Every finding on record at St Crispin Living Community

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent an accident for 1 of 1 residents reviewed for elopement risk (R1). R1 was known to wander and had a WanderGuard (electronic monitor used to detect when a resident with dementia from exiting the facility) in place. R1 exited the facility through an emergency door, subsequently fell and sustained no injury. Although the facility repaired the door following the incident, the facility failed to implement additional supervision for R1.Findings include: R1's care plan dated 8/15/25 indicated R1 was at risk for elopement and had a WanderGuard on. He had a history of exiting the stairwell door. His goals with a target date of 9/18/26 indicated he would not leave the facility unattended, his safety would be maintained, and he would demonstrate happiness with daily routines. His approaches were: 8/15/25 Reorient him to person, place and time as needed (PRN).8/15/25 Identify a pattern of wandering: was it purposeful, aimless, or escapist?8/15/25 Document all incident of wandering.8/15/25 Assess for a fall risk.8/15/25 Apply an alarm for alarm doors i.e., at the elevator and door to the staircase.8/15/25 Was R1 looking for something? Was wandering a need for more exercise?9/30/25 WanderGuard in place on right wrist, monitor functioning daily.8/5/26 For wandering elopement attempts, redirector and offer R1 an independent activity when he returned to his room, such as a word puzzle or call family.R1's care plan did not indicate any staff supervision of R1. R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 4 indicated severe cognitive impairment. R1 used a walk and/or a wheelchair for ambulation. R1 required maximal assistance with toileting, lower body dressing and moderate assistance with upper body dressing and transferring. R1's pertinent diagnoses were coronary artery disease, post-traumatic stress disorder (PTSD), insomnia, diabetes, and chronic kidney disease. R1's event details dated 8/2/26 at 10:01 p.m. indicated R1 had an unwitnessed fall at 6:00 p.m. R1 was noted missing at around 6:00 p.m. from the unit, last seen before 6:00 p.m. R1's nurse was attempting to give him his medications and R1 was not in his room and nowhere to be found in the neighborhood. An immediate search was initiated; all the residents' rooms and common areas were checked without success. During ongoing rounds, a beeping sound was heard at the back door the nurse attempted to open the door without the code. R1 was found sitting on the floor of the first-floor landing of the back stairwell near the back door beside his wheelchair. R1 was alert, responsive, denied and discomfort. Assessment revealed no visible injuries and no signs of head injuries or distress. R1 was assisted back to his wheelchair and wheeled back to his room on the second floor. R1 was sent to the emergency department. R1's hospital after visit summary dated 8/2/26 indicated, no acute traumatic findings in the chest from the abdomen and pelvis. No acute intracranial findings and no acute traumatic findings in the cervical spine. R1's after event elopement risk observation dated 8/3/26 at 12:00 p.m. indicated R1 exhibited wandering with no rational purpose and he had a recent history (last 6 months) of wandering the facility or elsewhere. R1 had anxiety disorder, dementia, and PTSD. The observation indicated that he was not an elopement risk. The prevention actions taken were: Care plan developedStaff educated on the individual program planWander detection system appliedResident photo added to the electronic chartProvider updated The facilities Ad Hoc QAPI Meeting/Four-Point Plan or Correction Agenda and Summary dated 8/3/26 indicated: Problem statement: The resident, with a functioning WanderGuard in place, exited the secured neighborhood through the back stairwell door. The resident entered the stairwell and was subsequently found on the stair landing, seated on his buttocks with his back toward the stairs and facing the wall. The resident's wheelchair observed upright next to him on the landing. Factors: The doors locking mechanism failed to properly engage, allowing the resident to push the door open while seated in his wheelchair. Door alarm was sounding and audible, but due to the door's location was unable to be heard throughout the neighborhood. Routine environmental safety checks did not identify the mechanical failure before the event occurred. Root causes: The back stairwell door locking mechanism was inoperable, however the WanderGuard did function. This allowed the residents to push the door open and enter the stairwell. Routine inspection and testing processes did not identify the defective door locking mechanism before the event. The mechanical failure was undetected until the resident gained access to the stairwell. Systemic changes: Repair the malfunctioning stairwell door locking mechanism and verify proper operation before removing 24/7 staff from the area. Increase the volume of the door alarms to improve audibility throughout the surrounding area. Conduct a facility-wide inspection and functional testing of all secured exit doors, locking mechanisms, and WanderGuard-controlled access points. Implement additional documented testing of secured exit doors and locking mechanisms - daily two times a week then weekly thereafter with results reported to QAPI for review of continuation. Staff monitoring the area whenever a secured exit door is found to be malfunctioning until repairs are completed. The changes did not include any staff supervision for R1. R1's nursing assistant care assist daily sheet dated 8/10/26 did not indicate any staff supervision of R1. Upon interview on 8/10/26 at 11:31 a.m. nursing assistant (NA)-A stated R1 would either stay in his room an entire shift or roam the hallways an entire shift. Every resident was checked on every two hours as part of the facilities rounding, but there was no specific criteria for staff supervision of R1. Upon interview on 8/10/26 at 11:50 a.m. (NA)-B stated R1 thought he was independent and often wandered trying to leave the facility. Her intervention for R1 was to give him non-alcoholic beer or his mechanical cat when R1 started to wander. There were no guidelines to supervise him on a schedule. Upon interview on 8/10/26 at 1:19 p.m. licensed practical nurse (LPN)-A stated after R1's accident she received training on checking the door and to be sure to not turn any alarm off until a resident was found. When she worked, she would check on R1 every time she passed his room. She denied any formal supervision of R1. Upon interview on 8/10/26 at 2:28 p.m. registered nurse (RN)-B, the nursing supervisor stated R1 had gotten out the back door as the door magnet failed, however his WanderGuard was working. The evening nurse noted he was not in his room and began a search for R1, then they heard the WanderGuard alarm sounding. She stated the staff used the WanderGuard for supervision and he also had interventions of redirection by offering him his mechanical cat and calling his family. R1 had a lot of interactions during the day, and staff walk by his room frequently to check on him, but there were no specific times to check on him. Upon interview on 8/10/26 at 2:44 p.m. (NA)-C stated on the evening of 8/2/26 he had taken R1 back to his room following dinner around 5:45 p.m. He was offered R1 the bathroom R1 refused and was talking about wanting to leave the facility in his car to see a friend. (NA)-C reassured him he had a room at the facility, and it was too late to go out. R1 seemed o.k. with (NA)-C's idea. A few minutes later (NA)-C heard staff yelling from the stairwell door needing assistance. He ran to the door and found R1 had gotten down the first flight of stairs and was seated on his buttocks with his wheelchair behind him on the first landing. (NA)-C stated the facility fixed the lock mechanism on the door and all staff were educated on how the door worked and to be sure to check the entire stairwell when a resident was missing. When R1 was wandering he was to be redirected and given ice cream or coffee. The staff did not really need to supervise the residents with WanderGuards as the unit was small and the staff knew which residents were at risk for elopements. Upon interview on 8/10/26 at 3:08 p.m. the director of nursing (DON) stated for supervision of residents at risk for elopement the staff were completing checks to ensure the WanderGuards were placed correctly at each shift and were checked weekly that the WanderGuards were working. Staff were aware of residents wandering tendencies per their care plan. A facility policy titled Elopement dated 2018 indicated following an elopement that the resident's care plan must be reviewed and revised to reflect the elopement and a prevention plan developed. The policy did not include any staff supervision of the residents.

Based on interview and record review, the facility failed to maintain a medical record that was accurately documented for 1 of 1 resident (R49), who was reviewed for weight monitoring.Findings include: R49's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R49 had moderate cognitive impairment with no behaviors. R49 required substantial/maximal assistance with personal hygiene, showering/bathing, and upper body dressing. R49 was dependent on facility staff for lower body dressing, position transfers, and toileting. R49's diagnosis included ischemic heart disease (a condition where reduced blood flow to the heart muscle, usually caused by plaque buildup, causes oxygen deprivation), generalized muscle weakness, dementia (a decline in mental ability), and dysphagia (difficulty swallowing, often caused by dementia, can lead to malnutrition and dehydration). R49's provider orders included an order to obtain daily weights for registered dietician review on 4/8/25. R49's dietary supplements were discontinued on 1/26/26. During record review, R49's daily weights fluctuated with inconsistent readings noted at several intervals. Weight measurements included:-3/16/25: 132-4/9/25: 128-4/22/25: 129-4/23/25: 128-8/4/25: 123-8/13/25: 134-8/18/25: 118-8/19/25: 130-11/19/25: 142-12/14/25: 100-12/19/25: 213-12/24/25: 141-3/12/26: 145 R49's dietary supplements were adjusted on the following dates:-3/21/25: start Glucerna (nutritional supplement drink) 8 oz in the morning w/breakfast-3/27/25: increase Glucerna 8 oz twice per day-4/15/25: change to Ensure (nutritional supplement drink) 8 oz twice per day-12/15/25: change to Ensure 8 oz daily-1/26/26: discontinue supplement During an interview on 3/19/26 at 12:33 p.m., Regional Director of Services (RDS) reviewed R49's weight documentation; confirmed weight documentation is inconsistent and likely incorrect. RDS stated inaccurate weight documentation should have been deleted. During an interview on 3/19/26 at 2:23 p.m., registered dietician (RD) stated R49's weight has fluctuated for some time. RD stated she had previously asked facility staff to assist her with getting and documenting accurate weights. RD stated she asked for a weight verification order on 3/11/26; obtain resident weight two times x 1 week on 3/12/26 and on 3/15/26. A weight was documented on 3/12/26, but there was no documentation of weight in the treatment administration record (TAR) nor a progress note indicating why the order was not completed on 3/15/26. RD stated it has been difficult to make dietary supplement recommendations due to the inaccuracy of R49's documented weights. During interview on 3/19/26 at 3:36 p.m., RDS confirmed again the inaccurate weights for R49 should have been deleted. RDS confirmed how difficult it could have been to manage R49's dietary supplements when the documented weights were inaccurate. RDS stated it is important to get accurate weights and document appropriately to ensure residents get the correct treatment based on accurate information. A facility policy for accurate charting was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure proper food storage for 2 of 2 resident refrigerators that contained undated and unlabled food.Findings include:During observation on 3/18/26 at 11:46 a.m., the 2nd floor refrigerator located near the dining room contained an undated and unlabeled yogurt container 3/4 full with a pasta salad. A 2nd undated and unlabeled yogurt container was 3/4 full with soup. A sign on the refrigerator stated stored items should contain the date placed in the fridge, use-by date (3 days from the original date), resident name, and room number. Any items with missing information will be discarded immediately. Not to be stored in a re-used single use container i.e. cottage cheese and salad dressing containers cannot be reused for food storage. Following the 3rd day, items and containers will be disposed of. [Facility name] will not be responsible for returning containers, they will be discarded.During an interview on 3/18/26 at 11:53 a.m., dietary aide (DA)-A stated dietary staff check the temperatures of the resident refrigerator however housekeeping is responsible for cleaning the inside and verifying food is labeled and dated. During an interview on 3/18/26 at 12:11 p.m., housekeeper (H)-A stated they are responsible for cleaning the dining rooms and common areas. They do not clean resident use refrigerators. During an observation on 3/18/26 at 3:25 p.m., the 1st floor refrigerator located near the dining room contained a clear plastic container of fresh pineapple. The container had a room number however was not dated. During an interview on 3/18/26 at 3:37 p.m., the dietary manager (DM) stated dietary staff are responsible for checking the temperature of the refrigerators however housekeeping cleans and checks dates of the food twice a week. The DM also stated staff have a habit of putting their personal food items in the refrigerator. During an interview on 3/18/26 at 3:55 p.m., the environmental services director stated dietary staff are responsible for checking the temperature of the refrigerators. One housekeeper is responsible for cleaning resident rooms on each floor. A float housekeeper is responsible for cleaning and checking the dates and labels of food items in the resident refrigerators weekly. The environmental services director stated staff should not be putting personal foods in the resident refrigerator and confirmed the items in question were not dated or labelled appropriately. During an interview on 3/19/26 at 7:20 a.m., H-B stated the resident refrigerator is checked weekly by the common area housekeeper. During an interview on 3/19/26 at 10:37 a.m., the Regional Director of Clinical Services (RCS) stated housekeeping staff are responsible for cleaning the resident refrigerators and ensuring all food items are dated and labeled appropriately twice a week.A policy titled Safe Food Storage and Handling for Food Brought in by Residents, Families, and visitors dated 2019 indicated All food stored in the refrigerator/freezer units should be in covered, seamless containers or otherwise suitably protected with date the product was given to the community for storage, use by date (max of 3 days) name and room number of resident. Storage of large quantities of food in oversized containers should be avoided. The policy also indicated All residents should be verbally informed that a product has been placed for them in storage and that all products not used within 3 days will be discarded. Single-use containers such as cottage cheese and salad dressing containers cannot be re-used for direct food storage.

Based on interview and record review the facility failed to complete medication side effect monitoring for 1 of 5 residents (R49) reviewed for unnecessary medications who received antipsychotics. Findings include: R49's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R49 had moderate cognitive impairment with no behaviors. R49 required substantial/maximal assistance with personal hygiene, showering/bathing, and upper body dressing. R49 was dependent on facility staff for lower body dressing, position transfers, and toileting. R49's care plan dated 3/13/2025, titled Psychotropic Drug Use-I have a DX: Depression et receive psychotropic medication as ordered indicated: R49 will not experience any adverse reactions through the review date. R49's care plan lacked guidelines for orthostatic blood pressure monitoring; a potential side effect of psychotropic medications. R49's Medication Administration Record (MAR) indicated the following:-Give Risperdal (an antipsychotic medication used to treat psychiatric symptoms) 0.5 mg once in the evening. R49's orders lacked orthostatic blood pressure monitoring. R49's vital signs record lacked orthostatic blood pressure readings. R49's progress notes lacked documentation orthostatic blood pressures were attempted or any refusals. During an interview on 3/18/26 at 12:33 p.m., licensed practical nurse (LPN)-A stated not many residents have orders for orthostatic blood pressure monitoring. LPN-A stated orthostatic blood pressure monitoring would be a provider order or a task populated from the care plan. LPN-A stated R49 did not have a provider order or care planned task for orthostatic blood pressure monitoring. LPN-A was unsure why someone on antipsychotic medication would need orthostatic blood pressure monitoring. During an interview on 3/19/26 at 9:32 a.m., Regional Director of Clinical Services (RCS) and Registered Nurse (RN)-A stated when a resident is started on an antipsychotic, such as Risperdal, the facility has a protocol they implement to ensure side effect and symptom monitoring is completed. RCS stated side effect monitoring included orthostatic blood pressure monitoring. RCS and RN-A confirmed orthostatic blood pressure monitoring orders and care planned tasks were not completed for R49. RCS stated orthostatic blood pressure monitoring is important for residents taking antipsychotic medications because low blood pressure can be a side effect of the medications. A facility policy for psychotropic medication monitoring was asked for and was not received.

Based on observation, interview, and record review the facility failed to provide for activities of daily living (ADL) for 2 of 2 residents (R1, R3) who were dependent on staff for timely incontinence care and eating assistance (R1) and assistance for personal hygiene (R3).Findings include: R1: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment with no behaviors. R1 required substantial assist with eating, was dependent on staff for all other ADLs, received a mechanically altered diet, and received hospice care. R1 also had a stage 3 pressure injury. R1's diagnoses list, undated, included dementia, kidney disease, anemia, and left heel pressure injury. R1's provider orders included hospice care due to late onset Alzheimer's (a disorder causing progressive decrease in cognition), provide oversight/intake assistance at mealtimes and as needed, and treatment orders to a pressure injury to left heel. R1's care plan last reviewed 2/10/26, indicated incontinent of bladder and bowel and check and change every 2-3 hours and as needed', reposition every 2-3 hours and provide assistance with eating, per nursing determination and left heel pressure injury. R1's progress notes dated 3/13/26, indicated Resident fed by staff food and fluids this shift. Ate 100% of meal. Resident could not feed self, due to continued weakness. During semi-continuous observation on 3/18/26 the following was observed: -9:29 a.m., R1 was seated in the wheelchair in the common area -10:15 a.m., an unidentified staff member took R1 to church service. -11:39 a.m., an activities aide brought R1 back from church to the dining room for lunch. -12:04 p.m., a staff member [NAME] R1 her lunch of a peanut butter and jelly sandwich, mashed potatoes, and cooked carrots. The staff member handed half the sandwich to R1. R1 ate the half sandwich however made no attempt to eat the rest of the food on her plate. No staff present to assist or encourage R1 to eat. -12:15 p.m., nursing assistant (NA)-B handed R1 the other half sandwich and offered her a drink. R1 ate the half sandwich while NA-B assisted tablemates. When the tablemates declined assistance, NA-B walked away. R1 finished the half sandwich and made no further attempt to eat. -12:21 pm., a staff member was observed sitting at a table on the other side of the dining room assisting another resident. A nurse arrived a R1's table and assisted a tablemate to eat. The nurse spoke to R1 however did not offer to assist with feeding. -12:33 p.m., R1 remained at the table. No attempts made to eat or drink. No staff present to assist. -12:47 p.m., R1 remained at the table with the remainder of her food untouched. Incontinence care/eating assistance During an interview on 3/18/26 at 12:49 p.m., nursing assistant (NA)-A stated R1 is dependent on staff for all activities of daily living and is provided incontinence care every 2-3 hours. NA-A stated R1 was provided incontinence care at around 10:00 a.m., however then stated she was not aware R1 was taken to church. NA-A then stated, I have to lay her down now and change her. NA-A stated R1 will hold and eat sandwiches however requires staff assistance with other foods. R1 doesn't each much but will if someone helps her. NA-A confirmed she did not assist R1 with eating at lunch. During observation at 12:55 p.m., (3 hours and 26 minutes after the first observation) R1 was taken back to her room and transferred into bed. R1 had been incontinent of urine and the back of R1's thighs had reddened indentations resembling the shape of the waffle pressure relieving cushion on her wheelchair. During interview on 3/18/26 at 3:19 a.m., licensed practical nurse (LPN)-A stated R1 has advanced dementia and requires assistance for all ADLs. LPN-A stated R1 sits at the assisted table and will sometimes feed herself. One nursing assistant is assigned to monitor the dining room however they will occasionally get pulled out [of the dining room]. Eating assistance During an interview on 3/19/26 at 9:08 a.m., registered nurse (RN)-B confirmed R1 is under hospice care. RN-B stated R1 required full assistance with eating. R1 will stare at food in front of her and make no attempt to feed self. RN-B stated, even if I hand her finger food, she will put it down. RN-B stated she tries to schedule visits during mealtimes to assist R1 with eating. There are days R1 does not eat much however will normally eat 100% when RN-B assists her. During an interview on 3/19/26 at 9:25 a.m., the registered dietician (RD) confirmed R1 is under hospice care and nutrition is provided for comfort. The RD confirmed R1 has a pressure injury and continues to be followed while under hospice care. The RD stated it is common sense nutrients are needed for wounds to heal and not get worse. The nursing department determines the type of assistance a resident requires for eating. Eating assistance/Incontinence care During an interview on 3/19/26 at 10:37 a.m., the Regional Director of Clinical Services stated it is expected all dependent residents are repositioned and provided incontinence care every 2-3 hours. It is also expected staff assist dependent residents with eating to promote wound healing. A policy titled Activities of Daily Living dated 2021 indicated residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility. Care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), elimination (toileting) and dining (meals and snacks). R3: R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 was cognitively intact with some refusals of care from specific staff. R3 is dependent on staff for personal hygiene, toileting hygiene, and lower body dressing. R3 requires substantial/maximal assistance for oral hygiene, shower/bathing, and upper body dressing. R3's diagnosis includes Alzheimer's disease (progressive, incurable neurological disorder that causes brain cells to die), peripheral neuropathy (damage to the peripheral nerves, often causing numbness, tingling, weakness, in hands and feet), major depressive disorder, and generalized weakness. R3's provider orders included bath day Thursday PM: obtain weight, vitals, and observe for new skin issues. Include grooming performed, shaving, nail care etc. Document refusals and approaches used. R3's treatment administration record (TAR) indicated R3 received a bath on 3/5/26 at 7:34 p.m., Bath completed, redness under right breast noted, Linens changed. VSS done and recorded. Resident had all snack between meals 100%, pleasant and cooperative with cares. Additionally, R3 received a bath on 3/12/26 at 11:40 p.m., Resident received a scheduled tub bath, no c/o pain or discomfort, no skin issues noted. Vital signs are intact. R3's care plan dated 1/26/26, titled I have a self-deficit with the following activities of daily living, bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder indicated: R3 will participate as able. R3's interventions for self-deficit included asking for assistance, require assistance of 2 for toileting needs, and assist of 1 with dressing/undressing, grooming, and hygiene. During an observation on 3/17/26 at 5:44 p.m., R3 had multiple long hairs on her upper lip and multiple long hairs on her chin. During an observation and interview on 3/18/26 at 10:06 a.m., R3 stated she does not like the hairs on her face (upper lip and chin), stated she had told staff that she wanted them removed but no one has helped her. R3 stated she wonders why they don't do it on bath days, that would be the easiest. During an interview on 3/18/26 at 12:29 p.m., nursing assistant (NA)-C confirmed R3 had several long hairs on both her upper lip and chin. NA-C stated facial hair removal or shaving occurred on bath days. NA-C stated R3 is very particular about who provides her care; R3 will complete tasks without issue if she trusts you. NA-C confirmed R3 had not refused bathing/grooming assistance in the last month. During an interview on 3/18/26 at 12:33 p.m., licensed practical nurse (LPN)-A stated R3 will refuse cares if she doesn't know or trust you. LPN-A stated when a nursing assistant tells her the resident is refusing something, LPN-A will make sure to ask a trusted nursing assistant to complete the task. LPN-A confirms hair removal and grooming typically occurs on bath days. LPN-A stated she did see the long hairs on R3's upper lip and chin while administering medications this morning. LPN-A stated she was aware the facial hair bothered R3; she would go back and assist R3 with hair removal in a little bit. During an interview on 3/18/26 at 12:41 p.m., regional director of services (RDS) stated facial hair removing and grooming typically occurs on bath days. RDS stated the expectation is facial hair on women is removed as it grows, as it is care planned, and generally on bath days. RDS confirmed R3 has an order to shave on bath days and there were no documented refusals of grooming/hygiene care. RDS stated it is important the resident's grooming needs are met, especially if the lack of grooming was upsetting to the resident.

Based on interview and document review, the facility failed to ensure proper antibiotic time out follow-up and ensure that appropriate antibiotics were utilized to prevent potential antibiotic resistance for 1 of 1 resident (R55) reviewed for multiple urinary tract infections.Findings include:R55s quarterly Minimum Data Set (MDS) assessment, dated 02/17/2026 identified R55 no cognition impairment, and substantial assistance with activities of daily living. R55 had diagnoses including hypertensive heart failure, diabetes mellitus with diabetic chronic kidney disease, and benign prostatic hyperplasia (prostate enlargement) with lower urinary tract symptoms.R55's January 2026 medication administration record (MAR) identified R55 was administered Macrobid (nitrofurantoin) 100 mg capsule, by mouth 2 times a day from 1/13/26 to 1/18/206 for urinary tract infection.Review of R55's medical record identified a urine analysis was completed on 01/10/26, result received on 1/11/26 indicated positive urine analysis. Urine culture results received on 1/15/26 indicated organisms identified as Proteus mirabilis with sensitivity to the following antibiotics: Ampicillin, Piperacillin /tazobactam, Cefazolin, Ceftazidime, Ceftriaxone, Cefepime, Aztreonam, Ertapenem, Meropenem, Gentamicin, Tobramycin, Levofloxacin, Trimethoprim/Sulfamethoxazole.R55 was treated with an antibiotic not sensitive to the organism identified based on the urine culture result.R55's 72-Hours Antibiotic time out (a formal structured reassessment of a patient antimicrobial therapy conducted 48-72 hours after initial administration of antibiotic) review completed on 1/16/26 indicated McGeer 's Criteria (standardized surveillance definition used to identify and track infections such as urinary tract infection) to treat indicated, met.R55's record review indicated McGeer 's Criteria and culture was not met.R55 's March 2026 MAR identified R55 was administered ciprofloxacin 250 mg by mouth 2 times a day from 03/6/26 to 03/13/26 for urinary tract infection.Review of R55's medical record identified no urine analysis was ordered or completed before or after the start of the antibiotic.R55's 72 -Hours Antibiotic time out review completed on 3/10/26 indicated, McGeer 's Criteria to treat was not met, and culture or imaging test did not confirm infection.During an Interview on 3/19/2026 11:19 a.m., the infection preventionist (IP) acknowledged 72 -Hours Antibiotic time out reviews completed on 1/16/26 and 3/10/26 lacked accuracy and follow up on issues identified.Facility policy titled: Antibiotic Stewardship Program and Community Protocols reviewed on 3/2025 indicated, based on review of the clinical situation, pertinent lab and diagnostic tests, the provider and nursing associate will identify whether antibiotics are warranted or whether those that have already been started should continue or change.

Based on observation, interview, and record review the facility failed to ensure effective pharmacy services for availability in opioid pain medication for 1 of 3 residents (R1) reviewed for pharmacy services. As a result of the facility's failures pain medications were not administered to R1 due to prolonged medication unavailability which caused escalating severe unmanaged pain that was more than transient and possible early opioid withdrawal symptoms without alternate treatment or monitoring. In addition, the facility failed to ensure proper reconciliation, transcription and accountability of controlled substance medications when staff did not accurately transcribe physician orders into the narcotic record, including the prescription number, medication name, dosage and complete order instructions. Narcotic records were incomplete and inconsistent with pharmacy delivery documentation, compromising the facility's ability to track, verify, and ensure availability of ordered controlled substances. The immediate jeopardy (IJ) began on 2/2/26 when the facility failed to ensure R1's prescribed morphine was available for administration, resulting in one scheduled dose being administered at a reduced amount and three additional scheduled doses not administered. As a result, R1 went approximately 24 hours and 7 minutes without receiving a full scheduled 15 mg dose of morphine and approximately 20 hours and 33 minutes with only a partial 7.5 mg PRN dose rather than his ordered scheduled regimen. During this period, R1 experienced severe unmanaged pain, increased anxiety, sweating, decreased activity, and reduced oral intake, placing him at immediate likelihood for additional serious consequences, including worsening uncontrolled pain and possible early opioid withdrawal. The regional director of clinical services (RDCS), administrator, director of nursing (DON), and clinical reimbursement manager were notified of the IJ on 2/26/26 at 5:04 p.m. The IJ was removed on 2/27/26; however, noncompliance remained at a lower scope and severity of D, indicating no actual harm with potential for more than minimal harm that was not widespread. Findings include R1's face sheet, printed 2/24/26, identified diagnoses including chronic pain syndrome (long-term, ongoing pain that is difficult to manage); acquired absence of the left leg above the knee (loss of the left leg due to prior injury); left hand post-traumatic osteoarthritis with contracture (arthritis, stiffness, and limited movement of the left hand resulting from a prior shrapnel injury caused by a landmine explosion); and post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing a traumatic event). R1's annual Minimum Data Set (MDS), dated [DATE], indicated his cognition was intact. He was dependent on staff for transfers and toileting and utilized a motorized scooter for mobility. The MDS further identified that R1 was on a scheduled pain management regimen and did not receive PRN pain medications or non-pharmacological pain interventions. During the pain assessment interview, R1 reported experiencing frequent pain of moderate intensity over the past five days, which occasionally limited his daily activities. The MDS also documented that during the previous seven days, R1 received high-risk medications including antianxiety, antidepressant, and opioid medications. R1's care plan dated 5/8/19, identified a problem related to high-risk medications that place R1 at risk for adverse reactions, including opioids. The corresponding intervention dated 5/8/19 was to administer medications per MD (Medical Doctor) order and report indications of intolerance, which include sweating, chills, diarrhea, anxiety, and irritability. R1's MD orders dated 11/28/23, identified for R1 to receive Morphine immediate release (IR) 15 mg tablet four times a day for chronic pain syndrome at the following times: 6:30 a.m. - 8:30 a.m., 11:30 a.m. - 1:00 p.m., 4:00 p.m. - 5:00 p.m., and 8:00 p.m. - 10:00 p.m. An additional order dated 11/14/22, identified for R1 to receive morphine (IR) 7.5 mg twice a day PRN (as needed). Facility document, All Conversations: Med Refill, for R1 dated 2/2/26, identified at 3:26 p.m., note from triage registered nurse on-call (TRNO)-A to nurse practitioner (NP-A) indicated skilled nursing facility (SNF) nurse called and needs a refill oh [sic] morphine only has half dose left. SNF nurse call intake refill needed. R1's medication administration record (MAR) dated 2/2/26, identified R1's 11:30 a.m. - 1:00 p.m. Morphine (IR) 15 mg dose was documented as given and charted late at 1:29 p.m. During an interview on 3/2/26 at 10:05 a.m., registered nurse (RN)-C stated he worked the day shift on 2/2/26 on R1's unit. RN-C reported that during his shift he identified R1 would not have a sufficient supply of his scheduled morphine IR 15 mg tablets to continue as ordered. RN-C stated he did not contact the provider to obtain a new prescription before the end of his shift due to time constraints. RN-C described R1 as very stoic, stating that staff must often prod him to report or describe his pain. He reported that he communicated the need for a new prescription to the oncoming charge nurse but did not verify that the prescription had been obtained prior to leaving his shift.R1's medication administration record (MAR) dated 2/2/26, identified R1's 4:00 p.m. - 5:00 p.m. Morphine (IR) 15 mg dose was documented as Not Administered due to the drug not being available. Pharmacy and on-call provider were contacted three times.R1's MAR dated 2/2/26, identified R1's PRN Morphine (IR) 7.5 mg dose was documented as given at 5:03 p.m. due to full scheduled dose not available, waiting for new prescription from on-call provider.R1's MAR dated 2/2/26, identified R1's 8:00 p.m. - 10:00 p.m. Morphine (IR) 15 mg dose was documented as Not Administered. R1's progress notes dated 2/2/26 at 7:49 p.m., identified R1 had only a single 7.5 mg half tab of morphine available for the evening shift. The on-call provider was contacted at 3:21 p.m. to send a morphine prescription. The PRN dose was given at the scheduled time since the full dose was not available. The on-call provider has been called three times, and the pharmacy has been contacted four times with no confirmation of the prescription. R1 had another scheduled dose due at 8:00 p.m. Staff will continue to follow up to ensure the prescription is completed. During a phone interview on 2/25/26 at 11:10 a.m., RN-A stated she was the charge nurse on 2/2/26 for the evening shift on R1's unit. She was informed by the day shift nurse that R1 only had a single 7.5 mg PRN dose of morphine remaining. RN-A attempted to contact NP-A multiple times between 2:30 p.m. and 10:00 p.m. but only reached the triage nurse. RN-A administered the 7.5 mg PRN dose around 5:03 p.m. and observed that by 8:30 p.m., R1 appeared uncomfortable, quiet, making small facial grimaces and showing subtle signs of pain. RN-A described R1 as very stoic, stating that staff must often prod him to report or describe his pain. RN-A also noted that the MAR reorder button could not be used because a new prescription was required. RN-A stated she finally reached NP-A via phone around 10:00 p.m. and asked if the morphine order had been sent. NP-A stated she had sent it at 7:00 p.m., but refused to resend it electronically that night, saying she would do it in the morning. NP-A did not offer any alternative pain management, did not give orders to monitor opioid withdrawal symptoms, or directions of what to do with increased pain. RN-A identified the root cause as the failure to obtain a new prescription in a timely manner, which put R1 at risk to experience significant unmanaged pain. She emphasized that timely medication ordering and monitoring for missed doses are critical to prevent resident harm. R1's progress notes dated 2/2/26 at 10:05 p.m., contacted NP-A, who stated she sent R1's prescription for morphine to the pharmacy at 7:00 p.m. The pharmacy had been called three times after this and had not received or been able to locate the prescription. NP-A stated she would not fax the prescription to the facility tonight but may do so in the morning. During a phone interview on 2/26/26 at 2:31 p.m., NP-A stated she was on-call provider on 2/2/26, and she received a call in the evening from a nurse at the facility regarding a refill for R1's morphine. She could not recall the exact time, but it was before bedtime. NP-A stated she had already reviewed the refills earlier that day and clicked sign on the order in Epic. She was not aware if the prescription reached the pharmacy and did not have time to verify. NP-A stated she was unaware and didn't think to ask if R1 had already missed a dose and did not know he did not have medication for that evening. She stated that she would not have instructed the nurses to assess R1 for increased pain or monitor for withdrawal symptoms over a missed dose. NP-A further stated it was not typical to call the pharmacy to provide a verbal order for morphine and that, in their setting, they generally allow a day and a half for this type of medication delivery. She indicated that if a resident misses a dose or two, there is little the facility can do, as they are not in a hospital and must rely on the pharmacy's delivery schedule. NP-A reported she found out the next day that R1 never received the scheduled morphine prescription. She initially thought the inquiry was about a probiotic, not morphine. NP-A was asked if she recalled receiving an email from the DON inquiring about R1's morphine order on 2/3/26, and she had responded in the email stating she had heard or seen nothing about R1's morphine. NP-A stated she recalled the email but could not recall what her response was. NP-A further stated that when e-prescribing fails, she has no knowledge of a backup plan and that it was above her level of authority. She verified that she did not check to ensure the morphine prescription was sent to the pharmacy, did not provide orders for alternate pain management, and did not instruct nurses to monitor for signs or symptoms of increased pain or withdrawal for R1. R1's MAR dated 2/3/26, identified R1's 6:30 a.m. - 8:30 a.m. Morphine (IR) 15 mg dose was documented as Not Administered. R1's progress notes dated 2/3/26, at 10:20 a.m., spoke with TRNO-A regarding the unavailable 6:30 a.m. - 8:30 a.m. Morphine 15 mg QID (four times a day) dose. TRNO-A stated she sent a renewed order to AlixaRx pharmacy at that time and also contacted the on-call provider, certified physician assistant (CPA)-A, in case the prescription needed to be sent again. Email correspondence: On 2/3/26 at 9:51 a.m., the DON sent a message stating: We called for a morphine prescription for R1. AlixaRx says they still do not have it, but I see a note you sent to Alixa last night, NP-A? Can we have assistance with this? Thanks. Facility document, All Conversations: Med Refill, for R1 dated 2/3/26, identified at 10:16 a.m., note from TRNO-A to CP-A identified, can we get this signed and sent, none left, also need order to take AM dose from the E-kit. At 10:19 a.m., PA-C then routed this conversation to TRNO-A. At 11:22 a.m., TRNO-A sent message to CPA-A, thank you for ordering medication, they also need an order for AM dose that stated it's ok to hold it. R1's progress notes dated 2/3/26, at 10:20 a.m., spoke with TRNO-A regarding the unavailable 6:30 a.m. - 8:30 a.m. Morphine 15 mg QID (four times a day) dose. TRNO-A stated she sent a renewed order to AlixaRx pharmacy at that time and also contacted the on-call provider, certified physician assistant (CPA)-A, in case the prescription needed to be sent againFacility document, All Conversations: Med Refill, for R1 dated 2/3/26, identified at 11:22 a.m., TRNO-A sent message to CPA-A, thank you for ordering medication, they also need an order for AM dose that stated it's ok to hold it.Return Email correspondence to the DON on 2/3/26 At 11:53 a.m., NP-A replied: R1's message was for his probiotic. I sent in the probiotic yesterday. I did not see or hear of anything regarding R1's morphine. R1's MAR dated 2/3/26, identified R1's 11:30 a.m. - 1:00 p.m. Morphine (IR) 15 mg dose was documented as Late Administration and given at 1:36 p.m. R1's treatment administration record (TAR) dated 2/3/26, documented a pain intensity rating of moderate, 7 out of 10 on the day shift. Review of R1's medication orders and February 2026 MAR and TAR identified that R1's last full scheduled dose of Morphine IR 15 mg before the medication gap was administered on 2/2/26 at 1:29 p.m. The next scheduled 4:00 p.m. dose on 2/2/26 was not administered due to the medication being unavailable. R1 then received only a partial PRN dose of Morphine IR 7.5 mg at 5:03 p.m. on 2/2/26 because the full scheduled dose was not available. The 8:00 p.m. scheduled dose on 2/2/26 and the 6:30 a.m. scheduled dose on 2/3/26 were also not administered. The next full scheduled 15 mg dose was not administered until 1:36 p.m. on 2/3/26. As a result, R1 went from 1:29 p.m. on 2/2/26 until 1:36 p.m. on 2/3/26, approximately 24 hours and 7 minutes, without receiving a full scheduled 15 mg dose of morphine, and from 5:03 p.m. on 2/2/26 until 1:36 p.m. on 2/3/26, approximately 20 hours and 33 minutes, with only a partial 7.5 mg PRN dose rather than his ordered scheduled regimen. During this period of omitted and delayed scheduled morphine dosing, R1 experienced severe pain, increased anxiety, sweating, and functional decline, according to resident interview, family interview, staff interview, and record review. These findings were consistent with possible early opioid withdrawal; however, the facility did not complete a comprehensive assessment for opioid withdrawal symptoms. During a phone interview on 2/25/26 at 11:42 a.m., RN-B stated she worked the day shift on 2/3/26 on R1's unit. RN-B reported she had not been informed by the night shift that R1 had missed two doses of morphine the previous evening and that no medication was available for his morning dose. As a result, she did not contact the on-call provider until after 10:00 a.m., once she became aware he was out of morphine. RN-B stated she spoke with TRNO-A and requested a refill for R1's morphine. TRNO-A initially thought NP-A had processed the refill the previous night. Upon learning the prescription had not gone through, TRNO-A sent a message to CPA-A to have it filled and to obtain a dose from the E-kit. RN-B stated that when she entered R1's room to administer his morning medications, he asked if his morphine was available and indicated it had been out, remarking that it felt like a week to him. She documented R1's pain at a level 7 out of 10, noting it was significant for him and that he did not get out of bed during the shift due to pain. RN-B described R1 as very stoic, stating that staff must often prod him to report or describe his pain. She noted this was not the first time he had run out of his medications and emphasized the need for a more reliable system to prevent these occurrences in the future. RN-B stated by the time she got the actual morphine it was not given until 1:36 p.m., when she documented it. R1's Vitals Report dated 2/2/26 through 2/3/26 identified no food intake documented for either day. On 2/4/26, intake documentation reflected improved oral intake. Resident and family interviews also indicated decreased appetite during the medication gap. During an observation and interview on 2/24/26 at 9:28 a.m., R1 was dressed in pajamas and seated in his wheelchair in front of a card table in his room, watching the news on the television. He was noted to have an above-the-knee amputation on his left leg. R1 indicated he was a Navy war medic from the Vietnam War era and that his left lower leg was blown off when he stepped on a landmine over 57 years ago. He stated that he sustained several pieces of shrapnel to his left leg, groin, and both arms, which could not be surgically removed and continue to cause him significant pain to this day. R1 reported he receives short-acting morphine four times a day. When he receives all scheduled doses, his pain is at his baseline, which he rated as 5 out of 10. He stated that he had run out of morphine before at the facility, which he indicated happens periodically due to either staff forgetting to order it or the pharmacy not filling the prescription correctly. In the past, when the facility ran out, he was given liquid morphine, which he reported worked better for him. R1 stated that on 2/2/26, he ran out of morphine in the afternoon and did not receive it again until the following afternoon, leaving him without his scheduled doses for almost a full day. During this time, he reported his pain was a 10 out of 10, he was unable to get out of bed, and his appetite was decreased. He further stated that his anxiety worsened, making it difficult to swallow because it felt like his throat was closing. R1 reported that family member (FM)-A, his advocate, becomes upset when he does not advocate for himself because she does not want to see him in pain. He stated part of the reason he does not ask for morphine when in significant pain is that he just shuts down and does not want to bother anyone. R1 identified his biggest complaint at the facility was not having his pain medication available when he needed it. During a follow-up interview on 2/26/26 at 8:50 a.m., R1 stated that he does not like to complain about pain and tends to zone out when experiencing it. R1 did not recall waking up during the night on 2/2/26 due to pain. The following morning, he described the pain as being concentrated in his left leg and right hands, feeling as if they were being stabbed with a million knives and also affecting the back of his left leg and his groin. R1 stated that when his pain reaches that intensity, he shuts down and is unable to think clearly. He did not remember eating that day, explaining that extreme pain makes it impossible for him to function. R1 further stated that facility staff do not ask for specifics about his pain and only request a numerical rating, which he finds unhelpful and difficult for accurately describing the severity of his pain. During an interview on 2/24/26 at 10:30 a.m., FM-A stated that R1 was her husband, and they had been married for 48 years. FM-A reported that because of the shrapnel in his groin, R1 had experienced severe pain when he was at home, particularly at night, which sometimes required him to sit in a tub of hot water to help ease the pain. FM-A described the events of 2/2/26 and 2/3/26, when the facility ran out of his morphine, stating that R1 was in so much pain he even reported that his hands hurt. She noted that when R1 experienced severe pain, he loses his appetite and was unable to eat much. On that day, he was lying in bed, and the pain was particularly intense in the back of his upper left leg, running upward through the back. FM-A stated that she encouraged R1 to ask for the liquid morphine, but he reported that it was unavailable as well. She added that the entire incident exacerbated his anxiety. FM-A reported that she visits R1 every day after lunch and spends a few hours with him. She also stated that R1 calls her every evening after supper to talk before going to bed. During a follow-up interview on 2/26/26 at 8:58 a.m., FM-A stated that she arrived around 12:00 p.m. to 12:30 p.m., on 2/3/26. She reported that R1 was very stoic about his pain and becomes very quiet when experiencing it. When she arrived, he was in bed, and she knew he was in pain because he was not talking much. She observed that he was sweating and that the back of his pajamas were wet. FM-A asked the nurse where the liquid morphine backup was, and the nurse stated it was not available. She noted that she did not stay long because R1 had his eyes closed, did not want to talk, and was in too much pain. Before she left, she observed R1 attempting to use the TV remote. He was unable to operate it correctly, which was unusual for him, and they were unable to watch the Westminster Kennel Club dog show as they had planned. FM-A stated that he was confused, in too much pain, and needed to rest. She found this very upsetting, knowing he was suffering and that there was nothing she could do to help. FM-A also noted that R1 did not call her that night, which was unusual because he normally calls her after supper. Review of R1's record did not identify a nursing assessment of altered mental status, cognitive change, or increased anxiety during this period During an interview on 2/24/26 at 2:09 p.m., LPN-A stated she has worked at the facility for 13 years. LPN-A explained that the process for ensuring narcotic medications do not run out is to call the on-call provider for a new prescription when there are three to four days' worth of medication remaining so it can be filled within the next day or two. She stated she was unsure how R1 could have run out of his morphine and noted that the facility has a high number of agency staff, who may not be familiar with the process for ordering narcotics. LPN-A further stated R1 has been on morphine for a long time and would be dangerous for him to miss several doses. During an interview on 2/24/26 at 3:13 p.m., the DON stated she was not aware that R1 had gone without multiple scheduled morphine doses, including omitted doses on 2/2/26 at 4:00 p.m. and 8:00 p.m. and on 2/3/26 at 6:30 a.m., with the 11:30 a.m. dose on 2/3/26 administered late at 1:36 p.m. She acknowledged that this could place R1 at risk for acute withdrawal and significant pain, representing a significant medication error. The DON noted that it did not appear the provider had been notified about the missed doses and that no orders were in place during this time to control his pain. She further stated that a medication error report was not completed because she was not aware of the incident until just now. The DON explained that the facility uses AlixaRx for ordering medications, and timely ordering was critical. She stated that if medication was unavailable, staff should contact the provider and pharmacy; in this case, it appeared to be a prescription issue. When asked what actions she would take now that she was aware of the error, the DON stated that education would be provided to ensure all nurses are familiar with the ordering process. She noted that there is a feature in the electronic medication administration record (EMAR) that allows staff to order medications electronically. The DON stated she was unsure of the root cause of this incident and will need to investigate further. She also indicated she was unsure whether R1 was comprehensively assessed for pain or withdrawal symptoms during the missed doses but noted that missing a dose would typically trigger such assessments. During a follow-up interview on 2/25/26 at 8:39 a.m., the DON stated she would have expected nursing staff to contact her if a narcotic dose for any resident was missing and confirmed that she was not notified when this occurred. The DON described the facility's narcotic tracking and refill system, noting that nurses are responsible for monitoring narcotic counts shift-to-shift and are expected to reorder medications when there are approximately five days remaining. Medications were originally reordered via stickers faxed to the pharmacy, then through the Alixa portal, and more recently electronically through Matrix within the EMAR. Once the reorder button was clicked, the pharmacy prepares the medications for overnight delivery and contacts the provider for a new prescription if needed. The DON confirmed that R1's was not monitored for withdrawal or alternative pain management when med was not available. The DON also confirmed that NP-A did not have any orders in place to comprehensively assess R1 for increased pain or opioid withdrawal symptoms. She stated that without an active prescription, medications cannot be pulled from the e-kit. Had NP-A sent the prescription electronically when contacted on 2/2/26, the medications would have been available. During a phone interview on 2/25/26 at 9:39 a.m., consultant pharmacist (CP)-A confirmed through R1's medical record that R1 had orders to receive morphine (IR) 15 mg tablets four times a day for chronic pain syndrome. CP-A verified that R1 went without morphine doses for over 18 hours and expected that this would result in increased pain. CP-A stated that staff should monitor anxiety, sweating, agitation, tremors, and tachycardia, which could indicate signs and symptoms of opioid withdrawal. CP-A confirmed through R1's medical record that there were no comprehensive assessments or monitoring for pain or acute opioid withdrawal during this period. During a phone interview on 2/26/26 at 11:04 a.m., pharmacist (P)-A stated the pharmacy received a prescription on 2/3/26 at 11:19 a.m., for 120 tablets of Morphine Immediate Release (IR) 15 mg. The prescribing provider was CPA-A. The prescription included authorization to obtain a dose from the emergency kit (e-kit) at 11:19 a.m. P-A stated the pharmacy did not receive a morphine prescription from NP-A on 2/2/26. P-A explained that prescriptions are typically sent electronically. After hours, the pharmacy allows nurses to provide the provider's contact number so the pharmacy can obtain an emergency verbal prescription for controlled substances. She stated this process has been in place for the three years she has worked there and that the pharmacy maintains 24-hour staffed pharmacists. P-A stated she was not aware of four calls reportedly made to the pharmacy on 2/2/26 during the evening hours regarding R1 and reported there were no corresponding notes in the pharmacy call log from 3:00 p.m. to 10:00 p.m., from the facility. She stated the nurse would need to specifically request an emergent controlled substance verbal order and provide the provider's contact information. After the situation involving R1 was described to her to include his reports of pain and symptoms, P-A stated this would have been considered an emergent situation and the lack of medication would have constituted an omission medication error. Regarding Morphine IR, P-A stated it generally lasts approximately 4 to 5 hours before another dose is needed, and the patient would begin exhibiting signs and symptoms of pain. She stated that being 20 hours after the last 7.5 mg dose would be considered an emergent situation. She explained that missing doses for over 20 hours significantly increases the likelihood of severe pain and early opioid withdrawal symptoms, including sweating, fevers, and chills. P-A stated she would expect nursing staff to monitor for increased pain and signs and symptoms of withdrawal after the first missed dose. Review of staff documentation and interview statements identified that facility staff reported contacting the pharmacy multiple times on 2/2/26 regarding R1's unavailable morphine prescription. However, during interview on 2/26/26, P-A stated there were no corresponding pharmacy call log notes from 3:00 p.m. to 10:00 p.m. related to R1 from the facility. Therefore, while the record supports repeated staff attempts to address the missing medication, the exact nature and documentation of all reported pharmacy contacts on 2/2/26 could not be fully verified from the pharmacy call log provided. In addition, NP-A's interview statements and documented communications were inconsistent with facility staff interviews, pharmacy records, and pharmacist interview findings, which confirmed that no morphine prescription from NP-A was received by the pharmacy on 2/2/26. These inconsistencies indicate a breakdown in prescription communication, prescription processing, and follow-up verification. During an interview on 2/26/26 at 12:18 p.m., CPA-A stated she received a message through Epic on 2/3/26 indicating that R1 was out of his morphine. She stated she electronically sent the prescription to the pharmacy that day for refill. CPA-A reported that if she had been the on-call provider on 2/2/26 when R1 needed the refill, the prescription would have been sent, and R1 would not have missed a dose. CPA-A stated that missing three 15 mg doses of (IR) morphine within a 20-hour time span would increase the likelihood of the resident experiencing increased pain. She further stated that if a dose were missed, she would enter orders for comprehensive assessment of signs and symptoms of increased pain and to be monitoring for acute opioid withdrawal symptoms. During a phone interview on 2/26/26 at 12:32 p.m., the medical director stated that NP-A reported she had sent R1's morphine prescription on 2/2/26; however, the pharmacy did not receive it. He explained that if NP-A had called to obtain an emergency supply, the missed doses could have been prevented. He further stated that if he had been contacted, he could have authorized an emergency supply. He reported he was not notified of the situation at the time. The Medical Director stated that even one missed scheduled dose of (IR) morphine could result in physiological changes by approximately 9:00 p.m., as R1 did not receive his full dose. He emphasized that a missed dose should trigger nursing staff to assess and monitor escalating pain and signs and symptoms of acute opioid withdrawal. He stated the failure to notify him, and the lack of enhanced monitoring represented a breakdown in clinical oversight. Regarding pharmacology, he explained that the half-life of (IR) morphine was approximately 3 to 4 hours. He stated that it generally takes 3 to 4 half-lives for a medication to be substantially eliminated from the system, which would be approximately 16 to 20 hours. He indicated that during this time, R1 would not be in his usual state and would theoretically experience pain worse than his baseline. He identified worsening physical pain, sweating, nausea, and vomiting as expected signs and symptoms when morphine is no longer present in the system. He further noted that pulse rate may not be a reliable indicator in this case because R1 was on blood pressure medications. The Medical Director reiterated that if an emergency supply had been requested on 2/2/26, the situation could have been prevented. He emphasized that the clinical team is responsible for ensuring appropriate communication, medication availability, and monitoring when a scheduled opioid dose is missed. Reconciliation and accounting of controlled substances between the narcotic book, supply on hand, and pharmacy packing slips. During an observation and interview on 2/25/26 at 2:02 p.m. with LPN-B and the DON, a review of the Spruce Hill Unit medication cart locked drawer of controlled substances identified multiple discrepancies involving R1's morphine. 1. Controlled substance documentation incomplete (Page 69). The Controlled Substance Book, page 69, identified R1 received 24 tablets of morphine 15 mg on 2/17/26; however, the sheet did not include the RX number, prescriber name, or prescriber directions for administration. No bubble pack was present for verification, as the last tablet was documented as administered on 2/24/26 at 7:36 a.m. The pharmacy packing slip identified RX number 28373012, label 1 of 2, for 24 tablets of morphine 15 mg delivered on 2/17/26; however, the packing slip did not identify a delivery time. 2. Discrepancy in quantity received and incomplete documentation (Page 70).R1's morphine 15 mg bubble pack labeled RX number 28373012, label 2 of 2, directed to take one-half tablet (7.5 mg) twice daily as needed, showed 6 half-tablets remaining. Numbers 7 through 12 on the bubble pack were empty and no longer sealed, with handwritten initials by each corresponding number. The Controlled Substance Book, page 70, documented that 12 tablets were received on 2/17/26, but did not indicate these were to be administered as half-tablets (7.5 mg). The sheet also lacked the RX number, prescriber, and prescriber directions. Documentation indicated doses were administered on 2/24/26 at 12:25 p.m., 4:00 p.m., and 8:00 p.m., with 6 tablets remaining. The pharmacy packing slip for RX number 28373012, label 2 of 2, identified a quantity of 6 tablets delivered on 2/17/26, indicating a discrepancy between the pharmacy delivery record (6 tablets) and the Controlled Substance Book documentation (12 tablets received). 3. Discrepancy in quantity received (Page 78).R1's morphine 15 mg bubble pack labeled

Based on interview and document review, the facility failed to ensure a nurse practitioner or physician provided timely orders to address a resident's immediate care needs when a scheduled prescribed narcotic pain medication was not available for administration for 1 of 3 residents (R1) reviewed for physician services. This had the potential to affect all residents residing in the facility.Findings include:R1's physician orders dated 11/28/23, identified an order for morphine immediate release (IR) 15 milligram (mg) tablet to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m.R1's February 2026, medication administration record (MAR) identified the following missed doses of scheduled morphine due to the medication not being available in the facility:-On 2/2/26 the scheduled 4:00 p.m. and 8:00 p.m., doses of morphine (IR) 15 mg were documented as Not Administered.-On 2/2/26 at 5:03 p.m., PRN morphine 7.5 mg tab was given, as regular dose was not available.-On 2/3/26 the 6:30 a.m., scheduled dose was documented as Not Administered, and the 11:30 a.m. dose was administered late at 1:36 p.m.R1's progress notes dated 2/2/26 at 7:49 p.m., identified staff contacted the on-call provider and pharmacy multiple times regarding the morphine prescription and documented the medication was not available for administration. At 10:05 p.m., identified that nurse practitioner (NP)-A stated she had sent R1's prescription for morphine to the pharmacy at 7:00 p.m.; however, the pharmacy had not received or located the prescription despite multiple follow-up calls. NP-A stated she would not fax the prescription to the facility that evening but may do so the following morning.R1's progress note dated 2/3/26 at 10:20 a.m., identified that staff spoke with triage registered nurse on-call (TRNO)-A regarding the unavailable 6:30 a.m. - 8:30 a.m., morphine dose. TRNO-A stated she sent a renewed order to the pharmacy and contacted the on-call certified physician assistant (CPA)-A in case the prescription needed to be sent again.During an observation and interview on 2/24/26 at 9:28 a.m., R1 stated that on 2/2/26, he ran out of morphine in the afternoon and did not receive it again until the following afternoon, leaving him without his scheduled doses for almost a full day. During this time, he reported his pain was a 10 out of 10, he was unable to get out of bed, and his appetite was decreased. He further stated that his anxiety worsened, making it difficult to swallow because it felt like his throat was closing.During a phone interview on 2/25/26 at 11:10 a.m., registered nurse (RN)-A stated she was the charge nurse on 2/2/26 for the evening shift on R1's unit. She was informed by the day shift nurse that R1 only had a single 7.5 mg PRN dose of morphine remaining. RN-A attempted to contact NP-A multiple times between 2:30 p.m. and 10:00 p.m. but only reached the triage nurse. RN-A administered the 7.5 mg PRN dose around 5:03 p.m. and observed that by 8:30 p.m., R1 appeared uncomfortable, quiet, making small facial grimaces and showing subtle signs of pain. RN-A also noted that the MAR reorder button could not be used because a new prescription was required. RN-A stated she finally reached NP-A via phone around 10:00 p.m. and asked if the morphine order had been sent. NP-A stated she had sent it at 7:00 p.m., but refused to resend it electronically that night, saying she would do it in the morning. NP-A did not offer any alternative pain management, did not give orders to monitor opioid withdrawal symptoms, or directions of what to do with increased pain. RN-A identified the root cause as the failure to obtain a new prescription in a timely manner, which put R1 at risk to experience significant unmanaged pain. She emphasized that timely medication ordering and monitoring for missed doses are critical to prevent resident harm.During a phone interview on 2/26/26 at 2:31 p.m., NP-A stated she was on-call provider on 2/2/26, and she received a call in the evening from a nurse at the facility regarding a refill for R1's morphine. She could not recall the exact time, but it was before bedtime. NP-A stated she had already reviewed the refills earlier that day and clicked sign on the order in Epic. She was not aware if the prescription reached the pharmacy and did not have time to verify. NP-A stated she was unaware and didn't think to ask if R1 had already missed a dose and did not know he did not have medication for that evening. She stated that she would not have instructed the nurses to assess R1 for increased pain or monitor for withdrawal symptoms over a missed dose. NP-A further stated it was not typical to call the pharmacy to provide a verbal order for morphine and that, in their setting, they generally allow a day and a half for this type of medication delivery. She indicated that if a resident misses a dose or two, there is little the facility can do, as they are not in a hospital and must rely on the pharmacy's delivery schedule. NP-A reported she found out the next day that R1 never received the scheduled morphine prescription. She initially thought the inquiry was about a probiotic, not morphine. NP-A was asked if she recalled receiving an email from the DON inquiring about R1's morphine order on 2/3/26, and she had responded in the email stating she had heard or seen nothing about R1's morphine. NP-A stated she recalled the email but could not recall what her response was. NP-A further stated that when e-prescribing fails, she has no knowledge of a backup plan and that it was above her level of authority. She verified that she did not check to ensure the morphine prescription was sent to the pharmacy, did not provide orders for alternate pain management, and did not instruct nurses to monitor for signs or symptoms of increased pain or withdrawal for R1.During a phone interview on 2/26/26 at 11:04 a.m., pharmacist (P)-A stated the pharmacy did not receive a morphine prescription from NP-A on 2/2/26; the pharmacy received a prescription on 2/3/26 at 11:19 a.m., for 120 tablets of Morphine Immediate Release (IR)15 mg written by CPA-A. The prescription included authorization to obtain a dose from the emergency kit (e-kit) at 11:19 a.m. P-A explained that prescriptions are typically sent electronically. After hours, the pharmacy allows nurses to provide the provider's contact number so the pharmacy can obtain an emergency verbal prescription for controlled substances. She stated this process has been in place for the three years she has worked there and that the pharmacy maintains 24-hour staffed pharmacists. After the situation involving R1 was described to her to include his reports of pain and symptoms, P-A stated this would have been considered an emergent situation and the lack of medication would have constituted an omission medication error.During an interview on 2/24/26 at 3:13 p.m., the Director of Nursing (DON) confirmed staff contacted the on-call practitioner when the morphine was not available and verified the medication had not been obtained in time for R1's scheduled doses.During a phone interview on 2/26/26 at 12:32 p.m., the medical director stated that NP-A reported she had sent R1's morphine prescription on 2/2/26; however, the pharmacy did not receive it. MD-A explained that if NP-A had called to obtain an emergency supply, the missed doses could have been prevented, and he further stated that he could have authorized an emergency supply if contacted. He reported he was not notified of the situation at the time.Facility policy entitled, Physician Services, revised on 1/2019, identified requirements for physician supervision and oversight of residents, including that a physician, nurse practitioner, or physician assistant must provide orders for the resident's immediate care needs, all physician orders must be followed and documented, and residents must be seen by a physician at specified intervals. The policy outlined the delegation of tasks to nurse practitioners, physician assistants, dieticians, and therapists under the supervision of the attending physician, and required timely communication, documentation of verbal orders, and 24-hour availability of physician services in case of emergency. The policy emphasized that residents remain under physician care and that physician visits, whether personal or via delegated provider, review the resident's total program of care, including medications and treatments.

Based on interview and document review, the facility failed to report an allegation of neglect to the State Agency (SA) within the required timeframe for 1 of 3 resident (R1) reviewed for pharmacy services.Findings include:R1's physician orders dated 11/28/23, identified an order for Morphine immediate release (IR) 15 milligrams (mg) tablet to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. An additional order dated 11/14/22, identified Morphine (IR) 7.5 mg twice daily as needed for pain.R1's February 2026, medication administration record (MAR) identified the following missed doses of scheduled morphine due to the medication not being available in the facility:-On 2/2/26, the scheduled 4:00 p.m. and 8:00 p.m. doses of morphine (IR) 15 mg were documented as Not Administered. On 2/3/26, the 6:30 a.m. scheduled dose was documented as Not Administered, and the 11:30 a.m. dose was administered late at 1:36 p.m.R1's progress notes dated 2/2/26 at 7:49 p.m., identified staff contacted the on-call provider and pharmacy multiple times regarding the morphine prescription and documented the medication was not available for administration. At 10:05 p.m., identified that nurse practioner (NP)-A stated she had sent R1's prescription for morphine to the pharmacy at 7:00 p.m.; however, the pharmacy had not received or located the prescription despite multiple follow-up calls. NP-A stated she would not fax the prescription to the facility that evening but may do so the following morning. At 10:20 a.m., identified that staff spoke with triage registered nurse on-call (TRNO)-A regarding the unavailable 6:30 a.m. - 8:30 a.m., morphine dose. TRNO-A stated she sent a renewed order to the pharmacy and contacted the on-call certified physician assistant (CPA-A) in case the prescription needed to be sent again.R1's progress note dated 2/3/26 at 10:20 a.m., identified that staff spoke with triage registered nurse on-call (TRNO)-A regarding the unavailable 6:30 a.m. - 8:30 a.m., morphine dose. TRNO-A stated she sent a renewed order to the pharmacy and contacted the on-call certified physician assistant (CPA)-A in case the prescription needed to be sent again.During an interview on 2/24/26 at 3:13 p.m., the director of nursing (DON) stated she was not aware that R1 had missed multiple scheduled doses of morphine on 2/2/26 and 2/3/26 due to the medication not being available. The DON confirmed the event constituted an allegation of neglect and had not been reported to the State Agency.Facility policy titled Abuse Prevention Plan, revised 8/14/20, identified all forms of abuse, neglect, misappropriation of resident property, and financial exploitation of residents by facility staff are strictly prohibited. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further identified that any person with knowledge or suspicion of abuse, neglect, misappropriation of resident property, or financial exploitation must report the concern immediately to the charge nurse or supervisor, who will notify the Executive Director or designee. The policy indicated that the facility is responsible for reporting suspected abuse or neglect in accordance with legal requirements. If the event involves abuse or results in serious bodily injury, the suspicion must be reported immediately but not later than two hours after forming the suspicion. If the event does not involve serious bodily injury, the suspicion must be reported no later than 24 hours after forming the suspicion. The policy further identified that for Minnesota facilities, suspected abuse or neglect must be reported to the Minnesota Department of Health (MDH) via the online reporting system immediately upon receiving the report.

Based on observation, interview, and document review, the facility failed to ensure scheduled pain medication was re-ordered and available per physician orders for 1 of 3 residents (R1) reviewed for pain management. Findings include: R1's face sheet, printed 2/24/26, identified diagnoses including chronic pain syndrome (long-term, ongoing pain that is difficult to manage); acquired absence of the left leg above the knee (loss of the left leg due to prior injury); left hand post-traumatic osteoarthritis with contracture (arthritis, stiffness, and limited movement of the left hand resulting from a prior shrapnel injury caused by a landmine explosion); and post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing a traumatic event). R1's annual Minimum Data Set (MDS), dated [DATE], indicated his cognition was intact. He was dependent on staff for transfers and toileting and utilized a motorized scooter for mobility. The MDS further identified that R1 was on a scheduled pain management regimen and did not receive PRN (as needed) pain medications or non-pharmacological pain interventions. During the pain assessment interview, R1 reported experiencing frequent pain of moderate intensity over the past five days, which occasionally limited his daily activities. The MDS also documented that during the previous seven days, R1 received high-risk medications including antianxiety, antidepressant, and opioid medications. R1's care area assessment (CAA) dated 2/2/26, identified Section 19, Pain, noting that R1 complained of frequent, moderate pain over the last five days and had not used PRN pain medication during that period. The CAA indicated that nursing staff would continue to assess R1's pain each shift, notify the provider of any unrelieved pain, and utilize both pharmacological and non-pharmacological interventions to maintain effective pain management. R1's care plan dated 5/8/19, identified a problem related to pain/discomfort; however, the problem statement was left blank, and no baseline pain level was documented. The corresponding approach, also dated 5/8/19, included interventions when pain is expressed, such as offering heat, repositioning, analgesics, and mindful relaxation techniques. An additional approach dated 1/5/22, required completion of a pain scale every shift. Review of R1's care plan lacked clear guidance for documenting baseline pain and did not provide comprehensive direction for managing chronic pain, scheduled opioid administration, or monitoring for severe pain when medications were unavailable. R1's physician orders dated 11/28/23, identified an order for morphine immediate release (IR) 15 milligram (mg) tablet to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. An additional order dated 11/14/22, identified to administer morphine (IR) 7.5 mg twice daily as needed for pain. R1's February 2026, medication administration record (MAR) identified the following missed doses of scheduled morphine due to the medication not being available in the facility: -On 2/2/26 the scheduled 4:00 p.m. and 8:00 p.m., doses of morphine (IR) 15 mg were documented as Not Administered. -On 2/2/26 at 5:03 p.m., PRN morphine 7.5 mg tab was given, as regular dose was not available. -On 2/3/26 the 6:30 a.m., scheduled dose was documented as Not Administered, and the 11:30 a.m. dose was administered late at 1:36 p.m. R1's progress notes dated 2/2/26 at 7:49 p.m., identified staff contacted the on-call provider and pharmacy multiple times regarding the morphine prescription and documented the medication was not available for administration. At 10:05 p.m., identified that nurse practitioner (NP)-A stated she had sent R1's prescription for morphine to the pharmacy at 7:00 p.m.; however, the pharmacy had not received or located the prescription despite multiple follow-up calls. NP-A stated she would not fax the prescription to the facility that evening but may do so the following morning. R1's progress note dated 2/3/26 at 10:20 a.m., identified that staff spoke with triage registered nurse on-call (TRNO)-A regarding the unavailable 6:30 a.m. - 8:30 a.m., morphine dose. TRNO-A stated she sent a renewed order to the pharmacy and contacted the on-call certified physician assistant (CPA)-A in case the prescription needed to be sent again. R1's Vitals Report dated 2/2/26 through 2/3/26 identified no food intake documented for either day. On 2/4/26, intake documentation reflected improved oral intake. Resident and family interviews also indicated decreased appetite during the medication gap. In review of R1's record between 2/2/26 and 2/3/26 there was no indication of completed comprehensive pain assessments completed that would include pain characteristics. In addition, the record did not include documentation of non-pharmacological interventions attempted or offered, no indication of increased monitoring for escalating pain symptoms and opioid withdraw symptoms and no offer or suggestion for emergency transfer to the hospital for pain management. During an observation and interview on 2/24/26 at 9:28 a.m., R1 was dressed in pajamas and seated in his wheelchair in front of a card table in his room, watching the news on the television mounted on the wall in front of the table. He was noted to have an above-the-knee amputation on his left leg. R1 indicated he was a Navy war medic from the Vietnam War era and that his left lower leg was blown off when he stepped on a landmine over 57 years ago. He stated that he sustained several pieces of shrapnel to his left leg, groin, and both arms, which could not be surgically removed and continue to cause him significant pain to this day. R1 reported he receives short-acting morphine four times a day. When he receives all scheduled doses, his pain was at his baseline, which he rated as 5 out of 10. R1 stated that on 2/2/26, he ran out of morphine in the afternoon and did not receive it again until the following afternoon, leaving him without his scheduled doses for almost a full day. During this time, he reported his pain was a 10 out of 10, he was unable to get out of bed, and his appetite was decreased. He further stated that his anxiety worsened, making it difficult to swallow because it felt like his throat was closing. R1 reported that family member (FM)-A, his advocate, becomes upset when he does not advocate for himself because she does not want to see him in pain. He stated part of the reason he does not ask for morphine when in significant pain was that he just shuts down and does not want to bother anyone. R1 identified his biggest complaint at the facility was not having his pain medication available when he needed it. During a follow-up interview on 2/26/26 at 8:50 a.m., R1 stated that he does not like to complain about pain and tends to zone out when experiencing it. R1 did not recall waking up during the night due to pain. The following morning, he reported severe pain that prevented him from getting out of bed. He described the pain as being concentrated in his left leg and right hands, feeling as if they were being stabbed with a million knives and also affecting the back of his left leg and his groin. R1 stated that when his pain reaches that intensity, he shuts down and is unable to think clearly. He did not remember eating that day, explaining that extreme pain makes it impossible for him to function. R1 further stated that facility staff do not ask for specifics about his pain and only request a numerical rating, which he finds unhelpful and difficult for accurately describing the severity of his pain. During an interview on 2/24/26 at 10:30 a.m., FM-A stated that R1 was her husband, and they had been married for 48 years. FM-A reported that because of the shrapnel in his groin, R1 had experienced severe pain when he was at home, particularly at night, which sometimes required him to sit in a tub of hot water to help ease the pain. She further stated that he has numerous pieces of shrapnel in his left arm and left leg. FM-A described the events of 2/2/26 and 2/3/26, when the facility ran out of his morphine, stating that R1 was in so much pain he even reported that his hands hurt. She noted that when R1 experienced severe pain, he loses his appetite and was unable to eat much. On that day, he was lying in bed, and the pain was particularly intense in the back of his upper left leg, running upward through the back. FM-A stated that she encouraged R1 to ask for the liquid morphine, but he reported that it was unavailable as well. She added that the entire incident exacerbated his anxiety. FM-A reported that she visits R1 every day after lunch and spends a few hours with him. She also stated that R1 calls her every evening after supper to talk before going to bed. During a follow-up interview on 2/26/26 at 8:58 a.m., FM-A stated that she arrived around 12:00 p.m. to 12:30 p.m., on 2/3/26. She reported that R1 was very stoic about his pain and becomes very quiet when experiencing it. When she arrived, he was in bed, and she knew he was in pain because he was not talking much. She observed that he was sweating and that the back of his pajamas were wet. FM-A asked the nurse where the liquid morphine backup was, and the nurse stated it was not available. She noted that she did not stay long because R1 had his eyes closed, did not want to talk, and was in too much pain. Before she left, she observed R1 attempting to use the TV remote. He was unable to operate it correctly, which was unusual for him, and they were unable to watch the Westminster Kennel Club dog show as they had planned. FM-A stated that he was confused, in too much pain, and needed to rest. She found this very upsetting, knowing he was suffering and that there was nothing she could do to help. FM-A also noted that R1 did not call her that night, which was unusual because he normally calls her after supper. During an interview on 3/2/26 at 10:05 a.m., registered nurse (RN)-C stated he worked the day shift on 2/2/26 on R1's unit. RN-C reported that during his shift he identified R1 would not have a sufficient supply of his scheduled morphine IR 15 mg tablets to continue as ordered. RN-C stated he did not contact the provider to obtain a new prescription before the end of his shift due to time constraints. RN-C described R1 as very stoic, stating that staff must often prod him to report or describe his pain. During a phone interview on 2/25/26 at 11:10 a.m., RN-A stated she was the charge nurse on 2/2/26 for the evening shift on R1's unit. RN-A confirmed she did not have scheduled dose of morphine to give at 4:00 p.m., or 8:00 p.m., so she administered the 7.5 mg PRN dose around 5:03 p.m. RN-A observed that by 8:30 p.m., R1 appeared uncomfortable, quiet, making small facial grimaces and showing subtle signs of pain. RN-A described R1 as very stoic, stating that staff must often prod him to report or describe his pain. RN-A indicated missing doses of scheduled morphine put R1 at risk of significant unmanaged pain. During a phone interview on 2/25/26 at 11:42 a.m., RN-B stated she worked the day shift on 2/3/26 on R1's unit. RN-B confirmed R1 had missed 4 full doses of his scheduled morphine. RN-B stated that when she entered R1's room to administer his morning medications, he asked if his morphine was available and indicated it had been out, remarking that it felt like a week to him. She documented R1's pain at a level 7 out of 10, noting it was significant for him and that he did not get out of bed during the shift due to pain. RN-B described R1 as very stoic, stating that staff must often prod him to report or describe his pain. RN-B stated by the time she got the actual morphine it was not given until 1:37 p.m., when she documented it. During an interview on 2/24/26 at 3:13 p.m., director of nursing (DON) stated she was not aware that R1 missed four doses of morphine-on 2/2/26 at 4:00 p.m. and 8:00 p.m., and on 2/3/26 at 6:30 a.m., and 11:30 a.m., resulting in several hours without his pain medication. She acknowledged that this could place R1 at risk for acute opioid withdrawal and significant pain, representing a significant medication error. The DON noted that it did not appear the provider had been notified about the missed doses and that no orders were in place during this time to control his pain. She also indicated she was unsure whether R1 was comprehensively assessed for pain or withdrawal symptoms during the missed doses but noted that missing a dose would typically trigger such assessments. During a follow-up interview on 2/25/26 at 8:39 a.m., the DON stated she reviewed R1's TAR and noted that on 2/3/26, his pain was documented at a level 7 out of 10 on the day shift. She further stated that she would have expected nursing staff to contact her if a narcotic dose for any resident was missing and confirmed that she was not notified when this occurred. The DON confirmed that R1's missed morphine doses were not monitored for withdrawal or alternative pain management during the time the medication was unavailable. The DON also confirmed that NP-A did not have any orders in place to comprehensively assess R1 for increased pain or opioid withdrawal symptoms due to the missed doses. During a phone interview on 2/26/26 at 11:04 a.m., pharmacist (P)-A was informed of the situation involving R1 was described to her to include his reports of pain and symptoms, P-A stated this would have been considered an emergent situation. Regarding Morphine IR, P-A stated it generally lasts approximately 4 to 5 hours before another dose is needed, and the patient would begin exhibiting signs and symptoms of pain. She stated that being 20 hours after the last 7.5 mg dose would be considered an emergent situation. She explained that missing doses for over 20 hours significantly increases the likelihood of severe pain and early opioid withdrawal symptoms, including sweating. P-A stated she would expect nursing staff to monitor for increased pain and signs and symptoms of withdrawal after the first missed dose. During a phone interview on 2/26/26 at 2:31 p.m., NP-A confirmed that she did not check to ensure the morphine prescription was sent to the pharmacy on 2/2/26, did not provide orders for alternate pain management, and did not instruct nurses to monitor for signs or symptoms of increased pain or withdrawal for R1. During a phone interview on 2/26/26 at 12:32 p.m., the medical director stated that even one missed scheduled dose of (IR) morphine could result in physiological changes by approximately 9:00 p.m., as R1 did not receive his full dose. The Medical Director stated that even one missed scheduled dose of (IR) morphine could result in physiological changes by approximately 9:00 p.m., as R1 did not receive his full dose. He emphasized that a missed dose should trigger nursing staff to assess and monitor escalating pain and signs and symptoms of acute opioid withdrawal. Regarding pharmacology, he explained that the half-life of (IR) morphine was approximately 3 to 4 hours. He stated that it generally takes 3 to 4 half-lives for a medication to be substantially eliminated from the system, which would be approximately 16 to 20 hours. He indicated that during this time, R1 would not be in his usual state and would theoretically experience pain worse than his baseline. He identified worsening physical pain, sweating, nausea, and vomiting as expected signs and symptoms when morphine is no longer present in the system. He further noted that pulse rate may not be a reliable indicator in this case because R1 was on blood pressure medications. He emphasized that the clinical team is responsible for ensuring appropriate communication, medication availability, and monitoring when a scheduled opioid dose is missed. Facility policy entitled, Pain Management, revised 09/07/23, identified that residents' pain should be evaluated, documented, and reassessed at regular intervals, with each new report of pain, and after pharmacological or non-pharmacological interventions. The policy emphasized an interdisciplinary approach, resident and responsible party involvement, and consideration of physical, emotional, social, spiritual, and financial domains of pain. Review of the policy does not specify when or where a comprehensive pain assessment must be completed, lacks guidance for documenting baseline pain, and does not outline steps to follow when scheduled pain medications are missed or unavailable, limiting its effectiveness in ensuring safe and timely pain management.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment used to keep food warm prior to serving. Findings include: During an observation and interview on 2/24/25 at 1:47 p.m., culinary director (CD) was preparing the lunch meal and placing food into a hotbox (an insulated container for food storage). CD stated the food was kept in the hotbox until ready to go to each floor's kitchenette. The hotbox had a top and bottom compartment. There was a container of egg rolls in the top compartment of the hotbox to be served to the residents for dinner. The internal temperature of the bottom compartment read 156 degrees, the top compartment did not have an internal thermometer and an external display which read E00. CD was unable to provide clarification on what the E00 meant. CD was uncertain of when the last time the hotbox was serviced. During an observation of second floor dining room on 2/24/25 at 5:09 p.m., dietary aid (DA-A) took temperatures of egg rolls with an internal reading of 120 degrees. Surveyor intervened and asked what the temperatures should be of foods being served to the residents. CD removed the egg rolls to rewarm prior to serving. During an interview on 2/25/25 at 9:01 a.m., CD reviewed the use of the hotbox and stated it is only used for 20-30 minutes prior delivering foods to kitchenettes. CD was unaware the machine was not working and could not provide an explanation off what the display E00 reading meant. CD was unaware of any maintenance on the hotbox or if serviced on a regular basis. CD stated the expectation would be to have a working thermometer for both the top and bottom compartments prior to usage. The staff were to be monitoring the temperatures of the items placed in the hotbox and the temperatures should have been logged. CD indicated improper food temperatures increased the risk of a food borne illness. CD explained when equipment is not working properly, staff were to notify the supervisor and/or maintenance to get the machine fixed. During an interview on 2/25/25 at 3:21 p.m., environmental services manager (ESM) stated he could not find a service slip or maintenance request since January. ESM mentioned, at one time there had been two of the hotboxes in the kitchen and used one to fix the current one but could not verify the timeframe on when this occurred. During an interview on 02/27/25 at 11:40 a.m., administrator stated being unaware of the equipment not working in the kitchen. Administrator explained the expectation would be if staff identify something wrong or broken, then the piece of equipment should be taken out of service until the department supervisor or maintenance could review and repair. Administrator verified there was a potential for foodborne illness if food was not held at correct temperatures. Maintenance logs and equipment information was asked for and not provided.

Based on observation, interview and record review, the facility failed to properly bag and contain contaminated linen placed under a basket of clean resident laundry and maintain a clean laundry room used for resident personals. This had the potential to affect all 15 residents on the 300 unit. Findings include: During a tour of the 300-unit laundry room on 2/26/25 at 7:32 a.m., registered nurse (RN)-A stated dirty linens are bagged and put in the soiled utility room to be picked up by housekeeping staff on each unit and taken to the main utility room to be picked up by a contracted linen company. The process for resident clothing is completed by nursing assistant (NA)'s on resident's bath day. NA's bring resident's personal laundry to the unit laundry room, washes and dries the items and places them back in a basket on wheels. The basket on wheels is taken to the resident room to be folded or hung. The NA's used a dry erase board to communicate to other staff what residents' items are in each machine. The 300-unit laundry room had an unbagged yellow-stained contaminated bed sheet on the floor; with residents' clean personal laundry sitting in the basket on wheels above the contaminated linen. The floor of laundry room was dirty with used lint scraps under the sink and under basket on wheels. There was a used paper towel under the sink. Lint pieces were stuck to the white board and along floorboards. The detergent compartment on the washer was dirty with lint scraps and old soap. RN stated they used to use the pods for detergent but had recently switched to Ecolab products and the detergent was now completed with this system. The 300-laundry room smelled of wetness and mildew . During an interview on 2/26/25 at 7:22 a.m., maintenance (M)-A stated resident personal laundry is completed in the laundry rooms on each unit. M-A stated he does not collect dirty linens from unit laundry rooms. During an observation and interview on 2/26/25 at 8:30 a.m., NA-A stated it was the responsibility of the NA's to keep the unit laundry room tidy and clean. The wetness and mildew smell remained, the garbage remained, and the soiled bedsheet remained on the floor. During an interview on 2/26/25 at 9:05 a.m., housekeeper (H)-A stated the NA's do the laundry and keep the laundry room clean. She does the housekeeping for the resident rooms and common areas. During an observation and interview on 2/26/25 at 10:24 a.m., director of nursing (DON) and regional registered nurse (RRN) viewed the 300-unit laundry room. RRN confirmed there is a yellow-stained unbagged dirty bed sheet sitting beneath resident clean laundry in the basket on wheels. The DON and RRN confirmed the piece of unbagged contaminated linen should be bagged and in the dirty linen utility room . The DON stated the NA's are responsible for keeping the laundry rooms clean. The RRN confirmed the laundry room smelled wet like mildew and the DON had donned gloves to put the contaminated sheet in a plastic bag, placed in the soiled utility room returned to tidy up. During an interview on 2/27/25 at 9:43 a.m., the infection preventionist (IP) stated facility soiled linens (bed clothes, towels, wash cloths, incontinence pads) are bagged at point of care and taken to the soiled utility room at the end of each hall. Soiled linens are outsourced for washing. Resident's personal laundry is stored in baskets in the resident's room and then taken to the laundry room on each unit for washing. Resident's laundry is washed one resident at a time. The IP stated there are times soiled facility linens get mixed up with the residents' personal clothing. IP confirmed all dirty linens/clothing to be kept separate from clean linen. A policy dated 5/15/24 stated dirty linens should be bagged at the point of use and kept separate from clean laundry and linens.

Based on interview and document review, the facility failed to assess, monitor and treat a surgical wound according to physician orders for 1 of 1 resident (R1). This resulted in immediate jeopardy (IJ) when the wound dehisced and became infected resulting in a five-day hospital admission with surgical intervention, antibiotic therapy, and wound vacuum assisted closure (VAC). The immediate jeopardy began on [DATE] when R1 admitted to the facility and the facility failed to comprehensively assess the surgical wound and transcribe physician's orders for its monitoring and treatment, and was identified on [DATE]. The administrator and director of nursing were notified of the immediate jeopardy on [DATE] at 4:53 p.m. The immediate jeopardy was removed on [DATE] at 5:17 p.m., but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE] from a hospital with diagnoses including multiple fractures of pelvis with stable disruption of pelvic ring (multiple pelvic fractures where the broken bones remain in a stable position), other fracture of right femur, hip fracture, contusion (bruise) of right thigh, and complication of unspecified artery following a procedure. The MDS indicated R1 was cognitively intact, had an indwelling catheter and was occasionally incontinent of bowel, had a recent fall with fracture and recent major surgery, had surgical wound(s) and surgical wound care, and was 73 inches tall and weighed 252 pounds. R1's hospital After Visit Summary (Facility) document dated [DATE], indicated R1 was discharged from the hospital and the Lines/Drains/Airways/Wounds list included Wound [DATE] Incision Groin Left. Discharge Wound/Incision Care Instructions were included for a hematoma/contusion (collection of blood trapped outside of a blood vessel), but the document did not include instructions regarding the left groin incision. R1's hospital Discharge Summary document dated [DATE], indicated R1 discharged from the hospital on [DATE] and included a section titled VASCULAR SURGERY RECOMMENDATIONS with subheading Mepilex Ag Dressing [an antimicrobial foam adherent dressing]. The provider recommendations were 1. You had a special dressing placed over your left groin incision on [DATE]. This is to aid in wound healing and prevent wound breakdown where the skin surface causes friction. 2. You may shower with this dressing in place. 3. If three of the dressing edges are saturated with drainage, please immediately remove the dressing. 4. This dressing will stay in place for seven days. Remove your dressing on [DATE]. 5. If you note that there is redness or drainage around the incision, please call [doctor's] advanced practice provider through the [hospital's] operator [phone number]. 6. After removing the dressing, keep the groin area clean and dry. The following section was titled VASCULAR RECOMMENDATIONS and included In ,d+[DATE] days, our team would like to see him either in [clinic] or here in hospital to assess the groin incision and drain (appointment created). The outpatient follow-up appointments list included an appointment with vascular scheduled for [DATE]. The details of hospital stay narrative section indicated a diagnosis of femoral pseudoaneurysm (outpouching of the wall of the femoral artery due to injury with leaking blood that collects in surrounding tissue) post procedural complication and identified R1 had a hematoma associated with his left femoral artery that was removed, a drain (Jackson Pratt surgical drain, JP drain) was placed into the site of the hematoma, the femoral artery was repaired with sutures, and a wound VAC was placed over the wound that was later removed though the drain and sutured site remained with a plan for later removal of the drain. In review of R1's electronic health record (EHR), the treatment orders for R1's left groin incision from vascular surgery included on the Discharge Summary dated [DATE], were not present. The treatment orders were not transcribed into R1's physician orders, were not present on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and were not included in the baseline care plan. Review of R1's EHR did not identify any documentation noting the presence, absence, or removal of the Mepilex Ag dressing ordered to be in place over the left groin incision through [DATE]. R1's physician order dated [DATE], instructed staff to-complete full admission skin assessment utilizing skin check sheet, with 2 nurses signing; remove all NON-SURGICAL dressing to observe skin; turn into care manager (CM) when complete scheduled for completion one time between 2:30 p.m. and 10:00 p.m. on [DATE]. R1's TAR included the order charted as not administered: other on [DATE] at 11:39 p.m. R1's physician order dated [DATE], instructed staff to complete Weekly Bath/Skin Note (similar to admission note), VS [vital signs], weight, observe for new skin issues, include grooming performed, shaving, nail care, transferring assist to/from shower/bath, amount of assistance needed. Document refusals and approaches used schedule for completion once daily on Mondays with start date of [DATE]. R1's baseline care plan for skin with creation date of [DATE], noted I am at risk for alteration of skin status d/t [due to] assist with adls [activities of daily living] and mobility. Goals included I will not have further skin alteration related to _____ (describe current skin breakdown or wound). Interventions included I require a wound treatment plan as follows: ______ (describe steps). The skin care plan contained blanks and was not completed or individualized for R1, it did not identify his current alterations in skin integrity. A Skin Risk Observation with Braden Scale assessment dated [DATE], identified R1 had a surgical wound however the location and description was not included. A Clinical Documentation (Admission) assessment dated [DATE], included Skin Assessment with Braden Score: . indwelling catheter that is draining dark yellow clear urine at time of assessment. Ketoconazole [anti-fungal] cream applied to groin and folds and Polysporin applied to scrotum and penis daily for redness and has swelling to scrotum with scrotum sling in use . Skin is observed by CNA with cares and assessed weekly by licensed nurse. Goal is to remain free from pressure related skin impairments through next review date. No referrals or change of action needed at this time. Will continue with POC and update Provider with any changes as needed. It did not identify R1's left groin incision. R1's progress notes dated [DATE] at 5:50 a.m., identified presence of the JP drain, progress note at 1:56 p.m. identified R1 had skin care and treatments, which were not defined, and progress note at 9:58 p.m. indicated skin care and treatments were completed to R1's scrotum. None of the three progress notes identified the presence of the left groin incision. R1's progress notes dated [DATE] at 6:19 a.m. identified R1's catheter and JP drain and progress note at 2:54 p.m. indicated R1 had skin care and treatments, however neither progress notes identified the left groin incision. A progress note dated [DATE] at 9:39 p.m., identified antibiotic ointment was applied to the scrotum and penis, noted the presence of the catheter, and indicated abdominal and groin folds had been cleansed and patted dry with no redness or foul odor noted. Progress notes dated [DATE] did not identify the presence of R1's left groin incision. R1's progress notes dated [DATE] at 6:15 a.m. and 4:28 p.m. identified R1's JP drain however, did not mention R1's left groin incision. A progress note dated [DATE] at 9:11 p.m., indicated R1 received a bed bath and included observe for new skin issues: no new issues observed. Continues to have multiple old bruises on right forearm, right hip and leg, swollen scrotum which is treated with polysporin [antibiotic ointment] this eve[ening] per md [doctor] orders. Abdominal folds and groin have slight redness no foul odor or tenderness. Cleansed patted dry and anti-fungal applied per md[doctor] order. It did not identify R1's left groin incision. A paper skin observation charting form dated [DATE], indicated it was completed with R1's bed bath on the p.m. shift. It included an outline of a person with a circle around the left hip and L[left] side large bruise. It contained no further assessment of the bruise such as size, color, or pain and did not note R1's left groin incision. A second paper skin observation charting form dated [DATE], included a depiction of the front of a body with a circle around the outer edge of the right forearm and note scattered bruises, a circle around the outer right hip with note bruise, circles around the lower abdomen and left groin with note faint redness. The depiction of the back of the body included a circle around the outer right forearm with note scattered bruises, circle around the peri-area with note swollen scrotum, and circle around the outer right hip with note bruising. No further assessment of the noted bruises, redness, or swelling was included and it did not note R1's left groin incision. R1's baseline care plan for infection with creation date of [DATE], noted I require Enhanced Barrier Precautions r/t [related to] presence of indwelling catheter, JP drain, and surgical incision. Goals included I will not develop signs or symptoms of infection. Interventions included monitor for signs and symptoms of infection, and notify physician/nurse practitioner if signs and symptoms occur. R1's record that included progress notes dated [DATE], [DATE], and [DATE] mentioned R1's JP drain however did not identify the presence of R1's left groin incision. A progress note dated [DATE] at 3:20 p.m., identified R1 was seen by the primary care provider Physician Assistant, had a clinic appointment the next day, and noted the presence of the JP drain. It did not identify R1's left groin incision. A Physician Assistant visit note dated [DATE], indicated R1 had an appointment with vascular surgery the next day but did not include identification or assessment of R1's left groin incision. A progress note by the director of nursing (DON) dated [DATE] at 12:38 p.m., included Resident went out to his follow-up ortho[pedics] appointment today where it was found that his left groin incision had dehisced. He was admitted for surgical management, left groin irrigation, and debridement. He will remain in the hospital throughout the weekend. A vascular surgery office visit note by nurse practitioner (NP)-A dated [DATE], indicated R1 was seen in the clinic for wound assessment. It included [R1] presents today with no information from his nursing facility . He believes the facility removed the Mepilex from his left groin incision a few days ago. They have not been utilizing any gauze to his groin incision . Left groin incision: wound dehiscence to the very center aspect of the incision, approximately 1.5 cm . [R1] unfortunately has experience [sic] dehiscence of his left groin incision. Admit to [physician's] surgical service and proceed to operating room for left groin irrigation and debridement. A hospital Surgeon Documentation note dated [DATE], indicated R1 was known by the surgical service from his previous surgery for evacuation of a large left-sided groin hematoma and primary repair of his actively bleeding femoral artery. It noted He was seen in clinic today for evaluation of his wound and was found to have some dehiscence with opening of the skin around his nylon sutures. For this reason he was brought to the operating room for irrigation and debridement [removal of infected or diseased tissue in a wound and washing out the open wound] . Upon initial inspection of the wound it was clear that he had had dehiscence in the medical portion of the suture line but has [sic] other sutures remained intact . we sharply debrided [cut away] a 3 x 3 x 3 cm [centimeter] area of necrotic fat The decision was made to place a wound VAC for ongoing drainage . we will plan to bring him back to the operating room on Monday for another irrigation and debridement. A hospital Infectious Disease physician consult note dated [DATE], identified bacterial culture swabs from R1's left groin site returned positive for two types of bacteria, enterococcus faecalis and citrobacter koseri. The recommendations included continuing the intravenous antibiotics R1 was already receiving and, upon discharge, to complete a further course of oral antibiotics for two weeks after the date of his last debridement. A hospital Discharge Summary dated [DATE], noted R1 was admitted on [DATE] and discharged on [DATE]. Follow-up noted wound vac is to continue until you are re-evaluated by a member of [doctor's] surgical team, and will most likely continue for many weeks, possibly up to a few months. The Details of Hospital Stay, noted R1 was directly admitted from [clinic] on [DATE] for management of left groin wound dehiscence. He proceeded to the operating room on [DATE] and underwent left groin irrigation and debridement with wound VAC placement . He proceeded to the operating room again on [DATE] and underwent left groin irrigation and debridement. Left groin incision with wound vac in place. In an interview on [DATE] at 12:30 p.m., hospital vascular nurse practitioner (NP)-A stated she had previously cared for R1 when his left femoral artery required nylon sutures and indicated he discharged from the hospital on [DATE] with nylon sutures that were very nicely closed and no issues whatsoever with any openings and a Mepilex Ag dressing that was to stay on for seven days. NP-A stated she saw R1 at a vascular surgery clinic appointment on [DATE] and the Mepilex was off and his groin incision was very obviously dehisced. She states we should have been called or talked to about it and that required him to be readmitted and needing a couple of wash-outs of that groin and now wound VAC placement. The cultures from that came back positive for enterococcus requiring him to be on antibiotics. NP-A stated R1 reported no one even looked at his groin while he was at the facility and NP-A noted R1 was a larger guy and it would require lifting up his pannus to visualize the groin area where the incision was located. She stated that, upon inspection at the appointment, the groin incision was approximately six inches and had dehisced in the center of the incision probably two centimeters wide and at minimum a centimeter and a half deep. She stated R1 also had a JP drain on the left side, but it was approximately four to six inches away from the incision. NP-A stated possible outcomes of the dehiscence were repeat surgical intervention, overall infection risk, he could have gone septic from this, I think that would be the worst outcome from this if it were to have gotten any worse, or if it got down to the artery and if the artery was exposed he could have bled to death. NP-A stated I would say that it [the dehiscence] was probably happening over a minimum of three days. Regarding treatment, NP-A noted the expectation from the vascular surgery group was that if the Mepilex Ag dressing had stayed intact it would be removed at the seven day mark ([DATE]) and gauze would be placed in the area to avoid any moisture or skin-on-skin contact to prevent breakdown, and even though the discharge instructions did not say specifically to use gauze they instructed staff to keep the area clean and dry. In an interview on [DATE] at 9:33 a.m., R1 stated facility staff didn't pay attention to that groin area incision that I had when I went there. I just had a couple of stitches in the groin . I went with the stitches and a little drainage bag [JP drain], they drained the bag but they never checked the groin where the incision was, it was on the left side. R1 stated staff never checked on the incision or cleaned around the incision. He did not recall having a dressing on it and stated there was no dressing, one of them looked at it and said I don't know why there isn't gauze there but they didn't pay attention to that. R1 stated he wasn't able to visualize the incision because of its location and he thought everything was going well with it until his appointment with vascular surgery and noted bacteria was found in the incision so I imagine it must have been open for more than one day. He stated he was admitted right away after his appointment and then I had surgery again, I think I was put under two or three times and now I have a wound VAC on that area where the incision is which is another thing I have to deal with, another machine on me . It has delayed everything and not only do I still not have my weight bearing on that leg now I also have the wound VAC to deal with and physical therapy is limited as to what they can do with me. In an interview on [DATE] at 8:08 a.m., licensed practical nurse (LPN)-A stated she remembered R1 wasn't there long, but he was a big guy with a drain and a catheter. LPN-A stated he had an incision, a surgical incision, I don't remember where it was LPN-A stated I don't remember documenting his incision site and I didn't remember an order in there to do anything with it and noted this was an oversight because they should have had an order. LPN-A stated R1 arrived at the facility during her shift, but second shift usually completed skin check and confirmed she would include surgical incisions and bruises on a skin assessment. LPN-A stated with a surgical incision with no orders she would contact the clinical manager and assumed they were to leave it alone, but if it was wet and nasty she would call the provider to get an order to do something. In an interview on [DATE] at 1:26 p.m., LPN-B stated she remembered R1 and had taken care of him for a few days. She noted R1's groin area had been bruised and she thought he had an angiogram in the hospital where they nicked an artery and he had a bleed in the groin area, but did not recall an incision or dressing in his groin. In an interview on [DATE] at 1:54 p.m., registered nurse (RN)-C stated R1 had a femoral dressing in his groin from something post-operative and thought it was on the left, but honestly I can't recall if I ever saw it. RN-C did not identify a dressing present on the left grin incision. In an interview on [DATE] at 8:55 a.m., RN-B stated she was covering for clinical manage (CM)-A when R1 admitted and completed his admission assessments though she did not provide direct care for him. RN-B stated he has an incision, can't remember which side, it was in his hip and he had a JP drain out of a separate spot on his left side and stated she had never seen the incision. RN-B stated she was aware R1 had orders for wound care but did not recall the details of the wound care orders. She stated if someone had a surgical incision and a dressing and no orders she would call to get orders and check with her manager. RN-B noted she would look at orders to see how to manage a specific wound because hospital discharge orders usually specify what you have to do. In an interview on [DATE] at 11:06 a.m., CM-A stated she was not familiar with R1 as did not work during the time of his admission. CM-A confirmed R1's admission skin assessment, Skin Observation Form dated [DATE], should have been completed on [DATE], noted a need for surgical wound care but did not identify the wound, did not identify the left groin surgical incision, did not note the JP drain site, did not meet her expectations for assessment of bruises, and did not constitute a comprehensive skin assessment. CM-A confirmed R1's EHR did not include orders for monitoring or treatment of the left groin surgical incision, progress notes did not include documentation of monitoring, there was no documentation of a dressing over the left groin surgical incision, no documentation that wound care for the surgical incision was provided per provider orders, and stated I don't see the assessment or monitoring of the surgical incision in the groin anywhere. She further confirmed R1's baseline care plan was not completed and did not identify his left groin surgical incision or the treatment plan, stated it should have been included in the care plan, and noted the baseline care plan should have been completed per protocol within 48 hours of admission. CM-A noted wound care orders for the left groin surgical incision were included in the hospital's Discharge Summary but not the After Visit Summary and the facility utilized the After Visit Summary for admission orders, not the Discharge Summary, but she was aware the hospital sometimes has other orders in the Discharge Summary that are not included in the After Visit Summary. She confirmed that if R1 had a surgical incision but did not have wound care orders she would expect nursing staff to notice something was missing and obtain orders by reaching out to her or the on-call provider. CM-A stated I have no idea what happened, I was gone and it fell through the cracks. It appears a couple checks didn't happen. She identified potential outcomes of the lack of assessment, monitoring, and treatment as infection, sepsis, and he could have died if we're going for worst case scenario. In an interview on [DATE] at 12:41 p.m., the DON stated R1 had had admitted to the facility with the left groin surgical incision and at a follow-up provider appointment on [DATE] they noted the incision had dehisced and he was admitted for further care of his incision. The DON confirmed she was aware there were discrepancies between the orders in R1's hospital Discharge Summary and After Visit Summary. She confirmed R1's EHR lacked documentation of assessments of the incision and stated there was no comprehensive assessment. The DON noted she would expect the incision to have been assessed within eight hours of admission, to be monitored every shift, findings to be documented, and the provider to be updated with any concerns or abnormalities noted. The DON stated she would expect the incision's dressing to be put in as an order and to have been documented. She noted the assessment and monitoring of R1's bruises were not in line with her expectations for monitoring every shift and weekly comprehensive skin assessments. The DON stated she could not demonstrate that R1's left groin surgical incision was treated in accordance with physician orders or assessed and monitored in accordance with physician orders and facility policy. She identified potential outcomes as adverse events, infection, many terrible things. In an interview on [DATE] at 1:59 p.m., the facility's medical director (MD) stated he had spoken to the DON about R1 and knew a bit about the situation. The MD stated he would expect staff to identify the presence of a dressing, wound, incision, or skin or soft tissue abnormality through orders from the hospital to monitor and care for it, in the discharge summary if it wasn't in the orders, or from the initial body audit (comprehensive skin assessment on admission) completed same day or by the morning after admission. He would expect treatment and monitoring per physician orders and if there were no orders, would expect staff to talk to the attending provider or hospital provider to make sure they didn't omit orders and, if they did, find out what needs to be done in terms of monitoring and dressing changes. The MD identified possible outcomes of the femoral groin incision not being monitored, assessed, and treated as a potential delay in observing a change in condition of the groin, superficial or deeper infection, wound dehiscence, aneurysm or pseudoaneurysm, or other potential vascular complications. The MD stated, it is more of a delay in identification if it [the incision] dehisced before the person [R1] was at the office visit, and noted we know there was a delay in identifying anything that might have been doing on but when it exactly was going on was unclear. The MD stated, treatment should be provided in accordance with orders so you can identify changes in condition when they occur more promptly and to carry out what a specialist wants in terms of particular wounds. The MD confirmed the incision was seemingly not tended to and noted the facility lacked a plan of care for the incision. Facility policy titled Prevention and Treatment of Skin Breakdown dated [DATE], included Resident skin integrity is assessed upon admission and weekly thereafter . Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care . A licensed nurse completes Braden Skin Risk Assessment: Upon admission or readmission; Weekly for the first 4 weeks post admission or readmission . A resident centered care plan is implemented/updated for skin risk with interventions based upon; Areas of risk; Resident Assessment; Braden evaluation score of 15 or less; Clinicians assessment/evaluation; Resident preferences. Members of the care team are notified and consulted as necessary. Skin integrity is monitored and abnormal findings are documented: Skin is observed daily with cares. If any skin concerns are noted, they are reported to the licensed nurse; Weekly skin audits are performed by a licensed nurse. Facility policy titled Comprehensive Assessments and Care Planning dated [DATE], included A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals, and sign and certify that the assessment is completed. The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. The baseline care plant includes the minimum healthcare information necessary to care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury. Baseline care plans address, at a minimum, the following: Initial goals based on admission orders; Physician orders . The baseline care plan reflects the resident's stated goals and objectives, and includes interventions that address his or her current needs . The assessment must accurately reflect the resident's status, and each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment . The following assessments and time frames are calculated from the day of admission unless otherwise noted . Baseline Care Plan developed with 48 hours of admission . skin assessment within 8 hours. Facility policy titled Order Review dated ,d+[DATE] included Purpose: To assure appropriate medications and treatments are in place for each resident. Procedure: EHR System: Orders are transcribed into the electronic health record. The immediate jeopardy that began on [DATE], was removed on [DATE], when it was verified the facility implemented the following corrective actions: -Educated licensed nursing staff about skin and wound care protocols, reviewing hospital discharges, admission skin assessments, skin and wound assessment and monitoring, following physician orders, and provider notification with competency testing; -Reviewed hospital discharge orders for current residents admitted since [DATE] for transcription accuracy and completeness and identification of skin impairments and treatments; interviewed said residents regarding skin care and treatments; -Completed comprehensive skin assessments on said residents; reviewed and updated skin care plans as needed for said residents; -Reviewed facility Prevention and Treatment of Skin Breakdown policy for accuracy; added surgical incisions to weekly wound rounds; and added surgical incisions to daily inter-disciplinary team meetings,

Based on observation, interview, and document review, the facility failed to comprehensively assess suicidal ideation and develop safety interventions for 1 of 1 residents (R23) who had made suicidal statements and was assessed for behavioral-emotional health. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], indicated R23 had intact cognition with no behaviors noted. R23's mood was not assessed. The MDS indicated that R23 required partial assistance for toileting and dressing. R23's significant change MDS dated [DATE], indicated R23 had moderately impaired cognition with disorganized thinking and an altered level of consciousness. The MDS indicated that R23's mood assessment was not completed. The MDS indicated R23 had delusions present with symptoms such as hitting, scratching, pacing, or disruptive sounds. R23's Care Area Assessment (CAA) dated 8/15/23, indicated R23 triggered for delirium, cognitive loss/dementia, communication, psychosocial well-being, mood state, and behavioral symptoms. R23's significant change MDS dated [DATE], indicated R23 had intact cognition and required set-up help with eating and dependent assistance with toileting. The MDS indicated that R23 was diagnosed with depression, anxiety, and a psychotic disorder. R23's CAA dated 11/2/23, indicated R23 triggered for cognitive loss/dementia and behavioral symptoms. R23's order summary dated 2/7/23, indicated an order to monitor for antidepressant target behaviors such as wanting to/talking about dying, yelling, frowning, lack of interest in activities, social isolation, negative statements, crying, and sad facial expressions. The order also indicated nursing staff should monitor for antidepressant side effects. R23's emergency department provider note dated 2/8/23 at 3:26 p.m., indicated R23 was at the emergency department related to altered mental status and auditory and visual hallucinations. The note indicated the voices had told her that she should die. The note indicated that she had no suicidal plans. The note indicated the provider thought the confusion could have been related to oxycodone (opioid pain medication) use with the addition of Zoloft (an antidepressant) and recommended holding the oxycodone. R23's care plan dated 4/12/23, indicated R23 preferred staff to check on her hourly during the waking hours. R23's order summary dated 4/14/23, indicated an order to check in with R23 hourly during waking hours. R23's medical/treatment record dated 7/1/23- 7/31/23, indicated R23 had made comments about wanting to/talking about dying on 7/29/23. R23's medical/treatment record dated 8/1/23- 8/31/23, indicated R23 had made comments about wanting to/talking about dying on 8/1/23, 8/2/23, 8/17/23, 8/20/23, 8/26/23, 8/27/23, and 8/28/23. R23's Resident Mood Interview form dated 7/17/23, indicated R23 had no thoughts such as being better off dead or about hurting herself in some way, or other symptoms of depression at the time of the interview. R23's progress note dated 7/26/23 at 4:06 p.m., indicated family had requested that staff speak to R23 related to her strange comments and ['things not adding up'] R23 indicated there was too much going on in her life right now and hoped everything would be better when a new month came. The note indicated that R23 appeared to have been unable to process her life events, including the death of a family member. R23's progress note dated 7/28/23 at 1:06 p.m., indicated family had asked staff again to talk with R23 related to concern that R23 was more ['mixed up.'] R23's progress note dated 7/28/23 at 4:00 p.m. identified the provider was notified of family request to increase Zoloft. The provider increased the Zoloft on 7/29/23. R23's progress note dated 7/29/23 at 8:50 p.m., indicated R23 was crying and yelling frantically at family members and made comments about dying. The note indicated R23 had deescalated, taken her medications, and then again became very agitated with a depressed mood and made a statement about wanting to die. R23's progress note dated 7/31/23 at 10:35 a.m., indicated social services and the DON had assessed R23 related to staff and family requests. The note indicated R23 was abnormally slow to respond when asked how she was doing. The note indicated R23 eventually said great but was unable to expand further. The note indicated social services emailed the family and the county care coordinator to follow up on a mental health appointment. The facility also submitted a referral to a local clinic but an appointment was not scheduled. R23's progress note dated 7/31/23, at 11:30 a.m. identified the provider was notified of behaviors and provider stated, There really isn't much we can do, she is not physically hurting herself or others, so there is no hard [sp] being done. R23's progress note dated 8/2/23 at 12:01 p.m., indicated R23 had been filling the trash cans in her room with her personal items so staff were checking the trash cans for these items. The note indicated nursing staff would continue to monitor R23's safety but did not indicate suicidal ideation had been assessed. R23's care plan dated 8/2/23, indicated R23 had a history of behavioral symptoms related to incorrect perceptions of reality and listed triggers to her symptoms such as the anniversary of her sister's death and exacerbating behaviors with one-to-one time with staff. The care plan listed interventions such as allowing the resident to have control over the situation when possible, attempting one-to-one conversations, establishing trust, identifying relationships the resident could draw from, and psychiatric referrals as needed. R23's progress note dated 8/3/23 at 9:16 a.m., indicated R23 refused all morning medications, threw her breakfast tray all over the room, and the one-to-one time spent with R23 was not effective. R23's progress note dated 8/3/23 at 5:17 p.m. identified an order was obtained with ok to send to ED for evaluation and treatment of psychosis if refuses lab/x-rays. R23's progress note dated 8/4/23 at 1:03 p.m., indicated family had significant concerns for resident safety due to behaviors. The note indicated the facility informed the family that the family can pursue the ED or look into inpatient mental health to address these concerns. R23's progress note dated 8/4/23 at 1:14 p.m., indicated that R23 was sent to the emergency department (ED) per the family's request. R23's provider note with an addendum dated 8/4/23, indicated R23 had increased confusion and statements such as saying 'She wanted to die.' The note indicated that R23 had been refusing medication routinely and was not eating her meals. The note indicated that R23 had been attempting to pack up her room and throw away her belongings. R23's hospital psychotherapy note dated 8/6/23 at 3:24 p.m., indicated R23 had acute suicidal thoughts that put her at risk for self-harm, harm to others, or harm to property. The note indicated R23 had more days than not that she would rather be dead. The note indicated that R23 had vivid memories in her mind that she could not get out. The writer attempted to assess R23's suicide risk but when asked, R23 was unable to elaborate on suicidal comments. The note indicated due to R23's limited conversation and confusion she was unable to obtain enough information to make an official mental health diagnosis. The writer recommended a formal self-harm evaluation. R23's hospital nursing progress note dated 8/6/23 at 6:02 p.m., indicated R23's family member visited and R23 informed her, she wanted to kill herself by wrapping a cord around her neck. The note indicated R23 stated 'I would like to die and would use a rope around my neck but I don[']t have a rope.' R23 also stated, 'I can't handle it anymore, these thoughts are terrible. I can't take it.' The note indicated cords were removed from R23's room while in the hospital and R23 was continuously monitoring for her safety. R23's hospital psychiatry consult note dated 8/7/23 at 10:39 a.m., indicated R23 continued to demonstrate disorganized thinking, confusion, psychosis, impulsivity, agitation, and intermittently threw things across the room. The note indicated R23 was extensively assessed for a potential medical diagnosis that may have contributed to her mental health symptoms with no clear cause identified. R23 denied any active or passive suicidal ideation but endorsed voices telling her to do things and a desire to quiet those voices. The provider recommended administering risperidone (an antipsychotic medication) for R23's mental health symptoms and monitoring for its potential side effects. The note also recommended inpatient psychiatry placement for R23. The note indicated that R23 could return to the facility depending on behaviors and recurring suicidal thoughts. R23's Level II Preadmission Screening dated 8/11/23, indicated R23 reported suicidal intent in the last two months. R23's hospital discharge note dated 8/11/23, indicated R23 had presented to the ED on 8/4/23, for worsening mental status over the previous two weeks. During this stay, she was evaluated by the psychology team and they felt R23 was experiencing delirium rather than acute psychosis or worsening dementia. The note indicated that behavioral health was consulted but it was difficult to obtain an accurate self-harm risk assessment due to R23's impaired cognitive status. The patient was maintained on one-to-one suicide precautions pending a behavioral health evaluation and determined R23 was not at risk for self-harm. The note indicated family continued to have concerns related to R23 failing to return to her mental health baseline. The note indicated that R23 would have benefitted from ongoing care with a geriatric psychiatrist or a psychologist. The note indicated that R23 was stable at discharge. R23's progress note dated 8/11/23 at 2:18 p.m., indicated R23 had returned to the facility from the hospital. The note did not indicate facility knowledge of R23's previously stated suicide plan or assessment of the possible need for environmental safety modifications. R23's progress note dated 8/11/23 at 2:33 p.m., indicated R23's family requested checks on R23. The note did not indicate facility knowledge of R23's previously stated suicide plan or assessment of the possible need for environmental safety modifications. R23's progress note dated 8/12/23 at 2:22 a.m., indicated R23 would not respond verbally to questions and was found banging the table with her call light but would not say what she needed. R23's progress note dated 8/12/23 at 8:16 p.m., indicated R23 refused her meal and personal care that evening and told staff, 'I'm dead, I'm dead.' The note indicated time was spent with the resident and safety was ensured. The note did not indicate suicidal ideation had been assessed. R23's progress note dated 8/13/23 at 9:46 a.m., indicated R23 continued to refuse care and her medications. The note indicated that the nursing assistant stayed in the room with R23 related to assistance needed for activity. R23's care plan dated 8/14/23, indicated R23 had behavioral symptoms such as not responding to staff, stating she was dead, throwing meal trays, and refusing medications. The care plan goal was to ensure that the resident would not harm herself or others during her delusional periods. The approach was assigning consistent staff members as able, not arguing against the residents' belief system, encouraging ventilation of feelings, providing a safe quiet environment during delusional periods, reinforcing and focusing on reality, and using clear concise terms. R23's progress note dated 8/14/23 at 11:39 a.m., indicated R23 was at risk for falls related to a recent psychiatric decline, and the call light and frequently used items were to remain in reach of the resident. The note did not address alterations to this call light or continuous supervision. R23's progress note dated 8/14/23 at 10:25 p.m., indicated R23 had spit out most of her medications, did not allow cares, and showed little emotion. The note indicated R23 was very depressed and confused. The note indicated R23 was checked on frequently to ensure safety. R23's progress note dated 8/14/23 at 1:52 p.m. the provider was notified of R23's distressing behaviors and ordered 1. Risperidone 0.5 mg in morning and keep bedtime dose. 2. Occupational Therapy to evaluate and treat. R23's Resident Mood Interview form dated 8/15/23 at 12:48 p.m., indicated R23 had thoughts such as being better off dead or about hurting herself in some way, half or more days in the past two weeks. Where the form asked if the responsible staff or provider had been informed of the results, the box was left blank. R23's progress note dated 8/15/23 at 1:27 p.m., indicated R23 required some one-to-one time with staff related to R23 removing her clothing, banging the tray table against the wall, and yelling out. R23's psychiatry progress note dated 8/16/23 at 8:45 a.m., indicated R23 denied suicidal ideation at this time. The note indicated that R23's family member informed the writer that 'she does talk about suicidal thoughts sometimes.' The note indicated how important a daily routine was to R23 for her anxiety and how when the routine was changed, it had a negative effect on her. R23's progress note dated 8/17/23 at 2:37 p.m., indicated R23 continued to display distressing behaviors and the provider was notified who increased her risperidone dose. R23's care plan dated 8/17/23 indicated R23 had the potential for discomfort and side effects related to the use of antidepressant and antipsychotic medications. The care plan indicated nursing staff was ordered to observe the following anti-depressant target behaviors every shift: wanting to/talking about dying, yelling, frowning, lack of interest in activities, social isolation, negative statements, crying, and sad facial expressions. R23's care plan dated 9/8/22, indicated R23 was at an increased risk for altered mood related to her placement at the facility and need for assistance with daily tasks. The care plan indicated as an intervention, staff was to assess if R23 wanted alone time or encouragement to participate with others. R23's progress note dated 8/19/23 at 1:20 p.m., indicated facility staff replaced R23's call light with a soft touch call light because R23 had been hitting herself with the previous call light. R23's progress note dated 8/21/23 at 5:46 a.m., indicated R23 had told nursing staff, 'I will be dead in the morning.' The note indicated nursing staff regularly checked and changed R23 but did not indicate suicidal ideation or the need for safety modifications had been assessed. R23's facility provider note dated 8/22/23 and signed on 8/24/23, indicated R23 was admitted to the local hospital from 8/4/23 to 8/11/23 for psychosis and suicidal ideation. During her hospital stay, R23 informed her family that she wanted to kill herself by wrapping a cord around her neck. The note indicated family was concerned that R23 had not returned to baseline but R23 had no acute medical needs and was discharged back to the facility. R23's progress note dated 8/26/23 at 12:55 p.m., indicated R23 was found in her room by staff trying to put a plastic bag over her head. The provider was contacted and medications were increased. The note indicated that R23 continued to groan, yell, and attempt to get up independently from her wheelchair. The note indicated staff were unable to leave R23 alone at this time but did not indicate plastic bags had been removed from her room. R23's progress note dated 8/26/23 at 8:51 p.m., indicated R23 remained on one-to-one observation the entire shift but when staff would walk away R23 would start calling out for help but was unsure what she needed. The note indicated R23 had stated, 'My mind is playing tricks on me. There are so many things going on in my mind.' R23's progress note dated 8/27/23 at 11:35 a.m., indicated R23 would scream for help when no one was around and would throw items when left alone. The note also indicated that R23 required supervision to ensure safety. R23's progress note dated 8/28/23 at 10:40 a.m., indicated provider updated on continual distressing behaviors, risperidone dose subsequently increased to a total of 2.5 mg per day. R23's progress note dated 8/28/23 at 5:57 a.m., indicated R23 would yell out when left alone in her room. R23's progress note dated 8/29/23 at 10:27 a.m., indicated R23 was found in her room with the call light cord wrapped one time loosely around her neck. The note indicated R23 was then brought out to activities. The note indicated R23 continued to call out for help repeatedly but did not know what she wanted when she was questioned. R23 was placed on 1:1 supervision. R23's progress note dated 8/29/23 at 10:48 a.m., indicated nursing staff updated the provider and received an order to send R23 to the emergency department. R23's progress note dated 8/29/23 at 12:47 p.m., indicated R23 left the facility with a family member to receive treatment at an inpatient psychiatric facility. R23's hospital psychiatry provider note dated 8/31/23, indicated that per R23's family, she had attempted to either strangle or suffocate herself four times in the last six weeks via cords and plastic bags. R23 indicated she was unsure why she was in the emergency department and did not remember her self-harm behaviors. The note indicated that R23 believed she had perfect memory. R23's family indicated that R23 had been hearing the voice of her mother telling her that it is 'okay to go' and has been observed talking to herself. The note indicated R23 had self-injurious behavior by beating items with her fists causing significant bruising. The note indicated R23 had a gradual onset of confusion, behavioral changes, and worsening mood with impulsive self-harm behaviors that were highly suggestive of an onset of a major neurocognitive disorder. The note indicated that R23 was admitted to an inpatient psychiatric hospital unit for care. R23's progress note dated 9/12/23 at 1:18 p.m., indicated R23 returned to the facility at 11:50 a.m. The note did not indicate what assessments and safety measures were to prevent death by suicide. R23's provider note dated 9/16/23 at 8:10 p.m., indicated R23 was admitted to an inpatient psychiatric unit on 8/30/23 for a history of four suicide attempts. The note indicated that on the day of discharge from the psychiatric hospital, R23 was not an acute safety risk but there remains a considerable moderate chronic risk for suicide and violence given the overall history. The note indicated that psychiatry can make a judgment regarding the level of risk for suicide and violence, we cannot predict if or when a patient may attempt suicide or become violent. The note indicated that such an evaluation was limited to a resident's willingness to divulge information. R23's progress note dated 10/7/23 at 1:42 p.m., indicated R23 called out for help the entire shift. The note did not indicate mental health status was assessed for R23. The psychiatry progress note dated 11/6/23 at 2:35 p.m., indicated R23 and her daughter reported mental health symptoms had been improving. The note indicated R23's protective factors against dying by suicide include living in a staffed facility. The note indicated R23 remained a low to moderate suicide risk. The psychiatry progress note dated 12/7/23 at 3:00 p.m., indicated R23 had a diagnosis of prolonged grief disorder and adjustment disorder with depressed mood. The note indicated R23's mood was anxious and depressed. During an observation on 12/4/23 at 4:01 p.m., R23 was sitting in her recliner with the call light in the left cup holder of the recliner's arm. The call light cord was more than six feet long and the cord was coiled once on the floor and the controller was in the left cup holder of the recliner's armrest. During an observation on 12/6/23 at 7:55 a.m., R23 was observed sitting in her recliner with her call light in the cup holder on the left armrest next to her with the call light cord hanging down the left side of the chair, pooling on the ground and wrapped behind the chair slightly above the top of the recliner where it was plugged into the wall. During an interview on 12/6/23 at 8:38 a.m., nursing assistant (NA)-A indicated she was not aware R23 had attempted suicide twice or if there were any interventions in place to ensure R23's safety. NA-A verified R23's call light cord had been accessible to R23 and was long enough to be wrapped around her neck while she was sitting in the recliner. During an interview on 12/6/23 at 9:16 a.m., registered nurse (RN)-A, the floor nurse in charge of R23's care, thought R23 had a nervous breakdown and was sent to an inpatient psychiatric facility but was unaware of her suicidal ideation history. RN-A verified that R23's care plan lacked indication of R23's suicide attempts or interventions related to them. During an interview on 12/6/23 at 12:58 p.m., R23 stated she remembered not thinking straight but could not recall her past suicide attempts. R23 stated she felt she had been sleeping more lately than she wanted but did not currently have suicidal ideations. During an interview on 12/6/23 at 8:47 a.m., the assistant director of nursing (ADON) stated R23 had experienced depression and confusion leading to R23's inpatient psychiatric hospital stay, but was unsure about any further details or interventions to prevent further attempts. During an interview on 12/6/23 at 10:36 a.m., the director of nursing (DON) stated that R23 was solely being seen for her mental health needs virtually by a psychiatric therapist her family had set up for her. The DON stated they did not have access to R23's therapist's notes nor did they receive any form of updates related to R23's suicidal ideations or other mental health concerns, behaviors, or recommended interventions. The DON stated she was unaware of R23's statement indicating she wanted to kill herself by wrapping a cord around her neck or of any interventions in place to prevent future suicide attempts. The DON further stated that R23's care plan should have been updated to include interventions to ensure R23's continued safety and mental well-being. During an interview on 12/6/23 at 3:37 p.m., the physician assistant (PA) stated R23 had a history of depressive episodes with a change of mental status including in February and August of 2023. The PA stated that R23's episodes would come on quickly and were not always predictable. The PA stated she expected staff to review hospital discharge notes and provider notes to assess for resident changes and possible interventions such as R23's threat to strangulate herself with her call light cord. The PA stated she expected staff to remove items from R23's room that R23 could have or had used to harm herself, including the call light cord and plastic bags. The PA stated R23's family conflict was a known trigger for symptoms of depression. The PA further stated that R23's care plan also should have been updated with interventions to ensure her ongoing safety and well-being. During an interview on 12/7/23 at 10:11 a.m., nurse manager (RN)-D stated R23 had an episode during August of 2023, where she was very confused, refused her medications, threw items around her room, and would frequently say things like I am dead or this is the day I am going to die. RN-D stated she thought family conflicts as well as the death of a loved one had caused R23 emotional distress and had been one of the triggers for this episode. RN-D stated as interventions for her behaviors, facility staff utilized family visits and spent individual time with R23. RN-D stated that nursing staff would complete and document hourly checks on R23 that were recorded in the treatment administration record (TAR). RN-D stated they did not remove the corded call lights from R23's room. RN-D stated the facility did not use the associated clinic of psychology (ACP) personnel so the family had found a therapist for R23 to see themselves. RN-D stated they did not have access to R23's psychotherapy visits or receive updates from this provider but acknowledged this would have helped assess when revisions for R23's care plan were needed or what mental health interventions would have been helpful. RN-D stated nursing staff had not been aware that R23 had stated a desire to die by suicide using a call light cord and therefore had not removed it. RN-D stated because of this unawareness, she had thought the attempts to die by suicide were more likely behavioral than related to suicidal ideation. RN-D stated the nurse managers were supposed to read through the after-visit summaries (AVS) but indicated she had not after R23 was hospitalized from 8/4/23 to 8/11/23. RN-D stated this knowledge would have helped prevent R23's non-fatal attempt at suicide on 8/29/23. RN-D stated nursing staff did not read through the facility provider notes and this also would have helped prevent this attempt. During an interview on 12/7/23 at 10:34 a.m., Family member (FM)-A stated during February of this year, R23 had an episode where she wanted to die and was hallucinating about the devil. FM-A stated that R23's second mental health episode began in the middle of July of this year. FM-A stated that R23 was very confused and had behaviors such as crying out for help and discarding her personal items. FM-A stated there had been a family conflict that may have triggered some of these behaviors. FM-A stated that R23 was then admitted to the hospital for the first time during this second episode and attempts were made to alter her psychiatric medication regimen before readmitting R23 to the facility. FM-A stated she then received a call from the facility informing her that they had found R23 with a plastic bag over her head. FM-A stated the facility then informed her that she needed to help them find a way for R23 to receive psychiatric care. FM-A stated a psychiatric facility was eventually found for R23 but the facility had not been able to find transportation for her. FM-A stated she was informed that she would have to bring R23 to a psychiatric facility and was not offered staff assistance. FM-A stated she was very concerned for R23's safety given her active plans to die by suicide and drove with the car child locks in place so R23 could not jump out. FM-A stated it was a horrific experience but she had to do what she had to do to get her back. FM-A stated she had been informed by the facility that the county could assess R23 for psychotherapy but was unaware of further assistance the facility provided her regarding this. FM-A stated she initially set up R23's psychotherapy appointments and continued to do so. During an interview on 12/7/23 at 1:57 p.m., RN-D stated after R23's inpatient psychiatric stay and hospitalization they had updated her care plan and adjusted her medications but because her behaviors seemed stable, they had not done any further suicide prevention interventions for R23. During an interview on 12/7/23 at 2:46 p.m., the DON stated she expected the nurse manager to review the hospital notes and AVS to ensure no changes were needed to the plan of care. The DON also stated she would expect the provider to update them on any significant changes in condition such as plans to die by suicide. If they had been aware of the plan to die by suicide, they would have removed the call light cord and added additional interventions into the care plan to prevent this from happening. The facility Suicide Threats by the Resident policy dated 2/19, indicated that residents who had an active risk of dying by suicide should not have been cared for at the facility and should have been assessed by a medical professional as soon as possible. The policy indicated if a staff member observed potential suicidal statements and behaviors by a resident, those should have been reported to the supervisor immediately and measures should have been taken to promote safety. The policy indicated that residents should have been screened for mood indicators including suicidal ideation and if a resident's statements or actions reflect suicidal ideation at any time, immediate actions should have been taken to maintain safety. The policy indicated all staff members were obligated to report risk factors and warning signs of possible suicidal ideation to their supervisor. The undated facility Suicide Assessment, indicated if a resident showed warning signs or risk factors for suicide, staff were to express concern to the resident and ask them specific questions. Staff then should have assessed the resident's risk of suicide by determining if they had a clear intent to die by suicide, determined if they had a plan that was imminent and capable of resulting in self-harm or death could have been implemented by the means the resident had available. If these risk factors were present staff, should immediately implement a crisis plan, monitor the resident continuously at an arm[']s length, and transport the resident via ambulance to an acute care setting. If the resident was ambivalent regarding their intent to die by suicide, expressed a vague plan, or described a plan the resident was clearly incapable of implementing, staff should implement individualized safety checks. If the resident made vague statements such as, 'sometimes I wish I wasn't here' or 'I wish I just wouldn't wake up again,' or had changes in behavior such as becoming more withdrawn, giving away items, recent changes in medical status, hopeless/helpless statements, staff should have completed frequent monitoring checks or increased supervision of the resident. The assessment indicated they should have an emergency interdisciplinary team meeting and notify the physician, or established psychologist of this event. The assessment also indicated if the resident displayed any of these risk levels, staff should assess the resident's environment and remove items or modify conditions to ensure safety, consult with supervisor, physician, and psychologist, document what was observed in the medical record, and update the care plan to include risk factors and interventions.

Based on interview and document review the facility failed to comprehensively assess, develop, and implement interventions for ongoing and unplanned weight loss for 1 of 1 residents (R30) who had significant weight loss. Findings include: R30's significant change in status Minimum Data Set (MDS) dated [DATE], indicated R30 had impaired cognition, needed set up assistance with eating and required extensive assistance for all other activities of daily living (ADLs). R30's diagnoses included dementia, malnutrition, depression, chronic obstructive pulmonary disease (COPD), low back pain, high blood pressure, and osteoporosis (weak and brittle bones). R30's Care Area Assessment (CAA) sated 10/27/23, indicated R30 triggered for visual function, ADL function, urinary incontinence, falls, nutritional status, pressure ulcer and psychotropic drug use. R30's care plan dated 11/03/22, indicated R30 had potential for altered nutrition/hydration status related to dysphagia (difficulty swallowing), dementia, anemia, history of aspiration pneumonia (occurs when food or fluid is breathed into the airway or lungs instead of being swallowed), history of unstageable pressure injury, fracture at admission, malnutrition, low BMI (low body weight), osteoporosis (weak and brittle bones). Care plan indicated R30 prefers to remain in bed, supplements in place to help meet nutritional needs. Interventions included diet per MD, honor likes/dislikes and offer preferred fluids with and between meals, water at bedside. Interventions also included nutritional related meds and supplements per MD, provide meal set-up and/or assistance with eating per SLP, snacks per patient request and/or policy, monitor weight, intake labs, texture tolerance, skin and/or additional nutrition/hydration parameters as appropriate and no eggs. R30's nutrition progress note dated 11/22/23, indicated that weight loss is not planned or prescribed. R30's nutrition progress note dated 11/19/23, indicated the registered dietician (RD) indicated R30 requires supervision with meals. Meal intakes: many poor with two being good during ARD [time period for significant change assessment after hospitalization ]. Supplement three times daily is variable. R30's nutrition progress note dated 10/27/23, indicated supplement provided with meals is mostly good but variable. R30's weights (in pounds) were as follows: -6/2/23 at 1:54 p.m., 107.3 Fairly stable weights -9/15/23 at 1:27 p.m., 104 -10/13/23 at 10:35 a.m., 100.4 -11/15/23 at 1:44 p.m., 94.6 11/23/23 at 1.53 p.m., 92 On 06/02/2023, the resident weighed 107.3 pounds. On 11/23/2023, the resident weighed 92 pounds which is a negative 14.26 % weight loss. R30's diet orders included: 3/14/23: Chocolate ensure with meals 11/28/23: 8 oz ensure clear between meals R30's meal intake summary dated 11/7/23 - 12/7/23 -over the last 30 days, overall poor intake R30's physician note dated 11/10/23, indicated R30 had no appetite, weight noted on 11/9/23 of 47.7 kg [99.8 lbs.] and to continue with speech therapy, modified diet, nutritional supplement, and monitoring. During observation on 12/4/23 at 2:52 p.m., R30 had two ensures and a water on her bedside table. One of the ensures was full and the other ensure was two-thirds full. During interview and observation with R30 on 12/5/23 at 11:53 a.m., R30 stated that she does not eat in the dining room because staff would have to help get her up. Upon entry to R30's room, the door was closed tight. R30 had her lunch tray which had mashed potatoes, meatloaf, whole cooked carrots, and a brownie. R30 had eaten some of the mashed potatoes. R30 had three bottles of ensure on her bed side table next to her lunch tray. During interview and observation on 12/6/23 at 8:19 a.m., R30 stated that no staff are with her when she eats meals. R30 was observed to be slouched down in bed, the head of the bed was elevated and R30 stated she was done eating breakfast. R30's door was shut upon entrance. During an interview on 12/6/23 at 8:25 a.m., nursing assistant (NA)-B stated R30 always ate breakfast in her room as that was her preference, liked her door shut and did not need assistance with meals. NA-B stated that R30 does not need supervision with meals, was recently in the hospital due to complications from COVID and is back to her baseline. During an interview on 12/6/23 at 3:57 p.m., assistant director of nursing (ADON) stated R30's intake can be poor, recently had COVID and pneumonia, likes her supplements and needs supervision with her meals. ADON stated R30 need for supervision was on her care plan to help ensure she is sitting up right as she has a hernia and had aspiration pneumonia. ADON stated supervision during a meal means that staff needs to be able to see the resident while they are eating. During interview on 12/7/23 at 8:04 a.m., nursing assistant (NA)-C stated that she is not aware of R30 needed supervision or assistance with meals. During interview on 12/7/23 at 8:05 a.m., nursing assistant (NA)-D stated that R30 always had the door to her room closed. NA-D stated that R30 is not supervised during meals and R30 is a set up for meals. NA-D stated that if R30 needs anything R30 would put her call light on. On 12/7/23 at 8:25 a.m., it was observed that R30's breakfast tray was delivered to R30's room. At 8:27a.m., staff delivering tray exited R30's room. During an interview on 12/7/23 at 8:29 a.m., nursing assistant (NA)-E verified that they had just delivered R30's breakfast tray to R30. NA-E verified the door was shut and there is no staff in R30's room. NA-E stated that R30 does not need supervision with meals, she just needs set up, and she is not checked on during meals. During an interview on 12/7/23 at 9:23 a.m., registered dietician (RD) stated she would run a report to look for significant weight changes, and if a significant weight change was noted, RD would request the resident to be reweighed to ensure accuracy, then address the concern if the weight was not expected or desired. RD stated she has not met with R30 to discuss weight loss. RD stated that her communication has been with the staff. RD stated that she indicated that R30 needed supervision with meals. RD indicated the expectation with the supervision would be staff would provide encouragement to eat to help her increase her food intake. RD stated she does this for residents who have had weight loss and suffer from dementia as it has been beneficial as residents with dementia need encouragement and supervision with meals. During an interview on 12/7/23 at 10:04 a.m., R30 stated that no staff had talked to her about any weight loss. R30 stated she does not want to lose any weight. R30 is unsure what she weighs now but majority of her life she has weight between 107-110 lbs which is what she thinks she is at. The facility Weight Protocol policy dated 8/1, residents were to be weighed upon admission and at least monthly thereafter. Each resident's weight is monitored and fluctuations of greater than or equal to 5% in one month, or 7.5% in three months, or 10% in six months will be assessed and appropriate individualized dietary interventions and documentation will be implemented. A resident's physician and responsible party were to be notified of any significant weight change.

Based on observation, interview and record review the facility failed to ensure timeliness of person-centered care conferences for 2 of 2 residents (R19, R35) to include review and revision of the care plan by an interdisciplinary team and the resident. Findings include: R19's quarterly Minimum Data Set (MDS), dated [DATE], indicated R19 was admitted to the facility on [DATE], was cognitively intact, was independent with bed mobility, needed supervision with transfers, required set up to eat, oral hygiene, and needed moderate assistance with personal hygiene and bathing. Diagnoses included chronic kidney disease, diabetes mellitus, hyperlipidemia (high blood cholesterol), depression, and hypertension (high blood pressure). R19's care plan revised on 10/3/23, indicated the last conference was on 4/12/23 and documented the next care conference was on 7/12/23. R19's Care Conference Report dated 12/6/23, had documentation of care conferences held on 7/13/22, 10/5/22, 1/11/23 and 4/23/23. During an interview on 12/4/23 on 1:34 p.m., R19 stated she had not attended a care conference for at least 6 to 8 months. R19 stated, usually her brother, herself (R19) and a staff member attended her care conference. R19 stated, usually a nurse comes to my room and asks me if a have any concerns and how am I doing? During an interview on 12/6/23 at 1:18 p.m., social worker (SW)-A stated R19's care conference was due in January 2024. SW-A stated the care conferences were scheduled based on the MDS assessments' schedule. SW-A stated for long term residents the care conferences are scheduled every three months and as needed. SW-A verified R19's electronic record lacked documentation of a care conference since 4/12/23. During an interview on 12/7/23 at 10:46 a.m., the nurse manager/register nurse (RN)-D stated care conferences were done quarterly. RN-D stated on 10/5/23 she met with R19 in her room, no other staff member participated, and verified there was no documentation of this meeting on R19's electronic medical record. During an interview on 12/7/23 at 11:28 a.m., the director of nursing stated the long-term care resident had care conferences quarterly and as needed for significant changes or per resident request. The DON stated, care conferences needed to be attended by all disciplines and if any discipline was unable to attend, the discipline needed to send their information to the social worker to discuss it with the resident or their family. 49034 R35's quarterly MDS dated [DATE], indicated R23 was admitted on [DATE], and had no cognitive deficits. A review of R35's progress notes indicated that R35's last care conference was on 7/14/23. A review of R35's medical record did not demonstrate a care conference had occurred after 7/14/23 or a reason this would not have been practicable for R35. During an interview on 12/4/23 at 2:04 p.m., R35 stated he didn't remember the last time he had a care conference with his providers and wished he had been more updated and involved with his care. During an interview on 12/5/23 at 1:10 p.m., SW-A stated R35 was supposed to have his care conference on 10/22/23 for this quarter but it was missed. SW-A stated that R35 would not have his next care conference until the following quarter. During an interview on 12/7/23 at 2:46 p.m., the DON stated that SW-A scheduled the quarterly care conferences. The DON stated these conferences were important to ensure residents were informed about their care and were able to personalize the plan as needed. The facility's Comprehensive Assessments and Care Planning policy dated 7/2/18, indicated the care planning process should include direct observation and communication with the resident. The resident or resident representative should have been involved in creating a person-centered care plan and if it was not practicable for them to have been involved, it must be documented in the resident's medical record. Policy titled Resident/Family Participation in Care Planning dated 2017, indicated the purpose was to ensure residents were informed of their rights and actively participated in person centered care planning per their discretion. The policy also indicated the resident and invitees participated in the care planning process with the interdisciplinary team.

Based on observation, interview and document review, the facility failed to ensure provider orders were followed for 1 of 1 residents (R45) who had developed edema in his right arm after a stroke. Findings include: R45's admission Minimum Data Set (MDS) dated [DATE], indicated R45 had severe cognitive deficits and was dependent for all activities of daily living (ADLs). R45's diagnoses included hemiplegia/hemiparalysis (partial one-sided paralyis) to right dominant side secondary to a stroke and hypertensive (high-pressure) kidney disease. R45's Care Area Assessment (CAA) dated 10/16/23, indicated R45 triggered for communication, pressure ulcers, and pain. R45's progress noted dated 10/9/23, indicated R45 had no edema. R45's order dated 10/30/23, indicated to elevate R45's right upper extremity (RUE) as much as possible to decrease edema. R45's order dated 11/10/23, indicated to apply a tubi-grip wrap (compression wrap) to R45's RUE during the day and to remove it at night. During an observation on 12/4/23 at 3:52 p.m., R45 was semi-reclined in bed with his right arm on one pillow raising it to the level of the top of his right thigh. R45's right arm lacked a tubi-grip wrap and was bluish-purple and swollen to his elbow. During an observation on 12/5/23 at 11:00 a.m., R45 was in bed. His right arm was on one pillow at the level of his right thigh with a tubi-grip wrap on it. R45's hand was bluish-purple, and his hand and arm were swollen to his elbow. During an observation on 12/6/23 at 8:05 a.m., R45 was sitting up in bed, feeding himself breakfast with his right arm between a pillow and his right thigh. R45's right arm lacked a tubi-grip wrap and appeared bluish-purple and was swollen. During an observation on 12/6/23 at 11:06 a.m., R45 was reclined in his bed with his right arm resting on one pillow and no tubi-grip wrap applied. R45's right arm was bluish-purple and swollen. During an observation on 12/7/23 at 8:09 a.m., R45 was lying in bed, semi-reclined and awake. R45's right arm was on a single pillow with no tubi-grip wrap applied. During an observation and interview on 12/7/23 at 9:20 a.m., R45 was sitting up in bed, his right arm was elevated on two pillows and appeared pink in color with swelling noted only to his hand and no tubi-grip wrap applied. R45 asked if this surveyor could help him put on his tubi-grip wrap because it works really good and he liked to have it on every day. During an interview on 12/4/23 at 5:25 p.m., licensed practical nurse (LPN)-A stated staff were supposed to elevate R45's right arm, however, it was a never-ending battle. During an interview on 12/7/23 at 9:24 a.m., registered nurse (RN)-B stated R45 should have two pillows under his right arm to ensure it is elevated high enough to decrease his swelling. RN-B further stated R45 was to have a tubi-grip wrap on his right arm all day to help decrease the swelling also. During an interview on 12/6/23 at 11:45 a.m., the assistant director of nursing (ADON) stated R45's tubi-grip arm wrap should have been applied every day, all day, and removed at night according to his orders to control edema unless R45 had refused. The ADON further verified although R45 did not have a tubi-grip wrap on his arm, his electronic medical record (EMR) had been charted to indicate he did. During an interview on 12/7/23 at 2:07 p.m., the director of nursing (DON) stated R45's right arm should be on two pillows to ensure it was elevated at or above his heart to decrease swelling and improve circulation and his tubi-grip wraps should have been applied during waking hours as ordered. A facility policy related to treatment of edema was requested but not received.

Based on observation, interview and document review the facility failed to ensure 1 of 1 residents (R101) was comprehensively assessed and deemed safe to self-administer medications, including a narcotic that was found at his bedside. Findings include: R101's Resident Face Sheet indicated R101 was admitted to the facility on [DATE]. Therefore, R101 did not have a reported Minimum Data Set (MDS) or Care Area Assessment (CAA) completed. R101's care plan dated 12/5/23, indicated R101 had a risk for impaired psychosocial wellbeing related to a dementia. Interventions included encouraging relaxation techniques, activities, and one to one visits. R101 also had an alteration in communication related to cognitive impairment. The care plan also indicated R101 took psychotropic drugs for insomnia, and bipolar disorder (a mental health disorder causing extreme moods from mania to depression). Interventions included administering medication per order, monitoring for target behaviors, and reporting efficacy of medication use. R101's care plan also indicated R101 had an activities of daily living (ADL) deficit and required assistance with transfers, bathing, grooming, oral cares, ambulation, and mobility. R101's diagnoses included acute respiratory failure with hypoxia (low oxygen levels), dementia with Lewy bodies, other specified crystal arthropathies (pseudo-gout, a formation of calcium pyrophosphate crystals in the joints resulting in pain and inflammation), obstructive sleep apnea, bipolar disorder, and a kidney transplant. R101's orders dated 11/29/23, indicated R101 took amitryptyline 2% (an antidepressant) gabapentin 5% (an anticonvulsant), Ketamine 5% (an anesthetic controlled substance) in a compounded lipoderm cream twice a day topically, as needed, for pain. R101's Medication Administration Record (MAR) lacked indication R101 had used the cream since his admission to the facility. R101's Self-Administration of Medication Assessment (SAM) dated 11/29/23, indicated R101 did not want to self-administer medication including creams/ointments. No further assessment was completed. During an observation and interview on 12/4/23 at 5:45 p.m., R101 was lying in bed and his family member (FM)-A was visiting. Two medication bottles were on R101's bedside table. The bottles labels were worn and no information including resident name or medication name was visible. R101 stated he rubbed the medication onto his shoulders and neck, almost daily, for gout pain. R101 further stated the medication was from his home and contained amitriptyline, ketamine and a third medication he could not recall. During an observation on 12/5/23 at 10:58 a.m., nursing assistant (NA)-B exited R101's room with a portable vitals machine. The two unmarked medication bottles remained on R101's bedside table. During an observation on 12/6/23 at 8:10 a.m., R101 was asleep in bed and the two medication bottles remained on his bedside table. During an observation and interview on 12/6/23 at 11:41 a.m., the assistant director of nursing (ADON) verified the two medication bottles remained in R101's room. The ADON stated because the bottles were unlabeled and had been opened prior to R101 being admitted to the facility, staff were unable to verify the contents of the bottles. The ADON also stated controlled substance medications were to be double locked in a medication cart or medication room to ensure proper usage. The ADON further stated R101 had a history of not taking his medications appropriately and the provider did not want him self administering medications. During an interview on 12/7/23 at 1:56 p.m., the director of nursing (DON) stated all medications brought into the facility from a resident's home needed to be labeled and unopened. The DON also stated residents wanting to self-administer medications were to be assessed to determine their ability to self-administer medications safely and appropriately. The DON further stated all controlled substance medications were to be double locked in a medication cart or room for safe storage. The facility Self-Administration of Medications policy dated 2020, indicated each resident's mental and physical ability was to be assessed for the appropriateness of self-administering medications. If it was determined a resident was unable to self-administer medications safely, nursing staff was to administer the medications to the resident and document when the medications were taken. A facility Medication Storage policy was not received.

Based on observation, interview, and document review, the facility failed to maintain infection control practices during wound care to minimize the risk of infection for 1 of 1 residents (R35) observed for wound care. Findings include: An Infection Control Assessment and Response Program (ICAR) article titled Wound Care Infection Prevention Recommendations for Long-Term Care Facilities dated 11/30/22, indicated during wound care, health care providers should doff their gloves after handling dirty surfaces and supplies and before handling clean surfaces of a wound. R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated R23 had intact cognition and required maximal assistance for bathing and personal hygiene and R35 was dependent on staff for toileting needs. R35's physician progress note dated 11/13/23, indicated R23 was diagnosed with diabetes, peripheral arterial disease (PAD- a condition in which narrowed arteries reduce blood flow to extremities), diabetes, a left below-the-knee and a right above-the-knee amputation, kidney disease, and heart failure. The note indicated R35 had a wound on his left knee with exposed bone and no signs of osteomyelitis (infection of the bone). This wound had been debrided from two smaller wounds and treated with intravenous antibiotics and R35 was discharged on oral antibiotics. R35's order dated 12/2/23, indicated R35's left knee wound care consisted of a daily cleansing with wound cleanser spray, applying a cream to the wound, and covering it with a foam pad. During an observation and interview on 12/4/23 at 1:54 p.m., R35 was observed lying on his back in bed when licensed practical nurse (LPN)-C entered the room. LPN-C was observed donning personal protective equipment (PPE) including a gown and gloves. LPN-C then removed the visibiley soiled left knee foam pad dressing, sprayed wound cleanser onto the wound bed, and blotted cleanser off the wound with gauze. LPN-C continued wound care with the same pair of gloves and applied the wound cream directly to her gloved finger and spread the cream over the wound and exposed bone. LPN-C then applied the new foam dressing and doffed PPE. R35 stated he had recently had his wound debrided and the doctor had expressed concern over the detrimental effects an infection would have, with his bone exposed. LPN-C stated she had not changed gloves between removing the soiled dressing and applying the cream and new dressing to the wound bed. During an interview on 12/7/23 at 2:41 p.m., the director of nursing (DON) stated she expected the nurse to change her gloves after removing the soiled dressing and before applying the new one. The DON stated was worried about R35's risk for infection and the effects this might have, if this was not completed correctly. A policy outlining infection control practices during wound care was not provided.

Based on observation, interview, and document review the facility failed to complete comprehensive fall analysis to determine accurate causal factors and implement care plan interventions to prevent or mitigate the risk of recurrent falls for 2 of 3 residents (R1, R3) reviewed for falls. The facility's failures resulted in actual harm when R1's care plan was not followed resulting in a left hip fracture. Findings include: R1's face sheet, printed 12/28/22, identified R1 diagnoses: left femur fracture and hemiplegia (one-sided muscle paralysis or weakness) following a stroke affecting the left non-dominant side. R1's fall Care Area Assessment (CAA) dated 2/8/22, identified R1 was at increased risk for falls related to left sided hemiplegia and incontinence. R1 had one fall this quarter related to self-transfer attempt; R1 was aware she needed to call for staff assistance. R1's fall assessment dated [DATE], identified R1 was high risk for falls. Identified R1's fall interventions included: use call light for assist, one staff assist with transfers to bed and wheelchair and two staff assist for toileting and walking. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 did not have cognitive impairment. R1 required extensive assistance from two staff for toileting and transfers. R1 was frequently incontinent of bowel and bladder which identified R1 had a decline in bladder and bowel continence since MDS dated [DATE]. The MDS indicated R1 did not have any falls within the last three months. R1's discharge MDS assessment dated [DATE], identified R1 had 1 fall with major injury. R1's care plan dated 12/15/21, R1 was at risk for falls due to requiring assistants with activities of daily living (ADL)'s and mobility, left sided weakness, and episodes of incontinence. Additionally, R1 had a history of self-transfers. R1's fall intervention included assist to toilet prior to bed (start 10/25/21). Bowel/bladder care plan dated 7/19/22, reflected R1's toileting program had changed from every 2-3 hours to toilet R1 upon demand. During an observation and interview on 12/27/22, at 12:59 p.m. R1 sat in her wheelchair in her room. R1 stated she needed two staff to assist her to the toilet. She was not on a toileting schedule but wished she was. R1 would put on her call light when she needed to go. R1 explained when she put her call light on to be taken to the bathroom, by the time two staff were available to take her, it would be too late; they never get here on time. R1 reported the day she fell she had put on her call light for help to use the bathroom; she waited and waited and waited. Somehow, she ended up on the floor but could not remember what she was doing that caused her to fall to floor. Her fall resulted in a broken hip. R1's progress note dated 12/14/22, at 9:40 a.m. identified R1 was found on the floor of her bathroom lying on her left side. R1 had put on her call light and waiting for staff to assist her with toileting. R1 had reported moderate hip and thigh pain in her left lower extremity (LLE) with movement along with pelvic pain. At 11:18 a.m. R1 was complaining of increased pain in LLE and pelvic area and requested to be sent to the emergency room . At 6:15 p.m. R1 was admitted to the hospital for left hip fracture. R1's fall care plan was revised on 12/14/22 with new intervention of antiroll brakes applied to wheelchair R1's resident occurrence management project ([NAME]), dated 12/15/22, identified R1 had an unwitnessed fall when she was found on the floor in her bathroom, had her call light for toileting assist and wheelchair brakes were not being utilized. Root cause indicated, resident safety awareness deficit, and the prevention intervention was to apply antiroll brakes to R1's wheelchair and Dycem to wheelchair. R1's care plan was revised on 12/15/22 to reflect the Dycem to wheelchair. The [NAME] did not identify if R1's toileting care plan was followed at the time of her fall. Even though R1's MDS dated [DATE] identified R1 had an increase in bowel and bladder incontinence, R1's record did not include a causal analysis or clinical evaluation of R1's increased incontinence. Further it was not evident R1's toileting plan was revised to improve bowel and bladder continence and mitigate R1's fall risk for self-transfers. During an interview on 12/27/22, at 1:59 p.m. licensed practical nurse (LPN)-A explained she was working on 12/14/22 when R1 had her fall that resulted in left hip fracture. Nursing assistant (NA)-A had reported to her R1 had been found on the floor in the bathroom. R1 had her call light on waiting for staff to assist her with toileting and was not aware of how long R1's call light had been on. LPN-A reviewed R1's fall documentation and indicated resident safety awareness deficit was not the appropriate root cause and documentation did not address toileting. During a phone interview on 12/27/22, at 4:00 p.m. nursing assistant (NA)-A explained she worked on 12/14/22 when R1 fell . She was the only aide scheduled to work on the unit that R1 resided on. At around 7:30 a.m. NA-A had changed R1's brief that was very wet, washed and dressed R1, however did not take her to the toilet. R1 then went down to breakfast. Sometime after breakfast R1 put on her call light to use the bathroom. Since R1 needed two staff assist, NA-A shut R1's call light off, left R1's room to find help with the transfer. After she left R1's room, she was side-tracked by a dietary staff member who told her she needed to assist a resident across the hall from R1. NA-A indicated after she was done assisting that resident, she noticed R1's call light on again. She went into R1's room and found R1 on the bathroom floor. We got R1 off the floor and transferred her to her bed. Once R1 was back in her bed, we tried to roll her on her side to check her brief to see if it was wet, but she was too sore. NA-A was not sure if R1 had been incontinent. R1 was sent to the emergency room because of the pain. During an interview on 12/28/22, at 12:40 p.m. director nursing (DON) indicated the facility had a video surveillance and had reviewed the footage from 12/14/22. DON reported R1 had put her call light on twice. The first time was at 8:50 a.m., NA-A answered the call light and turned it off and walked back out of the room. The second time R1 put her call light on was at 9:18 a.m. R1's call light remained on until she was found on the floor by NA-A at 9:40 a.m. DON reported R1 was not assisted to the bathroom twice per her request which resulted in R1 waiting over 50 minutes since she first requested to be assisted to the bathroom. DON further verified this fall resulted in a left fractured hip. DON stated the root cause of the fall was R1 was not toileted on demand per the care plan. DON stated R1 had a decline in bowel and bladder continence and was not able to articulate why R1's toileting care plan was changed from every 2-3-hour toileting to on demand toileting. Further, the interventions that had been put into place did not address toileting to prevent future falls. R3 R3's face sheet printed 12/28/22, identified R3 had diagnoses of benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. R3's significant change MDS dated , 9/9/22, identified R3 had severe cognitive impairment and required limited assist of one staff to assist with transfers and toileting, was occasionally incontinent of bladder and always continent of bowel. R3's fall Care Area Assessment (CAA) dated 9/12/22, identified R3 was at increased risk for falls related to impaired balance, weakness, decreased awareness, and history of falls. R3 has had one fall in the facility since admission. R3's quarterly MDS dated [DATE], identified R3 had moderate cognitive impairment and required extensive assist of one staff to assist with transfers and toileting, was frequently incontinent of bladder, always continent of bowel and had one fall with injury. R3's care plan dated 12/8/22, indicated R3 was at risk for falls related to assist with ADL's and mobility, prescribed medication use, weakness, history of falls and self-transfers. Interventions dated 8/11/22 included place call light and frequently used items within reach. 9/6/22, offer gripper socks daily, 9/14/22 urinal at bedside, and 9/15/22 grip strips in place by left side of bed and expanded on 12/20/22. R3's toileting program dated, 8/15/22, directed staff to toilet R3 upon demand. During an observation and interview on 12/28/22, at 2:24 p.m. R3 sat on the edge of his bed wearing a t-shirt, white brief, and purple grippy socks. R3's urinal was on the headboard of the bed and out of R3's reach. R3 stated he was aware of when he needed to go to the bathroom, and he needed staff to assist him. R3 explained he used his call light when he needed to go but sometimes it took a long time, so then he would take himself because he didn't want to go in his pants. There has been a lot of times he has fallen trying to get himself to the bathroom. R3's progress report dated, 9/14/22, at 2:09 a.m. R3 initiated call light, staff went to his room, sitting on the floor leaning up against his recliner. R3 stated he was trying to go to the bathroom but when he stood up, he felt dizzy and slipped. R3 sustained skin tear on his left lower arm from his watch. Reminded R3 to wait for staff to assist him to the toilet due to high risk of fall. Given urinal by the bedside. Corresponding Event Report dated 9/26/22, identified additional intervention of grip strips placed on the floor next to bed. R3's [NAME] form dated 10/3/22, identified the aforementioned fall documentation. Root cause was altered gait/balance and resident safety awareness deficit. New intervention: R3 was reminded to wait for staff to assist him to the toilet due to high risk of fall, grip strips placed next to bed and given urinal by the bedside. R3's progress report dated 12/20/22, at 11:41 a.m. R3 was found on right side, almost on stomach with head under the foot of the bed. No injury noted. Staff had seen resident approx. 20 min prior to discovery of fall. Staff had assisted to bathroom, back to recliner, and given blanket at that time. R3 stated he was trying to, go to the bathroom. The report did not specify if staff had toileted R3 while in the bathroom. R3 sustained 1 cm (centimeter) skin tear to right forehead above eye noted. Immediate intervention was to expand grippy strips on the floor. R3's [NAME] form dated 12/26/22, identified the aforementioned fall documentation. R3 was interviewed and stated he was attempting to self-transfer to the bathroom. Root cause was altered gait/balance and resident safety awareness deficit. Intervention was to extend grip strips on floor to area where fall occurred. Although fall documentation on 9/14/22 and on 12/20/22 indicated R3 was attempting to go to the bathroom at the the time of the fall, the assessments did not indicate or address if R3's toileting care plan had been followed. Further it was not evident an analysis/evaluation of R3's toileting program was appropriate for R3. During an interview on 12/28/22, at 11:42 a.m. LPN-B reviewed R3's fall records. LPN-B indicated on 9/14/22, R3 did not have gripper socks on per the care plan. However, it was not determined if they had been on and R3 had taken them off. Because he fell trying to get to the bathroom, the intervention was to put a urinal at bedside. The fall documentation on 12/20/22 did not identify if R3 was continent at the time of the fall and if R3's urinal had been within reach. LPN-B reported there was not enough information to determine root cause or if the care plan had been followed at the time of the fall; it cannot be ascertained if the new fall prevention interventions were appropriate to prevent recurrent falls. During an interview on 12/28/22, at 12:09 p.m. director of nursing (DON) explained the facilities fall program which included: the nurse would assess the resident, complete required notifications, write a progress note. Then the unit manager completed the Event form, the interdisciplinary team (IDT) then fills out the [NAME] form. The [NAME] form includes the IDT's root cause analysis and prevention interventions. They have monthly fall meetings with the unit managers, pharmacist, and the medical director. The DON reviewed R3's fall record, and verified there was not enough information to determine if R3's care plan was followed. The root causes in R3's [NAME] forms were generalized and the root cause for both of R3's falls should have been toileting. DON confirmed R3's toileting plan of, on demand was not re-evaluated or determined to be appropriate for R3 after his falls. Facility policy titled, Integrated Fall Management, dated 8/24/17, indicated a purpose: Fall risk assessment, identification, and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Policy: Residents are assessed for their risk of falls upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the residents condition, provides care for, safety and comfort . Procedure: 3. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment. 4. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist.

Based on observation, interview, and document review the facility failed to follow the care plan, failed to complete comprehensive fall assessments for causal factors/root cause and identify care plans were not followed for 2 of 3 residents (R8, R5). The facility's failures resulted in actual harm to R8 when the first fall resulted in head lacerations that required treatment in the emergency room . In addition, the facility failed to ensure a comprehensive fall assessment was completed to ensure safe transfer for R5 following a fall. Findings include: R8's face sheet identified R8 had diagnoses of chronic [CONDITION(S)], [CONDITION(S)] in multiple sites, displaced interochanteric fracture of the left femur and presence of left artificial shoulder joint. R8's discharge, minimum data set (MDS) assessment, dated 5/23/22, identified that R8 was cognitive and had 1 fall with an injury. R8's significant change, MDS assessment, dated 6/2/22, indicated R8's cognition was intact. The MDS identified R8 did not walk, required extensive assist of two staff with bed mobility and was totally dependent on two staff with transfers. R8 had a functional limitation in range of motion in both of his upper extremities and used a wheelchair for mobility. R8's pain management identified that R8 had been on a scheduled pain medication, received PRN (as needed) medications and non-medication interventions for pain, his pain was occasional and moderate and made it hard to sleep at night. Further identified that R8 had a fall in the last month prior to admit. R8's care plan dated 8/9/21, identified R8 was at risk for falls related to impaired mobility and history of falls; intervention included call light within reach at all times. R8's also identified R8 had a problem with pain due to left shoulder replacement, history of left femur fracture, and impaired mobility; interventions included when R8 expresses pain to offer repositioning, rest. Cold therapy and prn analgesics and to monitor pain every shift. Additionally, R8 required 1-2 staff for assist with bed mobility and assist of 2 with mechanical stand for transfers and did not walk. Review of R8's record identified R8 had falls on 5/15/22 and 6/27/22. During an interview on 7/7/22 at 8:04 a.m. family member (FM)-A stated R8 had told them the night he fell on [DATE], he had put on his call light at 3:00 a.m. to get out of bed because his back was hurting. The nursing assistant told him she would be back in a while as they did not have time to get him out of bed. FM-A stated since no one would help him he tried to get himself out of bed and fell to the floor. FM-A stated R8 had to be transferred to the hospital for lacerations. FM-A indicated facility staff were slow at responding to the call lights during the night. During an interview on 7/7/22 at 8:20 a.m. R8 stated he has had back pain for a long time, even before coming to the facility. R8 explained when he was at home he would have back pain during the night; R8 stated he would get out of bed and move around a little bit and go to his recliner. R8 stated he remembered the fall on 5/15/22, stated he had put on his call light around 3:00 a.m. and wanted to get out of bed because his back was hurting. R8 stated a white female responded and told him she was too busy to get him up, would have to wait, and would go tell the nurse his back was hurting. R8 stated he got the Tylenol, did not recall the time, but continued to have back pain. R8 then stated he tried to get out of bed himself because of the pain and fell on to the floor. R8 indicated he does not recall someone sitting him up on the side of the bed. R8 stated since the fall he has had some right shoulder pain as well. R8 indicated he had fallen a second time, didn't remember all the details, but remembered he wanted to sit up because his back was hurting and he had put his call light on. R8's call light log reviewed for 5/15/22, and indicated he had turned his call light on at the following times: -2:46 a.m. and took staff 19 minutes and 57 seconds to respond and were in his room for 15 seconds. -4:28 a.m. and took staff 6 minutes and 7 seconds to respond and were in his room for 9 minutes and 46 seconds. R8's progress note dated 5/15/22, indicated that R8 had complained of lower back ache at 3:40 a.m. and requested some Tylenol, which was somewhat effective. R8's record lacked evidence non-pharmacological interventions were attempted or offered in accordance with the care plan and did not identify what pain control measures were taken after it was identified the Tylenol was somewhat effective. R8's Event Report dated, 5/15/22, at 5:15 a.m. indicated R8 had an unwitnessed fall from his bed (did not identify what time the fall occurred), was observed lying on his right side with his right arm tucked underneath him and a pool of blood under his head. When asked what happened R8 stated that he was sitting on the edge of the bed and had tried to reach for his TV remote so he could then lay back down because his back still hurt, then suddenly he slipped out onto the floor hitting his head on the tray table. R8 had complained of lower back pain from earlier in the night. R8 received two lacerations on his forehead above his right eye and steri strips were applied. R8 complained of being nauseous. When blood was being scrubbed out of his hair R8 vomited clear fluids, MD was notified and R8 was sent to the ED for a CT scan for possible increasing ICP (intracranial pressure). Immediate intervention was to offer to get up at 4:00 a.m. if not already awake. R8's ED Provider Notes, dated 5/15/22, at 6:29 a.m., indicated R8 had a diagnosis of chronic lumbar spinal stenosis and [CONDITION(S)] and was being assessed from a fall where R8 stated he was sitting on the side of the bed because of his chronic low back pain where he was leaning on one of the tables and fell hitting the right side of his head on the table. R8 sustained some abrasions and lacerations to the right frontal area, has complaints of neck pain, right shoulder pain and tingling from his elbows to his fingers bilaterally. Noted to have 2 right frontal lacerations that are 3 cm in length with surrounding abrasions and bruising. R8 had labs completed, CT of cervical spine and head without IV contrast and received laceration repaired with Dermabond (surgical skin glue). R8's record lacked a comprehensive fall assessment; the post fall assessment dated [DATE] identified the intervention was to offer to get R8 up at 4:00 a.m. if not already awake even though R8's care plan directed staff to reposition R8 if he were having pain. R8's Event Report, dated 6/27/22, at 4:08 a.m. indicated R8 had an unwitnessed fall from bed and was found on his buttocks next to bed (did not identify what time the fall occurred). R8 stated his call light had fallen to the floor and when he kicked his legs over the side of the bed to get into a sitting position, his pressure reducing boots he was wearing slid him to the floor. Immediate intervention that was placed was to knot the call light to the side rail of bed to prevent it from falling on the floor. R8's call light log reviewed for 6/27/22 and indicated he had turned his call light on at the following times: -12:35 a.m. and took staff 3 minutes and 34 seconds to respond and did not identify any time spent in his room. -3:15 a.m. and took staff 10 minutes and 39 seconds to respond and identified staff spent 25 minutes and 42 seconds in his room. R8's record lacked a comprehensive fall assessment. During an observation on 7/7/22 at 8:02 a.m. R8 sat in his recliner. R8's bed did not have a side rail and the clip to the call light was broken. FM-A stated R8's side rail was removed from his bed 4 days ago, the facility told us the state would not allow side rails because it was against regulation. R8 stated he used the side rail for re-positioning. At 8:21 a.m. maintenance staff entered the room and put on new bed rail. During an interview on 7/7/22, at 8:04 a.m. licensed practical nurse (LPN)-A indicated she had been R8's nurse the night of 5/15/22. LPN-A was not able to articulate R8's back pain history and stated R8 only had shoulder pain. LPN-A indicated she administered Tylenol at 3:40 a.m., had not attempted non-pharmacological interventions which included repositioning, and at 4:15 a.m. she had went to re-evaluate the effectiveness of the Tylenol. LPN-A stated medication was somewhat effective, so she had instructed the NA's to get R8 out of bed. LPN-A first indicated R8 had been reaching for the remote and slipped on the floor, however then stated R8 had reported to her that he had requested to get out of bed and the NA's had not gotten him up. LPN-A indicated as part of the fall investigation she had not tried to determine how R8 sat up on the side of the bed independently, had not reviewed the call light log, and had not interviewed NA's to ascertain additional causal factors. LPN-A indicated she had revised the care plan without completing a comprehensive fall assessment and the intervention of offering him to get up at 4:00 a.m. came from had the NA's gotten R8 out of bed when he requested the fall would not have occurred. LPN-A stated on 6/27/22 she had also been R8's nurse, R8 had put on his call and when we responded to the call light around 4:00 a.m. he had been on the floor. When asked what R8 had put his call light on for, LPN-A stated an unawareness. LPN-A indicated the root cause was that the call light had fallen on the floor but did not know how the call light got there or if the call light had been secured and within reach prior to the fall. LPN-A indicated she had not interviewed staff for additional causal factors to ensure appropriate interventions in place to mitigate further risk. During an interview on 7/7/22 at 8:41 a.m. NA-H stated a familiarity with R8. NA-H indicated during the night R8 had pain in his left shoulder, back, right hand/wrist. NA-H indicated warm/cold packs and repositioning were R8's interventions to relieve pain. NA-H stated R8 was an early riser, he was always up at 3:00 a.m., and always wanted to get out of bed because of back pain; that had been his routine since admission last year. NA-H stated he knew he wouldn't have tried to get out of bed himself but thought he had enough upper body strength to pull himself up onto the edge of the bed. During an interview on 7/7/22, at 1:00 p.m. NA-G stated R8 could independently make small position changes in bed however required physical assist of two staff to sit on the edge of the bed. NA-G stated there is no possible way R8 could independently get to a sitting position, someone would have to assist him. NA-G stated she had worked overnight shift on 5/15/22, R8 had put on his call light around 3:00 a.m. and only wanted Tylenol, so she went and told LPN-A. NA-G indicated at about 3:45 right after the Tylenol was given, R8 requested to get out of bed however wanted to give Tylenol time to work. NA-G stated she had not gone back in the room until when she had found him on the floor. NA-G indicated an unawareness of how R8 would have been sitting on the side of the bed according to the fall report and was not aware if another staff member had assisted him. NA-A stated R8 typically got out of bed around 4:00 a.m. and that was his norm., NA-G also indicated R8 typically had back pain at night, but it was usually around 4:00-4:30 not 3:00 a.m. R5 R5's admission Minimum Data Set (MDS), dated [DATE], indicated R5 had moderate cognitive impairment and had diagnoses that included cerebral infarction with [CONDITION(S)] and [CONDITION(S)], ataxia (loss of coordination of voluntary muscle movements) Alzheimer's disease, stress incontinence. R5 required extensive one assist from staff for dressing and personal hygiene and extensive two assist for bed mobility, transfer, and toilet use. The MDS indicated R5 did not reject/refuse care or other behaviors. R5's admission fall risk assessment dated [DATE], identified R5 was a fall risk, had a history of falls, had functional range of motion limitation of one upper extremity and one lower extremity of the left side related to stroke, and was steady during transfers. R5's care plan dated 4/29/22, identified R5 was not able to walk and directed R5 was a pivot transfer with assist of two staff in the morning except to recliner, which was assist of two with mechanical lift, and in the evening R5 was a assist of two with mechanical lift. The care plan did not identify what type of mechanical lift nor a sling/harness size. R5's care plan also identified R5 was at risk for falls related to cognitive deficit, impaired mobility, and use of [CONDITION(S)] medications. The fall care plan dated 4/29/22 included the intervention of ensure call light is within reach. R5's fall incident report dated 6/27/22, at 9:29 a.m. indicated R5 was lowered to the floor in her bathroom after her knees gave out while transferring to the toilet. R5 did not sustain injuries. Immediate intervention was R5 downgraded from pivot transfer with two staff to mechanical stand with two assist. R5's corresponding progress note indicated the fall occurred at 9:25 a.m. when two staff pivot transferred R5 off the toilet. R5's record identified R5 had an assisted fall to the floor on 6/27/22 at 9:29 a.m. Interview with facility staff and review the facility's video surveillance did not correlate with the information documented in R5's progress note related to the fall. Video surveillance was watched with facility social worker; video identified only one NA was in the room when R5 had the fall, the NA left the room and shortly thereafter came back to R5's room with another NA. During an interview on 7/7/22, at 10:18 a.m. LPN-A stated she was R5's nurse and completed the incident report. LPN-A stated she had not interviewed the staff involved and assumed two staff were present at the time because when she got to R5's room, there were two aides in the room. LPN-A was not aware NA-B had not followed R5's care plan and transferred R5 by herself. LPN-A stated after the incident she had downgraded R5 to a mechanical standing lift without completing a comprehensive lift assessment prior to changing the care plan and could not articulate what a safe lift assessment consisted of. LPN-A stated she had not consulted with physical or occupation therapy and was not aware that therapy had deemed the standing lift unsafe for R5 to use because of R5's muscle weakness. During an interview on 7/7/22 at 12:30 p.m. NA-C stated she had worked on 6/27/22, NA-C stated NA-B came to get her from the unit she was working on after she had transferred R5 to the toilet by herself. NA-C stated R5 was supposed to use two assist to pivot transfer because her knees get a little wobbly and can't tolerate standing a long time. NA-C indicated R5 was not safe to transfer with one. During an interview on 7/7/22, at 11:25 a.m. occupational therapist (OT) stated she had not been aware R5 had to be lowered to the floor and was not aware nursing had changed R5 to a mechanical standing lift. OT stated nursing should have downgraded R5 to a full body lift because R5 could not tolerate the standing lift related to her ataxia. OT indicated therapy had already determined a standing lift would not have been appropriate for her to use. R5's record identified R5 had another fall on 7/4/22, indicated R5's fall was related to toileting. R5's record lacked a comprehensive fall assessment that identified causal factors/root cause and did not include an evaluation of the effectiveness or appropriateness of R5's toileting program. The fall records indicated R5 had an unwitnessed fall without injury on 7/4/22 at 7:30 p.m. when she had attempted to use her bathroom. R5's progress note dated 7/4/22, included Resident had attempted to get up out of her wheelchair to use the toilet. Resident's legs could not hold her up and she sat down on the floor. Immediate intervention was to offer R5 toileting immediately after husband leaves room and then assist resident into bed. R5's bladder/bowel care plan dated 4/29/22 (prior to the fall) identified R5's toileting program was every two to three hours and as needed. Although the R5's record included a bowel/bladder assessment, the assessment was not comprehensive; the assessment did not identify what type of bladder incontinence R5 had or evaluation of R5's toileting routines. During an observation and interview on 7/6/22, at 7:34 a.m. NA-A and NA-B observed performing toileting cares and assisting resident up to wheelchair prior to breakfast. R5 observed heavily incontinent of urine which had soaked through her brief and linens and onto mattress down to her knees. NA-B offered R5 to use bedpan. R5 stated, I'd rather use the toilet. NA-B stated R5 was unable to use the toilet due to a physical therapy recommendation and wanted her to get stronger before using a toilet. R5 voided a large amount of urine in bedpan. A mechanical full body lift was used to transfer R5 from bed to wheelchair. When interviewed on 7/6/22, at 10:28 a.m. R5 stated she would rather use the bathroom toilet; however, staff have told me I am unable to use the toilet as they fear I will fall. During an interview on 7/7/22, at 10:18 a.m. LPN-A reviewed R5's record and indicated she had not interviewed nursing staff after the fall and was not aware if R5's toileting plan had been followed. LPN-A further indicated the intervention of toileting R5 after her husband left was implemented without a full investigation and stated a comprehensive bowel/bladder assessment was not completed after the fall. LPN-A stated she would have expected NA's to follow the toileting care plan. On 7/7/22, at 3:09 p.m. director of nursing (DON), social worker (LSW), and regional nurse executive director (RNED) were interviewed. DON stated the expectation the nurse would complete the fall assessment, determine probable root cause, and implement immediate interventions. DON indicated then the interdisciplinary team reviews the fall and determines if the intervention was appropriate and implement additional interventions if necessary. DON stated she expected the nurse(s) to have a fall huddle after the fall to collect information, review the resident record in order to collect pertinent information and that information documented. RNED indicated the facility currently was not using safe mechanical lift transfer assessments and would get those implemented immediately. Facility policy Integrated Fall Management dated 5/6/2021 included Residents are assessed for their risk of falls upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the residents condition, provides care for, safety and comfort. Post fall Procedure included the following: 7. When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment. 8. The medical provider is notified of the fall and resident condition. Orders, if given, are implemented. 9. The resident's representative (as applicable) is notified of the fall and the resident's condition. 10. The DON and Administrator or their designees are notified of the fall. 11. The environment of the fall is evaluated for possible contributing factors and addressed. 12. The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions. 13. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. 14. Documentation of the above items is completed.