources staff is responsible for completing the background checks prior to hiring an employee.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and sanitary in non-food contact areas when the ceilings, shelving, walls, and floors were not kept clean and in good repair. The facility census was 118.1. Review of the facility's policy, Guidelines for Ceiling Vents, Doors, Walls, and Ceiling, dated May 2015, showed the following:-Walls, doors, vents, and ceiling must be free from chipped and or peeling paint and must be kept in good repair;-Walls, doors, vents, and ceiling must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently;-The type of surface will determine the type of detergent and cleaning method, following manufacturer's directions.Review of the facility policy titled Guidelines for Cleaning cabinets, Drawers and Shelves, dated May 2015, showed the following:-Rinse shelves and drawers with a clean sponge or cloth, using detergent solution and hot water; -Use appropriate strength of solution for sanitizing;-Clean on a weekly basis, or more often if needed.Observation of the kitchen on 04/13/26, beginning at approximately 9:00 A.M., showed the following:-The vents coming out of the ceiling, above the dishwasher, had no covering;-The wall directly behind the stove, grill, deep fryer, and miscellaneous equipment, was discolored and covered with cobweb/lint buildup, as well as food splatters and stains;-The wall directly behind the dishwashing machine's drain area, was discolored and covered with cobweb/ lint buildup, and had food splatters and stains;-The wall directly behind the three-bin sink, was discolored and covered with cobweb/ lint buildup, as well as food splatters and stains;-The air conditioning unit, hanging from the ceiling in the dishwashing room, was discolored and with cobweb/ lint buildup; -The ceiling tiles directly above the metal shelving, holding serving supplies, were discolored and broken;-Exit signs above the back door, were covered in cobweb/lint buildup.Observation on 04/13/26, beginning at approximately 9:00 A.M., showed the following:-The metal shelving unit, next to the kitchen entrance, was covered with cobweb/lint buildup; -The cabinet over the hand washing sink was covered with cobweb/lint buildup.During an interview on 04/17/26, at approximately 11:45 A.M., Dietary Aide (DA) J said the following:-He/she tried to clean up the area during and after he/she worked;-There were not enough hours or enough people helping;-There were supposed to be two staff doing dishes. Right now it is just him/her and then only one staff worked the days he/she was off;-He/she did not know who was responsible for cleaning the higher areas.During an interview on 04/17/26, at approximately 1:20 P.M., DA E said the following:-He/she tried to keep the food surface areas, such as countertops clean and wiped down;-There is a list for chores, but no one used it. He/she kept his/her own working area clean.During an interview on 04/17/26, at approximately 1:20 P.M., [NAME] G said the following:-He/she thought whoever was doing the dishes, would be the one to clean the dishwashing area;-There used to be a cleaning schedule, but he/she did not know where it was now;-Everyone cleaned up their own area, where they had been working;-The deep-cleaning is not getting done because there are not enough staff and no one knows what their job is;-If someone is asked to do something, they will say, That's not my job, because no one has been told their job.During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager said the following:-Everyone was expected to clean up any messes as they are noticed;-Cleaning as it is seen or needed was the expectation;-The dishwashers are very busy, and they do a lot to keep that area going.During an interview on 04/17/26, at approximately 3:20 P.M., the Maintenance Director said the following:-He/she was sure there was a cleaning schedule that the kitchen staff followed, but was unsure of how they do any specific tasks;-If items are up high and require a ladder, he/she would be the one to clean that area;-Ceiling vents and dirty ceiling tiles would be cleaned by maintenance;-He/she had not been in the kitchen for awhile;-He/she had not seen the kitchen's upper areas in a while nor been notified by any of the kitchen staff that any of these areas need attention.During an interview on 04/17/26, at approximately 5:35 P.M., the Administrator said the following:-If an area is up high or required a ladder, he/she would expect maintenance to handle the cleaning;-The areas up high, such as vents, air conditioning units, tall shelving or the ceiling itself, should be cleaned on a regular schedule. 2. Review showed the facility did not provide a policy regarding floor maintenance. Observation on 04/13/26, beginning at approximately 9:00 A.M., showed the following:-An unused electrical outlet and large metal casing for the cord, were coming out of the floor and had a coating on it including cobweb /lint buildup, and food splatters.-The floor in the dishwashing room was dirty with a build-up of grime and missing tiles under the dishwasher;-The floor under the stove was dirty with a build-up of grease and grime;-The floor between the stove and grill, and around the grill, was dirty with a build-up of grease and grime;-The floor between the grill and deep fryer, and around the deep fryer, was dirty with a build-up of grease and grime.During an interview on 04/17/26, at approximately 2:00 P.M., [NAME] G said the following:-The outlet coming out of the floor used to work for something that was there, but it has been like that for a long time;-He/she tried to keep the floor clean, especially where the food prep area is at and the stove and fryer.During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager said the following:-There is a cleaning schedule that has the floors listed, as a task, but it has not been used in a while;-The floors should be swept and mopped every day, following every meal.During an interview on 04/17/26, at approximately 5:35 P.M., the Administrator said the following:-If an area in the kitchen was dirty, he/she expected it to be cleaned daily, if needed;-This would include the floor being swept and mopped, following each meal and as needed.

Based on observation, interview, and record review, the facility failed to implement a complete and effective infection program when staff failed to follow Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent, these pathogens are frequently resistant to most available antimicrobial agents) that employs targeted gown and glove use during high contact resident care activities) practices when providing wound care to three residents (Residents #4, #72, and #2) and when providing foley catheter (tubing placed to drain the bladder to outside the body into a collection bag) care for one resident (Resident #89). A sample of 29 residents was reviewed for infection control during personal care. The facility census was 118. Review of Centers for Disease Control and Prevention' (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central line (a long, flexible tube inserted into a large vein in the chest, neck, or arm, with the tip ending close to the heart), urinary catheter (a thin, flexible, indwelling urinary tube inserted through the urethra into the bladder to drain urine continuously), feeding tube (a medical device used to deliver liquid food, fluids, and medications directly to the stomach or small intestine), tracheostomy (a surgical procedure that creates an opening, called a stoma, through the neck directly into the windpipe (trachea) /ventilator (a medical machine that helps a patient breathe or fully breathes for them)and wound care of any skin opening requiring a dressing. Review of the facility's policy entitled Enhanced Barrier Precautions to Infection Control Guidance, updated 3/2024, showed the following: -Purpose to prevent broader transmission of MDRO and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; -Residents known to be infected or colonized with a MDRO; residents with an indwelling medical device including the following: central venous catheter (tubing inserted into a blood vein for long-term access, medication, nutrition or blood tests), urinary catheter, feeding tube (PEG tube, G-tube), tracheostomy/ventilator regardless of their MDRO status; and resident with a wound, regardless of their MDRO status require EBP: -Use EBP when providing high-contact resident care activities such as bathing/showering; transferring resident from one position to another; providing hygiene; changing bed linens; changing briefs or assisting with toileting; caring for or using an indwelling medical device; and performing wound care; -Conduct proper hand hygiene before starting care; -Gloves and donning/doffing of gown are required when conducting high-contact resident care activities that are listed above. Gloves and gowns should be removed and discarded after each resident care encounter; -Residents with a wound or indwelling medical device and excretions or secretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO should be placed on contact precautions unless or until a specific organism is identified; -Secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for environmental contamination and risk of transmission of a pathogen; -EBP should be followed when performing transfers or assisting during bathing in a shared/common shower and when working with residents in the therapy gym (specifically, when anticipating close contact while assisting with transfers and mobility); -Residents that are placed on EBP should have PPE (personal protective equipment; such as gloves, gowns, masks) in close proximity outside the door and a trash can in residents' room for disposal prior to leaving the room; -Multi-resident medical equipment must be sanitized between resident uses. 1. Review of Resident #4's face sheet showed the following: -admission date of 05/09/25; -Diagnoses that included non-pressure chronic ulcer of right ankle, non-pressure chronic ulcer of part of right foot and Stage 3 pressure ulcer (full thickness tissue loss) of left thigh. Review of the resident's care plan, dated 05/09/25, showed the following: -Staff care plan resident's pressure ulcers; -Staff did not care plan related to EBP. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/16/26, showed the following: -Cognition was intact; -Had one Stage 3 pressure ulcer; -Had diabetic foot ulcers. During an interview on 04/15/26, at 2:38 P.M., Licensed Practical Nurse (LPN) L, wound nurse, said the resident had a wound on the left lateral thigh, left ankle, right lateral (outside of) foot, and an area on the right heel which was not open and put skin prep applied. Observation on 04/15/26, at 2:38 P.M., showed the following: -No protective gowns located outside or inside the resident's room; -LPN L took a bed pad and placed it on the sink counter top and then placed the wound supplies on the bed pad and placed several loose gloves on the sink countertop by the bed pad with the wound supplies; -LPN L washed his/her hands at the sink and put on gloves. The LPN did not don a gown; -The LPN L provided wound care; -Certified Nursing Assistant (CNA) M entered the room, put on gloves without washing or sanitizing hands, and did not put on a protective gown; -The LPN and CNA provided incontinent care and applied barrier cream; -CNA M removed gloves and washed hands and left the room; -LPN L removed gloves and washed hands before leaving the room. 2. Review of Resident #72's face sheet showed the following: -admission date of 08/22/24; -Diagnoses included indwelling urethral catheter (tubing placed to drain the bladder to outside the body into a collection bag) and pressure ulcer of sacral region. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Indwelling urinary catheter; -Ostomy; -One pressure ulcer present on admission; stage 4 (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures). Review of the resident's care plan, updated 02/02/26, showed the following: -Colostomy due to sacral wound; -Foley catheter due to recurring sacral wound; -admitted with pressure ulcer, Stage 3 to sacrum. (Staff did not care plan regarding EBP.) Observation on 04/13/26, at 10:47 A.M., showed signage on the resident's door indicating the need for EBP. Observation on 04/15/26, at 10:42 A.M., showed the resident lying in bed on his/her back. LPN T and LPN L washed their hands and donned gloves. The LPNs did not don protective gowns. LPN T turned the resident onto his/her right side. LPN L provided wound care. LPN L removed his/her gloves and sanitized his/her hands. 3. Review of Resident #89's face sheet showed the following: - admission date of 02/17/26; -Diagnoses chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), urinary tract infection (UTI - An infection in any part of the urinary system, the kidneys, bladder), obstructive (structural or functional blockage inhibiting normal urine flow ), and reflux uropathy (abnormal backward flow of urine from the bladder). Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Indwelling catheter; -Use of wheelchair; -Supervision or touching assistance for toileting hygiene, dressing, personal hygiene; -Partial to moderate assistance with showering. Review of the resident's care plan, updated 03/02/26, showed the following: -Resident was at risk for complications related to indwelling catheter; -Staff should change the catheter monthly and as needed; -Staff should drain urine, measure, record every shift and as needed using aseptic technique; -Staff should complete foley catheter care every shift and as needed. (Staff did not care plan related to EBP.) Observation on 04/13/26, at 11:30 A.M., showed the resident in his/her room in a wheelchair with catheter bag in a dignity bag under the chair. The resident's door had no sign related to EBP, there was no gown or gloves near the door or inside the resident's room. Observation on 04/15/26, 1:00 P.M., showed the resident in his/her room in a wheelchair with a catheter bag inside a dignity bag under the chair. The resident's door had no sign related to EBP, and there were no gown or gloves located near the door or inside the resident's room. Observation on 04/16/26, at 4:00 P.M., showed the following: -Resident resting in bed with eyes open;-CNA H entered resident room and washed his/her hands at the sink and talked with resident about the procedure; -He/she applied gloves and obtained wet wipes and opened resident's brief; -Wiped the inner thighs with a wet wipe and disposed of the wipe, -Wiped private area and catheter tubing with wet wipes using appropriate technique; -Disposed of wet wipes, closed the resident's brief; -Pulled sheet up over resident and removed gloves; -Washed hands at sink; -Removed trash and left the resident room; -He/she did not wear a gown during catheter and incontinent care. 4. Review of Resident #2's face sheet (brief resident profile sheet) showed admission date of 05/09/23. Review of the resident's physician's order sheet (POS), dated 03/18/26, showed a order for wound care. Review of the resident's care plan, reviewed/revised on 04/02/26, showed the following: -Resident had two, stage two pressure ulcers to left inner buttock and right inner buttock; -Provide treatments as ordered; -Apply moisture barrier as appropriate; -Clean and dry resident's skin after each incontinent episode; -Perform perineal care when incontinent; -Encourage adequate hydration to promote skin integrity. (Staff did not care plan related to EBP.) Observation on 04/16/26 at 12:50 P.M., showed the following: -The resident was in shower room. CNA U had gloves on and was not wearing gown. The wound care nurse washed her hands, put on gloves, and did not put on a gown; -The wound are nurse and CNA provided incontinent care and wound care; -CNA U and wound care nurse washed their hands at the sink. 5. During an interview on 04/16/26, at 4:15 P.M., CNA H said sometimes staff should wear a gown if the resident had wounds, but it was not needed during catheter care. He/she did not know any details about EBP. During an interview on 04/16/26, at 4:25 P.M., LPN I said there currently were no residents on the memory care unit that required EBP. He/she said that a gown and gloves were required during personal cares for residents with open wounds, catheters, feeding tubes, or any type of infection. Gowns were typically used when working with a resident who was on isolation precautions. During an interview on 04/17/26, at 12:05 P.M., Registered Nurse (RN ) C said that gowns and gloves should be worn when providing cares for residents that had a catheter, chronic wounds, or tube feeding. There should be a cart at the door with gowns and gloves for staff use. There would be a small sign on the door frame that stated EBP. During interview on 4/17/26 at 1:45 P.M, LPN K said the following: -EBP was protection for staff for residents who had catheters, wounds, feeding tubes since they were higher risk for infection, and certain illnesses; -If resident had a catheter, staff were to wear gloves and he/she would sometimes encourage staff to wear protective gown; -If resident had wounds, they were to always wear gloves, and wear gowns if needed. During interview on 4/17/26 at 3:35 P.M., LPN L said the following: -He/she would wear PPE (Personal Protective Equipment) such as gowns when a resident had any chronic wounds, a urinary catheter, ostomy; -A chronic wound was a wound that hadn't healed within three to six months ,or comes and goes, and had not improved; -If a resident had an open wound, he/she would wear a protective gown. During interview on 04/17/26 at 3:58 P.M., the Director of Nursing (DON) said the following: -Staff were to wear gown and gloves with EBP; -EBP was for any intravenous lines, tubes, devices, chronic wounds, and antibiotic resistant infections. -Residents #4, #72, and #2 had chronic wounds and staff were to wear a gown when doing cares and treatments with the residents; -Gown and gloves should be worn when providing direct cares to residents with MDRO infection, any type of inserted lines, tubing, devices, chronic wounds, and catheters. Supplies should be near the resident room for staff to put on a gown with cares. During interview on 04/17/26, at 5:25 P.M., the Administrator said the following: -Staff were to wear a gown and gloves when they entered a resident's room who was on EPB; -They were to do hand hygiene and put on gloves before cares and during cares, remove gloves, and do hand hygiene before leaving the room.

Based on observation, interview, and record review, the facility failed to ensure food served was palatable when staff served food that was tough and the food that was not an appetizing temperature. The facility census was 118. Review of the facility's policy titled Food Temperatures, dated May 2015, showed the following: -Keep the temperature of hot foods no less than 140 degrees Fahrenheit (F) during meal service; -Hot foods should be at least 120 degrees F when served to the residents; -Food is not held in warm ovens more than 30 minutes before meal service; -It is recommended that food not be held on the steam table for longer than two hours before meal service; -Food items such as soup and pureed foods are never portioned ahead of time due to losing temperature; -Food carts are delivered immediately to the special care unit. 1. During the Resident Council Meeting on 04/14/26, at approximately 11:00 A.M., Resident #83 said the meat was hard as a rock. There were a few items that were okay, but the food was not very good. Observation on 04/14/26, at 5:10 P.M., in the memory care unit, showed the following: -Staff placed meal trays on the table for residents in the dining room; -The meal provided included pork chop, onion rings, mixed vegetables, bread, and pears; -Staff assisted residents to cut meat using a fork and spoon; -The meat was very tough to cut with only the fork and spoon and staff struggled to cut meat into bite size pieces for the residents; -Staff were holding the fork and spoon at the base of the silverware with their hand touching food at times due to struggling to cut the meat. During an interview on 04/14/26, at 5:30 P.M., Certified Nurse Aide (CNA) AA said that the kitchen does not send any knives to the memory care unit, not even a knife for the staff to use when cutting up resident food. Tonight's meat was difficult to cut with only a fork and spoon. Observation on 04/14/26, at 5:30 P.M., showed Resident #45 requested assistance to cut up his/her pork chop. Licensed Practical Nurse (LPN) CC exhibited difficulty cutting the meat using a fork and knife. During an interview on 04/14/26, at 6:50 P.M., Resident #14 said the pork chop served for dinner could have been used as a hockey puck and the vegetables were so overcooked and mushy that he/she could have sipped them through a straw. 2. During the Resident Council Meeting on 04/14/26, at approximately 11:00 A.M., residents in attendance said the following: -Resident #83 said the food was stone-cold. They did used to request the food to be reheated, but no longer does so, as staff act as if they are put out; -Resident #101 said he/she used to eat in his/her room but no longer does. It is partially because the food was cold when delivered to the rooms. He/She had never received a hot meal at the facility. There were a lot of bad meals. Observation on 04/15/26, at approximately 1:30 P.M., showed the following: -A lunch meal test tray from the hall service was tested; -The ham and beans had few ham or beans, was mostly broth; -The diced, fried-potatoes, temperature measured 118.2 degrees F and were undercooked; -The cabbage temperature measured 115.5 degrees F and was not seasoned. Observation on 04/16/26, at approximately 1:35 P.M., showed the following: -A lunch meal test tray from the hall service was tested; -Chili was bland; -Hot dog on bun, temperature measured as 115.8 degrees F; -Corn fritter, temperature measure as 119.9 degrees F. 3. During an interview on 04/15/26, at 10:45 A.M., Resident #2 said: -The food does not taste good; -The food does not have any flavor. During an interview on 03/13/26, at approximately 12:45 P.M., Resident #117's family member said the following: -He/She came every other day to visit the resident and had lunch with him/her each visit. -The food was not very good; it's plain, never seasoned and is almost always overcooked. -If the resident is served cold food, he/she will not ask anyone to reheat the food; -Staff have an attitude and it's obvious that it makes them feel inconvenienced when asked. During an interview on 04/17/26, at approximately 1:20 P.M., Dietary Aide (DA) E said the following: -He/she had heard the residents complain that the food was not hot enough or the meat was too tough; -The food gets out to the halls timely, but then they just sit there; -Many of the residents have spoken to him/her about the food; -Most are not very happy with it. He/she can tell by how many plates are still covered in food. During an interview on 04/17/26, at approximately 1:45 P.M., DA F said the following: -Food complaints were constant from the residents: too cold and too tough; -The food does come out of the kitchen late sometimes, but it is hot. The hall trays lose heat because they sit in the hall for an hour or longer. During an interview on 04/17/26, at approximately 2:00 P.M., [NAME] G said the following: -They will send out the hall trays but then they are not delivered to the room and sit in the hall for a long time; -Residents do complain about food being cold but they know why it is cold because they see the trays just sitting and they have complained about it. During an interview on 04/17/26, at approximately 2:20 P.M., the Dietary Manager said the trays get made up ahead of time and are still warm, but the hall aides don't pass the trays fast enough, so the food becomes cold. During an interview on 04/17/26, at approximately 2:35 P.M., the Director of Nursing said he/she had been watching the serve-out of meals this past week and has seen trays sitting longer than preferred. During an interview on 04/17/26, at approximately 5:35 P.M., the Administrator said the following: -It is expected that food is seasoned and has a pleasant taste; -It is expected that temperatures are met, to keep plates warm and to the resident's preference.

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when staff failed to maintain sink hot water temperatures between 105 and 120 degrees Fahrenheit (F) in four resident rooms (rooms 100, 102, 103, and 106) increasing the risk of burns due to hot water and when staff failed to ensure smoking materials and lighters were secured for one resident (Residents #28). The facility census was 118. Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when staff failed to maintain sink hot water temperatures between 105 and 120 degrees Fahrenheit (F) in four resident rooms (rooms 100, 102, 103, and 106) increasing the risk of burns due to hot water and when staff failed to ensure smoking materials and lighters were secured for one resident (Residents #28). The facility census was 118. 1. Review showed the facility did not provide a policy pertaining to water temperature range. Review of the United States Consumer Product Safety Commission (CPSC) document Avoiding Tap Water Scalds, dated 03/2012, showed the following: -Most injuries involving tap water scalds are to the elderly and children under the age of five; -The CPSC urges all users to lower their water heaters to 120 degrees F; -Most adults will suffer third-degree burns if exposed to 150 degrees F water for two seconds; -Burns will also occur with a six-second exposure to 140 degrees F water or with a thirty second exposure to 130 degrees F water; -If the temperature is 120 degrees F, a five-minute exposure could result in third-degree burns. Observation on 04/14/26 showed the following hot water temperatures in the residents' sink : -At 6:15 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 123.4 degrees F; -At 6:17 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 124.3 degrees F; -At 6:20 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 124.5 degrees F; -At 6:22 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 124 degrees F. Observation on 04/15/26 showed the following hot water temperatures in the residents' sink: - At 4:17 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 124.3 degrees F; - At 4:19 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 122.9 degrees F; - At 4:22 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 124.5 degrees F; -At 4:24 P.M., the hot water in resident occupied room [ROOM NUMBER] measured 124.2 degrees F. Observation on 04/16/26, at 3:05 P.M., showed the hot water heater in the closet on the 100 hall set at just below 130 degree temperature. During interviews on 04/16/26, at 3:00 P.M. and 4:30 P.M., the Maintenance Director said the following: -He/she chose two rooms per hall to check the hot water temperatures and does this on a monthly basis; -It was the facility policy that hot water was 05 degrees to 120 degrees F. The hot water was not to be over 120 degrees F. During interview on 04/17/26 at 5:20 P.M., the Administrator said he would expect staff to maintain the hot water temperatures between 105 degrees to 120 degrees F range. 2. Review of the facility's admission Packet Resident Rules and Regulations showed for safety reasons, the resident and any visitor to this facility is hereby advised not to smoke except under supervision and/or in designated smoking areas. Residents may not retain matches or lighters. Review of the facility's Independent Smoking Policy, dated 06/16/25, showed the following: -Current independent smokers who are found appropriate to independently smoke by completing the smoking assessment will be allowed to keep their cigarettes in a lock box assigned to them individually in their room. The resident will have an assigned key that the resident will be responsible for; -New residents that are admitted in the building will need to provide their own lock box and key; -Residents who are independent will need to continue to check out a lighter from the nurses' station. Annually and after a change of condition the resident will be reassessed through the smoking assessment to ensure safety; -Signature lines were indicated for the resident and a witness. 3. Review of Resident #28's face sheet (gives basic profile information) showed the following information: -admission date of 04/06/26; -Diagnoses included fracture of lower spine and pelvis, multiple fractures of ribs, traumatic pneumothorax (partial or complete lung collapse caused by air entering the surrounding space due to chest injury), depression, anemia due to blood loss, anxiety, and postprocedural pain. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 04/22/26, showed the following: -Cognitively intact; -Functional limitation in range of motion included impairment to upper extremity, one side and bilateral lower extremities; -Required partial/moderate assistance with wheelchair mobility; -Required substantial/maximal assistance withbed/chair transfers; -Current tobacco use. Review of the resident's Smoking Risk Assessment, dated 04/06/26, showed the following: -Smoked cigarettes; -Memory intact; -Independent for decision making; -Understands and follows smoking guidelines per policy; -Recommendation for supervised smoking until further observation. Review of the resident's care plan, dated 04/06/26, showed the following: -Not allowed to smoke in his/her room. Can smoke with staff supervision in designated smoking area and may take smoking materials when on leave of absence; -Will dispose of his/her cigarette/butts in designated receptacles; -Observe/document non-compliant smoking behaviors exhibited as indicated; -Complete a smoking safety assessment per protocol within 14 of admission, quarterly, and as needed; -Observe resident routinely to ensure safety while smoking; -Smoking is allowed during designated times, with staff supervision in designated area only. Observation on 04/14/26, at 11:40 A.M., showed the resident rested in bed. A pack of cigarettes and a lighter were on the back edge of the vanity countertop. Observation on 04/16/26, at 12:45 P.M., showed a pack of cigarettes and a lighter lying on the right side of the sink. During the observation the resident said he/she was a smoker, but had not smoked since he/she was admitted to this facility. Nobody had told him/her anything about securing the cigarettes or lighter. During an interview on 04/17/26, at 1:10 P.M., Certified Nurse Aide (CNA) B said residents' cigarette lighters should be kept at the nurses' desk. The resident must ask for the lighter and return it to the desk. During an interview on 04/17/26, at 1:16 P.M., Registered Nurse (RN) C said residents could keep their own smoking materials secured in their room if they were assessed and deemed safe to maintain them. During an interview on 04/17/26, at 1:24 P.M., CNA DD said residents who were assessed as independent smokers could keep their cigarettes secured in their rooms. All residents' lighters were to be kept secured at the nurses' desk. The resident had to ask for it and return it. During an interview on 04/17/26, at 1:28 P.M., Licensed Practical Nurse (LPN) K said cigarettes can be kept secured in a resident's own room. All lighters should be locked in the medication room or in a drawer at the nurses' desk. During an interview on 04/17/26, at 3:52 P.M., the Director of Nursing (DON) said independent smokers could keep their own cigarettes on them or in their rooms, but were required to check in/out their lighter from the nurses' station. During an interview on 04/17/26, at 5:20 P.M., the Administrator said cigarettes and lighters should be kept at the nurses' station.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities when staff failed to provide activities to three residents (Resident #11, #94, and #115) on the memory care unit who voiced importance of attending activities. The facility census was 118.Review of the facility policy Resident Activities, dated March 2012, showed the following;-The activities services of each facility will, plan, organize, and carry out a program of activities to meet individual resident needs;-The program is designed to give residents entertainment, communication, exercise, relaxation and an opportunity to express their creative talent;-Through the activities, residents can fulfill basic psychological, social and spiritual needs;-The Activity Director plans and organizes a program of approved activities for residents on a group and for individuals, to meet the needs of the residents;-A calendar of events will be posted on the activity bulletin board to inform residents, visitors and staff of scheduled activities;-All staff are responsible for assisting residents with activities of their choices;-An activity program is planned for each resident as part of their total resident care by the Activity Director, in cooperation with nursing service and with physician approval;-Residents shall be encouraged, but not forced, to participate in activities of choice;-An individualized program will be implemented for residents unable to participate in or attend activities;-Activity Director will consider the following related to environment and structured activities:-Activity Director will ensure that adaptive equipment is available for residents to participate in activity;-Activity area will be accessible to residents in wheelchairs, specialized chairs;-The Activity Director will develop a monthly activity calendar based on the residents' needs and interests;-The calendar should include a wide variety of activities to meet all aspects of daily living;-Activities should include physical, spiritual, emotional, cognitive, sensory, work service related and fun recreational;-Activities should be planned for both large and small groups;-A monthly calendar of events for general participation is posted in the facility for quick reference by personnel, residents and visitors;-A monthly activity calendar will be provided to each resident;-The nursing supervisor is informed of the scheduled activities for residents on his/her unit and where they are to take place;-The Activity Director consults with the nursing supervisor concerning resident's condition and the most appropriate time and location for activities. Review of the facility's April 2026 Activity Calendar showed the following:-Stronger Longer exercise Monday, Wednesday, and Fridays, no time noted;-Devotions on Monday, Wednesday, and Fridays, no time noted;-Movie with your meal on Monday, Wednesday, and Fridays, no time noted;-Puzzles and independent games on Saturdays;-Guys & Gals nails on Mondays, no time noted;-Refreshment cart on Mondays, no time noted;-Movie outing on 04/15/26, at 12:00 P.M.;-Monthly birthday party in the dining room on 04/16/26 at 2:30 P.M. 1. Review of Resident #94's face sheet showed the following information:-admission date of 09/17/25;-Diagnoses included dementia (decline in mental ability severe enough to interfere with daily life) without behavioral disturbance, muscle weakness, and cerebrovascular disease (group of conditions that affect blood vessels in the brain, restricting oxygen flow and potentially causing brain tissue damage). Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 10/28/25, showed the following:-Severe cognitive impairment;-Preference of having books, magazines, listening to music, being around animals, was somewhat important;-Preference of having snacks between meals, keeping up with news, doing things with groups of people, getting fresh air and participating in religious services, was very important. Review of the resident's April 2025 Activity Calendar showed the following:-On 04/02/26, the resident received easter treats;-On 04/03/26, the resident received snack cart;-On 04/05/26, the resident attended services in the chapel;-On 04/09/26, the resident watched a movie with the meal and hot cocoa bar;-On 04/12/26, the resident participated in National Wear a Star Day;-On 04/13/26, the resident had refreshments cart;-On 04/15/26, the resident participated in hot cocoa bar;-On 04/16/26, the resident watched a movie with the meal.(Staff did not document offering other activities from the activity calendar to the resident.) During an interview on 04/13/26, at 11:00 A.M., the resident said he/she likes to be involved in activities when available, but there are not many activities. 2. Review of Resident #11's face sheet showed the following:-admission date of 11/25/24;-Diagnoses included vascular dementia (cognitive decline caused by reduced blood flow to the brain, damaging tissue), repeated falls, and anxiety disorder. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Preferred snacks between meals, family involvement in care discussion, reading, listening to music, being around animals, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious activities. Review of the resident's April 2026 Activity Calendar showed the following:-On 04/02/26, the resident assembled easter eggs;-On 04/05/26, the resident attended services in the chapel;-On 04/09/26, the resident watched a movie with the meal and hot cocoa bar and the resident visited with his/her family member;-On 04/12/26, the resident participated in National Wear a Star Day;-On 04/14/26, the resident watched a movie with lunch;-On 04/15/26, the resident participated in hot cocoa bar;-On 04/16/26, the resident watched a movie with the meal.(Staff did not document offering other activities from the activity calendar to the resident.) During an interview on 04/13/26, at 12:15 P.M., the resident's family member said the resident liked to be involved in activities when available. There are not many activities provided. He/she was unaware of any staff providing one-to-one activities or conversations with the resident. 3. Review of Resident #115's face sheet showed the following information:-admission date of 04/29/24;-Diagnoses included frontal temporal neurocognitive disorder (progressive brain disease causing atrophy (wasting away, shrinkage) in the front and side of the brain, primarily affecting personality, behavior, and language), vascular dementia, and need for assistance with personal cares. Review of the resident's MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Preference of reading books, magazines, listening to music, doing things with groups of people, spending time outdoors, participating in favorite activities, participating in religious activities. Review of the resident's April 2026 Activity Calendar showed the following:-On 04/02/26, the resident received easter treats;-On 04/03/26, the resident had therapy;-On 04/06/26, the resident participated in music therapy;-On 04/09/26, the resident had therapy and movie with the meal;-On 04/12/26, the resident participated in National Wear a Star Day;-On 04/14/26, went for a drive with family and had move with lunch;-On 04/16/26, the resident watched a movie with the meal.(Staff did not document offering other activities from the activity calendar to the resident.) During an interview on 04/13/26, at 11:20 A.M., the resident's family said the resident liked to be involved in activities when available. 4. Observation on 04/13/26, at 11:00 A.M., in the memory care unit showed the following:-No activity schedule posted in common area;-Activity schedule posted near the nurses' desk, not visible for residents or visitors;-Staff provided packaged refreshments on individual basis when residents were in the common area;-A radio near the nursing station that was not turned on;-Staff assisting residents with toileting, dressing, and bathing;-No observation of activities with residents. Observation on 04/14/26, at 10:00 A.M., in the memory care unit showed the following:-No activity schedule posted in common area;-Activity schedule posted near the nurses' desk not visible for residents or visitors;-A radio near the nursing station that was not turned on;-Two aides and one nurse present. One aide providing showers, one aide redirecting residents and providing snacks as needed, and a nurse completing paperwork at the nursing desk;-No observation of activities with residents. Observation on 04/14/26, at 2:35 P.M., in the memory care unit, showed the following:-Three residents seated in the dining room in wheelchairs, one resident with their head on table and eyes closed, one resident leaning to his/her left side and touching parts on their wheelchair, and one resident with their head hanging forward and eyes closed. No staff present in the room;-No observation of activities with residents. Observation on 04/15/26, at 4:30 P.M., in the memory care unit showed the following:-Licensed Practical Nurse (LPN) I present in the dining room with four residents and one family member;-LPN I turned on music and encouraged the four residents to raise their arms and stomp their feet for exercise. The activity lasted approximately five minutes;-LPN I documented the four resident's attendance in the activity calendar book. Observation on 04/16/26, at 2:30 P.M., in the main dining room, showed a birthday party with cake and outside entertainment with one resident from memory care unit in attendance. Observation on 04/16/26, at 4:00 P.M., in the memory care unit, showed the following:-The radio on in the common area;-The television turned on in the dining room;-No birthday party with cake or outside entertainment was provided for residents in the memory care unit.5. During an interview on 04/14/26, at 11:30 A.M., Certified Nurse Aide (CNA) AA said the following:-Activity staff bring a daily activities schedule to the nurse and sometimes supplies if needed;-The nurse and aides on the memory care unit were responsible for providing the daily activities;-The activities do not always occur as the aides are busy providing care to residents; -He/she had not observed activities staff providing one-on-one activities with the residents; -There are not many activity supplies available. During an interview on 04/16/26, at 4:00 P.M., CNA H said the following:-Staff will occasionally take one or two memory care residents to the main dining room for the monthly birthday parties;-Sometimes a few pieces of cake are brought to the residents in the memory care unit. During an interview on 04/15/26, at 4:20 P.M., LPN I said the following:-Memory care unit staff try to provide activities during the day as much as possible;-There are not a lot of supplies available for the staff to use;-He/She had purchased 12 plastic blow up balls for the residents to toss around;-A resident's family member brought in a bingo game but only four or eight people can play;-It is difficult for staff to provide activities when only one aide is working on the unit. During an interview on 04/17/26, at 10:00 A.M., Activity Director (AD) said the following:-The activity calendar for the memory care unit had been modified from the main calendar to suit the residents' needs;-The activity calendar is located at the nursing station. A daily activity calendar is provided to the nursing staff;-Memory care residents do not have a copy of the calendar by their doors, as they take it off the wall;-The memory care staff provide activities in the unit. If they do not have time, they can contact the activity staff to assist;-One-on-one activities are not provided unless it is in the resident's care plan;-During large activities in the main dining room, when snacks are provided, leftovers are given to residents that did not attend the activity. There was a large crowd for this month's birthday party, therefore there were no birthday cake leftovers. During an interview on 04/17/26, at 10:40 A.M., the Director of Nursing (DON) said the following: -Activity calendars were provided to the whole building;-The activity department provided supplies to the memory care unit for activities;-LPN I turned on music when he/she worked;-Staff assist memory care residents to events in the activity room and main dining room as appropriate;-A hospice company hosts the monthly birthday party and provides cake;-This month there was a large group in attendance, and there was no leftover cake to share with residents who did not attend the party;-Previously, the facility had an activity assistant, which helped in getting more residents involved; -If memory care unit staff are unable to complete activities, they can notify the activity department and supplemental staff can assist. During an interview on 04/17/26, at 1:35 P.M., Social Services Director said the following:-Residents should be encouraged to attend activities of their preference;-Staff should provide residents in the memory care unit with activities and keep them engaged; -The activity department is responsible for the activity preferences portion of the MDS and should discuss preferences with the residents and their families. During an interview on 04/17/26, at 5:10 P.M., the Administrator said the following:-The memory care unit has its own activity calendar;-Aides provide activities when they are available;-Memory care staff and families can take residents to activities outside the unit.

Based on observation, interview, and record review, the facility failed to ensure all resident medications were secure, when staff members failed to lock medication carts containing resident medications while out of their line of sight and failed to ensure the narcotic medications (controlled substances regulated due to high potential for abuse, addiction, or dependence) were double locked inside of the medication carts. The facility census was 118.Review showed the facility did not provide a policy related to medication storage. 1. Observation on 04/16/26, at 12:05 P.M., showed the following:-Certified Medication Tech (CMT) N stood at a medication cart preparing medications. The medication cart was located in the hall, outside of the main dining room;-CMT N prepared a resident's medications while standing at the medication cart;-CMT N placed the medications in a medicine cup;-CMT N opened the second right drawer and opened the narcotic box without using a key and dispensed a narcotic medication;-He/she closed the narcotic box without engaging the lock;-CMT N closed the drawer and did not lock the cart. CMT N walked away from the cart, into the dining room, out of line sight of the cart;-When CMT N returned to the medication cart, he/she opened the cart without using a key and then opened the second right drawer and opened the narcotic box without using a key and dispensed a narcotic medication;-He/she closed the narcotic box without engaging the lock;-CMT N closed the drawer and did not lock the cart, then walked away from the cart, into the dining room, out of line sight of the cart.2. Observation on 04/16/26, at 3:35 P.M., showed the following:-CMT D prepared medications in the 100 hall;-CMT D closed the medication drawer and pressed in slightly on the medication cart lock. The lock was protruding approximately one inch from the front of the cart with a visible red dot on the side of the lock;-CMT D walked away from the cart, down the hall, and into a resident's room, out of line of sight of the cart;-When CMT D returned to the medication cart, he/she pulled the lock out with his/her fingers, without the use of a key, and opened the cart drawers to prepare another resident's medications;-After preparing the medications and placing in a medication cup, CMT D again pressed in slightly on the medication cart lock. The lock was protruding approximately one inch from the front of the cart with a visible red dot on the side of the lock;-CMT D walked away from the cart, down the hall, and into the resident's room, out of line of sight of the cart;-When CMT D returned to the cart, he/she pulled the lock with his/her fingers, without the use of a key and opened the cart drawers. 3. Obsevation and interview on 04/17/26, at 12:00 P.M., showed the following:-CMT D stood in the 100 hall near the medication cart;-CMT D opened the medication cart without using a key and then opened the narcotic box without using a key to complete a random narcotic count with the surveyor;-CMT D said once the locking mechanism was pushed in about one-half way the drawers could not be opened without pulling out the lock mechanism;-He/she said the residents do not have strong enough hand function to open the lock. During an interview on 04/17/26, at 12:15 P.M., Registered Nurse (RN) C said the following:-The medication carts and treatment carts should be locked when staff step away from the cart;-The narcotic box should be locked when not in use;-It is good practice to lock the carts every time. If the carts are not locked anyone could open and take any medication out of the cart;-He/she taught staff to pull the cart up to resident door, with the cart facing the resident door, for extra security. During an interview on 04/17/26, at 1:15 P.M., the MDS Coordinator said the following:-The medication carts should be locked when staff walk away from the cart;-The narcotic box should be locked when not in use. It requires double lock;-The medication cart should not be only half locked. During an interview on 04/17/26, at 1:20 P.M., Licensed Practical Nurse (LPN) I said the following:-The medication cart should be locked when not in line of sight;-The narcotic box should be locked when not in use. It required a double lock;-Staff should not leave the cart unlocked. During an interview on 04/17/26, at 1:30 P.M., the Assistant Director of Nursing (ADON) said the following:-Medication carts should be locked when staff walk away from the cart and the narcotic boxes should be locked every time;-Staff should shut the narcotic box until it clicks closed and the cart should be locked all the way. During an interview on 04/17/26, at 2:10 P.M., the Director of Nursing (DON) said the following:-No medication carts should be left unlocked and unattended;-The narcotic box should be locked and the medication cart should be locked when staff walk away; -Staff should not partially lock the carts. During an interview on 04/17/26, at 5:10 P.M., the Administrator said the following:-Nurses and medication technicians should lock the medication carts when they are not in use and when the cart is not in their line of sight;-The narcotic box on the cart should be locked;-Staff should not half lock the medication carts.

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment to all residents and family when staff failed to address broken blinds in one resident's (Resident #94) room, failed to address a broken drawer handle in one resident's (Resident #3) room, and failed to address missing handrail end caps bumped into by one resident's (Resident #11) family member. The facility census was 118.Review showed the facility did not provide a policy related to physical environment and repairs. 1. Observation and interview on 04/13/26, at 9:30 A.M., with Resident #94 showed the following:-The resident's window blind was pulled approximately halfway up;-The blind slats were bowed with slat was missing;-Near the resident's bathroom, a blind slat, approximately 2 inches wide and five feet long, leaned up against the wall;-He/she said he/she would like to have the blinds closed, as it would be frightening to look out at night and see a face in the window;-He/she did not remember the last time the blinds were able to completely close. 2. Observation and interview on 04/13/26, at 9:40 A.M., with Resident #3 showed the following:-The resident's 3-drawer bedside stand had the bottom drawer handle hanging toward the floor with only one screw present;-He/she said he/she did not know how long the handle had been broken;-The dresser was hard to open with the broken handle. 3. Observations and interviews on 04/13/26, at 11:50 P.M. and 12:15 P.M, showed the following:-In the common area, near the nursing desk, three handrails missed the end caps, with exposed plastic edges;-Resident #11's family member bumped his/her elbow on the end of the handrail when sitting down in the chair. He/she said he/she worried that a resident will bump the railing end and receive a bruise or skin tear. 4. During an interview on 04/15/26, at 11:30. A.M., Certified Nurse Aide (CAN) X said staff should verbally notify maintenance or write in the maintenance log at the nurses' desk if there were any broken items or concerns of damage in the facility. During an interview on 04/16/26, at 4:20 P.M., Licensed Practical Nurse (LPN) I said the following:-Each nursing station has a maintenance log to enter any broken items or repairs needed; -Maintenance staff check the log daily;-Staff should notify maintenance of broken blinds and missing handrails caps;-Maintenance had repaired the handrails in the past but a resident pulled the end caps off. During an interview on 04/17/26, at 2:10 P.M., the Director of Nursing (DON) said the following:-Staff should notify maintenance of any broken items;-Maintenance logbooks are located at each nursing station. During an interview on 04/17/26, at 3:00 P.M., the Maintenance Supervisor said the following:-Staff can document needed repairs in the maintenance logbooks, located at each nursing desk;-Maintenance staff check the logbooks daily;-Staff can verbally notify maintenance staff of broken items or repairs needed;-He/she was unaware of the broken blinds or the missing handrail end caps. During an interview on 04/17/26, at 5:10 P.M., the Administrator said the following:-Staff should write any concerns related to repairs or maintenance in the logbook at the nurses' desk;-The staff should notify maintenance of any broken items or disrepair, no matter how small, such as paint chips, broken blinds, or broken handrails.

Based on interview and record review, the facility failed to ensure a system was in place that clearly and consistently represented each resident's choice of code status (if they wished to receive cardiopulmonary resuscitation (CPR - lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped)) when staff failed to ensure two residents' (Residents #18 and #100) code status was consistent throughout the medical record. The facility census was 118.Review of the facility policy Advance Directive, dated [DATE], showed the following:-The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; -Upon admission of a resident, the social services designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives; -Information about whether or not the resident was executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Review of Resident #18's face sheet (gives basic profile information) showed the following:-admission date of [DATE]; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), dementia (decline in mental ability—such as memory, language, problem-solving, and thinking, severe enough to interfere with daily life) with anxiety, history of transient ischemic attack (TIA – often called a mini-stroke, is a temporary blockage of blood flow to the brain) and cerebral infraction (stroke, a condition where blood flow to the brain is interrupted, causing brain tissue to die) without residual deficits; -Do Not Resuscitate (DNR - legally binding medical document, signed by a doctor, instructing healthcare providers not to perform CPR if a patient's heart stops beating or they stop breathing). Review of the resident's Health Care Declaration / Living Will (written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent), dated [DATE], showed the following: -If not able to make and communicate health care decisions, then resident's physicians are to follow the resident's written choices of life-sustaining treatment; -The resident directed and authorized his/her health care provider to withhold or withdraw all life sustaining treatment and procedures as permitted by law. Review of the resident's Physician's Order Sheet (POS), current as of [DATE], showed an order, dated [DATE], for code status of full code (wished to receive CPR). Review of the resident's baseline care plan, dated [DATE], showed DNR. Review of the resident's Outside the Hospital Do-Not-Resuscitate (OHDNR) Order, dated [DATE], showed the form signed by resident's representative. Observation on [DATE], at 1:00 P.M., showed the resident's name on a red tag (indicating DNR) by their door. 2. Review of Resident #100's face sheet showed the following: -admission date of [DATE]; -Diagnoses included cancerous brain tumor, stroke affecting right dominant side (weakness, paralysis), muscle wasting and weakness, repeated falls, difficulty swallowing, speech disturbances, pain, depression, high blood pressure, and low thyroid function; -Code status of DNR. Review of the resident's POS, current as of [DATE], showed an order, dated [DATE], for code status of full code. Review of the resident's OHDNR showed the form was signed by the resident's representative on [DATE] and by the physician on [DATE]. Review of the resident's care plan, last updated [DATE], showed staff did not care plan related to code status. Observation on [DATE], at 6:30 P.M., showed the resident's name plate was on red paper (indicating DNR). 3. During an interview on [DATE], at 12:05 P.M., Certified Nursing Assistant (CNA) B said the following: -A resident's code status can be quickly identified by looking at their name plate on their door: green means full code and red means DNR; -The nurse verifies the resident's code status in the electronic medical record; -Resident code status should match throughout the chart and on the name plate on their door. During an interview on [DATE], at 4:00 P.M., CNA H said the following: -Resident code status was located in the electronic medical record on the face sheet and on the name tag on the doors: red for DNR and green for full code status; -A resident's code status should be the same in the chart and on the name tags. During an interview on [DATE], at 4:20 P.M., Licensed Practical Nurse (LPN) I said the following: -Resident code status preference is documented in the resident's electronic medical record (EMR), on the face sheet, and the physician orders; -The original signed DNR document is uploaded to the documents tab; -Resident code status should match throughout the chart. During an interview on [DATE], at 11:50 A.M., Certified Medication Technician (CMT) D said the following: -A resident's code status can be viewed in their electronic medical record. It shows up on the banner in the medication administration page; -He/she would speak to a nurse if there were questions regarding a resident's code status. During an interview on [DATE], at 12:05 P.M., Registered Nurse (RN) C said the following: -Staff can locate a resident's code status on the banner of any page in the resident's medical record; -The name tags on resident doors are red for DNR and green for full code; -Nurses can check physician orders for code status; -All code status information should match. If staff have questions regarding code status, they can look in the resident documents tab of the chart for the signed DNR paperwork; -The Admissions Coordinator audits resident charts for accuracy. During an interview on [DATE], at 1:10 P.M., the Admissions Coordinator said the following: -He/She completed admission paperwork. If he/she was not available any charge nurse could start the admission process; -The Minimum Data Set (MDS – a federally required assessment completed by facility staff) Coordinator completed the code status; -He/She audited all open events related to admission. Code status should match in the chart. During an interview on [DATE], at 1:15 P.M., the MDS Coordinator said that Social Services reviewed and entered code status information. He/she did not audit any charts or enter code status in the medical records. During an interview on [DATE], at 1:25 P.M., the Social Services Assistant said the following: -Code status information is in the admission packet; -Social services ensures the DNR form is complete and signed by a physician; -Social services updates the code status banner in the medical record; -The code status should be entered in the care plan; -The charge nurses enter the physician order for the code status; -All the areas should match. During an interview on [DATE], at 1:30 P.M., the Assistant Director of Nursing (ADON) said the following: -Admissions ensures the admission check list is complete and accurate; -Admissions checks the orders to ensure they match the hospital paperwork; -The code status should be consistent throughout the resident's record. During an interview on [DATE], at 2:10 P.M., the Director of Nursing (DON) said the following: -Resident code status should match throughout the chart; -Social Services audits the code status after the physician signs the DNR form; -Any nurse can change the code status in the chart; -When a resident admits, they are considered full code until a physician completes the order; -A verbal order for a DNR is acceptable until the physician signs the paperwork the next time they are in the facility. During an interview on [DATE], at 5:10 P.M., Administrator said nursing staff should ensure code status is consistent in the chart and everything should match. Social Services monitors the name tags on the doors for accuracy of code status.

Based on observation, interview, and record review, the facility failed to provide timely and complete urinary incontinence care for residents dependent on staff when staff did not check one resident (Resident #96) for incontinence for more than eight and one-half hours and did not provide complete and thorough perineal care for one resident (Residents #96). A sample of 29 residents was reviewed for personal hygiene and toileting needs. The facility census was 118. Review of the facility's policy titled Toileting Plans for Urinary Incontinence, undated, showed the following: -Purpose to provide guidance for the initiation and monitoring of and/or a toileting plan for the resident with urinary incontinence; -An incontinent management program involves checking the resident's continence status at regular intervals and providing incontinent care and garments as indicated by individual need. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Review of Resident #96's face sheet (brief resident profile sheet) showed the following information: -admission date of 03/06/25; -Diagnoses included severe vascular (blood vessel system) dementia without behavioral disturbance, other abnormalities of gait (manner of walking or moving on foot) and mobility, generalized muscle weakness, type two diabetes, developmental disorder of scholastic skills (academic abilities); and candidiasis (a common fungal infection caused by an overgrowth of candida yeast). Review of the resident's functional abilities assessment, dated 02/23/26, showed the following: -Dependent on toileting hygiene; -Dependent on personal hygiene. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/18/26, showed the following: -Severe cognitive impairment; -Dependent for toileting hygiene, bathing, dressing, oral care, and personal hygiene; -Required substantial/maximal assistance to get on and off a toilet and to transfer in and out of a shower; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, reviewed/revised on 03/19/26, showed the following: -At risk for complications related to incontinence of bowel and/or bladder; -At increased risk for moisture-associated skin damage caused by prolonged exposure to moisture from urine and feces; -Perform perineal care for incontinent episode; -Check on frequently to ensure needs are met; -Assist to restroom as appropriate; -Monitor frequently when in wheelchair; -Staff must anticipate resident's needs at times; -Assist resident to maintain good personal hygiene and clean clothes. Observation on 04/14/26 showed the following: -At 10:44 A.M., the resident sat in the wheelchair across from the nurses' station with his/her head down, chin on chest, and eyes closed; -At 11:03 A.M., Certified Nursing Assistant (CNA) A wheeled the resident down the hall towards the dining room. He/she did not take the resident to his/her room or the bathroom; -At 12:45 P.M. to 1:01 P.M., Nurse Aide (NA) W and CNA A delivered drinks to resident rooms on Hope unit; -At 1:17 P.M., CNA Y wheeled the resident down from the dining room to an area across from the nurses' station. He/she did not take the resident to his/her room or to the bathroom; -At 1:28 P.M., the resident continued to sit in his/her wheelchair, across from the nurses' station. CNA A walked passed the resident to the break room and did not check on resident; -At 1:30 P.M., dietary staff delivered food warmer box to the Hope unit. The resident continued to sit in same place; -At 1:33 P.M. to 1:50 P.M., four aides passed out lunch trays to Hope unit resident rooms while the resident sat in his/her wheelchair at the nurses' station; -At 2:00 P.M., the resident continued to sit in the wheelchair, beside another resident at the nurses' station; -At 2:05 P.M. to 2:19 P.M., CNA A and NA W provided care to another resident on Hope unit. The resident sat in same place near nurses' station; -At 2:24 P.M., the resident sat in wheelchair, head down, eyes closed, in same place near nurses' station; -At 3:38 P.M., the resident continued to sit in wheelchair, in same place near nurses' station; -At 4:47 P.M., the resident sat in the dining room and waited for supper. -At 5:57 P.M., the resident ate supper and continued to sit in the dining room; -At 6:02 P.M., the resident continued to sit in same place in dining room; -At 6:08 P.M., resident wheeled back from the dining room and placed near the nurses' station. Staff did not take the resident to the bathroom or his/her room; -At 6:13 P.M., a certified medication technician (CMT) administered medications with a spoon to the resident; -At 6:32 P.M., the resident sat in the wheelchair beside another resident in same place near nurses' station, eyes closed; -At 6:50 P.M., the resident continued to sit in the wheelchair, same place near nurses' station, two other residents sat at his/her side; -At 7:06 P.M., the resident continued to sit in the wheelchair near the nurses' station, one resident at his/her side; -At 7:15 P.M., day shift aides gave shift report to oncoming nightshift NA Z; -At 7:30 P.M., CNA B wheeled the resident to his/her room, positioned resident beside the bed, and left room to help another resident; -At 7:44 P.M., CNA B wheeled the resident out of his/her room, to the hallway bathroom. CNA B said there was more room to move around in that bathroom. CNA B did not wash hands or use hand sanitizer. CAN B put on gloves, and placed gait belt on the resident; -At 7:48 P.M. to 8:01 P.M, NA Z knocked on bathroom door, did not wash hands or use hand sanitizer, put on gloves, used a gait belt, held onto hand rail beside toilet, and assisted resident to stand and pivot to toilet. NA Z pulled down his/her pants and brief, and resident sat on toilet; -The resident's shirt back, pants, brief, and pad on the seat of the wheelchair were soaked with urine. NA Z placed dirty clothes in trash bag for laundry. While CNA B wet and applied soap to washcloths. NA Z cleaned the resident's wheelchair and CNA washed the resident's face and hands while he/she sat on the toilet; -NA Z washed his/her hands at sink and put on clean gloves. CNA B did not wash hands or change gloves. The resident had a medium, soft-formed bowel movement when prompted. He/she used the grab bar at their side, stood up while NA Z used gait belt and CNA B wiped resident's bottom from front to back; -The resident's skin on his/her bottom was a dark red and purple color, non-blanchable (does not turn white when pressed), and intact. CNA B said to the resident, your bottom is red and applied barrier cream to the area. Aides assisted the resident back on the toilet, then placed a clean brief at the knees, put clean pants and a clean shirt. The resident's front genital area and legs were not washed; -Both aides placed their gloves in the trash and washed their hands at the sink. CNA B wheeled the resident to his/her room and assisted the resident to bed. Observation on 04/15/26 showed the following: -At 10:09 A.M., the resident sat in the wheelchair near the nurses' station, neck bent, chin at chest, eyes closed, blanket covering legs; -At 10:27 A.M., the resident sat in the wheelchair, placed near the nurses' station; -At 11:24 A.M., the resident continued to sit in the wheelchair near the nurses' station; -At 12:28 P.M., the resident sat in the wheelchair at the dining room table eating lunch. Observation on 04/17/26 showed the following: -At 10:40 A.M., the resident sat in the wheelchair, with head down, eyes closed, near the nurse's station; -At 11:05 A.M., the resident sat in the wheelchair and ate a candy bar near the nurses' station; -At 11:34 A.M., the resident continued to sit in the wheelchair near the nurses' station; -At 11:40 A.M., CNA A wheeled the resident down the hall toward the dining room. The aide did not take the resident to his/her room or bathroom. During an interview on 04/17/26, at 12:03 P.M., CNA A said the following: -Staff should change residents' briefs often, apply barrier cream, keep skin clean and dry, and reposition at least every two hours; -Proper perineal care would be to wipe from front to back, wipe the clean area to dirty area, use clean wipes, and wash all dirty areas including the skin folds; -The resident was incontinent and a two person assist; -CNA A has never gotten the resident out of bed or his/her wheelchair to the toilet or to change his/her brief; -No other aides asked the CNA for help on any cares for the resident. During an interview on 04/17/26, at 12:19 P.M., CNA B said the following: -Staff should check for resident needs often, reposition every two hours, check residents briefs every two hours and before and after meals, and apply barrier cream to prevent skin breakdown; -Proper incontinence care for a resident would include washing all dirty areas from front to back with soap and water and change clothes; -CNA B had not changed the resident's brief today. During an interview on 04/17/26, at 2:38 P.M., Registered Nurse (RN) C said the following: -Proper incontinence care for a resident would include at least two-hour checks, wipe entire area front to back with clean wipes, and wash in the creases; -RN C would expect the resident's brief to be checked every two hours and before meals; -Staff usually take the resident to the bathroom near the nurses' station. During an interview on 04/17/26, at 3:52 P.M., the Director of Nursing (DON) said the following: -The DON would expect staff to be proactive to provide resident needs and check frequently for pain, toileting assistance and repositioning; -The DON would expect staff to provide proper perineal care to all residents at least every two hours; -The DON would expect staff to clean all dirty areas of the body, to wipe from the clean to dirty areas, and to perform proper hygiene; -DON would expect the resident to be changed and repositioned as needed and every two hours. During an interview on 04/17/26, at 5:10 P.M., the Administrator said the following: -He would expect staff to follow proper incontinent care and follow policy and professional standards; -He would expect staff to check residents for toileting assistance, repositioning or changing every two hours.

Based on observation, record review, and interview, the facility failed to ensure access to survey results to family, visitors, and residents when the prior survey results were not kept in a readily accessible, public location at all times of the day. The facility census was 118.Review showed the facility did not provide a policy regarding survey results accessibility. 1. Observations on 04/13/26, at 8:15 A.M., 04/14/26, at 10:40 A.M., and 04/16/26, at 8:30 A.M., showed the following:-A sign at the front entry desk of the building, approximately five feet high, stating the survey binder was available at the front desk;-No survey binder located or visible at the front desk. During an interview on 04/17/26, at 12:10 P.M., Registered Nurse (RN) C said the survey book was located at the front desk and should be available for anyone to view at any time. During an interview on 04/17/26, at 12:30 P.M., the receptionist said the survey result book was kept in the cupboard behind the receptionist's desk. After 4:00 P.M., the book was locked in the reception area. A visitor requested to see the book a couple of months ago. During an interview on 04/17/26, at 12:45 P.M., Certified Medication Technician (CMT) D said he/she did not know where the survey book was located. During an interview on 04/17/26, at 1:00 P.M., Resident #6 said he/she did not know where a book containing past survey information was located or when it was available. During an interview on 04/17/26, at 1:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said that the survey book was at the front desk in the past. He/she did not know if it was still located there. During an interview on 04/17/26, at 2:15 P.M., the Director of Nursing (DON) said the survey book was located at the front desk. The receptionist was responsible for ensuring it was available when a visitor or resident wants to review the book. During an interview on 04/17/26, at 5:10 P.M., the Administrator said the survey result book was located at the front desk. There was a sign noting that it was available. When the receptionist left for the day, the book was locked behind the receptionist's desk. The book was not left out at all times as they do not want it to be stolen.

The Administrator was notified on 01/29/26, at 5:29 P.M., of an Immediate Jeopardy (IJ) which began on 01/23/26. The IJ was removed on 01/30/26 as confirmed by surveyor on-site verification. 1.Please refer to F684, event ID 1DA88A-H2, exit date 02/02/26.NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level.Complaints #2727145 and #2728765

Based on observations, interview, and record review the facility failed to ensure an environment as free from accident hazards as possible when staff failed to identify, assess, investigate, and document bruising of an unknown source for one resident (Resident #1). The census was 123. Based on observations, interview, and record review the facility failed to ensure an environment as free from accident hazards as possible when staff failed to identify, assess, investigate, and document bruising of an unknown source for one resident (Resident #1). The census was 123. Review of the facility's policy named, Event Investigation, undated, showed the following:-Purpose to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed and to identify any injuries after a resident sustains an event;-Handle resident gently, examine the entire skin surface, interview the resident to determine cause of any conditions identified, interview any witnesses to determine cause of any conditions identified, measure vital signs, assess pain, identify all skin discolorations, redness, swelling, edema (swelling), tenderness, breaks, or changes in temperature, measure the size, depth, color and location of any skin conditions identified, palpate peripheral pulses, gently perform passive and active range of motion of all joints, assess any change in mental and cognitive status through observation and interview of the resident, observe and assess all neurological signs, notify the resident's attending physician of a change of condition or any concerns that have been identified,notify the resident's representative of a change of condition or any concerns that have been identified, attempt to determine the cause of any conditions identified, implement preventive measures as appropriate, if resident abuse is suspected, proceed with abuse investigation;-Complete a Report of Event Form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor;-Examples of when a form should be completed include allegation or known abuse of a resident by a staff member, visitor or resident, fracture/dislocation of unknown origin, bruise/skin tear of unknown origin, elopement from the facility, equipment malfunction, fall or person found on the floor, burn/scald from hot beverage or hot water temperature, occurrence involving medication, self-inflicted injury, suicide or attempted suicide, and damaged or lost personal property;-Any staff member who discovers, witnesses or is involved in an event should immediately report the event to the nurse in charge. The charge nurse is responsible for completion of the Report of Event form and forwarding to the Director of Nursing (DON) as soon as possible. Events resulting in injury, life-threatening nature and/or allegation of or known abuse/neglect, the charge nurse will notify the DON and Administrator immediately. Upon notification of an event resulting in hospitalization or need to notify outside agency, the Administrator will notify the Quality Assurance Nurse Consultant and Director of Operations immediately;-The following should be completed on the form facility name; who the event involved; person's by name; date and time of the event; description of the event; witness names and contact information; primary diagnoses; cognitive status; exact location of event; equipment involved; type of event; observations; exact location of the injury and measurement ; vital signs; mental/neuro status - after the event; range of motion; complaint of pain; first aid given; what was done immediately to prevent event from happening again; nurse completing report and date with nurse signature with date;-Follow up section to be - These questions are to be completed by the DON to ensure an entry was made in the nurses' notes regarding the event, the event was logged for tracking/trending purposes, the facility's investigation was completed to determine causal factors of the event and to determine changes in resident plan of care or facility practice to reduce the likelihood of recurrence, the plan of care was revised, 72 hour monitoring initiated in nurses' notes and any further comments. If any of the questions are answered no there must be further explanation of why;-Administrative action taken, to be completed by the Administrator after review of the event report and investigation findings. Provide information regarding any further administrative action including but not limited to personnel action or policy revision. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 10/23/25;-Diagnoses included cerebral infarction (the death of brain tissue due to a lack of blood flow, typically caused by a blood clot), hemiplegia and hemiparesis (a complete paralysis on one side of the body, while hemiparesis is weakness on one side), muscle weakness, cognitive communication deficit, dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety disorder, and aphasia (impaired speech) following cerebral infarction. Review of the resident's admission clinical assessment dated [DATE], at 7:26 P.M., showed staff noted no skin issues. Review of the resident's skin monitoring shower sheet, dated 10/27/25, showed staff noted no new skin conditions. Review of the resident's weekly skin assessment, dated 10/27/25, showed the resident had scattered bruising especially right arm prior to admission.Review of the resident's care plan, dated 10/27/25, showed staff did not care plan regarding any bruising.Observations of the resident on 10/29/25, at 9:38 A.M., showed the following:-The resident had bruising on the right side of his/her forehead about the size of a golf ball that was dark purple in color;-The resident had dark purple bruising to the left ring finger.During an interview on 10/29/25, at 9:38 A.M., the resident's family said the following:-The resident did not have the bruising on his/her forehead or finger prior to her coming to the facility or as of 10/26/25;-They reported to the staff that the resident had new bruising. They did not think the nurse had assessed the resident;-The resident was not able to tell them what caused the bruising;-The facility did not report any incidents that may have caused the bruising. During an interview on 10/29/25, at 10:42 A.M., Licensed Practical Nurse (LPN) A said the following:-He/she was not aware of any bruising on the resident's forehead of finger when he/she worked on 11/26/25;-He/she noticed bruising to the resident's left finger about an hour ago and planned to assess it;-He/she was not aware of any bruising on the resident's forehead;-He/she planned to talk to the certified nurse aides (CNA) regarding the bruising to figure out the possible cause;-He/she would also notify the Director of Nursing (DON) and Assistant Director of Nrusing (ADON) of the bruising;-Any new bruising on the resident should be documented;-There was nothing documented or told to him/her in report that would have caused the bruising overnight;-The resident does lower him/herself to the floor, but he/she does not fall or go down unsafely.Review of the resident's progress note, late entry on 10/29/25 at 1:06 P.M., showed LPN A said the resident's family noti ed him/her of bruising to left third nger. It was purple in color. The resident reported no pain and was unable to recall any incident related to the area of concern due to advanced state of disease process. ADON and DON aware of bruising. Family aware at time of discovery by this nurse. (The resident's progress notes did not show any documentation regarding a bruise on the resident's forehead.) During an interview on 10/29/25, at 12:52 P.M., CNA B said the following:-He/she gave the resident a shower on 10/24/25. He/she remembered there being bruising on the right shoulder/arm from admission, but that was it. He/she saw bruising on the resident's finger earlier this morning around 8:30 A.M. It appeared to be blackish/ purple in color and swollen;-There was also a purple circular bruise on the resident's forehead. He/She did not tell the nurse because the morning was hectic;-He/she did not know how he/she got the bruising, but the resident does put him/herself down on the floor and will crawl around at times. During an interview on 10/29/25, at 3:13 P.M., CNA G said the following:-Today around 7:00 A.M., he/she saw bruising on the resident's left hand/finger. It was reddish purple and swollen. He/she did not tell the nurse;-He/she worked on 11/26/25 and he/she did not have the bruise then. He/she assumed the bruise happened in the two days that he/she had off;-If there is new bruising he/she was supposed to report to nurse;-He/she was not aware of the bruise on his/her forehead, but he/she had bangs so she maybe would not see it. During an interview on 10/30/25, at 7:48 A.M., LPN C said the following:-He/she worked on the nights of 10/27/25 and 10/28/25;-He/she was not aware of any new bruising on the resident;-The CNA's generally report any new bruising to him/her and he/she would assess the resident;-If a resident had new bruising it should be documented so it can be monitored. During an interview on 10/30/25 at 8:04 A.M., CNA D said the following:-He/she saw bruising on the resident's left ring finger on 10/27/25, in the evening. It was dark purple. He/she did not report the bruising because he/she thought maybe he/she had come from the hospital with it;-He/she thought it could have been from a ring;-The resident was unable to say where the bruise came from;-If a resident had bruising and the staff member was not sure the nurse is aware of it they should report it;-He/she also brushed the resident's hair that night and did not notice any bruising on his/her head. During an interview on 10/31/2,5 at 5:02 A.M., CNA E said if a resident had any new bruises the CNA's are supposed to report it to the nurse so they can assess it. During an interview on 10/31/25, at 8:59 A.M., the Social Services Designee he/she spoke with the resident the morning of 10/29/25 and noticed a bruises on the resident's left finger and on forehead. They were both purple in color. He/she did not report the bruises to the nurse because he/she believed he/she was aware of it. During an interview on 11/06/25, at 12:59 P.M., LPN F said the following:-He/she saw bruising on the resident's left finger, but he/she did not feel it was significant. It was purple in color. He/she did not assess it. He/she did not document anything about it. He/she was not sure what day he/she saw it;-He/she did not see bruising on the resident's forehead but if he/she had, he/she would have assessed it and most likely started neuro checks. He/she would have made a nurses note, and an event made. They generally investigate the bruise to find the cause if possible;-The resident had been witnessed getting down on the floor on purpose and then refusing to let staff help her up. During an interview on 11/06/25, at 2:18 P.M., CNA H said he/she remembered the resident having a bruise on his/her forehead. He/she believed it was on the left side. He/she believed he/she notified LPN F. During interviews on 10/29/25, at 2:35 P.M., and on 11/06/25, at 2:28 P.M., the ADON said the following:-He/she saw bruising on the resident's finger this morning. He/she did not remember seeing it the morning of 10/29/25. He/she did not see bruising on the resident's head;-The CNA should report any new bruising to the nurse. If it is of unknown origin the nurse should contact on call person;-The nurse should assess the resident and notify the on-call person. He/She would expect the nurse to document information regarding the bruise such as location, description and how the resident got the bruise and out in an event. During interviews on 10/29/25, at 2:09 P.M., and on 11/06/25\, at 3:05 P.M., at the DON said the following:-The resident's family reported bruising on her finger and her forehead. He/she was not sure where it came from;-The CNA's should always report new bruising to the nurse. They should check with the nurse if they are not sure if it is new;-The nurse should assess the resident and then document what they observed in a note and an event;-A bruise on a resident's head should he assessed timely;-All events should be reported to the DON. During an interview on 11/06/25, at 3:39 P.M., the Administrator said the following:-If a CNA sees bruising on a resident, they should report it to the nurse so they can assess it. There should be documentation regarding the bruise and the assessment in a progress note;-All bruising should be reported to the nurse within the same shift. 26534798

Based on observations, interview, and record review , the facility failed to provide care per standards of practice when staff failed to promptly assess one resident (Resident #2) after a change in condition. The census was 123.Review of the facility's policy named, Event Investigation, undated, showed the following:-Purpose to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed and to identify any injuries after a resident sustains an event;-Handle resident gently, examine the entire skin surface, interview the resident to determine cause of any conditions identified, interview any witnesses to determine cause of any conditions identified, measure vital signs, assess pain, identify all skin discolorations, redness, swelling, edema (swelling), tenderness, breaks, or changes in temperature, measure the size, depth, color and location of any skin conditions identified, palpate peripheral pulses, gently perform passive and active range of motion of all joints, assess any change in mental and cognitive status through observation and interview of the resident, observe and assess all neurological signs, notify the resident's attending physician of a change of condition or any concerns that have been identified,notify the resident's representative of a change of condition or any concerns that have been identified, attempt to determine the cause of any conditions identified, implement preventive measures as appropriate, if resident abuse is suspected, proceed with abuse investigation;-Complete a Report of Event Form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor;-Examples of when a form should be completed include allegation or known abuse of a resident by a staff member, visitor or resident, fracture/dislocation of unknown origin, bruise/skin tear of unknown origin, elopement from the facility, equipment malfunction, fall or person found on the floor, burn/scald from hot beverage or hot water temperature, occurrence involving medication, self-inflicted injury, suicide or attempted suicide, and damaged or lost personal property;-Any staff member who discovers, witnesses or is involved in an event should immediately report the event to the nurse in charge. The charge nurse is responsible for completion of the Report of Event form and forwarding to the Director of Nursing (DON) as soon as possible. Events resulting in injury, life-threatening nature and/or allegation of or known abuse/neglect, the charge nurse will notify the DON and Administrator immediately. Upon notification of an event resulting in hospitalization or need to notify outside agency, the Administrator will notify the Quality Assurance Nurse Consultant and Director of Operations immediately;-The following should be completed on the form facility name; who the event involved; person's by name; date and time of the event; description of the event; witness names and contact information; primary diagnoses; cognitive status; exact location of event; equipment involved; type of event; observations; exact location of the injury and measurement ; vital signs; mental/neuro status - after the event; range of motion; complaint of pain; first aid given; what was done immediately to prevent event from happening again; nurse completing report and date with nurse signature with date;-Follow up section to be - These questions are to be completed by the DON to ensure an entry was made in the nurses' notes regarding the event, the event was logged for tracking/trending purposes, the facility's investigation was completed to determine causal factors of the event and to determine changes in resident plan of care or facility practice to reduce the likelihood of recurrence, the plan of care was revised, 72 hour monitoring initiated in nurses' notes and any further comments. If any of the questions are answered no there must be further explanation of why;-Administrative action taken, to be completed by the Administrator after review of the event report and investigation findings. Provide information regarding any further administrative action including but not limited to personnel action or policy revision. 1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 07/31/24;-Diagnoses included chronic kidney disease - stage 5 (end-stage kidney disease - when the kidneys have failed or have very low function), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), and mood disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/17/25, showed the following:-Resident had mild cognitive impairment;-The resident required set-up or clean up assistance for oral hygiene;-The resident required substantial/maximal assistance for transfers and used a wheelchair. Review of the resident's care plan, dated 07/31/24, showed the resident required dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) three times per week. The resident was at risk of fluid volume excess and or/depletion.Review of the resident's hospital records showed the following:-The resident admitted to the hospital on [DATE];-The resident arrived at the hospital by emergency medical services from a dialysis clinic after he/she was dropped off by transport. They found him/her to have altered mental status. He/she was normally oriented to person, place, time, and situation but was only oriented to person;-The resident was diagnosed with metabolic encephalopathy and hypoglycemia (low blood sugare);-The resident returned to the facility on [DATE]. Review of the resident's records showed staff did not document regarding the resident's change in condition or transfer to the hospital on [DATE]. Review of the resident's progress note dated 11/01/25, at 6:15 P.M., showed License Practical Nurse (LPN) I noted the resident readmitted from the hospital for acute encephalopathy. During an interview on 10/29/25, at 11:12 A.M., Certified Nursing Aide (CNA) J said the following:-On 10/27/25, he/she transported the resident to dialysis;-He/she helped CNA K get the resident ready for the appointment around 10:15 A.M. to 10:30 A.M., ;-He/she noticed that the resident was not acting like his/her normal self. The resident kept dropping (3 times) his/her toothbrush while trying to brush his/her teeth and couldn't lean forward to spit in the skin and spit on him/herself. The resident seemed a little incoherent and was mumbling. This was not normal for the resident, and he/she felt it was a change in condition;-Generally, the resident can brush teeth with just a little set-up help and can converse;-He/she was concerned about the resident and checked the resident's vital signs;-He/she then reported to the LPN I that the resident was talking nonsense and was not acting like herself. He also told the nurse that she was kept dropping his/her toothbrush and what the vital signs were;-The nurse did not have concerns about the resident's vital signs;-He/she thought the nurse would go assess the resident, but he/she did not. LPN I told him/her to go ahead and take the resident to his/her dialysis appointment and dialysis would take care of him/her if it was really that bad. LPN I did not go talk to the resident;-He/she would have considered what was going on with her has really bad;-He/she did what the nurse told him/her to do and transported the resident to dialysis;-He/she let the receptionist at dialysis know that the resident was not him/herself;-A staff member immediately came out and assessed the resident;-The resident's speech was now slurred and the staff from dialysis immediately sent him/her to the hospital;-He/she called the Administrator and told him/her that the resident was being sent to the hospital and about the change in condition and mumbling speech;-The Administrator asked if he/she had told the nurse. He/she told the Administrator that he/she had and he/she said okay and the conversation ended. The Administrator did not ask if the nurse had assessed the resident;-Generally, if there is a change in condition or anything seems off with a resident the CNA's are supposed to let the nurse know so they can assess them. The CNA's can take vital signs to help with the assessment. During an interview on 10/29/25, at 11:30 A.M., CNA I said the following:-The resident seemed out of it on the morning of 10/27/25. The resident had a normal baseline of being oriented and coherent. He/she could generally brush his/her teeth with set up from staff. He/she did not generally mumble or slur his/her words;-The resident was mumbling on 10/27/25 and just acting off and really tired;-He/she was not sure if anything serious was going on and felt it should be reported to the nurse;-He/she thought he/she told LPN I around 10:45 A.M. that the resident was not acting like him/herself;-He/she expected that LPN I would assess the resident before leaving for his/her dialysis appointment. The resident generally leaves around 11:00 A.M. because his/her appointment is at 11:30 A.M.,-He/she remembered LPN I saying he/she thought the resident would be admitted to the hospital from dialysis due to him/her acting weird;-The resident got admitted to the hospital from dialysis;-CNA's are supposed to report any changes in condition to the nurse. He/she felt this was a change in condition and that was why she reported it to LPN I. During an interview on 10/29/25, at 11:12 A.M., Certified Medication Tech (CMT) K said the following:-He/she was to report any resident changes in condition to the nurse;-On 10/27/25, at around 9:45 A.M. to 10:00 A.M., he/she went to give the resident medications. The resident was leaning far over to the left side and when he/she asked the resident why he/she was leaning he/she said there was a man pushing her and he/she had told him to stop but there was nobody else in the room;-He/she felt this was a change in condition because the resident does not usually hallucinate, and he/she was not acting like her/himself;-He/she repositioned the resident;-He/she then let the nurse know that the resident thought there was a man in her room and he/she was not acting like herself. He/she thought it was LPN I that he/she spoke to;-He/she then continued on passing medications and did not see LPN I assess the resident, but he/she assumed that he/she would. During an interview on 10/30/25, at 8:31 A.M., LPN I said the following:-The resident went to dialysis three times a week;-On the morning of 10/27/25, at around 10:30 A.M., he/she was told by two staff , CNA J and CNA K, that the resident was not acting like him/herself;-The resident was talking to him/herself and acting different from his/her normal;-The CMT said that the resident was talking to someone that was not there;-He/she had a CNA get vital signs and they were okay for the resident;-He/she did not go and assess the resident;-The resident has had hallucinations in the past, but it is when the resident has metabolic encephalopathy or a urinary tract infection and she goes to the hospital;-He/she did tell the CNA to go ahead and take him/her to dialysis and he/she would assess him/her when she returned;-If the resident was not going to dialysis, he/she would have assessed him/her. Due to the resident going to dialysis, he/she did not think he/she needed to. Normally, he/she would assess for change in condition and contact the physician;-He/she forgot to put in a nurses note regarding the change in condition. He/she would generally put in a note;-The resident was sent to the hospital from dialysis. During an interview on 10/30/25, at 12:05 P.M., the resident's Physician said the following:-The resident's health waxes and wanes, but he/she was able to converse and hold a toothbrush;-He/she would expect the nurse to complete and face to face assessment if the resident was acting out of the normal;-He/she could understand why the nurse would want the resident to go ahead to the dialysis appointment, but he/she would have liked an assessment first;-He/she felt it was important for the resident to get to his/her dialysis appointment due to it possibly helping the resident's change in condition;-Any changes in the resident's condition should be documented. During an interview on 10/31/25, at 8:01 A.M., the resident's Nurse Practitioner (NP) said the following:-On 10/27/25, he/she did not get to assess the resident because he/she had just left for dialysis when he/she was arriving to the building;-He/she was informed by LPN I that the resident was not acting right more confused and talking out of her head ;-He/she ordered labs for the resident, but the resident did not return from dialysis;-The resident tends to get very sick quickly due to all his/her conditions;-The resident can sometimes have some confusion but had not heard of her having hallucinations or dropping her toothbrush multiple times at her normal baseline;-The resident missed dialysis on 10/24/25;-He/she assumed that LPN I had assessed the resident, and he/she would have expected for the nurse to assess the resident;-If a resident had a change in condition, they should be assessed with a head-to-toe assessment and check vital signs;-He/she had heard from the hospital that the resident was diagnosed with metabolic encephalopathy and his/her blood sugars were very low. During an interview on 11/06/25, at 12:59 P.M., LPN F said the following:-If a resident was acting out of their normal baseline then the nurse should assess them;-A resident that is normally oriented that is acting more confused and hallucinating would indicate to him/her a change condition that would require an assessment;-Then he/she would document in the chart the resident's status and steps taken to address the change in condition. During an interview on 11/06/25, at 2:28 P.M., the Assistant Director of Nursing (ADON) said the following:-The majority of the time the resident is oriented, and he/she was not aware of the resident having any hallucinations and would consider that a change condition;-He/she was not aware of the resident having a change in condition, but would expect the nurse to assess a resident if they have a change in condition;-He/she took care of the resident the night before on 10/26/25 and he/she was not acting confused, but he/she did refuse to eat. During an interview on 11/06/25, at 3:05 P.M., at the DON said the following:-He/she initially thought that the resident's NP had assessed the resident due to there being lab orders;-He/she would expect a nurse to check on and assess any resident that is acting off or with a change in condition;-A change in condition should be reported to the DON and documented in the resident's progress notes;-He/she would expect a CNA to get the ADON or the DON if they report a change in condition and the nurse does not assess the resident. During an interview on 11/06/25, at 3:39 P.M., the Administrator said the following:-He/she was not aware of the resident having hallucinations;-He/she would have expected the nurse to assess the resident. A nurse should assess resident's if they have a change in condition;-He/she would expect there to be a note in the resident's chart regarding the resident's change in condition. 2653479

1.Please refer to event ID HP9H-H2, exit date 09/04/25, for citation details. Complaint #2572449 and #2586807

Based on observation, interview, and record review, the facility failed to document regarding identification of potential pressure ulcers, failed to document timely assessment and tracking for potential pressure ulcers, and failed to care plan regarding newly identified possible pressure ulcers. The facility census was 116.Review of the facility policy titled Wound Care and Treatment, undated, showed prevention strategies include on-going skin assessment with weekly documentation of status, minimize dry skin by applying lotion, avoid massage, minimize friction and sheer through proper positioning, transferring, and turning, and develop and implement a method of communication position changing. Review of the facility policy titled Care Area Assessments, dated March 2015, showed the following: -Care area assessments (CAA's) will be used to help analyze data obtained from the MDS and to develop individualized care plans;-CAA's are the link between assessment and care planning;-Triggered care areas will be evaluated by the interdisciplinary team to determine the underlying causes, potential consequences and relationships to other triggered care areas;-Review the triggered CAA's by doing an in-depth, resident-specific assessment of the triggered condition, which includes history taking, physical assessment, gathering of relevant information such as labs or tests and sequencing of clinically significant events;-The problem shall be defined by identifying the implications of the problem and the relationships between risk factors, triggers and problems;-Decisions about the care plan are made;-Document interventions on the care plan. Review showed the facility did not provide a policy regarding assessment of skin and wounds and documentation protocol of those wounds. 1. Review of Resident #1's face sheet (a brief look at the residents personal, incoming information) showed the following: -admission date of 03/02/22;-Diagnoses included Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement, but also involves non-motor symptoms), dementia (a general term for a decline in mental ability severe enough to interfere with daily life) and palliative care (specialized medical care focused on improving the quality of life for individuals with serious illnesses, like cancer, by managing symptoms and side effects of treatment). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 05/22/25, showed the following: -Cognitively impaired;-Dependent on staff assistance for all activities of daily living (ADL- to include dressing, bathing, transfers, and mobility). Review of the resident's care plan, dated 03/02/22, showed the following: -At risk for skin breakdown, with contractures, impaired mobility, incontinence, and disease processes;-Goal to be free from skin breakdown;-Apply moisture barrier as appropriate;-Check positioning in wheelchair and bed regularly;-Clean and dry skin after each incontinent episode;-During staff assisted showers, note and report any areas of redness/breakdown to the skin. Review of the resident's Physician Order Sheet (POS), dated 06/01/25 through 07/10/25, showed an order, dated 03/14/25, to apply barrier cream to left glute (buttock) two times a day (BID). Review of the resident's shower sheet, dated 06/06/25, showed the resident had redness to bilateral (both) buttocks and the peri-area. Review of the resident's progress notes, dated 06/06/25 through 06/11/25, showed staff did not document regarding the identified redness to the resident's buttocks. Review of the resident's POS dated 06/01/25 through 07/10/25, showed no new physician orders for the identified redness to the resident's buttocks. Review of the resident's care plan showed staff did not update the care plan regarding the identified redness to the resident's buttocks and any new treatments or interventions. Review of the resident's hospice shower sheet, dated 06/30/25, showed the resident had a small open area to the left buttock. Review of the resident's progress notes, dated 06/30/25, showed the resident had a small open area to the coccyx (a small triangular bone at the base of the spinal column). Hospice was notified. Review of the resident's weekly skin assessments showed staff had not completed a skin assessment completed since December 2024. Review of the resident's wound management log, dated 06/30/25, showed staff did not document regarding the discovered wound. Review of the resident's POS, dated 06/30/25 through 07/07/25, showed no new orders for the resident's open area. Review of the resident's progress notes, late entry dated on 07/10/25, at 9:56 A.M., for 07/06/25, at 9:56 A.M., showed the Director of Nursing (DON) observed the resident's area of concern to the right buttock, physician was notified, and new orders were placed. Hospice aware. Review of the resident's wound management log, dated 07/07/25, showed the resident had a stage two (an open wound that involves partial-thickness skin loss, affecting the epidermis and dermis) pressure ulcer to the left buttock, measuring 0.4 centimeter (cm) by 0.4 cm with a 0.1 cm depth. Peri-wound was pink/red and blanchable (skin that turns pale or white when pressed on and then quickly returns to normal when pressure is released.) No drainage present. Review of the resident's July 2025 POS showed an order, dated 07/08/25, to cleanse buttock wound with wound cleanser, apply calcium alginate (alginate dressings are a highly absorptive, non-occlusive dressing made of soft, non-woven calcium alginate fibers derived from brown seaweed or kelp) to the wound bed, and cover with an abdominal pad and tape daily. During an interview on 07/07/25, at approximately 11:20 A.M., Certified Nursing Assistant (CNA)/Shower Aide A, said the following: -Residents are changed every two hours or more often, if needed;-Most residents receive two showers a week;-He/she does give showers to the residents receiving hospice;-Shower aids are expected to document any skin issues onto the resident's shower sheet;-Skin issues would include any redness, open areas, bruising, any changes to the skin, and should be reported to the nurse;-Nurses will do an assessment if there are any reports of skin issues;-He/she has seen a red spot on the resident's coccyx in the past, while assisting with some of the residents personal care;-He/she was unsure of the date, but thinks it was a week, or so, prior to today's date of 07/07/25;-He/she did report the skin redness to the nurse and the nurse did put barrier cream on the resident's bottom. During an interview on 07/07/25, at approximately 11:40 A.M., CNA/Shower Aide B, said the following: -Residents receive showers twice a week, unless they request something different;-Hospice also provides showers;-Shower aides are expected to document any signs of redness, sores, or markings to the skin onto the shower sheet and pass onto the nurse;-If it is bad, the nurse will look right then but if not as bad, may look at it later but within the shift. During an interview on 07/07/25, at approximately 12:00 P.M., the Licensed Practical Nurse (LPN) C said the following: -He/she visits the resident twice a week;-Two aides also come twice weekly and an RN comes once a week;-There is a full-body skin assessment completed weekly;-Has seen there was a small red spot on the resident, but unsure when, as he/she did not do the last couple skin assessments and another nurse had completed;-It would be expected that the wound was assessed and reported to the physician and that nurses are treating the open area, as the physician has prescribed. During an interview on 07/07/25, at approximately 12:50 P.M., the Director of Nursing (DON) said the following: -Either the treatment nurse, or whichever nurse is on the floor, is expected to assess the resident's skin, when there are concerns;-Nurses are usually informed of skin concerns following an aide providing personal care, such as changing an incontinent resident or giving a resident a shower;-Nurses are expected to put barrier cream on the resident twice each shift, to ensure they are continuously assessing, and the aides are to use each time they change the resident;-The size of the open area on the right buttock small, measuring .2x.3, if that large;-The size of the open area on the left buttock is even smaller, measuring .2x.1;-The treatment orders had no date because he/she just added them earlier today. During an interview on 07/10/25, at approximately 10:25 A.M., Nursing Assistant (NA) D, said the following: -If there are any kind of skin concerns, he/she will immediately let a nurse know;-He/she will also turn the resident onto his/her side or in a different position, to relive any pressure;-He/she would expect the nurse to do a skin assessment right away;-He/she has not seen a nurse ignore anything such a skin concerns. During an interview on 07/10/25, at 10:40 A.M., LPN E said the following: -The facility has a treatment nurse Monday through Friday. The staff nurses only complete wound treatments on the weekends;-He/she has cared for the resident. The resident had two small open areas. One to the left buttock and one to the right buttock. At that time the ordered treatment was skin prep to the surrounding skin and barrier cream to the open areas, frequent repositioning, and to be laid down after meals. He/she and his/her staff had those areas healed about a week prior to this date;-He/she was then not scheduled to work for three days and when he/she came back to work, the resident had a large opening to the right buttock;-The treatment to the area has since changed to calcium alginate. They have also implemented a wedge for repositioning the resident;-The DON does the measurements on any open areas, weekly;-Skin assessments are to be completed weekly;-LPN looked in the resident's electronic medical record (EMR) and said the resident had not had a skin assessment completed since December 2024. This is due to the order being put in incorrectly;-The bath aides should also be filling out a shower sheet with any areas of concern, those sheets should be turned into the charge nurse. If a concern is reported, the charge nurse should call the doctor, call the residents family, document, and initiate a treatment;-Wounds and wound treatment should be visible in the resident's care plan. Observation on 07/10/25, at 10:45 A.M., showed the following: -The resident lay on his/her left side in bed. The wound was uncovered. The treatment nurse was in the room to provide wound care;-There was a pinpoint opening to the upper left buttock;-There was an open area to the upper right buttock, approximately larger than a golf ball. At least 25 % slough (non-viable tissue, yellow in color), at least 10 % eschar (non-viable tissue, black in color), with the rest of the tissue appearing to be granulation tissue (red healthy tissue);-Scant (small) amount of bloody drainage when the treatment nurse would cleanse the area. Moderate amount of yellow drainage also observed. No odor. During an interview on 07/10/25, at approximately 10:45 A.M., CNA F said the following:-He/she is unsure who does skin assessments but thinks it is a nurse;-When asked who he/she would report skin concerns to, he/she said the nurse;-He/she thinks nurses do skin assessments weekly. During an interview on 07/10/25, at 11:05 A.M., the DON said the following: -She measures wounds weekly, but is usually a week behind with her documentation and has to backdate the information;-She was told about the wound on 07/07/25 and observed the resident's wounds on that date, at that time the resident had a pea-sized area to the right buttock which was dusky colored with granulation tissue present. Treatment of barrier cream was already in place. That treatment was appropriate for the left side wound, however due to decline of the right buttock wound, the treatment was changed to calcium alginate;-Initially the wound was documented as pressure;-Skin assessments are expected to be completed weekly by the treatment nurse;-If a staff member discovers a new or worsened wound, they should immediately report it to the charge nurse, herself, and notify the physician and/or hospice team;-She measured the wounds as one whole wound which is why she documented it as a wound to the left buttock versus the right. She will update and correct that in the resident's EMR;-Wounds and wound treatment should be found in the care plan. During an interview on 07/10/25, at approximately 11:30 A.M., Licensed Practical Nurse (LPN) G, said the following: -He/she is an MDS coordinator, so he/she will enter information regarding the resident's care, onto the care plan;-The information regarding the resident comes from nurse's assessments, reports from staff, risk management meetings, and wound and therapy reports;-The weekly skin assessments are discussed weekly by all staff at the risk management meetings;-The skin assessments should be completed by the nurses. During an interview on 07/10/25, at approximately 11:55 A.M., Registered Nurse (RN) H, said the following: -He/she was an MDS coordinator;-The ADON or DON should be letting him/her know at the risk management meeting, if there has been a change in condition, for any resident;-The information gets to the ADON or DON from one of the RN's on the floor, who does assessments on residents;-Assessments are to be done weekly;-Any skin issues should be put on the care plan;-When any skin integrity issues are brought to his/her attention, the problem, interventions or treatments and goals are set, as well as following the progress of the healing and updating, as needed. During an interview on 07/10/25, at approximately 12:35 P.M., RN I said the following: -He/she is an RN and also a case manager for the resident;-He/she had just learned about the pressure ulcer on the resident, this past Monday, 07/07/25;-He/she saw it for the first time on 07/08/25;-The physician orders had already been updated by the time he/she had seen the open area on the resident. During an interview on 07/10/25, at approximately 12:50 P.M., the Administrator, said the following: -Skin assessments are expected to be done weekly, as scheduled, for all residents;-If the nurse is notified of a skin issue or an assessment finds this to be the case, the nurse is expected to report this to the DON and then the physician, for orders;-Everything regarding skin issues should be care planned. Complaint #1759506

1.Please refer to event ID HP9H-H2, exit date 09/04/25, for citation details. Complaint #2572449 and #2586807

Based on interview and record review, the facility failed to ensure all residents' right to free from misappropriation was protected when medication of three residents (Resident #1, Resident #2, and Resident #3) went missing and were unaccounted for while in the possession of the facility. The facility had a census of 110. Review of the facility provided document titled, The National Consumer Voice Fact Sheet: Abuse, Neglect, Exploitation, and Misappropriation of Property, showed federal law gave each nursing home resident the right to quality care and quality of life. This included freedom from neglect, abuse, exploitation, and misappropriation of property. Review of the facility's Abuse Prohibition Protocol Manual: Identification, undated, showed the following: -It is the policy of the facility to identify, correct, and intervene in situations in which physical and mental abuse, neglect, adverse events, exploitation, mistreatment, involuntary seclusion, and/or misappropriation of resident's property may occur; -Monitoring for indicators of abuse, mistreatment, exploitation, neglect, misappropriation will be conducted by all staff and reported immediately to the Administrator and/or Director of Nursing (DON). Staff will intervene appropriately. 1. Review of the facility's completed investigation, dated 06/05/25, showed the following: -On 05/28/25, at 12:00 A.M., a nurse reported the DON that he/she suspected a certified medication tech (CMT) had popped bills out of a card, tore the top off, and put the pills in a pocket; -On 05/29/25, at 9:30 A.M., a nurse reported finding three labels for three medication cards containing gabapentin (medication used to treat nerve pain and seizures) in the shred bin. The cards belonged to Resident #1, Resident #2, and Resident #3; -The audit showed approximately 60 gabapentin were missing. 2. Review of Resident #1's face sheet showed the following: -admission date of 08/15/24; -Diagnoses included pain. Review of the resident's pain care plan, dated 08/15/24, showed the following: -Resident was at risk for altered comfort related to weakness, impaired mobility, and disease processes; -Staff to observe resident for effective pain management; -Staff to assess the resident routinely for the presence of pain and document the onset, location, quality, and intensity of the pain; -Staff to consider the type and source of pain when selecting relief strategies; -Staff to administer pain medications as ordered. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/12/25, showed the following: -Resident had moderately impaired cognitive skills; -Staff administered scheduled pain medication. Review of the resident's most recent Physician Order Sheet (POS) showed the following: -An order, dated 08/22/24, for staff to assess the resident's pain weekly using a pain scale of 0 to 10; -An order, dated 09/26/24, for gabapentin 300 milligram (mg) oral capsule twice a day. Review of the pharmacy proof of delivery packing slip, dated 05/16/25, showed the pharmacy delivered two cards of the resident's 30 gabapentin 300 mg (60 total tablets). Review of the resident's May 2025 medication administration history showed the following: -An order, dated 9/26/24, for staff to administer gabapentin 300 mg orally twice a day (once between 6:00 A.M. and 10:00 A.M. and and once between 6:00 P.M. and 10:00 P.M.) for diagnoses of neuralgia (nerve pain) and neuritis (nerve inflammation); -Beginning 05/19/25, staff documented the medication was not given because the resident was in the hospital. During an interview on 06/03/25, at 12:05 P.M., the DON said the following: -Staff found a gabapentin label for the resident in the shred bin; -The resident was in the hospital at the time of the discovery; -On 05/16/25, the pharmacy filled a card of 30 gabapentin pills and the resident should have had 25 pills left when he/she went to the hospital on [DATE]. Staff could not locate any gabapentin for the resident. 3. Review of Resident #2's face sheet showed the following: -admission date of 03/18/25; -Diagnoses included pain. Review of the resident's admission MDS, dated [DATE], showed the following: -Resident had moderately impaired cognitive skills; -Staff administered scheduled and as needed pain medication to the resident; -Indicators of pain in the last five days included, non-verbal sounds, facial expressions, and protective body movements. Review of the resident's current physician orders showed: -An order, dated 03/18/25, for gabapentin 800 mg, three times a day; -An order, dated 03/25/25, for pain assessment every week (scale 0 to 10). Review of the resident's pain care plan, dated 03/31/25, showed the following: -Resident was at risk for altered comfort related to weakness, impaired mobility, and disease processes; -Staff to observe resident for effective pain management; -Staff to assess the resident routinely for the presence of pain and document the onset, location, quality, and intensity of the pain; -Staff to consider the type and source of pain when selecting relief strategies; -Staff to administer pain medications as ordered. Review of the pharmacy proof of delivery packing slip, dated 05/06/25, showed the pharmacy delivered three cards of the resident's 30 gabapentin 800 mg (90 total tablets). Review of the resident's May 2025 medication administration history showed: -An order, dated 03/18/25, for staff to administer gabapentin 800 mg orally three times a day (once between 6:00 A.M. and 10:00 A.M., once between 12:00 P.M. and 4:00 P.M., and once between 6:00 P.M. and 10:00 P.M.) for diagnosis of generalized muscle weakness. -Staff initialed administration of doses of the medication from 05/01/25 to 05/31/25, with the following exceptions: During an interview on 06/03/25, at 12:05 P.M., the DON said the following: -Staff found a gabapentin label for the resident in the shred bin; -The resident currently resided at the facility; -On 05/06/25, the pharmacy filled three cards of 30 gabapentin pills and the resident should have had 55 pills remaining, but staff could only locate 30 pills of gabapentin for the resident. 4. Review of Resident #3's face sheet showed: -admission date of 03/03/22; -Diagnoses included spinal muscular atrophy (causes progressive muscle weakness and wasting), contractures (shortening, hardening or muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both hands, and muscle weakness. Review of the resident's pain care plan, dated 03/31/22, showed the following: -Resident was at risk for altered comfort related to weakness, impaired mobility, and disease processes; -Staff to observe resident for effective pain management through next review; -Staff to assess the resident routinely for the presence of pain, document the onset, location, quality, and intensity of the pain; -Staff to consider the type and source of pain when selecting relief strategies; -Staff to administer pain medications as ordered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident had moderate cognitive impairment; -Staff administered scheduled and as needed pain medications for occasional pain. Review of the resident's current physician orders showed the following: -An order, dated 10/18/23, for gabapentin 600 mg, three times a day; -An order, dated 10/25/23, for pain assessment every week (scale 0 to 10). Review of the pharmacy proof of delivery packing slip, dated 05/19/25 showed the pharmacy delivered three cards of the resident's 30 Gabapentin 600 mg (90 tablets total). Review of the resident's May 2025 medication administration history showed the following: -An order, dated 10/18/23, for staff to administer gabapentin 600 mg orally three times a day (once between 6:00 A.M. and 10:00 A.M., once between 12:00 P.M. and 4:00 P.M., and once between 6:00 P.M. and 10:00 P.M.) for diagnosis of chronic pain syndrome. During an interview on 06/03/25, at 12:05 P.M., the DON said the following: -Staff found a gabapentin label for the resident in the shred bin; -The resident currently resided at the facility; -On 05/18/25, the pharmacy filled three cards of 30 gabapentin pills (90 pills) and the resident should have had approximately 60 pills left. but staff could only locate 30 pills of gabapentin for the resident. 5. During an interview on 06/05/25, at 9:35 A.M., Licensed Practical Nurse (LPN) D said the following: -On the night of 05/28/25, while working with CMT C, the LPN heard multiple popping noises, at least 8 times. The LPN turned around saw the CMT tear off the top portion of a pill card and toss it into the shred box. The LPN saw the CMT placed his/her hand into the front pocket of his/her backpack and appeared to drop something into the pocket; -The LPN called the DON and the DON told the nurse to confront CMT C. The LPN left the nurse's station to get the other nurse and when the two nurses returned to the area, the CMT had left the building. This occurred at the end of the CMT's shift. -The LPN checked the shred bin and found resident medication card prescription labels for gabapentin. During an interview on 05/30/25, at 11:00 A.M., Licensed Practical Nurse (LPN) A said the following: -Only nurses and CMTs had access to the resident medications; -Medications are kept locked in the medication cart or locked in the medication room. During an interview on 05/30/25, at 11:53 A.M., CMT B said the following: -In the past, when a nurse or CMT used the last of a resident medication, he/she was supposed to tear the label off the medication and place the label in the shred box before disposing of the empty card to protect the resident's health information; -If he/she suspected a staff member of taking resident medications, he/she would immediately notify his/her charge nurse; -Staff administered resident medications as ordered; -On 05/29/25, he/she arrived for work and LPN D said he/she saw CMT C pop resident medication out of a bubble pack card and place the medication in the CMT's backpack; -The LPN said he/she notified the DON of the situation; -LPN D went to get another nurse before confronting the CMT and by the time he/she returned to the unit, the CMT had left the facility; -The nurses opened the locked shred box to look for medication labels; -Nurses found a label for Resident #1's gabapentin, but the resident was in the hospital and should not have been out of gabapentin; -Nurses found a label for Resident #2's gabapentin, but this resident should not have been out of his/her supply of the medication. During interviews on 05/30/25, at 12:56 P.M. and at 2:55 P.M., and on 06/03/25, at 3:56 PM., the DON said the following: -On Wednesday night (05/28/25), the LPN D called the DON and reported he/she thought CMT C had taken some pills from the medication room and placed these pills into his/her backpack; -LPN D also reported he/she saw CMT C throw some medication labels from bubble packs into the shred bin; -The DON instructed the LPN to ask the CMT about the medication and ask to check his/her back pack; -The LPN went to get another nurse as a witness and while gone to do so, CMT C left the facility; -The next morning nurses discovered three residents with missing cards of gabapentin. They were Resident #1, Resident #2, and Resident #3; -The facility CMTs generally order the resident medications; -If staff discover or someone makes an allegation of misappropriation of resident medication, staff should immediately go to the charge nurse or to the DON; -The nurse should immediately report all allegations or misappropriation to the DON; -As the DON, he/she would notify the Administrator of the allegation; -For allegations of misappropriation, staff notifies the Department of Health and Senior Services (DHSS), the facility notifies the resident and/or responsible party, the resident physician, assess the resident for pain or signs/symptoms of oversedation, and submit a completed investigation to DHSS within 5 days. During an interview on 06/03/25, at approximately 4:05 P.M., the Administrator said the following: -No staff were allowed to take any resident medications; -The LPN who observed the issue immediately called the DON and the DON notified DHSS within 24 hours. MO00254977

Based on observation, record review, and interview, the maintain residents free from accident hazards when the facility failed to fully document fall events/investigations and to follow, update, develop, and ensure the accuracy of care plans and failed to implement new interventions in attempt to prevent falls consistent with the residents' physical and cognitive abilities for four residents (Residents #1, #3, #4 and #5). The facility census was 114. Review of the facility's policy Fall Prevention Manual, dated 06/2006, showed the following: -Identify all current residents at risk for falls at the beginning of the program using the facility risk assessment form or a chosen form. This should be done by the charge nurse, supervising registered nurse, or interdisciplinary care team (IDT); -Assess all new residents for fall risk on admission using an additional fall assessment screen. The form should be completed within the first 12 hours following admission by the admitting nurse, or the oncoming nurse; -Implement a resident orientation program, making social services and nursing accountable for providing information. Orient all new residents to the facility. Concentrate on areas which are of particular importance for the resident based on assessment and resident interview; -Reassess all residents as a part of quarterly assessment and care planning; -The effectiveness of a facility's fall prevention program should be part of continuous quality improvement. Keep a fall log to analyze causes of falls and facility trends or needs. The data in the log may point to variables that are present when falls commonly occur. Review the surveillance fall log to make sure the process is working, and falls are being prevented. Include tracking of falls on new admissions as an indicator of the effectiveness of fall risk assessment and orientation; -Once trends are identified, review the trend for a potential cause for this group of falls (do not assume the cause); implement an action plan based on root cause; set a re-evaluation date to determine how the solution is working; and perform follow-up and document results; -Continue the action, if it is working, or perform additional analysis as to why it is not working and decide on a new action plan for implementation; -Investigate the fall to determine cause; -Log the fall, remove cause of fall, if possible. If cause can't be removed, revise plan to further address risks. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE] -Diagnoses included cerebrovascular disease (a group of conditions that affect the blood vessels in the brain, leading to reduced blood flow and oxygen supply to the brain), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (refers to a condition where a person experiences weakness or paralysis on the left side of their body due to a stroke (cerebral infarction) that damaged the right side of their brain, which controls the left side of the body), muscle weakness, and repeated falls. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff),dated 12/08/24, showed the following: -The resident was cognitively intact; -The resident used a walker and a wheelchair; -The resident had two falls since admission with minor injury. Review of the resident's care plan, dated 01/27/24 and updated 01/29/24, showed the following: -The resident was at risk or falls with history of falls prior to admission, impaired mobility/vision, use of tethering equipment, medication regimen, weakness, and disease processes; -Avoid clutter on resident's floor surface; -Avoid unnecessary rearrangement of resident's physical environment; -Complete resident fall assessment quarterly and as needed; -Ensure that resident was positioned appropriately; -Ensure that the resident was wearing appropriate footwear that fits well, fastened securely, and had nonskid soles; -If resident had a fall, do an assessment, including vital signs, prior to moving him/her. Notify resident's family and physician. Complete documentation per facility policy protocol; -Keep call light within reach in his/her room; -Keep needed items within easy reach; -Observe for any changes in condition that may warrant increased supervision/assistance and notify his/her physician. Review of the resident's Fall Risk Assessment, dated 12/09/24, showed staff assessed the resident as a high fall risk. Review of the resident's nurses' notes dated 01/08/25, at 3:29 P.M., showed Registered Nurse (RN) D said a certified nurse aide (CNA) walked by the resident's room and saw resident lying on the floor on his/her left side. The resident denied pain and no injury noted was noted. The resident was assisted to the wheelchair. The resident was able to stand and bear weight. The call light was in reach and neuro check were started. Review of the resident's fall event dated 01/08/25, at 3:28 P.M., showed the following: -The fall was unwitnessed with no injury; -The fall occurred in the resident's room; -Staff did not complete the assessment and intervention portion; -Vital signs were normal -Staff did not note review of the care plan; -Physician notified; -Event observation completed for new fall follow-up, fall prevention program initiated, and care plan updated. Review of the resident's care plan showed staff did not update the care plan with the fall or any new interventions to prevent future falls. Review of the resident's fall event dated 01/13/25, at 8:50 A.M., showed the following: -The fall was witnessed with no injury. Neurological assessments were initiated; -The fall occurred in the resident's room -The fall was unwitnessed. The facility must begin 72 hour neurochecks per protocol and document appropriately; -The resident was ambulating just prior to the fall; -Resident had no pain; -Resident had no injury; -Range of motion was without pain or limitations with no rotation, deformity or shortening noted; -Resident was alert; -Staff did not complete the neurological check section; -Possible contributing factors included resident had a wheelchair present, but was not using it; -Immediate measures taken were none; -Preventative interventions implemented (care plan updated) were shoes with non-skid soles and assist resident to bed if tired; -Outcome of interventions were somewhat effective, describe below (no description given); -Staff noted care plan was not reviewed; -Physician notified; -Event observation completed for new fall follow-up, fall prevention program initiated, and care plan updated. Review of the resident's care plan showed staff did not update the care plan with the fall or any new interventions to prevent future falls. Review of the resident's fall event dated 01/23/25, at 8:00 P.M., showed the following: -The resident was observed on the floor with no injury. Neurological assessments were initiated; -The resident was self-transferring to bed; -The fall was unwitnessed and the facility must begin 72 hour neurochecks per protocol and document appropriately; -Resident had pain to the left shoulder; -Resident had no injury; -Range of motion was without pain or limitations with no rotation, deformity or shortening noted; -Resident was alert; -Neurochecks were normal; -Possible contributing factors included cardiac respiratory disease; -Immediate measures taken were none; -Preventative interventions implemented (care plan updated) was monitor; -Outcome of interventions: No interventions used; -Care plan was not reviewed; -Physician notified; -Event observation completed for new fall follow-up, fall prevention program initiated, and care plan updated. Review of the resident's care plan showed on 01/24/25 staff updated the care plan with initiate facility fall protocol. Staff did not update the care plan with recent falls or new interventions. Review of the resident's fall event, dated 02/14/25, showed the following: -The resident was observed on the floor with no injury. Neurological assessments were initiated; -The resident was transferring in the bathroom; -The fall was unwitnessed and the facility must begin 72 hour neurochecks per protocol and document appropriately; -Resident had no pain; -Resident has no injury; -Range of motion was without pain or limitations with no rotation, deformity or shortening noted; -Resident was alert; -Neurochecks were normal; -Possible contributing factors - none of the above; -Resident takes analgesics and antihypertensives; -Immediate measures taken - none; -Preventative interventions implemented (care plan updated updated), shoes with non-skid shoes; -Outcome of interventions. Interventions somewhat effective, describe below (there was no description given); -Care plan was not reviewed; -Physician not notified; -Vital signs taken; -Event observation completed for new fall follow-up, fall prevention program initiated, and care plan updated. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event, dated 02/16/25, showed the following: -The resident was observed on the floor with a gash to the back of the head. Neurological assessments were initiated; -The fall was unwitnessed and the facility must begin 72 hour neurochecks per protocol and document appropriately; -Resident had mild (2/10) pain on the back of the left side of head and left shoulder; -The resident had an abrasion/laceration; -Range of motion was without pain or limitations with no rotation, deformity or shortening noted; -Resident was alert; -Neurochecks were normal; -Possible contributing factors - cardiac/respiratory disease; -Resident takes analgesics and antihypertensives; -Immediate measures taken - direct pressure to wound; -Preventative interventions implemented (care plan updated updated) - monitor frequently; -No interventions used; -Physician and next of kin notified; -Order received for resident to be sent to the hospital for evaluation and treatment. Review of the resident's nursing notes showed the following: -On 02/16/25, at 2:00 A.M., showed Licensed Practical Nurse (LPN) noted at 12:35 A.M., the staff heard a thud and went to the resident's room. The resident was observed laying on the floor in front of the sink on the left side. There was bleeding from the left side of the back of his/her head. There was a laceration to the left side of the back of the head. It was approximately 1 1/2 inches long. A pressure dressing was applied. Neuro checks within normal limits. Range of motion (ROM) was assessed. The resident was assisted up with two person assistance to bed. The resident had walked to the sink with the walker. The physician was notified at 12:42 A.M. and orders were received to send the resident to the hospital for evaluation and treatment. Attempts were made to reach the resident's family. At 12:50 A.M., hospice was notified. At 12:55 A.M., the ambulance arrived and resident was transferred to the hospital at 1:20 A.M. Review of the resident's nursing notes, showed the following: -On 02/17/25, at 12:36 A.M., LPN A noted the resident continued on fall monitoring for recent fall. The staples were intact to the back of the head. Neuro checks are within normal limits for the resident. Resident was resting quietly; -On 02/17/25, at 11:30 P.M., Registered Nurse (RN) B noted the resident was on fall follow up for unwitnessed fall with injury. Neuro checks are unchanged from baseline. The staples were intact to wound on the back of the head. The residents said it was sore. The resident was re-educated on the need to call for assistance prior to getting up. Staff will continue to monitor; Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. During an interview on 02/28/25, at 8:48 A.M., the resident said the following: -He/she had multiple falls at the facility; -The last fall happened due to wearing slippers that were slippery on the bottom. He/she cut his/her head open when he/she fell . Observations on 02/28/25, at 8:48 A.M. and 2:40 P.M. showed the resident's door frame did not show a leaf that staff used to designate that the resident was at risk of falls. 31464 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included cognitive communication deficit, muscle weakness, osteoarthritis, low back pain, abnormality of gait and mobility, insomnia, and left hip fracture. Review of the resident's care plan, dated on 12/30/24, showed the following: -Resident at risk for falls related to altered cognition and impaired mobility; -Staff to keep call light in reach, monitor for any change in condition, provide standby assistance for mobility, complete my fall risk assessment quarterly and as needed, and ensure appropriate footwear that fits well, fastens securely, and has nonskid soles. Review of the resident's fall event report, dated 01/04/25, showed the resident had an unwitnessed fall. Resident was observed on floor with possible injury to the left hip. Staff began neuro checks and completed full assessment. Resident complained of moderate pain to left hip. Review of the resident's nurses' notes showed staff documented the following: -On 01/04/25, at 11:05 P.M., resident was found on the floor on his/her back. Resident complained of left hip pain. Physician ordered on-site x-ray and mobile x-ray unable to respond until 8:00 A.M. Physician was made aware; -On 01/05/25, staff noted x-ray negative. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's admission MDS, dated [DATE], showed the following information: -Resident had moderately impaired cognition; -Resident dependent on assistance for wheelchair mobilization, dressing, personal hygiene, bed mobility, standing from sitting, and bed/chair transfers; -Ambulation did not occur during the 7-day look back period. Review of the resident's fall event report, dated 01/16/25, showed the following: -An unwitnessed fall with injuries and skin tears to left forehead and left wrist; -Staff began 72-hour neurochecks per protocol and to document appropriately; -Staff document full assessment documented and complaint of left leg pain; -Interventions immediate measures of first aid. Preventative interventions of encouraged to use call light for assistance; -Outcome of interventions: no interventions used, resident in bed resting at this time. Review of the resident's nurses' notes showed staff documented the following: -On 01/16/25, at 12:55 A.M., resident was alert and oriented to person and place with periods of confusion and restless at times and easily redirected; -On 01/16/25 at 10:05 P.M., aide reported a fall. Nurse observed resident lying down on his/her left side with skin tears to forehead that measured 0.4 centimeters (cm) and left wrist 1.0 cm. Resident complained of pain and was unable to tell staff what happened. Staff obtained order for x-ray in the morning. Staff will continue to monitor; -On 01/17/25, at 12:05 A.M., resident alert to person and place with periods of confusion, trying to get out of bed without assistance. Resident required total assist with cares and used wheelchair for mobility; -On 01/17/25, at 9:23 A.M., resident noted to have left hip fracture related to fall on 01/16/25 that was confirmed by mobile x-ray. Family advised and physician advised of results. Resident sent to hospital at 9:10 A.M. for evaluation and treatment. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. 3. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included arthritis, osteoporosis, left pubic fracture (on admission), insomnia, restlessness and agitation, hallucinations, repeated falls (on admission), osteoarthritis to right shoulder, and chronic pain. Review of the resident's admission MDS, dated [DATE], showed the following information: -Resident had moderate to severely impaired cognition; -Resident required partial to moderate assistance for toileting hygiene and upper body dressing; -Resident required substantial to maximal assistance for bed mobility, standing from sitting, bed/chair transfers, and ambulation of 10 feet. Review of the resident's care plan, dated 12/31/24, showed the following: -Resident at risk for falls related to history of falls, altered cognition, impaired mobility, medication regimen, general debility, and disease processes; -Staff to avoid clutter on floor surface, complete fall risk assessment quarterly and as needed, ensure appropriate footwear that fits well, fastens securely, and has nonskid soles, and place a fall mat next to the bed. Review of the resident's fall event report, entered 01/01/25 at 1:16 A.M., showed the following: -Event date of 12/31/24 at 6:30 P.M.; -Resident found lying in floor next to bed; -Unwitnessed fall. Staff began 72-hour neurochecks per protocol and to document appropriately; -Full assessment documented with no injuries noted and resident denied pain. Resident exhibited agitation, anxiety, and confusion; -Resident placed at nurses' station for monitoring; -Falls Prevention Program initiated and care plan updated. Review of the resident's fall event report, entered 01/01/25 at 1:44 A.M., showed the following: -Event date of 12/31/25 at 8:00 P.M.; -Resident found by staff lying in floor of room next to bed; -Interventions was left blank; -No injuries noted; -Vital signs documented; -Falls Prevention Program initiated and care plan updated. Review of the resident's fall event report, entered 01/01/25 at 2:41 A.M., showed the following: -Event date of 01/01/25 at 1:00 A.M.; -Resident found lying in floor of room next to bed and stated, I had to help my roommate. Resident had placed roommate in chair; -Interventions were left blank; -Resident refused vital signs and full assessment; -Falls Prevention Program initiated and care plan updated. Review of the resident's fall event report, entered on 01/01/25 at 5:57 A.M., showed the following: -Event date of 01/01/25 at 5:57 A.M.; -Resident found lying in floor next to bed and unable to state what happened; -Unwitnessed fall and staff began 72-hour neurochecks per protocol and to document appropriately; -No injuries noted and resident denied pain; -Interventions of other and left blank. Outcome of interventions noted no interventions used; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurses' notes showed staff documented the following: -On 12/31/24, at 6:30 P.M., resident found by staff lying in floor of room next to bed and unable to say what occurred. Staff noted no injuries and placed resident back in bed. Staff informed physician and family; -On 12/31/24, at 8:00 P.M., resident found by staff lying in floor next to bed and unable to say what occurred. Staff noted no injuries and placed resident in wheelchair and brought to nurses' station for observation. Staff informed physician and family; -On 01/01/25, at 1:00 A.M., resident found on floor next to bed. Resident stated he/she had to help his/her roommate and had gotten roommate up to wheelchair. Resident refused vital signs and full assessment. Resident placed in wheelchair and sat by nurses' station for monitoring; -On 01/01/25, at 5:52 A.M., resident found lying on floor of room next to bed and unable to state what occurred. Staff noted no injuries noted and placed resident back in bed. Staff informed family of all falls and physician to be notified by day shift; -On 01/01/25, at 5:59 A.M., resident found lying in floor of room next to bed with no injuries noted. Resident refused assessment and staff informed family informed; -On 01/01/25, at 6:13 A.M., staff informed Assistant Director of Nursing (ADON) of all falls. Review of the resident's care plan showed staff did not update the care plan with the falls or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/07/25 at 2:52 P.M., showed the following: -Event date of 01/07/25 at 2:51 P.M.; -Resident found on floor beside his/her bed; -The fall was unwitnessed fall and staff begin 72-hour neurochecks per protocol and to document appropriately; -Resident had bruising/hematoma with no location noted; -Interventions included rest, fall mat placed, and use of relaxation techniques such as white noise, soothing music, fish tank; -Outcome of interventions were somewhat effective; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 01/08/25, at 12:57 A.M., showed the resident continued on fall monitoring and had a bruise to right side of face from previous fall. Vital signs and range of motion (ROM) within normal limits (WNL) to baseline. Resident did not complain of pain or discomfort. Staff will continue to monitor. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/10/25 at 1:57 P.M., showed the following: -Event date of 01/09/25 at 7:45 P.M.; -Observed resident on floor beside bed with no injury noted and neurochecks initiated; -Resident had dozed off. Resident assisted up with two assist. Resident stated that he/she was trying to get into bed, but didn't quite make it. Neuros initiated and baseline for resident. Resident with advanced dementia and no retention to educate. Vital signs stable. Staff assisted to bed with bed in low position and mat beside bed. -Fall was unwitnessed and staff began 72-hour neurochecks per protocol and to document appropriately; -Mental status of confusion and sleepiness; -Possible contributing factors included recent decline in ADLs (activities of daily living) abilities and dementia; -Resident on antipsychotics and anti-anxiety medications; -Interventions of fall mat placed, ensure necessary items are in reach, and assist resident to bed when tired were somewhat effective; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's notes showed a late entry dated 01/10/25, at 2:04 A.M., for 01/09/25 at 7:59 P.M. Resident observed lying on floor beside bed. Resident had dozed off. Staff assisted resident up with two assist. Resident stated that he/she was trying to get into bed, but didn't quite make it. Neuros initiated and baseline for resident. Resident with advanced dementia and no retention to educate. Vital signs stable. Staff assisted to bed with bed in low position and mat beside bed. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/10/25 at 2:03 P.M., showed the following: -Event date of 01/10/25 at 2:00 P.M.; -Observed on the floor at the foot of his/her bed with no injury and neurochecks initiated; -Resident stated he/she went to get up to put him/herself to bed and slipped and fell . Resident denied pain or discomfort; -Fall was unwitnessed fall and staff began 72-hour neurochecks per protocol and to document appropriately; -No changes in mental status; -Interventions noted to ensure necessary items are in reach and assist resident to bed when tired; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 01/10/25, at 2:08 P.M., showed the resident was observed lying on the floor at the foot of his/her bed. Resident stated that he/she went to get up to put him/herself to bed and slipped and fell . Resident denied any pain or discomfort and had full range of motion (FROM). Neurochecks initiated and at baseline for resident. Staff notified physician and family. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/14/25 at 5:54 P.M., showed the following: -Event date of 01/14/25 at 12:00 P.M.; -Witnessed fall with no injury; -Interventions of non-slip socks; -Falls Prevention Program initiated and care plan updated. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 02/09/25 at 11:57 A.M., showed the following: -Event date of 02/09/25 at 10:00 A.M.; -Resident was heard to yell out. Upon entering room staff observed resident sitting on the floor. Resident stated he/she was trying to go to the bathroom and slipped and fell . Brief noted on the floor with a puddle under resident's feet. Resident had a small laceration to back of head and right elbow. Area to back of the head cleaned with wound cleanser and covered with one steri-strip. Resident denied pain and neurochecks initiated; -Fall was unwitnessed fall and staff began 72-hour neurochecks per protocol and to document appropriately; -No change in mental status; -Immediate intervention of first aid; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 02/09/25, at 10:10 A.M., showed resident was heard to yell out. Upon entering room resident was observed sitting on the floor. Resident stated he/she was trying to go to the bathroom and had slipped and fell . Brief noted on the floor with a puddle under resident's feet. Resident had small laceration to back of head and right elbow. Area to back of the head cleaned with wound cleanser and pressure applied until bleeding stopped. Area to right elbow cleansed with wound cleanser and covered with one steri-strip. Resident denied any pain or discomfort. FROM to all extremities. Resident assisted up via two staff members. Staff initiated neuros and at baseline for resident. Staff notified physician and family. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 02/23/25 at 10:04 A.M., showed the following: -Event date of 02/23/25 at 6:30 A.M.; -Fall was witnessed. Resident was sitting at the nurses' desk and stood up out of her wheelchair, slipped on the floor, fell , and hit her head on the counter with no injuries noted. Staff completed full assessment and neurochecks initiated. Staff will continue to monitor. Review of the resident's nurse's note dated 02/23/25. at 6:30 A.M., resident was sitting at the nurses' desk and stood up out of her wheelchair, slipped on the floor, fell , and hit her head on the counter with no injuries noted. Resident had FROM to all extremities. Resident assisted up via two staff members. Staff initiated neuros and resident at baseline for resident. Staff notified physician and family. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Observation on 02/27/25, at 9:30 A.M., showed the resident rested in bed that was was in the lowest position. A wheelchair was positioned close to the bed. A fall mat was folded in half and was standing on edge at the foot of the bed. Observation on 02/27/25, at 10:56 A.M., showed the resident rested in bed with his/her eyes closed. A fall mat was fold up and positioned at the foot of the bed. Observation on 02/28/24, at 2:15 P.M., showed the resident rested on his/her bed. A wheelchair was positioned close to the bed with wheels locked and a fall mat was folded up close to the vacant bed across the room. The resident's doorframe did not have a maple leaf magnet attached to it. 4. Review of Resident #5's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease with late onset, dementia, delusions, history of repeated falls, and difficulty with near vision. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -No ambulation and used manual wheelchair, assisted by staff; -Dependent on others for eating, hygiene/bathing, dressing, sitting/lying/ sitting/standing, and chair/bed transfers; -No functional limitation on upper or lower extremities; -Falls since prior assessment (quarterly (dated 10/16/24)) were two without injury, two with minor skin injury, and none with major injury. Review of the resident's significant change MDS assessment, dated 01/26/25, showed the following; -Severely impaired cognition; -No ambulation, manual wheelchair assisted by staff; -Dependent on others for eating, hygiene/bathing, dressing, sitting/lying, sitting/standing, and chair/bed transfers; -No functional limitation on upper or lower extremities; -No falls since prior assessment. Review of the resident's care plan, initiated on 04/15/24 and last reviewed/revised 01/29/25, showed the following; -Resident required assist of one to two staff for ADLs related to severe cognitive loss, impaired mobility, weakness, and disease processes; -Resident preferred to be in the floor at times and this was a long-term habit; -Resident up daily to a wheelchair via one to two assist and required assistance for locomotion; -Resident at risk for falls related to history of falls, impaired safety awareness, impaired mobility, medication regimen, general debility, and disease processes; -Resident slept on mattress in the floor to ensure safety and was personal preference to sleep in the floor; -Initiate facility fall protocol; -Avoid clutter on the floor surface; -Complete a fall risk assessment quarterly and as needed; -Ensure resident wears appropriate footwear that fits well, fasten securely, and has non-skid soles; -If resident falls, do an assessment, including vital signs, prior to moving. Review of the resident's fall event report, entered on 12/01/24 at 5:46 P.M., showed the following: -Event date of 12/01/24; -Witness stated resident was rocking in wheelchair, pushing table, and suddenly slid out of wheelchair onto floor. Witness stated resident did not hit head. Resident agitated and appeared anxious. Certified medication technician (CMT) to give resident medication for anxiety. Staff assisted resident assisted up into wheelchair and placed at table to eat dinner. Staff Will continue to monitor; -No pain reported and no injury noted; -Immediate interventions of none. Preventative interventions of fall mat placed and shoes with non-skid soles; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note, dated 12/01/24, showed witness stated resident was rocking in wheelchair, pushing table, and suddenly slid out of wheelchair onto floor. Witness stated resident did not hit head. Resident agitated and appears anxious. CMT to give resident anxiety medication. Staff assisted resident up into wheelchair and placed at table to eat dinner. Staff will continue to monitor. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall e [TRUNCATED]

1. Please refer to event ID XGPT712, exit date 08/16/23, for citation details. MO00222956

Based on interview and record review, the facility staff failed to ensure the safety of all residents when lack of staff supervision on the locked special care (memory) unit resulted in extended resident to resident interaction that ended with one resident (Resident #2) pushing one resident (Resident #1) to the floor resulting in one resident (Resident #1) sustaining a hip fracture. A sample do 25 residents were reviewed in a facility with a census of 94. Review of the facility policy titled, Routing Monitoring of Events (Incidents and Accidents), dated 11/14/16, showed the following: -This is a general guideline for event monitoring, to include, but not limited to bruises, skin tears, and falls; -Event prevention and actions to minimize them are ongoing each shift/day. Staff should report and/or take action for circumstances that may result in an event or lessen the likelihood of an event; -Events are reviewed at the time of occurrence by staff on duty, looking for causes and or methods/actions to minimize future occurrence; -Events are monitored/reviewed by management daily, not including weekends and holidays. However, events triggering the abuse prohibition protocol are reported to the nurse on call after hours, weekends, and holidays; -Education is ongoing with all staff. Event education is routinely completed at staff meetings and immediately as required/applicable. 1. Review of the Facility Assessment Tool (an assessment used to make decisions about direct care staff needs, and what resources are necessary to care for the residents), dated 02/24/23, showed the following: -The average daily census was 105 to 120 residents; -The average number of residents who required one to two staff assist for transfer was 40% to 60%; -The average number of residents who required one to two staff assist for toileting was 40% to 60%; -Day shift needed three to five licensed nurses, two to four certified medication technicians (CMTs), and four to sixteen nurse aides; -Night shift needed two to three licensed nurses, and three to nine nurse aides. (The Facility Assessment Tool showed the home did not address the staffing needs specific to the special care unit in the Facility Assessment.) Review of the Facility Staffing Roster, dated 07/19/23 through 08/15/23, showed the following on overnights: -Two nurses in the building, with no nurse was in the memory unit; -Four to five aides in the building, with one being in the memory unit. Review of the facility's Daily Census Report, dated 08/13/23, showed 17 residents in the memory unit as of midnight on 08/13/23, with six of those residents requiring one to two assist for transfer and toileting. Review of the Facility Fall Log, dated 07/16/23 to 08/16/23, showed 12 falls occurred on the memory hall, with three occurring during the overnight shift. 2. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included unspecified intellectual disabilities, epilepsy (a disorder in which nerve cells activity in the brain is disturbed, causing seizures), repeated falls, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence, and a history of traumatic brain injury (TBI-a brain injury caused by an outside force, usually a violent blow to the head). Review of Resident #1's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 08/03/23, showed the following: -The resident was severely cognitively impaired; -Wandering occurred one to three days of the seven day look back period (the period of time the evaluation was done); -The resident required setup to one person assist for eating, toileting, and transfers. Review of Resident #1's care plan, updated 08/12/23, showed the following: -Resident has a tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety) while dragging personal belonging behind him/her (i.e. clothing, purses, chair); -Required assist of one staff for all activities of daily living (ADLs-transfers, toileting, bathing, dressing, grooming) related to impaired mobility and weakness at times and disease processes. Including hygiene and toileting; - Resident is at risk for complications and physical injury related to seizure disorder. Review of Resident #1's nursing notes showed the following: -On 07/04/23, at 8:42 A.M., staff documented the resident was standing at nurses' station after bath and fell straight backwards hitting his/her head on floor. Resident obtained skinned left arm with hematoma (bruising). The resident was noted to be having grand mal seizure (a type of seizure that causes strong muscle movements on both sides of your body, including convulsions), both eyes turning towards the right, snorting and shaking lasted approximately two minutes. A pillow was placed under his/her head and he/she was turned on his/her side with another licensed practical nurse (LPN) at his/her side. The resident came out of the seizure, stood up by him/herself, was unsteady on his/her feet, and was assisted by the certified nurse aide (CNA) and nurse to ambulate. Staff administered as needed (PRN) Ativan (an anti-seizure medication). Staff notified the resident's responsible party to see what his/her wishes were. Responsible party asked for staff to monitor. Staff notified the physician with no new orders written. Staff notified the Assistant Director of Nursing (ADON). Staff assisted the resident to bed and resident is resting with his/her eyes closed at this time. Vital signs are high on blood pressure, neurological checks (an assessment to evaluate the resident's level of mental function) intact (no change to level of consciousness, movement to all four extremities or unchanged from baseline, pupil reactions equal and brisk, hand grip equal and strong or unchanged from baseline, speech unchanged from baseline), and at baseline, his/her right eye is starting to darken, and a small bump noted to right lower base of skull; -On 07/21/23, at 5:05 P.M., staff documented the resident was observed sitting on the floor of his/her room leaning against sink console surrounded by books and two purses. The resident was unable to relate how or what occurred but it was noted during the assessment, a red purse strap was wrapped around his/her leg and he/she had previously trying to carry large load of books/magazines. No marks or sign of injury apparent. The resident was restless and not wanting to sit still for complete vital signs. Resident had normal movement with no pain displayed. Neuro-checks within normal limits. Staff called the nurse practitioner at 4:50 P.M. and the responsible party at 4:55 P.M. The resident is calm at present time and allowing further assessments and vital signs; -On 07/26/23, at 9:45 A.M., staff documented the resident has been taking all the chairs from around nurses' station to his/her room along with several overhead tables. The physician was present and observed behaviors. Staff administered PRN Ativan one hour prior. Physician gave an order to give an extra dose of Ativan. Staff administered the dose and the resident is still moving chairs. He/she is not easily able to be redirected; -On 07/26/23, at 5:55 P.M., staff documented the resident continued to take all chairs around the nurses' station to her room along with the overhead tables, then poured water pitcher on floor. The floor was cleaned up, and chairs were attempted to be replaced at desk. The resident continued to move chairs back to his/her room. Staff administered PRN medication with no relief; -On 07/28/23, at 10:13 A.M., staff documented the resident up to nurses' station taking everything to his/her room, all the books, paperwork, gloves, supplies, all items were taken off the desk and put into the med room. Staff administered PRN medication for wandering, attempting to get in med room, and rummaging; -On 07/30/23, at 9:10 A.M., staff documented the resident has been pacing and wandering much of the morning. His/her appetite remained good. He/she been somewhat irritable and trying to drag furniture off to his/her room. Upon attempting to take chairs to room, staff noted resident had some unsteadiness of gait and would have fallen with the chair if staff had not intervened. Staff administered a PRN medication for anxiety. The resident continued to display agitation upon not letting him/her drag chairs. Staff attempted diversion with walking. Resident was calmer after walking in courtyard. Upon return inside consented to lie down for rest; -On 08/01/23, at 8:13 A.M., staff documented the resident had been agitated and restless all morning, he/she had been moving chairs and overhead tables from nurses' station to her room, and when staff attempted to remove excess chairs and tables from his/her room he/she tried to throw him/herself backwards. The resident has been a one-on-one (a care giver providing support specifically to one individual) this morning. Staff administered PRN medication with little relief. He/she is also taking things from nurses' station. The resident's purse keeps getting wrapped around his/her feet and had to be removed several times. He/she remains a high fall risk due to TBI, seizure history, and poor insight to safety from TBI; -On 08/02/23, at 8:18 A.M., staff documented the resident has been up pacing and pulling chairs and tables and the dehumidifier into his/her room. The night shift reported he/she has been up since 3 A.M. and was throwing him/herself backwards when asked to leave the chairs and tables alone. He/she had several chairs already in his/her room. Staff administered PRN medication with some relief. When the resident has these behaviors he/she was working him/herself up and crying. He/she was helped back to bed and is resting peacefully at this time face is more relaxed; -On 08/02/23, at 5:40 P.M., staff documented the resident continued to pace and pull chairs and tables into his/her room. He/she becomes agitated when chairs are removed from the room and he/she is not allowed to pull on them. The chairs pose a trip hazard. He/she is unsteady on his/her feet, and when the chairs are removed he/she throws him/herself backwards and repeats over and over chairs, chairs. The responsible party states the resident had an interest in chairs at home. The resident has been unable to be redirected today. His/her appetite is poor, and he/she does not want to sit still long enough to eat. He/ she did nap for a short time today; -On 8/03/23, at 8:58 A.M., staff documented the resident is pacing and attempting to drag chairs to his/her room. He/she is unaccepting of redirection and yelling and holding onto furniture. A PRN dose of Ativan was given. The resident consented to go on a walk with staff and then lie down for rest. -On 08/06/23, at 5:58 P.M., staff documented the resident has been moving all the chairs and overhead tables from the dining room and around the nurses' station to his/her room. He/she has knocked over several of them when dragging them, has gone through all the drawers and cubby holes at nurses' station and taking anything he/she can get. He/she has been rummaging in other residents' rooms as well. He/she is difficult to redirect. Staff administered PRN medication with no relief; -On 08/08/23, at 4:10 P.M., staff documented that at 3:15 P.M., the resident was observed pushing the over bed table behind the nurses' desk. When the table became caught on a chair, the resident pulled back on the table and fell backwards to the floor and bumped the back of his/her head on another chair. Neuro-checks were initiated with normal results. The resident had a small bump on upper right side of his/her head. No redness or tenderness was observed. No other marks or sign of injury were apparent. Staff notified the physician and responsible party; -On 08/09/23, at 4:06 P.M., staff documented the resident had been wandering in the hallways, holding on to two purses and books. He/she had dropped the books he/she was holding numerous times and bent over to pick them up. He/she is also picking up the trash cans and carrying them up and down the hallways. The resident is pleasant, but busy; -On 08/10/23, at 3:19 P.M., staff documented the resident wandered up and down the hallways and was unsteady on his/her feet, but can correct unless he/she was upset than he/she throws him/herself backwards. He/she was carrying two purses and drops things at times then bends down to pick them up. He/she does fall at times. He/she has a bruise on top of his/her head at this time, but no signs or symptoms of pain; -On 08/13/23, at 2:45 A.M., staff documented the CNA reported that he/she came out of bathroom from assisting another resident when he/she saw Resident #1 on the floor. The resident was crying and had his/her hand on his/her right mid lateral (outer) leg. Staff notified the responsible party, Assistant Director of Nursing (ADON), and physician with no new orders at that time; -On 08/13/23, at 4:30 A.M., staff documented a telephone order was received for an x-ray to the resident's right lower extremity; -On 8/13/23, at 4:59 A.M., staff documented resident's responsible party to transport resident to emergency room (ER) for x-ray. Staff informed him/her that the physician had ordered an x-ray, but the responsible party opted not to wait for the mobile x-ray to arrive. Encouraged to keep staff posted on resident's condition; -On 08/13/2023, at 10:47 A.M., staff documented a call was received from the responsible party who informed staff that resident had a fractured hip and would be having surgery later that day. Review of Resident #1's hospital records, dated 08/13/23, showed the following: -The resident was admitted for further evaluation of a closed intertrochanteric (the upper thigh bone) fracture of the right hip, sustained after a fall at his/her living facility. 3. Review of Resident #2's face sheet showed the following: -admitted [DATE] -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) restlessness and agitation, and insomnia (persistent problems falling and staying asleep). Review of Resident #2's discharge MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/she required one person for assist for ADLs; -He/she exhibited wandering four to six days of the seven day look behind period, but no other physical or verbal behaviors. Review of Resident #2's care plan, updated 08/15/23, showed the following: -The resident required assist of one for all ADL's related to occasional weakness and disease processes, including transfers and toileting; -He/she has a tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety). (Staff did not address any other behaviors in the care plan.) Review of Resident #2's nursing notes showed the following: -On 08/02/23, at 5:44 P.M., staff documented the resident had been pacing in hallways introducing self to everyone. He/she was pleasant and cooperative. Resident testing all the doors and setting off alarms. Resident was able to be redirected at this time; -On 08/02/23, at 7:47 P.M., staff documented the CNA reported that the resident continued with extreme aggressive behaviors (pushing on all exit doors, throwing things at others, trying to exit through windows). Staff notified the on-call nurse practitioner (NP) regarding residents behaviors and received new order for lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), one tablet by mouth (PO) times one dose. The new order was entered in the medical record and med pulled from the emergency kit (STAT safe); -On 08/02/23, at 10:37 P.M., staff documented the CNA and CMT reported to this nurse that the resident was having suicidal ideations. The resident told the CMT that he/she wished the lorazepam was poison, wanted to climb to out of windows on the memory unit and walk out into traffic, and wanted to know if he/she climbed up on the desk and jumped would it kill him/her. The resident was assisted to bed by two staff members due to the effectiveness of one dose of lorazepam. Staff notified on-call for the physician, the NP, the Director of Nursing (DON), and ADON. Staff implemented 15-minute checks. The responsible party was called and message left to return call to facility at his/her convenience. Staff made aware of checks and resident was resting in bed with his/her eyes closed at this time; -On 08/03/23, at 6:40 A.M., staff documented the resident pulled two fire alarms in the memory unit. He/she is anxious and stating that we have to get out of here, we are all going to burn. Staff reassured resident that there was not a fire and everyone is safe. The resident continued pacing toward doors. Staff called the NP with a report of the incident. A new order for lorazepam 0.5 mg every 6 hours was written. Staff will administer as soon as available from STAT safe; -On 08/05/23, at 12:07 A.M., staff documented the resident was wandering the unit. He/she ambulating with a steady gait. He/she attempted to exit earlier and was redirected with some success. The resident is resting quietly at this time, and remains on 15 minute monitoring for behaviors; -On 08/05/23, at 6:34 A.M., staff documented the resident remained on 15 minute monitoring for suicidal ideations. He/she had no plan, but voiced the idea. The resident was in his/her room at this time with the door barricaded by the sofa. He/she stated he/she is ok, with no suicidal ideations. The resident is up wandering in his/her room; -On 08/05/23, at 4:45 P.M., staff documented the resident has been up pacing in the hallways and asking to smoke numerous times. He/she had been taken out several times. His/her responsible party came to visit and stayed approximately 30 minutes. The resident was upset after the responsible party left. The responsible party voiced his/her concerns about the resident doing self-harm and stated he/she tried at home. The resident said he/she wanted to die after the responsible party left. The resident pacing hallways and setting off alarms. He/ she did get outside and tried to get out the gate. Staff administered a PRN medication and he/she is on the psychiatrist's list for next week. The resident is on one-on-one care at this time; -On 08/05/23, at 6:06 P.M., staff documented the resident had been crying and putting him/herself on the floor and praying to die. He/she has not voiced any plans or suicidal ideation. Resident has not been eating or drinking, and is more depressed after his/her responsible party leaves. Staff notified the physician and a new order was received for Remeron (an antidepressant) 7.5 mg at bedtime. Staff made the responsible party aware. The resident had set off every alarm in unit and had been outside several times; -On 08/06/23, at 1:16 A.M., staff documented the resident is resting quietly this shift. He/she was wandering the memory unit earlier and attempting exit seeking; -On 08/06/23, at 12:52 P.M., staff documented the resident was witnessed falling in front of the nurses' station. The resident had been up pacing. His/her gait was unsteady. He/she made quick turns and walks with his/her head facing the ground. The resident fell to the right side, causing a skin tear to his/her right elbow. Staff assessed the resident and first aid administered to his/her arm. Staff notified the ADON and attempted to call the responsible party. Neuro checks were intact and at baseline. Resident had previous old bruise to left forehead, his/her range of motion was within normal limits, and he/she had no complaints of pain; -On 08/06/23, at 2:32 P.M., staff documented the resident slept in a chair for a short time, woke up and started running. He/she is very unsteady on his/her feet and has almost fallen several times. The resident did have a witnessed fall and hit his/her head. He/she is very impulsive, at times does put him/herself on the floor and cover his/her head and prays and cries. The resident has not been as tearful today; -On 08/07/23, at 4:48 P.M., staff documented resident to be praying God take me, I want to die. What have I done to deserve this, over and over. Attempted to redirect and reassure resident, but he/she is having difficulty accepting. The responsible party in to visit and expressed concern regarding resident's continuing statements about wanting to die. -On 08/09/23, at 3:01 P.M., staff documented the resident was attempting to break the glass doors in the dining room with a metal chair, is wandering into the other residents' rooms, and tearing up the rooms. Staff to administer PRN medication and monitor the resident for falls; -On 08/09/23, at 3:53 P.M., staff documented the resident is wandering the hallways, took the fire extinguisher out of the holder on wall, and attempted to hit the CNA with it. He/she had also tried to tear up the fax machine on the memory unit. Staff administered PRN medication, but it was ineffective. The resident had been having hallucinations and stated the CMT is in the medication room lighting candles. The CMT is preparing drinks for residents. The resident is one-on-one at this time. He/she was seen by the NP earlier this day; -On 08/10/23, at 9:44 A.M., staff documented the resident had been up wandering the halls, exit seeking, trying all the doors and setting alarms off. He/she had been at the nurses' desk attempting to argue with staff and had been in other residents' rooms attempting to take their belongings. The resident had been verbally abusive with staff and wanting to go out and smoke repeatedly. He/she had attempted to take the drawers out of copy machine. Staff administered a PRN medication; -On 08/10/23, at 3:49 P.M., staff documented the resident had been pacing the hallways, had been up to nurses' station numerous times, had been going into other residents' rooms and taking things, and was setting off the alarms on the doors. Staff administered a PRN medication and was awaiting relief; -On 08/11/23, at 8:34 A.M., staff documented the resident was up all night and had been very agitated this morning. He/she had been pacing halls and threatening nurse physically, but no physical contact made. The resident did follow staff while passing medications and obtaining blood sugars. Staff administered PRN medication. The resident is now resting peacefully; -On 08/11/23, at 3:11 P.M., staff documented the resident had been agitated this afternoon and asked to go smoke frequently. Staff reminded resident of the smoking times. The resident was cursing at the nurse and flipping the nurse the bird. He/she was able to be redirected away from nurses' station, but is coming by nurses' station and making threatening and vulgar remarks. Staff contacted the NP. Staff were waiting for a return call; -On 08/11/23, at 5:00 P.M., staff documented the NP gave a one-time order for Haldol (an antipsychotic medication) 1 mg intramuscularly (IM-injected into the muscle) for behaviors. Staff notified the responsible party; -On 08/11/23, at 6:00 P.M., staff documented the resident was not as agitated, but was still exit seeking and setting off all the alarms; -On 08/13/23, at 9:43 A.M., staff documented that at 6:35 A.M., the resident was observed after being awakened from dozing in a chair near the nurses' station, take two steps while turning, fall against the doorway, and hit his/her head on door frame. The resident then fell on his/her left side. Neuro-checks initiated were initiated. The resident complained of pain to his/her left hip, but was able to straighten his/her leg with no rotation and the left leg was even with the right leg. The resident was lifted into a wheelchair with an assist of two staff. The resident continued to complain of left hip pain, stating my hip is out of place. No misalignment was apparent. Staff called the physician at 7:52 A.M. and order was received for stat (immediate) left hip and pelvis x-rays. Staff called the responsible party at 8:02 A.M., and notified him/her of the event and x-ray orders. Resident resting in bed at this time per request. Staff administered Tylenol for continued pain. Staff called the mobile x-ray company notified of the order for x-rays; -On 08/13/23, at 10:23 P.M., staff documented that at 8:30 P.M., staff received the x-ray results of intertrochanteric fracture of left hip. Staff notified the physician at 8:30 P.M. and orders were received at 8:35 P.M. to transport resident to hospital. At 8:40 P.M., staff notified the responsible party and ADON of orders. The resident was transported via ambulance at 8:55 P.M., to the hospital. 4. Review of the Facility Investigation, dated 08/13/23, showed the following: -On 08/13/23, at 2:45 A.M., video footage noted Resident #1 approach Resident #2 three times in quick succession; -On two occasions, it appeared Resident #2 motions for Resident #1 to stay away; -On the third interaction/push, Resident #1 fell to the ground; -Upon staff observation of Resident #1, fall protocols were initiated; -No staff or residents reported knowledge or observation of the event; -Resident #1 and Resident #2 were the only observable individuals during the event that resulted in a fall. Review of summary of interview with witness on the Facility Investigation showed the following: -Recorded documentation by Registered Nurse (RN) A addressed the event as observed on floor due to no staff witnesses. Notifications to the Primary Care Provider (PCP) and responsible party were completed and documented. Orders for an x-ray was issued, but not completed as the responsible party elected to transport the resident to the emergency room . Observation of the facility video footage on 08/15/23, at 1:40 P.M., showed the following: -On 08/13/23, at 2:10 A.M., Resident #1 was leaned over in front of the memory care nurses' station with a bag. Resident #2 was standing at a chair behind him/her. No staff was visible; -Resident #2 walked behind and around the left side of Resident #1, behind the side of the nurses' station, and Resident #1 followed; -Resident #2 pushed Resident #1 back, Resident #1 stumbled, but did not fall; -Resident #1 went back towards Resident #2; -Resident #2 pushed Resident #1 again, Resident #1 fell , landing on his/her right side next to the nurses' station; -No staff was visible throughout the video. Review of CNA B's written statement, dated 08/13/23, showed the following: -At around 2:30 A.M., on 08/13/23, CNA B was in the shower room helping a resident. While CNA B was in the shower room, he/she could hear Resident #1 crying. CNA B rushed out to find him/her laying on his/her right side crying out for his/her purse that was in Resident #2's hands. CNA B got the purse back, then helped Resident #1 off the floor and into a chair. After Resident #1 was in a chair, he/she repeated the word Devil while looking at Resident #2. Resident #1 continued to cry and complain of pain in his/her right hip and upper right thigh. During an interview on 08/16/23, CNA B said he/she works overnights and has worked all the units. He/she has worked on the Faith Unit (the memory care unit). After 10:00 P.M., he/she is usually the only staff on the memory unit. If he/she needs help, he/she has to call another unit. If no one is available, he/she waits until someone is available, which is usually around 20 minutes. He/she said that happens often. Over the past couple weeks, the acuity of the hall has become heavy. He/she hadn't seen any interactions between Resident #1 and Resident #2, but Resident #2 had been having behaviors. Both residents had been being up most nights. It was a challenge being in the memory unit alone with both residents up. CNA B said he/she did not call for help on the night Resident #1 fell , because the residents were not interacting with each other before the fall. Normally he/she could take someone to the restroom with no issues. The CNA said there is not enough staff on the memory unit to meet the residents' needs and they cannot provide oversight. Review of the Maintenance Supervisor's Statement, undated, showed the following: -He/she said the camera time is off approximately 40 minutes; -At 2:11 A.M., on 08/13/23, Resident #1 and Resident #2 were at the nurse's desk; -Resident #1 walked up to Resident #2, and Resident #2 pushed Resident #1 away; -Resident #1 walked back to Resident #2, and Resident #2 pushed Resident #1 away again; -When Resident #1 went up to Resident #2 the next time, Resident #2 pushed Resident #1 and Resident #1 fell ; -The aide was in the shower room toileting another resident. When the aide came out, he/she assisted Resident #1 to sit in the chair and got on the phone. 5. During an interview on 08/15/23, at 8:10 P.M., Nursing Assistant (NA) C said he/she had worked on the memory unit, and after 10:00 P.M., he/she is alone. He/she did not feel there was enough staff to meet the residents' needs. Once the residents are in bed, it is better, but trying to get everyone in bed is a challenge. When he/she needs assistance from another staff member, he/she calls to another hall for assistance. It usually takes a minute for staff to respond. He/she was aware of Resident #2 having behaviors towards staff members. 6. During an interview on 08/16/23, at 9:35 A.M., LPN D said he/she always worked on the memory unit. There are at least five residents that require two person assist depending on the day, sometimes six. During the day, there are three staff, at night one aide and a nurse floats between the memory unit and another unit. If an aide goes in a room to take care of a resident, that leaves the hall basically uncovered. The aide doesn't usually call for assistance unless there is a problem or they are going on break. Resident #1 was very protective of his/her belongings. LPN D said he/she had not seen anyone take Resident #1's belongings. Resident #2 had behaviors and was aggressive to staff. There had been four broken hips occur in the last two months on the memory unit. On a good night, one staff member might be enough, otherwise, no. The aide should call for assistance before going into a room to perform cares. A resident to resident altercation could occur in a matter of minutes. 7. During an interview on 08/16/23, at 9:45 A.M., LPN E said he/she floats to different units to assist when needed. He/she has heard of the memory unit being short staffed overnight, having one aide overnight, and a nurse going back and forth between the memory unit and another unit. Some nights he/she would consider that appropriate and some nights not appropriate. If residents are still up wandering in the unit, the aide should call for assistance before assisting another resident in their room. 8. During an interview on 08/16/23, at 12:25 P.M., CNA F said there was not enough help in the memory unit. It was difficult to perform ADLs for the residents. He/she has taken care of Resident #1 and Resident #2. Resident #2 had behaviors that consisted of aggression towards staff. The aide was afraid Resident #2 would hurt someone if staff did not intervene. He/she said he/she did not believe one staff is enough at night to prevent residents from wandering into the other residents' rooms. He/she hears from the night shift that they need more help. 9. During an interview on 08/16/23, at 10:20 A.M., the Nurse Practitioner said she was aware of both resident's behaviors. It is up to the facility to determine staffing for the halls. If the staff feel they need more assistance, they should let the Director of Nursing (DON) know. 10. During an interview on 08/16/23, at 1:18 P.M., the DON and Administrator said staffing is based on a reasonable census and acuity of the residents. They look at the acuity of the residents and base it on that and the facility assessment tool. No one had brought concerns to the DON or Administrator regardin [TRUNCATED]

Based on interview and record review, the facility staff failed to ensure the safety of all residents when lack of staff supervision on the locked special care (memory) unit resulted in extended resident to resident interaction that ended with one resident (Resident #2) pushing one resident (Resident #1) to the floor resulting in one resident (Resident #1) sustaining a hip fracture. A sample do 25 residents were reviewed in a facility with a census of 94. Review of the facility policy titled, Routing Monitoring of Events (Incidents and Accidents), dated 11/14/16, showed the following: -This is a general guideline for event monitoring, to include, but not limited to bruises, skin tears, and falls; -Event prevention and actions to minimize them are ongoing each shift/day. Staff should report and/or take action for circumstances that may result in an event or lessen the likelihood of an event; -Events are reviewed at the time of occurrence by staff on duty, looking for causes and or methods/actions to minimize future occurrence; -Events are monitored/reviewed by management daily, not including weekends and holidays. However, events triggering the abuse prohibition protocol are reported to the nurse on call after hours, weekends, and holidays; -Education is ongoing with all staff. Event education is routinely completed at staff meetings and immediately as required/applicable. 1. Review of the Facility Assessment Tool (an assessment used to make decisions about direct care staff needs, and what resources are necessary to care for the residents), dated 02/24/23, showed the following: -The average daily census was 105 to 120 residents; -The average number of residents who required one to two staff assist for transfer was 40% to 60%; -The average number of residents who required one to two staff assist for toileting was 40% to 60%; -Day shift needed three to five licensed nurses, two to four certified medication technicians (CMTs), and four to sixteen nurse aides; -Night shift needed two to three licensed nurses, and three to nine nurse aides. (The Facility Assessment Tool showed the home did not address the staffing needs specific to the special care unit in the Facility Assessment.) Review of the Facility Staffing Roster, dated 07/19/23 through 08/15/23, showed the following on overnights: -Two nurses in the building, with no nurse was in the memory unit; -Four to five aides in the building, with one being in the memory unit. Review of the facility's Daily Census Report, dated 08/13/23, showed 17 residents in the memory unit as of midnight on 08/13/23, with six of those residents requiring one to two assist for transfer and toileting. Review of the Facility Fall Log, dated 07/16/23 to 08/16/23, showed 12 falls occurred on the memory hall, with three occurring during the overnight shift. 2. Review of Resident #1's face sheet showed the following: -admission date of 05/08/23; -Diagnoses included unspecified intellectual disabilities, epilepsy (a disorder in which nerve cells activity in the brain is disturbed, causing seizures), repeated falls, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence, and a history of traumatic brain injury (TBI-a brain injury caused by an outside force, usually a violent blow to the head). Review of Resident #1's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 08/03/23, showed the following: -The resident was severely cognitively impaired; -Wandering occurred one to three days of the seven day look back period (the period of time the evaluation was done); -The resident required setup to one person assist for eating, toileting, and transfers. Review of Resident #1's care plan, updated 08/12/23, showed the following: -Resident has a tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety) while dragging personal belonging behind him/her (i.e. clothing, purses, chair); -Required assist of one staff for all activities of daily living (ADLs-transfers, toileting, bathing, dressing, grooming) related to impaired mobility and weakness at times and disease processes. Including hygiene and toileting; - Resident is at risk for complications and physical injury related to seizure disorder. Review of Resident #1's nursing notes showed the following: -On 07/04/23, at 8:42 A.M., staff documented the resident was standing at nurses' station after bath and fell straight backwards hitting his/her head on floor. Resident obtained skinned left arm with hematoma (bruising). The resident was noted to be having grand mal seizure (a type of seizure that causes strong muscle movements on both sides of your body, including convulsions), both eyes turning towards the right, snorting and shaking lasted approximately two minutes. A pillow was placed under his/her head and he/she was turned on his/her side with another licensed practical nurse (LPN) at his/her side. The resident came out of the seizure, stood up by him/herself, was unsteady on his/her feet, and was assisted by the certified nurse aide (CNA) and nurse to ambulate. Staff administered as needed (PRN) Ativan (an anti-seizure medication). Staff notified the resident's responsible party to see what his/her wishes were. Responsible party asked for staff to monitor. Staff notified the physician with no new orders written. Staff notified the Assistant Director of Nursing (ADON). Staff assisted the resident to bed and resident is resting with his/her eyes closed at this time. Vital signs are high on blood pressure, neurological checks (an assessment to evaluate the resident's level of mental function) intact (no change to level of consciousness, movement to all four extremities or unchanged from baseline, pupil reactions equal and brisk, hand grip equal and strong or unchanged from baseline, speech unchanged from baseline), and at baseline, his/her right eye is starting to darken, and a small bump noted to right lower base of skull; -On 07/21/23, at 5:05 P.M., staff documented the resident was observed sitting on the floor of his/her room leaning against sink console surrounded by books and two purses. The resident was unable to relate how or what occurred but it was noted during the assessment, a red purse strap was wrapped around his/her leg and he/she had previously trying to carry large load of books/magazines. No marks or sign of injury apparent. The resident was restless and not wanting to sit still for complete vital signs. Resident had normal movement with no pain displayed. Neuro-checks within normal limits. Staff called the nurse practitioner at 4:50 P.M. and the responsible party at 4:55 P.M. The resident is calm at present time and allowing further assessments and vital signs; -On 07/26/23, at 9:45 A.M., staff documented the resident has been taking all the chairs from around nurses' station to his/her room along with several overhead tables. The physician was present and observed behaviors. Staff administered PRN Ativan one hour prior. Physician gave an order to give an extra dose of Ativan. Staff administered the dose and the resident is still moving chairs. He/she is not easily able to be redirected; -On 07/26/23, at 5:55 P.M., staff documented the resident continued to take all chairs around the nurses' station to her room along with the overhead tables, then poured water pitcher on floor. The floor was cleaned up, and chairs were attempted to be replaced at desk. The resident continued to move chairs back to his/her room. Staff administered PRN medication with no relief; -On 07/28/23, at 10:13 A.M., staff documented the resident up to nurses' station taking everything to his/her room, all the books, paperwork, gloves, supplies, all items were taken off the desk and put into the med room. Staff administered PRN medication for wandering, attempting to get in med room, and rummaging; -On 07/30/23, at 9:10 A.M., staff documented the resident has been pacing and wandering much of the morning. His/her appetite remained good. He/she been somewhat irritable and trying to drag furniture off to his/her room. Upon attempting to take chairs to room, staff noted resident had some unsteadiness of gait and would have fallen with the chair if staff had not intervened. Staff administered a PRN medication for anxiety. The resident continued to display agitation upon not letting him/her drag chairs. Staff attempted diversion with walking. Resident was calmer after walking in courtyard. Upon return inside consented to lie down for rest; -On 08/01/23, at 8:13 A.M., staff documented the resident had been agitated and restless all morning, he/she had been moving chairs and overhead tables from nurses' station to her room, and when staff attempted to remove excess chairs and tables from his/her room he/she tried to throw him/herself backwards. The resident has been a one-on-one (a care giver providing support specifically to one individual) this morning. Staff administered PRN medication with little relief. He/she is also taking things from nurses' station. The resident's purse keeps getting wrapped around his/her feet and had to be removed several times. He/she remains a high fall risk due to TBI, seizure history, and poor insight to safety from TBI; -On 08/02/23, at 8:18 A.M., staff documented the resident has been up pacing and pulling chairs and tables and the dehumidifier into his/her room. The night shift reported he/she has been up since 3 A.M. and was throwing him/herself backwards when asked to leave the chairs and tables alone. He/she had several chairs already in his/her room. Staff administered PRN medication with some relief. When the resident has these behaviors he/she was working him/herself up and crying. He/she was helped back to bed and is resting peacefully at this time face is more relaxed; -On 08/02/23, at 5:40 P.M., staff documented the resident continued to pace and pull chairs and tables into his/her room. He/she becomes agitated when chairs are removed from the room and he/she is not allowed to pull on them. The chairs pose a trip hazard. He/she is unsteady on his/her feet, and when the chairs are removed he/she throws him/herself backwards and repeats over and over chairs, chairs. The responsible party states the resident had an interest in chairs at home. The resident has been unable to be redirected today. His/her appetite is poor, and he/she does not want to sit still long enough to eat. He/ she did nap for a short time today; -On 8/03/23, at 8:58 A.M., staff documented the resident is pacing and attempting to drag chairs to his/her room. He/she is unaccepting of redirection and yelling and holding onto furniture. A PRN dose of Ativan was given. The resident consented to go on a walk with staff and then lie down for rest. -On 08/06/23, at 5:58 P.M., staff documented the resident has been moving all the chairs and overhead tables from the dining room and around the nurses' station to his/her room. He/she has knocked over several of them when dragging them, has gone through all the drawers and cubby holes at nurses' station and taking anything he/she can get. He/she has been rummaging in other residents' rooms as well. He/she is difficult to redirect. Staff administered PRN medication with no relief; -On 08/08/23, at 4:10 P.M., staff documented that at 3:15 P.M., the resident was observed pushing the over bed table behind the nurses' desk. When the table became caught on a chair, the resident pulled back on the table and fell backwards to the floor and bumped the back of his/her head on another chair. Neuro-checks were initiated with normal results. The resident had a small bump on upper right side of his/her head. No redness or tenderness was observed. No other marks or sign of injury were apparent. Staff notified the physician and responsible party; -On 08/09/23, at 4:06 P.M., staff documented the resident had been wandering in the hallways, holding on to two purses and books. He/she had dropped the books he/she was holding numerous times and bent over to pick them up. He/she is also picking up the trash cans and carrying them up and down the hallways. The resident is pleasant, but busy; -On 08/10/23, at 3:19 P.M., staff documented the resident wandered up and down the hallways and was unsteady on his/her feet, but can correct unless he/she was upset than he/she throws him/herself backwards. He/she was carrying two purses and drops things at times then bends down to pick them up. He/she does fall at times. He/she has a bruise on top of his/her head at this time, but no signs or symptoms of pain; -On 08/13/23, at 2:45 A.M., staff documented the CNA reported that he/she came out of bathroom from assisting another resident when he/she saw Resident #1 on the floor. The resident was crying and had his/her hand on his/her right mid lateral (outer) leg. Staff notified the responsible party, Assistant Director of Nursing (ADON), and physician with no new orders at that time; -On 08/13/23, at 4:30 A.M., staff documented a telephone order was received for an x-ray to the resident's right lower extremity; -On 8/13/23, at 4:59 A.M., staff documented resident's responsible party to transport resident to emergency room (ER) for x-ray. Staff informed him/her that the physician had ordered an x-ray, but the responsible party opted not to wait for the mobile x-ray to arrive. Encouraged to keep staff posted on resident's condition; -On 08/13/2023, at 10:47 A.M., staff documented a call was received from the responsible party who informed staff that resident had a fractured hip and would be having surgery later that day. Review of Resident #1's hospital records, dated 08/13/23, showed the following: -The resident was admitted for further evaluation of a closed intertrochanteric (the upper thigh bone) fracture of the right hip, sustained after a fall at his/her living facility. 3. Review of Resident #2's face sheet showed the following: -admission date of 08/02/23 -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) restlessness and agitation, and insomnia (persistent problems falling and staying asleep). Review of Resident #2's discharge MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/she required one person for assist for ADLs; -He/she exhibited wandering four to six days of the seven day look behind period, but no other physical or verbal behaviors. Review of Resident #2's care plan, updated 08/15/23, showed the following: -The resident required assist of one for all ADL's related to occasional weakness and disease processes, including transfers and toileting; -He/she has a tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety). (Staff did not address any other behaviors in the care plan.) Review of Resident #2's nursing notes showed the following: -On 08/02/23, at 5:44 P.M., staff documented the resident had been pacing in hallways introducing self to everyone. He/she was pleasant and cooperative. Resident testing all the doors and setting off alarms. Resident was able to be redirected at this time; -On 08/02/23, at 7:47 P.M., staff documented the CNA reported that the resident continued with extreme aggressive behaviors (pushing on all exit doors, throwing things at others, trying to exit through windows). Staff notified the on-call nurse practitioner (NP) regarding residents behaviors and received new order for lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), one tablet by mouth (PO) times one dose. The new order was entered in the medical record and med pulled from the emergency kit (STAT safe); -On 08/02/23, at 10:37 P.M., staff documented the CNA and CMT reported to this nurse that the resident was having suicidal ideations. The resident told the CMT that he/she wished the lorazepam was poison, wanted to climb to out of windows on the memory unit and walk out into traffic, and wanted to know if he/she climbed up on the desk and jumped would it kill him/her. The resident was assisted to bed by two staff members due to the effectiveness of one dose of lorazepam. Staff notified on-call for the physician, the NP, the Director of Nursing (DON), and ADON. Staff implemented 15-minute checks. The responsible party was called and message left to return call to facility at his/her convenience. Staff made aware of checks and resident was resting in bed with his/her eyes closed at this time; -On 08/03/23, at 6:40 A.M., staff documented the resident pulled two fire alarms in the memory unit. He/she is anxious and stating that we have to get out of here, we are all going to burn. Staff reassured resident that there was not a fire and everyone is safe. The resident continued pacing toward doors. Staff called the NP with a report of the incident. A new order for lorazepam 0.5 mg every 6 hours was written. Staff will administer as soon as available from STAT safe; -On 08/05/23, at 12:07 A.M., staff documented the resident was wandering the unit. He/she ambulating with a steady gait. He/she attempted to exit earlier and was redirected with some success. The resident is resting quietly at this time, and remains on 15 minute monitoring for behaviors; -On 08/05/23, at 6:34 A.M., staff documented the resident remained on 15 minute monitoring for suicidal ideations. He/she had no plan, but voiced the idea. The resident was in his/her room at this time with the door barricaded by the sofa. He/she stated he/she is ok, with no suicidal ideations. The resident is up wandering in his/her room; -On 08/05/23, at 4:45 P.M., staff documented the resident has been up pacing in the hallways and asking to smoke numerous times. He/she had been taken out several times. His/her responsible party came to visit and stayed approximately 30 minutes. The resident was upset after the responsible party left. The responsible party voiced his/her concerns about the resident doing self-harm and stated he/she tried at home. The resident said he/she wanted to die after the responsible party left. The resident pacing hallways and setting off alarms. He/ she did get outside and tried to get out the gate. Staff administered a PRN medication and he/she is on the psychiatrist's list for next week. The resident is on one-on-one care at this time; -On 08/05/23, at 6:06 P.M., staff documented the resident had been crying and putting him/herself on the floor and praying to die. He/she has not voiced any plans or suicidal ideation. Resident has not been eating or drinking, and is more depressed after his/her responsible party leaves. Staff notified the physician and a new order was received for Remeron (an antidepressant) 7.5 mg at bedtime. Staff made the responsible party aware. The resident had set off every alarm in unit and had been outside several times; -On 08/06/23, at 1:16 A.M., staff documented the resident is resting quietly this shift. He/she was wandering the memory unit earlier and attempting exit seeking; -On 08/06/23, at 12:52 P.M., staff documented the resident was witnessed falling in front of the nurses' station. The resident had been up pacing. His/her gait was unsteady. He/she made quick turns and walks with his/her head facing the ground. The resident fell to the right side, causing a skin tear to his/her right elbow. Staff assessed the resident and first aid administered to his/her arm. Staff notified the ADON and attempted to call the responsible party. Neuro checks were intact and at baseline. Resident had previous old bruise to left forehead, his/her range of motion was within normal limits, and he/she had no complaints of pain; -On 08/06/23, at 2:32 P.M., staff documented the resident slept in a chair for a short time, woke up and started running. He/she is very unsteady on his/her feet and has almost fallen several times. The resident did have a witnessed fall and hit his/her head. He/she is very impulsive, at times does put him/herself on the floor and cover his/her head and prays and cries. The resident has not been as tearful today; -On 08/07/23, at 4:48 P.M., staff documented resident to be praying God take me, I want to die. What have I done to deserve this, over and over. Attempted to redirect and reassure resident, but he/she is having difficulty accepting. The responsible party in to visit and expressed concern regarding resident's continuing statements about wanting to die. -On 08/09/23, at 3:01 P.M., staff documented the resident was attempting to break the glass doors in the dining room with a metal chair, is wandering into the other residents' rooms, and tearing up the rooms. Staff to administer PRN medication and monitor the resident for falls; -On 08/09/23, at 3:53 P.M., staff documented the resident is wandering the hallways, took the fire extinguisher out of the holder on wall, and attempted to hit the CNA with it. He/she had also tried to tear up the fax machine on the memory unit. Staff administered PRN medication, but it was ineffective. The resident had been having hallucinations and stated the CMT is in the medication room lighting candles. The CMT is preparing drinks for residents. The resident is one-on-one at this time. He/she was seen by the NP earlier this day; -On 08/10/23, at 9:44 A.M., staff documented the resident had been up wandering the halls, exit seeking, trying all the doors and setting alarms off. He/she had been at the nurses' desk attempting to argue with staff and had been in other residents' rooms attempting to take their belongings. The resident had been verbally abusive with staff and wanting to go out and smoke repeatedly. He/she had attempted to take the drawers out of copy machine. Staff administered a PRN medication; -On 08/10/23, at 3:49 P.M., staff documented the resident had been pacing the hallways, had been up to nurses' station numerous times, had been going into other residents' rooms and taking things, and was setting off the alarms on the doors. Staff administered a PRN medication and was awaiting relief; -On 08/11/23, at 8:34 A.M., staff documented the resident was up all night and had been very agitated this morning. He/she had been pacing halls and threatening nurse physically, but no physical contact made. The resident did follow staff while passing medications and obtaining blood sugars. Staff administered PRN medication. The resident is now resting peacefully; -On 08/11/23, at 3:11 P.M., staff documented the resident had been agitated this afternoon and asked to go smoke frequently. Staff reminded resident of the smoking times. The resident was cursing at the nurse and flipping the nurse the bird. He/she was able to be redirected away from nurses' station, but is coming by nurses' station and making threatening and vulgar remarks. Staff contacted the NP. Staff were waiting for a return call; -On 08/11/23, at 5:00 P.M., staff documented the NP gave a one-time order for Haldol (an antipsychotic medication) 1 mg intramuscularly (IM-injected into the muscle) for behaviors. Staff notified the responsible party; -On 08/11/23, at 6:00 P.M., staff documented the resident was not as agitated, but was still exit seeking and setting off all the alarms; -On 08/13/23, at 9:43 A.M., staff documented that at 6:35 A.M., the resident was observed after being awakened from dozing in a chair near the nurses' station, take two steps while turning, fall against the doorway, and hit his/her head on door frame. The resident then fell on his/her left side. Neuro-checks initiated were initiated. The resident complained of pain to his/her left hip, but was able to straighten his/her leg with no rotation and the left leg was even with the right leg. The resident was lifted into a wheelchair with an assist of two staff. The resident continued to complain of left hip pain, stating my hip is out of place. No misalignment was apparent. Staff called the physician at 7:52 A.M. and order was received for stat (immediate) left hip and pelvis x-rays. Staff called the responsible party at 8:02 A.M., and notified him/her of the event and x-ray orders. Resident resting in bed at this time per request. Staff administered Tylenol for continued pain. Staff called the mobile x-ray company notified of the order for x-rays; -On 08/13/23, at 10:23 P.M., staff documented that at 8:30 P.M., staff received the x-ray results of intertrochanteric fracture of left hip. Staff notified the physician at 8:30 P.M. and orders were received at 8:35 P.M. to transport resident to hospital. At 8:40 P.M., staff notified the responsible party and ADON of orders. The resident was transported via ambulance at 8:55 P.M., to the hospital. 4. Review of the Facility Investigation, dated 08/13/23, showed the following: -On 08/13/23, at 2:45 A.M., video footage noted Resident #1 approach Resident #2 three times in quick succession; -On two occasions, it appeared Resident #2 motions for Resident #1 to stay away; -On the third interaction/push, Resident #1 fell to the ground; -Upon staff observation of Resident #1, fall protocols were initiated; -No staff or residents reported knowledge or observation of the event; -Resident #1 and Resident #2 were the only observable individuals during the event that resulted in a fall. Review of summary of interview with witness on the Facility Investigation showed the following: -Recorded documentation by Registered Nurse (RN) A addressed the event as observed on floor due to no staff witnesses. Notifications to the Primary Care Provider (PCP) and responsible party were completed and documented. Orders for an x-ray was issued, but not completed as the responsible party elected to transport the resident to the emergency room. Observation of the facility video footage on 08/15/23, at 1:40 P.M., showed the following: -On 08/13/23, at 2:10 A.M., Resident #1 was leaned over in front of the memory care nurses' station with a bag. Resident #2 was standing at a chair behind him/her. No staff was visible; -Resident #2 walked behind and around the left side of Resident #1, behind the side of the nurses' station, and Resident #1 followed; -Resident #2 pushed Resident #1 back, Resident #1 stumbled, but did not fall; -Resident #1 went back towards Resident #2; -Resident #2 pushed Resident #1 again, Resident #1 fell, landing on his/her right side next to the nurses' station; -No staff was visible throughout the video. Review of CNA B's written statement, dated 08/13/23, showed the following: -At around 2:30 A.M., on 08/13/23, CNA B was in the shower room helping a resident. While CNA B was in the shower room, he/she could hear Resident #1 crying. CNA B rushed out to find him/her laying on his/her right side crying out for his/her purse that was in Resident #2's hands. CNA B got the purse back, then helped Resident #1 off the floor and into a chair. After Resident #1 was in a chair, he/she repeated the word Devil while looking at Resident #2. Resident #1 continued to cry and complain of pain in his/her right hip and upper right thigh. During an interview on 08/16/23, CNA B said he/she works overnights and has worked all the units. He/she has worked on the Faith Unit (the memory care unit). After 10:00 P.M., he/she is usually the only staff on the memory unit. If he/she needs help, he/she has to call another unit. If no one is available, he/she waits until someone is available, which is usually around 20 minutes. He/she said that happens often. Over the past couple weeks, the acuity of the hall has become heavy. He/she hadn't seen any interactions between Resident #1 and Resident #2, but Resident #2 had been having behaviors. Both residents had been being up most nights. It was a challenge being in the memory unit alone with both residents up. CNA B said he/she did not call for help on the night Resident #1 fell, because the residents were not interacting with each other before the fall. Normally he/she could take someone to the restroom with no issues. The CNA said there is not enough staff on the memory unit to meet the residents' needs and they cannot provide oversight. Review of the Maintenance Supervisor's Statement, undated, showed the following: -He/she said the camera time is off approximately 40 minutes; -At 2:11 A.M., on 08/13/23, Resident #1 and Resident #2 were at the nurse's desk; -Resident #1 walked up to Resident #2, and Resident #2 pushed Resident #1 away; -Resident #1 walked back to Resident #2, and Resident #2 pushed Resident #1 away again; -When Resident #1 went up to Resident #2 the next time, Resident #2 pushed Resident #1 and Resident #1 fell; -The aide was in the shower room toileting another resident. When the aide came out, he/she assisted Resident #1 to sit in the chair and got on the phone. 5. During an interview on 08/15/23, at 8:10 P.M., Nursing Assistant (NA) C said he/she had worked on the memory unit, and after 10:00 P.M., he/she is alone. He/she did not feel there was enough staff to meet the residents' needs. Once the residents are in bed, it is better, but trying to get everyone in bed is a challenge. When he/she needs assistance from another staff member, he/she calls to another hall for assistance. It usually takes a minute for staff to respond. He/she was aware of Resident #2 having behaviors towards staff members. 6. During an interview on 08/16/23, at 9:35 A.M., LPN D said he/she always worked on the memory unit. There are at least five residents that require two person assist depending on the day, sometimes six. During the day, there are three staff, at night one aide and a nurse floats between the memory unit and another unit. If an aide goes in a room to take care of a resident, that leaves the hall basically uncovered. The aide doesn't usually call for assistance unless there is a problem or they are going on break. Resident #1 was very protective of his/her belongings. LPN D said he/she had not seen anyone take Resident #1's belongings. Resident #2 had behaviors and was aggressive to staff. There had been four broken hips occur in the last two months on the memory unit. On a good night, one staff member might be enough, otherwise, no. The aide should call for assistance before going into a room to perform cares. A resident to resident altercation could occur in a matter of minutes. 7. During an interview on 08/16/23, at 9:45 A.M., LPN E said he/she floats to different units to assist when needed. He/she has heard of the memory unit being short staffed overnight, having one aide overnight, and a nurse going back and forth between the memory unit and another unit. Some nights he/she would consider that appropriate and some nights not appropriate. If residents are still up wandering in the unit, the aide should call for assistance before assisting another resident in their room. 8. During an interview on 08/16/23, at 12:25 P.M., CNA F said there was not enough help in the memory unit. It was difficult to perform ADLs for the residents. He/she has taken care of Resident #1 and Resident #2. Resident #2 had behaviors that consisted of aggression towards staff. The aide was afraid Resident #2 would hurt someone if staff did not intervene. He/she said he/she did not believe one staff is enough at night to prevent residents from wandering into the other residents' rooms. He/she hears from the night shift that they need more help. 9. During an interview on 08/16/23, at 10:20 A.M., the Nurse Practitioner said she was aware of both resident's behaviors. It is up to the facility to determine staffing for the halls. If the staff feel they need more assistance, they should let the Director of Nursing (DON) know. 10. During an interview on 08/16/23, at 1:18 P.M., the DON and Administrator said staffing is based on a reasonable census and acuity of the residents. They look at the acuity of the residents and base it on that and the facility assessment tool. No one had brought concerns to the DON or Administrator regarding Resident #1 or Resident #2. They were aware after the fact. MO00222956

Based on observation, interview and record review, the facility failed to ensure staff accurately assessed the skin condition of residents to identify pressure ulcers, failed to accurately monitor, document and track the progress of the pressure ulcers, and ensure new ulcers did not develop for two residents (Resident #1 and #2) that staff identified as having a history of pressure ulcers and/or at risk for developing pressure ulcers. Staff failed to follow their policy and ensure a trained registered nurse assessed the pressure ulcers at least weekly as part of the Interdisciplinary Team Review. Thirteen residents were chosen for review in a facility with a census of 78. 1. Record review of the Merck Manual of Geriatrics (third edition), showed risk factors for the development of pressure ulcers included the following: -Moisture (as it occurs with urinary and fecal incontinence); -Unrelieved pressure for more than two hours; -Immobility; -Inactivity; -[MEDICAL CONDITION]; -Infection; -Malnutrition; -Declined ability to respond to pressure related discomfort; -History of pressure ulcers. Record review of the facility's policy titled, Wound/skin Care, revised [DATE], showed the following information: -All residents will have their skin assessed by a licensed nurse on a minimal weekly basis. -Document weekly skin assessments for all long term care residents on the back of the treatment sheet of that resident. -Document weekly skin assessments for all skilled care residents in the resident's computer chart (EPIC). -The resident care coordinator (RCC) and the nursing supervisor (including the Director of Nursing (DON) and Assistant Director of Nursing (ADON) will monitor compliance of skin assessments weekly. -On all identified skin concerns, the charge nurse will follow the skin care protocol. -When breakdown is noted, the staff is to complete the skin care progress report (SCPR). The skin care reference guide will be followed and/or the physician contacted for orders. -The DON and/or the ADON will monitor residents on a daily basis by reviewing the 24-hour report sheets. -The DON and/or the ADON will monitor skin concerns weekly by reviewing the skin care progress report. The RCC or designee nurse will complete weekly documentation on the skin SCPR of residents with pressure ulcers. -The Skin Care Committee will meet monthly to review residents with skin concerns and their plan of treatment, make sure that treatments are being followed and revised as appropriate to the resident's needs. Record review of the facility's Skin Care Protocol, undated, showed the following: -For a pressure ulcer the nurse is to document assessment findings in nurses' notes, care plan and the skin care progress report. -The physician and family are notified and documented. -The staff follows the skin care reference guide. -A dietary consult is ordered. -An occupational therapist consults. -The nursing staff is to document weekly on skin care progress report. -If the wound has not changed in two weeks, the staff will notify the physician for a change in the treatment orders. -The staff discusses the wound monthly in the skin care focus group during the healing process. According to the National Alliance of Wound Care and Ostomy, initially, a deep tissue injury (DTI) presents as a localized area of intact skin with dark discoloration, such as purple, maroon, or a bruise like appearance, or a blood-filled blister. The tissue in the DTI area may be preceded by tissue that's painful, firm, mushy, boggy, or warmer or cooler than adjacent tissue. A stage I pressure ulcer will have light discoloration, such as light pink or light red, of intact skin. If the pressure ulcer initially presents with a fluid-filled blister versus a blood-filled blister, it would be considered a stage II pressure ulcer. As a DTI evolves, clinicians may see a thin blister over a dark wound bed on the skin. The skin may open up superficially, which causes many clinicians to erroneously stage the DTI as a stage II pressure ulcer. Clinicians should continue to stage the wound as a DTI, but should describe the characteristics of how the skin is blistering or has superficial open areas. The DTI may further evolve and become covered by thin eschar, and further evolution may be rapid, exposing additional layers of tissue, even with optimal treatment. Once the DTI has fully opened, exposing the level of tissue damage, it can then be accurately staged as III or IV pressure ulcer. 2. Record review of Resident #2's face sheet showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's [DATE] nurses' notes showed staff documented no concerns related to skin breakdown on the resident's bottom. Record review of the resident's February 2016 treatment administration record (TAR) showed the following: -On [DATE], a nurse documented on the back of the TAR, the resident had scant redness to both buttocks. The nurse did not document measurements of the reddened area or notification of the physician; -On [DATE], a nurse documented on the back of the TAR, the resident's skin assessment. The nurse did not document any information on the redden buttocks; -The nursing staff did not document a skin assessment for [DATE]; -On [DATE], the nursing staff added an order: apply Venolex (an ointment used to promote wound healing and the treatment of [REDACTED]. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, odor, and appearance of surrounding tissue. Record review of the resident's Physician order [REDACTED]. Record review of the resident's medical record showed no documentation on a SCRP for the open area or wound on the resident's bottom (coccyx - tail bone) completed by staff for February 2016. Record review of the resident's February 2016 nurses' notes showed the staff documented no concerns related to an open area on the resident's bottom. The nurse did not document an assessment of the wound on the resident's bottom, to include size, appearance of the wound bed, drainage, odor, and appearance of surrounding tissue. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated [DATE], showed the following information: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Required total staff assistance with transfers, ambulation, eating, and toileting, bathing and personal hygiene; -Regular diet (no added salt); -Functional limitation in Range of Motion (ROM) upper and lower extremities; -Used a wheelchair for mobility; -Incontinent of bowel and bladder; -At risk for developing pressure ulcers; -Stage I (a persistent area of skin redness without a break in the skin, that is nonblanchable) pressure ulcer, moisture associated skin damage (MASD- skin problems that occur due to prolonged exposure to wound drainage, fecal and/or urinary incontinence and perspiration) to the coccyx; -Required pressure-relieving device to wheelchair. Record review of the physician progress notes [REDACTED]. -The physician examined the resident's left buttock wound on [DATE]; -The physician identified the wound as a Stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) pressure ulcer to the left buttock; -The staff should monitor the resident's pressure ulcer and notify him/her if it does not improve. Record review of the resident's [DATE] TAR showed the following: -On [DATE], a nurse documented he/she completed the treatment to the open area on the resident's bottom. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, odor, appearance of surrounding tissue; -On [DATE], a nurse documented the resident's weekly skin assessment: opened area above butt crack and a second area to the left of the butt crack; no new concerns at this time. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, odor, appearance of surrounding tissue; -On [DATE], a nurse documented the resident's weekly skin assessment: open area to coccyx, treatments completed as ordered with no other concerns. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, odor, appearance of surrounding tissue; -On [DATE], the nurse documented the treatment to the resident's bottom did not get completed. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, odor, appearance of surrounding tissue; -On [DATE], a nurse documented the treatment to the open area on the coccyx continued. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, odor, appearance of surrounding tissue; -On [DATE], a nurse documented the resident's weekly skin assessment: No open areas at this time; -Staff failed to document the completion of the treatment as ordered 5 times ([DATE], [DATE], [DATE], [DATE] and [DATE]) out of 29 opportunities. Record review of the resident's nurses' notes for [DATE] showed no concerns related to skin breakdown on the resident's bottom. Record review of the resident's medical record showed no documentation on a SCRP for the open area or wound on the resident's bottom (coccyx) completed by staff for [DATE]. Record review of the resident's [DATE] TAR showed on [DATE] a nurse documented the treatment to the pressure ulcer on the coccyx continued to with small open areas. The surrounding skin was dry with no new concerns. The nurse did not document an assessment of the wound to include size, appearance of the wound bed, drainage, and odor. Record review of the monthly care plan summary, dated [DATE], showed the following information: -Braden scale showed the resident's total score was 13, indicating moderate risk for pressure ulcer development; -Open area on the coccyx; -Provide Venolex with [MEDICATION NAME] to the coccyx and complete weekly skin assessments. Record review of the resident's [DATE] TAR showed on [DATE] the nurse documented the resident's weekly skin assessment. The nurse completed the treatments to the coccyx wound. The nurse did not document an assessment including size, appearance of the wound bed, drainage, and odor. Record review of the physician progress notes [REDACTED]. -The physician examined the resident on [DATE] for a cough; -The physician did not document any information regarding the Stage II pressure ulcer to the left buttock on the report; -The physician documented the staff reported no other skin concerns. Record review of the resident's [DATE] TAR showed the following: -On [DATE], the nurse failed to document the resident's weekly skin assessment. The staff documented the treatments for the resident's groin continued and has redness. The nurse did not document an assessment including size, appearance of the wound bed, drainage, and odor; -On [DATE], the nurse documented he/she did not complete the resident's treatment to the coccyx pressure ulcer due to the resident attending an activity; -On [DATE], the nurse documented the resident's weekly skin assessment. The nurse did not document any coccyx pressure ulcer concerns. The nurse did not document an assessment including size, appearance of the wound bed, drainage, and odor; -On [DATE], the nurse documented an order to irrigate (area not identified) with saline and pack with [MEDICATION NAME] gauze (a type of gauze infused with an antiseptic compound used to treat infected and necrotic (dead tissue) wounds), and cover with [MEDICATION NAME] daily. The nurse documented the tunneling (open tunnels extending from the wound, sometimes to other wounds) should be measured daily and documented; -On [DATE], the nurse documented a single measurement: 3.5 centimeters (cm). The nurse did not document an assessment of the wound to include complete size, appearance of the wound bed, drainage, odor, and appearance of surrounding tissue or pain. Record review of the SCPR, dated [DATE], showed the nursing staff documented the resident had a Stage III (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) to Stage IV (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) pressure ulcer to the coccyx, measuring 0.75 cm x 1.25 cm, with 2.75 cm x 2 cm (depth) and no drainage. Staff packed the pressure ulcer with [MEDICATION NAME]. The nurse did not document a full assessment of the wound including appearance of the wound bed, odor, and appearance of surrounding tissue. Record review of the resident's POS, dated [DATE], showed the following: -The staff identified a wound to the resident's left inner thigh. The physician ordered the area cleansed with warm soap and water, dried, and covered with [MEDICATION NAME] daily. -The physician identified the wound on the coccyx as a State III to Stage IV pressure ulcer. The physician ordered the area irrigated with saline daily, packed with [MEDICATION NAME] gauze and covered with [MEDICATION NAME] daily. The staff should measure and document the wound depth daily; -An x-ray and labs ordered due to tunneling of the pressure ulcer; -The staff notified the family of the advancement of the wound. Record review of the resident's laboratory results report, dated [DATE], showed the resident's [MEDICATION NAME] level was low at 3.0 (normal range is 3.4 to 5.0). According to [MEDICAL CONDITION]'s Clinical Geriatric Nutrition, low levels of [MEDICATION NAME] ([MEDICATION NAME] carries vital nutrients and hormones, and provides your body with the proteins it needs to maintain growth and repair tissue) and total protein show low visceral protein stores and in the elderly are highly predictable of pressure sores and increase morbidity. Record review of the physician's progress note, dated [DATE], showed the following: -On [DATE] the physician examined the pressure ulcer on the resident ' s coccyx on [DATE]; -The weekend of the [DATE] through [DATE] nursing staff notified the physician the resident's coccyx pressure ulcer had declined; -The resident had increased pain near his/her rectum; -The physician assessed the pressure ulcer on the coccyx and found tunneling to the surrounding tissue; -The wound was identified as a Stage III-IV pressure ulcer over the coccyx with deep tunneling to at least 3 cm with concerns that the tunneling has gone down to the bone. The wound did not have drainage or odor; -The physician wrote orders including a different treatment to the coccyx pressure ulcer, antibiotics and a bone scan to the sacrum and coccyx; -The physician also identified an excoriated area on the left inner thigh. Staff reported the excoriation (the destruction and removal of the surface of the skin by scraping) on the left inner thigh was due to an incontinent brief rubbing the resident's skin; -The physician reviewed the recent x-rays and lab ordered. Record review of the resident's nurses' note dated [DATE], at 3:40 P.M. (a late entry for [DATE]), showed a nurse documented the physician assessed the resident's pressure ulcer on his/her bottom. The nurse measured the pressure ulcer at 2.75 cm x 2.25 cm with tunneling. The physician ordered blood work and x-rays. The staff notified the family of the new orders. Record review of the resident's POS, dated [DATE], showed the following: -an order for [REDACTED].>-an order for [REDACTED]. -an order for [REDACTED].>-an order for [REDACTED]. Record review of the resident's care plan, last reviewed and updated on [DATE], showed the following information: -Resident at risk for skin breakdown related to bladder and bowel incontinence; -Resident has no skin breakdown since last revision on [DATE]; -The staff should assess/record/ monitor skin with cares and weekly assessments and provided treatments per physician order [REDACTED].>-The staff should provide the resident a pressure relieving cushion in his/her chair, turn and reposition before treatments. Record review of the resident's sacral/coccyx x-ray report, dated [DATE], showed the resident had wound tunneling with no signs of osseous (bone) damage. Record review of the resident's [DATE] TAR showed the following: -On [DATE], the nurse documented the resident's weekly skin assessment: left inner (posterior) thigh 3 cm x 3 cm with dark (eschar) in the middle of the pressure ulcer. The nurse documented the treatment was completed as ordered. The nurse did not document a complete assessment of the wound including appearance of the wound bed, drainage, odor or pain. -On [DATE], the nurse documented the resident's weekly skin assessment: redness present on the left groin. The pressure ulcer on the coccyx continued to have tunneling at 12 o'clock and 6 o'clock. The wound to the left gluteal/groin fold continued to have treatments as ordered. No other areas of concern identified by the nursing staff. The nurse did not document a full assessment of the wound to include size, appearance of the wound bed, drainage, odor or pain. Record review of the resident's POS, dated [DATE], showed the following: -an order for [REDACTED].>-An update to the order on the coccyx pressure ulcer: cleanse the area with saline, measure wound and pack with [MEDICATION NAME] gauze, cover with a gauze pad then an abdominal pad and tape. The staff should change the resident's dressing twice a day and as needed; -An update to the order on the left inner thigh: apply Venolex to dark center and cover with [MEDICATION NAME] daily and as needed; -An order to refer to the wound clinic. Record review of the resident's coccyx wound culture, dated [DATE], showed the following: -The culture grew several (heavy) types of gram-positive cocci, gram negative and positive type rods (all different types of bacteria); -The staff documented on the lab report the physician discontinued the resident's current antibiotics (Cipro and [MEDICATION NAME]) on [DATE] and started [MEDICATION NAME] (an antibiotic). Record review of the SCPR, dated [DATE], showed the nursing staff documented the resident had a Stage IV (full thickness tissue loss involving the exposed bone, tendon, and/or muscle slough or eschar may be present on some parts of the wound bed with undermining or tunneling) pressure ulcer to the coccyx, measuring 1.0 cm x 2 cm, with 4.0 cm (depth) and tan drainage. Staff packed the pressure ulcer with [MEDICATION NAME]. The nurse did not document a full assessment of the wound including appearance of the wound bed, and odor. The staff documented a second open, red area on the coccyx (un-staged by staff) measuring 2.0 cm x 5 cm, around wound. The nurse did not document a full assessment of the wound to include treatment, appearance of the wound bed, drainage, and odor. Record review of the referral request made to the hospital's Wound Care Center, dated [DATE], and showed the following: -The nurse made an initial call on [DATE] to the Care Center for a coccyx pressure ulcer and a left groin/gluteal fold wound, both identified on [DATE]; -The staff documented the pressure ulcer is currently treated with Iodaform packing and covered with [MEDICATION NAME] foam. Record review of the resident's monthly care plan summary, dated [DATE], showed the following information: -Resident's pain increased since the last assessment: daily, relieved with Tylenol as needed; -The resident's Braden scale score totaled 13, indicating moderate risk for pressure ulcer development; -The resident had an open area on his/her coccyx with green drainage; -The staff documented in the comments the resident now had an open Stage IV pressure ulcer to his/her coccyx. Record review of the SCPR, dated [DATE], showed the nursing staff documented the resident had a Stage IV pressure ulcer to the coccyx, measuring 2.0 cm x 3.7 cm, with a ,[DATE] cm (depth) and serosanguinous (composed of serum and blood) drainage. The nurse documented the wound tissue as larger, healthier looking tissue and no odor. The staff documented a second, open wound above the coccyx (un-staged by staff), measuring 0.4 cm x 1.2 cm x 0.1 cm (depth). The nurse did not document a full assessment of the wound to include treatment, appearance of the wound bed and odor. Record review of the resident's nurses' note dated [DATE], at 3:00 P.M., showed the following: -The resident had two wounds on his/her coccyx and one on his/her right buttock; -Stage IV pressure ulcer on the coccyx measured 2 cm x 3.7 cm x 4 cm with serosanguinous drainage and no odor. The staff documented the tissue around the wound as slightly red; -A smaller pressure ulcer just above the coccyx (sacrum) measured 1.2 cm x 0.4 cm x 0.1 cm. The staff described the wound base to be white in color. The nurse did not document a full assessment of the wound to include treatment, staging and odor. -The resident's right buttock had a pressure ulcer that measure 2.4 cm x 1.8 cm x 0.1 cm. The pressure ulcer bed was yellow and white with no blackened areas. The nurse did not document a full assessment of the wound to include treatment, staging and odor; -The physician wrote new orders. Record review of the resident's [DATE] TAR showed on [DATE] a nurse documented the resident's weekly skin assessment: the resident's left groin continued to be red. The resident's left gluteal fold wound and coccyx wound continued to worsen (refer to the nurse notes). The staff completed the treatments as ordered with no additional skin concerns documented. Record review of the resident's nurse notes, dated [DATE] to [DATE], showed the following: -On [DATE] at 3:20 P.M., a nurse documented the coccyx pressure ulcer opened (two areas enlarged to one area) with odor and purulent drainage present. The resident's dressing contained blood. The nurse did not document notifying the physician of the pressure ulcers deterioration; -On [DATE] at 4:30 A.M., a nurse documented the pressure ulcer continued to have a foul odor with a gray/black appearance. The nurse did not document notifying the physician; -On [DATE] at 1:00 P.M., a nurse documented the pressure ulcer on the resident's coccyx had a small amount of slough (white or yellow dead tissue that clings to the wound bed in strings or clumps) and eschar (brown or black dead tissue) from inside the wound; -On [DATE] at 5:00 A.M., a nurse documented the resident had no changes with his/her wounds. Record review of the SCPR, dated [DATE], showed the nursing staff documented the resident had a Stage IV pressure ulcer to the coccyx, measuring 1.75 cm x 5.0 cm, with a ,[DATE] cm (depth) and serosanguinous drainage. The nurse documented the large coccyx wound and the smaller coccyx wound was now one wound. The nurse did not document a full assessment of the wound to include treatment and appearance of the wound bed. Record review of the resident's nurse's note dated [DATE], at 10:15 A.M., showed a nurse documented the resident's coccyx wound measured 5.5 cm x 1.75 cm x 5 cm deep at (12 o'clock) and 4 cm straight into the wound bed. The area above the coccyx (sacrum) opened and had yellow serosanguinous drainage. The nurse did not document notifying the physician. Record review of the resident's [DATE] TAR showed on [DATE] a nurse documented the resident's weekly skin assessment: the resident's skin on the left groin and gluteal fold is red, but remain intact. Staff continued to perform the treatment on the Stage IV pressure ulcer on the resident's coccyx. Staff placed a [MEDICATION NAME] dressing on the resident's left gluteal fold. The nurse did not document a complete assessment of the wounds including size, appearance of the wound bed and surrounding skin, drainage odor or pain. Record review of the resident's bone scan, dated [DATE], showed no evidence of osteo[DIAGNOSES REDACTED] and soft tissue inflammation/[MEDICAL CONDITION] (a bacterial infection of the skin and tissues beneath the skin) in the left buttock and coccyx region. Record review of the resident's nurses' notes, dated [DATE] to [DATE], showed no additional wounds identified on the resident. The staff completed the pressure ulcer treatments as ordered with no additional skin concerns. Record review of the resident's POS, dated [DATE], showed the following: -A written order (by the wound care center) for the coccyx wound: irrigate with normal saline (NS) to cleanse, pat dry, and pack with Dakin's 0.125% (an antiseptic solution consisting of sodium hypochlorite and 0.4% boric acid) soaked gauze. The staff should secure the dressing with [MEDICATION NAME] (gentle, breathable tape) and changed daily; - A written order (by the wound care center) for the left ischial tuberosity (large bony projection at the junction of the lower back part of the hip bone) wound (first documention regarding this wound): cleanse with NS, pat dry, apply [MEDICATION NAME] AG (an adhesive foam dressing containing silver; silver kills bacteria), [MEDICATION NAME] and secure with [MEDICATION NAME] . The staff should change the dressing daily. Record review of the resident's nurses' notes, dated [DATE] to [DATE], showed no documentation of a left ischial tuberosity pressure ulcer. Record review of the resident's SCPR, dated [DATE], showed the following: - A single Stage IV wound measuring 2.5 cm x 7 cm x 5 cm with serosanguinous drainage and treated with a new order from the wound care center. The staff should pack the wound daily with Dakin's soaked gauze. The nurse did not document a full assessment of the wound including appearance of the wound bed or surrounding tissue, and odor; -No measurement provided for the newly identified wound (left ischial tuberosity) on [DATE] by the wound care center. The nurse did not document a full assessment of the left ischial tuberosity wound to include: measurements, staging, wound drainage, appearance of the wound bed or surrounding tissue, and odor. Record review of the resident's POS dated [DATE] showed an order for [REDACTED]. Observations and interviews on [DATE] showed the following: -At 9:16 A.M., Certified nurse Aid (CNA) A and CNA B transferred the resident from his/her wheelchair to his/her bed with a Hoyer lift ( a mechanical lift requiring a cloth sling). The CNAs positioned the resident onto his/her back. The resident yelled and moaned with positioning and said, I'm gonna cuss, but he/she did not speak any further; -At 9:30 A.M., Registered Nurse (RN) C arrived at the resident's room and gathered supplies for the resident's wound care. The RN C placed a towel on the resident's bedside table and arranged the wound care supplies. CNA A and CNA B opened the resident's brief and provided incontinent care to the resident's right and left groin area. The resident's groin and perineal area were red, but did not have any open areas. The CNAs rolled the resident onto his/her right side. The resident had feces on his/her bottom and down his/her left hip. The resident had a dressing on his/her coccyx area with visible feces present. The resident did not have a dressing on a wound on the left hip. The CNAs cleaned the resident with personal cleansing wipes until the skin was free from feces. The RN removed the soiled dressing with gloved hands. The CNAs positioned the resident's skin on his/her buttocks so the RN could remove the resident's wound gauze. The CNA gently pulled the resident's skin open around the wound to expose the soiled wound bed. The resident's wound was approximately the size of a small human fist or a tennis ball. The resident's wound bed was a deep, red hole, covered with stringy, brown slough. The wound did not have an odor. The CNAs continued to expose the open wound area to allow the RN to clean the internal area and apply clean, Dankin's soaked wound gauze. The RN washed her hands and applied clean gloves; -At 9:40 A.M., the resident closed his/her eyes and rested quietly as the staff provided care. The CNA said the dressing on the resident's hip was not present at the start of care. The RN cleansed the resident's left hip and applied the dressing as ordered. The CNAs applied a clean brief and repositioned the resident in his/her bed. RN C said the coccyx wound started about three weeks prior and is currently under the care of the Wound Clinic. The RN said the coccyx wound presented as a Stage III-Stage IV pressure ulcer with tunneling. The RN said the area on the resident's hip started a few days prior. The staff performed hand hygiene and exited the room. During an interview on [DATE] at 8:35 A.M., CNA F said the following: -The resident's coccyx wound appeared as a dime to a quarter sized red spot for one to two weeks. A second red spot, located above the first area, appeared a couple of days after the first red spot appeared. The CNA reported the second red spot, to the charge nurse and completed a CNA observation sheet; -In about one week, the two red spots on the resident's coccyx became one wound. The large wound had tunneling present when it opened; -The CNA said the resident yells with his/her bath and has pain with the wound; the staff is unsure if the shower technique is making the resident yell or the wound. The staff said the resident has yelled during the shower before the wound had been on the resident's coccyx. The family is working with the CNA on different techniques to make bathing more comfortable for the resident; -The CNA discovered the resident's hip wound (ischial tuberosity) during a recent shower. The CNA informed the charge nurse and requested the nurse come to the shower room and assess the wound. The CNA completed the CNA observation sheet and stapled the form to the resident's 24-hour Nurse Report sheet. The CNA did not recall the date of the finding. Record review of the [DATE]-hour Nurse Report sheets and the resident's medical record, showed no documentation of a wound discovered by CNA F or any CNA observation sheets. During an interview on [DATE] at 9:55 A.M., RN D said the staff did not locate any completed CNA observation sheets for the resident. During an interview on [DATE], at 11:15 A.M., the physician/Medical Director said the following: -Staff should have documented the coccyx pressure wound progress on the skin monitoring sheets once the area first opened on the SCPR; -The physician was unaware the wound had declined until [DATE]. During an interview on [DATE], at 2:50 P.M., the DON and RN J/Wound Nurse said the DON and the wound nurse identified the resident's pressure ulcer as a red spot the end of February 2016. The staff notified the physician of the skin area. The physician ordered a treatment for [REDACTED]. The DON and the wound nurse said they expect n

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions for one resident (Resident #14), who the facility assessed as high risk for falls, who fell and sustained a right shoulder fracture. After the fall, the facility determined the new fall prevention intervention would be ineffective for the resident and failed to implement a new fall prevention intervention in a timely manner. The facility failed to attempt new interventions after each fall to prevent additional falls for one resident (Resident #20), who the facility assessed as high risk for falls and had multiple falls. The facility failed to use fall prevention interventions appropriately for two residents (Resident #16 and #11), who the facility assessed as high risk for falls and had multiple falls. in a sample selection of 24 residents in a facility with a census of 145. 1. Record review of Resident #14's nurses' notes, showed the resident entered the facility on 5/25/11, at 6:10 P.M. Record review of the admission assessment form, dated 5/25/11, showed staff assessed the resident's fall history and assessed the resident's fall risk. The resident's fall risk assessment score was 10 (high). If the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The facility documented the immediate plan of care for the resident on the admission assessment form which included staff to keep the call light in reach and encourage the resident to wait for assistance. The nurse assessed the resident as oriented to person, place, time, and situation with intermittent confusion. The plan of care included to reorient and redirect the resident as needed. Monitor the resident for changes. The resident required one person staff assistance for transfers and toileting. The resident had generalized weakness. Record review of the resident's current care plan, admitted [DATE], showed the following information: -Problem included history of falls and/or potential for falls; -Give verbal reminders not to ambulate or transfer without assistance; -Ensure the resident wears properly fitting non-skid soled shoes; -Maintain environment free of clutter and safety hazards; -Place items frequently used within easy reach to avoid reaching for items; -Call light within easy reach; -Provide environment with adequate lighting; -Physical therapy per physician orders. Record review of the nurses' notes showed on 5/25/11, at 11:20 P.M., the nurse documented the resident getting out of bed. The nurse placed a personal alarm (a device attached to personal clothing and a stationary object in which an alarm sounds when movement is detected beyond set parameters) on the resident. The resident denied needing to use the bathroom. Record review of the resident's current care plan, admitted [DATE], showed on 5/25/11, staff wrote in, "personal alarm" and to "ensure the personal alarm is intact", to the existing care plan. Record review of the nurses' notes showed the following information: -On 5/26/11, at 12:45 P.M., the nurse documented the resident alert and confused at times. -On 5/27/11, at 5:15 A.M., the nurse documented the resident as confused and required guidance to take his/her medications, not just hold them in his/her hands. -On 5/27/11, at 7:30 P.M., the nurse documented the resident oriented to person and required assistance of one staff for ambulation to the bathroom with a roller walker. The resident frequently attempts to ambulate without the walker. Staff reminded the resident to use it with all ambulation. -On 5/30/11, at 1:00 A.M., the resident complained of being anxious and that it was hard to catch his/her breath. The nurse notified the physician and obtained an order to send the resident to the emergency room . -On 5/30/11, at 1:27 A.M., the resident left the facility per ambulance. Record review of the admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument required to be completed by facility staff, dated 5/30/11, showed the following information: -Short and long term memory problem; -Modified independence for decision-making skills; -Required limited assistance of one staff person for transfers, ambulation, dressing, personal hygiene, and toilet use; -Always continent of bowel and bladder; -Urinary tract infection in the last 30 days; -Staff documented the resident did not have any falls or fractures in the previous six months prior to admission to the facility; -Staff documented the resident did not have any falls since admission to the facility. Record review of the nurses' notes showed on 6/2/11, at 4:40 P.M., the resident re-entered the facility. Record review of the admission assessment form, dated 6/2/11, showed staff assessed the resident as oriented to person, place, time, and situation with confusion at times. Staff to keep the call light in easy reach at all times, redirect and reorient the resident as needed. The resident had short term memory loss and impaired attention span. Staff assessed the resident's fall risk score as 10 (high). Staff should keep the call light in easy reach and encourage the resident to await assistance. Record review of the nurses' notes showed the following information: -On 6/4/11, at 2:00 A.M., the resident told the aide he/she was going into cardiac arrest. When the nurse got to the room, the resident was eating a sandwich. The resident was alert and oriented to self. The resident thought he/she was at a family member's house. -On 6/5/11, at 12:15 A.M., staff documented the resident as alert and confused. Staff documented call light in reach. -On 6/6/11, at 12:40 A.M., the resident sat on the side of the bed. Staff assessed the resident as alert and confused. The resident seemed sleepy with slurred speech. The nurse documented the resident's call light in reach. -On 6/6/11, at 11:00 A.M., the nurse assessed the resident as alert and oriented to self. The resident had confusion. -On 6/6/11, at 11:40 P.M., the nurse documented the resident had a personal alarm attached and call light within reach. -On 6/8/11, at 9:50 A.M., the resident sat on the side of the bed after breakfast. The nurse assessed the resident as confused and disoriented. The resident's call light remained in reach. -On 6/8/11, at 8:00 P.M., the resident is mostly disoriented with intermittent orientation to self, situation, and place. -On 6/9/11, at 9:30 A.M., the resident sat in the chair in the room. At 7:00 P.M., the resident is alert and oriented to self only. The resident insists that he/she slept in a different bed last night. Staff could not reorient or redirect the resident. At 11:30 P.M., the nurse documented the resident as alert and oriented to self and wandering into other peoples' room. -On 6/10/11, at 11:00 P.M., the nurse documented the resident as oriented to self and occasionally wandering from room. The resident needs redirection to find own room again. -On 6/11/11, at 12:50 A.M., the resident sat on the side of the bed. The nurse assessed the resident as alert and oriented to self. At 10:10 A.M., the resident sat on the side of the bed. The resident complained that he/she is unable to sleep due to the noises at the facility. The resident complained of feeling tired. Staff documented the call light in reach. At 10:10 P.M., the nurse assessed the resident as oriented to person only. The resident's family remained on the unit for several hours. At 11:10 P.M., staff found the resident laying on his/her right side on the floor. The nurse assessed the resident. When staff found the resident on the floor, they found the resident's walker by the bedside. Staff placed a personal alarm on the resident. Record review of the co-worker witness fall report (fall investigation), dated 6/11/11, at 11:10 P.M., showed staff were unsure what precipitated the fall. The fall occurred when the resident was going to the bathroom. Staff was unsure of when the last time the resident used the toilet. In response to the question of " Had the resident been confused lately? " the nurse documented "usual" for the resident. To prevent this from happening again, staff documented they applied a personal alarm and encouraged the resident to leave the personal alarm on and to use the call light. Record review of the fall risk assessment, dated 6/11/11, showed the resident's fall risk score was 12 (high). The assessment showed the resident had a balance problem while standing and walking. The resident had decreased muscular coordination. The resident required use of an assistive device. Record review of the nurses' notes, showed the following information: -On 6/12/11, at 12:50 A.M., staff documented the resident was up by his/herself to the bathroom. The resident took off the personal alarm. Staff assisted the resident to the bathroom when they found the resident ambulating by self. At 1:40 A.M., resident again ambulatory to bathroom by self. The resident had removed the personal alarm. The resident's pajama bottoms were positioned at mid-thigh. Staff assisted the resident to the bathroom and back to bed. Staff encouraged the resident to use the call light when getting up. Staff reapplied the personal alarm. At 3:50 A.M., the resident stood up and leaned on the roommate's bed. Staff assisted the resident to the nurses' station. The resident complained of his/her shoulder hurting. Staff notified the physician and received orders for Tylenol 650 mg as needed and to obtain an x-ray of the right shoulder. During interview on initial tour on 6/13/11, at 8:35 A.M., Registered Nurse (RN) A (charge nurse for the unit and resident care coordinator) said the resident had a fall over the weekend with no injuries. They had obtained an x-ray of the resident's right shoulder and the results were pending. The resident ambulates with a walker, transfers self, and toilets self. The resident would not be interviewable because he/she is confused. The resident has a personal alarm that he/she can take off. The resident does not sleep much and is up and down a lot during the day and night. The facility is going to change the personal alarm to a seat (pressure) alarm (a mat placed on a chair which will sound an alarm when movement is beyond set parameters). The resident had not had any recent infections. Record review of the physician order [REDACTED]. The physician ordered Bactrim DS (antibiotic) one tablet twice a day for seven days for urinary tract infection. The physician ordered a bed and chair alarm. Record review of the urinalysis laboratory results showed the following indicators of urinary tract infection: -Slightly cloudy urine (normal is clear); -Large leukocyte esterase (normal is negative); -White blood cell 11-15 (normal is 0-2); -Few bacteria (normal is none seen). (Urinary tract infections can increase confusion in the elderly and increase urgency.) Record review of the nurses' notes on 6/13/11, (at unknown time), the nurse documented x-ray results showed the resident had a fractured right shoulder. Record review of the resident's current care plan, admitted [DATE], showed staff added the following information to the existing care plan: -On 6/13/11, staff wrote in bed and chair alarm; -On 6/13/11, staff wrote in current non-displaced fracture of right humerus (upper arm). Record review of the June 2011 treatment administration record (TAR) showed staff added the bed alarm and chair alarm on 6/13/11, for staff to monitor every shift. Staff circled their initials on 6/14/11,(indicating the treatment was not administered) and documented on the back of the TAR that the bed alarm was not available at this time. Personal alarm is in place. Staff documented the bed alarm on order. Observation on 6/13/11, at 2:02 P.M., showed the resident sat in the recliner in the room with a personal alarm attached to the resident. Record review of the physician office note, dated 6/14/11, showed the physician saw the resident for orthopedic evaluation of the right shoulder. The resident says he/she does not hurt much, but it does bother him/her some when he/she tries to push up from a chair and get up on his/her own. The physician recommended the resident avoid weight bearing on the right upper extremity, such as not pushing up out of the chair by self. The family member said the resident is able to use the walker without putting weight through the upper right extremity, using it for balance only. Record review of the resident's current care plan, admitted [DATE], showed staff added on 6/14/11, non-weight-bearing right upper extremity and okay for walker use. Record review of the nurses' notes, showed the following information: -On 6/14/11, at 9:30 A.M., the nurse documented the resident alert and oriented to self with confusion noted. The resident frequently removes the personal alarm. Staff reminded the resident to use the call light. -On 6/14/11, at 9:00 P.M., the resident was very confused and sat on the side of the bed. Observation and interview on 6/14/11, showed the following information: -At 8:08 A.M., showed the resident sat in the recliner by the bed. The resident sat eating breakfast with regular blue socks on his/her feet. (The care plan directed staff to ensure the resident wore properly fitting non-skid soled shoes.) -At 10:44 A.M., the resident ambulated in the room. The resident had white tennis shoes on his/her feet. The resident did not use the walker for ambulation. No alarm sounded as the resident walked in the room. The resident's walker did not appear to be in the room. The resident did not have any sling to support his/her arm and did not have any device to prevent the resident from bearing weight on the arm. Restorative nursing assistant (RNA) E entered the room and placed a gait belt on the resident and assisted the resident to the wheelchair. RNA E said he/she provided restorative nursing services on the other unit. The aide assisted the resident to the bathroom. RN A and certified nursing assistant (CNA) B entered the resident room. CNA B took the resident's personal alarm out of the drawer of the nightstand. CNA B said it was the third alarm this morning. The resident keeps putting the alarms different places. RN A said the pressure alarm is ordered, but the facility staff has to get it from the supply services. -At 10:55 A.M., RN A assisted the resident to pull up the resident's pants and incontinent brief. CNA B attached the resident's personal alarm to the resident. The alarm had a long string. The resident was able to stand without the alarm sounding. -At 1:17 P.M., the resident was up in the bathroom on the toilet by self. Staff entered the room and assisted the resident. The staff had the resident stand so he/she could finish cleaning the resident's bottom. The staff assisted the resident to pull up his/her pants with the personal alarm attached to the wheelchair and to the resident. The string reached from the resident to the wheelchair without detaching and sounding the alarm. -At 1:29 P.M., staff asked the resident if he/she wanted to lie down. The resident said no. The resident's personal alarm was attached to the resident at this time. Record review of the nurses' notes, showed the following information: -On 6/15/11, at 12:15 A.M., staff encouraged the resident to leave on the personal alarm and to call for assistance. At 8:45 A.M., the nurse documented the resident as disoriented and confused. The resident's call light remained in reach. At 9:00 P.M., the nurse assessed the resident as oriented to self only. Record review of the June 2011 TAR showed staff circled their initials for monitoring of the bed alarm and chair alarm (indicating the treatment was not administered). Staff documented on the back of the TAR the bed alarm not available at this time. Observation on 6/15/11, at 8:25 A.M. and 8:45 A.M., showed the resident sat in the recliner in the room with the personal alarm attached. During interview on 6/15/11, at 10:40 A.M., CNA C said he/she was pretty familiar with the resident. The aide said they first put on the personal alarm because he/she kept getting up and going to the bathroom by self. The resident always took the personal alarm off when no one was around. This occurred before and after the fall. At this time, the resident still has the personal alarm and he/she continues to take it off. Staff tries to check the resident every 15 minutes to see how the resident is doing and take him/her to the bathroom. Observation on 6/15/11, at 11:06 A.M., showed the resident sat on the side of the bed with the personal alarm attached. At 12:38 P.M., the resident sat in the recliner in the room with the personal alarm attached. During interview on 6/15/11, at 12:40 P.M., CNA B said the resident had the personal alarm since he/she came in. The resident has always removed the alarm. The resident hates it. When his/her family is not here, the resident is very confused. Since the fall, the resident has the personal alarm still. Staff just tries to take the resident to the bathroom more frequently. This is the second time the resident has been at the facility. Record review of the nurses' notes, showed on 6/16/11, 12:40 A.M., the nurse documented the resident refused to lie down. The nurse documented the bed alarm not available. The resident had on the personal alarm. The nurse documented the call light in reach. Record review of the June 2011 TAR showed staff wrote in chair alarm when available with the order date of 6/13/11. Staff did not initial use of the chair alarm. The record showed staff did not place the order for the personal alarm on the form until 6/17/11 to ensure staff monitored the use and function of the personal alarm. Observation on 6/16/11, at 8:17 A.M., showed the resident sat at the nurses' station with the personal alarm attached. At 8:39 A.M. and 9:00 A.M., the resident continued to sit in the chair by the nurses' station with the personal alarm attached. At 9:10 A.M., CNA B wheeled the resident to the room. Observation on 6/17/11, showed the following information: -At 7:55 A.M., showed the resident up ambulating in the room without any alarm sounding. The resident did not have any sling to support his/her arm and did not have any device to prevent the resident from bearing weight on the arm. A nurse walked by the room and an aide walked by the room and did not look into the room. The resident's personal alarm remained attached to the bed. The resident did not have any other alarm in the room. When questioned, the resident said he/she thought he/she could make it. The resident held onto the door and the bed and walked back toward the bed. The resident said he/she loses his/her balance easily. The resident wore one non-skid sock on one foot and the other foot did not have any sock on it. The other non-skid sock lay on the bed. -At 8:02 A.M., RN A walked by and looked into the room. The resident sat on the side of the bed at that time. -At 8:05 A.M., a certified medication technician passed medications on the hall and an aide passed out breakfast trays on the hall. -At 8:07 A.M., the resident stood up in front of the recliner and held onto the overbed table to assist him/her to sit in the recliner. -At 8:08 A.M., the resident sat in the recliner. -At 8:12 A.M., no staff had entered the room or checked on the resident. The resident sat in the recliner with the personal alarm still attached to the bed and not to the resident. The resident did not have any other alarms. -At 8:19 A.M., the resident dropped something onto the floor. The resident leaned forward to pick it up and then sat back up again. -At 8:23 A.M., CNA C entered the room and brought the resident's breakfast tray into the room. The resident said he/she needed to use the bathroom. CNA C applied a gait belt and said the resident was missing a sock. The aide placed the non-skid sock on the bare foot. The aide brought the resident's walker over to the resident and assisted the resident to stand. The resident ambulated to the bathroom. -At 8:27 A.M., the resident sat on the toilet. CNA C shut the bathroom door and left to get a "clean one". -At 8:28 A.M., the aide returned to the room and knocked on the bathroom door and checked on the resident. The aide shut the bathroom door again. -At 8:29 A.M., CNA C picked up the personal alarm and laid it on the nightstand. The aide straightened the bed. -At 8:30 A.M, the resident continued to be in the bathroom alone with the door shut. The aide removed his/her gloves, washed his/her hands, and applied new gloves. The aide obtained a new incontinent brief out of the drawer. The resident opened the bathroom door. The resident stood with his/her pants pulled up into place. The resident ambulated with the walker to the sink. The aide assisted the resident to wash his/her hands. The aide picked up the personal alarm and attached it to the side rail by the recliner. The aide assisted the resident to ambulate to the recliner. -At 8:44 A.M., CNA C brought the breakfast tray to the resident. The resident received a phone call. The aide partially set-up the tray and then put a cover over the plate. -At 8:48 A.M., the aide left the room. The resident did not have the personal alarm attached at that time. -At 8:50 A.M., the resident turned on the call light. CNA C entered the room and finished set-up of the breakfast tray. -At 8:52 A.M., CNA C attached the personal alarm to the resident. During interview on 6/16/11, at 8:55 A.M., licensed practical nurse (LPN) D said he/she thought the resident had the personal alarm from the beginning. The resident did not sleep. If the staff put the resident in bed, he/she would not sleep. They leave the resident in the chair to sleep. During interview on 6/16/11, at 8:55 A.M., RN A said the resident removes the personal alarm. The resident will even take off his/her shirt to get the alarm off. The resident always gets the alarm off especially during the night. The resident does not like to be by the nurses' station at night. Staff tries to keep the personal alarm on the resident. The staff is trying to get a pressure alarm for the bed. That way, the resident cannot get it off. The resident does not remember to use the call light. The staff has to order the pressure alarm. It is ordered. They will try to get it by the end of the week. The facility does not keep the alarms in stock. The environmental coordinator orders all the supplies and safety stuff. The administrator has to put a special order for the alarms. Staff keeps an eye on the resident and complete special checks on the resident. During an interview on 6/17/11, at 11:07 A.M., the environmental coordinator said she got a pressure alarm from another resident who had discharged . She cleaned it and gave it to the resident. During an interview on 6/17/11, at 11:55 A.M., the director of nursing (DON) said after a fall, staff complete a report and fall investigation on the fall. They document in the nurses' notes about the fall and document assessments. They complete a co-worker witness report and notify the physician and family. The staff looks at the care plan interventions. If the resident has frequent falls, they look at the situation. They review the 24 hour report and discuss the fall in the morning meeting. The supervisor obtains information about the fall. The fall investigation is reviewed by the administrator, safety officer, and the DON. If they start a new order, they obtain a physician's orders [REDACTED]. The new intervention is noted on the 24 hour sheet. The staff usually obtains a physician order [REDACTED]. The nurse implements a change in interventions and documents it in the nurses' notes and passes it on in report. The resident had a fall and sustained a fracture to the humerus. The fall occurred on the weekend. The DON got the report on Monday (6/13/11) that it was a possible fracture. The nurse called the physician and the DON talked to the family and the resident. The DON would expect the personal alarm to be on the treatment sheet to monitor placement. The facility gets the pressure alarm from the supply person. The supply person did not have an alarm available for the resident. They had some on order but they had not come in. Usually, the facility has alarms on hand. In the meantime, (while waiting for the pressure alarm to come in), staff should make sure the personal alarm is in place, the resident has good footwear. Staff should continue the prior intervention as before the fall. The DON was not sure how long it takes for the facility to obtain a pressure alarm that would be a question for the environmental coordinator person. During interview on 6/17/11, at 1:21 P.M., the DON said they began the personal alarm on the resident on 5/25/11. The resident discharged from the facility early morning on 5/30/11. The personal alarm did not appear on the treatment record, but the nurse mentioned it in the nurses' notes daily. Staff noted the personal alarm on the 24 hour report every day. The facility readmitted the resident on 6/2/11 but did not obtain an order for [REDACTED]. The nurse implemented the personal alarm on 6/11/11. During interview on 6/20/11, at 9:07 A.M., the care plan coordinator said staff updates the care plan as needed. The DON and assistant director of nursing (ADON) discuss every morning before the morning meeting with the nurse regarding which residents have had falls, during the week. They bring that information to the morning meeting. If a fall intervention is not working, the resident care coordinator reviews the plan and determines if the plan is working or if they need to tweak what the facility is doing. The resident came in and left. The resident initially entered the facility on 5/25/11. The resident went to the emergency roiagnom on [DATE]. The resident re-entered the facility on 6/2/11. On 5/25/11, the nurse completed the nursing admission assessment. The resident did not have a history of falls. The nurse completed the fall risk assessment and the resident scored a 10 (which is high risk for falls). On 5/25/11, the nurse initiated a personal alarm for safety per the physician's orders [REDACTED]. On 6/2/11, the nurse completed the admission nursing assessment and the fall risk score was the same. If a resident is out of the facility for three days, when they come back, they get new physician's orders [REDACTED]. After the fall on 6/11/11, the staff obtained an x-ray for the resident and the resident became non-weightbearing (NWB) on the right upper extremity. Staff should be monitoring the NWB status and should remind the resident to not use the right arm. Upon reviewing the care plan for fall prevention interventions, the coordinator said on 6/13/11, the care plan referred to a bed and chair alarm. The chair alarm is a personal alarm he/she thought, but he/she would confirm what type of alarm for sure that means. During interview on 6/20/11, at 10:50 A.M., the DON said the physician's orders [REDACTED]. As of 6/15/11, the bed pressure alarm was in place. The facility is still waiting for the chair pressure alarm to arrive. Staff monitors the resident frequently and they changed the clip on the personal alarm to a safety pin to hold it in place better. Staff monitors the resident by passing the room in the hall and looking in. The staff does not have any specific time frame for monitoring. The resident's room is close to the nurses' station. 2. Record review of Resident #20's nurses' notes, dated 6/3/11, at 10:30 A.M., showed the resident entered the facility. Record review of the admission assessment form, dated 6/3/11, showed staff oriented the resident to the call light, but documented the resident did not understand. The resident was oriented to person only. The nurse assessed the resident's fall history and risk. The resident had a history of [REDACTED]. The resident's fall risk score was 18 (high risk). The plan of care included for two staff to assist the resident with all transfers. The resident should wear non-skid foot wear with all transfers. The resident is unable to use the call light. Staff should ensure the resident wears a personal alarm at all times. Record review of the fall risk assessment, dated 6/3/11, showed the resident scored an 18. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Record review of the physician's admission orders [REDACTED].M., showed the physician ordered medications, diet, catheter and bladder training instructions. The physician ordered the resident up with assistance. The physician did not order any alarms or fall prevention interventions. Record review of the nurses' notes, showed the following information: -On 6/3/11, at 11:00 P.M., the resident was confused. The resident wanted to get out of the chair to "feed the dogs" and does not redirect. -On 6/4/11, at 11:45 P.M., staff found the resident on the floor at the table next to the nurses' station. The personal alarm was disconnected. The resident lay on the right side in front of the wheelchair with his/her head against the wall. The nurse assessed the resident and assisted the resident back to the wheelchair and was taken to bed. The nurse documented the resident's call light in reach. Record review of the co-worker witness fall report, dated 6/4/11, at 11:45 P.M., showed the following information: -The incident happened next to the nurses' station. -The resident sat in the wheelchair and possibly was trying to get up; -To prevent this from happening again, the nurse documented for staff to ensure personal alarm is clipped to resident's clothing in a place it cannot be undone. Record review of the nurses' notes, showed the following information: -On 6/6/11, at 10:00 A.M., RN A documented the resident as confused. Safety precautions utilized included call light in reach, non-skid footwear during transfers, clear pathway, and safe lighting. -On 6/6/11, at 8:00 P.M., staff found the resident on the floor next to the wheelchair by the break room. The resident's alarm sounded. The nurse assessed the resident and determined the resident had no apparent injuries. Record review of the fall risk assessment, dated 6/6/11, showed the resident scored a 20 (high risk). Record review of the co-worker witness fall report, dated 6/6/11, at 8:00 P.M., showed the following information: -The incident happened near the break room; -The resident had been sitting in the wheelchair; -To prevent this from happening again, the nurse documented the resident is in a reclining wheelchair currently. The resident also has a personal alarm, which was in place. Family suggested a wheelchair wedge cushion (special cushion to assist with positioning in the chair)or geri-chair (a high back cushioned wheelchair that reclines preventing rising). Record review of the physician order [REDACTED].M., (two days after the previous fall), the physician ordered staff may apply wedge cushion to the wheelchair for proper safe positioning. (The resident had two falls before staff initiated the wedge cushion intervention). Record review of the nurses' notes, showed the following information: -On 6/9/11, at 3:00 P.M., staff found the resident sitting on the edge of t