Every finding on record at St. Francisville Nursing and Rehab, LLC

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by Resident #1 for 1 (#3) of 3 residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. This deficient practice resulted in an actual harm for Resident #3 on 07/01/2026 when Resident #1 hit Resident #3 causing him to fall to the ground. Resident #3 was sent to a local hospital and a Computed Tomography (CT) Scan revealed a mildly displaced fracture of the intertrochanteric left hip and acute traumatic non-displaced fracture of the right seventh, eighth, and ninth ribs. Resident #3 required emergent surgical intervention on 07/01/2026. Prior to the incident with Resident #1 on 07/01/2026 Resident #3 had been independently ambulatory and able to perform (ADL's) with verbal cues from staff. After the incident on 07/01/2026 Resident #3 required a wheelchair for mobility, moderate assistance from staff with ADL's, and maximum assistance from staff with transfers.Review of the facility's policy titled, Preventing Abuse, Neglect, and Exploitation last revised 09/2022 revealed the following, in part: Abuse is the willful infliction of injury.with resulting physical harm, pain, or mental anguish. Types of resident abuse: Physical abuse: Physical abuse includes any kind of intentional and aggressive physical contact such as hitting, slapping, punching. Resident to resident abuse: It is the facility's responsibility to maintain a safe environment for all residents. This can mean that residents with behaviors that provoke reactions in other residents and residents with a history of altercations with other residents are treated and supervised appropriately. Resident #3 Review of Resident #3's Clinical Record revealed an admission date of 05/13/2026 and had diagnoses of Alzheimer's and Dementia. Review of Resident #3's admission MDS with an ARD of 05/26/2026 revealed a BIMS of 3, which indicated he was severely cognitively impaired. Review of Resident #3's Nurses' Notes dated 07/01/2026 revealed the following, in part: On 07/01/2026 at 7:51 a.m., Resident #3 involved in an incident with Resident #1, resulting in a fall. Physical assessment completed at this time. Resident #3 unable to perform active range of motion to left lower extremity. Complained of pain to left hip. Nurse Practitioner gave order to send resident to acute care hospital for medical evaluation. Resident #3 transferred out via ambulance. Review of Resident #3's Acute Care Hospital Record dated 07/01/2026 – 07/03/2026 revealed the following, in part. X-ray of Left hip. Findings: acute traumatic comminuted proximal, intertrochanteric left femur fracture. - CT of Left Lower Extremity. Findings: acute comminuted mildly displaced fracture of the intertrochanteric left hip. - CT Chest without contrast. Findings: acute traumatic nondisplaced fracture of the right seventh, eighth and ninth ribs, located in the midaxillary line. These are singular fractures at each rib. No pneumothorax. -Left Hip Cephalomedullary Nail by Orthopedic Surgeon on 07/01/2026. Resident #1 Review of Resident #1's Clinical Record revealed an admission date of 03/24/2020 and diagnoses, which included Personal History of Traumatic Brain Injury, Paranoid Schizophrenia, Other Specified Depressive Episodes, Major Depressive Disorder-Recurrent-Severe with Psychotic Symptoms, Intermittent Explosive Disorder, and Anxiety Disorder. Further review revealed Resident #1 was transferred to a local behavioral hospital on [DATE] and did not return to the facility. Review of Resident #1's Quarterly MDS with an ARD of 07/01/2026 revealed he had BIMS of 15, which indicated intact cognition. Further review revealed he had physical and verbal behavior toward others. Review of Resident #1's Care Plan revealed the following, in part: Problem: Behavior: Socially inappropriate/disruptive behavior. Does not like loud sounds and has physically abusive behavior. History of verbal aggression toward other residents. Interventions: 07/01/2026 Resident with behaviors. He was immediately put on 1:1 observation. Resident was sent to a local hospital with a Physician's Emergency Certificate. Review of Resident #1's Nurses Notes dated 02/26/2026 through 07/01/2026 revealed Resident #1 exhibited aggressive behaviors toward other residents on 02/26/2026 and 04/17/2026. Further review revealed the following: On 05/17/2026 at 10:22 a.m. by S5LPN: Resident #1 was observed in wheelchair coming up to the nurses' station by CNA to ask for a snack. Resident #3 started screaming at Resident #1. Resident #1 stood up from his wheelchair and grabbed Resident #3's shirt. Staff immediately intervened and reoriented Resident #1 to his room. On 07/01/2026 at 8:34 a.m. by S5LPN: Resident #1 had a physical altercation with Resident #3 during breakfast. Resident #1 got out of his wheelchair after exchanging words with Resident #3. Resident #1 proceeded to slap Resident #3 twice and proceeded to try to harm Resident #3 once on the ground. This nurse broke up the altercation. Resident #1 was immediately put on 1:1 observation. Resident #1 to be PEC'd to behavioral hospital. Review of Resident #1's Physician Progress Note by S3NP dated 07/01/2026 revealed the following, in part: Today, Resident #1 physically struck another resident and attempted to hit another resident. He showed no remorse and stated he would do it again. Patient placed under PEC and sent to local Emergency Room. An interview was conducted with S5LPN on 07/28/2026 at 8:05 a.m. She stated Resident #1 had a history of verbally yelling out if another male resident yelled. She stated, on 07/01/2026, her medication cart was parked immediately outside of the dining room so she could see the dining area. She stated Resident #3 wandered into the dining room and screamed he wanted to go home. She stated she heard Resident #1 say shut up and Resident #3 replied come make me. She stated she immediately ran into the dining room. She stated before she made it to Resident #1, he ran across the dining room and hit Resident #3 twice in the face. She stated Resident #3 backed away from Resident #1 and fell. She stated Resident #1 tried to continue to hit Resident #3 while he was on the ground. She stated she physically removed Resident #1 from Resident #3 because verbal redirection was not successful. She stated Resident #1 was immediately escorted to his room. She stated once Resident #3 was put into bed, he complained of pain and was unable to straighten his left leg. She stated Resident #3 was transferred to a local hospital for imaging. She stated once Resident #1 was escorted to his room, a CNA was assigned to 1:1 and never left him until he was transported to the hospital via ambulance. She stated S3NP PEC'd Resident #1. She stated the Sheriff's Office was also notified and responded to the facility prior to Resident #1 being transferred to the hospital. She confirmed Resident #1 physically abused Resident #3 on 07/01/2026. She stated abuse training was provided after the incident. She stated the facility provided training on handling residents with behaviors, including removing them from any triggering situation, escalating situation, and monitoring them for any escalating behaviors. She stated there had been increased staff presence in the dining area for all meals. She stated 2 CNAs from each hall, the nurse, and a department head during the week were assigned to the dining room during meal times. She stated there were also two CNAs from each hall, the nurse, and the RN supervisor present in the dining room on the weekends. An interview was conducted with S3NP on 07/28/2026 at 10:55 a.m. She stated she received a phone call regarding the incident with Resident #1 hitting Resident #3 on 07/01/2026. She stated Resident #3 was immediately sent to the hospital for imaging. She stated Resident #1 was immediately placed on 1:1 observation. She stated when she arrived, she saw Resident #1, and Resident #1 reported he hit Resident #3 and would do it again so she PEC'd him. She confirmed Resident #3 sustained a left hip fracture which required surgical intervention and several ribs fractures from the incident. She confirmed Resident #1 physically abused Resident #3 on 07/01/2026. She stated, in response to the incident, the administrative staff had shifts of dining room duty. She stated there have been more staff present in the dining room since the incident on 07/01/2026. An interview was conducted with S2DON on 07/28/2026 at 11:21 a.m. S2DON stated Resident #1 has a history of behaviors. S2DON stated the staff were repeatedly trained on redirection and managing behaviors. S2DON stated, on 07/01/2026, she was entering the facility when she heard commotion in the dining room. S2DON stated once she arrived in the dining room, Resident #3 was on the floor with the nurse and staff caring for him. S2DON stated she immediately instructed a staff member to escort Resident #1 to his room and provide 1:1 observation. She stated Resident #1 remained on 1:1 observation until he exited the facility with ambulance personnel. S2DON stated she went to Resident #1's room, and Resident #1 reported he hurt Resident #3 and would do it again. S2DON stated Resident #1 had no remorse and was saying he would do it again with a smile on his face. S2DON stated, based on video footage and Resident #1's interview, prior to the physical contact Resident #3 was waving his arms and saying no, Resident #1 called him a p**** and stated you made me walk all the way over here, you're going to get it. She stated Resident #1 then hit Resident #3 in the face. S2DON stated Resident #1 was PEC'd, sent to a local hospital, and was admitted to a behavioral health unit. S2DON stated Resident #3 sustained a hip, femur, and rib fractures. S2DON confirmed, since the incident on 07/01/2026, she had been monitoring the dining room during meal service per the new department head schedule. An interview was conducted with S1ADM on 07/28/2026 at 11:21 a.m. S1ADM stated, based on the video footage, it was difficult to determine if Resident #3 fell from Resident #1's hit or if he was backing away from Resident #1 and fell. S1ADM confirmed Resident #3 made gestures to Resident #1 that he did not want to fight. S1ADM stated Resident #1 reported Resident #3 verbally told him he did not want to fight. An interview was conducted with S1ADM on 07/28/2026 at 12:37 p.m. She stated the facility immediately put protections in place after the incident with Resident #1 on 07/01/2026. She stated Resident #1 was removed from the facility for a psychiatric stay, and ultimately, due to his behaviors at the psychiatric hospital, was involuntarily discharged from the facility. She stated all staff had been re-educated on abuse, redirection, and how to approach residents when they become aggressive. She stated monitoring was increased in the dining room for all meals and for large group activities. She stated monitoring was in place to identify if any residents were having any outbursts or behaviors. She stated the facility changed the dining schedule so that instead of residents going by hallway, it was first come first served. She stated there was a department head assigned to the dining room for each meal during the week. She stated on the weekends, the RN supervisor monitored the meal service. She stated one CNA remained on the hall to pass trays and all other CNAs responded to the dining room for the meal service. She stated she monitored the dining room to ensure the staff were where they were supposed to be for that given meal. Review of the facility's in-service records revealed all staff had been re-educated on abuse, redirection, and how to approach residents when they are becoming aggressive. Review of the facility's meal service assignment schedule revealed a department head was assigned to observe each meal in the facility. The facility had implemented the following actions to correct the deficient practice: Corrective action accomplished for Resident #1, resident was removed from the dining room and placed one on one with staff until the ambulance arrived to transport to the hospital on a PEC for his aggressive behaviors. All residents have the potential to be affected by the residents' aggressive behaviors. All staff have been educated on abuse, redirection and how to approach residents when they are becoming aggressive. Continuing corrective action is to increase monitoring in the dining room and at large group activities. In order to monitor theses corrective actions, the facility has changed the dining schedule. Instead of the residents eating by hall, the residents will eat first come first serve. A department head will be assigned to monitor a specific meal on a specific day of the week. The department head will be monitoring for any outbursts or aggressive behaviors. Also, there will be one aide on each hall to pass the hall trays and the others will be in the dining room directing the residents to the table and passing out trays. The administrator/designee will monitor the dining room to ensure the staff are where they should be every day for 1 week, then 5 times a week for 2 weeks, the 3 times a week for 2 weeks, then once a week for 2 weeks. Then randomly thereafter. Completion date: 07/13/2026. Throughout the survey from 07/27/2026 to 07/29/2026, observations, interviews, and record reviews revealed the above listed actions were implemented. Observations were made of the facility's bingo activity in the main dining room on 07/27/2026 at 10:00 a.m. and the meal services on 07/27/2026 at 11:18 a.m., 07/28/2026 at 7:24 a.m., and 07/29/2026 at 7:20 a.m. with multiple CNAs, one nurse, and one administrative personnel present. Staff interviews revealed staff received training on the facility's abuse policy and procedure, redirection, and how to approach residents when they are becoming aggressive. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

Based on interviews and record review, the facility failed to ensure a resident's involuntary discharge notice met the requirement for discharge for 1 (#1) of 3 residents reviewed for transfer and/or discharge by failing to ensure the notice:Was made as soon as practicable before discharge; and Contained the mailing address, email address, and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.Findings: Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Personal History of Traumatic Brain Injury, Paranoid Schizophrenia, Other Specified Depressive Episodes, Major Depressive Disorder-Recurrent-Severe with Psychotic Symptoms, Intermittent Explosive Disorder, and Anxiety Disorder. Further review revealed Resident #1 was discharged from the facility on 07/20/2026. Review of Resident #1's Quarterly MDS with an ARD of 07/01/2026 revealed he had a BIMS of 15, which indicated intact cognition. Further review of the MDS revealed he had physical and verbal behavior toward others. Review of Resident #1's Discharge summary dated [DATE] revealed the following:Hospital Course:Diagnoses and all orders for this visit:History of Traumatic Brain Injury (Primary)Overview: He has remained in a room by himself at the facility. Unfortunately, due to his TBI he continues to have outbursts and behaviors that put others at risk. On 07/01/2026, he had an unprovoked altercation with another resident and showed no remorse. He was admitted to BHU at a local hospital under PEC. Resident is unable to return to the nursing facility due to ongoing aggressive behavior in which he needs a higher level of care to meet his needs. The safety of individuals in the facility is in danger due to the behavior status of Resident #1.Schizophrenia, Unspecified TypeOverview: . He has a history of impulsive and aggressive behaviors. On 07/01/2026, he physically struck another resident and attempted to hit another resident. He showed no remorse and stated he would do it again. Patient was placed under PEC and sent to a local hospital. He is being discharged from [Facility]. Review of the facility's Emergency Transfer Log dated July 2026 revealed Resident #1 was emergently transferred to a local hospital on [DATE] for behaviors and was emergently discharged from the facility while in the hospital. Review of the facility's Notification of Involuntary Discharge for Resident #1 dated 07/17/2026 revealed the following:Re: IMMEDIATE Involuntary Discharge pursuant to S483.15(c)(1)(i)(C) and (D), pursuant to S483.15(c)(4)(ii). Specific to S483.15(c)(1)(i)(C)-(D): The health and safety of individuals, particularly other residents in the facility, is endangered due to the clinical or behavioral status of the resident.Dear Resident #1, The [Facility] issues to you, Resident #1, this written notice of involuntary discharge pursuant to S483.15(c)(1)(i)(A), (C), and (D) and S483.15(c)(4)(ii). (i) Your immediate discharge is warranted pursuant to S483.15(c)(1)(i)(A),(C), and (D) and S483.15(c)(4)(ii) because your actions, behaviors, and misconduct endangered and continues to endanger both the health and safety of individuals in the Facility. (ii) In accordance with 42 C.F.R. S483.15(c)(4)(ii), the effective date of your discharge is immediate; thus, your discharge is effective 07/01/2026, the date of your actual immediate transfer, notice being provided on the date above.Further review revealed the discharge notice did not contain the mailing, email address, and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. Review of Resident #1's BHSF-142 revealed the following:Approved for admission by Level II authority effective 12/29/2015.OBH-PASRR Level II Evaluation Summary & Determination Notice:The individual has a serious mental illness. Review of documentation for receipt of the above discharge notice letter revealed the following parties received the notification letter on the following dates:Resident #1 - 07/20/2026;Resident #1's RP - 07/24/2026;Ombudsman's office - 07/28/2026; andAdministrative Law Judge - 07/25/2026. A telephone interview was conducted with Resident #1's RP, on 07/27/2026 at 4:27 p.m. She stated she received Resident #1's involuntary discharge notice via email from the facility on 07/24/2026, which was after the date of discharge. An interview was conducted with S3NP on 07/28/2026 at 10:55 a.m. She stated she officially discharged Resident #1 on 07/20/2026 due to him needing a higher level of care and his behavior status being a danger to other residents in this facility. An interview was conducted with S1ADM on 07/28/2026 at 3:00 p.m. She confirmed Resident #1's involuntary discharge notice reflected a discharge date of 07/01/2026. She stated Resident #1 was discharged from the facility on 07/20/2026. She confirmed Resident #1's involuntary discharge notice was received by Resident #1 on 07/20/2026 via hand delivery, Resident #1's RP on 07/24/2026 via email, Administrative Law Judge on 07/25/2026 via certified mail, and the Ombudsman's Office on 07/28/2026 via certified mail. She confirmed the mailing address, email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act was not listed on the discharge notice. An interview was conducted with S1ADM on 07/29/2026 at 12:35 p.m. She confirmed Resident #1's involuntary discharge notice was issued to the required parties after the date of discharge listed in the notice.

Based on observation, interviews, and record review, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive care plan by failing to adequately assess and intervene when a resident experienced pain after a fall for 1 (#100) of 3 residents reviewed for falls. This deficient practice resulted in an actual harm for Resident #100, a cognitively intact resident, beginning on 05/15/2026 when Resident #100 continued to complain of left hip pain after a fall, required increased staff assistance with ADLs, and did not ambulate as normal. An interview with Resident #100 on 05/18/2026 revealed, after her fall on 05/15/2026, she remained in bed and required perineal care after urinary and bowel elimination due to new left hip pain. Staff interviews revealed Resident #100 began requiring staff assistance with ADLs, complained of pain during ADL care, and did not transfer out of bed after her fall on 05/15/2026. Nursing staff failed to notify Resident #100's NP/MD and/or on-call NP of Resident #100's increased pain. Nursing staff also failed to administer pain medications as ordered to alleviate pain. On the morning of 05/18/2026, S10NP was notified of Resident #100's pain, and Resident #100 was transferred to a local hospital. Resident #100's Computed Tomography (CT) scan at the local hospital revealed a Mildly Impacted Left Femoral Neck Fracture and Traumatic Non-displaced Fractures of the Left Superior and Inferior Pubic Rami, which required surgical intervention on 05/19/2026.Findings: Review of the facility's policy, revised June 2023, titled, Pain - Clinical Protocol revealed the following, in part:Assessment and Recognition: 2. The nursing staff will assess each individual for pain.whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example.ambulation or repositioning.Monitoring:1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain.a. For example, review frequency and intensity of pain, ability to perform ADLs.3. The staff will discuss significant changes in levels of comfort with the attending physician who will consider adjusting interventions accordingly. Review of the facility's Standing Physician Orders, revised 01/10/2020, revealed the following, in part:Common symptoms/complaints:9. Paina. Tylenol 650 mg by mouth every four hours as needed. Review of Resident #100's Clinical Record revealed an admission date of 01/25/2026 and diagnoses, which included Other Frontotemporal Neurocognitive Disorder and Polyneuropathy. Review of Resident #100's Quarterly MDS with an ARD of 04/08/2026 revealed a BIMS of 15, which indicated intact cognition. Further review revealed Resident #100 was independent with toileting hygiene, transfers, and ambulation. Review of Resident #100's current Care Plan revealed the following, in part:Problem: Resident has chronic pain related to lower back and bilateral knees.Interventions (initiated 01/06/2026): Administer pain medication per order; Determine resident's satisfactory pain level; Evaluate effectiveness of pain-relieving interventions (non-medication and medication); Evaluate for non-verbal indicators of pain; Evaluate mood/behavior Review of Resident #100's current Physician Orders revealed the following, in part:Start date: 01/06/2026 - Assess for pain each shift. Notify NP/MD for new onset of pain or unrelieved pain and document in notes NP/MD notification BID;Start date: 01/05/2026 - Pregabalin 75 mg PO TID at 7:30 a.m., 2:00 p.m., and 7:30 p.m.; andStart date: 02/19/2026 - Voltaren external gel 1% apply to bilateral knees topically two times daily for pain.Further review of Resident #100's current Physician orders revealed no additional order for pain medication. The facility's standing order for Tylenol was not transcribed into Resident #100's Physician Orders. Review of Resident #100's Nurses Notes dated 05/15/2026 revealed the following:05/15/2026 at 11:01 a.m. by S18LPN: Resident observed ambulating in the hallway when resident tripped over her shoe. Resident reported pain to left hip/buttocks. S10NP notified. X-ray ordered. Tylenol 325 mg given for pain. Review of Resident #100's Left Hip with Pelvis X-Ray Report dated 05/15/2026 at 2:54 p.m. revealed the following, in part:Impression: Degenerative change of the left hip without acute osseous abnormality.Caveat: Up to 10% of hip fractures may be occult on radiographs. If clinical concern persists or the patient fails to bear weight, consider short interval follow-up radiographs versus MRI, the gold standard of hip interrogation. Review of Resident #100's MAR dated May 2026 revealed the following, in part:Assess for pain each shift. Notify MD/NP for new onset of pain or unrelieved pain and document in notes NP/MD notification two times a day. 05/18/2026 day shift - pain level 8. Further review of Resident #100's MAR for assess for pain each shift revealed her pain was documented as a level 3 on 05/09/2026 and documented as a level 0 on all other shifts except 05/18/2026 listed above.Pregabalin 75 mg three times daily was documented as not administered on the following dates and times by the following nurses:05/17/2026 at 2:00 p.m. by S8LPN;05/17/2026 at 7:30 p.m. by S7LPN; and05/18/2026 at 7:30 a.m. by S19LPN.Voltaren External Gel 1% apply to bilateral knees topically two times daily for pain was documented as administered on the following dates and times with the following pain level documented: 05/15/2026 at 7:30 a.m. - pain level 8;05/15/2026 at 7:30 p.m. - pain level 7; and05/16/2026 at 7:30 a.m. - pain level 7.Further review of Resident #100's MAR revealed no documentation any other form of pain medication was administered. Tylenol was available for administration and not utilized. Review of Resident #100's Nurses Notes dated 05/18/2026 revealed the following:05/18/2026 at 9:05 a.m. by S19LPN: Resident complaining of pain to left hip. Resident had a fall on Friday, 05/15/2026. Resident seen by S10NP at bedside at 9:00 a.m. and received new order to send resident to emergency room for evaluation. Review of Resident #100's Physician Progress Note by S10NP dated 05/18/2026 revealed the following, in part:Resident seen today for fall.Assessment/Plan:Resident had a fall on Friday and was complaining of left hip pain. Left hip x-ray negative. Today, she continues to complain of pain and is unable to ambulate. Transferring to local hospital for advanced imaging. Review of Resident #100's Hospital Record dated 05/18/2026 revealed the following, in part:History of present illness: .resident presented to the emergency room after a mechanical fall on Friday at the nursing home after tripping on her right shoe. She landed on her left hip. She has since not able to bear weight. She was sent for further evaluation today.Orthopedic was consulted in emergency room. Plan surgical repair in the morning.Treatment given in emergency room: Morphine 2 mg and Orphenadrine 60 mg intravenously.Physical Exam:Musculoskeletal: tenderness, deformity, and signs of injury present; Comments: left hip with pain, left lower extremity externally rotated.CT lower extremity left without contrast:Impression:Mildly impacted left femoral neck fracture; andTraumatic Non-displaced fractures of the left superior and inferior pubic rami.Vital Signs:05/18/2026 at 10:25 a.m. Pain adult numerical scale level 9. Review of Resident #100's CNA & Nursing Assignments dated 05/15/2026 through 05/18/2026 revealed the following:05/15/2026:6:00 a.m. to 6:00 p.m.: S18LPN and S22CNA6:00 p.m. to 6:00 a.m.: S6LPN and S23CNA05/16/2026:6:00 a.m. to 6:00 p.m.: S20LPN and S24CNA6:00 p.m. to 6:00 a.m.: S7LPN and S23CNA05/17/2026:6:00 a.m. to 6:00 p.m.: S8LPN and S26CNA6:00 p.m. to 6:00 a.m.: S7LPN and S23CNA05/18/2026:6:00 a.m. to 6:00 p.m.: S19LPN and S25CNA An observation and interview was conducted of/with Resident #100 on 05/18/2026 at 9:02 a.m. She was lying in bed. She stated she had a fall on 05/15/2026 in the hallway. She stated her left hip had been hurting since her fall. She stated the nurses had given her something for pain, which was mildly effective but not completely effective. She explained she had been staying in the bed since the fall and was having to use a brief for urination and bowel movements due to her left hip pain. She stated she normally could bring herself to the bathroom but it hurt too bad to get up. On 05/18/2026, Resident #100 was transferred to a local hospital for advanced imaging of her Left Hip. Resident #100 remained in the hospital for the duration of the survey. An interview was conducted with S22CNA on 05/19/2026 at 3:27 p.m. She confirmed she was assigned to Resident #100 from 6:00 a.m. to 6:00 p.m. on 05/15/2026. She stated, after Resident #100's fall, Resident #100 did not get out of bed, required incontinence care, was in pain, and was unable to ambulate. She stated, during care for Resident #100 on 05/15/2026, Resident #100 was taking deep breaths and had facial grimaces when she would move. She stated Resident #100 had to stop multiple times during care and take a breath because she was in pain. She stated she notified S18LPN at least twice during her shift of Resident #100's change in condition and pain. She stated Resident #100 was requesting pain medication. A telephone interview was conducted with S18LPN on 05/19/2026 at 4:00 p.m. She confirmed she was assigned to Resident #100 when she fell on [DATE]. She stated Resident #100 initially complained of pain to her left hip. She stated she administered two 325 mg Tylenol tablets to Resident #100 for pain. She stated an x-ray was performed and revealed no acute findings. She stated Resident #100 not getting out of the bed, urinating in an incontinence brief, and requiring staff assistance with incontinence care was a change in condition for Resident #100. She stated she was not notified of a change in condition for Resident #100. She stated if she had been notified of the change in condition, she would have performed an additional assessment, to identify the cause of the change, and notified the NP or on-call NP of the change in condition. She confirmed Resident #100 not getting out of bed could have been related to pain. A telephone interview was conducted with S23CNA on 05/20/2026 at 11:14 a.m. She confirmed she was assigned to Resident #100 on 05/15/2026, 05/16/2026, and 05/17/2026 from 6:00 p.m. to 6:00 a.m. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated Resident #100 did not ever complain of pain. She stated, prior to Resident #100's fall, she was up and out of bed nightly when she would arrive for her shifts. She stated, on 05/15/2026, 05/16/2026, and 05/17/2026, Resident #100 was in bed when she arrived for her shifts and was having incontinent episodes. She stated she was unsure why Resident #100 was in bed when she arrived for her shifts and having incontinent episodes. She stated Resident #100 did rub her left leg during care. A telephone interview was conducted with S7LPN on 05/20/2026 at 3:39 p.m. She stated she was assigned to Resident #100 on 05/16/2026 and 05/17/2026 from 6:00 p.m. to 6:00 a.m. She stated, on 05/16/2026 and 05/17/2026, Resident #100 was rubbing her leg and saying she had a fall. She stated Resident #100 was not getting out of bed as normal and was calling the CNAs to change her incontinence brief. She stated Resident #100 said she was not getting up because of her fall. She stated she did not assess Resident #100 for pain and did not ask Resident #100 if she was hurting. She stated she should have assessed and asked Resident #100 if she was in pain. She confirmed she did not administer any pain medication to Resident #100. She explained she assumed Resident #100 was not getting out of bed because of fear from falling. She confirmed Resident #100 did not receive Pregabalin on 05/17/2026 at 7:30 p.m. as ordered. She confirmed she did not notify the physician Pregabalin was not available for administration. An interview was conducted with S26CNA on 05/20/2026 at 7:55 a.m. She confirmed she was assigned to Resident #100 on 05/17/2026 from 6:00 a.m. to 6:00 p.m. She stated Resident #100 required incontinence care three times during her shift. She stated Resident #100 complained of pain to her left hip during movement. She stated Resident #100 guarded her hip and said, ow, ow, ow during care. She stated each time Resident #100 complained of pain, S12RCNA reported it to the nurse. She stated S12RCNA reported Resident #100's pain to S21RN. An interview was conducted with S12RCNA on 05/20/2026 at 8:38 a.m. She confirmed she provided care for Resident #100 on 05/17/2026 on the day shift. She stated, on 05/17/2026, Resident #100 did not get out of bed and was utilizing an incontinence brief for urinary and bowel elimination. She stated, during care on 05/17/2026, Resident #100 was yelling and saying she was in so much pain. She stated, prior to Resident #100's fall, she never complained of pain. She stated she summoned S21RN. She stated S21RN observed Resident #100's care and pain. A telephone interview was conducted with S21RN on 05/20/2026 at 10:27 a.m. She confirmed, on 05/17/2026, she was notified Resident #100 was complaining of pain. She stated she observed the staff changing Resident #100's incontinence brief, and Resident #100 reported she was unable to bear weight on her left leg. She stated the hall nurse was administering Resident #100's medications and reported Resident #100 had something ordered for pain. She stated she was not made aware Resident #100 was out of Pregabalin. She stated the NP/MD and/or on-call provider should have been notified of Resident #100's pain and Resident #100's Pregabalin being unavailable. She stated the facility had a standing order for Tylenol that could have been utilized. Multiple attempts were made to contact S20LPN, S24CNA, and S8LPN throughout the survey, which were unsuccessful. S15ADON was notified during the survey of the attempted interviews and was also unsuccessful in reaching the aforementioned employees. An interview was conducted with S25CNA on 05/19/2026 at 3:39 p.m. She stated she provided care for Resident #100 on the morning of 05/18/2026. She stated, during incontinence care on 05/18/2026, Resident #100 complained of pain, was guarding her hip, and saying, ouch. She stated it was abnormal for Resident #100 to complain of pain. She stated S19LPN was aware and had notified S10NP. An interview was conducted with S19LPN on 05/19/2026 at 2:29 p.m. She confirmed she was assigned to Resident #100 on 05/18/2026 beginning at 6:00 a.m. She stated, on the morning of 05/18/2026, Resident #100 was complaining of pain to her left leg, was not getting out of bed, and was requiring an incontinence brief and staff to change her. She stated she notified S10NP, and S10NP assessed Resident #100. She stated S10NP ordered Resident #100 to go to a local emergency room. She confirmed Resident #100 did not receive her 7:30 a.m. of Pregabalin on 05/18/2026. An interview was conducted with S1DON on 05/19/2026 at 12:00 p.m. She confirmed Resident #100 had a fall on the morning of 05/15/2026. She stated x-rays were immediately ordered and obtained. She stated the x-ray results were negative. She stated Resident #100 was unable to bear weight on 05/18/2026 so the nurse contacted the NP and received orders to transfer the resident to the hospital. She stated the hospital performed a CT, which revealed a left hip fracture. An interview was conducted with S10NP on 05/19/2026 at 2:20 p.m. She confirmed she was notified of Resident #100's fall on 05/15/2026 at the time of her fall, and she ordered a left hip x-ray. She stated the x-ray was negative. She stated she assessed Resident #100 on the morning of 05/18/2026, and Resident #100 was in pain. She stated Resident #100 said her thigh was hurting. She explained Resident #100's thigh pain was referred pain from her hip. She stated Resident #100 would not allow S10NP to touch her leg. She stated she ordered Resident #100 be transferred to the hospital for a CT. She stated the hospital CT showed Resident #100 had a left hip fracture. She stated Resident #100 had left hip surgery this morning. She stated she would expect Resident #100 to be in pain with a hip fracture. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She confirmed the nurses did not contact the on-call NP this weekend related to continued pain for Resident #100. She stated if she had been notified or the on-call NP had been notified, they would have ordered Resident #100 be sent to the hospital for a CT at that time. An interview was conducted with S1DON on 05/20/2026 at 3:10 p.m. She was made aware of staff interviews revealing Resident #100 was not getting out of the bed as usual over the weekend, requiring an incontinence brief, requiring changing by the staff, and complaining of pain. She stated when Resident #100 complained of pain, the nurse should have administered the standing order for Tylenol and contacted the NP or on-call NP. She reviewed Resident #100's clinical record and confirmed the nurse documented Tylenol administration immediately following the fall. She confirmed there was no other documentation of pain medication administration from 05/15/2026 through 05/18/2026. She stated Resident #100's Pregabalin should have been available and administered.

Based on observation, interviews, and record review, the facility failed to consult with a resident's physician when the resident experienced a change in ambulation, assistance with ADLs, and continued pain after a fall for 1 (#100) of 3 residents reviewed for falls. This deficient practice resulted in an actual harm for Resident #100, a cognitively intact resident, beginning on 05/15/2026 when Resident #100 continued to complain of left hip pain after a fall, required increased staff assistance with ADLs, and did not ambulate as normal. Prior to the fall on 05/15/2026, Resident #100 was independently ambulatory and continent. An interview with Resident #100 on 05/18/2026 revealed, after her fall on 05/15/2026, she remained in bed, required perineal care after urinary and bowel elimination, and experienced left hip pain. Staff interviews revealed Resident #100 began requiring staff assistance with ADLs, complained of pain during ADL care, and did not transfer out of bed independently after her fall on 05/15/2026. Nursing staff failed to notify Resident #100's NP/MD and/or on-call NP of Resident #100's change in condition. On the morning of 05/18/2026, S10NP was notified of Resident #100's change in condition, and Resident #100 was transferred to a local hospital. Resident #100's Computed Tomography (CT) scan at the local hospital revealed a Mildly Impacted Left Femoral Neck Fracture and Traumatic Non-displaced Fractures of the Left Superior and Inferior Pubic Rami, which required surgical intervention on 05/19/2026.Findings: Review of the facility's policy, revised December 2016, titled, Change in Resident's Condition or Status revealed the following, in part:Policy statement:Our facility shall promptly notify the resident, his or her attending physician.of changes in the resident's medical/mental condition and/or status (eg. Changes in level of care.)Policy Interpretation and Implementation:1. The nurse will notify the resident's attending physician or physician on call when there has been a (an):d. significant change in the resident's physical/emotional/mental condition;e. Need to alter the resident's treatment significantly2. A significant change of condition is a major decline or improvement in the resident's status that:a. Will not normally resolve itself without intervention by staff.b. Impacts more than one area of the resident's health status. Review of Resident #100's Clinical Record revealed an admission date of 01/25/2026 and diagnoses, which included Other Frontotemporal Neurocognitive Disorder. Review of Resident #100's Quarterly MDS with an ARD of 04/08/2026 revealed a BIMS of 15, which indicated intact cognition. Further review revealed Resident #100 was independent with toileting hygiene, transfers, and ambulation. Review of Resident #100's current Physician Orders revealed the following, in part:Assess for pain each shift. Notify NP/MD for new onset of pain or unrelieved pain and document in notes NP/MD notification twice daily. Review of Resident #100's Nurses Notes dated 05/15/2026 through 05/18/2026 revealed the following:05/15/2026 at 11:01 a.m. by S18LPN: Resident observed ambulating in the hallway when resident tripped over her shoe. Resident was witnessed by staff. Resident noted to land on right hip/buttocks after rolling from her left hip/buttocks. No head strike observed. Resident alert and responsive immediately after incident. No loss of consciousness noted. Resident reported pain to left hip/buttocks. Resident was helped off the floor by staff and rolled via wheelchair to room. Resident assisted to bed and is resting. S10NP notified. X-ray ordered. Tylenol 325 mg given for pain. Responsible party notified.05/18/2026 at 9:05 a.m. by S19LPN: Resident complaining of pain to left hip. Resident had a fall on Friday, 05/15/2026. Resident seen by S10NP at bedside at 9:00 a.m. and received new order to send resident to emergency room for evaluation.Further review revealed no documentation of communication with the physician between the above listed dates/times. Review of Resident #100's current Care Plan revealed the following, in part:Problem: Risk for falls; 05/15/2026 - fallInterventions:05/15/2026: Resident assessed immediately for injury. NP notified. X-ray ordered. Tylenol 325 mg given for pain. No fracture noted to x-ray, degenerative changes noted.5/18/2026: Resident complaining of pain to left hip. Resident seen by S10NP at bedside at 9:00 a.m. and received new order to send resident to a local emergency department for evaluation.Initiated 01/12/2026 Problem: Risk for impaired urinary elimination.Interventions: monitor for new incontinence; Notify provider immediately if any voiding abnormalities. Review of Resident #100's Left Hip with Pelvis X-Ray Report dated 05/15/2026 at 2:54 p.m. revealed the following, in part:Clinical Information: Fall rule out fracture.Findings:No acute fracture or dislocation. Impression: Degenerative change of the left hip without acute osseous abnormality.Caveat: Up to 10% of hip fractures may be occult on radiographs. If clinical concern persists or the patient fails to bear weight, consider short interval follow-up radiographs versus MRI, the gold standard of hip interrogation. Review of Resident #100's Physician Progress Note by S10NP dated 05/18/2026 revealed the following, in part:Resident seen today for fall.Assessment/Plan:Fall, Subsequent Encounter:Resident had a fall on Friday and was complaining of left hip pain. Left hip x-ray negative. Today, she continues to complain of pain and is unable to ambulate. Transferring to local hospital for advanced imaging. Review of Resident #100's CNA & Nursing Assignments dated 05/15/2026 through 05/18/2026 revealed the following:05/15/2026:6:00 a.m. to 6:00 p.m.: S18LPN and S22CNA6:00 p.m. to 6:00 a.m.: S6LPN and S23CNA05/16/2026:6:00 a.m. to 6:00 p.m.: S20LPN and S24CNA6:00 p.m. to 6:00 a.m.: S7LPN and S23CNA05/17/2026:6:00 a.m. to 6:00 p.m.: S8LPN and S26CNA6:00 p.m. to 6:00 a.m.: S7LPN and S23CNA05/18/2026:6:00 a.m. to 6:00 p.m.: S19LPN and S25CNA Review of Resident #100's Hospital Record dated 05/18/2026 revealed the following, in part:History and Physical: Patient seen and evaluated by me with left hip fracture after fall on Friday.History of present illness: .resident presented to the emergency room after a mechanical fall on Friday at the nursing home after tripping on her right shoe. She landed on her left hip. She has since not able to bear weight. She was sent for further evaluation today.Treatment given in emergency room: Morphine injection 2 mg and Orphenadrine injection 60 mg intravenously.Physical Exam:Musculoskeletal: tenderness, deformity, and signs of injury present; Comments: left hip with pain, left lower extremity externally rotated.Assessment and Plan:Closed Displaced Fracture of Left Femoral Neck:Admit for surgical repair in the morning; andOrthopedics consulted in emergency department.Vital Signs:05/18/2026 at 10:25 a.m. Pain adult numerical scale level 9.CT lower extremity left without contrast:Impression:Mildly impacted left femoral neck fracture; andTraumatic Non-displaced fractures of the left superior and inferior pubic rami.Orthopedic Consult note dated 05/18/2026:Chief complaint: fallPlan: Percutaneous screw fixation left hip per CT result tomorrow once cleared by hospital medicine. Physical Exam:Musculoskeletal: tenderness to palpation pain with internal/external rotation of hip only. Decision for surgery: After extensive discussion regarding risks, benefits and alternatives to surgery, the patient elected to proceed with surgery. Plan for operating room as soon as possible. An observation and interview was conducted of/with Resident #100 on 05/18/2026 at 9:02 a.m. She was lying in bed. She stated she had a fall on 05/15/2026 in the hallway. She stated her left hip had been hurting since her fall. She stated the nurses had given her something for pain, which was mildly effective but not completely effective. She explained she had been staying in the bed since the fall and was having to use a brief for urinary and bowel elimination. She stated she normally could transfer and ambulate to the bathroom independently but it hurt too bad to get up. An interview was conducted with S22CNA on 05/19/2026 at 3:27 p.m. She confirmed she was assigned to Resident #100 from 6:00 a.m. to 6:00 p.m. on 05/15/2026. She stated she did not witness Resident #100's fall on 05/15/2026 but was notified of the fall. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated, after the fall, Resident #100 did not get out of bed and required incontinence care. She stated, after the fall, Resident #100 said she was in pain and could not walk. She stated, during care for Resident #100 on 05/15/2026, Resident #100 was taking deep breaths and had facial grimaces when she would move. She stated Resident #100 had to stop multiple times during care and take a breath because she was in pain. She stated she notified S18LPN at least twice during her shift of Resident #100's change in condition and pain. She stated Resident #100 was requesting pain medication, and she notified the nurse. A telephone interview was conducted with S18LPN on 05/19/2026 at 4:00 p.m. She confirmed she was assigned to Resident #100 when she fell on [DATE]. She stated Resident #100 was independently ambulatory and was walking in the hallway when she lost her footing, tripped, and fell. She stated Resident #100 initially complained of pain to her left hip. She stated S1DON was present in the facility and assisted with the assessment. She stated S1DON immediately notified S10NP via phone, and S10NP ordered an x-ray of the left hip. She stated the x-ray was performed immediately and revealed no acute findings. She stated she administered two 325 mg Tylenols to Resident #100 for pain. She stated she assessed Resident #100's pain after administration of the Tylenol, and it was effective. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated Resident #100 not getting out of the bed, urinating in an incontinence brief, and requiring staff assistance with incontinence care was a change in condition for Resident #100. She stated she was not notified of a change in condition for Resident #100. She stated if she had been notified of the change in condition, she would have performed an additional assessment and notified the NP or on-call NP of the change in condition. A telephone interview was conducted with S6LPN on 05/20/2026 at 9:19 a.m. She confirmed she was assigned to Resident #100 on 05/15/2026 from 6:00 p.m. to 6:00 a.m. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated Resident #100 would get up once or twice through the night and would independently ambulate to the nurses' station and request different things. She confirmed Resident #100 required incontinence care in the early morning of 05/16/2026, which was a change in condition. She stated that morning, Resident #100 ambulated to the bathroom with staff. She stated Resident #100 was not ambulating and toileting herself independently, which was as change in condition, and the NP should have been notified. A telephone interview was conducted with S23CNA on 05/20/2026 at 11:14 a.m. She confirmed she was assigned to Resident #100 on 05/15/2026, 05/16/2026, and 05/17/2026 from 6:00 p.m. to 6:00 a.m. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated, prior to Resident #100's fall, Resident #100 was up and out of bed nightly when she would arrive for her shifts. She stated on 05/15/2026, 05/16/2026, and 05/17/2026, Resident #100 was in bed when she arrived for her shifts and was having incontinent episodes. She stated she notified S7LPN Resident #100 was having incontinent episodes, which was a change in condition. A telephone interview was conducted with S7LPN on 05/20/2026 at 3:39 p.m. She stated she was assigned to Resident #100 on 05/16/2026 and 05/17/2026 from 6:00 p.m. to 6:00 a.m. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated, on 05/16/2026 and 05/17/2026, Resident #100 was rubbing her leg and saying she had a fall. She stated Resident #100 was not getting out of bed as normal and was calling the CNAs to change her incontinence brief. She stated Resident #100 said she was not getting up because of her fall. She stated she did not assess Resident #100 for pain and did not ask Resident #100 if she was hurting anywhere. She stated she should have assessed and asked Resident #100 if she was in pain. She explained she assumed Resident #100 was not getting out of bed because of fear from falling. She confirmed she did not notify the NP or on-call of Resident #100's change in condition. An interview was conducted with S26CNA on 05/20/2026 at 7:55 a.m. She confirmed she was assigned to Resident #100 on 05/17/2026 from 6:00 a.m. to 6:00 p.m. She explained 05/17/2026 was her first day working with Resident #100 so S12RCNA assisted her. She stated Resident #100 required incontinence care three times during her shift. She stated Resident #100 complained of pain to her left hip during movement. She stated Resident #100 guarded at her hip and said, ow, ow, ow during care. She stated each time Resident #100 complained of pain, S12RCNA reported it to the nurse. She stated S21RN was also at the facility as the supervisor that day, and S12RCNA reported it to S21RN. An interview was conducted with S12RCNA on 05/20/2026 at 8:38 a.m. She confirmed she provided care for Resident #100 on 05/17/2026 on the day shift. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated, on 05/17/2026, Resident #100 did not get out of bed and was utilizing an incontinence brief for urination and bowel movements. She stated, during care on 05/17/2026, Resident #100 was yelling and saying she was in so much pain, which was a change in condition. She stated she summoned S21RN. She stated S21RN observed Resident #100's care and pain. She stated S21RN stated Resident #100 received an x-ray, which was negative. She stated Resident #100 had never stayed in bed all day like she did on 05/17/2026. A telephone interview was conducted with S21RN on 05/20/2026 at 10:27 a.m. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She confirmed, on 05/17/2026, she was notified Resident #100 was complaining of pain. She stated she observed the staff changing Resident #100's incontinence brief, and Resident #100 reported she was unable to bear weight on her left leg. She stated she thought Resident #100 pulled a muscle since her x-ray was negative. She stated she assessed Resident #100's leg, and there were no outward signs of a fracture. She confirmed Resident #100 did not get out of bed on 05/17/2026. She confirmed Resident #100 requiring incontinence care was a change in condition. She stated the change in condition happened after Resident #100 fell. She stated the NP/MD and/or on-call provider should have been notified of Resident #100's change in condition. Multiple attempts were made to contact S20LPN, S24CNA, and S8LPN throughout the survey, which were unsuccessful. S15ADON was notified during the survey of the attempted interviews and was also unsuccessful in reaching the aforementioned employees. An interview was conducted with S25CNA on 05/19/2026 at 3:39 p.m. She stated she provided care for Resident #100 on the morning of 05/18/2026. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated, on 05/18/2026, Resident #100 required incontinence care in her bed, which was a change in condition. She stated Resident #100 was complaining of pain during care, was guarding her hip and saying, ouch. She sated S19LPN was aware of Resident #100's condition and had contacted the ambulance. An interview was conducted with S19LPN on 05/19/2026 at 2:29 p.m. She confirmed she was assigned to Resident #100 on 05/18/2026 beginning at 6:00 a.m. She stated, on the morning of 05/18/2026, Resident #100 was complaining of pain to her left leg, was not getting out of bed, and was requiring an incontinence brief and the staff to change her, which was a change in condition. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated she notified S10NP and S10NP assessed Resident #100. She stated S10NP ordered Resident #100 to go to a local emergency room for evaluation via ambulance related to needing a CT. She stated Resident #100 was transported to a local hospital via ambulance. An interview was conducted with S1DON on 05/19/2026 at 12:00 p.m. She confirmed Resident #100 had a fall on the morning of 05/15/2026. She stated x-rays were immediately ordered and obtained. She stated the x-ray results were negative. She stated Resident #100 was unable to bear weight on 05/18/2026 so the nurse contacted the NP and received orders to transfer the resident to the hospital. She stated the hospital performed a CT, which revealed a left hip fracture. An interview was conducted with S10NP on 05/19/2026 at 2:20 p.m. She confirmed she was notified of Resident #100's fall on 05/15/2026 at the time of her fall, and she ordered a left hip x-ray. She stated the x-ray was negative. She stated she assessed Resident #100 on the morning of 05/18/2026, and Resident #100 was in pain. She stated Resident #100 did not rate her pain but said her thigh was hurting. She explained Resident #100's thigh pain was referred pain from her hip. She stated Resident #100 did perform active range of motion of the left leg at that time but would not allow S10NP to touch her leg. She stated she ordered Resident #100 be transferred to the hospital for a CT. She stated the hospital CT showed Resident #100 had a left hip fracture. She stated Resident #100 had left hip surgery this morning. She stated she would expect Resident #100 to be in pain with a hip fracture. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She stated Resident #100 requiring incontinence care and not ambulating was a change in condition. She confirmed the nurses did not contact the on-call NP this weekend related to continued pain or change in condition for Resident #100. She stated if Resident #100 had a change in condition, the nurses should have contacted the on-call NP. She stated if she had been notified or the on-call NP had been notified, they would have ordered Resident #100 be sent to the hospital for a CT at that time. An interview was conducted with S1DON on 05/20/2026 at 3:10 p.m. She stated, prior to Resident #100's fall, she was independent with transfers, ambulation and toileting, and was continent of bladder and bowel. She was made aware of staff interviews revealing Resident #100 not getting out of the bed as usual over the weekend, requiring an incontinence brief, and requiring changing by the staff. She confirmed this was a change in condition for Resident #100. She stated she would have expected the nurses to contact the physician when Resident #100 had a change in condition to obtain new orders.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered as ordered for 3 (#10, #46, and #100) of 10 residents reviewed for medication administration. Review of the facility's policy titled, Administering Medications with a revision date of 12/2012, revealed the following, in part: Policy: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 3. Medications must be administered in accordance with the orders, including any required time frame. Review of the facility's policy titled, Emergency Medications with a revision date of 04/2021, revealed the following, in part: Policy: The facility shall maintain a supply of medications typically used in emergencies. Policy Interpretation and Implementation: 2. The emergency medication kit will include medications and biologicals that are essential in providing emergency treatment. 4. The contents of emergency medication kit will be clearly listed. Resident #10 Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Critical Illness Myopathy, Chronic Kidney Disease, Stage 3B, and Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. Review of Resident #10's Quarterly MDS with an ARD of 05/13/2026 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #10's Physician Orders dated May 2026 revealed the following, in part: Order date: 02/09/2026, Start date: 02/10/2026- Lidocaine External Patch Apply to back topically one time a day for pain. Order date: 02/09/2026, Start date: 02/10/2026 - Risperidone Oral Tablet 0.5 mg. Give 1 tablet by mouth one time a day for antipsychotic. Review of Resident #10's Medication Administration Record dated May 2026 revealed the following, in part: Lidocaine External Patch documentation was blank on the following dates: 05/07/2026, 05/08/2026, 05/12/2026, 05/16/2026, 05/17/2026. Lidocaine External Patch was documented as 9 indicating other on the following dates: 05/09/2026, 05/10/2026, 05/11/2026, 05/15/2026, Risperidone Oral Tablet 0.5 mg was documented 9 indicating other on the following dates: 05/16/2026 and 05/18/2026. Risperidone Oral Tablet 0.5 mg was documented as administered on 05/17/2026. Review of Resident #10's Nurses Notes dated May 2026 revealed the following, in part: Review of Nurse's Notes revealed the following: 05/09/2026 at 4:53 a.m. Lidocaine External Patch-Apply to back topically one time a day for pain-Pending delivery - Signed by S31LPN 05/10/2026 at 5:15 a.m. Lidocaine External Patch-Apply to back topically one time a day for pain-Pending delivery - Signed by S31LPN 05/11/2026 at 5:13 a.m. Lidocaine External Patch-Apply to back topically one time a day for pain-Pending delivery -Signed by S31LPN 05/15/2026 at 5:05 a.m. Lidocaine External Patch-Apply to back topically one time a day for pain-Pending delivery/restock - Signed by S31LPN 05/16/2026 at 7:03 a.m. Risperidone Oral Tablet 0.5 mg-Give 1 tablet by mouth one time a day or antipsychotic – Pending delivery - Signed by S30LPN 05/18/2026 at 10:15 a.m. Risperidone Oral Tablet 0.5 MG-Give 1 tablet by mouth one time a day or antipsychotic – Pending delivery – Signed by S28LPN Further review revealed no documented evidence the pharmacy or provider were notified of the above doses of medications were not available for administration. An interview was conducted with the facility's Pharmacist on 05/19/2026 at 12:05 p.m. He verified he was a pharmacist for the facility. He reviewed Resident #10's record and stated the refill request for Resident #10's Risperidone 0.5 mg with a 30 day supply was received on 05/18/2026 and the facility would have received the medication that same day around 10 pm. An interview was conducted with S28LPN on 5/19/2026 at 3:12 p.m. She stated medications should be ordered when the medication gets low on the medication card indicated by a blue color. S28LPN stated medications were usually ordered when last white strip on the medication card was used up. S28LPN verified she worked on 05/18/2026 and was assigned to Resident #10. She reviewed Resident#10's May 2026 MAR and confirmed she had documented 9 on the 05/18/2026 a.m. Risperidone 0.5 mg dose due to medication being unavailable. She stated 9 indicated other and there would be a progress note. She reviewed the progress note for the same day, and confirmed it stated pending delivery. She further reviewed and confirmed Resident #10 had not received his a.m. dose of Risperidone 0.5 mg tablet on 05/16/2026 and 05/18/2026 due to it being unavailable in the facility, and should have. S28LPN stated Resident #10 should not have run out of his medication. She stated she had not checked the facility's emergency kit for the medication, and had not notified the DON nor the NP regarding Resident #10's missed Risperidone 0.5 mg doses. An interview was conducted with S30LPN on 05/19/2026 at 4:53 p.m. S30LPN stated she would reorder medications when she finished the last white strip and begins the blue strip on the medication card. She stated if a resident was totally out of a medication she should notify the nurse practitioner and check the emergency kit. She stated if the medication was not in the emergency kit she would call the pharmacy and see why it had not been delivered. She verified she worked on 05/16/2026 and 05/17/2026 and was assigned to Resident #10. She stated a 9 on the MAR indicated other and to see progress note. She stated Resident #10 was out of his Risperidone 0.5mg a.m. dose on 05/16/2026 and 5/17/2026 and it was not administered. She stated she documented medication as administered on 05/17/2026 in error and she did not actually administer the medication as it was not available. S30LPN stated she did not notify the NP nor DON Resident #10 had missed doses of his prescribed Risperidone. She stated she was not sure if this medication was in the emergency kit and she did not check the emergency kit to see if medication was available. An interview was conducted on 05/20/2026 9:01 a.m. with S10NP. S10NP reviewed Resident #10's May 2026 MAR and confirmed the above listed missed Risperidone 0.5 mg doses. She stated Risperidone 0.25 mg was in the emergency kit and staff could have given 2 tablets to equal his prescribed dosage. S10NP stated she would have expected staff to check the emergency kit, notify her of the missed doses, and/or call the pharmacy to see check on the prescription delivery. S10NP stated Resident #10 should not have missed his Risperidone 0.5 mg doses since they were available in the emergency kit. An interview was conducted with S27LPN on 05/20/2026 at 1:05 p.m. She verified she worked on the following 6p.m.-6a.m. shifts: 05/07/2026, 05/11/2026, 05/12/2026, 05/15/2026, and 05/16/2026 and was assigned to Resident #10. She stated the DON was responsible for ordering OTC stock medications and staff should notify her when supply was low. She further verified Lidocaine External Patches were an OTC stock medication. She confirmed Resident #10's Lidocaine External Patch was not available for administration when she worked on the above listed dates, and therefore was not administered. She stated when she realized the stock supply of Lidocaine External Patches were empty she slid a note under the administrator's door to let him know. S27LPN stated she did not notify the DON or the NP of Resident #10's missed administration of his prescribed Lidocaine External Patch. An interview was conducted with S31LPN on 05/20/2026 at 1:16 p.m. She verified she worked on the following 6 p.m.-6 a.m. shifts: 05/09/2026, 05/10/2026, 05/11/2026, and 05/15/2026 and was assigned to Resident #10. She confirmed she did not administer these doses due to medication not being available. She stated if a resident was completely out of a medication she would notify the DON. She stated she had charted 9 on Resident #10's MAR on the above listed dates which indicated see progress notes. S31LPN stated she notified DON that resident was out of his Lidocaine patches, but did not notify the NP. Resident #46 Review of Resident #46's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Personal History Of Pulmonary Embolism, Long Term Current Use Of Anticoagulants, Personal History Of Other Venous Thrombosis And Embolism, Paraplegia, and Neuromuscular Dysfunction Of Bladder. Review of Resident #46's Quarterly MDS with an ARD of 03/18/2026 revealed he had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he had an indwelling catheter and was taking Anticoagulants. Review of Resident #46's Physician Orders dated May 2026 revealed the following, in part: Order date: 10/28/2025, Start date: 10/28/2025- Eliquis oral tablet 5 mg give one tablet by mouth two times a day for history of Thromboembolism related to Personal History of Pulmonary Embolism; and Order date: 03/25/2026, Start date: 04/03/2026- Macrobid oral capsule 100 mg give one capsule by mouth one time a day for Urinary Tract Infection prophylaxis. Review of Resident #46's Medication Administration Record dated May 2026 revealed the following, in part: Eliquis was documented as not administered for the following doses: 05/11/2026 at 7:30 a.m., 05/13/2026 at 7:30 p.m., 05/14/2026 at 7:30 p.m., 05/15/2026 at 7:30 p.m., 05/16/2026 at 7:30 p.m., 05/17/2026 at 7:30 a.m., and 05/18/2026 at 7:30 p.m.; and Macrobid was documented as not administered for the following doses: 05/06/2026 at 7:30 a.m., 05/08/2026 at 7:30 a.m., 05/09/2026 at 7:30 a.m., and 05/11/2026 at 7:30 a.m. Review of Resident #46's Nurses Notes dated May 2026 revealed the following, in part: 05/06/2026 at 10:04 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Not available. Signed by S3LPN 05/08/2026 at 9:05 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Not available. Signed by S3LPN 05/09/2026 at 9:47 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Not available. Signed by S4LPN 05/11/2026 at 7:21 a.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. Reordered. Signed by S5LPN 05/11/2026 at 7:22 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Reordered. Signed by S5LPN 05/13/2026 at 6:40 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. On order. Signed by S6LPN 05/14/2026 at 8:02 a.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. Awaiting delivery. Signed by S5LPN 05/14/2026 at 6:42 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. On order. Signed by S6LPN 05/15/2026 at 6:41 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. On order. Signed by S6LPN 05/16/2026 at 7:51 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. Pending delivery. Signed by S7LPN 05/17/2026 at 7:40 a.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. Not available. Signed by S8LPN 05/18/2026 at 7:59 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o Thromboembolism related to Personal History of Pulmonary Embolism. Awaiting Delivery. Signed by S6LPN Further review revealed no documented evidence the pharmacy or provider were notified of the above doses of medications were not available for administration. An interview was conducted with the facility's Pharmacist on 05/19/2026 at 12:05 p.m. He verified he was a pharmacist for the facility. He stated medications were delivered to the facility once a day in the evenings, Monday through Friday. He stated the facility's nursing staff should use the color change indicator on the blister cards to order refills of medications. He stated medications refills should be requested on Monday through Friday. He stated the pharmacy was closed on Saturday's and Sunday's. He stated the pharmacy contracted with an on call pharmacy for emergency medications needed on the weekends, not for medication refills. He reviewed Resident #46's record and stated Macrobid was last refilled on 03/31/2026 and 05/11/2026 with a 30 day supply. He stated Resident #46's Eliquis was last refilled on 04/17/2026 and 05/18/2026 with a 14 day supply. An observation was made of the facility's electronic emergency medication kit with S1DON on 05/19/2026 at 12:37 p.m. S1DON reviewed the list of medications contained in the emergency medication kit. She stated the emergency kit contained 10 tablets of Eliquis 2.5 mg and 30 capsules of Macrobid 100 mg. During the observation, S1DON contacted the facility's Pharmacist who reported the facility's emergency kit contained 8 available tablets of Eliquis 2.5 mg and 16 available capsules of Macrobid 100 mg. An interview was conducted with S7LPN on 05/19/2026 at 1:04 p.m. She stated when the medication card label changed color indicating a refill was needed, she ordered the medication electronically through the computer system. She verified she was assigned to Resident #46 on 05/16/2026 from 6:00 p.m. to 6:00 a.m. She stated Resident #46 was ordered Eliquis. She stated she cannot recall if Resident #46's Eliquis was not available for administration on 05/16/2026 during her shift. She stated if she documented a nurse's note indicating she was waiting on pharmacy, then the medication was not available and she did not administer it. She confirmed she did not check the facility's emergency kit to see if the Eliquis was available. She confirmed she did not contact the pharmacy or notify the Nurse Practitioner the medication was not available for administration. An interview was conducted with S3LPN on 05/19/2026 at 1:35 p.m. She verified she was assigned to Resident #46 on 05/06/2026 and 05/08/2026 from 6:00 a.m. to 6:00 p.m. She stated if she documented a nurses' note and the medication was not administered on the MAR, then she did not administer the medication. She stated she could not recall if she notified the facility staff, the pharmacy or the Nurse Practitioner, Resident #46's Macrobid was not available for administration. She stated she did not check the facility's emergency kit to see if the medication was available. An interview was conducted with S5LPN on 05/19/2026 at 1:45 p.m. She stated if she documented Resident #46's Eliquis and Macrobid were not administered, it was because they were not available. She stated if a medication was not available to administer she would call the pharmacy, see if the medication was ordered, and if not she would reorder it. She stated she had never used the facility's emergency kit and was not sure what medications were available in it. She stated she did not notify the pharmacy, the Nurse Practitioner, or any staff at the facility of Resident #46's medications were unavailable. An interview was conducted with Resident #46 on 05/19/2026 at 2:18 p.m. He stated in the last month, some of the nurses, unsure who, told him they did not have some of his medications. He stated he did not know which medications were missing or why they did not have them. He stated he took Eliquis for a history of blood clots. He stated he had a catheter and took Macrobid, to prevent urinary tract infections. An interview was conducted with S8LPN on 05/19/2026 at 3:02 p.m. She verified she was assigned to Resident #46 on 05/17/2026 from 6:00 a.m. to 6:00 p.m. She stated Resident #46's Eliquis was not available for administration. She stated she did not notify the pharmacy or the Nurse Practitioner the medication was not available for administration. She stated she did not check the facility's emergency kit to see if the Eliquis was available. An interview was conducted with S6LPN on 05/19/2026 at 3:41 p.m. She verified she was assigned to Resident #46 on 05/13/2026, 05/14/2026, 05/15/2026, and 05/18/2026 from 6:00 p.m. to 6:00 a.m. She stated Resident #46's Eliquis was not available for administration, and therefore not administered on the above dates. She stated the Eliquis was reordered electronically, but she was not sure who or when it was reordered. She stated she left report with the morning nurse each day Resident #46's Eliquis was not available to follow up with the pharmacy. She stated she did not notify the pharmacy or the Nurse Practitioner Resident #46's Eliquis was not available. She stated she did not check the facility's emergency kit to see if the medication was available. She stated medication refill requests were ordered electronically when the medication card label changed color indicating a refill was needed. An interview was conducted with S4LPN on 05/19/2026 at 4:03 p.m. She verified she was assigned to Resident #46 on 05/09/2026 from 6:00 a.m. to 6:00 p.m. She stated his ordered Macrobid was not available. She stated she electronically reordered Resident #46's Macrobid on 05/09/2026 and let the oncoming night nurse, unsure who, know the Macrobid was not available and had been reordered. She stated she did not notify the Nurse Practitioner, pharmacist, or facility staff, Resident #46's Macrobid was not available for administration. She stated she did not check the facility's emergency medication kit for the medication. An interview was conducted with S10NP on 05/19/2026 at 4:15 p.m. She stated Resident #46 was prescribed Eliquis for a history of Deep Vein Thrombosis and a Pulmonary Embolism. She stated Resident #46 had an indwelling catheter and was prescribed Macrobid prophylactically for Urinary Tract Infections. She reviewed Resident #46's clinical record and verified the above-mentioned dates the Eliquis and Macrobid were not administered. She stated she was not notified Resident #46 missed any doses of Eliquis or Macrobid. She stated had she been notified she would have told the nurses both medications were available in the facility's emergency kits and to contact the pharmacy to have the medications delivered the next day. She confirmed she expected Resident #46's Eliquis and Macrobid to be administered as ordered. Resident #100 Review of Resident #100's Clinical Record revealed an admission date of 01/25/2026 and diagnoses, which included Other Frontotemporal Neurocognitive Disorder and Polyneuropathy. Review of Resident #100's current Physician Orders revealed the following, in part: Pregabalin 75 mg by mouth three times daily for Ployneuropathy at 7:30 a.m., 2:00 p.m., and 7:30 p.m. Review of Resident #100's MAR dated May 2026 revealed the following, in part: Pregabalin 75 mg three times daily was documented as not administered, see progress notes, on the following dates and times by the following nurses: 05/17/2026 at 2:00 p.m. by S8LPN; 05/17/2026 at 7:30 p.m. by S7LPN; and 05/18/2026 at 7:30 a.m. by S19LPN. Review of Resident #100's Nurses Notes dated 05/15/2026 through 05/18/2026 revealed the following: 05/17/2026 at 3:42 p.m. by S8LPN: Pregabalin Oral Capsule 75 mg give 1 capsule by mouth three times a day was not administered – medication unavailable, unavailable in emergency kit, and unable to reach provider. 05/18/2026 at 3:52 a.m. by S7LPN: Pregabalin Oral Capsule 75 mg give 1 capsule by mouth three times a day was not administered – pending delivery. 05/18/2026 at 8:30 a.m. by S19LPN: Pregabalin Oral Capsule 75 mg give 1 capsule by mouth three times a day was not administered – medication unavailable. Review of Resident #100's current Care Plan revealed the following, in part: Problem: Resident has chronic pain related to lower back and bilateral knees. Interventions: Administer pain medication per order. An interview was conducted with S7LPN on 05/19/2026 at 1:28 p.m. She confirmed Resident #100's Pregabalin was not administered on 05/17/2026 at 7:30 p.m. because it was not available for administration. She stated she did not contact the pharmacy regarding refill of the Pregabalin. She confirmed she did not contact the NP regarding the Pregabalin not being available for administration and should have. An interview was conducted with S19LPN on 05/19/2026 at 2:29 p.m. She confirmed Resident #100 missed her 7:30 a.m. dose of Pregabalin on 05/18/2026. She stated the medication was not available to be administered. She stated S10NP was in the facility on 05/18/2026 and she verbally notified her the medication was not available. Interviews attempted with S8LPN throughout the survey were unsuccessful. An interview was conducted with a pharmacist from the facility's contracted pharmacy on 05/20/2026 at 11:46 a.m. She confirmed Resident #100 had a physician's order for Pregabalin 75 mg by mouth three times daily. She stated there was a highlighted section on each medication card that should be reordered prior to reaching the first pill in the highlighted section. She stated Pregabalin required a hard script from the NP/MD so they would have to communicate with the provider to obtain the hard script. She stated the Pregabalin hard script was sent to the pharmacy on the evening of 05/17/2026, and it was filled and delivered to the facility on [DATE]. She stated the medication should have been ordered sooner to ensure delivery to the facility prior to the resident running out. She confirmed the pharmacy had a 24 hour on call service and there was always a pharmacist available to fill emergency medications. An interview was conducted with S10NP on 05/19/2026 at 2:20 p.m. She stated the nurses notified her on Friday, 05/15/2026 that Resident #100 was running low on Pregabalin. She stated she thought she sent the hard script to the pharmacy that day but she realized on 05/17/2026 she had not. She stated at that time, she sent the Pregabalin hard script to the pharmacy and the medication was delivered to the facility on the evening of 05/18/2026. She stated the nurses should have let her know sooner Resident #100 was running low on Pregabalin. An interview was conducted on 05/20/2026 at 1:50 p.m. with S1DON. She stated the nurses were responsible for obtaining medication refills. She stated medications could be refilled electronically or by phone. She stated if a medication was not available, the expectation was for the nurse to reach out to pharmacy to see why the medication was not available, or the backup pharmacy if needed. She stated resident medications should be available for administration and doses should not be missed. She stated the Nurse Practitioner should be notified of any missed doses of medication. She stated she was responsible for ordering the OTC stock medications and she had not been made aware the facility was running low on Lidocaine patches or had completely run out of lidocaine patches. S1DON stated staff should notify her if stock medication supply is low and she would reorder. S1DON further confirmed Resident #10 should not have missed his Lidocaine External Patch administration. She was notified of the above mentioned missed doses of Resident #10's Risperidone, Resident #46's Eliquis and Macrobid, and Resident #100's Pregabalin. She stated she would have expected Resident #10's Risperidone, and Resident #46's Eliquis and Macrobid to be administered as ordered as these medications were available in the facility's emergency kit. She further stated the nurses should have contacted S10NP if a hard script was needed for a medication. She stated the medication should have been ordered prior to running out. She stated when the medication was out, the nurse should have contacted the pharmacy and the NP or on-call NP to obtain the ordered medication.

Based on record review, observations, and interviews, the facility failed to ensure residents were free of significant medication errors for 1 (#46) of 10 residents reviewed for medication administration. The facility failed to ensure Resident #46 received Eliquis and Macrobid as ordered by the Physician. Findings: Review of the facility's policy titled, Administering Medications with a revision date of 12/2012, revealed the following, in part:Policy: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation:3. Medications must be administered in accordance with the orders, including any required time frame. Review of the medication Black Box Warning for Eliquis revealed the following, in part: Warning: Premature discontinuation of Eliquis can increase the risk of thrombotic events. To reduce this risk, consider coverage with another anticoagulant if Eliquis is discontinued for a reason other than Pathological bleeding or completion of a course of therapy. Eliquis is indicated for the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following initial therapy. Review of Resident #46's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Personal History Of Pulmonary Embolism, Long Term Current Use Of Anticoagulants, Personal History Of Other Venous Thrombosis And Embolism, Paraplegia, and Neuromuscular Dysfunction Of Bladder, Unspecified. Review of Resident #46's Quarterly MDS with an ARD of 03/18/2026 revealed he had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he had an indwelling catheter and was taking Anticoagulants. Review of Resident #46's Physician Orders dated May 2026 revealed the following, in part:Start date: 10/28/2025- Eliquis oral tablet 5 mg give one tablet by mouth two times a day for history of Thromboembolism related to Personal History of Pulmonary Embolism; and Start date: 04/03/2026- Macrobid oral capsule 100 mg give one capsule by mouth one time a day for Urinary Tract Infection prophylaxis. Review of Resident #46's Medication Administration Record dated May 2026 revealed the following, in part:Eliquis was documented as not administered for the following doses: 05/11/2026 at 7:30 a.m., 05/13/2026 at 7:30 p.m., 05/14/2026 at 7:30 p.m., 05/15/2026 at 7:30 p.m., 05/16/2026 at 7:30 p.m., 05/17/2026 at 7:30 a.m., and 05/18/2026 at 7:30 p.m.; and Macrobid was documented as not administered for the following doses: 05/06/2026 at 7:30 a.m., 05/08/2026 at 7:30 a.m., 05/09/2026 at 7:30 a.m., and 05/11/2026 at 7:30 a.m. Review of Resident #46's Nurses Notes dated May 2026 revealed the following, in part:05/06/2026 at 10:04 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Not available. Signed by S3LPN05/08/2026 at 9:05 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Not available. Signed by S3LPN05/09/2026 at 9:47 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Not available. Signed by S4LPN05/11/2026 at 7:21 a.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. Reordered. Signed by S5LPN05/11/2026 at 7:22 a.m. Macrobid oral capsule 100 mg give one capsule by mouth one time a day for UTI prophylaxis. Reordered. Signed by S5LPN05/13/2026 at 6:40 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. On order. Signed by S6LPN05/14/2026 at 8:02 a.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. Awaiting delivery. Signed by S5LPN05/14/2026 at 6:42 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. On order. Signed by S6LPN05/15/2026 at 6:41 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. On order. Signed by S6LPN05/16/2026 at 7:51 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. Pending delivery. Signed by S7LPN05/17/2026 at 7:40 a.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. Not available. Signed by S8LPN05/18/2026 at 7:59 p.m. Eliquis oral tablet 5 mg give one tablet by mouth two times a day for h/o thromboembolism related to Personal History of Pulmonary Embolism. Awaiting Delivery. Signed by S6LPNFurther review revealed no documented evidence the pharmacy or provider were notified the above doses of medications were not available for administration. Review of the facility's Emergency Kit List revealed Eliquis and Macrobid were available for use in the emergency kit. An interview was conducted with the facility's Pharmacist on 05/19/2026 at 12:05 p.m. He reviewed Resident #46's record and stated Macrobid was requested on 05/09/2026 and filled on 05/11/2026 with a 30 day supply. He stated Resident #46's Eliquis was requested and filled on 05/18/2026 with a 14 day supply. He stated there was no documented evidence the pharmacy was notified the medications were not available for administration on the above-mentioned dates. He stated Macrobid 100 mg capsules and Eliquis 2.5 mg tablets were available for administration in the facility's emergency kit. An observation was made of the facility's electronic emergency medication kit with S1DON on 05/19/2026 at 12:37 p.m. S1DON reviewed the list of medications contained in the emergency medication kit. She stated the emergency kit contained 10 tablets of Eliquis 2.5 mg and 30 capsules of Macrobid 100 mg. An interview was conducted with S7LPN on 05/19/2026 at 1:04 p.m. She verified she was assigned to Resident #46 on 05/16/2026 from 6:00 p.m. to 6:00 a.m. She stated Resident #46 was ordered Eliquis. She stated she cannot recall if Resident #46's Eliquis was not available for administration on 05/16/2026 during her shift. She stated if she documented a nurse's note indicating she was waiting on pharmacy, then the medication was not available and she did not administer it. She confirmed she did not check the facility's emergency kit to see if the Eliquis was available. She confirmed she did not contact the pharmacy or notify the Nurse Practitioner the medication was not available for administration. An interview was conducted with S3LPN on 05/19/2026 at 1:35 p.m. She verified she was assigned to Resident #46 on 05/06/2026 and 05/08/2026 from 6:00 a.m. to 6:00 p.m. She stated she could not recall if Resident #46 was ordered Macrobid. She stated if she documented a nurses' note and the medication was not administered on the MAR, then she did not administer the medication. She stated she could not recall if she notified the facility staff, the pharmacy or the Nurse Practitioner, Resident #46's Macrobid was not available for administration. She stated she did not check the facility's emergency kit to see if the medication was available. An interview was conducted with S5LPN on 05/19/2026 at 1:45 p.m. She stated she did not recall when she worked at the facility the month of May, but had worked on Resident #46's hall. She stated if she documented Resident #46's Eliquis and Macrobid were not administered, it was because they were not available. She stated she had never used the facility's emergency kit and was not sure what medications were available in it. She stated she did not recall notifying the pharmacy, the Nurse Practitioner, or any staff at the facility of Resident #46's medications were unavailable. An interview was conducted with Resident #46 on 05/19/2026 at 2:18 p.m. He stated in the last month, some of the nurses, unsure who, told him they did not have some of his medications. He stated he did not know which medications were missing or why they did not have them. He stated he took Eliquis for a history of blood clots. He stated he had a catheter and took Macrobid to prevent urinary tract infections. An interview was conducted with S8LPN on 05/19/2026 at 3:02 p.m. She verified she was assigned to Resident #46 on 05/17/2026 from 6:00 a.m. to 6:00 p.m. She stated Resident #46's Eliquis was not available for administration. She stated she did not notify the pharmacy or the Nurse Practitioner the medication was not available for administration. She stated she did not check the facility's emergency kit to see if Eliquis was available. An interview was conducted with S6LPN on 05/19/2026 at 3:41 p.m. She verified she was assigned to Resident #46 on 05/13/2026, 05/14/2026, 05/15/2026, and 05/18/2026 from 6:00 p.m. to 6:00 a.m. She stated Resident #46's Eliquis was not available for administration. She stated the Eliquis was reordered, but she was not sure who reordered it. She stated she did not notify the pharmacy or the Nurse Practitioner Resident #46's Eliquis was not available. She stated she did not check the facility's emergency kit to see if the medication was available. An interview was conducted with S4LPN on 05/19/2026 at 4:03 p.m. She verified she was assigned to Resident #46 on 05/09/2026 from 6:00 a.m. to 6:00 p.m. She stated his ordered Macrobid was not available. She stated she electronically reordered Resident #46's Macrobid. She stated she did not notify the Nurse Practitioner, pharmacist, or facility staff Resident #46's Macrobid was not available for administration. She stated she did not check the facility's emergency medication kit for the medication. An interview was conducted with S10NP on 05/19/2026 at 4:15 p.m. She stated Resident #46 was prescribed Eliquis for a history of Deep Vein Thrombosis and a Pulmonary Embolism. She stated Resident #46 had an indwelling catheter and was prescribed Macrobid prophylactically for Urinary Tract Infections. She reviewed Resident #46's clinical record and verified Eliquis and Macrobid were not administered on the above mentioned dates. She stated Resident #46 not receiving Eliquis as ordered put him at potential risk for blood clot development. She stated the potential risk of Resident #46 not receiving Macrobid as ordered was potential overgrowth of bacteria. She stated she was not notified Resident #46 missed any doses of Eliquis or Macrobid. She stated had she been notified she would have told the nurses both medications were available in the facility's emergency kits and to contact the pharmacy to have the medications delivered the next day. She confirmed she expected Resident #46's Eliquis and Macrobid to be administered as ordered. An interview was conducted with S1DON on 05/20/2026 at 8:15 a.m. She stated the nurses were responsible for obtaining medication refills. She stated if a medication was not available, the expectation was for the nurse to reach out to pharmacy to see why the medication was not available. She stated resident medications should be available for administration and doses should not be missed. She stated the Nurse Practitioner should be notified of any missed doses of medication. She was notified of the above mentioned missed doses of Resident #46's Eliquis and Macrobid. She reviewed Resident #46's clinical record and stated he had a history of blood clots and was prescribed Eliquis. She stated Resident #46 was prescribed Macrobid prophylactically for an upcoming suprapubic catheter procedure. She stated the possible risk of Resident #46 not receiving Eliquis as ordered was a blood clot and not receiving Macrobid as ordered was a Urinary Tract Infection. She confirmed she did not receive notification from any nurse about Resident #46's Eliquis or Macrobid not being delivered by pharmacy or administered to Resident #46. She stated she would have expected Resident #46's Eliquis and Macrobid to be administered as ordered, as both medications were available in the facility's emergency kit.

Based on observation, interviews and record review, the facility failed to ensure each resident received a therapeutic diet as ordered by the physician for 4 (#5, #31, #50 and #87) of 11 residents reviewed for dining.Resident #5Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Dementia and Abnormal Weight loss.Review of Resident #5's Current Physician Orders revealed a dietary order for double portions with a start date of 01/22/2026.Resident #31Review of Resident #31's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Alzheimer's disease.Review of Resident #31's Current Physician Orders revealed a dietary order for double portions with a start date of 06/03/2024.Resident #50Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Dementia and Abnormal Weight loss.Review of Resident #50's Current Physician Orders revealed a dietary order for double portions with a start date of 10/29/2025.Resident #87Review of Resident #87's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Acquired Absence of Other Specified Parts of the Digestive Tract.Review of Resident #87's Current Physician Orders revealed a dietary order for double portions with a start date of 04/02/2026.On 05/20/2026 at 11:44 a.m., an observation was made of Resident #5, #31, #50, and #87 eating lunch in the Restorative dining room. Each resident was observed receiving one plate of food.On 05/20/2026 at 12:25 p.m., an interview was conducted with S12RCNA. She reviewed Resident #5, #31, #50 and #87's meal tickets and confirmed they were supposed to receive double portions and did not.On 05/20/2026 at 12:29 p.m., an interview conducted with S16DM. She stated residents with orders for double portions are expected to receive two plates of food. She stated she expected her kitchen staff to review each meal ticket for special diet instructions, including double portions to ensure they supply each resident the correct type and amount of food. She confirmed Resident #5, #31, #50, and #87 had active orders for double portions and should have received two plates of food.On 05/20/2026 at 2:50 p.m., an interview was conducted with S2ADMIN. He confirmed all residents with an order for double portions should receive double portions for all meals.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure:1. Meat products were stored separate from or below dairy products in the facility's refrigerator; and2. The dishwasher reached 120 consistently during the rinse cycle while washing dishes.This deficient practice had the potential to affect 103 residents who consume food from the facility's kitchen.Review of the facility's policy dated 2001 and titled, Food Receiving and Storage, revealed, the following, in part:Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices.Refrigerated/Frozen Storage:8. Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Review of the facility's policy dated 2001 and titled, Sanitization, revealed the following, in part:Policy statement: The food service area is maintained in a clean and sanitary manner.Policy interpretation and implementation:5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: b. Low-Temperature Dishwasher (Chemical Sanitization):1. Wash temperature (120 )On 05/18/2026 at 8:03 a.m., a tour of the kitchen was conducted with S11CH. An observation was made of 2 boxes of diced chicken, 2 boxes of sausage, and a container including 2 rolls of ground meat stored directly above eggs and dairy products in the facility's refrigerator.On 05/18/2026 at 8:10 a.m., an interview was conducted with S11CH. She confirmed meat products should not have been stored above dairy products. She stated dietary staff was trained to store meat products in a separate refrigerator from dairy products. On 05/18/2026 11:57 a.m., an observation was made of the facility's dishwashing process with S11CH. The dishwashing process was observed for 5 sets of dishes, during which the rinse cycle did not reach 120 for 4 out of 5 sets of dishes washed.On 05/18/2026 at 12:10 p.m., an interview was conducted with S11CH. She confirmed the dishwasher did not reach 120 during the rinse cycle until the 5th set of dishes were washed. She further confirmed the dishwasher should reach 120 during each rinse cycle to ensure proper sanitization.On 05/18/2026 at 1:05 p.m., an interview was conducted with S2ADMIN. He confirmed meat products should not be stored above dairy products in the facility's refrigerator. He further confirmed the dishwasher should reach 120 during the rinse cycle each time it is utilized.

Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed proper glove usage and utilized proper Personal Protective Equipment (PPE) while providing care for 3 (#1, #89, and #98) of 4 sampled residents who were on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy, revised December 2024, titled, Enhanced Barrier Precautions revealed the following, in part: Policy Statement: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organism (MDROs) to residents. 2. Enhanced barrier precautions apply when: b. A resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gown and gloves are applied prior to performing the high contact resident care activity. 8. Exampled of high-contact resident care activities requiring the use of gown and gloves for EBPs include: c. providing hygiene or grooming; d. changing brief or assisting with toileting; f. providing bed mobility; i. device care or use; and j. wound care. Resident #1 Review of Resident #1's Clinical Record revealed an admission date of 09/24/2025 and diagnoses, which included Other Complications of Gastrostomy, and Left Gluteal Pressure Ulcer. Review of Resident #1's current Physician Order revealed the resident had daily treatment orders for a Left gluteal Pressure Ulcer and PEG site. Review of Resident #1's current Care Plan revealed the following, in part: Date Initiated: 09/29/2025 Problem: Risk for infection related to history of infection to PEG site. Intervention: (03/24/2026) Resident is on Enhanced Barrier Precautions. On 05/19/2026 at 8:49 a.m., an observation was made of the EBP sign above Resident #1's head of bed. The sign indicated the following: STOP - Enhanced Barrier Precautions Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Hygiene; Device care; and Wound care. On 05/19/2026 at 10:25 a.m., an observation was made of S35LPN performing wound care for Resident #1 with S36CNA assisting. S35LPN performed wound care to Resident #1's Left Glute Pressure Ulcer and PEG tube site. S36CNA assisted with turning Resident #1 from side to side in bed. S35LPN and S36CNA did not don a gown for any portion of the treatment. On 05/19/2026 at 10:38 a.m., an interview was conducted with S35LPN. She stated enhanced barrier precautions should have been followed when the resident had a catheter, PEG tube, or a wound. She stated Resident #1 was on EBP due to her Pressure Ulcer and PEG tube. She confirmed she should have worn a gown while providing wound care and PEG site care, and she did not. On 05/19/2026 at 11:12 a.m., an interview was conducted with S36CNA. She stated EBP was when you wear a gown and gloves for providing care to residents with indwelling medical devices and wounds. She confirmed Resident #1 had a PEG tube and a Pressure Ulcer. She confirmed she did not don a gown when assisting with providing care for Resident #1 and should have. On 05/19/2026 at 4:20 p.m., an interview was conducted with S1DON. She confirmed Resident #1 was on EBP for her PEG tube and Pressure Ulcer. She stated the expectation was for staff to don a gown and gloves when performing wound care and PEG site care. Resident #89 Review of Resident #89's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #89's current Physician's Orders revealed the resident had orders for enteral feeding. On 05/19/2026 at 8:40 a.m., an observation was made of the EBP sign above Resident #89's head of bed. The sign indicated the following: STOP - Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when the leaving the room Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Providing hygiene and changing briefs. On 05/19/2026 at 10:02 a.m. an observation was made of S17CNA performing peri-care for Resident #89. S17CNA performed hand hygiene and donned gloves. S17CNA removed Resident #89's soiled brief and cleaned resident with peri spray and wipes. Without removing the soiled gloves, performing hand hygiene, or donning clean gloves, S17CNA applied a clean brief and straightened residents clothing and bed linens. S17CNA did not don a gown while performing high contact care to Resident #89. On 05/19/2026 at 10:12 a.m. an interview was conducted with S17CNA. She stated she was not aware she should have worn PPE while changing Resident #89's brief. S17CNA confirmed she had not removed soiled gloves and performed hand hygiene before going from dirty to clean when performing peri care and should have. On 05/20/2026 at 10:00 a.m., an interview was conducted with S1DON. She stated staff should don a gown and gloves when providing high contact care for any residents on Enhanced Barrier Precautions. Resident #98 Review of Resident #98's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status. Review of Resident #98's current Physician's Orders revealed the resident had orders for PEG tube care and feeding. Review of Resident #98's current Care Plan revealed the following, in part: Date Initiated: 02/14/2026 Problem: Risk for infection related to Dysphagia, PEG tube status. Intervention: (03/24/2026) Resident is on Enhanced Barrier Precautions. On 05/20/2026 at 8:40 a.m., an observation was made of the EBP sign above Resident #98's head of bed. The sign indicated the following: STOP - Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when the leaving the room Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Device care or use: Feeding tube . On 05/20/2026 at 9:17 a.m., an observation was made of S9LPN administering tube feeding and water flushes for Resident #98. S9LPN pulled up Resident #98's gown, picked up the PEG tube and administered the tube feeding and water flush. S9LPN did not don a gown while performing high contact care to Resident #98. On 05/20/2026 at 9:30 a.m., an interview was conducted with S9LPN. She confirmed she did not don a gown prior to administering Resident #98's tube feeding. On 05/20/2026 at 10:00 a.m., an interview was conducted with S1DON. She stated Resident #98 had a PEG tube and was on Enhanced Barrier Precautions. She stated staff should don a gown and gloves when providing high contact care for Resident #98 and for any residents on Enhanced Barrier Precautions.

Based on observation, interviews and record review, the facility failed to maintain records in accordance with accepted professional standards and practices for 1 (#5) of 11 residents reviewed for dining. The facility failed to ensure Resident #5's eating ability and performance was documented daily and accurately.Review of the facility's policy dated 2001 and titled, Charting and Documentation, revealed the following, in part:Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation3. Documentation in the medical record will be objective, complete, and accurate.Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Dementia, Dysphagia, and Right Dominant Side Hemiplegia and Hemiparesis.Review of Resident #5's Current Care Plan revealed the following, in part:Focus: Restorative Nursing Programs needed due to assist in safely eating and drinking.Interventions: Please give a verbal and tactile cue to swallow. Check his mouth to make sure that it is clear. Continue until the meal is completed. Please check the resident's mouth to make sure it is clear when the meal is completed.Review of Resident #5's CNA Documentation Report for GG-Eating: The ability to use suitable utensil to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident, revealed missing documentation on the following dates: 04/03/2026, 04/08/2026, 04/09/2026, 04/11/2026, 04/13/2026, 04/14/2026, 04/18/2026, 04/19/2026, 04/21/2026, 04/23/2026, 04/27/2026, and 04/28/2026. Further review revealed the following documentation completed by S13CNA on 04/29/2026:7:30 a.m. and 12:30 p.m.: 06-Independent; and17:30 p.m.: 04-Supervision or Touching Assistance.On 05/20/2026 at 11:51 a.m., an observation was made of Resident #5 during his lunch meal. S12RCNA was observed providing Resident #5 1-on-1 feeding assistance during the entire meal. She was observed providing verbal and tactile cues for Resident #5 to swallow multiple times per bite of pureed solids. She was also observed feeding Resident #5 liquids and solids in an alternating pattern and checking his mouth throughout the meal to ensure it was clear before proceeding.On 05/20/2026 at 11:56 a.m., an interview was conducted with S12RCNA. She stated Resident #5 required 1-on-1 feeding assistance during meals due to impulsivity and high risk for aspiration and choking. She further stated all CNAs were required to accurately complete daily documentation regarding each resident's eating ability and performance.On 05/20/2026 at 1:40 p.m., an interview was conducted with S15ADON. She stated Resident #5 was not independent with eating in April of 2026. She stated he had always required at least close supervision due to cognitive safety concerns and ongoing swallowing issues. She reviewed the CNA documentation report for GG-Eating in April of 2026 and confirmed it was incomplete on the aforementioned dates. Upon further review, she confirmed Independent did not accurately reflect Resident #5's eating abilities. She stated she expected all CNAs to complete documentation daily and accurately in order to reflect each resident's eating ability and performance.On 05/20/2026 at 4:23 p.m., a phone interview was conducted with S13CNA. She stated she was familiar with Resident #5 and cared for him on 04/29/2026. She stated he always required at least close supervision during his meals due to his ongoing swallowing difficulties. She confirmed CNAs were required to accurately complete documentation daily to reflect each resident's eating ability and performance. She stated if an entry box was blank on the CNA Documentation Report, it was not completed and should have been. She further stated if she scored Resident #5's eating ability as Independent on 04/29/2026, it was inaccurate.

Based on observations, interviews, and record review, the facility failed to ensure resident equipment was maintained in a sanitary manner by failing to ensure wheel chairs were clean for 1 (#99) of 6 residents reviewed in the final sample.Findings: On 05/18/2026 and on 05/19/2026, observations were made of Resident #99 sitting in her wheelchair in the hallway. Resident #99's wheelchair frame appeared to be covered in approximately 1/2 inch thick, gray, dust-like substance. The frame of the wheelchair near the wheels had approximately 1/2 inch thick amount of hair and dust wrapped around it. On 05/19/2026 at 1:30 p.m., an interview was conducted with S32CNA. S32CNA observed Resident #99's wheelchair base to be covered in thick dust and hair. S32CNA confirmed Resident #99's wheelchair needed to be cleaned. She stated the night shift CNAs are expected to clean the wheelchairs. On 05/19/2026 at 1:34 p.m., an interview was conducted with S34CNA. S34CNA observed Resident #99's wheelchair base to be covered in thick dust and hair. S34CNA confirmed Resident #99's wheelchair needed to be cleaned. On 05/19/2026 at 1:38 p.m., an interview was conducted with S15ADON. S15ADON observed the above findings. S15ADON stated the night shift CNAs have a schedule to clean odd room wheelchairs every Monday, Wednesday, and Friday. S15ADON stated night shift CNAs clean even room wheelchairs every Tuesday, Thursday, and Saturday. S15ADON stated CNAs are expected to clean the entire wheelchair. S15ADON confirmed Resident #99's wheelchair needed to be cleaned. On 05/19/2026 at 2:02 p.m., an interview was conducted with S1DON. S1DON stated she expected CNA staff to follow the process on cleaning wheelchairs. S1DON stated wheelchairs should not be dirty. S1DON stated she expected CNA staff to be cleaning wheelchairs per the cleaning schedule.

Based on observations, interviews, and record review, the facility failed to implement a resident's comprehensive care plan by failing to ensure PEG tube free water flushes was administered as ordered by the physician for 1 (#1) of 3 residents reviewed for tube feeding.Findings: Review of Resident #1's Clinical Record revealed an admission date of 09/24/2025 and diagnoses, which included Cerebral Palsy, Moderate Protein-Calorie Malnutrition, and Other Complications of Gastrostomy. Review of Resident #1's current Physician Orders revealed the following, in part:Enteral Feed: Two Cal continuous feed at 40mL/hour and free water flushes at 54 mL/hr. Review of Resident #1's current Care Plan revealed the following, in part:Problem: Risk for altered fluid balance related to modified diet (NPO) with PEGInterventions: Fluids via PEG as ordered. An observation was made of Resident #1 on 05/19/2026 at 8:50 a.m. She had tube feeding and water flushes infusing via pump. The pump did not immediately display the water flush rate. An observation was made of Resident #1's tube feeding and pump with S19LPN on 05/19/2026 at 9:06 a.m. S19LPN toggled through the pump selections and observed Resident #1's water flush rate on Resident #1's tube feeding pump. S19LPN confirmed the water flush rate was set at 300 mL water flush every four hours. An interview was conducted with S19LPN on 05/19/2026 at 9:10 a.m. S19LPN reviewed Resident #1's clinical record and confirmed Resident #1 was ordered water flushes via PEG tube at 54 mL/hr. S19LPN confirmed Resident #1's water flush via PEG tube was not infusing at the ordered rate and should have been. S19LPN stated all nurses were responsible for checking tube feeding and water flush rates each shift. An interview was conducted with S1DON on 05/19/2026 at 4:20 p.m. She confirmed Resident #1's water flushes via PEG tube were not infusing at the physician ordered rate and should have been. She confirmed she observed the pump, and the free water was infusing at 300 mL every 4 hours and should have been at 54 mL/hr.

Based on observations, interviews, and record review, the facility failed to provide sufficient nursing staff to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care by failing to provide incontinence care timely for 1 (#4) of 6 residents reviewed for incontinence.Findings: Review of the facility's policy, revised August 2022, titled, Staffing, Sufficient and Competent Nursing revealed the following, in part:Policy statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.Policy Interpretation and Implementation:Sufficient Staff6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment.7. Factors considered in determining appropriate staffing ratios and skills include an evaluation of the disease, condition, physical or cognitive limitation of the resident population, and acuity.8. Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing. Review of the facility's Facility assessment dated 2026 revealed the following, in part:Function - Care Requirements:Types of care required-The resident population of the facility ranges from very high functioning with ADLs to very low functioning. The physical functioning of the residents has changed slightly with more residents needing 2 person or supervision versus 1 person assistance.Services required for the population currently are those of CNAs, LPNs, RNs.Staff/personnel required is the same as the minimum standard of 2.35 as per guidelines. Review of the facility's census dated 04/21/2026 revealed there were a total of 99 facility residents. Further review revealed there were 29 residents on Hall D, 40 residents on Hall E, and 30 residents on Hall F. Review of the facility's Daily Nursing Assignment Sheets for the day shift from 6:00 a.m. to 6:00 p.m. revealed the facility planned to staff 3 CNAs on each Halls D, E, and F. Review of Hall E's Assistance Required Sheet revealed there were 27 residents who were incontinent of bladder and 7 residents required transfers via the Hoyer lift. Review of the facility's Daily Nursing Assignment Sheet dated 04/21/2026 from 6:00 a.m. to 6:00 p.m. revealed S12CNA, S10CNA, and S8CNA were assigned to Hall E. Further review revealed no other CNAs were assigned to Hall E. Review of the facility's Daily Nursing Assignment Sheet dated 04/22/2026 from 6:00 a.m. to 6:00 p.m. revealed S9CNA, S13CNA, and S8CNA were assigned to Hall E. Further review revealed no other CNAs were assigned to Hall E. Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebrovascular Disease, Generalized Muscle Weakness, Anxiety Disorder, Hemiplegia and Hemiparesis, and Depression. Review of Resident #4's Quarterly MDS with an ARD of 01/21/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she was frequently incontinent of bladder and bowel and was dependent on staff for toileting hygiene and transfers. Review of Resident #4's current Care Plan revealed the following, in part:Problem: Incontinent of bowel and bladder since admission.Interventions: Change soiled clothing after each incontinent episode and check at least every two hours and as needed for incontinence. An interview was conducted with Resident #4 on 04/21/2026 at 2:48 p.m. She stated the night shift CNA got her out of bed at 4:00 a.m. this morning. She stated she had not been changed since she got out of bed this morning and she needed to be changed. She stated the day shift did not provide incontinence care every two hours or when she needed to be changed. She stated the CNAs told her they were short staffed. An observation was made of S7CNA and S8CNA transferring Resident #4 into bed on 04/21/2026 at 3:42 p.m. via the Hoyer lift. S7CNA and S8CNA provided incontinence care for Resident #4. Resident #4 had on a blue incontinence brief and a yellow incontinence brief. Both briefs were saturated with urine. Resident #4's pants were also saturated with urine. An interview was conducted with S8CNA on 04/21/2026 at 4:04 p.m. She stated she was assigned to Resident #4 today from 6:00 a.m. to 6:00 p.m. She explained she was assigned to Resident #4 each day she worked. She stated Resident #4 was always incontinent and required a Hoyer lift for transfers. She stated Resident #4 was transferred out of bed on night shift. She confirmed Resident #4 was saturated with urine and was double briefed during incontinence care today. She confirmed Resident #4 was up in her wheelchair when she arrived for her shift this morning. She confirmed Resident #4 had not received incontinence care during her shift today until 3:42 p.m. She stated Resident #4 was up in her wheelchair when she arrived for her shift at 6:00 a.m. every day. She stated, on the days she worked, she never checked or changed Resident #4 before 1:00 p.m. She stated she was assigned to 13 residents currently. She stated she ran non-stop all day trying to take care of every resident and was unable to meet the needs of the residents timely. She explained there was not enough staff on Hall E to check and change residents every two hours and as needed. She explained Resident #4 had to be transferred to bed with the Hoyer lift for incontinence care. She stated it was physically impossible for her to complete that every two hours and take care of all the other residents, which included incontinence care, feeding, showering, and addressing any additional needs. She stated she checked and changed other incontinent residents in her section two to three times during her twelve hour shifts. An interview was conducted with S10CNA on 04/21/2026 at 4:32 p.m. She confirmed she was assigned to Hall E today from 6:00 a.m. to 6:00 p.m. She stated incontinence rounds should have been conducted every two hours. She stated she was unable to check and change incontinent residents every two hours because there was not enough staff to meet the residents' needs timely. An observation was made of Resident #4 on 04/22/2026 at 7:53 a.m. She was seated in her room in her wheelchair. An interview was conducted with Resident #4 at that time. She stated the night shift got her out of bed with the Hoyer lift this morning at 4:00 a.m. She stated the CNAs changed her brief before they got her up. An observation was made of S8CNA and S9CNA transferring Resident #4 into bed to provide incontinence care on 04/22/2026 at 8:31 a.m. S8CNA and S9CNA placed Resident #4 into the bed with the Hoyer lift. Resident #4's urine saturated through her incontinence brief, pants, lift pad, and wheelchair cushion. An interview was conducted with S8CNA on 04/22/2026 at 9:04 a.m. She confirmed she was assigned to Resident #4 today from 6:00 a.m. to 6:00 p.m. She confirmed Resident #4's urine saturated through her incontinence brief, pants, lift pad, and onto the wheelchair cushion. She stated Resident #4 should have been changed before breakfast. She stated she had not had time to change Resident #4 prior to now. She stated Hall E needed more than 3 CNAs because they were not able to meet the residents' needs timely with 3 CNAs. An interview was conducted with S9CNA on 04/22/2026 at 9:28 a.m. She confirmed she was assigned to Hall E today from 6:00 a.m. to 6:00 p.m. She stated there were 3 CNAs assigned to Hall E. She stated she was not able to meet the residents' needs timely with 3 CNAs. She stated incontinence checks fell behind due to not being able to change all assigned residents timely. She stated there were multiple residents who required assistance of two staff members. She stated sometimes residents soiled their clothing with urine or bowel movement due to not being able to make rounds timely. She stated she also had to help in other sections for the residents who required 2-person assist. She stated the hall CNAs were responsible for showers/baths for their assigned residents. An interview was conducted with S13CNA on 04/22/2026 at 1:00 p.m. She confirmed she was assigned to Hall E today from 6:00 a.m. to 6:00 p.m. She stated there were 3 CNAs assigned to Hall E. She stated she was assigned to 12 residents. She stated 6 of the residents in her section required 2 person assistance. She stated 7 of her assigned residents were incontinent. She stated the hall CNAs were also responsible for their assigned residents' showers/baths. She stated incontinence rounds should have been conducted every two hours. She stated there were times when she was not able to complete all the assigned baths during her shift because she did not have time. She stated residents who required a Hoyer lift for transfers often had to wait because there had to be another staff member available to transfer them. She stated sometimes all staff were busy, which led to the Hoyer lift residents not receiving incontinence checks/care every two hours as required. An interview was conducted with S3ADON on 04/22/2026 at 2:40 p.m. She stated she expected CNAs to make incontinence rounds every two hours and as needed. She stated she was responsible for CNA staffing. She stated she had a staffing spreadsheet she utilized to determine CNA staffing levels. She stated the staffing was based on the facility's census. She explained the CNAs were distributed into sections based on acuity. She stated with the current census, the facility staffed 3 CNAs on each hall for day shift. An interview was conducted with S2DON on 04/22/2026 at 3:32 p.m. She stated she expected CNAs to make incontinence rounds every two hours and as needed unless otherwise care planned. She confirmed there were 29 residents on Hall D, 40 residents on Hall E, and 30 residents on Hall F. She confirmed there were 3 CNAs assigned to Hall D, Hall E, and Hall F. She stated the acuity was evenly distributed between all halls. An interview was conducted with S1ADM on 04/22/2026 at 10:12 a.m. He stated the facility staffed nurses and CNAs by ensuring they were always at or above the required 2.35 hours per person, per day (PPD). He stated the CNA assignments were made based on the residents' acuity at that given time.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received incontinence care timely to maintain good personal hygiene for 2 (#2 and #4) of 6 residents reviewed for incontinence.Findings: Resident #2Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Dementia With Psychotic Disturbance. Review of Resident #2's Quarterly MDS with an ARD of 04/01/2026 revealed she had a BIMS of 99, which indicated she was unable to complete the interview. Further review revealed she was always incontinent of bladder and bowel, was dependent on staff for toileting hygiene, and required substantial/maximal assistance for transfers. Review of Resident #2's current Care Plan revealed the following, in part:Problem: Incontinent of bowel and bladder.Interventions: Change soiled clothing after each incontinent episodeProblem: Activities of Daily Living self-care performance deficit related to incontinent of bowel and bladder.Interventions: Incontinent of bowel and bladder. Incontinent care during rounds and as needed. Review of Resident #2's Nurses' Notes dated 04/21/2026 through 04/22/2026 revealed no documentation she refused incontinence care. An observation was made of Resident #2 on 04/21/2026 at 3:30 p.m. She was seated in her wheelchair in the dining room. An observation was made of Resident #2 on 04/21/2026 at 4:30 p.m. She was seated in her wheelchair in the dining room. An observation was made of Resident #2 on 04/21/2026 at 5:35 p.m. She was seated in her wheelchair in the dining room. An observation was made of S10CNA entering the dining room on 04/21/2026 at 5:52 p.m. S10CNA wheeled Resident #2 from the dining room, down the hall to the common area, and placed her wheelchair near the television. S10CNA did not perform an incontinence care check for Resident #2. Resident #2 was observed in the common area until 7:54 p.m. No staff provided incontinence checks or care during this time. An observation was made of S6CNA and S11CNA transferring Resident #2 into bed on 04/21/2026 at 7:55 p.m. S6CNA and S11CNA provided incontinence care for Resident #2. Resident #2's brief was saturated with urine. Resident #2's shorts were saturated with urine. An interview was conducted with S6CNA on 04/21/2026 at 8:03 p.m. She confirmed Resident #2's incontinence brief and her shorts were saturated with urine. She stated she was unsure what time the day shift last changed Resident #2. She stated Resident #2 should have been changed at least every two hours and should not have been that saturated. An interview was conducted with S11CNA on 04/21/2026 at 8:06 p.m. She confirmed Resident #2 was overly saturated with urine through her brief and onto her shorts. She stated Resident #2 was not a heavy wetter and was usually dry when she put her to bed around 8:00 p.m. She stated Resident #2 could not have been changed timely with the amount of urine she had in her brief and on her clothing. An interview was conducted with S12CNA on 04/22/2026 at 9:35 a.m. She verified she was assigned to Resident #2 on 04/21/2026 from 6:00 a.m. to 6:00 p.m. She stated the last time she provided incontinence care to Resident #2 on 04/21/2026 was sometime before 3:30 p.m. She confirmed Resident #2 was incontinent of bowel and bladder. She stated incontinent care should be provided every 2 hours and as needed. An interview was conducted with S10CNA on 04/22/2026 at 10:00 a.m. She stated incontinent care should be provided to residents every 2 hours and as needed. She stated Resident #2 was incontinent. She confirmed on 04/21/2026 at 5:52 p.m. she wheeled Resident #2 in her wheelchair from the dining room to the common area. She confirmed she did not perform an incontinence care check for Resident #2. Resident #4Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Unspecified Sequelae of Unspecified Cerebrovascular Disease, Generalized Muscle Weakness, and Hemiplegia and Hemiparesis. Review of Resident #4's Quarterly MDS with an ARD of 01/21/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she was frequently incontinent of bladder and bowel and was dependent on staff for toileting hygiene and transfers. Review of Resident #4's current Care Plan revealed the following, in part:Problem: Incontinent of bowel and bladder since admission.Interventions: Change soiled clothing after each incontinent episode and check at least every two hours and as needed for incontinence. Review of Resident #4's Nurses' Notes dated 04/21/2026 through 04/22/2026 revealed no documentation she refused incontinence care. An interview was conducted with Resident #4 on 04/21/2026 at 2:48 p.m. She was seated in her wheelchair in her room. She stated the night shift got her up daily. She stated S6CNA got her out of bed at 4:00 a.m. this morning. She stated she had not been changed since she got out of bed this morning, and she needed to be changed. She stated the day shift did not provide incontinence care every two hours or when she needed to be changed. She stated the day shift CNAs would not change her throughout the day and would only change her when they put her back to bed around 4:00 p.m. She stated she asked the CNAs to put two briefs on her before because she knew how long she would be sitting up without being changed. She stated she wanted the staff to check her for incontinence every two hours and change her when she needed. She stated she did not always know when she had urinated or had a bowel movement so she needed the staff to check. An observation was made of S7CNA and S8CNA transferring Resident #4 into bed on 04/21/2026 at 3:42 p.m. via the Hoyer lift. S7CNA and S8CNA provided incontinence care for Resident #4. Resident #4 had on a blue incontinence brief and a yellow incontinence brief. Both briefs were saturated with urine. Resident #4's pants were also saturated with urine. Resident #4 had a bowel movement. An interview was conducted with S8CNA on 04/21/2026 at 4:04 p.m. She stated she was assigned to Resident #4 today from 6:00 a.m. to 6:00 p.m. She stated she was assigned to Resident #4 each day she worked. She stated Resident #4 was always incontinent and required a Hoyer lift for transfers. She stated Resident #4 was transferred out of bed daily on the night shift. She confirmed Resident #4 was saturated with urine and was double briefed during incontinence care today. She confirmed Resident #4 was up in her wheelchair when she arrived for her shift this morning. She confirmed Resident #4 had not received incontinence care during her shift today until 3:42 p.m. She stated incontinence rounds should have been conducted every two hours. She stated Resident #4 had not refused any incontinence care today. She stated Resident #4 should not have been double briefed. She stated sometimes Resident #4 had two briefs on when she changed her. She stated, on each shift she worked, she never checked or changed Resident #4 before 1:00 p.m. An interview was conducted with S4LPN on 04/21/2026 at 4:55 p.m. She stated rounds should have been conducted on all residents every two hours. She stated rounds included checking for incontinence. She confirmed Resident #4 was incontinent. She stated she was unaware Resident #4 had not been changed from 4:00 a.m. until 3:42 p.m. today. She stated Resident #4 should have been changed every two hours. An interview was conducted with S6CNA on 04/21/2026 at 6:18 p.m. She confirmed she was the night shift CNA for Resident #4. She stated Resident #4 was incontinent of bladder and bowel. She stated incontinence rounds should have been conducted on all residents at least every two hours. She stated she transferred Resident #4 out of bed on her shift daily. She confirmed she double briefed Resident #4 this morning. She stated she should not have placed two briefs on any resident. She stated she was trying to prevent Resident #4's clothing from being soiled by 8:00 a.m. An observation was made of Resident #4 on 04/22/2026 at 7:53 a.m. She was seated in her room in her wheelchair. An interview was conducted with Resident #4 at that time. She stated the night shift got her out of bed with the Hoyer lift this morning at 4:00 a.m. She stated the CNAs changed her brief before they got her up. She stated she had not been changed since she got up. She stated she needed to be changed. Resident #4 stated she tracked time using her watch. An observation was made of Resident #4's watch on her wrist, which read accurate time. An observation was made of S8CNA and S9CNA transferring Resident #4 into bed to provide incontinence care on 04/22/2026 at 8:31 a.m. S8CNA and S9CNA placed Resident #4 into the bed with the Hoyer lift. Resident #4's urine soiled through her incontinence brief, pants, lift pad, and wheelchair cushion. An interview was conducted with S9CNA on 04/22/2026 at 8:43 a.m. She confirmed Resident #4's urine saturated through her incontinence brief, pants, lift pad, and wheelchair cushion. An interview was conducted with S8CNA on 04/22/2026 at 9:04 a.m. She confirmed Resident #4's urine saturated through her incontinence brief, pants, lift pad, and onto the wheelchair cushion. She confirmed she had to replace the wheelchair cushion. She stated she was unaware what time the night shift got Resident #4 out of bed. She stated Resident #4 should have been changed before breakfast. An interview was conducted with S5LPN on 04/22/2026 at 9:11 a.m. She stated Resident #4 was out of bed when she arrived for her shift at 6:00 a.m. She stated Resident #4 was incontinent and had to be transferred via Hoyer lift. She stated CNAs should have checked for incontinence every two hours. An interview was conducted with S3ADON on 04/22/2026 at 2:40 p.m. She stated she expected CNAs to make incontinence rounds every two hours and as needed. An interview was conducted with S2DON on 04/22/2026 at 3:32 p.m. She stated she expected CNAs to make incontinence rounds every two hours and as needed unless otherwise care planned. She confirmed Resident #2 was incontinent and required staff assistance for transfers. She confirmed Resident #4 was incontinent and required a Hoyer lift for transfers. She stated double briefing was pointless and unacceptable.

Based on interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse and psychosocial harm for 1 (#75) of 2 (#46 and #75) residents reviewed for abuse. The facility failed to ensure Resident #75 was free from physical abuse and psychosocial harm by Resident #46. This deficient practice resulted in a psychosocial harm on 03/03/2025 at 12:12 p.m. when Resident #75 reported to S2DON she did not feel safe in her home after an incident where Resident #46 hit her on the head. Resident #75 did not want to leave her room on 03/04/2025 because she was afraid of Resident #46. Resident #75 reported to Resident #87 that she was being scared when Resident #46 returned from the hospital on 03/10/2025. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #75, Resident #75 experienced psychosocial harm when she verbalized she was afraid of Resident #46 and wanted to stay in her room after Resident #46 hit her in the head. It could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #46 hitting Resident #75 in the head, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2001 revealed, in part, the following: Policy Interpretation and Implementation: 1. Protect residents from abuse by anyone including, but not necessarily limited to: 2. Other Residents. Review of the facility's policy titled Recognizing Signs and Symptoms of Abuse/Neglect, dated 2001 revealed, in part, the following: All types of abuse .are strictly prohibited. Policy and Interpretation and Implementation 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. 4. The following are signs and symptoms of abuse/neglect . a. Signs of physical abuse 1. Injuries that are non-accidental or unexplained d. Psychological or behavioral signs of abuse or neglect: 1. Expression of fear of a person or place . Resident #46 Review of Resident #46's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included, Paranoid Schizophrenia, Cognitive Communication Deficit, Bipolar Disorder and Unspecified Dementia. Review of Resident #46's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/26/2025 revealed a BIMS (Brief Interview for Mental Status) score of 7, which indicated severe cognitive impairment. Review of the State Agency Report revealed the following: Event Occurred: 03/03/2025 at 9:55 a.m. Victim: Resident # 75 Accused: Resident # 46 Description: Resident #75 was observed standing in the lobby with her hand on the back of her head and stated she hit me and pointed at Resident #46. Resident #75 verbalized she was fearful of Resident #46. Review of Resident #46's nurses' notes revealed, in part, the following: 03/03/2025 at 10:00 a.m. Resident #46 walked up behind Resident #75 sitting on a couch and proceeded to hit Resident #75 on the head. Resident #46 stated, she is trying to kill everyone, and I am going to take care of her myself. Resident #46 was placed on one on one supervision. Resident #75 Review of Resident #75's clinical record revealed she was admitted on [DATE] with medical diagnoses, which included, Unspecified Dementia and Major Depressive Disorder. Review of Resident #75's quarterly MDS with an ARD of 02/26/2025 revealed she had a BIMS of 4, which indicated severe cognitive impairment. Review of Resident #75's nurses' notes revealed, in part, the following: 03/03/2025 at 11:07 a.m. Resident #75 reported to staff she was hit on the back of the head by Resident #46. Review of Resident #75's Nurse Practitioner notes revealed the following: 03/03/2025 Assessment/Plan: Resident #75 was seen today because she was hit in the back of the head by Resident # 46. Resident #75 verbalized she was fearful of Resident #46. On 04/15/2025 at 9:21 a.m., an interview was conducted with Resident #75. She stated she did not remember being hit on the head and could not recall the event. On 04/15/2025 at 9:21 a.m., an interview was conducted with S8LPN. She stated on 03/03/2025, staff reported Resident #46 hit Resident #75 in the head. She stated on 03/04/2025, Resident #75 was scared of Resident #46 and wanted to stay in her room. She stated on 03/10/2025 when Resident #46 returned from the hospital Resident #75 appeared nervous and asked her if Resident #46 was going to hurt her again. On 04/15/2025 at 1:17 p.m., an interview was conducted with Resident #87, a cognitively intact resident. She confirmed she shared a room with Resident #75. She stated on 03/03/2025, Resident #75 was sitting on the couch in the activity room and Resident #46 walked behind the couch and hit Resident #75 three times on the head with a closed fist. She stated Resident #75 told her she was scared Resident #46 would hurt her again when Resident #46 returned from the hospital on 03/10/2025. On 04/16/2025 at 11:25 a.m., an interview was conducted with S14DOO. He stated on 03/03/2025 he walked out of the conference room and into the activity room and saw Resident #75 holding her head. He stated Resident #75 pointed to Resident #46 and stated she hit me. On 04/16/2025 at 12:38 p.m., an interview was conducted with S7NP. She stated she was informed on 03/03/2025 that Resident #46 hit Resident #75 on the head. She stated she assessed Resident #46 and Resident #75 on 03/03/2025. She stated Resident #75 did not have any injuries but verbalized she was afraid of Resident #46 on 03/03/2025. On 04/16/2025 at 12:57 p.m., an interview was conducted with S2DON. She stated on 03/03/2025 it was reported Resident #46 hit Resident #75 on the head. She stated Resident # 75 had short term memory loss and was cognitively impaired. She stated initially Resident # 75 verbalized she was scared of Resident #46 but as time progressed, Resident #75 remembered less and less and was no longer fearful of Resident #46. She confirmed being hit on the head would be considered physical abuse and residents should feel safe in their home. On 04/16/2025 at 1:35 p.m., an interview was conducted with S1ADM. He stated he reviewed the video footage from 03/03/2025 and Resident #75 was sitting on the couch and Resident #46 walked behind her. He stated Resident #46's hand was open and he could not tell if she hit Resident #75. He stated Resident #75 then was seen holding her head with her hand and reported Resident #46 hit her on the head. He stated Resident #46 had an acute psychotic episode on 03/03/2025 and therefore he did not think it was physical abuse.

Based on record review and interview the facility failed to submit accurate payroll information for direct care staffing as required. Findings: Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter (QTR) 1 2025 dated 10/01/2024 through 12/31/2024 revealed triggers for the following: One Star Staffing Rating, Excessively Low Weekend Staffing, No Registered Nurse (RN) Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day. Further review of the PBJ staffing report revealed the triggers for No RN Hours and Failed to have Licensed Nursing Cover 24 Hours/Day had infraction dates of 12/01/2024 through 12/31/2024. On 04/16/2025 at 9:32 a.m., an interview was conducted with S1ADM. He stated he was responsible for uploading the PBJ reports. He confirmed he did not have a PBJ Final Validation Report for December 2024. He stated the codes for direct care staffing were not transferred over to the PBJ report accurately for December 2024, and should have been.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded the diagnoses of Post-Traumatic Stress Disorder for 2 of 2 (#40 and #87) residents reviewed for PTSD. Findings: Resident #40 Review of Resident #40's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included PTSD. Review of Resident #40's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed in part, the following: Section I: Active Diagnoses: Psychiatric/Mood Disorder I6100: PTSD was unchecked. Resident #87 Review of Resident #87's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included PTSD. Review of Resident #87's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2025 revealed in part, the following: Section I: Active Diagnoses: Psychiatric/Mood Disorder I6100: PTSD was unchecked On 04/16/2025 at 8:24 a.m., an interview was conducted with S17MDS. She stated she was responsible for completing MDS assessments. She reviewed Resident #40 and #87's diagnoses list, and confirmed both had an active diagnosis of PTSD. S17MDS then reviewed Resident #40 and #87's aforementioned MDS assessments and confirmed the PTSD diagnosis was not marked as present and should have been. On 04/16/2025 at 1:30 p.m., an interview was conducted with S2DON. She stated she expected MDS nurses to complete all assessments to accurately reflect each residents' active diagnoses and current status. 52097

Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure a resident received an appointment with an ENT specialist for 1 (#34) of 2 (#34 and #51) residents reviewed for hospitalization . Review of Resident #34's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Traumatic Subdural Hemorrhage and Dysphonia. Review of Resident #34's physician orders revealed in part, the following: 02/18/2025 please refer to a private physician for evaluation of persistent hoarseness. Review of Resident #34's Nurse Practitioner Progress notes revealed in part, the following: 03/05/2025 Referral toa private physician was denied for evaluation. Will refer to a local ENT. An interview was conducted with S10WC on 04/16/2025 at 12:17 p.m. She stated she was informed by the nurses, DON, or NP for any new request for appointments. She reviewed Resident #34's physician order dated 02/18/2025 for a referral to a private physician for evaluation. She confirmed on the top of the physician order, in her writing, it stated referral was denied, does not meet internal guidelines. She stated her normal process was to notify the DON or NP, but stated she could not confirm she notified them of the denied referral. She stated she was notified on 04/10/2025 of the physician order to schedule an appointment for Resident #34 with a local ENT. An interview was conducted with S18NP on 04/16/2025 at 12:38 p.m. She reviewed Resident #34's Nurse Practitioner progress note dated 03/05/2025 and confirmed S19NP noted to refer to a local ENT. She confirmed an appointment should have been made at that time. She stated on 04/10/2025 when Resident #34 presented with shortness of breath, she reviewed Resident #34's clinical record and noted the ENT appointment had not been scheduled. She confirmed during this interview time she reached out to S19NP, and S19NP informed her she could not remember if she gave a verbal order for staff to schedule an ENT appointment on 03/05/2025. An interview was conducted with S2DON on 04/16/2025 at 12:57 p.m. She stated the NP should enter their own orders. She stated the appointment for Resident #34 should have been scheduled prior to 04/10/2025 but they were not aware of the request until 04/10/2025. She confirmed there was not a system in place to check Nurse Practitioner progress notes against physician orders.

Based on interviews and record review, the facility failed to ensure residents who are trauma survivors received trauma-informed care and services in accordance with professional standards of practice for 2 of 2 (#40 and #87) residents reviewed with a diagnosis of Post-Traumatic Stress Disorder (PTSD). Findings: Resident #40 Review of Resident #40's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of Resident #40's most recent Care Plan revealed Resident #40 was not care planned for PTSD. Review of Resident #40's Psychiatric Note dated 07/17/2024 revealed in part, the following: Nurse reported that Resident #40 has been actively and aggressively responding to internal stimuli, cursing to himself and agitated. He had been yelling at staff and peers, as well. Resident #87 Review of Resident #87's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of Resident #87's most recent Care Plan revealed Resident #87 was not care planned for PTSD. On 04/15/2025 at 1:17 p.m., an interview was conducted with Resident #87. She stated her diagnosis of PTSD was from her first husband raping her and her father having tortured and abused her. She stated taking off her clothes in front of males was a trigger and made her feel uncomfortable. On 04/15/2025 at 12:32 p.m., an interview was conducted with S16LPN. She confirmed she was assigned to Resident #40 care. She stated she was not aware of Resident #40 PTSD diagnosis nor interventions to prevent triggers and/or trauma reoccurrence. She stated Resident #40 should have been care planned for PTSD and interventions should have been established through the resident-centered care plan. On 04/16/2025 at 8:24 a.m., an interview was conducted with S17MDS. She stated she was responsible for MDS assessments and care plans. She reviewed Resident #40 and #87's diagnoses list, and confirmed the residents had an active diagnosis of PTSD. S17MDS then reviewed Resident #40 and #87's Care plan and confirmed they were not care planned for the management of PTSD and should have been. On 04/16/2025 at 8:46 a.m., an interview was conducted S15SSD. She stated she completed the trauma assessment on admit and quarterly. She stated she was not aware Resident #87 had a history of sexual abuse and mental abuse. She confirmed she never asked Resident #87 why she had the PTSD diagnosis. She stated she did not know why Resident #40 had a diagnosis of PTSD due to being non-interviewable. She confirmed Resident #40 and #87 were not care planned for the management of PTSD and should have been. 52097

Based on observations, interviews and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. A multi dose vial of insulin was dated upon opening; and 2. Medication Cart #3 was kept locked when not under direct observation of authorized staff. This deficient practice had the ability to affect any of the 105 residents who received medications in the facility. Findings: Review of the facility's policy, titled Medication Labeling and Storage with a revised date of February 2023 revealed the following, in part: Medication Labeling: 5. Multi-dose vials that have been opened or accessed are dated . 1. On 04/14/2025 at 2:38 p.m., an observation was conducted of Refrigerator in Medication room [ROOM NUMBER] with S11LPN. Observed was an opened and undated multi-dose vial of insulin labeled with Resident #84's name. On 04/14/2025 at 2:40 p.m., an interview was conducted with S11LPN. She confirmed the observation of the opened multi-dose vial of insulin, and stated it should have been dated when opened and was not. 2. On 04/14/2025 at 2:56 p.m., an observation was conducted of Medication Cart #3 left unattended and unlocked in the hallway from 2:56 p.m., until S3LPN returned at 3:05 p.m. On 04/14/2025 at 3:06 p.m., an interview was conducted with S3LPN. She confirmed Medication Cart #3 was left unattended and unlocked while she performed resident care with the resident's door closed, and the cart should have been locked before she walked away. On 04/15/2025 at 2:34 p.m., an interview was conducted with S2DON. She confirmed she expected staff to label and date any multi-dose vial of medication such as insulin upon it being opened. She stated she expected staff to keep all medication carts locked when unattended.

Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The facility failed to ensure Resident #1 and Resident #3 were free from physical abuse by Resident #2. This deficient practice resulted in an actual harm on 11/22/2024, at 3:56 p.m., when Resident #2, a resident know with physically abusive behaviors towards other residents, physically punched Resident #1 in the face and neck multiple times resulting in Resident #1 being evaluated and treated at a local hospital with diagnostic testing. Resident #1 experienced physical pain, facial swelling, and bloody drainage from the nose as a result of this incident. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Harm. Findings: Cross Reference F656 Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed the following, in part: Policy Interpretation and Implementation 1. Protect residents from abuse by anyone including but not limited to .other residents. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart Disease and Stroke with Left Sided Weakness. Review of Resident #1's Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2024 revealed in part, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Dementia with Behavioral Disturbances and Psychotic Disorders. Review of Resident #2's Admission MDS with an ARD of 10/08/2024 revealed, in part, a BIMS of 5, which indicated the resident had severe cognitive impairment. Review of Resident #2's Plan of Care, dated 09/30/2024, and updated 11/22/2024, revealed in part: Focus: Behavior Management History of sun downing, confusion, wandering, delusional, hallucinations, cursing, yelling/screaming, takes items from others, refusal of meds at times. 11/04/2024 verbal altercation with peer. 11/06/2024 pushed a peer causing her to fall. Interventions: emergency room Evaluation, Psych NP evaluation, Medications adjusted. 1:1 Observation, and 11/19/2024 stepped down to line of sight observation. Review of the facilities incident report dated 11/22/2024, revealed the following in part: On 11/22/2024 at 3:56 p.m. Resident #2 entered the room of Resident #1. Resident #1 told Resident #2 to leave his room. Resident #2 pushed the door open and hit Resident #1 in the face and neck. Resident #1 was sent to the local emergency room . Resident #2 sustained no injuries and was transported to emergency room for evaluation. Review of Resident #2's Nurses' Note dated 11/22/2024 at 7:30 p.m., revealed the following, in part: S3LPN: This nurse was in a room with another resident. I was called down to Resident #1's room. I was informed that Resident #2 had tried to go into Resident #1's room. When Resident #1 tried to close the door, Resident #2 hit Resident #1. Residents were separated. Received order to send residents out for evaluation. On 12/16/2024 at 2:23 p.m., an interview was conducted with Resident #1. He stated on 11/22/2024, Resident #2 entered his room and appeared confused. He stated he made an attempt to redirect Resident #2. Resident #1 stated he was closing his bedroom door when Resident #2 pushed the door open and punched him 3 or 4 times in the face and neck. Resident #1 further stated staff came in the room and removed Resident #2 immediately. Resident #1 stated he had a bloody nose and swollen lip after the incident. He further stated he was given an ice pack for his face, pain medication, and was sent to the emergency room where a CT scan was done of his head. On 12/16/2024 at 2:30 p.m., an interview was conducted with S3LPN. S3LPN confirmed she was the nurse on duty when the incident occurred with Resident #1 and Resident #2 on 11/22/2024. She confirmed Resident #2 had behavioral issues which included becoming agitated. She stated on 11/22/2024 Resident #2 punched Resident #1 in the face, causing blood to come from his nose and a cut on his upper lip. S3LPN stated this was abuse. She stated Resident #2 and Resident #1 were separated immediately. She stated Resident #1 was given an ice pack, Tylenol for pain, and sent to the emergency room for further evaluation. She stated Resident #2 was sent to the emergency room to be evaluated for behaviors on 11/22/2024 and did not return to the facility. She further stated she has had in-services on Wandering Residents, Behavior De-escalation techniques, Identifying Behaviors and Abuse upon hire and on 12/01/2024. S3LPN was able to verbalize processes correctly. On 12/17/2024 at 1:50 p.m., an interview was conducted with S7LPN. She confirmed on 11/22/2024 Resident #2 hit Resident #1. She confirmed Resident #1 had a bloody nose and swollen lip and she provided an ice pack and pain medication to Resident #1 following the incident. She confirmed Resident #2 hitting Resident #1 in the face and neck was physical abuse. She further stated she has had in services on Wandering Residents, Behavior De-escalation techniques, Identifying Behaviors and Abuse upon hire and on 12/01/2024. S7LPN was able to verbalize processes correctly. On 12/18/2024 at 9:35 a.m., an interview was conducted with S5CNA. S5CNA stated he was assigned to care for Resident #2 on 11/22/2024. S5CNA stated Resident #2 was to be in line of sight observations at all times, which meant to keep eyes on Resident #2. He stated he was called away assist another resident and when Resident #2 was out of his line of sight, Resident #2 punched Resident #1. S5CNA confirmed Resident #2 punching Resident #1 in the face was physical abuse. He stated following the incident he was immediately asked to provide a written statement of events and was sent home until the facility's investigation was completed. He stated he was later terminated on 11/26/2024. He stated he was in-serviced, in October 2024 upon hire, on Identifying Behaviors and Abuse. On 12/18/2024 at 12:00 p.m., an interview was conducted with S6SW. She confirmed a transfer summary indicated Resident #2 was discharged from the facility as of 11/29/2024. Resident #3 Review of the Clinical Record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included Major Depressive Disorder and Heart Failure. Review of the Quarterly MDS with ARD dated 10/09/2024 revealed Resident #3 had a BIMS score of 14, which indicated she was cognitively intact. Review of facilities incident report dated 11/06/2024 at 8:30 p.m. revealed, in part: At 7:25 p.m. Resident #2 entered Resident #3's room and pushed Resident #3's left shoulder causing her to lose her balance and fall. Resident #3 complained of pain to the right hip, x-ray was ordered, and Resident #2 was placed on 1:1 observation. On 12/16/2024 at 2:10 p.m., an interview was conducted with Resident #3. She stated on 11/06/2024 Resident #2 entered her room, she asked Resident #2 to leave, Resident #2 pushed her on the shoulder causing her to fall. She stated Resident #2 was immediately removed from her room. She was given pain medication and had an x-ray done of her right hip and right elbow. On 12/17/2024 at 1:30 p.m., an interview was conducted with S1DON. She stated on 11/06/2024 Resident #2 went into Resident #3's room, and when she asked him to leave he pushed her on the shoulder causing her to fall down. S1DON confirmed this was resident to resident abuse. S1DON stated Resident #3 was evaluated with x-ray of right hip and right elbow, and was given pain medication as needed. S1DON stated Resident #2 was sent to the emergency room for behaviors and was placed on 1:1 observations upon return to the facility on [DATE]. On 12/18/2024 at 1:32 p.m., an interview was conducted with S1DON. S1DON confirmed Resident #2 pushing Resident #3 causing her to fall and Resident #2 punching Resident #1 was physical abuse. S1DON confirmed S5CNA was aware Resident #2 was to be in line of site at all times prior to leaving the resident unsupervised. S1DON confirmed S5CNA was terminated following the incident that occurred on 11/22/2024. She further on 11/22/2024 a poll was conducted with all CNAs to determine understanding of line of sight supervision and Resident #2's plan of care was updated due to additional behaviors. She stated an in-service was conducted on all nursing staff on supervision and posttest competencies was completed on 12/01/2024. On 12/18/2024 at 3:30 p.m., an interview was conducted with S2ADM. S2ADM confirmed Resident #2 pushing Resident #3 causing her to fall, and Resident #2 punching Resident #1 is abuse. S2ADM confirmed S5CNA was terminated following the incident that occurred on 11/22/2024. He confirmed on 11/22/2024 a poll was conducted with all CNAs to determine understanding of line of sight supervision and Resident #2's plan of care was updated due to additional behaviors. S2ADM stated an in-service was conducted on all nursing staff on supervision and posttest competencies was completed on 12/01/2024. He stated a prevention plan was implemented for behaviors on 11/22/2024 with an expected completion date of 02/15/2025. S2ADM provided documentation the facility initiated an effective Plan of Correction on 11/8/2024, which included: 1. Problem identified: Resident #2 was on direct line of sight supervision due to previous altercation with Resident #3 on 11/06/2024, and left unattended by the CNA on 11/22/2024. Resident #2 got into a physical altercation with Resident #1. 2. Plan of action with projected completion date of: 12/01/2024 Immediate Action: Residents were separated, assessed, and first aid provided. Resident #2 resumed 1:1 supervision until being sent out to the emergency room for evaluation. Facility performed audit to identify all residents with behaviors that could or do affect others. Completed 10/15/2024. Assessment and social history by Director of Social Services on Resident #2 to identify potential causes of behaviors, needs, triggers, or Post Traumatic Stress Disorder. Completed 10/14/2024. Corporate review of Care Plans and behavior residents identified by staff. All care plans were updated by team. Completed 11/15/2024. In-service education on: Wandering Residents, Behavior De-escalation techniques, Identifying Behaviors. Completed 11/17/2024. In-service Staff Supervision and when to report, with written posttest. Completed 12/01/2024. CNA Poll and written statements to determine understanding of Supervision. Completed on 11/22/2024. Plan was revised on 11/22/2024 due to additional behaviors that occurred on 11/22/2024. In-service education on supervision, and posttest competencies. Completed 12/01/2024. S3LPN was verbally educated to report non-compliance with supervision to S1DON. S5CNA was terminated on 11/26/2024 due to failure to follow procedures. Resident #2 never returned to facility and was discharged from facility on 11/29/2024. Plan reviewed and it was determined that Plan of Correction was effective, resolved 12/01/2024. QAPI on behavior interventions initiated on 11/22/2024. Expected completion date 02/15/2025. Throughout the survey from 12/16/2024 to 12/18/2024, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's abuse policy and procedure and were given questionnaires testing their knowledge. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified. 47732

Based on record review and interviews, the facility failed to implement the comprehensive person centered care plan for 1 (#2) of 3 (#1, #2, and #3) residents reviewed. The facility failed to maintain line of sight supervision per Resident #2's care plan. This deficient practice resulted in an actual harm on 11/22/2024 at 3:56 p.m., when S3LPN noticed S5CNA failed to maintain line of sight supervision per the care plan on Resident #2, a resident with known physical behaviors towards other residents. During this time, Resident #2 physically assaulted Resident #1. Resident #1 was evaluated and treated at a local hospital with diagnostic testing. Resident #1 experienced physical pain, facial swelling, and bloody drainage from the nose as a result of this incident. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Harm. Findings: Cross Reference F600 Review of the facility's policy, dated 07/2017, titled, Safety and Supervision of Residents, revealed the following, in part: Individualized, Resident Centered Approach to Safety: 4) Implementing interventions to reduce accident risks shall include: a. Communicating interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training; and d. Ensuring interventions are implemented Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Dementia with Behavioral Disturbances and Psychotic Disorders. Review of Resident #2's Admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2024 revealed in part, a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Review of Resident #2's Plan of Care, dated 09/30/2024, and updated 11/22/2024, revealed in part: Focus: Behavior Management History of sun downing, confusion, wandering, delusional, hallucinations, cursing, yelling/screaming, takes items from others, refusal of meds at times. 11/04/2024- verbal altercation with peer. 11/06/2024- pushed a peer causing her to fall. Interventions: 11/06/2024- emergency room Evaluation, Psych NP evaluation, Medications adjusted. 1:1 Observation. 11/19/2024 stepped down to line of sight observation. 11/22/2024- Resident #2 entered the room of a peer and hit peer. Resident separated immediately. Received order from NP to send Resident #2 for eval, 1:1 with staff until left building Review of the facilities incident report dated 11/22/2024, revealed the following in part: On 11/22/2024 at 3:56 p.m. Resident #2 entered the room of Resident #1. Resident #1 told Resident #2 to leave his room. Resident #2 pushed the door open, and hit Resident #1 in the face and neck. Resident #1 was sent to the local emergency room . Resident #2 sustained no injuries and was transported to emergency room for evaluation. Review of Resident #2's Nurses' Note dated 11/22/2024 at 7:30 p.m. revealed the following, in part: S3LPN: This nurse was in a room with another resident. I was called down to Resident #1's room. I was informed that Resident #2 tried to go into Resident #1's room. When Resident #1 tried to close the door, Resident #2 hit Resident #1. Residents were separated. Received order to send residents out for evaluation. On 12/17/2024 at 2:35 p.m., an interview was conducted with S3LPN. She stated on 11/22/2024 she was called from another resident's room because Resident #2 was hitting Resident #1. She stated Resident #2 was care planned to be line of sight supervision by staff after the resident pushed another resident down on 11/06/2024. S3LPN stated line of sight supervision meant keeping a resident in eye view and at arm's reach at all times. She stated, on 11/22/2024 prior to Resident #2's incident, she had to redirect S5CNA 4 to 5 times regarding keeping Resident #2 in line of sight supervision. She stated S5CNA was on his phone, standing in the hall not within arm's reach of Resident #2, and sitting outside when she had to redirect him. She stated she never notified S1DON of having to redirect S5CNA prior to Resident #2 assaulting Resident #1. She further stated she was in-serviced again on line of sight supervision and reporting non-compliance of line of sight supervision by S1DON on 11/22/2024. On 12/18/2024 at 9:35 a.m., a telephone interview was conducted with S5CNA. He confirmed, on 11/22/2024, he was assigned to Resident #2 for line of sight supervision. He stated he understood line of sight to mean keep his eyes on the resident at all times. He confirmed he was not assigned to any other residents during his shift on 11/22/2024. He stated, on 11/22/2024, he took his eyes off of Resident #2 to assist another resident with care. He stated at that time, Resident #2 entered another resident's room and punched that resident in the face. He confirmed he should not have let Resident #2 out of his line of sight. He confirmed he was in-serviced on line of sight supervision prior to his shift on 11/22/2024. He stated he was immediately relieved of his assignment, asked to write a statement of what occurred, sent home until further investigation, and was later terminated on 11/26/2024. On 12/18/2024 at 11:38 a.m., an interview was conducted with S8CNA. S8CNA stated line of sight supervision meant keeping a resident in eye view and at arm's reach at all times. She confirmed she was in-serviced and took a test on supervision of residents in November 2024. On 12/18/2024 at 11:57 a.m. an interview was conducted with S9CNA. S9CNA stated line of sight supervision meant keeping a resident in eye view and at arm's reach at all times. She confirmed she was in-serviced and took a test on supervision of residents in November 2024. On 12/18/2024 at 1:32 p.m., an interview was conducted with S1DON. She stated, on 11/22/2024, she conducted an in-service with S5CNA regarding line of sight supervision prior to the start of his shift. She stated, after Resident #2 hit Resident #1 on 11/22/2024, S3LPN reported she previously had to redirect S5CNA regarding line of sight supervision. S1DON stated the physical abuse could have been prevented if she was made aware S5CNA required redirection to provide line of sight supervision. S1DON stated she immediately in-serviced all nursing staff on line of sight supervision and when to report non-compliance with supervision by polling staff and posttest. On 12/18/2024 at 4:02 p.m., an interview was conducted with S2ADM and S1DON. S2ADM and S1DON confirmed, on 11/22/2024, line of sight supervision was not maintained for Resident #2 and should have been. The facility had implemented the following actions to correct the deficient practice on 11/22/2024: 1. Immediate Action: S3LPN was verbally educated to report non-compliance with supervision to S1DON. 2. S5CNA relieved of duties on 11/22/2024 and later terminated post facility investigation. 3. Resident #2's care plan was revised on 11/22/2024 due to additional behaviors that occurred on 11/22/2024. 4. 11/22/2024 new education implemented with posttest competencies. Random poll conducted to evaluate effectiveness of education on types of supervision. 5. 11/22/2024 in-service nursing staff understanding on different types of supervision the facility provides for residents. 6. In-service staff on supervision and when to report, with written posttest. Completed 12/01/2024. 7. Continued daily monitoring of behaviors that could potentially affect others by DON or designee. Education materials added to new hire packets and annual competencies. 8. Initiated a QA for wandering/behavior preventions and intervention with a target completion date of 02/15/2025. Throughout the survey from 12/16/2024 to 12/18/2024, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's safety and supervision policy and procedure and questionnaires testing their knowledge. Observations were made throughout the survey with no supervision concerns identified. Observations, interviews, and record review, revealed monitoring had begun

Based on interviews and record reviews, the facility failed to ensure a cognitively impaired resident received treatment and care in accordance with professional standards of practice for 1 (#2) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure: 1. S5LPN transcribed new telephone orders for Tylenol and an X-Ray for Resident #2; 2. S5LPN implemented a new telephone order for an X-Ray for Resident #2 after a fall and complaint of pain; and 3. S5LPN communicated Resident #2's change in status, fall, or new orders of Tylenol and an X-Ray to oncoming staff prior to leaving the facility at the end of her shift. This deficient practice resulted in an actual harm for Resident #2, a severely cognitively impaired resident, beginning on 04/01/2024 at 6:30 a.m. when S5LPN left the facility without communicating Resident #2's fall and new X-Ray order to any other staff. On 04/01/2024, between 10:30 a.m. and lunch time, Resident #2's CNA notified S4LPN that Resident #2 had complained of pain and required increased assistance with a transfer. S2NP assessed Resident #2, and she complained of left leg pain and would not allow S2NP to touch her leg. On 04/01/2024 around 1:41 p.m., a local imaging company was notified of S2NP's left leg and hip X-Ray order. On 04/01/2024 at 4:00 p.m., X-Ray revealed Resident #2 had a Displaced Left Femoral Neck Fracture that required surgical intervention. Due to Resident #2's impaired cognition, she did not recall the above events, but it could be determined that a reasonable person would have suffered physical harm as a result of the failed communication and delayed treatment. Findings: Review of the facility's policy with a revision dated of July 2016 and titled, Medication and Treatment Orders revealed the following, in part: Policy Interpretation and Implementation: 3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. 7. Verbal Orders must be recorded immediately in the resident's chart by the person receiving the order . Review of Resident #2's Clinical Record revealed an admitted [DATE] and diagnoses, which included Unspecified Signs and Symptoms Involving Cognitive Functions and Awareness, Cognitive Communication Deficit, History of Falling, Major Depressive Disorder, and Dementia. Further review revealed a new diagnosis of a Displaced Intertrochanteric Fracture of Left Femur on 04/01/2024. Review of Resident #2's MDS with an ARD of 04/12/2024 revealed she had a BIMS summary score of 99, which indicated Resident #2 had severely impaired cognition. Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 04/01/2024 at 2:29 a.m. Called to Resident #2's room by her roommate. Resident #2 found on the floor in bathroom. Resident #2 complained of pain to Left Knee. Spoke with S3OCNP at about 1:50 a.m. S3OCNP advised giving Tylenol for Knee Pain and X-Ray on 04/01/2024. Signed S5LPN. Review of Resident #2's Telephone Orders dated 03/31/2024 through 04/01/2024 revealed no evidence S5LPN transcribed the orders for Tylenol or X-Ray received from S3OCNP on 04/01/2024. Review of Resident #2's Hallway 24-Hour Report Log dated 03/31/2024 revealed the following, in part: Change of Condition: Resident #2 - unwitnessed fall New orders 6:00 p.m. to 6:00 a.m.: Resident #2 - X-Ray 04/01/2024 Review of Resident #2's Electronic Physician Orders dated April 2024 revealed no evidence Tylenol or an X-Ray was ordered on 04/01/2024. Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 4/01/2024 at 6:00 p.m. Late entry 04/01/2024 at 2:00 p.m. Resident #2 sitting in lobby in wheelchair. Resident #2 has complaints of pain to leg to staff. S2NP making rounds and assessed resident. S2NP with orders for X-Ray of Left Hip and Left Leg. Resident propelling self in wheelchair. Resident given Tylenol 650 mg for pain. Signed S4LPN. Review of Resident #2's Telephone Orders dated 04/01/2024 revealed the following: (04/01/2024) X-Ray of Left Leg and Left Hip Signed by S4LPN and S2NP. Review of Resident #2's Physician Progress Note dated 04/01/2024 revealed the following, in part: Assessment/Plan: 1. Left Hip Pain (Primary) Overview: will obtain X-Ray at this time Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 04/01/2024 at 6:08 p.m. At 4:00 p.m., a local imaging company arrived for X-Rays. Signed S4LPN. Review of Resident #2's Left Hip and Femur X-Ray results dated 04/01/2024 revealed the following, in part: Significant Findings: Displaced Left Femoral Neck Fracture Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 04/01/2024 at 11:30 p.m. Resident sent to a local emergency room . X-ray results showed Left Femoral Neck Displaced Fracture. An interview was conducted with Resident #2 on 05/06/2024 at 9:10 a.m. Due to Resident #2's impaired cognition, she was unable to recall having a fall, fracture, and/or surgery. A telephone interview was conducted with S5LPN on 05/06/2024 at 11:25 a.m. She confirmed she was assigned to Resident #2 on the early morning of 04/01/2024 when Resident #2 had a fall. S5LPN stated Resident #2's roommate notified her around 1:50 a.m. that Resident #2 was on the floor in the bathroom. She stated Resident #2 complained of left knee pain prior to her getting off the floor. S5LPN stated she notified the on-call nurse practitioner who gave her orders to administer Tylenol and obtain X-Rays in the morning. She stated she did not notify the X-Ray Company of Resident #2's order for an X-Ray. S5LPN stated she documented Resident #2's fall and X-Ray order in the 24-hour report book. She stated she left the facility around 6:30 a.m. that morning, and her relief was not present in the facility to verbally communicate report. S5LPN stated she did not notify any facility oncoming staff of Resident #2's fall, new order for Tylenol, and/or the order for an X-Ray. She stated she administered Tylenol, but did not transcribe the verbal order. She stated she did not transcribe or implement the new order for the X-Ray. An interview was conducted with S6CNA on 05/06/2024 at 1:15 p.m. She confirmed she was assigned to Resident #2 on 04/01/2024 from 6:00 a.m. to 6:00 p.m. She stated she was not aware Resident #2 had a fall on the night shift. She stated she was unable to recall the exact timeline of events, but Resident #2 complained of pain intermittently on 04/01/2024. She stated Resident #2 needed more assistance than normal during a transfer and complained of pain to her leg. She stated she notified S4LPN of Resident #2's change in condition and complaint of pain. An interview was conducted with S4LPN on 05/06/2024 at 11:49 a.m. She confirmed she was assigned to Resident #2 on 04/01/2024 from 6:00 a.m. to 6:00 p.m. S4LPN stated she arrived late to the facility on [DATE] around 7:00 a.m., and S5LPN had already left. S4LPN stated, between BINGO and lunch time, Resident #2's CNA notified her Resident #2 complained of pain and required increased assistance with a transfer. She stated at that point, she read Resident #2's Nurses' Notes and determined Resident #2 had a fall. S4LPN stated she then notified S2NP of Resident #2's change in condition and complaints of pain. S4LPN reviewed Resident #2's Hallway 24-hour report log dated 03/31/2024 and confirmed under new orders for 6:00 p.m. to 6:00 a.m. shift, Resident #2 had a new order for an X-Ray on 04/01/2024. She confirmed the 24-hour report log revealed Resident #2 had an unwitnessed fall. S4LPN confirmed she should have been aware of Resident #2's fall, complaint of pain, and X-Ray order at the beginning of her shift. She stated if she had been aware of Resident #2's change in condition and X-Ray order at the beginning of her shift, she would have immediately assessed Resident #2 and ordered the X-Ray. She stated S5LPN should have notified the X-Ray company when she received Resident #2's X-Ray order. S4LPN explained the nurse who received the X-Ray order was responsible to notify the X-Ray company of the order. She stated she notified a local imaging company of Resident #2's Left Hip and Leg X-Ray order around 2:00 p.m. on 04/01/2024. S4LPN stated the x-ray was performed around 4:00 p.m. A telephone interview was conducted with S3OCNP on 05/06/2024 at 2:26 p.m. She stated she was unable to recall the specified date, time, and scenario regarding Resident #2. She stated if after Resident #2's fall, she complained of pain to her left knee, she would have told the nurse to administer Tylenol and obtain an X-Ray. She stated the expectation would be for the nursing home to notify the X-Ray company first thing the next morning, which was 7:00 a.m. She stated a 2:00 p.m. notification the next day would not have been incredibly sufficient. An interview was conducted with S2NP on 05/06/2024 at 12:22 p.m. She stated, on 04/01/2024 around lunch time, S4LPN reported to her Resident #2 had a fall and was complaining of pain to her left leg. She stated she assessed Resident #2 at that time. She stated Resident #2 was seated in the dining room in her wheelchair. She stated when she attempted to perform range of motion to Resident #2's left leg, Resident #2 would not allow her to touch the leg, and Resident #2 complained of pain. She stated, at that time, she ordered an x-ray of the left hip and leg. She stated she was unaware the on-call Nurse Practitioner ordered x-rays. She stated if the x-rays were ordered overnight, the x-ray company should have been notified at that time. An interview was conducted with a representative from a local imaging company used by the facility on 05/06/2024 at 3:08 p.m. She stated the facility contacted the imaging company on 04/01/2024 at 1:17 p.m. for an x-ray for Resident #2. She stated the imaging company received X-Ray orders 24/7. An interview was conducted with S1DON on 05/07/2024 at 9:33 a.m. She stated residents' change in condition and any new orders should be communicated from shift to shift. S1DON stated there was a 24-hour communication tool at each nurses' station, and there should be a shift to shift verbal report given at the beginning and end of each shift. She stated, ideally, if the day nurse was running late, she would expect the night nurse to give the keys to another day shift nurse and give report so it could be communicated to the oncoming nurse once they arrived. S1DON stated she expected each nurse to review the 24-hour report communication tool at the beginning of their shift. She confirmed Resident #2's fall and X-Ray order was placed on the 24-hour report communication tool. She stated S5LPN should have notified the X-Ray company of Resident #2's X-Ray order when the order was received. S1DON reviewed Resident #2's Physician Orders and Telephone Orders and confirmed the orders S5LPN received for Tylenol and an X-Ray for Resident #2 from S3OCNP were not transcribed and should have been.

Based on observations, record review and interview, the facility failed to ensure a cognitively impaired resident, who exhibited exit-seeking behaviors, was adequately supervised to prevent unsafe wandering and elopement for 1 (#4) of 5 (#4, #54, #94, #99, and #163) residents reviewed. This deficient practice resulted in an immediate jeopardy situation on 12/02/2021 at 3:41 p.m., when Resident #4, a severely cognitively impaired resident identified as being a high risk for elopement, the resident was found climbing the fence with one leg over it behind the building. After this elopement attempt, Resident #4 was placed on Q 15 minute census checks and continue Q 1hour after 24 hours. 12/09/2021 at 1:00 p.m., the resident was found outside the front of the facility walking towards the highway. After the elopement attempt on 12/09/2021, the resident was placed on Q 15 minute census checks. 12/13/2021 at 3:10 p.m., the resident was caught in another resident's room attempting to get out of the window. 12/29/2021 at 11:52 a.m. the resident pushed the screen off the window and went into the secured yard. 12/29/2021 at 12:01 p.m. the resident exited the building and was found near a gate where the latch was broken. 01/06/2022 at 1:30 p.m., the resident was found outside the facility grounds, rattling a gate and attempting to get out. 02/01/2022 at 5:30 p.m., the resident was found outside the building unsupervised by a dietary staff member. S1ADM was notified of the Immediate Jeopardy on 02/10/2022 at 5:30pm. The Immediate Jeopardy was removed on 02/12/2022 at 5:00 p.m., after it was determined through observation, interview, and record review; the facility implemented an acceptable Plan of Removal prior to the survey exit, which included: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: a. Resident #4 (**) is affected, all residents have the potential to be affected that are at risk for elopement. 2. Specify actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring: a. Resident #4 placed on line of sight supervision on 02/11/2022. b. Line of sight- To be completed by staff member assigned to this duty for the shift. c. Training for this is included in the below in-services conducted. d. Line of sight will be re-evaluated by interdisciplinary team. via elopement risk assessment weekly until no longer deemed to be at increased risk of elopement as evidenced by (not trying to gain access to an unsafe area). Anticipated completion date cannot be given, as this will require ongoing evaluation of resident needs. e. B Lobby patio doors locked at all times. Completed on 02/11/2022 f. Hall 2 fire doors closed at all times and door alarm placed on fire doors. Completed on 02/11/2022 g. Window alarm installed in isolation room of Resident #4 and will be moved to Resident #4's regular room once isolation complete. Initiation and completion of alarm installation was done on 02/10/2022. h. Elopement risk assessment completed on 02/10/2022 on Resident #4 and all residents at risk for elopement. Elopement risk assessment form is utilized to complete this task and is completed on admission, quarterly and with a significant change in condition. i. Interventions for all residents at risk for elopement reviewed and evaluated for effectiveness on 02/10/2022. Completed on 02/11/2022. j. In-service training initiated on 02/10/2022 on wandering/elopement, safety/supervision, and window alarm, planned completion of in-service training is anticipated for 02/16/2022 k. In-service training completed, on all staff (all departments), included the examples/definitions of behaviors and wandering/elopement listed in F689. Staff was also trained on how to identify these behaviors and implementing measures to reduce risks. Anticipated completion is 02/16/2022. l. Assessment of facility grounds completed on 02/11/2022 by Director of Nursing. m. Supervision- Nurses and CNAs will be responsible for supervising residents at risk for elopement including Resident #4. Administrator/DON/designee will conduct informative rounds via direct observation extended to resident and staff interview, if necessary, on each hall per shift daily for one month then randomized thereafter to assess staff monitoring of residents. Length of time for the continuance of randomized audits will be evaluated monthly in the QAPI meeting. This will be recorded on the staff Observation Round Form. Rounds by administrative staff began on 02/11/2022. Anticipated completion date cannot be given as this will require ongoing evaluation. n. Sustained correction will be monitored via QAPI PIPs (Performance Improvement Project). This will be completed monthly by the QAPI team. St. Francisville Nursing and Rehab ensures correction is achieved and sustained through chart reviews (progress notes, incident reports, assessments, and MAR) of residents at risk for elopement completed weekly X4, then quarterly thereafter. Review will be completed by the DON/designee. Discovery of problems will be routed to the administrator and addressed immediately. Next QAPI scheduled for 02/16/2022. Anticipated completion date cannot be given, as this will require ongoing evaluation. 3. Date by which the entity assets the likelihood for serious harm to any recipient no longer exists: a. 02/11/2022 This deficient practice continued at a potential for more than minimal harm for the 5 residents residing in the facility identified as moderate to high risk for wandering and elopement. Findings: Review of the facility's policy titled Elopement Protocol revealed, in part: PROCEDURE: 1. A resident with high risk for elopement will be documented on a Q 1 hour census check until stable, after which documentation shall continue on the routine Q 2 hour census check for elopement risk. 2. During episodes of elevated elopement risk, the nurse in charge, DON, or Administrator may decide to implement an individual visual cue as needed to help identify a resident at high risk. In either case, staff shall be informed of a resident with an acute elevated risk. Review of the facility's policy titled Wandering and Elopement revealed, in part: Interpretation, Implementation, Interventions 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. g. Initiate increased supervision as indicated by individual resident's mood/behavior and situation. Increased supervision can take various forms and time frames, including but not limited to the following: Increased frequency of checks more than once per shift, such as q2h, q1h, q30min, q15 min, constant within line; One-on-one; on camera; continuous, during sundowning hours, at shift change; after visitors leave, or any other time frame identified as high risk trigger time; Duration of increased supervision is based on a personalized and individualized appraisal by present staff of current exit seeking behaviors and level of risk at hand. Resident #4 Review of the clinical record for Resident #4 revealed he was admitted to the facility on [DATE] with diagnoses including: Dementia with Behavioral Disorder, Major Depressive Disorder, Anterograde Amnesia, [CONDITION(S)], Folate Deficiency [CONDITION(S)], Unspecified, Hypertension, Unspecified Convulsions, and Gastro-[CONDITION(S)] Reflux Disease. Review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/04/2021 revealed Resident #4 had a BIMS (Brief Interview Mental Status) of 5, which indicated the resident was severely cognitively impaired. Further review revealed he was independent without assistance for transferring, locomotion on the unit, and locomotion off the unit. Review of Resident #4's Wandering/Risk Assessments from 05/03/2021 through 02/10/2022 revealed he was identified as a high risk for wandering and elopement. Review of Resident #4's care plan revealed, in part: Onset: 04/27/2021 Problem: Resident #4 has socially inappropriate behaviors due to Dementia (yelling, cursing, and threatening to leave). 07/22/2021, Resident #4 crawled out room window into enclosed yard. Interventions: educated on behavior, placed on Q 15 minutes checks. S20FDON visited with Resident #4 and he states he will not do it again. 08/27/2021, Resident #4 opened window, pushed out the screen and exited the window. Interventions: Counseled on behavior, continue to observe and redirect. 12/29/2021, Resident #4 climbed out of his window into enclosed yard. Interventions: sent to emergency room for evaluation. Onset: 04/27/2021 Problem: Resident #4 is at risk for injury related to elopement attempts. Interventions: census check Q 2hours, Q 1hour after elopement attempt for 24 hours or until settled, increase census checks to Q 1hour or more frequently following an elopement attempt, involve in structured activities, elopement risk assessment on admit, quarterly and significant changes, and code alert bracelet. 09/26/2021, Resident #4 walked around the secure yard to Hall 1's side of the building. He was able to go through the gate into Hall 1's backyard without any staff aware. Interventions: Schedule psychiatric visits as ordered, one on one visits as indicated, placed on Q 15 minute census checks until exit seeking behavior over. 10/17/2021, Resident #4 was let outside the locked front door of Hall 2 by a peer. Interventions: Resident #4 placed on Q 15 minute census checks, continue Q 1hour after 24 hours. 12/02/2021, Resident #4 exited Hall 2 patio door and tried to climb the fence. Interventions: Observation until calm, continue with wander guard and regular census checks. Further review of Resident #4's Care Plan revealed there were no new interventions following incident on 01/06/2022 and 02/01/2022. A review of Resident #4's Physician Orders revealed the following, in part: 07/20/2021 Wander guard to right ankle for elopement risk and dementia, check placement and functioning Q shift, 12/09/2021 Census checks Q 15 minutes. 12/30/2021 Resident may have one non-alcoholic beer in the evening per day. 01/06/2022 Send to ER for evaluation. Review of Resident #4's MAR (Medication Administration Record) for December 2021 and January 2022 revealed the following, in part: 07/20/2021, Wander guard to right ankle for elopement risk and Dementia. Check placement and functioning Q shift. 12/09/2021, Q 15 minute visual checks, documentation with staff initials once a shift at 5:00 a.m. and 5:00 p.m. Review of Resident #4's Nurse Practitioner Note revealed, in part: 12/15/2021 at 12:10 p.m., any explanations or recounts of facts are valid to Resident #4 for mere minutes then he does not remember having a conversation at all. He acts on long-term memories of needing to go home or work. He does not accept such reminders including discarding his own notes. He wanted a guitar but is rarely seen playing it. He asked for puzzles but do they not hold his attention and sit untouched at bedside. Diversional activities continue to be provided but they do not suffice to prevent any impulsive elopement ideas. Exit seeking behaviors as the underlying cause of processing memories is not correctable. Review of Resident #4's Nursing Notes revealed, in part: 07/22/2021 at 2:43 p.m. - Staff saw Resident #4 walking outside and went into his room to find window opened and screen pushed out. Resident #4 had crawled out of window. 08/27/2021 at 5:42 p.m. - Resident #4 very agitated and erratic this morning, jumped out of the lobby window in an attempt to escape. 08/31/2021 at 11:28 a.m. - Resident #4 was in Hall 2 commons area when he opened window and pushed out screen and climbed out window. 09/26/2021 at 6:52 p.m. - At approximately 5:45 p.m., Resident #4 went out of the unlocked Hall 2 patio door. He then toppled the fence gate over in an attempt to elope, he was found at the next locked gate by Hall 1. 10/17/2021 at 1:52 p.m. - Resident #4 eloped while staff were assisting/monitoring lunch. Alarm sounded when Resident #4 eloped the facility. Multiple staff ran out to get Resident #4 before he reached the highway. Resident #4 could not remember how he got out of the door. 12/02/2021 at 3:41 p.m. - CNAs informed charge nurse that Resident #4 tried to jump over the fence behind the building near the end of Hall 2. Staff were able to prevent him from jumping over the fence and returned Resident #4 safely to his room. 12/10/2021 at 12:26 p.m. - During assessment check, nurse noted Resident #4's wander guard missing off ankle. Band noted to be in Resident #4's trashcan. The band was torn and ripped apart. 12/13/2021 at 3:10 p.m. -Resident #4 was caught in another resident room attempting to get out of the window. 12/29/2021 at 11:52 a.m. - Resident #4 pushed the screen off the window and went into the secured yard. 12/29/2021 at 12:01 p.m. - Resident #4 left out of the Hall 2 unlocked patio door. Resident #4 continues rattling fence and gate for Hall 1, latch popped and broke open. 01/06/2022 at 1:30 p.m. - Resident #4 was out of facility grounds, rattling the gate and attempting to get out. 01/06/2022 at 5:59 p.m. - Resident #4 increasingly aggressive, sent to ER for evaluation. Review of the facility's incident reports revealed, in part: 07/22/2021 at 1:00 p.m., Resident #4 walked to his room, opened the window, pushed out the screen and climbed out the window into an area that is locked by a secure fence to prevent elopement. 08/17/2021 at 1:00 p.m., Resident #4 raised the window, pushed up the blinds and climbed out of the window onto the patio. Staff monitoring Hall 2 commons area noticed Resident #4 in patio area. 10/17/2021 at 12:10 p.m., Staff were assisting residents in the dining room. Another resident opens the door and Resident #4 walks out the door and closes the door behind him. Staff hear the audible alarm and sees Resident #4 in the parking lot. He is redirected back inside the facility. 12/02/2021 at 3:00 p.m., Resident #4 went outside and walked to the fence. He was noted to be standing and looking at the fence behind building B. He then walked along the fence, grabbed the fencing at the top, and was trying to bend it down. Staff noticed Resident #4 outside and walked out to get him. Resident #4 was trying to climb and two CNAs pulled him off the fence, as he would not calm down and come in. Resident received a skin tear from hitting his arm on the fence when staff pulled him down. 12/09/2021 at 1:00 p.m., Staff saw Resident #4 in the facility parking lot walking towards the highway. 12/29/2021 at 11:50 a.m., Resident #4 noted with exit seeking behavior. Pushed screen off window of his bedroom and climbed out into the yard. After redirection and in line of sight he went back into yard and broke gate. An observation was made of Resident #4's room on 02/09/2022 at 8:18 a.m. The room contained one window approximately 4 feet from the floor. The window was found to be unlocked and able to be opened up completely, approximately 3-4 feet. There was no alarm noted to notify staff if the window was opened. An interview was completed with S15CNA on 02/09/2022 at 10:13 a.m. She confirmed being familiar with Resident #4. She said the resident was confused and routinely tried to exit the facility through doors and windows. She said she was working on 12/02/2021 when the resident climbed out of his window and was found climbing on the fence behind the building of Hall 2. She said S8CNA noticed the resident was behind the building of Hall 2 on the fence. She and S8CNA got him down from the fence and brought him back inside the facility. She said administration was made aware of the incident and the resident was placed on Q 15 minutes checks for the next 24 hours. She said Resident #4 was to be checked on hourly. She said the staff were supposed to increase the checks to Q 15 minutes when Resident #4 was attempting to elope. She said the interventions were not effective because there was not enough staff to complete Q 15 minute checks on Resident #4. An interview was completed with S8CNA on 02/09/2022 at 10:42 a.m. She confirmed being familiar with Resident #4. She stated he goes to all the front doors daily from 1:00 p.m. to 4:00 p.m. and tries to open them and leave. She said on 12/02/2021, she was making rounds and noticed Resident #4 was missing. She said she looked out the locked back door on Hall 2 and noticed he had one leg over the exterior fence behind the building. She said she was able to get the resident down from the fence with help from S15CNA. She stated Resident #4 was physically capable of climbing over the fence. She said administration was aware and placed the resident on Q 15 minute census checks after the incident. She stated Resident #4 was found in the outside yard so frequently; it was hard to keep up with. She stated administration was aware Resident #4 would exit the facility by going through windows. She confirmed the windows were not locked or monitored by an alarm system. She said the interventions were not effective because the facility did not have enough staff to provide adequate supervision for the residents on Hall 2 and supervise Resident #4. An interview was completed with S4MDS on 02/09/2022 at 11:57 a.m. She confirmed she was responsible for completing the wandering/elopement risk assessment for the residents. She said Resident #4 was identified on the assessment as a high risk for elopement. She said the resident has a wander guard and S2DON tracked his behaviors. She said after each elopement attempt the staff should implement census checks Q 15 minutes on Resident #4 for 24 hours or until he stopped exhibiting exit-seeking behaviors. She stated after the exit seeking behaviors ended the staff would check on Resident #4 every 1 hour. She said S2DON reviewed the resident's behaviors in December 2021 and implemented interventions to increase staff attempts to engage him in activities, redirect him to play his guitar, have a CNA take him outside and began giving him a non-alcoholic beer in the evening. She said on 12/09/2021 staff were instructed to complete a census check on Resident #4 every 15 minutes, but were only required to document those checks once a shift at 5:00 a.m. and 5:00 p.m. She confirmed no changes were made to Resident #4's window or any of the windows in the building to prevent Resident #4 from exiting through them unsupervised. She said all residents were allowed to go outside into the yard unsupervised because it was secured by a fence. An observation was made of the front exterior of the facility on 02/10/2022 at 8:33 a.m. The facility was located off a major highway in a small rural town. The highway was approximately 100 yards from the front doors with a pond directly across the highway. An observation was made of the rear exterior of the facility on 02/10/2022 at 8:40 a.m. The facility yard was completely fenced in with a chain-linked fence that had three additional layers of angled smooth wire on top of the 6-foot fence. The yard was approximately one fourth of an acre with 2 movable wooden picnic tables, a movable 2-person glider and one basketball goal lying on the ground. On the other side of the fence was a wooded area that bordered the fence and extended on both sides of the facility. The yard behind the building of Hall 2 was not visible from Hall 2's patio or commons area. Behind the building of Hall 2, the fence was observed to be approximately a foot lower than the rest. A concrete walkway ran along the side and behind the building of Hall 2. The concrete walkway continued around the building to Hall 1. A black aluminum handrail served as protection to stay on the walkway, due to a 4-6 foot uneven drop off. At the corner of this handrail, the secure fence for the yard was within an arm's length reach. In between the handrail and fence was a 4-6 foot drop off to the ground. The walkway continued around the building of Hall 2 and separated Hall 1's patio by a fence and gate. This area was not able to be visualized when on Hall 2's patio or commons area. An observation was made of Resident #4's room on 02/10/2022 from 9:14 a.m. to 9:55 a.m. At 9:14 a.m., S3ADON was observed to exit the resident's room and close the door. From 9:14 a.m. to 9:55 a.m., no staff were observed to open the door and check on Resident #4 to ensure he was in the room. An observation was made of Hall 2 on 02/10/2022 from 11:05 a.m. to 12:05 p.m. Resident #4 was in his isolation room with the door closed. During this time, no staff were observed to open the door and check on Resident #4 to ensure he was in the room. An interview was completed with S16CNA on 02/10/2022 at 11:42 a.m. She said the wander guard system only worked for the front doors. She stated if a resident with a wander guard tried to exit the facility front doors it would alarm. She said if a resident with a wander guard was within 15 feet of the door, a light would flash on the system and the doors would automatically lock down. She confirmed none of the windows had an alarm on them. She said the patio doors were all unlocked and the residents were allowed to go outside unsupervised because it was fenced in. An interview was completed with S7LPN on 02/10/2022 at 11:55 a.m. She confirmed she was familiar with Resident #4. She stated he was confused and frequently attempted to exit the building through windows or out of doors. She stated the resident was independently ambulatory and able to physically climb out a window or walk out of the building. She said the CNA staff were responsible for completing Q 15 minute checks on Resident #4, but there was not enough staff assigned to Hall 2 for all the Q 15 minute checks to be completed. She said the staff did not have any way of knowing if the checks were completed or not. She stated the facility did not put alarms on any of the windows that Resident #4 attempted to exit through, but it would have helped the staff with knowing if the resident was trying to elope. An interview was completed with S7LPN and S3ADON on 02/10/2022 at 1:01 p.m. They both confirmed Hall 2's patio door was not locked and Resident #4 could exit the doors unsupervised into the yard. An interview was completed with S1ADM on 02/10/2022 at 3:20 p.m. He confirmed Resident #4 required a wander guard because the facility identified him as a high risk resident for elopement. He confirmed the doors to the patio were unlocked and did not connect to the wander guard system. He stated the residents, including Resident #4, were able to exit the facility and access the patio area unsupervised because the yard was secured by a fence. An interview was completed with S2DON on 02/10/2022 at 3:30 p.m. She stated on 12/09/2021 Q 15 minute checks were initiated on Resident #4's EMAR. She said the Q 15 minute checks should be documented on the EMAR once each shift at 5:00 a.m. and 5:00 p.m. She stated one on one observations should be documented in nurse's notes. She explained prior to 12/09/2021 the staff were not required to document one on one observations or Q 15 minute checks for Resident #4. An interview was completed with S10CNA on 02/11/2022 at 10:10 a.m. She said she was normally assigned to Resident #4. She said every afternoon he would go to the doors and try to leave by attempting to open the doors. She said on 12/29/2021 at 11:52 a.m., the resident climbed out of his bedroom window. He was redirected back inside the facility. She said on the same day at 12:01 p.m., Resident #4 exited Hall 2's patio door, and was found on Hall 1's patio after breaking the gate between the outside area of Hall 2 and 1. She said last week on 02/01/2022 at 5:30 p.m., a dietary staff member found the resident outside of Hall 2 and behind the building. She confirmed the staff did not know Resident #4 was outside when the dietary staff found him. She said she reported the incident on 02/01/2022 to the nurse. She said Resident #4 was on hourly census checks. She said if Resident #4 attempted to elope the staff would increase the checks to Q 15 minutes. She said the interventions were not effective because the facility did not have enough staff to supervise Resident #4 Q 15 minutes. An observation was made of Hall 2 on 02/11/2022 from 10:05 a.m. to 11:05 a.m. Resident #4 was in his isolation room at the end of Hall 2 with the door closed. During this time, only one staff member opened the door and checked on Resident #4. An interview was completed with S9CNA on 02/11/2022 at 10:23 a.m. She confirmed being familiar with Resident #4. She stated he was confused and tried to leave the facility often. She stated Resident #4 climbed out the window in his room and his roommate-notified the staff but she could not remember the date. She said later that same day she was monitoring Hall 2's commons area, and noticed the resident walking outside on the patio. She confirmed this was reported to administration and Q 15 minute checks were initiated. An interview was completed with S11CNA on 02/11/2022 at 11:05 a.m. She said she was normally assigned to Resident #4. She said on 08/17/2021, she was assigned to monitor Hall 2's commons area and noticed Resident #4 was outside on the patio. She said she went to his room and found the window open. She said when she was working last week, a dietary worker found Resident #4 behind the building of Hall 2 on the walkway unsupervised. She said Resident #4 should be one on one watch because he tried to leave the facility every chance he could. She said the interventions were not effective because the facility does not have enough staff to complete hourly checks or Q 15 minute census checks on Resident #4. An interview was completed with S17DIET on 02/11/2022 at 11:15 a.m. She said on 02/01/2021, she found Resident #4 on the walkway behind the building of Hall 2. She confirmed he was alone when she found him. An interview was completed with S18MAINT on 02/11/2022 at 11:49 a.m. He said Resident #4 had been pulled off the exterior fence and attempted to elope multiple times out of the doors. He confirmed Resident #4 had exited the facility through his bedroom window. He confirmed the window was not secured nor had an alarm placed on it after the resident was found exiting it. He confirmed Resident #4 could exit the facility through his window. An interview was completed with S2DON on 02/11/2022 at 12:28 p.m. She said Resident #4 had frequent behaviors of banging on the doors at the front of the building and on several occasions exited through a window. She said with each elopement attempt he was placed on Q 15 minute census checks by CNA staff for a minimum of 24 hours or until his exiting behaviors stopped. She said when he exited out the front door on 10/17/2021 another resident let Resident #4 out of the building. She said she did not think there was an issue with Resident #4 going out of the window because the yard was secure. She said all the residents, including Resident #4, were allowed outside unsupervised because the yard was securely fenced in. She said the wander guard was for the front doors of the facility. She confirmed the doors on Hall 1's patio, Hall 2's patio, and Hall 3's patio were not locked and the residents could go outside unsupervised. She said the facility increased Resident #4's security checks to Q 15 minutes on 12/09/2021 and placed the security checks on the EMAR. She confirmed even though staff were to check on Resident #4 Q 15 minutes it was only required to be documented twice a day. She said on 12/30/2021, she reviewed all Resident #4's notes from September 2021 to December 2021. She said she then implemented the following measures: activity director to assist Resident #4 with one on one activities during peak times, one non-alcoholic beer in the evenings, continue with Q 15 minutes checks, continue with staff redirection, composition notebook provided for reminders, reminders placed in his room and continue with wander guard in place. She stated the interventions were effective because he has not had another elopement attempt since 12/29/2021. She confirmed she did not know about the incident on 02/01/2022 when dietary staff found Resident #4 behind the building of Hall 2 unsupervised. She said she did not think it was an issue because the yard was fenced in and Resident #4 could not get over or out of the fence.

Based on interview and record review, the facility failed to ensure resident's received treatment and care in accordance with professional standards of practice and the comprehensive person-centered plan of care by failing to ensure the following for 1 (#6) of 2 (#6 and R1) residents by failing to: 1. Coordinate care with the hospice agency, 2. Conduct a comprehensive assessment of a resident after a fall, 3. Refer the resident timely for an X-ray, and 4. Ensure staff met the treatment and care needs of the resident. The deficient practice resulted in an actual harm for Resident #6 starting on 08/12/2019 at 11:00 a.m. when she was found on the floor by S11LPN. S11LPN failed to ensure the resident's fall was communicated with hospice and other staff in the facility caring for the resident. On 08/16/2019 at 12:45 p.m., Resident #6's hospice nurse made a visit and noted the resident was having severe pain in the right hip and upper thigh with movement that had not been present on the last visit on 08/09/2019. The hospice nurse ordered an x-ray of Resident #6's right hip and pelvis. The results of the x-ray revealed Resident #6 had an acute right superior and inferior pubis ramus fractures and possible subcaptial right proximal femur fracture. There were no interventions put in place to address the resident's fracture even after nursing staff became knowledgeable of the fracture; the CNAs were not notified and continued handling the resident in the same manner. Findings: Review of the Facility's Hospice Program policy revealed, in part: 10) It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination, with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: c) Notifying the hospice about the following: A significant change in the resident's physical, mental, social, or emotional status, and clinical complications that suggest a need to alter the plan of care. d) Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. 12) Our facility has designated the Director of Nursing to coordinate care provided to the resident by our facility staff and the hospice staff. She is responsible for the following: a) Collaborating with hospice representative and coordinating facility staff participation in the hospice care planning process for residents receiving theses services. b) Communicating with hospice representatives and other healthcare providers participating in the provision of care to ensure Quality of Care for the resident and the family. Review of the Facility's Hospice contract revealed, in part: Patient Care: The nursing facility shall familiarize itself with the personal care needs of the hospice patient. The nursing facility shall provide care to each hospice patient to keep him/her comfortable, clean, and protected from accident, injury, or infection. Coordination of Services: Hospice and the nursing facility shall coordinate, establish, and agree upon a coordinated plan of care for hospice patients residing in the facility. Monitoring and Notification: Hospice and the nursing facility will promptly inform the other of any change in condition of the patient. Resident #6 Resident #6 was an [AGE] year-old female admitted to the facility with diagnoses, which included [MEDICAL CONDITIONS], Supplemental Oxygen Dependence, Anxiety Disorder, Abnormalities of Gait and Mobility, Lack of Coordination, Muscle Wasting, and Pain. Review of the SC MDS with an ARD of 08/06/2019 revealed a BIMS of 8 which indicated Resident #6 was moderately cognitively impaired. Resident #6 required extensive two plus person physical assistance with bed mobility, transfer, locomotion, and walking. The resident was admitted to Hospice care on 08/02/2019 and was no longer in the facility. Care Plan: 04/12/2019, Actual impaired thought processes, short term or long-term memory loss, and decision-making d/t anxiety, [MEDICAL CONDITION], and memory loss. 04/12/2019, Falls are expected related to a history of falls, cardiovascular disease, fractures, limited mobility, and impaired cognition. History of a left hip replacement and when off oxygen Resident #6 forgets she cannot walk. 08/12/2019, fall with fracture to right hip and right pubis. Interventions: 08/21/2019, hospice noted fracture to right hip. 04/12/2019, alteration in comfort related to pain due to chronic pain. History of left hip ORIF. 08/21/2019 right [MEDICAL CONDITION], pubis fracture. Review of the facility's Investigative Report revealed, in part: 08/12/2019 at 11:00 a.m., fall with no head involvement. Resident #6 was attempting to transfer without assistance and fell . Hospice was notified of the fall. Review of Resident #6's (MONTH) 2019 Nurse's notes revealed, in part: 08/12/2019 at 11:51 a.m., Resident #6 was sitting on the floor. Hospice was called and I am awaiting a call back from the nurse. 08/14/2019 at 5:08 a.m., IDT - investigation of the fall completed. Hospice was notified of the fall. Review of the Physician's Progress Note dated 08/15/2019 revealed, in part: No events per nurse. Review of the hospice note dated 08/16/2019 revealed, in part: Evaluation: Resident #6 is lethargic, difficult to awaken. Right leg is elevated on a pillow. Complaint of severe pain in the right hip and upper thigh with movement. Resident #6 was unable to tell me how long she has had this pain. The facility and resident do not report any new falls. The pain was not present on the last visit. Details: Resident #6 has new pain in the location of the right thigh and hip area. She is no longer attempting to get out of bed due to pain. Review of Resident #6's pelvis and right hip x-ray dated 08/16/2019 revealed, in part: Acute right superior and inferior pubis ramus fractures and possible subcaptial right proximal femur fracture. Further review of the resident's (MONTH) 2019 Nurse's Notes revealed in part, 08/14/2019 at 1159 a.m., Resident #6 refused to be weighed this week. 08/21/2019 at 5:12 p.m., Hospice noted a fracture to Resident #6's right hip and pelvis from her fall on 08/12/2019. Resident #6 stated that her right hip did not hurt unless someone picked up her leg. 08/25/2019 at 3:18 a.m., Resident #6 complained of pain when she was repositioned. 08/26/2019 at 4:02 a.m., late entry for 7:00 a.m., Resident #6 was complaining of pain and discomfort. Complained of increased pain with movement and positioning. 08/26/2019 at 4:05 a.m., Resident #6 has not been getting out of bed to toilet. Review of Resident #6's weight log revealed the resident had been weighed on 07/01/2019, 07/09/2019, 07/16/2019, 07/30/2019, 08/06/2019, and then began refusing to be weighed on 08/13/2019. Further review of the resident's hospice notes dated 8/20/2019, 8/23/2019 and 8/30/2019 revealed, in part: -Evaluation on 8/20/2019-Resdient with complaint of right hip pain with movement on 08/16/2019. X-rays ordered that same evening and revealed fractures of the anterior and posterior symphysis pubis. Maintaining bedrest with [MEDICATION NAME] for breakthrough pain. -Evaluation on 8/23/2019 -Resident #6 is currently bedbound with severe pain with movement. -Evaluation on 8/30/2019- Resident #6 is currently bedbound with severe pain with movement. At today's visit, Resident #6 was crying out in pain as the facility's CNAs changed her diaper. Review of Resident #6's MAR from (MONTH) 2019 revealed the resident was receiving [MEDICATION NAME] 325 mg by mouth every four hours for pain as needed and [MEDICATION NAME] 50 mg every six hours as needed. Review of Resident #6's MAR from (MONTH) 2019 revealed [MEDICATION NAME] mg was changed from as needed every twelve hours to scheduled every twelve hours on 08/25/2019. [MEDICATION NAME] 50 mg was changed from every six hours as needed to every four hours as needed for breakthrough pain on 08/25/2019. An interview was conducted with S11LPN on 11/19/2019 at 1:20 p.m. She stated Resident #6 was cognitive enough to educate, but would often get up without calling for assistance. She stated the resident complained of generalized pain, but never specifically stated where the pain was coming from. She stated Resident #6 was started in hospice care in the beginning of (MONTH) after coming back from the hospital. She stated she contacted hospice for all orders related to Resident #6. She stated she should contact hospice in the event of a fall or a need for a change in the resident's care. S11LPN reviewed the note from (MONTH) 12, 2019 and confirmed she had entered into the record. She explained that she had walked into Resident #6's room and the resident was on the floor. She stated this was an unwitnessed fall. She stated she immediately let S2DON know about the fall. She stated she had contacted hospice and left a message, but was not sure if she had actually spoken with anyone about Resident #6 falling. She stated neurological checks should be implemented after an unwitnessed fall. She stated that would consist of checking on the resident more frequently to assess for any changes. She could not recall knowing if she had started neurological checks on Resident #6 after the fall on 08/12/2019 and confirmed she could not find any documentation to show that she did. She could not recall any communication with the hospice nurse on 08/16/2019 in regards to Resident #6 having new severe pain to the right hip and thigh area or of an x-ray being ordered. She stated she was not made aware Resident #6 had suffered from a right [MEDICAL CONDITION] after the fall on 08/12/2019. An interview was conducted with S18CNA on 11/19/2019 at 1:54 p.m. She stated Resident #6 was in a lot pain after falling in (MONTH) and was not like that when she entered the facility in (MONTH) 2019. She stated she was aware of the resident's fall, but was not present when the resident fell . She stated she was not made aware of Resident #6 sustaining any injuries or fractures due to falling in the facility. She stated she should have been made aware of a resident having a [MEDICAL CONDITION] because it would change the way she cared for that resident. She stated she would be more aware of how she assisted the resident with transfers and repositioning in order to prevent further injury or pain. She denied ever being made aware Resident #6 had a right hip/pelvis fracture. An interview was conducted with S22CNA on 11/20/2019 at 8:39 a.m. She explained Resident #6 complained of generalized pain, but would still stand up on the scale to be weighed. She stated Resident #6 had started to decline weights around (MONTH) 2019 due to pain. She stated in (MONTH) the resident had declined to a point where she could not get up out of bed and had to be weighed in the bed. An interview was conducted with S6DM on 11/20/2019 at 8:56 a.m. She provided a copy of Resident #6's weights in July, August, and (MONTH) of 2019. She confirmed Resident #6 began refusing to be weighed on 08/13/2019 according to the weight log. An interview was conducted with S19CNA on 11/20/2019 at 9:17 a.m. She confirmed she would bring Resident #6 to the shower room until she declined to the point where she could not go and then she was bathed in bed. She stated the resident started being bathed in bed towards the end of (MONTH) 2019. She stated she was never made aware Resident #6 had fallen and broken her right hip/pelvis on 08/12/2019. S19CNA stated she should have been made aware of the [MEDICAL CONDITION] because it would have changed the way Resident #6 was cared for, and she would not have tried to get her up to go to the shower room for baths. An interview was conducted with S23CNA on 11/20/2019 at 9:19 a.m. She stated she was not made aware Resident #6 had broken her right hip/pelvis after falling on 08/12/2019. She stated she should have been made aware by the nurse because it would have changed the way Resident #6 was cared for. She stated she would have been more cautious while assisting the residentwith activities of daily living. An interview was conducted with Resident #6's hospice nurse on 11/19/2019 at 10:11 a.m. She stated Resident #6 had been admitted to hospice on 08/02/2019 with a [DIAGNOSES REDACTED]. She stated upon admission to hospice, [MEDICATION NAME] mg twice a day was ordered to assist with Resident #6's severe anxiety from the dyspnea. She confirmed this medication could also be used to treat pain. She described Resident #6 as confused and a poor historian. She stated she had not been made aware of Resident #6 falling on 08/12/2019. She explained when she arrived to the facility for a scheduled visit on 08/16/2019 she found Resident #6 in bed complaining of severe pain to the right hip and thigh area. She stated the pain increased with pressure or movement. She stated Resident #6 was more lethargic and refused to get out of bed due to the pain in the right leg and hip. She confirmed prior to the visit on 08/16/2019, Resident #6 had not complained of pain to the right leg or hip area. She stated she communicated her findings on 08/16/2019 with S11LPN. She stated she let S11LPN know she was having an x-ray ordered for that evening. She stated the results of the x-ray were called into the hospice agency on 08/16/2019 at 8:36 p.m. She stated, on 08/21/2019 S2DON was made aware of the hip/pelvis fracture. She stated Resident #6 should have been on bed restrictions and having only bed baths after the fracture was identified. She confirmed Resident #6 should have been placed on bed rest or a non-weight bearing status and handled more gently for a while to let the fracture heal. An interview was conducted with S9WC on 11/20/2019 at 10:37 a.m. She stated after the fall on 08/12/2019, Resident #6 noticeably declined in mobility, repositioning, and would refuse to be moved due to pain. She confirmed Resident #6 had generalized pain prior to the fracture, but stated she would still get up and be repositioned. She stated, had she been aware of the fracture prior to 08/20/2019, she would have been more gentle with the way she handled Resident #6 during wound care. An interview was conducted with S13LPN on 11/20/2019 at 10:45 a.m. She stated she was aware of Resident #6 having a few falls while in the facility, but was unaware of her sustaining any injuries. She stated she should have been made aware of a right hip/pelvis fracture during verbal report and in the nurse's notes. She confirmed the staff would care for the resident differently if they were aware she had a hip/pelvis fracture. A telephone interview was conducted with S12LPN on 11/20/2019 at 11:45 a.m. She confirmed she had worked the evening/night with Resident #6 on 08/12/2019 and 08/16/2019. She denied being made aware that hospice had not been contacted in regards to the fall or that she needed to follow up with them on 08/12/2019. She denied being aware of completing any neurological checks on Resident #6 after the fall on 08/12/2019. She stated she was aware of the right [MEDICAL CONDITION], but did not know how she knew about it. She did not recall communicating the information about the fracture to anyone and denied any changes in Resident #6's care. An interview was conducted with S7MDS on 11/20/2019 at 11:51 a.m. She stated Resident #6 had a couple of falls in her room. She stated the assigned nurse would be responsible for communicating with the staff and MDS department of a fall in the team meetings. She stated she was made aware, on 08/21/2019, that Resident #6 had been diagnosed with [REDACTED]. She stated the staff would handle a resident differently if they were aware of a fracture to the right hip/pelvis area. She reported they would transfer and position her more gently. An interview was conducted with the Director of Nursing at the hospice agency on 11/20/2019 at 1:02 p.m. She stated S11LPN left a message on 08/12/2019 at 11:00 a.m. She stated the message was that Resident #6 had a new skin tear and there was no mention of a fall or a need for a return call. She confirmed there was no other documented communication between the facility and the hospice agency again until 08/20/2019. An interview was conducted with S2DON on 11/20/2019 at 2:18 p.m. She explained the nurses should start neurological assessments after all unwitnessed falls. She stated the nurses are supposed to assess for any changes in a resident after falls. She confirmed Resident #6 had fallen on 08/12/2019 and there was no documentation that a neurological assessment had been completed. She stated if a resident was receiving hospice care the nurse should notify them after a fall. She stated, if the hospice nurse did not respond in a timely manner the facility nurse should continue to try to contact them. She stated if the hospice nurse was not contacted prior to shift change, it should be verbally communicated in report and the oncoming nurse would take over the responsibility. She also reported that the attempted communications should be documented in a note. She stated she was made aware on 08/13/2019 that Resident #6 had fallen. She denied contacting hospice to report the fall and stated she had just assumed the nurse had contacted them. She stated once she was made aware of the right hip/pelvis fracture the staff were made aware via word of mouth and written report. She stated the nurses should have been aware of the right hip/pelvis fracture and communicated it with the CNA's. She confirmed she was unaware the staff did not know about Resident #6's fracture. She stated Resident #6 was on comfort measures and there would not have been any changes to her plan of care after finding out about the right hip/pelvis fracture. She confirmed there was no changes or added interventions after she was made aware of the fracture on 08/21/2019. She stated S12LPN should have been aware Resident #6 had a portable x-ray completed on 08/16/2019 and should have followed up on the results. She stated there was not an assigned representative at the facility to communicate with hospice. She stated she had started directly communicating with Resident #6's hospice nurse on 08/21/2019. S2DON confirmed there was a breakdown between the hospice and the facility.

Based on record review and interview, the facility failed to notify and consult with the Physician for 1 (#78) of 3 residents (#78, #36, #120) with weight loss out of a sample of 7 (#78, #68, #120, #60, #92, #61, #87) and for 1(#106) out of 10 (#34, #24, #29, #37, #63, #66, #98, #102, #106, #122) residents selected for medicine pass that failed to receive a medication. The facility failed to: 1) Immediately notify the physician when Resident #78 experienced severe unplanned weight loss (6.1% in 1 month) between December 2011 and January 2012. 2) Immediately notify the physician when a resident (#78) experienced severe unplanned weight loss (15% in 6 months) between July 2011 through January 2012. 3) Immediately notify the physician when Resident #78 experienced severe weight loss of (24.83% in 1 month) between February 6, 2012 and March 5, 2012. 4) Notify the physician that a blood pressure medication was not given as ordered for 1(#106) of 10 (#14, #24, #29, #37, #63, #66, #98, #102, #106, #122) residents observed during the medication pass. The Registered Dietician's Annual Nutrition assessment dated [DATE] for Resident #78 revealed an ideal body weight of 115 plus or minus 10 percent . The resident weighed 122 lbs on August 1, 2011, 115 lbs on October 3, 2011, and 111 lbs on November 7, 2011. The resident was in immediate jeopardy on 1/2/12 when the resident continued to experience severe weight loss to 104 lbs and the physician was not notified. The facility did not notify the physician of the resident refusals to eat and the resident continuing weight loss. On 2/6/12 the resident weighed 105.5 lbs. The resident continued in immediate jeopardy on 3/5/12 when the resident lost down to 79.3 lbs, a weight loss of 18.5 lbs in 1 month and the physician was not immediately notified. The immediate jeopardy was removed for this resident on 3/6/12 at 3:05 p.m. when the resident was transferred to the hospital. The deficient practice continued at a scope and severity of a level 3, actual harm, for this resident and a level 2 for all other residents with unplanned weight loss in the facility. Findings: Resident #78 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Diabetes Mellitus, Hypertension, [MEDICAL CONDITION], Bone Cartilage Disease and Mitral Valve Disorder. Review of Resident #78's Census Weight Data information which was automatically calculated by the Quality Indicator Survey (QIS) system revealed the following in part: Date: 02/06/2012; Weight: 105; BMI: 19 Date: 01/02/2012; Weight: 104; BMI: 18 Date: 11/07/2011; Weight: 111; BMI: 20 Date: 08/01/2011; Weight: 122; BMI: 22 The resident loss -.96% from the first weight to the second weight The resident loss 5.41% from the first weight to the third weight The resident loss 13.93% from the first weight to the fourth weight Review of the facility's Monthly Weights for March 2012 revealed that the resident weighed 79.3 pounds (lbs). Further review of Resident #78's weights revealed that from 2/6/12 to 3/5/12 the resident had a 24.83% weight loss. Review of Resident #78's Weight Change History revealed that the resident was weighed the 1st Monday of each month as follows: 2/7/11 119.60 3/7/11 120.10 4/4/11 115.30 5/2/11 117.80 6/6/11 121.50 7/4/11 122.50 8/1/11 122.0 9/5/11 114.60 10/3/11 115.20 11/7/11 111.30 12/5/11 110.80 1/2/12 104.0 2/6/12 105.50 On 3/9/12 at 2:12 p.m. an interview was held with S10CNA Supervisor. She stated that the CNA's do the monthly weights the 1st Monday of every month. She stated that she was not at work Monday, March 5, 2012. She confirmed that the CNA's get a paper from S12Treatment Nurse with everybody's name on it and they put the weights on it and give them back to S12Treatment Nurse. Review of Resident #78's Weight Change Alert Report printed on 3/8/12 revealed that on 12/5/11 the resident weighed 110.80 lbs and on 1/2/12 the resident weighed 104 lbs which triggered a 6.14% weight change. Further review of the documentation revealed that on 8/1/11 the resident weighed 122 lbs and on 1/2/12 the resident weighed 104 lbs which triggered a 14.75% weight change. Review of the facility's Nutritional At Risk Committee Meeting revealed the following in part: Date: January 2012 Resident #78 Action Taken: Left blank Weekly weights: No RD Consult: 2/18/11 Diet: Regular Puree Supplement: Pudding bid Additional information: Ideal Body Weight 104-127. Current weight 104 lbs. Last month weight 110.8 lbs. A 6.8 lb weight loss in 1 month. In August resident's weight was 122 lbs. An 18 lb weight loss in 6 months. Further review of the document revealed that the document was faxed 1/23/12 by the ward clerk with no documented evidence or a fax confirmation that the physician ever received the fax or responded. Review of Resident #78's Physician's Progress Notes for 8/31/11, 10/5/11, 12/14/11 and 2/11/12 revealed no documented evidence that the physician addressed Resident #78's weight problems. Further review of the documentation revealed that the resident's weight and vital signs had been left blank on the Physician's Progress Notes each time that he visited the resident at the facility. Review of the S13Dietary Manager's notes on 10/4/11 revealed the following in part: Per CNA's, Resident #78 will eat as long as there was sweets involved. Resident was assisted by CNA's for all her meals. Resident's diet was Regular Pureed. Will update as needed. Further review of S13Dietary Manager's notes revealed no documented evidence that Resident #78's weight loss of 7 lbs since 8/1/11 had been addressed. On 3/7/12 at 1:56 p.m., an interview was conducted with S13Dietary Manager. She stated that the facility had a weight loss committee. She stated that the computer triggers a resident's name if there's a significant weight loss of 5% or greater. She stated that depending on the resident's problem, they may put them on weekly weights or even daily weights. She stated that weights trigger at 1 month, 3 months and 6 months. She stated that when a resident has a gradual weight loss like Resident #78, their computer system would not trigger the weight loss because its over a period of time. On 3/7/12 at 2:07 p.m. an interview was conducted with S12Treatment Nurse. She stated that the resident weight triggered in January for a 1 month weight loss of 6.8 lbs. She stated in that same month, she triggered a second time for a 6 months weight loss of 18 lbs. She stated that she usually gives the RD a copy of her Weight Change Alert Report that the weight loss triggered on and the RD makes her determination on what she was going to do. She stated that she does not have any documented evidence that she gave the RD the trigger sheets for Resident #78's weight loss. She stated that after she gave the documentation to the RD, that was as far as she took it. She stated that once the resident triggered, they discussed Resident #78 at the Nutritional At Risk Committee meeting. She stated that after the January 2012 meeting she gave the Nutritional at Risk Committee Meeting report to the ward clerk, for her to fax and notify the physician. She stated that according to the Nutritional at Risk Committee meeting document, the document was faxed on 1/23/12, but she did not followup with the physician to see if he actually received the fax or checked to see if he made a recommendation for Resident #78's weight loss. She stated that the staff weighed the resident on the 1st Monday of each month which for this month was March 5th 2012. She stated that she gave the CNA staff a document with just the names on them so that they can write the weight on. She stated that she did not have knowledge of the resident's weight taken on March 5th; which was 79.3 lbs. She stated that if she had, she would have asked the staff to reweigh the resident. She confirmed that she does not have any documented evidence that she informed the RD and requested a consult or that the physician was notified of the resident's gradual weight loss. She stated that she had not seen the weight because she was busy. She stated that she did not know why the facility's protocol was not followed when the resident weights triggered twice for a 6.14% weight loss and a 14.75% weight loss respectively, but that it should have been. She stated that the resident was not put on a nutritional supplement for weight loss nor were there any new interventions put in place to ensure that the resident did not continue to lose weight. She stated that when the resident was weighed on 3/5/12 and 3/6/12, that there was no documented evidence that the physician was notified. She further stated that on 2/5/12, the resident weighed 105.50 lbs and on 3/5/12 the resident's weight was 79.3 lbs; which resulted in a 24.83% weight loss in 1 month. This too, was not reported to the physician. On 3/7/12 at 2:10 p.m. an interview was conducted with S3ADON. She confirmed that there was no documentation that the resident was ever put on a nutritional supplement for her gradual weight loss or that she was ever put on weekly weights when the resident triggered in January 2011 for a 6.8 # weight loss for 1 month or of a 18 lb weight loss for 6 months. She stated that when weights usually triggered, they put the resident on weekly weights. She confirmed that the resident was not on weekly weights and that she should have been. She stated that the resident had been put on ensure pudding because it helps her to eat her food and not as an intervention for weight loss. She stated that, after retrieving documentation of Resident #78's weight from S12Treatment Nurse's desk, she confirmed that the resident's weight was 79.3 lbs. She stated that she didn't know if the weight was accurate. She stated that if a CNA had brought her a weight of 79.3 lbs, that she would have asked for a reweigh. On 3/7/12 at 2:30 p.m. an interview was conducted with S10CNA Supervisor. She stated that she and S14CNA had reweighed Resident #78, on the stand up scale and on the lift, on 3/6/12. She stated that she gave S16LPN the reweight on 3/6/12. On 3/7/12 at 4:00 p.m. an interview was conducted with S17CNA. She stated that when she fed Resident #78 that last time she worked with her on Friday, March 2, 2012, she kept putting her hand over her mouth not letting her feed her. She stated that she notified S18LPN and S1Administrator. She stated that S18LPN told her that she was informed that when the resident does not eat, she was constipated and needed to be checked for an impaction. She stated that S18LPN told her that she was going to check the resident for an impaction and to keep trying to feed her. She stated that before March 2, 2012, the resident would eat a spoon full bite of her food and she would stop eating. She stated that she always informed nurse when she was not eating and she would tell me to watch her and try to continue to feed her and give her fluids. She stated that the CNA's documented the resident's consumption in the computer. Review of the Meal Intake Detail Report revealed the resident's meal consumption was 0% to 25% on numerous days from November 2011 to March 2012. Her consumption was documented as 25% or less on the dates and meals noted below: Breakfast Consumption: 11/2/11-Refused 11/3/11-25% 11/13/11-25% 11/16/11-25% 11/29/11-Refused 12/8/11-Refused 12/15/11-25% 12/18/11-Refused 12/22/11- Refused 12/24/11-25% 1/7/12- 25% 1/12/12-25% 1/17/12-25% 1/18/12-Refused 1/19/12-Refused 1/20/12-Refused 1/21/12-No documentation 1/22/12-25% 1/25/12- 25% 1/27/12- Refused 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12-25% 2/6/12-Refused 2/9/12-25% 2/13/12-25% 2/14/12-25% 2/18/12- 25% 2/19/12-25% 2/20/12-25% 2/23/12-25% 2/25/12-Refused 2/26/12-Refused 2/28/12-25% 3/1/12-Refused 3/2/12-25% 3/4/12-25% 3/5/12-25% Lunch Consumption: 11/5/11-25% 11/7/11-Refused 11/8/11-Refused 11/9/11-25% 11/12/11-Refused 11/17/11-25% 11/21/11-25% 11/29/11-Refused 12/13/11- Refused 12/18/11-Refused 12/20/11-25% 12/21/11-25% 12/22/11- Refused 12/23/11-25% 12/24/11-25% 12/25/11-25% 12/26/11- Refused 12/29/11-Refused 1/3/12- 25% 1/7/12-25% 1/8/12-25% 1/10/12-Refused 1/11/12-25% 1/12/12-25% 1/13/12-Refused 1/14/12-Refused 1/15/12-Refused 1/16/12-25% 1/17/12-25% 1/20/12-Refused 1/21/12-No documentation 1/22/12-25% 1/24/12-Refused 1/25/12-25% 1/26/12-25% 1/27/12-Refused 1/29/12-Refused 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12-25% 2/6/12-Refused 2/9/12-25% 2/13/12-25% 2/14/12-25% 2/18/12-25% 2/19/12-25% 2/20/12-25% 2/23/12-25% 2/25/12-Refused 2/26/12-Refused 2/28/12-25% 3/1/12-Refused 3/4/12-25% 3/5/12-25% Supper Consumption: 11/2/11-Refused 11/3/11-Refused 11/5/11-Refused 11/7/11-Refused 11/8/11- Refused 11/11/11-Refused 11/12/11-Refused 11/15/11-Refused 11/16/11-Refused 11/17/11-Refused 11/20/11-Refused 11/21/11-Refused 11/22/11-Refused 11/25/11-Refused 11/26/11-Refused 11/27/11-Refused 11/29/11-Refused 11/30/11-Refused 12/5/11-Refused 12/6/11-Refused 12/8/11-Refused 12/9/11-Refused 12/13/11-25% 12/15/11-Refused 12/18/11-Refused 12/20/11-25% 12/22/11-Refused 12/23/11-Refused 12/24/11-Refused 12/25/11-25% 12/26/11-Refused 12/27/11-Refused 12/28/11-Refused 12/29/11-25% 12/30/11-25% 12/31/11-Refused 1/2/12-Refused 1/3/12-Refused 1/5/12-Refused 1/7/12-Refused 1/2/12-Refused 1/3/12-Refused 1/5/12-Refused 1/7/12-Refused 1/8/12-Refused 1/10/12-Refused 1/11/12-Refused 1/12/12-Refused 1/13/12-Refused 1/15/12-Refused 1/16/12-25% 1/17/12-25% 1/18/12-Refused 1/19/12-Refused 1/20/12-25% 1/22/12-Refused 1/23/12-Refused 1/24/12-Refused 1/25/12-25% 1/26/12-Refused 1/27/12-Refused 1/29/12-25% 1/30/12-25% 1/31/12-25% 1/23/12-Refused 1/24/12-Refused 1/25/12-25% 1/26/12-Refused 1/27/12-Refused 1/29/12-25% 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12- 25% 2/7/12-No documentation 2/8/12-25% 2/9/12-25% 2/12/12-25% 2/13/12-25% 2/14/12-25% 2/17/12-25% 2/18/12-25% 2/19/12-25% 2/22/12-25% 2/23/12-25% 2/24/12-Refused 2/25/12-Refused 2/26/12-Refused 2/27/12-Refused 2/28/12-Refused 2/29/12-Refused 3/1/12-Refused 3/2/12-Refused 3/3/12-Refused 3/4/12-Refused 3/5/12-Refused On 3/7/12 at 4:18 p.m. an interview was conducted with S18LPN. She stated that Resident #78 was fed by the CNAs; but she was not a big eater. She said that the resident occasionally resisted the staff. She stated that the CNAs could not get the resident to eat all the time. She stated that she did not notify the doctor that the resident was not eating and resisted staff, because it was not a new problem. She stated that she was not aware of Resident #78 losing weight . She stated that when the CNAs take the weights, they give the weights to S12Treatment Nurse. She stated that S12Treatment Nurse informed her that there was suppose to be something that triggers if the resident had a weight loss in the system. She stated that if a resident had a weight loss, S12Treatment Nurse would have to tell her because she does not keep up with weights. She said that she had not noticed a drastic change in Resident #78's weight because she was the same size when she started in February and therefore she never notified the physician or the family. She stated that the staff who trained her told her that when the resident refuses to eat, check her for an impaction because she was constipated and needed an enema and that was what she normally did when the resident did not eat. On 3/7/12 at 4:03 p.m. an interview was conducted with S1Administrator. She stated that on 3/2/12, she informed S3ADON and S10CNA Supervisor that the resident was not eating. She stated that S10CNA Supervisor told her that she would inform S16LPN to check the resident for an impaction. Review of the facility's Departmental Notes dated 3/6/12 at 2:47 p.m. written per S16LPN revealed the following: Resident leaned out of wheelchair while sitting in the main lobby of facility and fell into floor, hitting head. .4 cm x 3 cm reddened raised area noted directly in middle of resident's forehead. Resident assisted back into wheelchair and then into bed by staff. Resident is exhibiting signs of increased pain by curling into a fetal position and making whining/crying noises. B/P 85/70, P 80, T 97 and O2 Saturation of 86% on room air. Contacted physician's office regarding fall and resident's symptoms. Received verbal order at this time to send resident out to a local hospital for further evaluation and treatment. Order noted. O2 at 2 liters per nasal cannula administered. 911 emergency contacted at this time to transfer resident to the hospital. Resident is currently being supervised by staff due to attempts to remove nasal cannula. 3/6/12 3:05 p.m. Emergency medical services here to transfer resident to a local hospital emergency room per Medical Doctor (MD) orders. Left on stretcher. All pertinent information given to ambulance employees at that time. Review of the emergency room Nurse Report dated of 3/6/12 revealed the resident was admitted to the hospital with [REDACTED]. Further review of the emergency room Assessment, General Admission Form dated 3/7/12 revealed primary [DIAGNOSES REDACTED]. That same form listed the resident's weight was of 90.2 lbs. On 3/8/12 at 10:17 a.m. an interview was conducted with S16LPN. She stated that on 3/6/12, before the resident fell , she was not going to send the resident out to the hospital. She stated that the reason she called the doctor was to clarify an order that had been written to obtain 3 stools to check for occult blood. She further stated that she could not get the first stool sample and wanted to know what the physician wanted her to do. She stated after Resident #78 fell out of the chair, they put her in the bed and she noticed that the resident had a decreased blood pressure, O2 saturation was low @ 86% on room air. She had decreased level of consciousness and she was holding her abdominal area, exhibiting signs of pain. On 3/8/12 at 3:30 p.m. S1Administrator, S2DON, S3ADON and S12Treatment Nurse came into the room where the surveyors were. S12Treatment Nurse stated that she was aware of the weight on 3/5/12 in the evening time. She stated that she asked for a reweigh on 3/6/12 because the resident weighed 79.3 lbs and she wanted to make sure that was the correct weight. She verified that the resident's physician was not notified and no new interventions were put in place and that the resident should have been put on weekly weights per protocol when she triggered twice in January 2012 for a 6.8 lb weight loss for 1 month and a 6 month 18 lb weight loss. S1Administrator, S2DON, S3ADON and S12Treatment Nurse confirmed that the facility "dropped the ball" regarding the resident's gradual weight loss and agreed that it should have been recognized by the facility. On 3/9/12 at 9:00 a.m. an interview was conducted with S14CNA. She stated that she weighed the resident Monday 3/5/12, after she ate lunch, using a standing scale assisted by S15CNA and she weighed 79 lbs. She said she brought the resident back to her room. After she finished weighing the other residents on the hall, she came back and told S16LPN that the resident weighed 79 lbs. She stated that S16LPN researched what Resident #78's normal weight was and asked her to reweigh the resident. She stated that she and S10CNA Supervisor reweighed the resident on the lift scale later that evening and informed S16LPN that she weighed 80 lbs. She stated that she knew it was not on 3/6/12 because that's when the resident went out to the hospital. On 3/9/12 at 9:05 a.m. an interview was conducted with S16LPN. She stated that the resident was weighed on Tuesday 3/6/12 the day when she sent the resident out to the hospital. She stated that she had no knowledge of what the reweight of the resident was and that she did not document anything about the resident's weight when she was weighed the first time or that she notified that physician that the resident had a 24.83% weight loss in 1 month. On 3/9/12 at 9:10 a.m. this surveyor was approached by S14CNA. She stated that, maybe she was wrong, she thought she weighed the resident on 3/6/12 after lunch. She stated that she remembered getting S15CNA to help her weigh the resident. She stated that after she gave S16LPN the weight on 3/6/12, S16LPN asked her to reweigh Resident #78 again and she reweighed her with S14CNA. She said that after she reweighed her, she gave the reweight of 80 lbs to S16LPN. On 3/9/12 at 9:40 a.m. an interview was conducted with S16LPN. She confirmed that she did have knowledge that the resident's reweight was 80 lbs, but that it must have been after the resident left the facility. On 3/9/12 at 12:40 p.m. an interview was conducted with S15CNA. She stated that she helped S14CNA weigh the resident on Tuesday, 3/6/12 the first time around 10 a.m. or 11 a.m.,. almost lunch time. On 3/9/12 at 1:55 p.m. an interview was conducted with S14CNA. She stated that whatever day S12Treatment Nurse brought them the weight sheets, that is when they got the weights. She stated that she weigh everybody on the same day for monthly weights, but she does not know exactly what day it was. On 3/9/12 at 2:30 p.m. an interview was conducted with S2DON. She confirmed that there was no documented evidence that the physician was notified of Resident #78's 26.2 lb weight loss from 2/6/12 to 3/5/12. She also stated that the there was no documented evidence that the physician was notified until 1/23/12 of the resident's gradual weight loss from 8/1/11 when she weighed 122.50 lbs to 1/2/12, when she weighed 104 lbs; resulting in a 18.5 lb weight loss. She verified that the facility had not put any interventions in place to ensure that the resident did not continue to lose weight. She confirmed that the NAS Pureed Diet with pudding bid ordered on [DATE] was not a new intervention because the resident had already been on a Regular Pureed Diet with pudding twice a day (bid) as noted on the RD's Annual Nutrition Assessment on 2/18/11. She stated that pudding bid was not an intervention used for weight loss, but as a means to get the resident to eat, because she would eat sweet things. She verified that the resident did not have an RD consult regarding nor was she put on weekly weights per facility protocol when a weight triggered a 5% or greater weight loss in January 2011. Resident #106 Review of the eMAR and physician's orders [REDACTED]. Review of the medications given during the medication pass on 3/6/12 at 8:05 a.m. revealed the [MEDICATION NAME] was not given by S4LPN. Review of the eMAR dated March 2012 revealed no documentation that the [MEDICATION NAME] was given as ordered on [DATE] at 8:05 a.m.. On 3/7/12 another review was done of the eMAR for the resident. The [MEDICATION NAME] dated 3/6/12 had an "N" documented with the nurse's initials. Review of the Nurses' notes dated 3/6/12 revealed no documentation that S4LPN had notified the resident's Physician of the missed dose of [MEDICATION NAME] that the resident was scheduled to receive 2 times a day. On 3/8/12 at 9:30 a.m. an interview with S2DON revealed she had spoken on the telephone with S4LPN about the medication. S2DON reported that S4LPN told her the resident's [MEDICATION NAME] was not on the medication cart and was not in the med room so she had to call the pharmacy. The DON said S4LPN told her the [MEDICATION NAME] had been ordered but hadn't been delivered so the nurse documented "N" for not given. S2DON reviewed the eMAR for March 2012 that was printed on 3/6/12 and verified the nurse did not document she had given the [MEDICATION NAME] that morning as ordered. On 3/9/12 at 9:00 a.m., an interview was held with S4LPN. She said when she was giving the resident his medications on Tuesday, 3/6/12, she realized the [MEDICATION NAME] and [MEDICATION NAME] wasn't on the cart but didn't say anything about it. She said she went to the medication room and found the [MEDICATION NAME] but didn't have the [MEDICATION NAME]. She said that she knew the [MEDICATION NAME] had been ordered because the label was pulled. She said she had called the pharmacist and found out that it had not been delivered. She reported she went back and found the fax sheet that was faxed to the pharmacist. She said the pharmacist sent the medication out that night. She acknowledged the resident had an order for [REDACTED]. She said he didn't receive his morning dose but he did get his night dose. She said his BP that morning was 143/93. She reported there wasn't a place on the MAR in the computer to document the BP so they would have to put it in the nurses' notes. She reviewed the nurses' notes dated 3/6/12 and acknowledged the BP wasn't recorded in the note. S4LPN reported that she didn't notify the physician that the medication was not given Tuesday morning. She said she was not sure if she had to report it to the physician. On 3/9/12 at 10:00 a.m., in an interview with S3ADON she revealed that the medication cards had a blue strip over the last few medicines on the card. She said that when the medicines got to the blue area then the nurse would pull the label from the card and fax it to the pharmacy. She added that when the medication was delivered by the pharmacy it would be placed on the medication cart or in the medication room. S3ADON also said that if the nurse saw that the medication had not came in from the pharmacy she should call the pharmacy. She also said that if a nurse didn't have a medication for the resident, and it had not been delivered by the pharmacy she could call the local pharmacy and get enough medicine for the patient until the medication was received from the facility pharmacy. She reported the nurse should have notified the physician that the medication was not given as ordered.

Based on interview and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to recognize and address the needs of a resident experiencing a weight loss for 2 (#78, #36) of 3(#78,#36, #120) residents out of a total of 7 (#78, #68, #120, #60, #92, #61, #87) Stage 2 residents meeting the criteria for a review of Nutrition. The facility's total census was 120 according to the Resident Census and Condition Form. The facility failed to: 1) Immediately notify the physician when Resident #78 experienced severe unplanned weight loss (6.1% in 1 month) between December 2011 and January 2012. 2) Immediately notify the physician when a resident (#78) experienced severe unplanned weight loss (15% in 6 months) between July 2011 through January 2012. 3) Implement new interventions to prevent unplanned weight loss for Resident #78 when resident experienced severe unplanned weight loss between December 2011 and January 2012 (6.1% in 1 month) and severe unplanned weight loss between July 2011 through January 2012 (15%). 4) Obtain a consultation from a Registered Dietician (RD) for Resident #78 who experienced severe unplanned weight loss (6.1% in 1 month) between December 2011 and January 2012 and severe unplanned weight loss (15%) between July 2011 and January 2012. 5) Implement weekly weights on a resident (#78) who triggered twice in January 2011 for a 1 month weight loss of 6.14% and a 6 month weight loss of 14.75% respectfully, between December 2011 and January 2012. 6) Immediately notify the physician when Resident #78 experienced severe weight loss of (24.83% in 1 month) between February 6, 2012 and March 5, 2012. 7) Provide a nutritional supplement as recommended by the Consultant Dietitian.(#36). The Registered Dietician's Annual Nutrition assessment dated [DATE] for Resident #78 revealed an ideal body weight of 115 plus or minus 10 percent . The resident weighed 122 lbs on August 1, 2011, 115 lbs on October 3, 2011, and 111 lbs on November 7, 2011. The resident was in immediate jeopardy on 1/2/12 when the resident continued to experience severe weight loss to 104 lbs and the physician was not notified and no new interventions were put in place to prevent additional unplanned weight loss. The facility did not increase monitoring of weights, notify the physician of the resident refusals to eat, monitor food intake and the resident continued to lose weight. On 2/6/12 the resident weighed 105.5 lbs. The resident continued in immediate jeopardy on 3/5/12 when the resident lost down to 79.3 lbs, a weight loss of 18.5 lbs in 1 month and the physician was not immediately notified and ended on 3/6/12 at 3:05 p.m. when the resident was transferred to the hospital. The deficient practice continued at a scope and severity of a level 3, actual harm, for this resident and a level 2 for all other residents with unplanned weight loss in the facility. Findings: Resident #78 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Diabetes Mellitus, Hypertension, [MEDICAL CONDITION], Bone Cartilage Disease and Mitral Valve Disorder. Review of Resident #78's MDS dated [DATE] in Section L-Oral/Dental Status in L0200B: revealed that the resident had no natural teeth. Review of the facility's Weight Assessment and Intervention Policy revealed the following in part: Policy Statement The multidisciplinary team will strive to prevent, monitor, and interview for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment: ...3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight was verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification. 5. The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for "significant" weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss=(usual weight-actual weight)/(usual weight) x 100): a. 1 month-5% weight loss was significant; greater than 5% was severe. 3 months-7.5% weight loss was significant; greater than 7.5% was severe. 6 months-10% weight loss was significant; greater that 10% was severe. Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: ...b. Chewing or swallowing abnormalities; ...e. Increased need for calories and/or protein;... Interventions: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: ...b. Nutrition and hydration needs of the resident;... e. Chewing and swallowing abnormalities and the need for diet modifications;... g. The use of supplementation and/or feeding tubes;... Review of Resident #78's Census Weight Data information which was automatically calculated by the Quality Indicator Survey (QIS) system revealed the following in part: Date: 02/06/2012; Weight: 105; BMI: 19 Date: 01/02/2012; Weight: 104; BMI: 18 Date: 11/07/2011; Weight: 111; BMI: 20 Date: 08/01/2011; Weight: 122; BMI: 22 The resident loss -.96% from the first weight to the second weight The resident loss 5.41% from the first weight to the third weight The resident loss 13.93% from the first weight to the fourth weight Review of Resident #78's Weight Change History form revealed that the resident was weighed the 1st Monday of each month as follows: 2/7/11 119.60 3/7/11 120.10 4/4/11 115.30 5/2/11 117.80 6/6/11 121.50 7/4/11 122.50 8/1/11 122.0 9/5/11 114.60 10/3/11 115.20 11/7/11 111.30 12/5/11 110.80 1/2/12 104.0 2/6/12 105.50 Further review of the facility's Monthly Weight document for March 2012 revealed that the resident weighed 79.3 lbs on 3/5/12. Review of Resident #78's March 2012 Physician order [REDACTED]. 1) No Added Salt (NAS) diet with pudding twice(bid) daily. Review of Resident #78's Comprehensive Plan of Care for Potential for Alteration in Nutrition revealed the following in part: Problem Onset: Date left blank ...History of weight loss Goals: Total intake will meet nutritional needs for nutrients and fluids... Weight maintain adequate nutritional status as evidenced by weight remaining stable overall for quarter Approaches: ...Monitor meal consumption & compliance with diet ...Notify RD regarding problems, complaints, or requests ...Monitor for any chewing/swallowing difficulties and refer to RD as needed ...Tends to have fluctuating weights from week to week. Weights monitored weekly, yet overview for trend over several weeks to determine if a weight change was permanent or fluctuating. Sometimes stands up for weight, per her choice. ...Staff to assist with feeding as resident often refuses and will consume some portion of meals with consistent encouragement. Staff also uses sweet'n low or sugar free pudding to "tip" food to encourage eating. Review of Resident #78's Nutritional Risk assessment dated [DATE] revealed the resident had a score of 12; At Risk for Nutrition. Review of Resident #78's Minimum Data Set (MDS)'s dated 7/13/11, 10/5/11 and 12/28/11 in Section K Swallowing/Nutritional Status K0300 revealed that the resident had no weight loss. Review of the facility's Annual Nutrition Assessment revealed that the resident was last seen by the RD on 2/18/11 with an ideal body weight of 115 pounds (lbs). Further review of the document revealed that the resident was on a Regular Puree; pudding bid. Review of the the facility's Weight Change Alert Report printed 3/8/12 revealed on 8/1/11, Resident #78 weighed 122 lbs and on 1/2/12, 104 lbs; which triggered a 14.75% weight loss. Further review of Resident #78's Weight Change Alert Report printed 3/8/12 revealed that on 12/5/11 the resident weighed 110.80 lbs and on 1/2/12, 104 lbs; which triggered a 6.14% weight loss. Review of the facility's January, 2012 Nutritional At Risk Committee Meeting report revealed the following in part: Resident #78 Action Taken: Left blank Weekly weights: No RD Consult: 2/18/11 Diet: Regular Puree Supplement: Pudding bid Additional information: Ideal Body Weight 104-127. Current weight 104 lbs. Last month weight 110.8 lbs. A 6.8 lb weight loss in 1 month. In August 2011, the resident's weight was 122 lbs, an 18 lb weight loss in 6 months. Further review of the document revealed that the document was faxed on 1/23/12 by the ward clerk. There was no documented evidence or a fax confirmation that the physician ever received the fax or responded. Review of Resident #78's December 2011 physician's orders [REDACTED]. On 3/7/12 at 1:47 p.m. an interview was conducted with S2DON. She stated that if a resident had a significant weight loss, greater than 5%, it would trigger on the facility's Weight Change Audit Report. She stated that S12Treatment Nurse reviewed residents weights and would inform S2DON and the resident would be discussed at the facility's Nutritional At Risk Committee Meeting. S2DON said through these meetings the RD would be notified and a dietary consult would be requested. She confirmed, after looking in her binder, where the RD consults are kept for residents, that there was no documentation a dietary consult was recommended for Resident #78. Review of the S13Dietary Manager's notes on 10/4/11 revealed the following in part: Per CNA's, Resident #78 will eat as long as there was sweets involved. Resident was assisted by CNA's for all her meals. Resident's diet was Regular Pureed. Will update as needed. Further review of S13Dietary Manager's notes revealed no documented evidence that Resident #78's weight loss of 7 lbs since 8/1/11 had been addressed. On 3/7/12 at 1:56 p.m., an interview was conducted with S13Dietary Manager. She stated that the facility had a weight loss committee. She stated that the computer triggers a resident's name if there's a significant weight loss of 5% or greater. She stated that depending on the resident's problem, they may put them on weekly weights or even daily weights. She stated that weights trigger at 1 month, 3 months and 6 months. She stated that when a resident has a gradual weight loss like Resident #78, their computer system would not trigger the weight loss because its over a period of time. On 3/7/12 at 2:07 p.m. an interview was conducted with S12Treatment Nurse. She stated that the resident's weight triggered in January for a 1 month weight loss of 6.8 lbs. She stated in that same month, she triggered a second time for a 6 month weight loss of 18 lbs. She stated that she usually gives the RD a copy of her Weight Change Alert Report of the weight loss triggered. S12Treatment Nurse said the RD would make her determination on what she would recommend. She stated that she did not have any documented evidence she gave the RD the triggered sheets for Resident #78's weight loss. She stated that after she gave the documentation to the RD, that was as far as she took it. She stated that once the resident triggered, they discussed Resident #78 at the Nutritional At Risk Committee meeting. She stated that after the January 2012 meeting she gave the Nutritional at Risk Committee Meeting report to the ward clerk to fax to the physician. She stated that according to the Nutritional at Risk Committee meeting document, the document was faxed on 1/23/12, but she did not followup with the physician to see if he received the fax. She said she did not check to see if he made a recommendation for Resident #78's weight loss. She stated that the staff weighed the residents on the 1st Monday of each month. The first Monday of this month was March 5th 2012. She stated that she gave the CNA staff a form with the residents names on them, so they could document the weight. She stated that she did not have knowledge of the resident's weight taken on March 5th; which was 79.3 lbs. She stated that if she had, she would have asked the staff to reweigh the resident. She confirmed that she does not have any documented evidence that she informed or requested a RD consult. She had no documentation the physician was notified of the resident's gradual weight loss. She stated that she had not seen the weight because she was busy. She stated that she did not know why the facility's protocol was not followed when the resident weights triggered twice for a 6.14% weight loss and a 14.75% weight loss respectively. She stated that the resident was not put on a nutritional supplement for weight loss nor were there any new interventions put in place to ensure that the resident did not continue to lose weight. She stated that when the resident was weighed on 3/5/12 and 3/6/12, that there was no documented evidence that the physician was notified. She further stated that on 2/5/12, the resident weighed 105.50 lbs and on 3/5/12 the resident's weight was 79.3 lbs; which resulted in a 24.83% weight loss in 1 month. This too was not reported to the physician. On 3/7/12 at 2:10 p.m. an interview was conducted with S3ADON. She confirmed that there was no documentation that the resident was put on a nutritional supplement for her gradual weight loss or that she was ever put on weekly weights when the resident triggered in January 2011 for a 6.8 # weight loss for 1 month of a 18 lb weight loss for 6 months. She stated that when a resident's weight triggered, they were put on weekly weights. She confirmed that the resident was not on weekly weights and she should have been. She stated that the resident had been put on Ensure pudding because it helped her to eat her food but not as an intervention for weight loss. After obtaining documentation of Resident #78's weight, she confirmed that the resident's weight was 79.3 lbs. She stated that she didn't know if the weight was accurate. She stated that if a CNA had shown her a weight of 79.3 lbs, she would have asked for a reweight. On 3/7/12 at 2:30 p.m. an interview was conducted with S10CNA Supervisor. She stated that she and S14CNA reweighed Resident #78, on the stand up scale and on the lift, on 3/6/12. She stated that she gave S16LPN the reweight on 3/6/12. On 3/7/12 at 4:00 p.m. an interview was conducted with S17CNA. She stated that when she fed Resident #78 the last time she worked with her on Friday, March 2, 2012, she kept putting her hand over her mouth not letting the CNA feed her. She stated that she notified S18LPN and S1Administrator. She stated that S18LPN told her that she was informed when the resident did not eat, she was constipated and needed to be checked for an impaction. She stated that S18LPN told her that she was going to check the resident for an impaction and to keep trying to feed her. She stated that before March 2, 2012, the resident would eat a spoon full of her food and she would then stop eating. She said the nurse would tell her to watch the resident and try to continue to feed her and give her fluids. She stated that the CNAs documented the resident's consumption in the computer. Review of the Meal Intake Detail Report revealed the resident's meal consumption was 0% to 25% on numerous days from November 2011 to March 2012. Her consumption was documented as 25% or less on the dates and meals noted below: Breakfast Consumption: 11/2/11-Refused 11/3/11-25% 11/13/11-25% 11/16/11-25% 11/29/11-Refused 12/8/11-Refused 12/15/11-25% 12/18/11-Refused 12/22/11- Refused 12/24/11-25% 1/7/12- 25% 1/12/12-25% 1/17/12-25% 1/18/12-Refused 1/19/12-Refused 1/20/12-Refused 1/21/12-No documentation 1/22/12-25% 1/25/12- 25% 1/27/12- Refused 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12-25% 2/6/12-Refused 2/9/12-25% 2/13/12-25% 2/14/12-25% 2/18/12- 25% 2/19/12-25% 2/20/12-25% 2/23/12-25% 2/25/12-Refused 2/26/12-Refused 2/28/12-25% 3/1/12-Refused 3/2/12-25% 3/4/12-25% 3/5/12-25% Lunch Consumption: 11/5/11-25% 11/7/11-Refused 11/8/11-Refused 11/9/11-25% 11/12/11-Refused 11/17/11-25% 11/21/11-25% 11/29/11-Refused 12/13/11- Refused 12/18/11-Refused 12/20/11-25% 12/21/11-25% 12/22/11- Refused 12/23/11-25% 12/24/11-25% 12/25/11-25% 12/26/11- Refused 12/29/11-Refused 1/3/12- 25% 1/7/12-25% 1/8/12-25% 1/10/12-Refused 1/11/12-25% 1/12/12-25% 1/13/12-Refused 1/14/12-Refused 1/15/12-Refused 1/16/12-25% 1/17/12-25% 1/20/12-Refused 1/21/12-No documentation 1/22/12-25% 1/24/12-Refused 1/25/12-25% 1/26/12-25% 1/27/12-Refused 1/29/12-Refused 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12-25% 2/6/12-Refused 2/9/12-25% 2/13/12-25% 2/14/12-25% 2/18/12-25% 2/19/12-25% 2/20/12-25% 2/23/12-25% 2/25/12-Refused 2/26/12-Refused 2/28/12-25% 3/1/12-Refused 3/4/12-25% 3/5/12-25% Supper Consumption: 11/2/11-Refused 11/3/11-Refused 11/5/11-Refused 11/7/11-Refused 11/8/11- Refused 11/11/11-Refused 11/12/11-Refused 11/15/11-Refused 11/16/11-Refused 11/17/11-Refused 11/20/11-Refused 11/21/11-Refused 11/22/11-Refused 11/25/11-Refused 11/26/11-Refused 11/27/11-Refused 11/29/11-Refused 11/30/11-Refused 12/5/11-Refused 12/6/11-Refused 12/8/11-Refused 12/9/11-Refused 12/13/11-25% 12/15/11-Refused 12/18/11-Refused 12/20/11-25% 12/22/11-Refused 12/23/11-Refused 12/24/11-Refused 12/25/11-25% 12/26/11-Refused 12/27/11-Refused 12/28/11-Refused 12/29/11-25% 12/30/11-25% 12/31/11-Refused 1/2/12-Refused 1/3/12-Refused 1/5/12-Refused 1/7/12-Refused 1/2/12-Refused 1/3/12-Refused 1/5/12-Refused 1/7/12-Refused 1/8/12-Refused 1/10/12-Refused 1/11/12-Refused 1/12/12-Refused 1/13/12-Refused 1/15/12-Refused 1/16/12-25% 1/17/12-25% 1/18/12-Refused 1/19/12-Refused 1/20/12-25% 1/22/12-Refused 1/23/12-Refused 1/24/12-Refused 1/25/12-25% 1/26/12-Refused 1/27/12-Refused 1/29/12-25% 1/30/12-25% 1/31/12-25% 1/23/12-Refused 1/24/12-Refused 1/25/12-25% 1/26/12-Refused 1/27/12-Refused 1/29/12-25% 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12- 25% 2/7/12-No documentation 2/8/12-25% 2/9/12-25% 2/12/12-25% 2/13/12-25% 2/14/12-25% 2/17/12-25% 2/18/12-25% 2/19/12-25% 2/22/12-25% 2/23/12-25% 2/24/12-Refused 2/25/12-Refused 2/26/12-Refused 2/27/12-Refused 2/28/12-Refused 2/29/12-Refused 3/1/12-Refused 3/2/12-Refused 3/3/12-Refused 3/4/12-Refused 3/5/12-Refused On 3/7/12 at 4:03 p.m. an interview was conducted with S1Administrator. She stated that on 3/2/12, she informed S3ADON and S10CNA Supervisor that the resident was not eating. She stated that S10CNA Supervisor told her that she would inform S16LPN to check the resident for an impaction. On 3/7/12 at 4:18 p.m. an interview was conducted with S18LPN. She stated that Resident #78 was fed by the CNAs; but she was not a big eater. She said that the resident occasionally resisted the staff. She stated that the CNAs could not get the resident to eat all the time. She stated that she did not notify the doctor that the resident was not eating and resisted staff, because it was not a new problem. She stated that she was not aware of Resident #78 losing weight . She stated that when the CNAs got the weights, they give the weights to S12Treatment Nurse. She stated that S12Treatment Nurse informed her that there was supposed to be something that triggered if the resident had a weight loss in the system. She stated that if a resident had a weight loss, S12Treatment Nurse would have to tell her because she does not keep up with weights. She said that she had not noticed a drastic change in Resident #78's weight because she was the same size when she started in February and therefore she never notified the physician or the family. She stated that the staff who trained her told her that when the resident refuses to eat, check her for an impaction because she was constipated and needed an enema and that was what she normally did when the resident did not eat. Review of Resident #78's Physician's Progress Notes for 8/31/11, 10/5/11, 12/14/11 and 2/11/12 revealed no documented evidence that the physician addressed Resident #78's weight loss problems. Further review of the Physician's Progress Notes revealed that the resident's weight and vital signs had been left blank each time the physician visited Resident #78 at the facility. Review of the facility's Departmental Notes dated 3/6/12 at 2:47 p.m. written per S16LPN revealed the following: Resident leaned out of wheelchair while sitting in the main lobby of facility and fell into floor, hitting head. .4 cm x 3 cm reddened raised area noted directly in middle of resident's forehead. Resident assisted back into wheelchair and then into bed by staff. Resident is exhibiting signs of increased pain by curling into a fetal position and making whining/crying noises. B/P 85/70, P 80, T 97 and O2 Saturation of 86% on room air. Contacted physician's office regarding fall and resident's symptoms. Received verbal order at this time to send resident out to a local hospital for further evaluation and treatment. Order noted. O2 at 2 liters per nasal cannula administered. 911 emergency contacted at this time to transfer resident to the hospital. Resident is currently being supervised by staff due to attempts to remove nasal cannula. 3/6/12 3:05 p.m. Emergency medical services here to transfer resident to a local hospital emergency room per Medical Doctor (MD) orders. Left on stretcher. All pertinent information given to ambulance employees at that time. Review of the emergency room Nurse Report dated of 3/6/12 revealed the resident was admitted to the hospital with [REDACTED]. Further review of the emergency room Assessment, General Admission Form dated 3/7/12 revealed primary [DIAGNOSES REDACTED]. That same form listed the resident's weight was of 90.2 lbs. On 3/8/12 at 10:17 a.m. an interview was conducted with S16LPN. She stated that on 3/6/12, before the resident fell , she was not going to send the resident out to the hospital. She stated that the reason she called the doctor was to clarify an order that had been written to obtain 3 stools to check for occult blood. She further stated that she could not get the first stool sample and wanted to know what the physician wanted her to do. She stated after Resident #78 fell out of the chair, they put her in the bed and she noticed that the resident had a decreased blood pressure, O2 saturation was low @ 86% on room air. She had decreased level of consciousness and she was holding her abdominal area, exhibiting signs of pain. On 3/8/12 at 3:30 p.m. an interview was conducted with S1Administrator, S2DON, S3ADON and S12Treatment Nurse. S12Treatment Nurse stated that she was aware of the weight on 3/5/12 in the evening time. She stated that she asked for a reweigh on 3/6/12 because the resident weighed 79.5 lbs and she wanted to make sure that was the correct weight. She verified that the resident's physician was not notified and no new interventions were put in place and that the resident should have been put on weekly weights per protocol when she triggered in January 2012 for a 1 month 6.8 lb weight loss and a 6 month 18 lb weight loss. S1Administrator, S2DON, S3ADON and S12Treatment Nurse confirmed that the facility "dropped the ball" regarding the resident's gradual weight loss and agreed that it should have been recognized by the facility. On 3/8/12 at 4:02 p.m. an interview was conducted with S3ADON and S2DON. S3ADON verified no one was assigned to ensure the CNAs accurately entered the ADL documentation into the computer. She further stated there was no one assigned to oversee that the documentation entered was sufficient to meet the residents food and fluid needs. S3ADON and S2DON both verified that some of the documentation was missing that was entered into the Kias system regarding the resident's meals and fluids. On 3/9/12 at 9:00 a.m. an interview was conducted with S14CNA. She stated that she weighed the resident Monday 3/5/12, after she ate lunch, using a standing scale and was assisted by S15CNA. She said the resident weighed 79 lbs. After she finished weighing the other residents on the hall, she came back and told S16LPN that the resident weighed 79 pounds. She stated that S16LPN found documentation of what Resident #78's normal weight was and asked her to reweigh the resident. She stated that she and S10CNA Supervisor reweighed the resident on the lift scale later that evening. She informed S16LPN that the resident weighed 80 lbs. She stated that she knew the resident was not weighed on 3/6/12 because that's when the resident went to the hospital. On 3/9/12 at 9:05 a.m. an interview was conducted with S16LPN. She stated the resident was weighed on Tuesday 3/6/12 the day the resident went out to the hospital. She stated that she had no knowledge of what the resident's reweight was. She said she did not document anything regarding the resident's weight when she was weighed the first time or that she notified the physician of the resident's 24.83% 1 month weight loss. On 3/9/12 at 9:10 a.m. an interview was conducted with S14CNA. She stated that, maybe she was wrong about when she weighed the resident on 3/6/12 after lunch. She stated that she remembered getting S15CNA to help her weigh the resident. She stated that after she gave S16LPN the weight on 3/6/12, S16LPN asked her to reweigh Resident #78 again and she reweighed her with S14CNA. She said that after she reweighed her, she gave the reweight of 80 lbs to S16LPN. On 3/9/12 at 9:40 a.m. an interview was conducted with S16LPN. She confirmed that she did have knowledge that the resident's reweight was 80 lbs, but that it must have been after the resident left the facility. On 3/9/12 at 10:12 a.m. an interview was conducted with S19MDS Coordinator. She stated that Resident #78's Comprehensive Plan of Care for Nutrition, had as an intervention for staff to obtain weekly weights on the resident. She stated that the resident was not on weekly weights and that S11MDS Coordinator forgot to take the resident off weekly weights when the resident had a previous weight loss. She stated that the resident's weight had stabilized at one point and it should have been removed from the resident's care plan. On 3/9/12 10:24 a.m. an interview was conducted with S11MDS Coordinator. She stated that on Resident #78's Comprehensive Care Plan for Diabetes did not reveal how the facility addressed the resident's chewing problem or if the chewing problem was a factor in the resident's weight loss. On 3/9/12 at 12:40 p.m. an interview was conducted with S15CNA. She stated that she helped S14CNA weigh the resident on Tuesday, 3/6/12, around 10 a.m. or 11 a.m. On 3/9/12 at 1:55 p.m. an interview was conducted with S14CNA. She stated that the day S12Treatment Nurse brought them the weight sheets, was when they did the weights. She stated that she weighed everybody on the same day for monthly weights, but she did not know exactly what day it was done. On 3/9/12 at 2:12 p.m. an interview was conducted with S10CNA Supervisor. She stated that the CNAs do the monthly weights the 1 st Monday of every month. She stated that she was not at work Monday, March 5, 2012. She confirmed that the CNAs obtained a paper from S12Treatment Nurse with everybody's name on it, they put the weights on it, and gave the form back to S12Treatment Nurse. On 3/9/12 at 2:30 p.m. an interview was conducted with S2DON. She confirmed that the resident weighed 122 lbs on August 1, 2011 and on November 7, 2011 the resident weighed 111 lbs; resulting in a 9% weight loss. She confirmed that when the resident was weighed on 1/2/12, she weighed 104 lbs which was a 6.3% weight loss from November. She also confirmed that the resident weighed 105. 5 lbs on 2/6/12. She confirmed the 3/5/12 weight was 79.3 lbs which resulted in a 24.83% weight loss in 1 month. She verified that the facility had not put any interventions in place to ensure that the resident did not continue to lose weight. She confirmed that the NAS pureed diet with pudding bid ordered on [DATE] was not an intervention because the resident was already on a Regular pureed diet with pudding bid as noted on the RD's Annual Nutrition Assessment on 2/18/11. She stated that pudding bid was not a new intervention because the pudding was used as a way to get the resident to eat. She said the staff found out that the resident loved to eat sweet things. She verified that the resident did not have an RD consult regarding the resident's weight loss and that she was not put on weekly weights per protocol once she triggered twice in the month of January for a 6.14% weight loss for 1 month and a 6 month 14.75% weight loss. She confirmed that there was no documented evidence that the physician was aware of the resident's gradual weight loss. Resident #36 Review of the resident's clinical record revealed that he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change in status assessment MDS, with an ARD of 8/30/11, revealed the following: Cognitive skills for daily decision making: coded 3. Severely impaired-never/rarely made decisions Acute onset mental status change: coded 1. Yes Eating: self-performance: 1. Supervision - oversight, encouragement or cueing Eating: support provided: 2. One person physical assist Weight (in pounds): 137 Weight loss: 1. Yes An interview was conducted with S12Treatment Nurse on 3/7/12 at 10:00 a.m. She said that the resident went to the hospital on [DATE] for being slow to respond, irregular pulse, and poor appetite. She said that the resident had regained weight in the month of September 2011, since his returned from the hospital. She added that the resident did not trigger for weight loss until De

Based on interview a record review, the Administrator and DON failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1(#78) of 3(#78, #36, #120) residents reviewed for nutrition out of 7 Stage 2 residents that met the criteria. The facility failed to have a system in place to: 1) Immediately notify the physician when a resident (#78) experienced severe unplanned weight loss (6.1% in 1 month) between December 2011 and January 2012. 2) Immediately notify the physician when a resident (#78) experienced severe unplanned weight loss (15% in 6 months) between July 2011 through January 2012. 3) Implement new interventions to prevent unplanned weight loss for a resident (#78) when resident experienced severe unplanned weight loss between December 2011 and January 2012 (6.1% in 1 month) and severe unplanned weight loss between July 2011 through January 2012 (15%). 4) Ensure a consultation from a Registered Dietician (RD) was obtained for a resident (#78) who experienced severe unplanned weight loss (6.1% in 1 month) between December 2011 and January 2012 and severe unplanned weight loss (15%) between July 2011 and January 2012. 5) Implement weekly weights on a resident (#78) who triggered twice in January 2011 for a 1 month weight loss of 6.14% and a 6 month weight loss of 14.75% respectfully, between December 2011 and January 2012. 6) Immediately notify the physician when Resident #78 experienced severe weight loss of (24.83% in 1 month) between February 6, 2012 and March 5, 2012. 7) Ensure that nutritional documentation entered into the Kias system was monitored and follow-up up for a resident (#78) who had 25% or less intake repeatedly and continued to lose weight. The Registered Dietician's Annual Nutrition assessment dated [DATE] for Resident #78 revealed an ideal body weight of 115 plus or minus 10 percent . The resident weighed 122 lbs on August 1, 2011, 115 lbs on October 3, 2011, and 111 lbs on November 7, 2011. The resident was in immediate jeopardy on 1/2/12 when the resident continued to experience severe weight loss to 104 lbs and the physician was not notified and no new interventions were put in place to prevent additional unplanned weight loss. The facility did not increase monitoring of weights, notify the physician of the resident refusals to eat, monitor food intake and the resident continued to lose weight. On 2/6/12 the resident weighed 105.5 lbs. The resident continued in immediate jeopardy on 3/5/12 when the resident lost down to 79.3 lbs, a weight loss of 18.5 lbs in 1 month and the physician was not immediately notified and ended on 3/6/12 at 3:05 p.m. when the resident was transferred to the hospital. The deficient practice continued at a scope and severity of a level 3, actual harm, for this resident and a level 2 for all other residents with unplanned weight loss in the facility. Findings: Resident #78 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Diabetes Mellitus, Hypertension, [MEDICAL CONDITION], Bone Cartilage Disease and Mitral Valve Disorder. Review of the facility's Weight Assessment and Intervention Policy revealed the following in part: Policy Statement The multidisciplinary team will strive to prevent, monitor, and interview for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment: ...3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight was verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification. 5. The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for "significant" weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss=(usual weight-actual weight)/(usual weight) x 100): a. 1 month-5% weight loss was significant; greater than 5% was severe. 3 months-7.5% weight loss was significant; greater than 7.5% was severe. 6 months-10% weight loss was significant; greater that 10% was severe. Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: ...b. Chewing or swallowing abnormalities; ...e. Increased need for calories and/or protein;... Interventions: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: ...b. Nutrition and hydration needs of the resident;... e. Chewing and swallowing abnormalities and the need for diet modifications;... g. The use of supplementation and/or feeding tubes;... Review of Resident #78's Weight Change History revealed that the resident was weighed the 1st Monday of each month as follows: 2/7/11 119.60 3/7/11 120.10 4/4/11 115.30 5/2/11 117.80 6/6/11 121.50 7/4/11 122.50 8/1/11 122.0 9/5/11 114.60 10/3/11 115.20 11/7/11 111.30 12/5/11 110.80 1/2/12 104.0 2/6/12 105.50 Further review of the facility's Monthly Weight for March 2012 revealed that the resident weighed 79.3 lbs. Review of Resident #78's Comprehensive Plan of Care for Potential for Alteration in Nutrition revealed the following in part: Problem Onset: Date Left blank ...History of weight loss Goals: ...Weight maintain adequate nutritional status as evidenced by weight remaining stable overall for quarter Approaches: ...Monitor meal consumption & compliance with diet ...Notify RD regarding problems, complaints, or requests ...Monitor for any chewing/swallowing difficulties and refer to RD as needed ...Tends to have fluctuating weights from week to week. Weights monitored weekly, yet overview for trend over several weeks to determine if a weight change was permanent or fluctuating. Sometimes stands up for weight, per her choice. Review of Resident #78's Nutritional Risk assessment dated [DATE] revealed the resident had a score of 12; At Risk for Nutrition. Review of the facility's Annual Nutrition Assessment revealed that the resident was last seen by the RD on 2/18/11 with and ideal body weight of 115 pounds (lbs). Further review of the document revealed that the resident was on a Regular Puree; pudding bid. Review of the the facility's Weight Change Alert Report printed 3/8/12 revealed on 8/1/11, Resident #78 weighed 122 lbs and on 1/2/12, 104 lbs; which triggered a 14.75% weight loss. Further review of Resident #78's Weight Change Alert Report printed 3/8/12 revealed that on 12/5/11 the resident weighed 110.80 lbs and on 1/2/12, 104 lbs; which triggered a 6.14% weight loss. Review of the facility's Nutritional At Risk Committee Meeting revealed the following in part: Date: January 2012 Resident #78 Action Taken: Left blank Weekly weights: No RD Consult: 2/18/11 Diet: Regular Puree Supplement: Pudding bid Additional information: Ideal Body Weight 104-127. Current weight 104 lbs. Last month weight 110.8 lbs. A 6.8 lb weight loss in 1 month. In August resident's weight was 122 lbs. An 18 lb weight loss in 6 months. Further review of the document revealed that the document was faxed 1/23/12 by the ward clerk with no documented evidence or a faxed confirmation that the physician ever received the fax or responded. On 3/7/12 at 1:47 p.m. an interview was conducted with S2DON. She stated that if a resident had a significant weight loss, greater than 5%, it would trigger on the facility's Weight Change Audit Report. She stated that S12Treatment Nurse reviewed residents weights and would inform S2DON and the resident would be discussed at the facility's Nutritional At Risk Committee Meeting. S2DON said through these meetings the RD would be notified and a dietary consult would be requested. She confirmed, after looking in her binder, where the RD consults are kept for residents, that there was no documentation a dietary consult was recommended for Resident #78. Review of the S13Dietary Manager's notes on 10/4/11 revealed the following in part: Per CNA's, Resident #78 will eat as long as there was sweets involved. Resident was assisted by CNA's for all her meals. Resident's diet was Regular Pureed. Will update as needed. Further review of S13Dietary Manager's notes revealed no documented evidence that Resident #78's weight loss of 7 lbs since 8/1/11 had been addressed. On 3/7/12 at 1:56 p.m., an interview was conducted with S13Dietary Manager. She stated that the facility had a weight loss committee. She stated that the computer triggers a resident's name if there's a significant weight loss of 5% or greater. She stated that depending on the resident's problem, they may put them on weekly weights or even daily weights. She stated that weights trigger at 1 month, 3 months and 6 months. She stated that when a resident has a gradual weight loss like Resident #78, their computer system would not trigger the weight loss because its over a period of time. On 3/7/12 at 2:07 p.m. an interview was conducted with S12Treatment Nurse. She stated that the resident's weight triggered in January for a 1 month weight loss of 6.8 lbs. She stated in that same month, she triggered a second time for a 6 month weight loss of 18 lbs. She stated that she usually gives the RD a copy of her Weight Change Alert Report of the weight loss triggered. S12Treatment Nurse said the RD would make her determination on what she would recommend. She stated that she did not have any documented evidence she gave the RD the triggered sheets for Resident #78's weight loss. She stated that after she gave the documentation to the RD, that was as far as she took it. She stated that once the resident triggered, they discussed Resident #78 at the Nutritional At Risk Committee meeting. She stated that after the January 2012 meeting she gave the Nutritional at Risk Committee Meeting report to the ward clerk to fax to the physician. She stated that according to the Nutritional at Risk Committee meeting document, the document was faxed on 1/23/12, but she did not follow-up with the physician to see if he received the fax. She said she did not check to see if he made a recommendation for Resident #78's weight loss. She stated that the staff weighed the residents on the 1st Monday of each month. The first Monday of this month was March 5th 2012. She stated that she gave the CNA staff a form with the residents names on them, so they could document the weight. She stated that she did not have knowledge of the resident's weight taken on March 5th; which was 79.3 lbs. She stated that if she had, she would have asked the staff to reweigh the resident. She confirmed that she does not have any documented evidence that she informed or requested a RD consult. She had no documentation the physician was notified of the resident's gradual weight loss. She stated that she had not seen the weight because she was busy. She stated that she did not know why the facility's protocol was not followed when the resident weights triggered twice for a 6.14% weight loss and a 14.75% weight loss respectively. She stated that the resident was not put on a nutritional supplement for weight loss nor were there any new interventions put in place to ensure that the resident did not continue to lose weight. She stated that when the resident was weighed on 3/5/12 and 3/6/12, that there was no documented evidence that the physician was notified. She further stated that on 2/5/12, the resident weighed 105.50 lbs and on 3/5/12 the resident's weight was 79.3 lbs; which resulted in a 24.83% weight loss in 1 month. This too was not reported to the physician. On 3/7/12 at 2:10 p.m. an interview was conducted with S3ADON. She confirmed that there was no documentation that the resident was put on a nutritional supplement for her gradual weight loss or that she was ever put on weekly weights when the resident triggered in January 2011 for a 6.8 lb weight loss for 1 month of a 18 lb weight loss for 6 months. She stated that when a resident's weight triggered, they were put on weekly weights. She confirmed that the resident was not on weekly weights and she should have been. She stated that the resident had been put on Ensure pudding because it helped her to eat her food but not as an intervention for weight loss. After obtaining documentation of Resident #78's weight, she confirmed that the resident's weight was 79.3 lbs. She stated that she didn't know if the weight was accurate. She stated that if a CNA had shown her a weight of 79.3 lbs, she would have asked for a reweigh. On 3/7/12 at 2:30 p.m. an interview was conducted with S10CNA Supervisor. She stated that she and S14CNA reweighed Resident #78, on the stand up scale and on the lift, on 3/6/12. She stated that she gave S16LPN the reweigh on 3/6/12. On 3/7/12 at 4:00 p.m. an interview was conducted with S17CNA. She stated that when she fed Resident #78 the last time she worked with her on Friday, March 2, 2012, she kept putting her hand over her mouth not letting the CNA feed her. She stated that she notified S18LPN and S1Administrator. She stated that S18LPN told her that she was informed when the resident did not eat, she was constipated and needed to be checked for an impaction. She stated that S18LPN told her that she was going to check the resident for an impaction and to keep trying to feed her. She stated that before March 2, 2012, the resident would eat a spoon full of her food and she would then stop eating. She said the nurse would tell her to watch the resident and try to continue to feed her and give her fluids. She stated that the CNAs documented the resident's consumption in the computer. Review of the Meal Intake Detail Report revealed the resident's meal consumption was 0% to 25% on numerous days from November 2011 to March 2012. Her consumption was documented as 25% or less on the dates and meals noted below: Breakfast Consumption: 11/2/11-Refused 11/3/11-25% 11/13/11-25% 11/16/11-25% 11/29/11-Refused 12/8/11-Refused 12/15/11-25% 12/18/11-Refused 12/22/11- Refused 12/24/11-25% 1/7/12- 25% 1/12/12-25% 1/17/12-25% 1/18/12-Refused 1/19/12-Refused 1/20/12-Refused 1/21/12-No documentation 1/22/12-25% 1/25/12- 25% 1/27/12- Refused 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12-25% 2/6/12-Refused 2/9/12-25% 2/13/12-25% 2/14/12-25% 2/18/12- 25% 2/19/12-25% 2/20/12-25% 2/23/12-25% 2/25/12-Refused 2/26/12-Refused 2/28/12-25% 3/1/12-Refused 3/2/12-25% 3/4/12-25% 3/5/12-25% Lunch Consumption: 11/5/11-25% 11/7/11-Refused 11/8/11-Refused 11/9/11-25% 11/12/11-Refused 11/17/11-25% 11/21/11-25% 11/29/11-Refused 12/13/11- Refused 12/18/11-Refused 12/20/11-25% 12/21/11-25% 12/22/11- Refused 12/23/11-25% 12/24/11-25% 12/25/11-25% 12/26/11- Refused 12/29/11-Refused 1/3/12- 25% 1/7/12-25% 1/8/12-25% 1/10/12-Refused 1/11/12-25% 1/12/12-25% 1/13/12-Refused 1/14/12-Refused 1/15/12-Refused 1/16/12-25% 1/17/12-25% 1/20/12-Refused 1/21/12-No documentation 1/22/12-25% 1/24/12-Refused 1/25/12-25% 1/26/12-25% 1/27/12-Refused 1/29/12-Refused 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12-25% 2/6/12-Refused 2/9/12-25% 2/13/12-25% 2/14/12-25% 2/18/12-25% 2/19/12-25% 2/20/12-25% 2/23/12-25% 2/25/12-Refused 2/26/12-Refused 2/28/12-25% 3/1/12-Refused 3/4/12-25% 3/5/12-25% Supper Consumption: 11/2/11-Refused 11/3/11-Refused 11/5/11-Refused 11/7/11-Refused 11/8/11- Refused 11/11/11-Refused 11/12/11-Refused 11/15/11-Refused 11/16/11-Refused 11/17/11-Refused 11/20/11-Refused 11/21/11-Refused 11/22/11-Refused 11/25/11-Refused 11/26/11-Refused 11/27/11-Refused 11/29/11-Refused 11/30/11-Refused 12/5/11-Refused 12/6/11-Refused 12/8/11-Refused 12/9/11-Refused 12/13/11-25% 12/15/11-Refused 12/18/11-Refused 12/20/11-25% 12/22/11-Refused 12/23/11-Refused 12/24/11-Refused 12/25/11-25% 12/26/11-Refused 12/27/11-Refused 12/28/11-Refused 12/29/11-25% 12/30/11-25% 12/31/11-Refused 1/2/12-Refused 1/3/12-Refused 1/5/12-Refused 1/7/12-Refused 1/2/12-Refused 1/3/12-Refused 1/5/12-Refused 1/7/12-Refused 1/8/12-Refused 1/10/12-Refused 1/11/12-Refused 1/12/12-Refused 1/13/12-Refused 1/15/12-Refused 1/16/12-25% 1/17/12-25% 1/18/12-Refused 1/19/12-Refused 1/20/12-25% 1/22/12-Refused 1/23/12-Refused 1/24/12-Refused 1/25/12-25% 1/26/12-Refused 1/27/12-Refused 1/29/12-25% 1/30/12-25% 1/31/12-25% 1/23/12-Refused 1/24/12-Refused 1/25/12-25% 1/26/12-Refused 1/27/12-Refused 1/29/12-25% 1/30/12-25% 1/31/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/1/12-Refused 2/2/12-Refused 2/3/12-25% 2/4/12-25% 2/5/12- 25% 2/7/12-No documentation 2/8/12-25% 2/9/12-25% 2/12/12-25% 2/13/12-25% 2/14/12-25% 2/17/12-25% 2/18/12-25% 2/19/12-25% 2/22/12-25% 2/23/12-25% 2/24/12-Refused 2/25/12-Refused 2/26/12-Refused 2/27/12-Refused 2/28/12-Refused 2/29/12-Refused 3/1/12-Refused 3/2/12-Refused 3/3/12-Refused 3/4/12-Refused 3/5/12-Refused On 3/7/12 at 4:03 p.m. an interview was conducted with S1Administrator. She stated that on 3/2/12, she informed S3ADON and S10CNA Supervisor that the resident was not eating. She stated that S10CNA Supervisor told her that she would inform S16LPN to check the resident for an impaction. On 3/7/12 at 4:18 p.m. an interview was conducted with S18LPN. She stated that Resident #78 was fed by the CNAs; but she was not a big eater. She said that the resident occasionally resisted the staff. She stated that the CNAs could not get the resident to eat all the time. She stated that she did not notify the doctor that the resident was not eating and resisted staff, because it was not a new problem. She stated that she was not aware of Resident #78 losing weight . She stated that when the CNAs got the weights, they give the weights to S12Treatment Nurse. She stated that S12Treatment Nurse informed her that there was supposed to be something that triggered if the resident had a weight loss in the system. She stated that if a resident had a weight loss, S12Treatment Nurse would have to tell her because she does not keep up with weights. She said that she had not noticed a drastic change in Resident #78's weight because she was the same size when she started in February and therefore she never notified the physician or the family. She stated that the staff who trained her told her that when the resident refuses to eat, check her for an impaction because she was constipated and needed an enema and that was what she normally did when the resident did not eat. Review of Resident #78's Physician's Progress Notes for 8/31/11, 10/5/11, 12/14/11 and 2/11/12 revealed no documented evidence that the physician addressed Resident #78's weight loss problems. Further review of the Physician's Progress Notes revealed that the resident's weight and vital signs had been left blank each time the physician visited Resident #78 at the facility. On 3/8/12 at 10:17 a.m. an interview was conducted with S16LPN. She stated that on 3/6/12, before the resident fell , she was not going to send the resident out to the hospital. She stated that the reason she called the doctor was to clarify an order that had been written to obtain 3 stools to check for occult blood. She further stated that she could not get the first stool sample and wanted to know what the physician wanted her to do. She stated after Resident #78 fell out of the chair, they put her in the bed and she noticed that the resident had a decreased blood pressure, O2 saturation was low @ 86% on room air. She had decreased level of consciousness and she was holding her abdominal area, exhibiting signs of pain. On 3/8/12 at 3:30 p.m. an interview was conducted with S1Administrator, S2DON, S3ADON and S12Treatment Nurse. S12Treatment Nurse stated that she was aware of the weight on 3/5/12 in the evening time. She stated that she asked for a reweigh on 3/6/12 because the resident weighed 79.3 lbs and she wanted to make sure that was the correct weight. She verified that the resident's physician was not notified and no new interventions were put in place and that the resident should have been put on weekly weights per protocol when she triggered in January 2012 for a 1 month 6.8 lb weight loss and a 6 month 18 lb weight loss. S1Administrator, S2DON, S3ADON and S12Treatment Nurse confirmed that the facility "dropped the ball" regarding the resident's gradual weight loss and agreed that it should have been recognized by the facility. On 3/8/12 at 4:02 p.m. an interview was conducted with S3ADON and S2DON. S3ADON verified no one was assigned to ensure the CNAs accurately entered the ADL documentation into the computer. She further stated there was no one assigned to oversee that the documentation entered was sufficient to meet the residents food and fluid needs. S3ADON and S2DON both verified that some of the documentation was missing that was entered into the Kias system regarding the resident's meals and fluids. On 3/9/12 at 9:00 a.m. an interview was conducted with S14CNA. She stated that she weighed the resident Monday 3/5/12, after she ate lunch, using a standing scale and was assisted by S15CNA. She said the resident weighed 79 lbs. After she finished weighing the other residents on the hall, she came back and told S16LPN that the resident weighed 79 pounds. She stated that S16LPN found documentation of what Resident #78's normal weight was and asked her to reweigh the resident. She stated that she and S10CNA Supervisor reweighed the resident on the lift scale later that evening. She informed S16LPN that the resident weighed 80 lbs. She stated that she knew the resident was not weighed on 3/6/12 because that's when the resident went to the hospital. On 3/9/12 at 9:05 a.m. an interview was conducted with S16LPN. She stated the resident was weighed on Tuesday 3/6/12 the day the resident went out to the hospital. She stated that she had no knowledge of what the resident's reweight was. She said she did not document anything regarding the resident's weight when she was weighed the first time or that she notified the physician of the resident's 24.83% 1 month weight loss. On 3/9/12 at 9:10 a.m. an interview was conducted with S14CNA. She stated that, maybe she was wrong about when she weighed the resident on 3/6/12 after lunch. She stated that she remembered getting S15CNA to help her weigh the resident. She stated that after she gave S16LPN the weight on 3/6/12, S16LPN asked her to reweigh Resident #78 again and she reweighed her with S14CNA. She said that after she reweighed her, she gave the reweight of 80 lbs to S16LPN. On 3/9/12 at 9:40 a.m. an interview was conducted with S16LPN. She confirmed that she did have knowledge that the resident's reweight was 80 lbs, but that it must have been after the resident left the facility. On 3/9/12 at 12:40 p.m. an interview was conducted with S15CNA. She stated that she helped S14CNA weigh the resident on Tuesday, 3/6/12, around 10 a.m. or 11 a.m. On 3/9/12 at 1:55 p.m. an interview was conducted with S14CNA. She stated that the day S12Treatment Nurse brought them the weight sheets, was when they got the weights. She stated that she weighed everybody on the same day for monthly weights, but she did not know exactly what day it was done. On 3/9/12 at 2:12 p.m. an interview was conducted with S10CNA Supervisor. She stated that the CNAs do the monthly weights the 1st Monday of every month. She stated that she was not at work Monday, March 5, 2012. She confirmed that the CNAs obtained a paper from S12Treatment Nurse with everybody's name on it, they put the weights on it, and gave the form back to S12Treatment Nurse. On 3/9/12 at 2:30 p.m. an interview was conducted with S2DON. She confirmed that the resident weighed 122 lbs on August 1, 2011 and on November 7, 2011 the resident weighed 111 lbs; resulting in a 9% weight loss. She confirmed that when the resident was weighed on 1/2/12, she weighed 104 lbs which was a 6.3% weight loss from November. She also confirmed that the resident weighed 105. 5 lbs on 2/6/12. She confirmed the 3/5/12 weight was 79.3 lbs which resulted in a 24.83% weight loss in 1 month. She verified that the facility had not put any interventions in place to ensure that the resident did not continue to lose weight. She confirmed that the NAS pureed diet with pudding bid ordered on [DATE] was not an intervention because the resident was already on a Regular Pureed diet with pudding bid as noted on the RD's Annual Nutrition Assessment on 2/18/11. She stated that pudding bid was not a new intervention because the pudding was used as a way to get the resident to eat. She said the staff found out that the resident loved to eat sweet things. She verified that the resident did not have an RD consult regarding the resident's weight loss and that she was not put on weekly weights per protocol once she triggered twice in the month of January for a 6.14% weight loss for 1 month and a 6 month 14.75% weight loss. She confirmed that there was no documented evidence that the physician was aware of the resident's gradual weight loss.