Every finding on record at St. John of God Retirement

Based on interview, and record review, the facility failed to implement the Care Plan for one of three sampled residents (Resident 2) which indicated to monitor Resident 2's location and document the resident's wandering behavior and attempted diversional interventions in the behavior log. This deficient practice resulted in Resident 2 having an altercation with Resident 1, after Resident 2 entered Resident 1's room and had the potential to result in injuries and harm to Residents 1 and 2. Findings:a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis included delirium (a serious and fast change in mental ability that causes confusion, trouble focusing, and changes in awareness), anxiety (a vague sense of dread, apprehension or uneasiness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 2's History and Physical (H&P), dated 7/24/2025 the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 2 cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 2 required substantial/maximum assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff for personal hygiene, bed mobility, transfers and walking 50-150 feet. During a review of Resident 2's Care Plan titled, The Resident is an elopement risk, related to (r/t) disoriented to place.Resident wanders aimlessly, significantly intrudes on the privacy or activities, dated 5/3/2026, the Care Plan goal indicated the resident's safety will be maintained through the review date. The Care Plan interventions indicated to monitor Resident 2's location, document wandering behavior, and attempted diversional interventions in behavior log.During a review of Resident 2's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/8/2026, the COC indicated Resident 2 had increased agitation and irritability. Resident 2 was yelling, banging on doors, kicking staff, hostile to interventions and refusing redirection. During a review of Resident 2's Multidisciplinary Care Conference (IDT-group of healthcare professionals working together to plan the care needed for each resident), dated 7/9/2026, the IDT indicated Resident 2 had increased agitation which resulted in a resident-to-resident altercation (between Residents 1 and 2) b. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 1's diagnoses included spinal stenosis (the narrowing of the spinal canal that compresses the spinal cord and nerves, leading to pain, numbness, and weakness), anxiety (a vague sense of dread, apprehension or uneasiness), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Resident 1's H&P dated 12/3/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 1 required supervision (helper provides verbal cues as resident completes activity) from staff for toileting hygiene, bed mobility and lower body dressing.During a review of Resident 1's IDT, dated 7/15/2026, the IDT indicated (on 7/8/2026) Resident 2 had an alleged resident to resident incident (with Resident 1). During a telephone interview on 7/23/2026 at 2:34 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated on 7/8/2026 during the evening shift (3:00 p.m. - 11:00 p.m.), Resident 2 was confused, wandering to other resident's rooms during the evening shift. CNA 2 stated she had to close the doors to some of the residents' rooms to stop Resident 2 from entering the other residents' rooms and became agitated when redirected. CNA 2 stated she reported these behaviors to the Licensed Vocational Nurse (LVN) 1. During a concurrent record review and interview on 7/23/2026 at 3:41 p.m., with LVN 1, Resident 2's Medication Administration Record (MAR) dated 7/2026 was reviewed. LVN 1 stated on 7/8/2026 during the evening shift, Resident 2 exhibited 20 episodes of agitation. Resident 2 made multiple attempts to go into residents' room and became agitated when she redirected the resident. LVN 1 stated she heard screaming in Resident 1's room and found Resident 2 agitated in Resident 1's room. During a concurrent interview and record review on 7/23/2026 at 4:43 p.m., with Registered Nurse (RN) 1, Resident 2's Care Plan titled, The Resident is an elopement risk, related to (r/t) disoriented to place.Resident wanders aimlessly, significantly intrudes on the privacy or activities, dated 5/3/2026, was reviewed. The Care Plan interventions indicated to monitor Resident 2's location, wandering behavior, and attempted diversional interventions in behavior log. RN 1 stated Resident 2's whereabouts were not monitored nor were the resident's wandering behavior and attempted interventions documented. Resident 2 was a wanderer, and the Care Plan interventions were not followed.During a review of the facility's P&P titled, Care Plans, Comprehensive and Revision, dated 3/2026, the P&P indicated a comprehensive, person-centered care plan will reflect treatment goals, timetables, and objectives in measurable outcomes. The P&P indicated to identify the professional services that are responsible for each element of care. The P&P indicated aid in preventing to reflect recognized standards of practice for problem areas and conditions.During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 3/2026, the P&P indicated resident safety, supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated implementing interventions to reduce accident risk, and hazards shall include communicating specific interventions to all relevant staff, ensuring the interventions are implemented and documented.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records according to professional standards for one of four sample residents (Resident 2), by failing to ensure Resident 2's wandering behaviors and episodes of agitation were documented. This deficient practice had the potential to result in a lack of communication between staff and a delay in provision of care or interventions for Resident 2. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis included delirium (a serious and fast change in mental ability that causes confusion, trouble focusing, and changes in awareness), anxiety (a vague sense of dread, apprehension or uneasiness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 2's History and Physical (H&P), dated 7/24/2025 the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Physician's Order dated 2/26/2026, the Order indicated to monitor Resident 2's behavior of anxiety manifested by (m/b) excessive agitation and resistive to care. Tally episodes per shift with hashmark. During a review of Resident 2's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 2 cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 2 required substantial/maximum assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff for personal hygiene, bed mobility, transfers and walking 50-150 feet. During a review of Resident 2's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/8/2026, the COC indicated Resident 2 had increased agitation and irritability. Resident 2 was yelling, banging on doors, kicking staff, hostile to interventions and refusing redirection. During a telephone interview on 7/23/2026 at 2:34 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated on 7/8/2026 during the evening shift (3:00 p.m. - 11:00 p.m.), Resident 2 was confused, wandering to other resident's rooms during the evening shift. CNA 2 stated she had to close the doors to some of the residents' rooms to stop Resident 2 from entering the other residents' rooms and became agitated when redirected. CNA 2 stated she reported to the Licensed Vocational Nurse (LVN) 1. During a concurrent record review and interview on 7/23/2026 at 3:41 p.m., with LVN 1, Resident 2's Medication Administration Record (MAR) dated 7/2026 was reviewed. LVN 1 stated on 7/8/2026 during the evening shift, Resident 2 exhibited 20 episodes of agitation. Resident 2 made multiple attempts to go into a resident's room and became agitated when she redirected the resident.During an interview on 7/23/2026 at 5:30 p.m., with the Director of Nursing (DON), the DON stated there was no documentation in the medical records indicating Resident 2 was continuously trying to go into residents' rooms and became more agitated (on 7/8/2026). The DON stated Resident 2's behaviors should have been documented, including the residents' whereabouts. The DON also stated failing to document the resident's behaviors and whereabouts compromised other residents' safety. During a review of the facility's P&P titled, Accuracy of Documentation, dated 3/2026, the P&P indicated 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 P&P indicated the information to be documented in the resident medical record included events, incidents, and progress toward the care plan goals and objectives. The P&P indicated the date and time the treatment was provided.

Based on observation, interview, and record review, the facility failed to ensure the California Department of Public Health (CDPH) was notified of an injury of unknown origin (an injury that was not witnessed and cannot be explained by the affected individual) for one of three sampled residents (Resident 4).This failure of not reporting the injury of unknown origin to CDPH within two hours delayed the investigation and placed Resident 4 at risk for further injuries.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 4's diagnoses included irritable bowel syndrome (a condition that affects the stomach and intestines), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 4's History and Physical (H&P), dated 1/31/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 4's cognitive skills for daily decision making (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort and helper lifts or hold trunk or limbs and provides more than half the effort) by staff for toileting hygiene and dressing. The MDS indicated Resident 4 was dependent (helper does all the effort) on staff for bed to chair transfers (the ability to transfer to and from a bed to a chair or wheelchair) and tub/shower transfers. The MDS indicated Resident 4's preferred language was Korean and needed or wanted an interpreter (to communicate with staff.During a review of Resident 4's change of condition record titled, Situation Background Assessment and Recommendation (SBAR), dated 6/1/2026, the SBAR indicated on 6/1/2026, Resident 4 had ecchymosis (is the medical term for a bruise a flat, purple or bluish-black patch that forms under the skin) to the anterior (front) left lower leg.During a review of facility's Five Day Investigation, unknown date, the five-day investigation indicated Resident 4 had a purplish discoloration to the left lower leg on 6/1/2026. The five-day investigation indicated the discoloration was of unknown origin.During a telephone interview on 6/12/2026 at 12:24 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated on 6/2/2026, Resident 4 complained of pain to her left leg. LVN 5 stated Resident 4's leg was bruised and swollen. LVN 5 stated he asked LVN 4 (who was Korean speaking) to translate. LVN 4 told LVN 5 that Resident 4 stated she was hit by a metal object. LVN 5 stated he reported the injury to the Director of Staff Development (DSD) and the Director of Nursing (DON). LVN 5 stated he did not notify the Administrator (ADM). LVN 5 stated he should have reported to the ADM because the ADM was the Abuse coordinator. LVN 5 stated this could have been potential abuse and needed to be reported within the time frame of two hours.During a concurrent interview and record review on 6/12/2026 at 3:05 p.m., with the ADM, the facility's Five Day Investigation, unknown date, was reviewed. The five-day investigation indicated on 6/1/2026, Resident 4 had a purplish discoloration to the left lower leg which was determined to be of unknown origin. The ADM stated he was not aware until 6/3/2026 when Resident 4 reported Certified Nursing Assistant (CNA 3) hit her with a metal object. The ADM stated once he clarified the incident using a Korean translator of what happened and/or of the injury of unknown origin it was to be reported. The ADM stated the police, Ombudsman, and CDPH were to be notified within two hours. The ADM stated there was a delay in reporting. The ADM stated not reporting within the timeframe could cause a delay in keeping the residents safe.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 3/2026, the P&P indicated as required by federal or state regulations, the facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of residents. The P&P indicated unusual occurrences are reported to appropriate agencies as required by current law and /or regulations within twenty-four (24) hours of an incident.During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, dated 3/2026, the P&P indicated all reports of resident abuse (including injuries of unknown origin) are reported local, state, and federal agencies. The P&P indicated the administrator or the individual making the allegation immediately reports to the following agencies (the Ombudsman, Law Enforcement, and the State responsible for surveying). The P&P indicated immediately was indicated to report within two hours of an allegation of abuse or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to implement a care plan (a personalized document outlining a patient's health needs, medical history, and specific goals for care) for the use a Korean-speaking interpreter for one of three sampled residents (Resident 4) when Resident 4 expressed discomfort to her left lower leg.This failure of not implementing the care plan had the potential for Resident 4 to not effectively communicate with staff regarding her injury.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 4's diagnoses included irritable bowel syndrome (a condition that affects the stomach and intestines), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Patient 4's History and Physical (H&P), dated 1/31/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 4's cognitive skills for daily decision making (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort and helper lifts or hold trunk or limbs and provides more than half the effort) by staff for toileting hygiene and dressing. The MDS indicated Resident 4 was dependent (helper does all the effort) on staff for bed to chair transfers (the ability to transfer to and from a bed to a chair or wheelchair) and tub/shower transfers. The MDS indicated Resident 4's preferred language was Korean and needed or wanted an interpreter to communicate with staff.During a review of Resident 4's care plan titled, Impaired Communication Skills, dated 2/10/2024, the care plain indicated Resident 4 had a language barrier due to the resident speaking fluently in Korean. The care plan indicated staff was to utilize a translator, communication device, and communication board.During an interview on 6/12/2026 at 9:54 a.m., with Resident 4, interpreted by Resident 4's Family Member [FM 1]), Resident 4 stated on 6/1/20276, there was no interpreter for her to explain to staff what happened to her left lower leg. Resident 4 stated on the following day (6/2/2026) there was a Korean interpreter who asked her what happened to her leg. During a concurrent interview and record review on 6/12/2026 at 10:35 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 4's care plan titled, Impaired Communication Skills, dated 2/10/2024 was reviewed. The care plan indicated Resident 4 had a language barrier due to the resident being fluent in Korean. The care plan indicated the staff was to utilize a translator, communication device, and communication board. LVN 3 stated on 6/1/2026, Resident 4 pointed to her left leg to show bruising. LVN 3 stated Resident 4 was speaking in Korean, and she could not understand what Resident 4 was saying. LVN 3 stated she did not use an interpreter to translate what Resident 4 was saying. LVN 3 stated by not using an interpreter Resident 4 would not be able to communicate what happened to her leg and other concerns she may have had. LVN 3 stated it was important to use a translator so the facility would know whether the resident had fallen or was abused.During an interview on 6/12/2026 at 2:06 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated on 6/1/2026, Resident 4 pointed to her left leg indicating she was in pain. CNA 3 stated she did not use a Korean communication pamphlet nor asked staff to translate what happened to Resident 4's leg. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated to identify problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. The P&P indicated to reflect the resident's expressed wishes regarding care and treatment goals.

Based on interview and record review, the facility failed to: 1. Ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained from resident representative prior to initiation of psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 1).This deficient practice had the potential for the resident representative to have a lack of knowledge to make an informed consent and not knowing in advance the potential risk and benefits of the psychotropic drug.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), knee surgery, and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical (H&P), dated 9/12/2025, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/7/2026, the MDS indicated, Resident 1 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 1 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, lower body dressing, and personal hygiene. During a review of Resident 1's Order Summary Report (a document containing active orders), dated 2/24/2026, the Order Summary Report indicated, the physician placed a telephone order on 2/2/2026 for Resident 1 to start on Cymbalta (drug to treat depression) 30 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to give one capsule by mouth in the morning for depression. During a review of Resident 1's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 2/4/2026 to 2/24/2026, the MAR indicated, Resident 1 was given Cymbalta 30mg daily in the morning. During a concurrent interview and record review on 2/24/2026 at 11:25 a.m., with the Assistant Director of Nursing (ADON), Resident 1's clinical records were reviewed. The ADON stated the facility had no documentation to indicate an informed consent for the use of Cymbalta was obtained and risks and benefits were explained by Resident 1's physician to Resident 1's representative regarding the use of Cymbalta. The ADON stated there was no informed consent for Cymbalta on Resident 1's chart. The ADON stated Resident 1 has resident representative as indicated on her admission Record. The ADON stated the facility staff can't initiate any psychotropic drug until the physician obtained an informed consent from Resident 1's representative. The ADON stated it is important to obtain an informed consent to create transparency between the facility and resident or resident representative. The ADON stated psychotropic drugs have adverse reaction (an unintended effect of a medication that is harmful or unpleasant) that would jeopardize resident's safety. During an interview on 2/24/2026 at 11:35 a.m., with the Director of Nursing (DON), the DON stated it is a violation of Resident's rights for not obtaining an informed consent prior to initiation of any psychotropic drug. The DON stated a resident or resident's representative has the right to make an informed decision whether to accept or decline a psychotropic drug. The DON stated psychotropic drug could affect severely the mind of the residents and have side-effects that are very deteriorating and life threatening to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Psychotropic Medication Use, dated 3/2025, the P&P indicated, Prior to initiating the use of, increasing the dose, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: A. non-pharmacological interventions, B. the indications and rationale for the recommendation, C. the potential risks and benefits, D. the resident's/representative's right to accept or decline the treatment.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was coded accurately for one of three sampled residents (Resident 3). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 3's health status.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 3's diagnoses included dementia (a progressive state of decline in mental abilities) and a history of falling. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severe cognitive impairment (difficulties with thinking, learning, memory, judgment, and problem-solving). The MDS indicated Resident 3 required partial to moderate assistance from staff for transfers in and out of bed. The MDS did not indicate Resident 3's daily use of a bed or wheelchair alarm (safety devices that sound an alert to caregivers when someone attempts to get out of bed, helping to prevent falls). During a review of Resident 3's physician order, dated 4/30/2024, the order indicated staff were to apply a wheelchair and bed alarm to alert staff when Resident 3 was trying to get up without assistance. During a review of Resident 3's Medication Administration Record (MAR), dated 12/1/2025 to 12/31/2025, the MAR indicated Resident 3 used a wheelchair and bed alarm every day during the month of December 2025. During an interview on 1/15/2026 at 3:45 p.m., with the MDS Assistant (MDSA), the MDSA stated that when coding use of alarms in the MDS, staff reviewed the previous seven days for use of alarms to determine the correct coding. The MDSA stated Resident 3 used alarms daily during the seven-day lookback period and stated her MDS dated [DATE] was not accurate. The MDSA stated the MDS should be accurate because it explained the clinical condition of the resident and the care they received or required. The MDSA stated the MDS also guided the plan of care, and stated that if the MDS indicated alarms were being used, it would prompt the interdisciplinary team to review the use of the alarms to determine if they can be discontinued. The MDSA stated that alarms were considered a restraint, and stated accurate MDS assessments helped in ensuring their use was routinely reviewed. During a review of the facility job description titled MDS Coordinator Lead, dated 8/2019, the job description indicated the MDS nurse was to ensure residents assessments presented an accurate reflection of the resident.

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed to reflect an order for floor mats (cushioned floor pads designed to help prevent injury should a person fall) for one of three sampled residents (Resident 1), related to the resident's high risk for falls. This deficient practice placed Residents 1 at risk of not having floor mats at the bedside, and placed the resident at risk for injuries related to potential falls. Cross Reference F689.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 1's diagnoses included cognitive impairment (a decline in mental abilities like memory, thinking, learning, judgment, and concentration) and lack of coordination. During a review of Resident 1's History and Physical (H&P), dated 8/21/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 1 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required substantial to maximal assistance from staff for repositioning left and right while in bed, and for transitioning from a lying to sitting position, and from a lying position to sitting at the edge of the bed. During a review of Resident 1's Change of Condition (COC) assessment, dated 8/11/2025, the COC indicated on 8/11/2025, nursing staff found Resident 1 sitting on the floor leaning on her bed following an unwitnessed fall. During a review of Resident 1's Fall Risk Evaluation, dated 8/11/2025 (after Resident 1's fall), the evaluation indicated Resident 1 was at high risk for falls. During a review of Resident 1's physician order, dated 8/11/2025 (after Resident 1's fall), the physician order indicated Resident 1 had orders for floor mats on either side of their bed. During a review of Resident 1's Rehab Post Fall Screen, dated 8/12/2025, the assessment indicated Resident 1 experienced confusion, impulsiveness, and had poor safety awareness. During a review of the Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal for a resident) Review notes, dated 8/12/2025, the IDT notes indicated placement of floor mats at Resident 1's bedside was recommended to reduce her injury risk. During a review of Resident 1's COC assessments, dated 8/18/2025 and 12/17/2025, the COC assessments indicated on 8/18/2025 and 12/17/2025, Resident 1 sustained two additional unwitnessed falls at her bedside. During an observation on 1/15/2026 at 9:10 a.m., at Resident 1's bedside, no fall mats were observed to either side of Resident 1's bed. During an interview on 1/15/2026 at 9:22 a.m., in Resident 1's room, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was at risk for falls due to her history of falls and frequent attempts to get out of bed unassisted. CNA 1 stated she usually removed the floor mat during the 7:00 a.m. to 3:00 p.m. (day) shift and was not sure if staff replaced the floor mat in the evening. During a telephone interview on 1/15/2025 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a history of falls and attempting to get out of bed unassisted and was at risk for additional falls. LVN 1 stated he could not recall any recent use of floor mats as a fall risk intervention for Resident 1 and was not aware if Resident 1 had orders for floor mats. LVN 1 stated floor mats should be care planned to ensure that all staff were aware of the reason they were needed. During an interview on 1/15/2026 at 12:16 p.m., with LVN 2, LVN 2 stated Resident 1 was at risk for falls and had orders for floor mats to either side of Resident 1's bed. LVN 2 stated he was responsible for ensuring that the physician orders were carried out. LVN 2 stated he did not recall checking to ensure Resident 1 had floor mats at her bedside that morning (1/15/2026). LVN 2 stated the purpose of the floor mats was to prevent slipping and to prevent and/or minimize injuries from falls. LVN 2 stated Resident 1 did not have a care plan for her use of floor mats and stated a care plan would have ensured staff were aware that they were ordered and ensured that they were implemented as ordered. During a review of the facility's policy and procedure (P&P) titled Care Plan, dated 3/2024, the P&P indicated the care plan was to be used in developing the resident's daily care routines and was to be available to staff who were responsible for providing care or services to the resident.

Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions, such as the use of floor mats and bed alarms and wheelchair alarms (a safety device that sounds an alert to caregivers when someone attempts to get out of bed, helping to prevent falls), were implemented for one of three sampled residents (Residents 1 and 2), who were at risk for falls when: 1. Resident 1 did not have floor mats at the bedside, as ordered, following a fall on 8/11/2025. 2. Resident 1's physician was not notified in a timely manner of the resident's refusal of bed and wheelchair alarms. 3. A fall risk evaluation was not conducted for Resident 2 following her fall on 1/11/2026. These deficient practices placed Residents 1 and 2 at risk for falls and associated injuries.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 1's diagnoses included cognitive impairment (a decline in mental abilities like memory, thinking, learning, judgment, and concentration) and lack of coordination. During a review of Resident 1's History and Physical (H&P), dated 8/21/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 1 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required substantial to maximal assistance from staff for repositioning left and right while in bed, and for transitioning from a lying to sitting position, and from a lying position to sitting at the edge of the bed. During a review of Resident 1's Change of Condition (COC) assessment, dated 8/11/2025, the COC indicated on 8/11/2025, nursing staff found Resident 1 sitting on the floor leaning on her bed following an unwitnessed fall. During a review of Resident 1's Fall Risk Evaluation, dated 8/11/2025 (following the fall), the evaluation indicated Resident 1 was at high risk for falls. During a review of Resident 1's physician order, dated 8/11/2025 (following the fall), the physician order indicated to place floor mats to either side of the bed. During a review of Resident 1's Rehab Post Fall Screen, dated 8/12/2025, the assessment indicated Resident 1 experienced confusion, impulsiveness, and had poor safety awareness. During a review of the Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Review notes, dated 8/12/2025, the IDT notes indicated placement of floor mats at Resident 1's bedside was recommended to reduce her injury risk. During an observation on 1/15/2026 at 9:10 a.m., at Resident 1's bedside, no fall mats were observed to either side of Resident 1's bed. One fall mat was observed stored behind the door to Resident 1's room. During an interview on 1/15/2026 at 9:22 a.m., in Resident 1's room, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was at risk for falls due to history of falls and frequent attempts to get out of bed unassisted. CNA 1 stated the fall mat behind the door belonged to Resident 1, and stated only one fall mat was placed at Resident 1's bedside while she was in bed. CNA 1 stated she usually removed the floor mat during the 7:00 a.m. to 3:00 p.m. (day) shift and was not sure if staff replaced the floor mat in the evening. During a telephone interview on 1/15/2025 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a history of falls and attempting to get out of bed unassisted and was at risk for additional falls. LVN 1 stated he could not recall any recent use of floor mats as a fall risk intervention for Resident 1 and was unaware of any orders for floor mats. During an interview on 1/15/2026 at 12:16 p.m., with LVN 2, LVN 2 stated Resident 1 was at risk for falls and had orders for floor mats to either side of Resident 1's bed. LVN 2 stated he was responsible for ensuring that the physician order was carried out. LVN 2 stated he did not check to ensure Resident 1 had floor mats at her bedside that morning (1/15/2026). LVN 2 stated the purpose of the floor mats was to prevent slipping and to prevent and/or minimize injuries from falls. During an interview on 1/15/2026 at 4:11 p.m., with the Assistant Director of Nursing (ADON), the ADON stated floor mats prevented and/or minimized injuries from falls, and stated that if ordered by the physician, the order should be followed. During a review of the facility's policy and procedure (P&P) titled Fall and Fall Risk Management, dated 3/2024, the P&P indicated staff, in conjunction with the physician, were to identify and implement relevant interventions to try to minimize serious consequences of falling. During a review of the facility's job description for Licensed Vocational Nurses (LVNs), dated 8/2019, the job description indicated LVNs were to ensure that physician orders were carried out. 2. During a review of Resident 1's COC assessment, dated 8/18/2025, the COC indicated on 8/18/2025, staff found Resident 1 on the floor following an unwitnessed fall. The COC assessment indicated Resident 1's physician recommended a wheelchair alarm as a fall precaution. The COC did not indicate Resident 1 had floor mats at her bedside at the time of the fall. During a review of Resident 1's physician order, dated 8/18/2025, the order indicated staff were to apply a bed alarm and wheelchair alarm to alert staff and promote safety awareness and prevent injury from falls when Resident 1 got up unassisted. During a review of Resident 1's care plan titled The resident uses Bed/wheelchair alarm related to (r/t) noncompliance and repeated falls, dated 8/31/2025, the care plan indicated staff were to monitor, document, and report as needed any changes regarding the effectiveness of Resident 1's bed and chair alarms. During a review of Resident 1's COC assessment, dated 12/17/2025, the COC indicated on 12/17/2025, nursing staff found Resident 1 sitting on the floor next to her bed following an unwitnessed fall. The COC did not indicate Resident 1 had floor mats or a bed alarm in place at the time of the fall. During a review of Resident 1's progress note, dated 12/17/2025, the progress note indicated Resident 1 reported mild pain near the tailbone following the fall. During a review of Resident 1's Fall Risk Evaluation, dated 12/17/2025 (after the fall), the evaluation indicated Resident 1 was at high risk for falls. During a review of Resident 1's Rehab Post Fall Screen, dated 12/18/2025, the assessment indicated Resident 1 fell in her room on 12/17/2025 at 7:45 p.m. The assessment indicated Resident 1 had poor safety awareness and forgetfulness. The assessment indicated an alarm was not in place at the time of the fall, and indicated staff should place alarms . if possible. During an observation on 1/15/2026 at 9:10 a.m., at Resident 1's bedside, observed Resident 1 did not have a bed alarm in place. During an observation on 1/15/2026 at 9:13 a.m., in the dining room, Resident 1 was observed sitting on a wheelchair. Resident 1 did not have a wheelchair alarm in place. During an interview on 1/15/2026 at 9:22 a.m., with CNA 1, CNA 1 stated she had not seen Resident 1 use a bed or wheelchair alarm. During an interview on 1/15/2026 at 11:45 a.m., with LVN 1, LVN 1 stated he had not observed the use of a bed or wheelchair alarm for Resident 1 to prevent falls. During an interview on 1/15/2026 at 11:57 a.m., with LVN 2, LVN 2 stated Resident 1 had orders for the use of a bed and wheelchair alarm due to her risk for falls. LVN 2 stated Resident 1 had a known history of removing her bed and wheelchair alarms and taking them apart. LVN 2 stated this was not a new behavior, and stated the physician was not notified until 1/15/2026. LVN 2 stated the behavior should have been documented and the physician should have been notified sooner. LVN 2 stated that absence of the wheelchair and bed alarms increased Resident 1's risk for falls and injuries. During an interview on 1/15/2026 at 4:09 p.m., with the ADON, the ADON stated the physician should be notified if the resident was refusing the alarms that were ordered for her safety. The ADON stated Resident 1 was a fall risk, and stated timely reporting of her refusal of the alarms would ensure her plan of care was reviewed and other interventions to prevent falls could be identified. During a review of the facility's P&P titled Fall - Clinical Protocol, dated 3/2024, the P&P indicated staff were to monitor and document the resident's response to interventions intended to reduce falling or the consequences of falling. 3. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 2's diagnoses included rheumatoid arthritis (a chronic disease where the immune system attacks the body's own tissues, primarily the lining of the joints). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required supervision or touch assist from staff for repositioning in bed, and transfers between surfaces (i.e., bed to chair, chair to bed). During a review of Resident 2's COC assessment, dated 1/11/2026, the COC indicated on 1/11/2026, staff found Resident 2 on the floor of the dining room following an unwitnessed fall. The COC indicated Resident 2 complained of pain to her right knee that did not require pharmacological intervention. During an interview on 1/15/2026 at 3:56 p.m., with the ADON, the ADON stated that following any kind of fall, a Fall Risk Evaluation assessment should be done immediately or within 24 hours. The ADON stated a Fall Risk Evaluation was not completed for Resident 2 following her unwitnessed fall on 1/11/2026 and stated it should have been. The ADON stated the Fall Risk Evaluation was important to promptly identify interventions to prevent further falls. During a review of the facility's P&P titled Fall - Clinical Protocol, dated 3/2024, the P&P indicated that after a fall, staff were to re-evaluate the situation and consider possible reasons for the fall and reconsider the current fall interventions.

Based on observation, interview, and record review, the facility failed to:Label and discard food items in two of three sampled refrigerators.Ensure test strips used to test sanitation strength were not expired.These failures had the potential to increase the risk of foodborne illness in the residents.Findings: 1.During a concurrent observation and interview on 12/2/2025 at 8:45 A.M. in the kitchen, the following items were found: In Refrigerator 1, a container filled with many individual serving sized salad dressing containers were not labeled and no open and/or use by dates. In Refrigerator 3, a large plastic container of mustard sauce had a best by use date of 10/21/2025; Italian salad dressing container's used by date was not legible, chocolate syrup had an used by date of 11/30/2025. Director of Food Services (DFS) stated all food items should be labeled with names and have an opened and used by date on them. DFS also stated that all expired, un-labeled, and un-dated food items should not be used by their kitchen. If residents were served the expired food, they may get sick. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 3/2025, P&P indicated all food stored in the refrigerator or freezer are covered, labeled and dated (use by date). 2.During a concurrent observation and interview on 12/2/2025 at 9:08 A.M. in the kitchen dishwashing area, the Director of Food Services (DFS) tested the dishwasher sanitation strength of a clean food tray after it was sanitized with a chlorine test strip. The test strips container indicated an expiration date of 10/2025. The DFS confirmed the test strip container had expired. During an interview on 12/5/2025 at 11:35 A.M. with the DFS, the DFS stated if the facility used expired chlorine test strips, then the cleanliness of food tray items cannot be verified, and this can result in the residents becoming sick.

Based on interviews and record reviews, the facility failed to provide a competency assessment (a skill or ability, especially one required to perform a particular job or role) for four of four CNA's. This failure had the potential to result in untimely and inaccurate weights and improper range of motion for the residents.Findings:During a record review on 12/4/2025 at 12:28 p.m., the Director of Staff Development (DSD) did not have the competency (the ability to perform a particular skill) checked off as competency demonstrated, for the skill of weighing residents for three CNAs and for the skill of providing range of motion exercises for one RNA. During an interview on 12/4/2025 at 12:52 p.m., in the Administration office, the DSD stated that it is possible the CNAs and RNA will not follow the steps listed in the competency and there is a possibility something unsafe could occur with the residents.During an interview on 12/5/2025 at 12:22 p.m. with the Director of Nursing (DON), the DON stated staff competency is very important because it reflects the care provided to the residents. If competencies are not completed, that would expose staff to making errors in providing care.During a review of Competency Checks-CNA policy and procedure (P&P), dated March 2025, the P&P indicated that, nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.c. plan of care.

Based on observation, interview and record review, the facility failed to: 1. Ensure narcotic (controlled medication) drug records were accurate for Med Cart 3 for Resident 15 and Med Cart 4 for Resident 49. 2. Ensure 2 signatures were obtained on a narcotic destruction form for Resident 146.This deficient practice had the potential to result in medication errors and medication diversions.Findings:a. During a review of Resident 15's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 15 was originally admitted on [DATE] and readmitted on [DATE]. The face sheet also indicated Resident 15's diagnoses' which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), epilepsy (seizures), anxiety (a feeling of unease, worry, or fear) and chronic obstructive pulmonary disorder (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 15's history and physical (H&P), dated 7/17/2024, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Sheet (MDS- a federally mandated resident assessment tool), dated 11/7/2025, the MDS indicated Resident 15's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 15 required substantial assistance from staff members with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent interview and record review, on 12/4/2025 at 10:45 a.m., at Medication Cart 3, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 observed Resident 15's bottle of Morphine Sulfate. LVN 1 stated Resident 15's morphine bottle had 16 mL yet the narcotic medication documentation stated Resident 15 had 13.75 mL in the bottle. LVN 1 stated the morphine bottle had usually came with more ml's than what was ordered. LVN 1 stated the facility documents based on the pharmacy label, not the surplus of what was inside the bottle. LVN 1 stated the risk of not documenting the full amount inside of the bottle could result in medication diversion.During a concurrent observation and interview, on 12/4/2025 at 11:08 a.m., with Registered Nurse 1 (RNS 1), RNS 1 stated Resident 15's morphine bottle had about 16-17 ml. RNS 1 stated the narcotic medication form indicated there was 13.75 ml in Resident 15's bottle. RNS 1 stated the bottle amount and narcotic documentation form did not match. RNS 1 stated the risk of not having correct dosage labeled on the narcotic medication form compared to the actual bottle could result in a possible narcotic diversion. b. During a review of Resident 49's face sheet, the face sheet indicated Resident 49 was originally admitted on [DATE] and readmitted on [DATE]. The face sheet also indicated Resident 49's diagnoses' which included malignant neoplasm of the bladder (bladder cancer), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), cerebral infarction (stroke), and dementia (a progressive state of decline in mental abilities).During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's cognitive skills were severely impaired. The MDS also indicated Resident 49 was dependent on staff members with ADLs.During a concurrent observation and record review, on 12/4/2025 at 11:16 a.m., on Medication Cart 4, with LVN 5, LVN 5 stated Resident 49's narcotic medication form indicated resident 49 had 15 mL's of morphine available yet the bottle contained 25 ml's. LVN 5 stated the amount in the bottle compared to the documentation on the narcotic medication form did not match. LVN 5 stated the risk for inaccurate narcotic count documentation indicate a staff member could be taking the medication.During a concurrent observation and interview, on 12/4/2025 at 11:32 a.m., with RNS 2, RNS 2 stated Resident 49 had around 24-25mL in his morphine bottle. RNS 2 observed the narcotic documentation form and stated the form indicated 15ml's in the bottle but it was not accurate compared to what was in the bottle. RNS 2 stated the documentation did not reflect the amount in the bottle compared to the documentation log. RNS 2 stated the risk of not reflecting an actual narcotic amount on a documentation form could result in a medication error and possible narcotic diversion. During an interview, on 12/4/2025 at 11:53 a.m., with a Pharmacist Consultant 1, he stated the facility should record the actual amount that is in the bottle rather than go by the mL's from the physician's order once a medication was delivered. The pharmacy consultant stated the risk of not documenting the actual medication volume could result a possible medication diversion.During an interview, on 12/4/25 at 12:24 p.m., with the Director of Nursing (DON), the DON stated if medication amount received from the pharmacy does not match order then staff were required to reconcile correct amount by the actual bottle and the prescription. The DON stated the actual amount in the bottle should be documented on the narcotic medication form and pharmacy should be notified. The DON stated the risk of not documenting the correct amount of a narcotic medication cause result in a medication diversion.c. During a review of Resident 146's face sheet, the face sheet indicated Resident 146 was originally admitted on [DATE] and readmitted on [DATE]. The face sheet also indicated Resident 146's diagnoses' which included malignant immunoproliferative disease (a type of cancer involving the abnormal, uncontrolled growth of immune cells), sialadenitis (inflammation or infection of the salivary glands), pulmonary fibrosis (a lung disease where lung tissue becomes scarred and thickened), and fibromyalgia.During a review of Resident 146's H&P, dated 10/31/2025, the H&P indicated Resident 146 had the capacity to understand and make decisions. During a review of Resident 146's MDS, dated [DATE], the MDS indicated Resident 146's cognitive skills were intact. The MDS also indicated Resident 146 required partial assistance from staff members with ADLs.During a concurrent observation and interview, on 12/4/25 at 12:05 p.m., with the DON, the narcotic destruction [NAME] was reviewed. The DON stated the pharmacist consultant and DON would dispose of unused narcotic medications. The DON stated Resident 146 was discharged from the facility and unused narcotic medication was destroyed by incineration. The DON stated she signed the destruction log for Resident 146's medication but the pharmacist did not. The DON stated both of them were responsible to provide a signature for destroying meds. The DON stated the risk of not obtaining two signatures for destruction of narcotic medication could result in medication diversion. During a review of the facility's policy and procedures (P&P), titled Controlled Substance, revised 3/2025, the P&P indicated Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication must count the controlled substances together. and Waste and/or disposal of controlled medication arc done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on observation, interview, and record review, the facility failed to:Label multi-use medication bottles (a container that holds a drug for multiple doses) with an open date in four of seven sampled medication storage areas (Medication Storage room [ROOM NUMBER], Medication Cart 2, Medication Cart 3, and Medication Cart 4).Refrigerate an opened Acidophilus (drug that maintains healthy bacteria) bottle in one of four sampled medication carts (Medication Cart 1).These failure had the potential to result in resident harm due to the weakened strength of the medication and the administration of ineffective drug dosages. Findings: a. During observation on [DATE] at 9:48AM in the first floor medication storage room, an opened tuberculin (proteins used to test for a bacterial infection) vial was not labeled with an open date. During an interview on [DATE] at 9:49 AM with Registered Nurse Supervisor 2 (RN 2), RN 2 stated the opened tuberculin vial should have an opened date, but it is missing. RN 2 stated that all opened medication vials must have an open date. RN 2 stated that residents are at risk for harm because medication may be expired. During observation on [DATE] at 10:31AM of medication cart 2, one opened box of Omeprazole (a drug used to treat conditions that cause increased stomach acid) tablets was not labeled with an open date. During an interview on [DATE] at 10:32 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the opened box of Omeprazole was open but was not labeled with an opened date. LVN 4 stated that having undated medications puts resident safety at risk. During observation on [DATE] at 10:44 AM of medication cart 3, two opened boxes of Tamiflu (a drug used to treat the flu) were not labeled with an open date. During an interview on [DATE] at 10:45 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the two boxes of Tamiflu were opened and undated. LVN 1 stated undated medication might not help the residents due to the potential decrease in the effectiveness of the medication. During observation on [DATE] at 11:15 AM of medication cart 4, one opened box of anti-diarrheal medication (a drug used to treat watery feces) was not labeled with an open date. During an interview on [DATE] at 11:16 AM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the antidiarrheal medication was opened and undated. LVN 5 stated that undated medications risk losing their effectiveness. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 8/2025, indicated the date a multidose container is opened must be recorded on the container. b. During an interview on [DATE] at 10:22 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated opened Acidophilus label indicated medication should be refrigerated after opening. LVN 3 stated the medication was not placed back in the refrigerator after finishing medication administration. LVN 3 stated leaving unrefrigerated medications that require refrigeration in the medication cart put residents' safety at risk. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised 7/2025, indicated medications requiring refrigeration are stored in a refrigerator located in the medication room or other secured location.

Based on observation, interview, and record review, the facility failed to:1. Perform hand hygiene (cleansing hands with soap or an alcohol-based rub) before assisting two of two sampled residents (Resident 68 and 144).2. Ensure one of one sampled residents (Resident 1) gastronomy tube ending was capped off to prevent contamination.This failure had the potential to expose Resident 68 and Resident 1 to potentially infectious organisms. Findings: a. During a review of Resident 68's admission Record (AR), dated 7/18/2023, the AR indicated that Resident 68 has a diagnosis of interstitial pulmonary disease (swelling and scarring in the lung tissue), cirrhosis of the liver (severe scarring of the liver tissue), and moderate protein-calorie malnutrition (a severe nutritional deficiency from a lack of protein). During a review of Resident 68's Minimum Data Set (MDS), dated [DATE], the MDS indicated that Resident 68's has limited vision, used a wheelchair, and required substantial/maximal assistance with personal hygiene, toileting, and lower body dressing. During a review of Resident 68's History & Physical (H&P), dated 4/6/2025, the H&P indicated that Resident 68 does not have the capacity to understand and make decisions. During a review of Resident 68's Order Summary Report (OSR), dated 12/5/2025, the OSR indicated that high touch areas (regularly touched by many different people) are to be cleaned hourly or as often as required with approved disinfectant per manufacturer's instruction in resident care environment, on every shift, dated 9/4/2024. b. During a review of Resident 144's admission Record (AR), dated 11/25/2025, the AR indicated that Resident 144 has a diagnosis of traumatic subdural hemorrhage (bleeding between the brain's outer covering and the surface of the brain), nontraumatic subarachnoid hemorrhage (bleeding in the space around the brain), and a right-side rib fracture (broken bone). During a review of Resident 144's History and Physical (H&P), dated 11/25/2025, the H&P indicated that Resident 144 does not have the capacity to understand and make decisions. During a review of Resident 144's Order Summary Report (OSR), dated 12/5/2025, the OSR indicated Resident 144 may be placed on Enhanced Barrier Precautions (wearing gloves and a gown when caring for patients) secondary to post craniotomy (surgery to remove a section of the skull to perform surgery) and staff are to promptly report any signs of infection to the medical doctor. During an observation on 12/3/2025 at 8:35 p.m., at the door of room [ROOM NUMBER], CNA 1 entered room [ROOM NUMBER], touching Resident 68 to place an updated identification band, and exited room [ROOM NUMBER] without performing hand hygiene. During an interview on 12/3/2025 at 8:37 a.m., with CNA 1, outside room [ROOM NUMBER], CNA stated if hand hygiene is not performed, residents can get infected from germs transferred to them and be hospitalized from the infection. During an interview on 12/3/2025 at 8:58 a.m., with RNS 1, in the hallway near the conference/board room, RNS 1 stated that if hand hygiene is not performed infectious organisms can spread to the residents and they can become ill and need hospitalization. During an interview on 12/5/2025 at 12:22 p.m., with Director of Nursing (DON), in the DON's office, the DON stated staff are expected to perform hand hygiene before engaging with any resident to prevent the outbreak of an infection which may lead to an adverse outcome for the residents. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 3/2025, indicated, hand hygiene is indicated immediately before touching a resident and after touching a resident with soap and water or an alcohol-based hand rub. c. During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), dysphagia (difficulty swallowing), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/1/2025, the MDS indicated Resident 1's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's history and physical (H&P) form, undated, the H&P indicated Resident 1 did not have the capacity to understand make decisions. During an observation, on 12/02/2025 at 3:51 p.m., Resident 1's g-tube was hanging on a feeding tube pole. Resident 1's gastronomy tube was observed without a cap at the end of g-tube, exposed to open air. During a concurrent observation, on 12/03/2025 at 11:22 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated when not in use, all gastronomy tubing must be capped to prevent bacterial growth. LVN 1 observed Resident 1's feeding tube and stated there was no cap on end of feeding tube. LVN 1 stated the risk of not capping a feeding tube could result in illness in residents, contamination of gastronomy tube. During a review of the facility's policy and procedures (P&P), titled Policies and Practices- Infection Control, revised 3/2025, the P&P indicated This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review the facility failed to ensure the temperature in the residents' rooms were within range for two of two sampled residents (Resident 63 and Resident 120).This failure had the potential to negatively affect the residents' quality of life.Findings:During a review of Resident 63's admission Record (undated), the admission Record indicated the facility admitted the resident on 2/15/2024, with diagnoses including but not limited to arthropathy (abnormal condition affecting a joint), iron deficiency anemia (condition where the body does not have enough healthy red blood cells), hypotension (abnormally low blood pressure), and dementia (a progressive state of decline in mental abilities).During a review of Resident 63's History and Physical (H&P) Examination, dated 2/23/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/2/2024, the MDS indicated the resident's BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score indicated he was moderate cognitive impairment. The MDS indicated Resident 63 can comprehend most conversations and can communicate words or thoughts if given time.During a review of Resident 120's admission Record (undated), the admission Record indicated the facility admitted the resident on 7/03/2023, with diagnoses including but not limited to lumbosacral spinal stenosis (narrowing of the spine in the lower back), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure).During a review of Resident 120's H&P, dated 10/17/2025, the H&P indicated the resident does have the capacity to understand and make decisions. During a review of Resident 120's MDS, dated [DATE], the MDS indicated the resident's BIMS score indicated she was cognitively intact. The MDS indicated Resident 120 can understand others and express wants or needs.During a concurrent observation and interview on 12/2/2025 at 11:56 AM with Resident 63 in Resident 63's room, the room's thermostat displayed 67 degrees Fahrenheit ( F- a temperature scale). Resident 63 stated the room is always cold. The resident stated he informed the staff, but the issue remains unresolved. During a concurrent observation and interview on 12/2/2025 at 2:13 PM with Resident 120 in Resident 120's room, the room's thermostat displayed 69 F. Resident 120 stated it gets cold in the room despite staff checking the temperature the previous day. During an interview on 12/3/2025 at 2:31 PM with Resident 63, Resident 63 stated his face is always cold and he feels uncomfortable because the room is cold. Resident 63 stated even with blankets, he still feels cold. Resident 63 stated he feels like he is developing a cold.During an interview on 12/3/2025 at 2:35 PM with the Maintenance Manager (MM). MM stated that residents' room temperatures should be maintained between 71-81 F. MM stated the daily temperature checks are performed using a laser thermometer in the rooms, and the readings are documented on temperature logs.During a concurrent observation and interview on 12/03/2025 at 2:42 PM with MM and Maintenance Supervisor (MS) in Resident 63's room, MM checked the room temperature using a laser thermometer. The laser thermometer indicated 66.2 F. MM stated that the room temperature was too cold. MS stated the room temperature should be no lower than 71 F. Maintaining temperatures above 71 F is part of the regulation and necessary for the comfort of the residents.During an observation on 12/3/2025 at 2:49PM with MM in Resident 120's room, MM measured the room temperature with a laser thermometer. The laser thermometer indicated 64.9 F During a concurrent observation and interview on 12/03/2025 at 2:50 PM with Resident 120, in Resident 120's room. Resident 120 was in bed covered by multiple blankets and had an uncomfortable look on her face. Resident 120 stated she was freezing even with multiple blankets. Resident 120 also stated it hurts to breath due to room being cold.During review of the facility's policy and procedure (P&P) titled, Room Temperature, revised 3/2025, indicated the required temperature range in all resident areas are to be maintained between 71 F and 80 F.

Based on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for two of 26 sampled residents (Resident 5 and Resident 130) by failing to: 1. Ensure Resident 5 and Resident 130's Gabapentin (medication used to treat seizure and nerve pain) was encoded as anticonvulsant medication. This failure had the potential to negatively affect the plan of care and services for Resident 5 and Resident 130. Findings:A. During a review of Resident 5's admission Record, the admission Record indicated, Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement, cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's History and Physical (H&P), dated 3/13/2025, the H&P indicated, Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/25/2025, the MDS indicated, Resident 5's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 5 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. During a review of Resident 5's Order Summary Report (a document containing active orders), dated 12/5/2025, indicated the physician placed a telephone order on 1/10/2025 for Resident 5 to start on Gabapentin (medication used to treat seizure and nerve pain) 100 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to take one capsule via GT in the evening (5 p.m.) for muscle spasm. During a concurrent interview and record review on 12/3/2025 at 10:45 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 5's MDS assessment, dated 9/25/2025, was reviewed. MDSN 1 stated MDS Section N (Medications) look back period (the specific time frame within which certain resident conditions and events are assessed) was 7 days before the completion date. MDSN 1 stated there should be a checked mark on Resident 5's MDS Section N0415 (High-Risk Drug Classes) K (anti-convulsant) since Gabapentin was classified as anti-convulsant medication. MDSN 1 stated Resident 5's MDS assessment was completed inaccurately. MDSN 1 stated MDS assessment should be completed accurately for the safety of the residents. B. During a review of Resident 130's admission Record, the admission Record indicated, Resident 130 was admitted to the facility on [DATE]. Resident 130's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and hypertension ([HTN] - high blood pressure). During a review of Resident 130's History and Physical (H&P), dated 7/12/2025, the H&P indicated, Resident 130 had the capacity to understand and make decisions. During a review of Resident 130's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/22/2025, the MDS indicated, Resident 130's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 130 required moderate assistance (helper does less than half the effort) from staff with showering, upper and lower body dressing, and personal hygiene. During a review of Resident 130's Order Summary Report (a document containing active orders), dated 12/5/2025, indicated the physician placed a telephone order on 3/25/2024 for Resident 130 to start on Gabapentin (medication used to treat seizure and nerve pain) 300 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to take one capsule by mouth at bedtime (9 p.m.) for neuropathic (nerve) pain. During a concurrent interview and record review on 12/3/2025 at 10:57 a.m., with Minimum Data Set Nurse 2 (MDSN 2), Resident 130's MDS assessment, dated 10/22/2025, was reviewed. MDSN 2 stated Resident 130's Gabapentin was not encoded as anticonvulsant medication on MDS Section N0415 (High-Risk Drug Classes) K. MDSN 2 stated accuracy of MDS assessment was important for the care planning of the resident, facility reimbursement and to improve quality measures (a specific tool used to quantify and evaluate the quality of care provided to residents in long term care facilities) of the facility. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Assessment, dated 3/2025, the P&P indicated, Any Person completing a portion of the Minimum data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.During a review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, indicated to code medications in item N0415 according to the medication's therapeutic category and/or pharmacological classification, not how it is used.

Based on interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan for anti-fungal (a drug that kills or stops the growth of harmful fungi causing infections in humans) medication for one of one sampled resident (Resident 143). This deficient practice had the potential not able to monitor the side-effect (undesired effects of a drug) of antifungal medication that could possibly harm Resident 143. Findings: During a review of Resident 143's admission record, the admission Record indicated, Resident 143 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 143's diagnoses included, urinary tract infection ([UTI] - an infection in the bladder/urinary tract), cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 143's History and Physical (H&P), dated 1/28/2025, the H&P indicated, Resident 143 did not have the capacity to understand and make decisions. During a review of Resident 143's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/8/2025, the MDS indicated, Resident 143's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 143 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 143's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from November to December, 2025, the MAR indicated, Resident 143 received fluconazole (anti-fungal drug) 100 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) once a day for yeast infection (fungal infection that affects different body parts) on 11/27/2025, 11/28/2025, 11/29/2025, 11/30/2025, 12/1/2025, 12/2/2025, and 12/3/2025). During a concurrent interview and record review on 12/4/2025 at 9:07 a.m., with Minimum Data Set Nurse 2 (MDSN 2), Resident 143's electronic health records, were reviewed. MDSN 2 stated there was no comprehensive person-centered care plan for Resident 143's use of antifungal medication. MDSN 2 stated each member of the interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) was responsible in creating a comprehensive person-centered care plan. MDSN 2 stated it was important to have a care plan for medication in order to monitor the side-effects or the black box warning (drugs that have special problems, particularly ones that may lead to death or serious injury) of the medication. MDSN 2 stated in general care plan should be developed to improve the standard of care and to provide interventions needed for the care of the residents. During an interview on 12/4/2025 at 10:29 a.m., with the Assistant Director of Nursing (ADON), the ADON stated it was important to develop care plan in order for the facility staff to be aware of each resident's individualized needs.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plan, dated 3/2025, the P&P indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to review and revise one of two sampled residents (Resident 76) when her condition changed. This failure had the potential to result in inappropriate plan of care, outdated treatments, and patient centered goals not being met. Findings: During a review of Resident 76's admission Record, it indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included but not limited to: Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder, adult failure to thrive and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 76's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 10/25/2025, the MDS indicated Resident 76 has severely impaired cognitive skills for daily decision making. Resident 76 requires a helper to do all of the effort for oral hygiene, toileting hygiene, shower/bathe, dressing, rolling left and right, sit to lying, chair/bed to chair transfer, and tub/shower transfer. During a review of Resident 76's Care Plan (CP), initiated on 2/12/2024, the CP indicated Resident 76 should have tab alarms in bed and wheelchair to alert staff of attempts to get up unassisted. This CP has a target date of 11/9/2025. During a review of Resident 76's Fall Risk Evaluation, dated 8/13/2025, it indicated Resident 76 cannot get up or stand on her own. Resident 76 is not a high risk for falls. During an observation on 12/2/2025 at 10:28 am in Resident 76's room, Resident 76 sitting upright in a wheelchair sleeping with no chair alarm. During an observation on 12/3/2025 at 8:20 am in Resident 76's room, Resident 76 was sitting upright in bed being fed breakfast. During an observation on 12/3/2025 at 12:50 pm in Resident 76's room, Resident 76 was upright in a wheelchair appearing sleepy, knee splints on, and with no chair alarm. During a concurrent observation and interview on 12/3/2025 at 1:00 pm with Certified Nursing Assistant (CNA) 1, in Resident 76's room, the resident does not have chair or bed alarm in her room. CNA 1 stated the alarms are used for residents on fall precautions to warn staff that the resident is getting up without their help. CNA 1 stated Resident 76 does not need an alarm because she is contracted and unable to get up on her own. During an interview on 12/5/2025 at 10:30 am with Registered Nurse Supervisor (RNS) 1, RNS 1 stated charge nurses and nurses are supposed to update the care plans as necessary. RNS 1 stated the CPs are for more structured goals to better the residents care and make sure they are getting better. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered revised March 2025, the P&P indicated care plans are revised as information or the resident's condition change. The P&P also indicated, the interdisciplinary team must review and update the care plan: -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -When the resident has been readmitted to the facility from a hospital stay; and -At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review, the facility failed to:Ensure low air loss mattress settings were accurate for two of 16 sampled residents (Resident 1 and Resident 3). Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), dysphagia (difficulty swallowing), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/1/2025, the MDS indicated Resident 1's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation, on 12/02/2025 at 3:48 p.m., Resident 1 was observed laying in bed on a low air loss mattress with weight settings at 350 lbs. During a concurrent observation and interview, on 12/3/2025, at 11:27 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated low air loss mattress settings were based on a resident's weight. LVN 1 stated Resident 1's low air loss mattress was set to 350 pounds. LVN 1 stated Resident 1 weighed 129 lbs. LVN 1 stated the low air loss mattress was on the wrong setting for Resident 1. LVN 1 stated the risk of setting a low air loss mattress on the wrong setting could result in skin breakdown and wounds. During a review of Resident 3's admission Record, it indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to: necrosis (death of most or all of the cells in an organ or tissue or failure of the blood supply) of amputation stump (left lower foot), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs), and stage 3 pressure ulcer (full-thickness loss of skin. Dead and black tissue may be visible) of the sacral region (above the buttocks and at the base of the spine). During a review of Resident 3's Minimum Data Set (MDS – a comprehensive assessment and screening tool) dated 10/24/2025, the MDS indicated Resident 3 has difficulty communicating some words or finishing thoughts and misses some part/intent of messages. Resident 3 requires a helper for all of the effort to roll left and right, sit to lying, and lying to sitting on side of bed. During a review of Resident 2's Care Plan (CP), initiated on 10/21/2025, the CP indicated Resident 3 will have a low air loss mattress, and to monitor for proper setting, placement and functioning every shift. During a review of Resident 3's Weights and Vitals Summary, it indicated Resident 3 weighed 150 pounds when last checked on 11/7/2025. During an observation on 12/3/2025 at 12:30 pm in Resident 3's room, Resident 3 was lying on her right side with the low air loss mattress set at 225 pounds. During a concurrent observation and interview on 12/4/2025 at 2:00 pm with Treatment Nurse (TN) 1 by Resident 3's room, TN1 stated the setting at 225 pounds is incorrect for Resident 3. If the low air loss mattress is set at the wrong weight, there is a potential for the pressure injury to worsen. During an interview on 12/5/2025 at 10:30 am with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the low air loss mattress is set based on the weight of the resident. If the weight setting is wrong, pressure ulcers can worsen. During a review of the facility's low air loss owner's manual, the manual indicated to adjust the air mattress to a desired firmness according to the resident's weight. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised March 2025, the P&P indicated, select the appropriate support surface based on resident's weight. Equipment can include a low air loss mattress.

Based on observation and interview, the facility failed to: 1. Ensure continuous supervision was provided for one of eight sampled residents (Resident 32).This deficient practice had the potential to result in injuries and accidents.Findings:During a review of Resident 32's face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 32's diagnoses included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy (chronic disease of the heart muscle) and benign prostatic hyperplasia (a common, non-cancerous enlargement of the prostate gland).During a review of Resident 32's Minimum Data Sheet (MDS- a federally mandated resident assessment tool), dated 11/26/2025, the MDS indicated Resident 32's cognitive (thinking) skills was severely impaired. The MDS also indicated Resident 32 was dependent on staff members with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 32's history and physical (H&P) form, dated 6/16/2025, the H&P indicated Resident 32 did not have the capacity to understand and make decisions.During a review of Resident 32's care plan, titled Resident is on 1:1 sitter, dated 8/24/2025 indicated Resident 32 was to be on continuous monitoring due to poor safety awareness. During an observation, on 12/2/2025 at 10:49 a.m., Resident 32 was observed laying in bed with floor mats on both sides of his bed. An empty seat was noted at the end of Resident 32's bed.During a concurrent observation and interview, on 12/2/2025 at 10:51 a.m., with Certified Nurse Assistant 9 (CNA 9), CNA 9 stated continuous monitoring required a staff member to be with a resident at all times. CNA 9 stated there was no staff member present to monitor Resident 32. CNA 9 state Resident 32 required continuous monitoring. CNA 9 stated the risk of not having 1:1 sitter at a resident's bedside as ordered could result in falls and/or accidents and is a safety hazard.During a review of the facility's policy and procedures (P&P), titled 1:1 Monitoring, revised 3/2025, the P&P indicated, It is the policy of this Skilled Nursing Facility to provide continuous, uninterrupted one-to-one observation for residents assessed to be at risk of harm to self or others, elopement, severe behavioral dysregulation, or significant fall risk.

Based on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 13) was provided with Bladder training (type of training that will help a person manage urinary incontinence).This deficient practice had the potential for decline in bladder function for Resident 13.Findings:During a review of Resident 13's admission Record, the admission Record indicated, Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips, hyperlipidemia (too many fats like cholesterol and triglycerides in your blood), and hypertension ([HTN] - high blood pressure). During a review of Resident 13's History and Physical (H&P), dated 11/5/2025, the H&P indicated, Resident 13 had the capacity to understand and make decisions.During a review of Resident 13's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/16/2025, the MDS indicated, Resident 13's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 13 required supervision (helper provides verbal cues) from staff with oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 13 was frequently incontinent (7 or more episodes or urinary incontinence, but at least one episode of continent voiding) of urine. The MDS also indicated that a trial of a toileting program such as scheduled toileting (a technique that involves using a set schedule to go to the bathroom), prompted voiding (behavioral strategy for bladder incontinence), or bladder training have not been attempted. During a concurrent interview and record review on 12/4/2025 at 8:04 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 13's Bowel and Bladder Assessment, dated 9/16/2025, was reviewed. The Bowel and Bladder Assessment indicated Resident 13 was not continent of both bowel and bladder function. The Bowel and Bladder Assessment indicated Resident 13 had a total score of 4 (candidate for bowel and bladder training). MDSN 1 stated there was no documented evidence in the clinical records of Resident 13's indicating staff implemented a bladder training. MDSN 1 stated Resident 13 would benefit for a trial of toileting program for bladder training to reduce problem with incontinence. MDSN 1 stated by not offering a toileting program, Resident 12 would be at risk for urine infection and skin breakdown. During an interview on 12/4/2025 at 10:23 a.m., with the Assistant Director of Nursing (ADON), the ADON stated offering toileting program such as bladder training was important for the dignity of the resident being able to use the bathroom on their own without using a diaper. During a review of the facility's policy and procedure (P&P) titled, Toileting Program, dated 3/2025, the P&P indicated, The options for managing urinary incontinence include primarily behavioral programs, toileting plans and medication therapy.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls, did not have a fall, by failing to ensure: 1. Staff implemented Resident 1's physician's order which indicated to apply a soft belt (a device that is placed on a person's waist to prevent them from falling out of a bed or a chair) on Resident 1 when up in a wheelchair for safety. 2. Staff followed Resident 1's care plan titled Restraint: Soft belt while up on wheelchair for safety, which indicated to apply a soft belt on the resident while up on a wheelchair for safety, to prevent falls and injuries. 3. Staff followed the facility's policy and procedure (P&P) titled Soft/ Self Release Belt, which indicated a wheelchair soft self-release belt was to be used on a resident for safety. As a result, Resident 1 fell on [DATE], (the 3rd fall in 8 days) sustained a fracture (broken bone) on the nasal bridge, which required hospitalization at a general acute care hospital (GACH), for evaluation and treatment. Findings: A review of Resident 1's Admission Record, indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included muscle weakness, dementia (impaired ability to remember, think, or make decisions that interfere with everyday activities), cerebral infarction (stroke), and urinary tract infection (UTI- an infection in the kidneys, bladder, ureters). A review of Resident 1's Minimum Data Set (MDS-a care planning and assessment tool) dated 2/29/2024, indicated Resident 1 had cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed-to chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). A review of Resident 1's quarterly fall risk evaluation dated 2/26/2024, indicated Resident 1 had a low risk for fall due to gait and balance problems and the use of antipsychotic medications. A review of Resident 1's care plan titled At risk for falls/injuries related to advanced age, dementia, and impaired mobility, dated 3/25/2024, indicated staff's interventions included to keep Resident 1 in frequently monitored areas when up in a wheelchair for closer staff monitoring, observe the resident's location through periodic visual checks and provide safety reminders. A review of Resident 1's care plan titled The resident uses bed/wheelchair alarm (device to notify staff when a resident attempts to get out of bed or wheelchair unassisted) related to poor safety awareness, dated 3/26/2024, indicated staff's interventions to anticipate and intervene potential causes which have precipitated (caused) prior falls, discuss with the resident/ family members the risks and benefits of the restraint, and evaluate the need for ongoing use and the continuing need of the restraint. A review of Resident 1's change in condition (COC) evaluation form dated 4/22/2024, indicated on 4/22/2024 at 8:30 a.m., Resident 1 was found by the charge nurse (unidentified)sitting on the floor mat at the bedside. The COC indicated Resident 1 sustained a laceration (skin tear) on the forehead and abrasion (skin scrape) on the right knee. The COC indicated a neuro check (observing how a person speaks, thinks, walks, moves, or interacts with the examiner) was done and first aid treatment was provided. A review of Resident 1's care plan titled Resident had an actual unwitnessed fall related to safety non-compliance, dated 4/22/2024, indicated Resident 1 had an unwitnessed fall 4/22/2024 with a lacerated forehead. The care plan indicated on 4/28/2024 Resident had another unwitnessed fall with bleeding and swelling on the nose. Resident 1's the care plan did not indicate changes made to the interventions for safety after Resident 1 fell on [DATE]. A review of Resident 1's Fall Risk Evaluation report dated 4/22/2024 indicated Resident 1 who had intermittent (on and off) confusion, had 1-2 falls in 3 months, and was chair bound. The report indicated Resident 1 required the use of assistive devices such as a wheelchair and a walker. The report indicated Resident 1 had a fall risk score of 15 (a score of 10 and above indicated high fall risk). A review of Resident 1's Interdisciplinary Team (IDT, group of healthcare professionals working together to provide residents with the care they need) Fall Review report dated 4/23/2024 indicated the IDT met and discussed Resident 1's unwitnessed falls on 4/20/2024, and 4/22/2024, which resulted in injuries upon body checks (locations not indicated). The IDT report indicated on 4/20/2024, Resident 1 was found sitting on a floor mat by his bed. The IDT report indicated on 4/22/2024, Resident 1 was found right side lying on a floormat by his bed, awake but unable to follow simple instructions. The report indicated Resident 1 had an impaired cognition, and impaired activities of daily living (ADLs) functioning with a history of falls. The IDT report indicated Resident 1 could not state what happened. The IDT report indicated the following recommendations: 1. Skilled rehabilitation services for safety with functional mobility and transfers. 2. Frequent visual checks. 3. Redirection and reorientation. 4. Monitor the resident in close one on one observations at all times. 5. Anticipate and provide the resident's needs on time. 6. Use of bed/wheelchair alarm. 7. The resident will be in front of the nursing station when up in a wheelchair. A review of Resident 1's physician order dated 4/23/2024, indicated to apply soft belt restraint when up in wheelchair. A review of Resident 1's IDT Fall Review report dated 5/3/2024 indicated on 4/28/2024 (time not indicated), Resident 1 had an unwitnessed fall. The report indicated a Charge Nurse (unidentified) observed Resident 1 wheeling himself in the hallway, then, heard a thud (dull)sound by Room A, and the resident was observed on a right-side lying position, on the hallway floor, near Room A. The report indicated Resident 1 was awake, unable to answer or follow simple instructions. The report indicated Resident 1 had nasal bleeding and swelling, without pain or discomfort. The report indicated preventive measures in placed prior to Resident 1's fall on 4/28/2024, included bed and wheelchair alarm, floor mats, siderails, bed in low position, visual checks, and call light placed within reach. The report did not indicate the use of a soft belt when in a wheelchair, per Resident 1's physician's order dated 4/23/2024. The IDT summary and new recommendations indicated the physician ordered a self-release belt (a seat belt on a resident's wheelchair that the resident can fasten and release without assistance) while on wheelchair. A review of Resident 1's Medication Administration Record (MAR) dated 4/23 to 4/28/2024, did not indicate Resident 1 was monitored for the use of a soft belt. A review of Resident 1's care plan titled, Restraint: Soft belt while up on wheelchair for safety, dated 4/23/2024, indicated staff will apply a soft belt on Resident 1 while the resident was on a wheelchair, for safety. Staff's interventions included to apply a soft belt when up on wheelchair to prevent Resident 1 from falls/injuries if the resident got up unassisted due to poor safety awareness and poor balance. A review of Resident 1's COC Evaluation form dated 4/28/2024, indicated on 4/28/2024 at 12:31 p.m., Resident 1 was found by an unidentified licensed nurse, on a right-side lying position (the third fall in two weeks), on the floor, by the nurses' station. The COC indicated Resident 1 had nasal bleeding and swelling with no pain. The COC did not indicate Resident 1 had a soft belt restraint on, at the time of fall. A review of Resident 1's nasal bones radiology (process of taking pictures to diagnose and treat diseases) result, dated 4/28/2024, at 4:37 p.m., indicated Resident 1 had a fracture on the bridge of the nose. A review of Resident 1's GACH records, dated 4/29/2024, at 1:29 a.m., indicated Resident 1 was admitted to GACH with diagnoses of acute fall at a skilled nursing facility, acute contusion (bruise to the brain), acute fracture of the nasal bone, abrasions of the forehead and the face and periorbital (around the lining of eyes) ecchymosis (bleeding underneath the skin.). The GACH records indicated Resident 1 was referred to an ear, nose, throat specialist due to the nasal fracture and contusion. During a concurrent interview and record review on 5/21/2024 at 2:38 p.m. with the Director of Nursing (DON), Resident 1's care plan titled Resident had an actual unwitnessed fall related to safety non-compliance, dated 4/22/2024, was reviewed. The DON stated, the care plan's interventions did not make sense. The DON stated Resident 1's care plan was not updated after the resident fell on [DATE], (2 days after the first fall dated 4/20/2024). The DON stated there were no additional interventions after the second fall on 4/22/2024, to prevent Resident 1 from falling the third time on 4/28/2024 (6 days after the second fall). During a concurrent interview and record review on 5/22/2024 at 2:05 p.m. with the DON, Resident 1's MAR dated 4/23 to 4/30/2024 was reviewed. The DON stated the MAR did not indicate Resident 1 had a soft belt when sitting in a wheelchair. The DON stated the MAR did not indicate Resident 1 was monitored for the application or use of a soft belt. The DON stated staff failed to carry out Resident 1's physician's order for the use of a soft belt. The DON stated these failures might have contributed to Resident 1's fall on 4/28/2024. During a telephone interview on 5/22/2024 at 5 p.m. with CNA 3, CNA 3 stated on 4/28/2024 at 12:30 p.m., Resident 1 was on a wheelchair by the nursing station. CNA 3 stated the wheelchair alarm was turned on for Resident 1. CNA 3 stated Resident 1 did not have a soft belt on him (Resident 1) while sitting on the wheelchair. CNA 3 stated Resident 1's recent fall on 4/28/2024, could have been prevented had the soft belt been applied on the resident. CNA 3 stated she was not aware Resident 1 had an order for a soft belt. A review of the facility's P&P titled, Fall Reduction (General) , dated 3/2024, indicated it is the policy of the facility to reassess all residents with falls every time a fall occurred. The P&P indicated residents will be assessed for a need of restraint/ safety device to minimize recurrence of falls such as alarms and self-releasing belts. A review of the facility's P&P titled, Soft/ Self Release Blet , dated 3/2024, indicated a wheelchair soft/ self-release belt was allowed for a resident to use to promote resident safety. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered , dated 4/2013, indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and must be implemented for each resident.

Based on interview and record review, the facility failed to provide supervision (an intervention and a means of mitigating accident risk) during walking and toileting for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling, sustaining a fracture (broken bone) to the right arm which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1 ' s admission record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including syncope and collapse (fainting), nontraumatic intracranial hemorrhage (bleeding in the brain), and a history of falling. During a review of Resident 1 ' s history and physical (H&P), dated 1/3/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s fall risk care plan titled At risk for fall and fall related injuries related to Resident with impaired balance when moving from a seated to standing position, walking, moving on and off the toilet, surface to surface transfers, dated 6/30/2023, care plan ' s the interventions included staff will assist the resident with safe transfers and provide enough support and anticipate the resident ' s needs. During a review of Resident 1 ' s care plan titled, Activities of Daily Living (ADL), dated 4/9/2021, the care plan interventions indicated staff would assist with bed mobility, transfers, ambulation (walking), locomotion (movement around the unit), dressing, eating, toileting, personal hygiene and bathing as indicated, and provide enough support. The care plan interventions also indicated staff will observe Resident 1 ' s ability to stand, transfer, and perform hygiene after toileting. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/8/2023, the MDS indicated Resident 1 was usually able to understand and was usually understood by others. The MDS indicated Resident 1 required supervision or touching assistance (staff provides verbal cues and/or touching/steadying and/or contact guard assistance [staff places one or two hands on the patient ' s body to help with balance] as resident completes activity) during mobility activities such as sitting to standing, chair/bed to chair transfer, toilet transfer, walking 10 feet and walking 50 feet. The MDS indicated Resident 1 required partial/moderate assistance (staff lifts, holds or supports resident) for walking 150 feet. During a review of the Interact situation, background, assessment and recommendation (SBAR) note, dated 12/28/2023, the SBAR note indicated Resident 1 fell on [DATE] and complained of pain and limited range of motion (movement) to the right elbow. The SBAR indicated Resident 1 ' s elbow x-ray (a test used to generate images of tissues and structures inside the body) indicated acute distal humerus (upper arm bone) fracture (broken bone) on 12/28/2023. During a review of Resident 1 ' s radiology (process of taking pictures to diagnose and treat disease) report dated 12/28/2023, the report indicated acute right supracondylar (a round part at the end of a bone) fracture of the distal humerus (lower end of the upper arm). During a review of Resident 1 ' s progress notes, dated 12/27/2023 at 11:25 p.m., the progress notes indicated, Licensed Vocational Nurse (LVN 1) completed initial bedside rounds (checking on the resident ' s status) and noted Resident 1 in the restroom, and told Resident 1 to use the call light for assistance. The progress notes indicated on 12/27/2023 at 11:35 p.m., LVN 1 heard Resident 1 call for help in the restroom and upon opening the door, LVN 1 observed Resident 1 face down on the floor. During a review of Resident 1 ' s progress notes dated 12/28/2023, the progress notes indicated Resident 1 ' s x-ray report indicated acute fracture of the right distal humerus. The progress notes indicated, Resident 1 was transferred to a GACH, on 12/28/2023 at 11:39 p.m. for further evaluation and treatment. The progress notes indicated Resident 1 ' s left forehead birth mark was purple in color, the right elbow and bilateral knees were swollen, and the left knee had a slight purplish skin discoloration. During an interview with Resident 1 on 1/4/2024 at 12:45 p.m., Resident 1 stated she went to the restroom by herself with her walker. Resident 1 stated when she stood up, she felt weak and fell forward. Resident stated she did not call for help and thought she could use the bathroom without using the call light. During a concurrent interview and record review with LVN 2 on 1/5/2024 at 9:57 a.m., Resident 1 ' s care plan titled, Activities of daily living (ADL) Functional, was reviewed, LVN 2 stated Resident 1 required a one person assist with toilet use. During a concurrent interview and record review with the interim Director of Nursing (DON) on 1/5/2024 at 11:18 a.m., Resident 1 ' s Investigative Summary was reviewed. The DON stated Resident 1 was in the restroom with a walker. The DON stated a Certified Nurse Assistant (CNA) 1 told Resident 1 to use the call light when Resident 1 was done using the restroom. The DON stated Resident 1 did not use the call light and fell . The DON stated CNA 1 should have stayed with Resident 1 and not left the resident alone in the restroom. During a phone interview with LVN 1 on 1/5/2024 at 12:22 p.m., LVN 1 stated during his rounds, he observed Resident 1 in the restroom and instructed Resident 1 to use the call light when done, while he continued with his rounds. LVN 1 stated about 10 minutes later, he heard Resident 1 calling for help from the restroom. LVN 1 stated he rushed to the restroom and found Resident 1 on the floor. LVN 1 stated no one was with Resident 1 when she fell because the resident usually used a walker and was mostly independent at night, including going to the restroom. LVN 1 stated he read only Resident 1 ' s MDS after Resident 1 fell and noted that Resident 1 was supposed to have supervision going to the restroom. During a review of Resident 1 ' s GACH Emergency Department (ED) Provider Note dated 12/28/2023, the ED note indicated Resident 1 presented to the ED with right elbow injury and a severe pain level of 8 out of 10 (a pain level of 10 is the worse pain), following a fall on 12/27/2024, in the facility. The note indicated Resident 1 ' s pain was worse with movement. The note indicated Resident 1 ' s right elbow fracture was treated with immobilization, closed reduction (a procedure to repair a broken bone without cutting the skin), pain control, and anti-inflammatories (medications to relieve pain, and reduce inflammation). The note indicated Resident 1 was discharged back to the facility on [DATE]. During a review of the facility ' s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 4/2017, the P&P indicated the care plan will reflect treatment goals, timetables, and objectives in measurable outcomes and aid in preventing or reducing decline in the resident ' s functional status and/or functional levels. During a review of the facility ' s P&P titled Safety and Supervision of Residents, revised 12/2017, the P&P indicated when accident hazards were identified, the Quality Assurance (QA&A)/safety committee shall evaluate and analyze the cause of hazards and develop strategies to mitigate or remove the hazards to the extent possible. The P&P indicated, in implementing interventions to reduce accident risks and hazards, it should include assigning the responsibility for carrying interventions, ensuring that interventions were implemented correctly and consistently. The P&P indicated resident supervision was a core component of the system ' s approach to safety. During a review of the facility ' s P&P titled Managing Fall and Fall Risk, dated 12/2018, the P&P indicated staff will identify interventions related to the resident ' s specific risks and causes to prevent the resident from falling and to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents, (Resident 2 and Resident 3) were free from falls and injuries, by failing to: 1. Ensure Resident 2, who fell on [DATE], had an accurate post fall risk assessment (an assessment conducted after a fall) to correctly identify and reflect Resident 2's clinical condition, as a high risk for fall. 2. Ensure Resident 2's fall risk care plan was revised to reflect fall safety interventions after Resident 2 fell on [DATE]. 3. Ensure Resident 3 had an updated care plan with interventions for safety after Resident 3 fell on [DATE]. Resident 3 had another fall on 11/20/2023, approximately 12 days after the previous fall. These failures resulted in Resident 2 falling and sustaining a left leg fracture (broken bone) which required hospitalization at a general acute care hospital (GACH) for evaluation and treatment. It also resulted in Resident 3 falling on 11/20/2023, exactly 12 days after she fell on [DATE]. Findings: 1. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and age-related osteoporosis (a condition where bones become weak and breaks easily), and high blood pressure. During a review of Resident 2's History and Physical exam (H&P) dated 3/30/2023, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's medical record titled eINTERACT (electronic communication) Change in Condition Evaluation (COC), dated 7/24/2022 at 2:49 p.m., the COC indicated Resident 2 had an unwitnessed fall on 7/24/2022. During a review of Resident 2's medical record titled Fall Risk Evaluation, (post fall assessment), dated 7/24/2022 indicated Resident 2's fall score was 4 (low fall risk). A fall risk score of 10 or greater indicated high risk for potential falls. The evaluation form indicated if a resident had a high fall risk, fall prevention measures should be initiated immediately and documented on the care plan. During a review of Resident 2's Interdisciplinary team (IDT, a team of health professionals working together to provide needed care to residents) Fall Review, dated 7/25/2022 at 3:53 p.m., the report indicated on 7/24/2022, the IDT discussed Resident 2's unwitnessed fall dated 7/24/2022 at 3:18 p.m. The report indicated Resident 2 had cognitive (mental/ thinking) and physical impairments prior to the fall, was receiving antipsychotic medication (medication to treat mental disorders) and had predisposing diseases. The report indicated IDT recommendations included to place Resident 2's call light within reach and encourage Resident 2 to use call light for assistance, to assist the resident with toileting, frequent visual check, bed in lowest position, wheelchair alarm (a fall prevention product that alerts caregivers monitor the movement of the patients who are frequently in a chair, like a wheelchair) to alert staff when resident is getting up on wheelchair without assistance, medication review, rehabilitation evaluation and treatment as indicated. During a review of Resident 2's care plan (CP) titled, At risk for fall and fall-related injuries revised 5/1/2023, the care plan did not indicate Resident 2 had a wheelchair alarm, to alert staff when Resident 2 got up on wheelchair without assistance. The care plan did not indicate the IDT had a follow up meeting and discussions if the wheelchair alarm for Resident 2 was no longer needed an alarm. A review of Resident 2's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool) dated 8/31/2022, indicated Resident 2 was cognitively impaired. The MDS indicated Resident 2 required extensive assistance (resident is involved in activity and staff provide the weight-bearing support) with bed mobility, transfer, locomotion (movement) on and off the unit, toilet use and personal hygiene. The MDS indicated Resident 2 used a wheelchair for movement and had history of fall. The MDS also indicated Resident 2 was receiving antipsychotic medicine on a routine basis. During a review of Resident 2's medical record titled Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 11/13/2023, the form indicated on 11/13/2023, Resident 2 had a fall which resulted in a left leg pain rated at 3 out of 10, (a numeric pain scale to measure pain intensity: with 0-no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10- worst pain possible) and a skin tear to the left ear. During a review of Resident 2's progress notes dated at 11/13/2023 3 p.m., the progress notes indicated Resident 2 was found by a Restorative Nurse Assistant (RNA 1), sitting on the floor in the resident's room with her back leaning against the wall, facing the bathroom door and both legs were extended. During a review of Resident 2's clinical progress notes dated 11/13/2023 at 4:50 p.m., the clinical progress notes indicated Resident 2 was transferred to GACH for further evaluation after he fell on [DATE]. During a review of Resident 2's imaging report from the GACH titled Computed Tomography (CT, computerized imaging procedure) Hip Left Without Contrast (without using contrast dye (colored substance]), dated 11/14/2023 the report indicated Resident 2 had a nondisplaced (still aligned) subcapital [the fracture that extends through the junction of the head and neck of femur(hip)] fracture of the left femoral (hip) neck. During a concurrent interview and record review, on 11/20/2023 at 12:44 p.m., with Registered Nurse (RN) 1, Resident 2's current care plans were reviewed. RN 1 stated Resident 2 did not have a current, at-risk for fall care plan with interventions to prevent falls. RN 1 stated she was unsure if Resident 2 had a history of falls. Resident 2 had a second unwitnessed fall on 11/13/2023. RN 1 also stated Resident 2 was at high risk for falls based on his diagnoses and impaired cognition. RN 1 stated there should have been a care plan with interventions in place to prevent falls and injury. During an interview on 11/20/2023 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 2 fell on [DATE] and was transferred to the hospital. LVN 2 stated he was unaware Resident 2 had a history of falls but was at risk for falls due to his unsteady gait, confusion, and diagnosis of vascular dementia. LVN 2 stated at the time of the fall on 11/13/2023, staff were not implementing any resident-specific interventions for Resident 2. LVN 2 also stated he could not recall if Resident 2's wheelchair had an alarm to alert staff when the resident attempted to get up and out of his wheelchair, unattended. During an interview on 11/20/2023 at 3:15 p.m., with the Director of Staff Development (DSD), the DSD stated all residents at risk for falls should have a fall risk care plan (CP with interventions to prevent falls) in place with resident-specific interventions to prevent falls. The DSD stated not having the fall risk care plan could negatively impact a resident's safety and could contribute to falls and injuries. During a concurrent record review with the Director of Nursing (DON), on 11/20/2023 at 3:57 p.m., Resident 2's Fall Risk Evaluation assessment dated [DATE], the IDT Fall Review dated 7/25/2022 and Resident 2's care plans were reviewed. The DON stated the Fall Risk Evaluation assessments must be conducted after a resident had a fall. The DON stated Resident 2's assessment indicated the resident had a low fall risk. The DON stated the assessment was incorrect because Resident 2 had a high fall risk. The DON stated a high fall risk would have prompted the staff to create a fall prevention care plan. The DON stated Resident 2 did not have an active fall prevention care plan in place at the time of the fall on 11/13/2023. The DON also stated IDT recommendations (frequent visual check, wheelchair alarm) following the first fall on 7/24/2022 were not incorporated into Resident 2's fall risk care plans to prevent further falls. 2. During a review of Resident 3's Admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including hemiplegia (loss of the ability to move and feel on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body that affects performing daily activities like eating or dressing), lack of coordination, difficulty walking, and history of falling. During a review of Resident 3's H&P, dated 10/8/2023, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severe cognitive impairment and was dependent on staff transferring from a sitting to standing position, to and from a bed or chair. The MDS indicated bed and chair alarms were used less than daily. During a review of Resident 3's care plans, the care plan indicated Resident 3 was at risk for falls related to difficulty walking, lack of coordination, multi medication use, incontinent (no control to urinate or to move bowels) episodes, impaired decision making at times, hypertension, and history of falls. The care plan interventions indicated a bed and wheelchair alarm, check for placement and functioning per facility protocol, and ensure the resident wore a well-fitted non-skid footwear. During a review of Resident 3's SBAR, dated 11/8/2023, the SBAR indicated Resident 2 fell on [DATE]. Resident 2 was observed on the floor mat by a Certified Nurse Assistant (CNA). During a review of Resident 3's Fall Risk Evaluation report dated 11/8/2023, the report indicated Resident 3 was high risk for falls. During a review of Resident 3's investigation report dated 11/8/2023, the report indicated the facility's corrective actions and plan of care to prevent re-occurrence of the incident was to do frequent visual checks, resident monitoring and assist the resident to the bathroom every 2 hours if possible. During a review of Resident 3's IDT fall, dated 11/10/2023, the IDT indicated Resident 3 had a history of fall. The IDT indicated new IDT recommendations including to continue to provide safe hazard-free environment and frequent visual checks. During a review of Resident 3's care plan, the care plan did not indicate the actual fall on 11/8/2023 nor any other interventions to be implemented to provide safety, to prevent further falls. During an interview on 12/1/2023 at 1:59 p.m. with the DON, the DON stated the IDT fall review on 11/10/2023 for Resident 3's fall on 11/8/2023, had incorrect documentation. The DON stated the interventions (frequent visual checks) discussed during IDT were not added into Resident 3's actual fall and at-risk care plans. The DON stated when care plans are not revised, it increases the possibility of a fall, which have contributed to Resident 3's fall on 11/20/2023. During a review of Resident 3's SBAR dated 11/20/2023, the SBAR indicated Resident 3 fell on [DATE]. During a concurrent observation and interview, on 11/17/2023 at 1:51 p.m., with Certified Nursing Assistant (CNA) 1, Resident 3 was sitting on the wheelchair in the hallway wearing one white furry house slipper and white socks on the right foot. One slipper was observed on the floor. CNA 1 stated Resident 3 was not wearing non-skid nor a well-fitted slipper. CNA 1 stated the purpose of the non-skid and a well-fitted footwear was to prevent falls. CNA 1 stated she was unaware Resident 3 had fallen in the facility. During a concurrent interview, and record review on 11/17/2023 at 2:32 p.m., with a Licensed Vocational Nurse (LVN) 1, Resident 3's fall prevention care plan, dated 10/19/2023 was reviewed. LVN 1 also stated the care plan had not been updated following Resident 3's fall on 11/8/2023. LVN 1 stated Resident 3 was at increased risk for falls and injury because the resident's care plan was not revised to prevent future falls. During a concurrent interview and record review on 11/20/2023 at 3:42 p.m., with the Director of Staff Development (DSD), the facility's undated Lesson Plan Fall Prevention was reviewed. The DSD stated the Lesson Plan indicated slip resistant or non-skid footwear with tread on the bottom, was an intervention to manage falls. The DSD also stated the fall risk care plans included resident-specific interventions to prevent falls. The DSD stated not having the fall risk care plan could negatively impact a resident's safety and contribute to falls. During an interview on 11/20/2023 at 3:57 p.m., with the Director of Nursing (DON), the DON stated the purpose of non-skid footwear was to reduce the risk of resident falls. The DON stated residents were more at risk for falls if non-skid footwear was indicated and not worn during ambulation (walking) or transfers. During a review of the facility's policy and procedure (P&P) titled Falls, dated 4/2018, the P&P indicated after a fall, a resident's medical record should have a record of appropriate interventions taken to prevent future falls. During a review of the facility P&P titled, Safety and Supervision of Residents, dated 12/2017, the P&P indicated measures to reduce accident risks and hazards included ensuring interventions were implemented correctly and consistently. During a review of the facility P&P titled Policy for Assessment/Change of Condition, dated 7/2017, the P&P indicated to ensure proper assessment for any resident with a condition change such as a fall, an assessment would be done and a care plan created, to treat the condition, observe and monitor the resident's response to treatment. During a review of the facility P&P titled, Care Plans, Comprehensive Person-Centered, dated 4/2017, the P&P indicated the comprehensive, person-centered care plan will describe the services that were to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. The P&P indicated the CP will incorporate identified problem areas and their causes and develop interventions for each resident. The P&P indicated care plans should be reviewed and updated when the desired outcome was not met.

Based on observation, interview, and record review the facility failed to provide adequate supervision for one of 29 sampled residents (Resident 92) by failing to: 1. Ensure Resident 92 had a safe room environment free from potential fire hazard and burns when using a candle maker. Resident 92 ordered a candle maker from a store a year ago. Resident 92 was using the candle maker to make candles and soap and with no supervision. The candle maker had the ability to reach high temperatures ranging from 196 - 315 degrees Fahrenheit (a scale of temperature). 2. Ensure Resident 92 did not have an excessive number of cluttered items (hoarding), including storage carts on wheels with empty containers (to hold the wax after the candles are created), refrigerator, coffee maker, heater, two fax machines, drills, arts and craft machines, large containers of food, large containers of unknown objects and sodas, stored in her room. This deficient practice of having a cluttered room and an improperly stored candle maker reaching a temperature of 315 degrees Fahrenheit without supervision in Resident 92 room placed Resident 92 and her roommate, staff, and other residents at risk for serious harm and injury and for a possible fire in the facility. On [DATE] at 4:55 p.m., the Administrator (ADM), Director of Nursing (DON), Social Services Director (SSD), and Director Staff Development (DSD) were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious, injury, harm, impairment, or death to a resident) was called due to Resident 92 having a candle maker in the room with temperatures reaching 315 degrees Fahrenheit and Resident 92 had a multiple items cluttered in her room which placed Resident 92 at risk for fire and safety hazards, and serious harm. The facility's ADM, DON, SSD, and DSD were notified of the seriousness of Resident 92's safety being endangered. An IJ Removal Plan was requested from the facility's staff. On [DATE] the facility submitted an acceptable IJ Removal Plan. On [DATE] at 3:28 p.m., the ADM and DON were notified the IJ was removed after on-site validation of the implementation of the IJ Removal Plan via observations, interviews, and record review. The IJ Removal Plan included the following: 1. The candle maker was removed from Resident 92's room on [DATE] at 9:47a.m. and unsafe items. Room was cleaned and cleared of clutter and hazardous items on [DATE] at 2:52p.m. 2. Candle maker and other belongings placed in a secure storage area in the facility on [DATE] at 3:00 p.m. 3. The Interdisciplinary Team (IDT) met on [DATE] to discuss findings and formulated a plan of care with the resident's involvement. The SSD and Activities Supervisor suggested Resident 92 may still use the candle maker with an activity staff in the activity room for Resident 92 safety and supervision. IDT meeting held with the resident on [DATE] to discuss belongings in resident room. Resident 92 made aware that belongings are excessive and causing a safety hazard for herself and roommate. IDT specified in IDT meeting items, such as candle maker and candle making materials are unsafe and not allowed in residents' rooms. Resident 92 acknowledged that belongings were excessive and need to be removed, gratitude was given to the resident for allowing the removal of most items. All food items will be dated and thrown out from the refrigerator after three days as per policy. For newly delivered packages, the resident will open it with staff assistance for inventory and identifying for safety of items. The resident's medical doctor, psychiatrist, and psychologist were made aware of the resident's concern. 4. In-services to all staff with regards to the following: a. Signs of hoarding, in-service started on [DATE] and completed on [DATE]). b. Checking and cleaning of resident's refrigerator and room. The housekeeping staff will clean and check the resident's refrigerator daily, in-service started on [DATE] and completed on [DATE]. c. Checking of food items and expired dated (nursing will check daily), in-service started on [DATE] and completed on [DATE]. d. Pest control maintenance will check resident's room daily, in-service started on [DATE] and completed on [DATE]. e. Delivery of packages to residents' room, support services will assist in delivery, in-service started on [DATE] and completed on[DATE]. All in-services started [DATE] on ,d+[DATE] shift by DSD, RN Supervisors and /or designees at the point of problem identification. A binder was created for the resident to monitor for compliance and safety on [DATE] and commenced the use on [DATE]. 5. The policy for Fire safety and Prevention was reviewed on [DATE] and noted the identification of hazardous materials to be stored in locked areas for safety. 6. Care Plan was reviewed and revised on [DATE] with regards to hoarding and risk for health hazards and any safety hazard, for example fire hazards, trip hazards, consumption of spoiled foods, etc. Findings: During a review of Resident 92's Admission Record (Face Sheet), the Face Sheet indicated Resident 92 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 92's diagnoses included dementia (the loss of thinking, remembering, and reasoning), anxiety (persistent worry and fear about everyday situations), schizophrenia (a serious mental condition involving inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy), and encephalopathy (damage or disease that causes brain dysfunction). During a review of Resident 92's History and Physical (H&P), dated [DATE], the H&P indicated Resident 92 has the capacity to understand a make decision. During a review of Resident 92's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated [DATE], the MDS indicated Resident 92's had the cognition (ability to learn, reason, remember, understand, and make decisions) to recall information and when asked, to repeat information. The MDS indicated Resident 92 had potential indicators of psychosis (a mental disorder characterized by a disconnection from reality) such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 92 had two falls with no injury. During a concurrent observation and interview on [DATE] at 10:24 a.m. with Resident 92, in the resident's room, Resident 92 was observed to have a cluttered and disorganized room including a candle maker in the corner of the room surrounded with items resting on top and against the candle maker, shelving blocking a window, multiple empty containers, dry food items on the floor, refrigerator with food items (cheese, olives, and green bell pepper), empty carbonated beverages cans on floor and throughout the room. Resident 92 stated, she uses the candle maker to make soap and candles and when the wax was melted, she would place the wax in the containers. Resident 92 stated the candle maker is a 10-quart container that hold up to 20 pounds of wax. Resident 92 stated, when she used the candle maker the wax gets hot enough to form the wax into candles. During an interview on [DATE] at 12:55 p.m. with Resident 92, Resident 92 stated, the candle maker melts up to 20 pounds of wax. Resident 92 stated, she plugged the device into an outlet to make the candles. Resident 92 stated she purchased the candle maker a year ago and had used it twice. Resident 92 stated, the staff had not done an inventory of her candle maker and did not have an interdisciplinary team meeting about the candle maker in the room. Resident 92 stated, she could not recall who monitored her while using the candle maker. During an interview on [DATE] at 2:09 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was not aware of a candle maker in Resident 92's room, and it was not discussed during huddles (daily communication meeting between staff members). CNA 1 stated Resident 92 room was very cluttered and there was no plan in place to prevent accidents for Resident 92 in the room. CNA 1 stated, if there was an emergency in the room there would be no space to help Resident 92. During an interview on [DATE] at 3:01p.m. with Registered Nurse (RN) 1, RN 1 stated, she was not aware of the candle maker in Resident 92's room. RN 1 stated, Resident 92 had a cluttered room, and it was a safety hazard. RN 1 stated, Resident 92's room had been cluttered for a long time. RN 1 stated, if there was an emergency in Resident 92's room there would be a delay in care because the staff would have to move the items out of the way, to reach Resident 92. During a concurrent interview and record review on [DATE] at 3:30 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 92's Care Plan (CP), dated [DATE] was reviewed. The CP indicated, Resident 92 preferred to have multiple appliances, hoard things at her bedside and was at risk for injury. The CP interventions were as follows: 1. Explain risk and benefits of multiple appliances at bedside and hoarding things. 2. Refer to psychiatry and psychology as needed. 3. Help resident to organized and sort items. 4. Offer storage. 5.Respect residents rights. 6. Do not force to clean up. 7. Notify Medical Doctor (MD) as needed. LVN 2 stated, she would tell Resident 92 the clutter in the room was not safe and would remind Resident 92 to be careful. LVN 2 stated, she was not aware of the candle maker in the room. LVN 2 stated, if the candle maker was used it could be a fire hazard and Resident 92 can get hurt. LVN 2 stated if there was an emergency in the room, there would be no space to help Resident 92 and the staff will be spending time moving the clutter out of their (facility's staff) way. LVN 2 stated, the plan in place was to continue to remind Resident 92 to move the clutter. During a concurrent interview and record review on [DATE] at 11:04 a.m., with the Social Service Director (SSD) 1, Resident 92's Intradisciplinary Team (IDT) Meeting, dated [DATE] was reviewed. The IDT note indicated, on [DATE] there was no reference of the hoarding conditions and no reference of the candle maker in Resident 92's room. SSD 1 stated there were multiple meetings regarding the hoarding and failed to mention the hoarding conditions at the last IDT meeting. SSD 1 stated, when Resident 92 uses the candle maker there should be a one-to-one supervision (the resident and one staff member to supervise the resident) and could be a risk for injury. SSD 1 stated, keeping the candle maker in the room was a potential fire hazard and if there was an emergency, the staff would not be able to provide services to Resident 92 due to the clutter in the room. During an interview on [DATE] at 12:11p.m., with the DON, the DON stated, Resident 92 continuously orders items, and was not aware of the candle maker in Resident 92's room. The DON stated it is not safe to have the candle maker in the room. The DON stated, she was not aware Resident 92 had used the candle maker. The DON stated, having the candle maker in the room was a fire hazard. The DON stated, there was no system in place to keep track of the items in Resident 92's room. The DON stated, if there was an emergency in Resident 92's room there would be a delay in care due to the clutter in the room. The DON stated, the facility's staff failed to keep track of the inventory of Resident 92's items and keep the room free from fire and safety hazards. During a concurrent observation and interview on [DATE] at 10:54 a.m. with the maintenance staff (MS) 1, in the basement, the candle maker was observed to have used wax on the inside, a ladle (a large, long-handled spoon with a cup-shaped bowl) inside of the container filled with wax, and a warning sign on the outside of the container indicating high temperature, do not touch. MS 1 plugged in the candle maker and in ten minutes the candle maker reached a temperature of 196.5 degrees Fahrenheit on the outside of the container and on the inside of the melted wax, the temperature reached 315 degrees Fahrenheit in the container. MS 1 stated, he was not aware of the candle maker in the room and Resident 92 room was cluttered. MS 1 stated, this was a fire hazard and using the candle maker would cause a burn if it encountered your skin. During a review of the facility's policy and procedure (P&P) titled, Fire Safety Precautions, dated ,d+[DATE], the P&P indicated, Personnel will follow facility established fire safety precautions in order to provide safety to all concerned .Do not allow accumulation of papers, boxes, clothes in resident rooms .Report all hazardous conditions and safety violations .Report all violations immediately. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated ,d+[DATE], the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Resident supervision is a core component of the systems approach to safety .The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview and record review, the facility failed to ensure that one of one residents (Resident 33), who was drinking alcohol, was provided with the needed care and services by failing to: 1. Ensure Resident 33 who was diagnosed with dementia (progressive impairments to memory, thinking and behavior, that affect the ability to perform everyday activities) was monitored for the consumption of alcohol and the accessibility of the alcohol located at the resident's bedside. 2. Ensure Licensed nurses documented on the Medication Administration Record (MAR) regarding the implementation of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Consult with the pharmacist regarding Resident 33's alcohol consumption for possible interactions with medications. These deficient practices had the potential for Resident 33 to have an increase in alcohol consumption (excessive) and interactions with medications that could lead to dizziness, drowsiness, impaired thinking, judgement, and motor coordination, that placed the resident at risk for injury. On 5/28/2021 at 4:00 p.m., during a recertification survey, the Department of Public Health called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in regards to Resident 33 having a large amount of alcohol in the room on the floor and in her unlocked personal refrigerator. The licensed nurses had no documentation of the amount of beer consumption by Resident 33 in the MAR. The resident has severe cognitive impairment, and the consulting pharmacist did not check drug interaction with alcohol. The IJ was called in the presence of the Administrator (Admin) and the Director of Nursing (DON). On 5/29/2021 at 2:45 p.m., the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the Plan of Action ([POA] a detailed plan to address findings) via observations, interviews and record review, given by the DON which included: 1. All alcoholic beverages were removed from the resident's room immediately on 5/28/2021. 2. The alcoholic beverages were placed under secure lock in the medication room on 5/28/2021, whereas only the Licensed Nurses have access. 3. The resident shall consume alcoholic beverages per order under staff supervision with monitoring related to potential drug cross sensitivity with consumption of alcoholic beverages, including but not limited to the following symptoms: low blood pressure, dizziness, drowsiness, light headedness, [CONDITION(S)], changes in pulse or heart rate, confusion, difficulty concentrating, impaired thinking, impaired judgement, or impaired motor coordination every shift. 4. The Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the resident) met on 5/28/21 to discuss the findings and formulated a plan of care with family/primary contact involvement, physician participation, and pharmacist review. The problem was resolved on 5/28/2021. 5. The facility conferred with the consulting pharmacist and received consultation with physician follow-up on 5/28/21. The attending Physician visited the facility, re¿interviewed the resident and documented his findings on 5/29/21. 6. In-service to the monitoring process for alcohol consumption started on 5/28/21 by the Director of Nursing, Registered Nurse (RN) Supervisors and/or designees at the point of problem identification. 7. The policy shall state that alcoholic beverages shall be treated as a medication and stored in the medication room on 5/28/21. 8. The Director of Nursing will monitor the outcomes of the systemic changes and report on any trends during monthly Quality Assurance and Performance Improvement ([QAPI] proactive approach to quality improvement) meetings for three months for further recommendations. Findings: During a review of Resident's 33 Admission Record (Face sheet), the Admission Record indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident's 33 Minimum Data Set (MDS), a standardized assessment and care screening tool), dated 3/12/2021, the MDS indicated Resident 33 sometimes had the ability to understand and be understood. Resident 33 required) total to extensive assistance with activities of daily living ([ADL's] daily self-care activities). During a review of Resident 33's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 33's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 33's Medication Administration Record (MAR), the MAR indicated the administration of wine by various licensed nurses but there was no monitoring of Resident 33's beer consumption indicated. During an interview on 5/27/2021 at 2:06 p.m. with Licensed Vocational Nurse 10 (LVN 10), LVN 10 stated wine was kept in Resident 33's personal refrigerator that was unlocked. LVN 10 stated the licensed nurses were responsible for pouring the alcohol in a medication cup, and sign it off at the time of administration in the MAR. LVN 10 stated beer was kept at Resident 33's bedside and in the refrigerator. There was no monitoring of how much intake the resident consumed. During a concurrent record review of Resident 33's care plan and concurrent interview with LVN 10 on 5/27/2021 at 2:06 p.m., LVN 10 stated there was no care plan for beer and wine to be kept at Resident 33's bedside. During an interview on 5/27/21 at 11:04 a.m. with Housekeeping (HK) 1, HK 1 stated, housekeeping was the one who cleaned the personal refrigerator of Resident 33 and it was always unlocked. During a concurrent observation and interview on 5/28/21 at 9:23 a.m. with Resident 33, in Resident 33's room there were three boxes of beer at the bedside and an unopened bottle of wine. In Resident 33's personal refrigerator was three cans of beers, and a bottle of wine observed. Resident 33 stated that she drank whenever she felt like drinking and as much as she wanted. During an interview on 5/28/2021 at 2:06 p.m. with Registered Nurse 1 (RN 1), RN 1 stated the nurses received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked regarding the policy for consumption of alcohol, RN 1 stated he was not fully aware of it. RN 1 stated the facility did not have a monitoring process on the MAR for the beer consumed by Resident 33. RN 1 was asked if there was documentation that the facility's pharmacist consultant was contacted for possible drug interaction with the alcohol and he was unable to provide an answer or documentation. During a telephone interview on 5/28/2021 at 12:29 p.m. with Pharmacy Consultant 1, Pharmacy Consultant 1 stated she came to review the medication regimen for the month of May because she was helping Pharmacy Consultant 2. Pharmacy Consultant 1 stated she rarely saw an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy Consultant 1 stated she did not receive a call from the nurse supervisor regarding the alcohol consumption of Resident 33. Pharmacy Consultant 1 stated usually the facility waited until pharmacy consultant next monthly visit even if the order was in the middle of the month. During a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (used to treat nerve pain) 100 milligrams ([mg] unit of measure) at bedtime for polyneuropathy, original order date 10/26/2020. 2. [MEDICATION(S)] (medication used to remove excess fluid from the body) 40 mg, one time per day for hypertension (high blood pressure), original order date 6/15/2020. 3. [MEDICATION(S)] (used to treat high blood pressure) Extended Release 25 mg tablet for hypertension. original order date 10/26/2020. During a telephone interview on 5/28/2021 at 11:29 a.m. with the Dispensing Pharmacist, the Dispensing Pharmacist stated she went over Resident 33's medication list and stated all medication interact with alcohol especially when drinking excessively. The Dispensing Pharmacist stated [MEDICATION(S)] should not be combined with alcohol, and any hypertension medication would interact with alcohol, extended release medication needed to avoid alcohol containing drinks. The Dispensing Pharmacist stated the facility's staff needed to initiate the call to the pharmacist to inform the pharmacist of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of facility's policy and procedure (P/P) titled, Alcoholic Beverages, revised 4/2017, the P/P indicated should such an order be received, the nurse supervisor receiving the order must contact the pharmacist to determine if any of the resident's current medications would interact with alcohol.

Based on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 33), who was drinking alcohol, was provided with a thorough drug regimen review. The facility's pharmacist consultant also failed to identify drug irregularities during the monthly Medication Regimen Review (MRR) when antipsychotic ([MEDICATION(S)] [MEDICATION(S)] [medication used to treat [CONDITION(S)]]) medication was used for the treatment of [CONDITION(S)] (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) without a documented clinical rationale for Resident 23 by failing to: 1. Ensure medications review for possible drug interactions (an interaction between a drug and another substance that prevents the drug from performing as expected) and/or irregularities when there was an order for the resident to consume alcohol while receiving prescribed medications. 2. Ensure licensed nurses contacted the pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs) to determine if any of the resident's current medications could interact with alcohol. This deficient practice had the potential for a drug/alcohol interaction, which could cause dizziness, drowsiness, impaired thinking, judgement, and motor coordination and placed Resident 33 at risk for injury, and had the potential for Resident 23 to receive uneccessary medication. On 5/28/2021 at 4 p.m., during a recertification survey, an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified and declared under F756 for Resident 33. The facility's staff failed to consult with the facility's Pharmacy Consultant (PC) for possible irregularities or drug alcohol interactions when Resident 33 had a physician's order to consume alcohol (beer and wine). The IJ was called in the presence of Administrator (ADM) and the Director of Nursing (DON). During an interview on 5/29/2021 at 2:45 p.m., the DON submitted an acceptable Plan of Action ([POA] interventions to correct the deficient practices). The IJ was lifted at 2:45 p.m., after the team verified and confirmed the POA was implemented per observations, interviews, and record review, while onsite. The acceptable POA included the following for Resident 33: 1. All alcoholic beverages were removed from the resident's room immediately on 5/28/2021. 2. The alcoholic beverages were placed under secure lock in the medication room on 5/28/2021, whereas only the Licensed Nurses have access. 3. The resident shall consume alcoholic beverages per order under staff supervision with monitoring related to potential drug cross sensitivity with consumption of alcoholic beverages, including but not limited to the following symptoms: low blood pressure, dizziness, drowsiness, light headedness, [CONDITION(S)], changes in pulse or heart rate, confusion, difficulty concentrating, impaired thinking, impaired judgement, or impaired motor coordination every shift. 4. The Interdisciplinary Team (a group of health care professionals with various areas of expertise who work together toward the goals of the resident) met on 5/28/2021 to discuss the findings and formulated a plan of care with family/primary contact involvement, physician participation, and pharmacist review. The problem was resolved on 5/28/2021. 5. The facility conferred with the consulting pharmacist and received consultation with physician follow-up on 5/28/2021. The attending Physician visited the facility, reinterviewed the resident and documented his findings on 5/29/2021. 6. In-service to the monitoring process for alcohol consumption started on 5/28/2021 by the Director of Nursing, Registered Nurse (RN) Supervisors and/or designees at the point of problem identification. 7. The policy shall indicate that alcoholic beverages shall be treated as a medication and stored in the medication room on 5/28/2021. 8. The Director of Nursing will monitor the outcomes of the systemic changes and report on any trends during monthly Quality Assurance and Performance Improvement ([QAPI] proactive approach to quality improvement) meetings for three (3) months for further recommendations. Findings: a. During a review of Resident 33's admission record (Face sheet), the Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 33's admitting diagnoses included toxic [CONDITION(S)] (a brain malfunction and toxic asserts the malfunction is caused by toxins on the brain), heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), [CONDITION(S)] (an irregular and often rapid heart rate) [CONDITION(S)] (a condition in which there are high levels of fat particles (lipids) in the blood), polyneuropathy (many nerves in different parts of the body are involved), dementia (progressive impairments to memory, thinking and behavior, that affect the ability to perform everyday activities). During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/12/2021, the MDS indicated Resident 33 sometimes had the ability to understand and be understood. According to the MDS, Resident 33 required total assistance with activities of daily living ([ADLs] such as grooming, toileting, eating etc.). During a review of Resident 33 Physician's order Recapitulation (summary), dated 4/30/2021, the orders indicated Resident 33 was receiving the following medications: 1.[MEDICATION(S)] 100 milligram ([mg]unit of measurement) at bedtime for polyneuropathy (simultaneous malfunction of many peripheral nerves (refers to parts of the nervous system outside the brain and spinal cord) throughout the body) with an original order date of 10/26/2020. 2. [MEDICATION(S)] 40 mg, one time per day for hypertension (high blood pressure), original order date 6/15/2020. 3. [MEDICATION(S)] Extended Release 25 mg tablet for hypertension with an original order date of 10/26/2020. During a review of Resident 33's Recapitulation orders, the physician order indicated Resident 33 could have 30 cubic centimeter ([cc] unit of measurement) of wine three (3x) times a day with an original order date of 8/29/2019. The physician's order indicated Resident 33 could also have beer twice (2x) per week with an original order date of 3/17/2020. During a review of Resident 33's Medication Administration Record (MAR) for the wine administration for the months of May 1-31, 2021, indicated it was signed by several Licensed Vocational Nurses (LVNs), but there was no documentation for Resident 33's beer consumption. During an interview on 5/27/2021 at 2:06 p.m., Licensed Vocational Nurse (LVN 10) stated Resident 33's wine was kept in the resident's personal unlocked refrigerator at the bedside. LVN 10 stated the licensed nurses were the ones pouring the wine in the medication cup for the resident and then signing the MAR at the time the wine is given. LVN 10 stated Resident 33's beer was at the resident's bedside and some kept in the resident's personal refrigerator. LVN 10 stated there was no monitoring of how much beer Resident 33 consumed. During an interview on 5/27/2021 at 11:04 a.m., Housekeeping 1 stated she was the one who cleaned Resident 33's personal unlocked refrigerator. During a concurrent observation and interview on 5/28/2021 at 9:23 a.m., in Resident 33's room, there were three (3) boxes (36 cans) of beer containing alcohol at the resident's bedside and an unopened bottle of wine. In Resident 33's personal refrigerator a few cans of beer and a bottle of wine was observed. Resident 33 stated, she drinks whenever she wanted to drink and as much as she wanted. During an interview on 5/28/2021 at 2:06 p.m., with Registered Nurse (RN) 1, RN 1 stated the process for when the residents received an order to have beer or wine, was to check the resident's allergies and medication for black box warning (appears on a prescription drug's label and is designed to call attention to serious or life-threatening risks) and ensure the family was aware. RN 1 was asked about the facility's policy and procedure (P/P) for the resident consumption of alcohol. RN 1 stated he was not aware of a facility's P/P for alcohol consumption. RN 1 was asked if the staff were monitoring and documenting Resident 33's consumption of beer. RN 1 stated there was no documentation on the MAR or anywhere for the beer Resident 33 was consuming. RN 1 was asked if the pharmacy was contacted for possible drug and alcohol interaction, RN 1 was unable to answer and/or provide any documentation. During a review of Resident 33's Medication Regimen Review ([MRR] a review of all medications the resident was currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy) for the month of 5/2021, the MRR indicated there was no findings, changes or recommendations by the pharmacist. During a telephone interview on 5/28/2021 at 11:29 a.m., Pharmacist Consultant 1 (PC 1) stated she reviewed Resident 33's medication list and stated all the resident's medication interacts with alcohol, especially if the resident was drinking excessively. PC 1 stated [MEDICATION(S)] and anti-hypertensive medications should not be combined with alcohol and any medication with an extended release (the drug is released slowly over time) alcohol should be avoided. PC 1 stated it was the facility's responsibility to initiate the call to the pharmacy of Resident 33's physician order to consume alcohol while receiving prescribed medications. During a telephone interview on 5/28/2021 at 12:29 p.m., Pharmacy Consultant 1 (PC 1) stated she came to the facility to review medication regimen for the month of 5/2021 because she was helping PC 2. PC 1 was asked what the process was if the physician orders alcohol consumption for resident while receiving medications. PC 1 stated she rarely sees an order for alcohol consumption but stated possible drug interaction should be check. PC 1 was asked if she had received a call from the facility's staff to check Resident 33 for a possible drug/alcohol interaction for the resident consuming alcohol while receiving prescribed medications. PC 1 stated she had not received a call from the staff regarding checking alcohol/drug interactions for Resident 33. During a review of the facility's P/P titled, Alcoholic Beverages with a revised date of 4/2017, the P/P indicated should such an order be received, the nurse supervisor receiving the physician's order must contact the pharmacist to determine if any of the resident's current medications would interact with alcohol. b. During a review of Resident 23's Admission Record, the Admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's diagnoses included dementia (progressive memory loss) and [CONDITION(S)] disorder. During a review of Resident 23's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 3/15/2021 indicated Resident 23 had the ability to make daily decision making. The MDS indicated Resident 23 required extensive assistance with activities of daily livings ([ADLs] self-care activities performed daily, such as eating, dressing, personal hygiene, and toilet use). The Care Area Assessment (CAA) of the MDS indicated Resident 23 triggered for [CONDITION(S)] drug use requiring frequent assessment from staff. During a review of Resident 23's physician's order dated 3/5/2021, the physician's order indicated to administer one tablet [MEDICATION(S)] [MEDICATION(S)] 25 milligram ([mg] unit of measurement) twice a day by mouth for [CONDITION(S)] manifested by restlessness and agitation. During a review of Resident 23's Medication Administration Record (MAR) for the month of 5/2021, the MAR indicated Resident 23 had been receiving [MEDICATION(S)] [MEDICATION(S)] 25 mg 1 tablet as ordered. During a review of Resident 23's monthly Medication Regimen Review (MRR) for 4/2021, the MRR did not indicate the identification of drug irregularities when [MEDICATION(S)] was used for the treatment [CONDITION(S)] with a diagnosis of dementia. During an interview on 5/27/2021 at 3:58 p.m. with the during an interview the Director of Nursing (DON) , the DON stated Resident 23 was admitted from Hospice (care provided during end of life, focusing on comfort) on [MEDICATION(S)], and no recommendation was made by their pharmacist. During an attempted interview on 6/1/2021 at 1:15 p.m., attempted to reach the facility's pharmacist by telephone for an interview, however was unsuccessful.

Based on interview and record review the facility failed to ensure one out of three residents (Resident 1) was transferred from the bed to a wheelchair by a mechanical lift (mechanical assistive device used to transfer a person with mobility problems) using a two person assist. This deficient practice resulted in Resident 1 falling and sustaining a bleeding laceration (deep cut) to the right side of the head, while being transferred from the bed to a wheelchair solely by Certified Nurse assistant (CNA) 1. Resident 1 was transferred to the general acute care hospital (GACH) and received sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) to stop the blood flow from the laceration and treatment for a neck fracture (broken bone). Resident 1 required admission to the intensive care unit. Findings: During a review of Resident 1's Admission Record, it indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. The record diagnoses included cerebral infarction (blockage of oxygen-rich blood to a portion of the brain causing the brain cells to die), [CONDITION(S)] (A disorder in which nerve cell activity in the brain is disturbed, causing seizures. During a [CONDITION(S)], a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness.), and [CONDITION(S)] (disorder that affects a specific area of the brain causing a person to have tremors at rest, limb rigidity, and balance problems). During a review of Resident 1's Fall Risk Evaluation (FRE) record dated 11/14/2019, the FRE indicated Resident 1 was at high risk for falls. During a review of Resident 1's Physical Therapist ([PT] (treat patients who have difficulty performing daily living and work activities due to illnesses, injuries, and disabilities) Evaluation and Plan of Treatment record dated from 6/4/2019 to 7/1/2019, the treatment record indicated Resident 1 was totally dependent for transfers. During a review of Resident 1's care plan, dated 1/12/2021, the care plan indicated Resident 1 was at risk for bleeding. The facility's staff interventions included to handle the resident gently during care especially during transfers, repositioning, and ambulation. During a review of Resident 1's care plan, dated 1/13/21, the care plan indicated, the resident had impaired activities of daily living ([ADL] routine activities such as grooming, bathing, eating, transferring, etc.). The care plan indicated the resident required an extensive assistance of one to two-persons with most ADLs. During a review for Resident 1's care plan dated, 1/13/2021, the care plan indicated Resident 1 was at risk for injuries related to diagnosis of [CONDITION(S)]. The staff interventions for this care plan included, providing a safe environment at all times and to keep the environment free of safety hazards. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/10/20, indicated Resident 1 was totally dependent and required a two-person assist with transfers, toileting, and personal hygiene. The MDS indicated the resident had [CONDITION(S)] and [CONDITION(S)]. During a review of Resident 1's Weekly Note, dated 3/24/2021 and timed at 10:21 a.m., the weekly note indicated Resident 1 was totally dependent with bed mobility, transfer, dressing, eating, toilet use and bathing. During a review of Resident 1's Change of Condition Evaluation (COCE), internal communication tool, dated 3/25/2021 and timed at 9:20 a.m., the COCE indicated Resident 1 had a fall and sustained a laceration to the right upper frontal lobe (front part of the brain). The COCE indicated the resident had decreased oxygen saturation (oxygen carried by the blood to the body) and required oxygen (odorless gas necessary to maintain life) at 15 liters ([L] unit of measure) per minute (min) by(via) a non-rebreather mask (used for the delivery of high concentrations of oxygen and is recommended for use in people who are critically ill) and had moderate bleeding to the right upper frontal lobe. The COCE indicated Resident 1 was on the floor with moderate blood noted on his face. The COCE indicated Resident 1 had a laceration to the right upper frontal lobe, a pressure pack dressing was applied to the site, 911(a phone number used to call an emergency service) was called and the resident was sent to GACH. During a review of Resident 1's Nurses' Progress Note (NPN), dated 3/25/2021 and timed at 9:10 a.m., indicated the resident had pain, facial grimace, guarded position, and was moaning related to the laceration on the right side of the head. A NPN dated 3/25/2021 and timed at 9:20 a.m. indicated Resident 1 had a fall and was on the floor with moderate blood on the face and had a laceration on the right upper frontal lobe, a pressure pack dressing was applied, 911 was called and the resident was taken to the GACH. During a review of Resident 1's interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) review, dated 3/25/2021 and timed 3:27 p.m., indicated the plan of care recommendations were to discourage unassisted transfers while explaining the risks involved with unassisted transfers. During a review of Resident 1's transfer form dated 3/25/2021, and timed at 9:40 a.m., the transfer form indicated Resident 1 was transferred to the GACH with a laceration to the right upper frontal lobe. The form indicated Resident 1 was receiving blood thinning medication two times a day. During an review of the GACH emergency department (ED) notes dated 3/25/20 and timed at 11:38 a.m., the ED notes indicated the skilled nursing facility reported to the ED the resident (Resident 1) was dropped from a mechanical lift while being transferred from the bed to the wheelchair because the device was not properly locked and suffered a head injury of a laceration to the head. The ED note indicated Resident 1 was in acute (immediate) distress with obvious head trauma, a large hematoma (a collection of blood outside of the blood vessel) in the right frontoparietal (area on the front and side of the head) scalp area, and was placed on a C-collar (collar used to stabilize the neck). On 3/25/20 at 12:34 a.m., the note indicated Resident 1 required an emergency laceration repair requiring eight stitches (a technique used to close a wound) and multiple interrupted sutures (material used to close a wound) to stop the flow of blood. The ED note indicated Resident 1 had a hematoma and arterial (blood vessels that carry oxygenated blood away from the heart to the tissues) bleeding from the scalp wound. The laceration description indicated the laceration on the right side of the head measured 10 centimeters ([cm] unit of measurement) in length and two millimeters ([mm] unit of measurement) in depth. The CT scan (a common imaging test that creates pictures of the inside of the), x-ray (pictures of the inside of the body) and a MRI (magnetic resonance imaging - a common imaging test that creates pictures of the inside of the) image of Resident 1's spine indicated he had a neck region spinal fracture (broken bone). The ED note indicated Resident 1 required admission to the intensive care unit (ICU) due to the concerning degree of the trauma. On 4/8/21 at 12:07 p.m., Resident 1 received a percutaneous (through the skin via a needle) gastrotomy tube (G-tube) placement (tube placed directly into the stomach) to receive nutrients. During an interview on 3/26/20 at 3:15 p.m., CNA 3 stated the facility's process to transfer residents with the mechanical lift was to use two people to assist with the transfer from the bed to the wheelchair and vice versa. CNA 3 stated she had transferred Resident 1 before and he required a two-person assist because he could not help with the transfer and had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During an interview and a concurrent record review on 3/26/20 at 3:45 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the CNAs were notified of the resident's fall risk during morning huddles. LVN 1 stated Resident 1 was unable to move and stayed in bed most of the time. LVN 1 stated Resident 1 required an extensive to total care and required a mechanical lift for transfers. LVN 1 stated the Resident 1 could not fall from the bed because he could not move. During an interview on 3/26/2021 at 4:10 p.m., the Social Service Staff (SS 1) stated Resident 1 had a fall from a mechanical lift transfer and the nurses were unable to control the resident's bleeding from the right side of Resident 1's head. During an interview on 3/26/2021 at 4:25 p.m., SS 2 stated the DON Informed her during the morning meeting that Resident 1 had a fall, his forehead was bleeding, and 911 was called. SS 2 stated she called Resident 1's responsible party (RP) to follow-up about Resident 1's health condition and the RP told her Resident 1 also had suffered a neck fracture (broken bone) from the fall. During an interview on 3/26/20 at 4:40 p.m., the DON stated CNA 1 was transferring Resident 1 from the bed to a wheelchair using a mechanical lift, Resident 1 fell through the side of the mechanical lift sling, hit the floor, and bleed from his head. DON stated Resident 1 had a gash (a long deep slash, cut, or wound) in his head that was pack with dressing to try to stop the bleeding and 911 was called. During an interview on 3/26/20 at 5:25 p.m., the Administrator (ADM) stated he was notified of Resident 1's incident on 3/25/20 at lunch time. The ADM stated Resident 1 just suffered a laceration to the front of his face during a transfer from the bed to the chair. The ADM stated he watched the surveillance camera and saw CNA 1 entering Resident 1's room with the mechanical lift by herself to transfer the resident and shortly afterwards, he saw staff running into the room. During an interview on 3/29/2021 at 1:49 p.m., CNA 1 stated on 3/25/2021 at approximately 8 a.m., she transferred Resident 1 from the bed to the wheelchair as part of Resident 1's routine care. CNA 1 stated the mechanical lift and the wheelchair were on the right side of the bed. CNA 1 stated the mechanical lift moved when Resident 1 shook, and the resident fell through the right side of the sling. CNA 1 stated she tried to hold the resident, but he fell and hit the floor on his right side. CNA 1 stated, A lot of people run into the room. CNA 1 stated she should not have transferred Resident 1 by herself. CNA 1 stated no one in the facility told her about Resident 1's shaky condition and nobody was available to help her with the transfer. CNA 1 stated she asked the Restorative Nursing Assistant (RNA [a CNA trained to help the residents achieve and maintain optimal physical activity]) 1 about the transfer for Resident 1 and RNA 1 told her Resident 1 required two-person assist with a mechanical lift and sling. CNA 1 stated she had not transferred Resident 1 before. During an interview on 3/29/20, at 4:20 p.m., CNA 1 stated prior to transferring Resident 1, she placed the sling under Resident 1, looked for a second staff member to help her, and grabbed the mechanical device. CNA 1 stated since she could not find someone to assist her, she transferred Resident 1 by herself with the mechanical lift. CNA 1 stated she ensured the mechanical device was placed correctly she put the brakes on, hooked the sling into the mechanical device by color code to ensure they met. CNA 1 stated she continued to lift Resident 1 from the bed with the mechanical lift into the wheelchair. CNA 1 stated she had Resident 1 in the mechanical lift when she noticed Resident 1's hand was jerking, and she started to call for help. CNA 1 stated CNA 2 who was passing by came into the room as Resident 1 fell on to the floor headfirst. CNA 1 stated Resident 1 fell from the top part of the sling. CNA 1 stated she was unable to catch Resident 1 as the accident happened so sudden and fast. CNA 1 stated Resident 1 sustained a cut on the right side of his head and had a lot of blood coming from the head area. CNA 1 stated when CNA 2 entered the room she told her, What did you do? what did you do? CNA 1 stated she could not remember what happened because she was in shock. CNA 1 stated licensed nurses came into the room and asked her to leave the room. CNA 1 stated she was aware Resident 1 required a two-person assist for transfer, but since everyone was busy, she transferred Resident 1 by herself. During an interview on 3/30/20 at 11:09 a.m., CNA 2 stated, CNA 1 asked RNA 1 to help with transferring Resident 1, but RNA 1 was busy feeding another resident. CNA 2 stated, CNA 1 did not ask anyone else for help. CNA 2 stated, she went to check on Resident 1's roommate and as she was about to enter the room, she saw Resident 1 falling from the right side of the mechanical lift. CNA 2 stated, Resident 1 was lifted above the height of the wheelchair and the bed. CNA 2 stated, the right side of the sling was loose when Resident 1 was falling, but by the time she entered the room, Resident 1 was already on the floor. CNA 2 stated, Resident 1 fell hard on his right side. CNA 2 stated, she saw some blood on the floor and by the time the staff (LVN 2 and RN 1) entered the room she looked at Resident 1 and saw more blood. CNA 2 stated, the incident could have been prevented if CNA 1 had asked for help to transfer Resident 1. CNA 2 stated, Resident 1 was unstable because he had [CONDITION(S)] and required two-person assistance with transfer. Everybody knows. CNA 2 stated, the sling used to transfer Resident 1 was big and was loose on the right side. CNA 2 stated, the facility had provided an in-service on how to use two-person assistance when transferring residents with the mechanical lift. During an interview on 3/30/20 at 11:21 a.m., LVN 2 stated, she was giving medication when she heard someone yell her name. LVN 2 stated, she went to Resident 1's room and saw the resident on the floor, his body faced down, his head and face were to the right side. LVN 2 stated, Resident 1 had a laceration to the right side of the head, close to the forehead. LVN 2 stated, she was unable to quantify the amount of blood loss from the fall. LVN 2 stated, the paramedics arrived and took the resident to the hospital. LVN 2 stated, the accident happened during a transfer from the bed to a wheelchair. LVN 2 said, the facility conducts daily huddles and provide CNAs with instructions on how to work with the residents. LVN 2 stated, that morning she did not believe they had huddle and she did not give CNA 1 specific instructions on how to transfer Resident 1. LVN 2 stated, the facility protocol was to use two-person assist to transfer residents who could not bear weight and Resident 1 required two-person assistance with transfers. LVN 2 stated, the resident should have a care plan to inform the staff the goal to maintain the patient safe and reach the goal for the care. LVN 2 stated, CNA 1 should not have transferred Resident 1 by herself. During a concurrent interview and record review on 3/31/20 at 10 a.m., the MDS nurse stated, she collects the MDS assessment information for section G (Regarding how much assistance the resident needs including transfers) by interviewing the CNAs, charge nurses and by observing the residents. The MDS nurse stated, she reviewed Resident 1's medical record for the pass seven days in order to determine the level of ADLs required for this resident in order to complete the MDS assessment. The MDS nurse stated on 2/10/21, she assessed Resident 1 required two persons assist with transfers. The MDS nurse stated, her assessment was based on her observations of the resident and the report she received from the staff about Resident 1's needing to have a two-person assist with transfers. The MDS nurse stated, the resident required total care with two person-assistance with transfers. During an interview on 3/31/20 at 10:28 a.m., RNA 1 stated, Resident 1's transfer required maximum assistance with the use of a mechanical lift, sling and at least two-person assistance, sometimes three-person assistance. RNA 1 stated, Resident 1 required at least two-person assistance to slowly transfer him as he was contracted. RNA 1 stated on 3/25/21, she was feeding a resident three to four doors down from Resident 1's room when she heard an unusual sound and she ran to see what had happened. RNA 1 stated, when she arrived at Resident 1's room, Resident 1's body was on the floor facing down, with the head facing the right side. RNA 1 stated she saw blood, but she could not tell where the blood was coming from. RNA 1 stated, the accident could have been prevented if CNA 1 had waited or asked for help. RNA 1 stated, about 20 minutes prior to the unusual sound CNA 1 called her in the hallway. RNA 1 stated, she asked CNA 1 what she wanted to do, and CNA 1 replied, she wanted to transfer the resident. RNA 1 stated, she told CNA 1 to keep Resident 1 on the bed and she would help transfer him after breakfast, then CNA 1 replied, ok. RNA 1 stated, she worked with Resident 1 for the past five years and the resident always needed two-person assistance with transfers because he did not have trunk control and was contracted. RNA 1 stated, Resident 1 required a special chair and a belt when he was sitting to ensure he did not fall forward when sitting. RNA 1 stated, the Director of Staff Development (DSD) conducted daily huddles reminding the staff that residents who were contracted required two-person assistance with the mechanical lift. RNA 1 stated, everybody is aware to use two-person assistance with the mechanical lift. During an interview with the Occupational Therapist (OT) on 3/31/20 at 11:30 a.m., he stated Resident 1 was last assessed by rehab in June of 2019, as needing maximum assist with two- person assistance for transfers. During an interview and concurrent record review on 3/31/20 at 11:31 a.m., the DSD stated, the staff was in-serviced on how to check the mechanical lift equipment and to always use a two-person assistance with the mechanical lift, one person to operate the machine and the other to help the resident for safety purposes. The DSD stated, Resident 1 required two-person assistance with transfers. The DSD reviewed the in-service record titled, Body Mechanics for Proper Transfer techniques dated 2/25/21 and stated, he could not find CNA 1's name in the attendance roster. The DSD stated, he had instructed CNA 1 to use two-person assistance for transfers during huddles, but he did not remember the date. The DSD stated, the resident's care plan should include the type of lift used to guide the staff on how to properly care for the resident. During an interview on 4/1/21, at 8:01 a.m., the Registered Nurse (RN 1) stated, on 2/25/21 at approximately 9:20 a.m., LVN 2 called her about a resident who had a fall. RN 1 stated, she went to Resident 1's room and saw Resident 1 lying on the floor on the right side of his face, body facing down, and blood all around him. RN 1 stated, that was a lot of blood, but she was unable to estimate how much. RN 1 stated, Resident 1 had an open laceration to the right frontal lobe between the forehead and the skull. RN 1 stated, she could not see how deep the laceration was. RN 1 applied pressure and wrapped the laceration, but the area kept on bleeding. RN 1 stated, CNA 1 told her Resident 1 was shaking and slipped thru the right side of the sling. RN 1 stated, Resident 1 was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), paralyzed (immobilized) on the right side, had tremors and often shook a lot. During an interview on 4/1/2021 at 1:10 p.m., Resident 1's RP (FM 1), stated on 3/25/2021 she was notified Resident 1 had a fall during transfer and suffered a gash on his head that required him to be transferred to the hospital. FM 1 stated, Resident 1 had a fractured neck, a neck collar (medical device used to support a person's neck), large bruises and stitches to his right shoulder. FM 1 stated, SS 2 notified her that CNA 1 wanted her to know that she felt very sorry about what happen to Resident 1. FM 1 stated, she asked SS 2 who was the second person doing the transfer and SS 2 responded, CNA 1 transferred the resident by herself because she was experienced. FM 1 stated, she asked SS 2 if the facility had changed their protocols as they always transferred Resident 1 with two-person assist and SS 2 responded by saying, the facility had not changed their transfer protocol. During an interview on 4/13/21 at 9:08 a.m., the ADM stated, on the day before the staff had a huddle to use two-person assist with the mechanical lift transfer. The ADM stated, the fall may had been prevented if two-person assistance was used to transfer the resident. The policy titled, Lifting Machine, Using a Portable, revised September 2016, indicated purpose to help lift residents with the manual lifting device. The policy indicated to review the resident's care plan to assess for any special needs of the resident and assemble the equipment and supplies needed. The policy procedure indicated to check the sling condition prior to any transfer procedure. The policy titled, Safe Lifting and Moving, revised December 2017, indicated to promote the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition would be incorporated into the goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis and staff would document resident transferring and lifting needs in the care plan. The policy indicated direct care staff would be trained in the use of the manual and mechanical lift devices. The staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment.

Based on interview and record review, the facility failed to notify a physician of one of three sampled residents (Resident 1) Change of Condition ([COC] a sudden clinically deviation from a resident's baseline in physical, cognitive [thought process], behavioral, or functional) on 10/3/2020. Resident 1, who experienced pain on the left hip for three (3) days on 10/3/2020 thru 10/5/2020, was not reported to the physician as stipulated in Resident 1's care plan and the facility's policy and procedures (P/P), Change of Resident's COC or Status. (crossed referenced to F689). This deficient practice resulted in a delay in diagnosis, care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During a review of Resident 1's Admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/24/2020, the MDS indicated Resident 1 had clear speech, impaired vision and had difficulty making herself understood and understanding others. The MDS indicated Resident 1 required extensive assists of two or more-person physical assist for bed mobility (moving between surfaces including to or from: bed, chair, wheelchair, standing position), transfer (from bed to wheelchair and standing position), and toilet use. According to the MDS, Resident 1 had functional limitation in the range of motion of one side (side not identified) of the lower extremities and used a wheelchair as a mobility device and had not received scheduled or as needed (PRN) pain medications. During a review of Resident 1's initial admission assessment, dated 8/15/2020, the assessment indicated Resident 1 had high risk for falls with a score of 13 (scores greater than 10 represented a high risk) and was disoriented (having lost sense of direction) at all times. During a review of Resident 1's care plan titled, At Risk for Pain Related to Right Hip Surgery, Managed with [MEDICATION(S)] for Moderate pain, dated 8/16/2020, the care plan indicated the staffs' interventions included to assess factors or events that trigger pain, assess resident's ability to function, assess type, location, frequency, severity of pain and report any signs of swelling or discomfort promptly to the physician. During a review of Resident 1's Nursing Progress Notes (NPN), dated 10/3/2020, the NPN indicated at 11:30 p.m., (10/3/2020) Resident 1 complained of pain of six (6) on a scale of [NAME] (0) to ten (10) (10 being the worse pain). During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's MARs for the month of 9/2020 the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's NPN, dated 10/5/2020 and timed at 12:10, the NPN indicated Resident 1 was noted grimacing (facial expression usually of pain, disgust, or disapproval), moaning and guarding the left lower extremity by the hip during physical therapy ([PT] treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NPN indicated Resident 1 was unable to identify the cause of the pain and the physician was notified on 10/5/2020 (three days after the initial complaint of pain) and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's x-ray results, dated 10/5/2020 received at 3:20 p.m., the exam results indicated Resident 1 had an acute left femoral neck subcapital fracture with superior and medial displacement. During a review of the facility's Investigation Report, dated 10/5/2020 and timed at 12:48 p.m., the report indicated Resident 1 was seen by the rehabilitation therapist (branch of medicine that aims to enhance and restore functional ability and quality of life to residents with physical impairments or disabilities) for daily exercises and Resident 1 was noted to have facial grimacing, moaning and guarding the left lower extremity by the hip area. During a review of Resident 1's GACH's emergency room (ER) note, dated 10/5/2020, the ER note indicated Resident 1 was admitted to the GACH on 10/5/2020 at 9:07 p.m. after complaining of left hip pain. The ER note indicated Resident 1 underwent surgery on 10/6/2020 for a hemiarthroplasty (surgical procedure that replaces one half of the hip joint with a prosthetic) of the left hip. During an interview on 10/15/2020 at 12:15 p.m., LVN 1 stated she was notified by a staff member (unknown) of Resident 1's pain on 10/4/2020. LVN 1 stated Resident 1 can only answer yes and no questions, and the staff should document in the resident's progress notes the location of the pain. LVN 1 stated she did not administer any pain medication to Resident 1 on 10/4/2020 and did not remembered why she did not administered pain medication. During an interview on 10/15/2020 at 12:33 p.m., CNA 1 stated on 10/4/2020, CNA 2 informed her Resident 1 was complaining of pain and grimacing holding both hips and pelvis below the stomach when she was attempting to get Resident 1 up from the bed. CNA 1 stated CNA 2 reported Resident 1's complains of pain to LVN 2 on 10/4/2020. CNA 1 stated on 10/3/2020 she got Resident 1 up unassisted from the bed to the wheelchair to go to the bathroom. During an interview on 10/15/2020 at 3 p.m., CNA 2 stated while caring for Resident 1 on 10/3/2020 on the 11 p.m. to 7 p.m. shift, she transferred Resident 1 unassisted to the wheelchair by holding Resident 1 from under her arms and lowering the resident to the wheelchair from the bed. CNA 2 stated she would only call for assistance when she needed. CNA 2 stated Resident 1 was weak on one side (undetermined) of her body due to her previous hip fracture. CNA 2 stated every time she attempted to touch Resident 1, she would make noises attempting to babble (talk rapidly and continuously in a foolish, excited, or incomprehensible way) something. CNA 2 stated she reported to LVN 1 Resident 1 was not the same and stated something was wrong with Resident 1. During a concurrent interview and review of Resident 1's NPN on 2/16/2021 at 2:30 p.m., the Director of Nursing (DON) stated the residents had standing orders for pain and per nursing standards of practice, the facility's staff has to assess the resident, medicate and notify the physician if the medications was not effective. The NPN indicated Resident 1 was experiencing moderate generalized body pain, but no documentation of Resident 1's physician notification of pain. During an interview on 2/16/2021 at 5:11 p.m., the Physical Therapist Aide 1 (PTA 1) stated on 10/5/2020 early morning, she went to get Resident 1 to perform her physical therapy, upon entering the room Resident 1 was in bed. PTA 1 stated when she asked CNA 5 why Resident 1 was not in her wheelchair ready for therapy, CNA 5 stated she was not getting Resident 1 up from the bed because she was experiencing pain. PTA 1 stated after removing the blanket from Resident 1 to assess her pain, she noticed Resident 1 guarding and holding on to her left leg and grimacing complaining of pain. PTA 1 stated Resident 1's left knee and foot where rotated outward (towards the outside) and elevated, which normally was an indication of dislocation or a fracture. PTA 1 stated on 10/2/2020 Resident 1 was able to perform her exercise without pain. During an interview on 2/17/2021 at 8:10 a.m., LVN 1 stated on 10/5/2020 he received a report from LVN 5 from the night shift stating Resident 1 was complaining of stomach pain. LVN 1 stated he did not ask LVN 5 how long Resident 1 had the stomach pain, what medications were given for the pain or if an assessment was done and documented. LVN 1 stated he placed Resident 1 on observation for the pain but did not assess Resident 1 for the cause of the stomach pain. LVN 1 stated he did not document the observations of Resident 1 for the pain. LVN 1 stated he does not document the monitoring or assessments conducted when he has a resident on observation. During an interview on 2/17/2021 at 9 a.m., CNA 5 stated she cared for Resident 1 on 10/5/2020 in the morning shift 7-3 p.m. CNA 5 stated the night shift staff from 10/4/2020 reported to her Resident 1 was still in bed due to the pain she was experiencing. CNA 5 stated she notified her charge nurse LVN 5 after she was notified Resident 1 remained in bed all day on 10/4/2020 because of the pain. During an interview on 2/17/2021 at 11:30 a.m., the DSD stated all CNAs are in-serviced and trained to notify the charge nurses. The DSD stated changes are to be reported immediately to charge nurses. During an interview on 2/17/2021 at 2:18 p.m., CNA 6 stated he provided care to Resident 1 on 10/4/2020 3-11 p.m. shift and remembered Resident 1 remained in bed and refused to get up. During an interview on 2/17/2021 at 2:32 p.m., CNA 7 stated on 10/5/2020, during the morning shift care, CNA 1 called her into Resident 1's room to observe the resident's appearance. CNA 7 stated Resident 1 appeared to be in excruciating pain and making faces. CNA 7 stated Resident 1 was in pain for three (3) days. During an interview on 2/17/2021 at 3:07 p.m., LVN 5 stated on 10/4/2020 during night shift (11 p.m.- 7 a.m.) Resident 1 received pain medication for generalized body pain. LVN 5 stated he was not able to determine where and what was causing the pain. LVN 5 stated he did not document the assessment or notification of the physician regarding Resident 1's pain. LVN 5 stated they do not document unless it was necessary, and he did not consider Resident 1's pain to be significant. During an interview on 2/18/2021 at 11:10 a.m., the DON stated the staff has been in-serviced on physician notification of any resident's COC. During a review of the facility's P/P titled, Change in Resident's Condition or Status (COC), last revised 12/2017, the P/P indicated the facility shall promptly notify the resident, his/her attending physician, and responsible party of changes in the resident's medical/mental condition and/or status. According to the P/P, a COC was a significant change in the resident's physical/emotional/mental condition. The P/P indicated the staff would document the date, time change of condition was observed, findings of observation, notification of physician, and identify underlying problem causing the condition change.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance and devices as per the resident's plan of care to use a two person-assist during transfers and ensure Certified Nursing Assistants 1, 2 and 3 (CNAs 1, 2 and 3) followed the facility's policy and procedures (P/P) for the use of a mechanical lift (an assistive device used to transfer residents using hydraulic power) for one of three sampled residents (Resident 1). CNAs 1, 2 and 3, transferred Resident 1 from the bed to the wheelchair without the use of a mechanical lift and/or a two-person physical assist as indicated in Resident 1's care plan. (cross referenced to F580). These failures of improper transfer technique and inadequate supervision resulted in Resident 1 complaining of pain to her left hip for three (3) days and sustaining a left femoral (femur [thigh bone]) neck fracture (broken bone) with displacement (move away from its position) requiring a transfer to a general acute care hospital (GACH), having pain, requiring surgery and a hospital stay for three days. Findings: During a review of Resident 1's Admission Record (Face sheet) the Face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included abnormalities of gait (walk) and mobility, right femur fracture, and dementia (group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/24/2020, the MDS indicated Resident 1 had clear speech, impaired vision and had difficulty making herself understood and understanding others. The MDS indicated Resident 1 required an extensive assist of two or more-person physical assist for bed mobility (moving between surfaces including to or from: bed, chair, wheelchair, standing position), transfer (from bed to wheelchair and standing position), and toilet use. According to the MDS, Resident 1 had functional limitation in the range of motion of one side (side not identified) of the lower extremities and used a wheelchair as a mobility device. During a review of Resident 1's initial admission assessment, dated 8/15/2020, the assessment indicated Resident 1 had high risk for falls with a score of 13 (scores greater than 10 represented a high risk) and was disoriented (having lost sense of direction) at all times. The assessment indicated Resident 1 required complete assistance of a two-person physical assistance or mechanical assistance for transferring. During a review of Resident 1's care plan titled, Impaired Activities of Daily Living ([ADL-daily activities] eating, brushing hair, showering, toileting etc.) related to generalized weakness and Dementia, dated 8/16/2020, the care plan indicated Resident 1 would be kept clean and free of odors. The staffs' interventions included to utilize a gait belt (device placed on a resident who has mobility issues prior to moving the resident; aids in the safe movement of a resident, from a standing position to a wheelchair) or other protective devices during transfers and utilize a mechanical lift machine with the assistance of two (2) staff during transfers. During a review of Resident 1's care plan titled, At Risk for Pain Related to Right Hip Surgery, Managed with [MEDICATION(S)] ([narcotic] medication use to treat pain) for Moderate pain, dated 8/16/2020, the care plan indicated the staffs' interventions included to assess factors or events that trigger pain, assess resident's ability to function, assess type, location, frequency, severity of pain and report any signs of swelling or discomfort promptly. During a review of Resident 1's Medication Administration Record (MARs) for the months of 9/2020 thru 10/5/2020, the MARs indicated Resident 1 received [MEDICATION(S)] 50 milligrams ([mg] units of measurement) by mouth for pain on four (4) occasions 9/2/2020, 9/3/2020, 10/3/2020 and 10/5/2020. The MARs indicated Resident 1 was not medicated or reported any pain during the other days. During a review of Resident 1's Nursing Progress Notes (NPN), dated 10/3/2020, the NPN indicated at 11:30 p.m. (10/3/2020), Resident 1 complained of pain of 6 on a scale of 0-10 (10 being the worse pain). The NPN did not indicate Resident 1's triggers for pain, type, location, frequency of pain and resident's ability to function. During a review of Resident 1's MAR for the month of 10/2020, the MARs indicated Resident 1 received two (2) tablets of [MEDICATION(S)] (a narcotic [MEDICATION(S)] [pain reliever]used in the treatment of moderate to severe pain) 50 milligrams ([mg] units of measurement) by mouth for moderate pain on 10/3/2020 at 11:30 p.m. and on 10/5/2020 at 1:05 p.m. During a review of Resident 1's NPN, dated 10/5/2020 and timed at 12:10 p.m., the NPN indicated Resident 1 was noted grimacing (facial expression usually of pain, disgust, or disapproval), moaning and guarding the left lower extremity by the hip during physical therapy ([PT] treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). The NPN indicated Resident 1 was unable to identify the cause of the pain and the physician was notified and gave an order for an X-ray (digital image of a part of the body) of the left hip. During a review of Resident 1's x-ray results, dated 10/5/2020, the exam results indicated the report was received on 10/5/2020 and timed at 3:20 p.m., of an acute left femoral neck subcapital fracture with superior and medial displacement. During a review of the facility's investigation report, dated 10/5/2020 and timed at 12:48 p.m., the report indicated Resident 1 was seen by the rehabilitation therapist (branch of medicine that aims to enhance and restore functional ability and quality of life to residents with physical impairments or disabilities) for daily exercises and was noted with facial grimacing, moaning and Resident 1 was guarding her left lower extremity by the hip area. During a review of Resident 1's GACH's emergency room (ER) note, dated 10/5/2020, the ER note indicated Resident 1 was admitted to the GACH on 10/5/2020 at 9:07 p.m. after complaining of left hip pain. The ER note indicated Resident 1 underwent surgery on 10/6/2020 for a hemiarthroplasty (surgical procedure that replaces one half of the hip joint with a prosthetic [artificial body part]) of the left hip. During an interview on 10/15/2020 at 12:15 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 required the assistance of two-staff members for transferring while utilizing a mechanical lift. LVN 1 stated on 10/5/2020 Resident 1 complained of pain during her PT treatment. LVN 1 stated she was notified by a staff member (unknown) of Resident 1's pain on 10/4/2020. LVN 1 stated Resident 1 can only answer yes and no questions. LVN 1 stated they document in the resident's progress notes the location of the pain. During an interview on 10/15/2020 at 12:33 p.m., CNA 1 stated on 10/3/2020 she got Resident 1 up unassisted from the bed to the wheelchair to go to the bathroom. CNA 1 stated on 10/4/2020, CNA 2 informed her Resident 1 was complaining of pain and grimacing holding both hips and pelvis below the stomach when she was attempting to get Resident 1 up from the bed. CNA 1 stated CNA 2 reported Resident 1's complaint of pain to LVN 1 on 10/4/2020. During an observation of Resident 1 and interview on 10/15/2020 at 1:09 p.m., in the presence of LVN 2, Resident 1 was unable to verbalize her name and answer questions. LVN 2 stated Resident 1 was unable to feed herself, make her needs known and required a two-person assist for transferring with the use of a mechanical lift. During an interview on 10/15/2020 at 3 p.m., CNA 2 stated while caring for Resident 1 on 10/3/2020 on the 11 p.m. to 7 p.m. shift, she transferred Resident 1 unassisted to the wheelchair by holding Resident 1 from under her arms and lowering the resident to the wheelchair from the bed. CNA 2 stated she would only call for assistance when she needed to. CNA 2 stated Resident 1 was weak on one side of her body due to her previous hip fracture. CNA 2 stated every time she attempted to touch Resident 1, she would make noises and babble (talk rapidly and continuously in a foolish, excited, or incomprehensible way) something. CNA 2 stated she reported to LVN 1 Resident 1 was not the same on 10/4/2020 and thought something was wrong with Resident 1. During an interview on 10/15/2020 at 3:20 p.m., LVN 3 stated Resident 1 required the use of a mechanical lift with a two-person physical assist during transfers from the wheelchair to bed and a two-person manual lift from the bed to wheelchair when going to the restroom. During an interview on 10/15/2020 at 5:05 p.m., CNA 3 stated Resident 1 was able to stand while in the restroom and hold herself up and use the hold bar to sit down and get up. CNA 3 stated she transfers Resident 1 without staff assistance or the use of a mechanical lift from the bed to wheelchair, wheelchair to the toilet and from the toilet back to the bed on 10/3/2020. During an interview on 2/12/2021 at 12:50 p.m., the Director of Staff Development (DSD) stated on 8/14/2020 he conducted an in-service to CNAs regarding transferring and the use of assistive devices and gait belts. The DSD stated the staff was supposed to use assistive devices listed on Resident 1's care plan. During an interview on 2/12/2021 at 1:10 p.m., the Director of Nursing (DON) stated the staff was instructed to use the method of transfer for the resident that was indicated in the resident's care plan. During an interview and review on 2/16/2021 at 2:30 p.m., the DON stated the staff should have utilized a mechanical lift to transfer Resident 1 from the bed to wheelchair. The DON indicated a review of the NPN indicated Resident 1 was experiencing moderate generalized body pain. The DON stated Resident 1 did not have any pain and was able to ambulate on 10/2/2020 and when he returned on 10/5/2020, Resident 1 was not able to get up from bed and was complaining of pain to her left hip. During an interview on 2/16/2021 at 5:11 p.m., the Physical Therapist Aide 1 (PTA 1) stated on 10/5/2020 early morning, she went to get Resident 1 to perform her physical therapy exercises and upon entering the room, Resident 1 was in bed. PTA 1 stated when she asked CNA 5 why Resident 1 was not in her wheelchair ready for therapy, CNA 5 stated she was not getting Resident 1 up from the bed because Resident 1 was experiencing pain. PTA 1 stated after removing the blanket from Resident 1 to assess her pain, she noticed Resident 1 guarding and holding on to her left leg and grimacing complaining of pain. PTA 1 stated Resident 1's left knee and foot where rotate outward (towards the outside) and elevated, which normally was an indication of dislocation (forcefully moved from a proper, original, or usual place) or a fracture. PTA 1 stated (three days prior) on 10/2/2020, Resident 1 was able to perform her exercise without pain. During an interview on 2/17/2021 at 8:10 a.m., LVN 1 stated on 10/5/2020 he received a report from the night shift from LVN 5 stating Resident 1 was complaining of stomach pain. LVN 1 stated he did not ask LVN 5 how long Resident 1 had the stomach pain, what medications were given for the pain or if an assessment was done and documented. LVN 1 stated he placed Resident 1 on observation for the pain but did not assessed the cause of the stomach pain. LVN 1 stated he did not document the observations of Resident 1's for the pain. LVN 1 stated he never documents the monitoring or assessments conducted when he has a resident on observation. LVN 1 stated he did not notify the physician of Resident 1's pain. During an interview on 2/17/2021 at 9 a.m., CNA 5 stated she cared for Resident 1 on 10/5/2020 in the morning shift 7-3 p.m. CNA 5 stated the night shift staff from 10/4/2020 reported to her Resident 1 was still in bed due to the pain she was experiencing. CNA 5 stated she notified her charge nurse (LVN 5) after she was notified Resident 1 remained in bed all day on 10/4/2020 because of the pain. During an interview on 2/17/2021 at 11:30 a.m., the DSD stated all CNAs are in-serviced and trained to notify the charges nurses of changes of condition (COC). The DSD stated changes are to be reported immediately to charge nurses. During an interview on 2/17/2021 at 2:18 p.m., CNA 6 stated he provided care to Resident 1 on 10/4/2020 on the 3-11 p.m. shift and remembered Resident 1 remained in bed and refused to get up. During an interview on 2/17/2021 at 2:32 p.m., CNA 7 stated on 10/5/2020, during the morning shift care, CNA 1 called her into Resident 1's room to observe the resident's appearance. CNA 7 stated Resident 1 appeared to be in excruciating pain while making faces. CNA 7 stated Resident 1 was in pain for three (3) days and all the charge nurses knew about it. During an interview on 2/17/2021 at 3:07 p.m., LVN 5 stated on 10/4/2020 during night shift (11 p.m.- 7 a.m.) Resident 1 received pain medication for generalized body pain. LVN 5 stated he was not able to determine where and what was causing the pain. LVN 5 stated he did not document the assessment or notification of the physician regarding Resident 1's pain. LVN 5 stated they do not document unless it was necessary, and he did not consider Resident 1's pain to be significant. During a review of the facility's policy and procedure (P/P), last revised 12/2017 and titled, Safe Lifting and Moving, the P/P indicated the facility utilized appropriate techniques and devices to lift and move residents in order to protect the safety and well-being of staff and residents and promote quality of care. According to the P/P, safe lifting and movement of residents was part of an overall facility employee health and safety program.

Based on observation, interview, and record review, the facility failed ensure a residents right to be free from physical abuse for one of three sampled residents (Resident 1), when a Licensed Vocational Nurse (LVN) and a Recreational Nursing Assistant (RNA) pinned Resident 1's arms down for a finger stick to obtain a blood sugar, against her will. As a result of this deficient practice, Resident 1 became upset, irritable, aggressive, agitated, combative, and refused to eat lunch. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H & P), dated 1/15/18, indicated Resident 1 did not have the capacity to understand and make decisions. A review of the comprehensive Minimum Data Sets (MDS), a standardized assessment and care-screening tool, dated 1/18/18, indicated Resident 1's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 1 required limited to extensive assistance with activities of daily living ((ADLs) activities such as eating, bathing, dressing, toileting, transferring and walking). The MDS further indicated Resident 1's gait (walk) was unsteady used a wheelchair for mobility. A review of Resident 1's plan of care, dated 1/11/18, and titled Non-Compliance related to refusal to take medications, refusal to be turned and repositioned and refusal to be assisted with ADLs, indicated the staff's interventions were to respect Resident 1's rights and notify the physician for any signs and symptoms of negative outcomes related to non-compliance of treatment. A review of Resident 1's plan of care, dated on 1/11/18, and titled Potential for Hypo/[MEDICAL CONDITION] episode Related to Diabetes Mellitus, indicated for the staff to notify the physician of signs, symptoms and uncontrollable blood sugars. A review of a Nurses' Progress Note, dated 1/12/18, and timed at 11:30 a.m., indicated Resident 1 refused lunch, ADLs, medications, and a scheduled blood sugar check, after being offered three times. A review of Resident 1's Nurses' Progress Notes indicated the resident refused blood sugar checks on the following dates: On 3/17/18 at 10 p.m. On 3/18/18, at 6:30 a.m., and morning medications after being offered three times. On 3/30/18, and timed at 10 a.m., after being offered three times. On 4/7/18 between 11 p.m. through 7 a.m. On 4/6/18 at 2 p.m., and morning medications after being offered three times. A review of a Change of Condition Record, dated 3/12/18, and timed at 11:45 a.m., indicated Resident 1 had increased episodes of physical aggressiveness towards the staff and increased irritability with no apparent reason. A review of Resident 1's plan of care, dated on 3/12/18, and titled Increased Physical Aggressiveness towards the staff and Increased Irritability with no apparent reason, indicated for the staff to approach Resident 1 in a calm manner, provide safety measures, and notify the physician when resident's symptoms worsen. A review of the Recapitulated (a summary) physician's orders [REDACTED]. The physicians' order indicated for the staff to perform blood sugar checks twice daily, before meals, at bedtime and administer Humalog Insulin Solution Injection 100 units/milliliter (mL) as per sliding scale before meals (AC) and at bedtime (HS) subcutaneously. According to the recapitulation of the physician orders [REDACTED]. 150-199 milligram (mg) per deciliter (dL) = 2 Units mg/dL 200-249 mg/dL = 4 Units 250-299 mg/dL = 6 Units 300-349 mg/dL = 8 Units 350- 399 mg/dL= 10 Units 400 or greater = give [MEDICATION NAME] (emergency medicine used to treat severe low blood sugar) and call the physician. A review of an untimed Social Services Designee (SSD) note, dated 4/18/18, indicated Resident 1 was irritable, restless with an outburst of anger and stated in Spanish, These sons of b-----es. The note indicated Licensed Vocational Nurse 1 (LVN 1) grabbed her hand, and poked the resident's finger to obtain a blood sugar check. The SSD note further indicated Resident 1 remained irritable and refused to eat lunch. During an observation, on 5/4/18 at 8:25 a.m., Resident 1 was observed sitting in her wheelchair in the activity room and refused to speak with the surveyor. During an interview, on 5/4/18 at 9:00 a.m., the Activity Director (AD) stated on 4/18/18, during lunch time, Resident 1 was sitting in the dining room calm, happy and in a good mood. The AD stated LVN 1 asked to check Resident 1's blood sugar, the resident stated No and LVN 1 continued asking Resident 1 by begging the resident to perform a blood sugar level. The AD stated when Resident 1 repeatedly stated No, LVN 1 called RNA 1 to the dining to room, RNA 1 stood behind Resident 1 and grabbed the resident's right arm, placed the resident's right arm to her back, held the resident's right arm to the back of her head, while LVN 1 obtained a blood sugar finger stick. The AD stated she observed blood was coming from Resident 1, and told LVN 1 and RNA 1 that Resident 1 had the right to refuse, and that they were abusing her and she would report them. The AD stated according to LVN 1, she had to obtain a blood sugar level from Resident 1, because the resident's sugar level had been high. The AD stated Resident 1 was upset, attempted to bite LVN 1 and RNA 1, and stated, It is my body you cannot do anything to my body. The AD further stated Resident 1 was emotionally distressed that she did not eat lunch. During an interview, on 5/418 at 10:57 a.m., RNA 1 stated on 4/18/18 at 11:45 a.m., LVN 1 called her to the social dining room to assist with Resident 1, because the resident was more familiar with RNA 1. RNA 1 stated LVN 1 was trying to convince Resident 1 in obtaining a blood sugar check. RNA 1 stated Resident 1 was sitting against the left side of the wall, when RNA 1 stood behind Resident 1 and leaned towards her face, and Resident 1 stated No. RNA 1 stated she held Resident 1's left arm down, while LVN 1 held the resident's right arm down and at the same time Resident 1 was striking out. RNA 1 stated Resident 1 was confused, combative, striking out and attempting to bite both her and LVN 1, yet, she was trying to protect the resident and LVN 1. RNA 1 stated Resident 1 was upset and wheeled herself out of the dining room. RNA 1 was asked, when Resident 1 put her hands up and stated No, why did she not stop, RNA 1 responded by stating she was trying to convince the resident and did not hear the resident indicate for her to stop. RNA 1 stated LVN 1 obtained a blood sugar finger stick from Resident 1. RNA 1 stated Resident 1 was not combative prior to holding the resident's arms. RNA 1 stated the AD indicted to both her and LVN 1, which she did not think we should have done that to Resident 1 and the resident had the right to refuse. RNA 1 stated she was not aware that the AD was in the room at the time of the incident with Resident 1 and further stated Resident 1 had the right to refuse. RNA 1 stated she was not disciplined and passed Resident 1's breakfast tray two days after the incident. During an interview, on 5/4/18 at 11:36 a.m., LVN 1 stated on 4/18/18 at 11:45 a.m., she called RNA 1 to assist her with holding Resident 1's arms in order to obtain a blood sugar level because the resident refused her blood sugar checks every day at 6:30 a.m., 4 p.m., and 9 p.m. LVN 1 stated when Resident 1 was able to accurately indicate yes and no. LVN 1 stated initially, she calmly approached Resident 1 to obtain her blood sugar, when Resident 1 stated No. LVN 1 stated she stood on the right side of Resident 1, RNA 1 stood on the left side of the resident, they both held Resident 1's hands down to stabilize her. LVN 1 stated Resident 1 began biting and scratching at them but, she was able to obtain a blood sugar level of 360 mg/dL from Resident 1. The LVN stated Resident 1 became more agitated, aggressive and refused having blood removed from finger and wheeled herself out of the dining room. The LVN stated there were times when the staff held Resident 1 down to obtain a blood sugar check, which there was a plan of care indicating to hold the resident down to obtain a blood sugar check dated on 4/22/18. LVN 1 stated she did not want Resident 1 to slip into a coma (being in an unconscious state for a long period of time), believed what she did to Resident 1 was not abusive and had to obtain the resident's blood sugar check. The LVN further stated even when residents refuse their medications or a blood sugar check, she would find a way and would continue to administer the medications and blood sugar checks. During an interview, on 5/4/18 at 1:41 p.m., the Registered Nurse Supervisor (RNS) stated on 4/18/18, she was made aware by the AD of Resident 1 being forced to provide a blood sugar sample by LVN 1 with assistance from RNA 1. The RNS stated when she assessed Resident 1, Resident 1's right arm was slightly red and discolored. The RNS further stated Resident 1 had the right to refuse a blood sugar check. A review of the facility's policy and procedure dated 4/2012, and titled Abuse Prevention Program indicated the facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility, staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. A review of the facility's policy and procedure dated 4/2013 and titled Residents Rights indicated employees shall treat all residents with kindness, respect, and dignity. The facility will make every effort to assist resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity.

Based on interview and record review, the facility failed to thoroughly assess a change of condition one of one sampled resident (1). Resident 1 was having trouble trouble breathing and the facility failed to continuously monitor the health status, leading to unresponsiveness. The resident was transferred to the General Acute Care Hospital (GACH) and expired. Resident 1 was found with loud breathing. At 5:55 a.m., the paramedics was called and the resident was transferred to the GACH. According to the GACH records, the resident was unresponsive, severely dehydrated (lost too much water) and was in septic shock (overwhelming amount of bacteria and their toxins which cause infection that may lead to tissue damage, organ failure and death). The resident expired on the same day at 4:09 p.m. The Certificate of Death indicated the immediate cause of death was [MEDICAL CONDITION]. The failure resulted in Resident 1 not being thoroughly assessed, intervened and monitored for the change of condition when exhibiting signs and symptoms of trouble breathing, leading to the transfer to the GACH and death due to [MEDICAL CONDITION]. Findings: On [DATE] at 11:40 a.m., a complaint investigation was initiated and the Director of Nursing (DON) was informed of the category of allegations. A review of the clinical records revealed Resident 1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE] indicated Resident 1 was non-verbal, was rarely understood and or understood others, the vision was highly impaired, and there was short and long term memory problems. The MDS assessment also indicated the resident required total care from staff for all activities of daily living such as; bed mobility, transfer, eating, and toilet use. A review of the Nurses Progress notes, dated [DATE] at 1 a.m., revealed Resident 1 was found by Licensed Vocational Nurse (LVN 1) with loud breathing. LVN 1's notes indicated the resident's O2 Sat level was at 90 %, without being administered any oxygen. The resident's head of the bed was elevated (HOB), oxygen was administered at 2 liters a minute and breathing treatment was given, resulting in O2 Sat increasing to 96 %. However, there was no further documentation about the resident's vital signs (respiratory rate, effort exerted while breathing, and auscultation (using stethoscope) of breath sounds) to ensure the resident was getting enough oxygen. There was no documentation about the resident's body temperature and heart rate to ensure the resident was not having an infection or dehydration (happens when your body does not have as much water as it needs). There was no documentation about the resident's level of consciousness (a measurement of a person's arousability and responsiveness to stimuli from the environment). The notes indicated at 3 a.m., the resident was asleep. However, there was no documentation about the resident's arousability, O2 Sat, breathing, heart rate, temperature. At 5:15 a.m., the notes Registered Nurse (RN 1) saw the resident having a change of condition. The notes indicated RN 1 was unable to arouse the resident. The resident was noted to be [MEDICAL CONDITION](hear beats faster than normal) and was tachypnea (abnormally rapid breathing), with breathing through the mouth and belly and was unable to be awakened. The resident's vital signs was documented by RN 1 as; blood pressure ,[DATE] millimeter per mercury (mmHg) (normal blood pressure ,[DATE]), pulse rate was 131 beats per minute (normal 60 - 100 beats per minute) and respirations 48 (normal respiration 12 - 20) breaths per minute. The resident was started on 15 liters of oxygen through a non-rebreather mask (a device used in medicine to assist in the delivery of oxygen therapy) and paramedics was called. At 5:35 a.m., RN 1 notes indicated the paramedics arrived and assessed the resident's vital sign as; blood pressure of ,[DATE] mmHg, heart rate of 142 beats per minute, finger stick blood sugar (test for sugar in the blood) at 131 milligram per deciliter (mg/dl) (normal blood sugar between 70 - 99 before meals) and O2 Sat was at 95 %. According to the RN 1 notes, the resident was transferred to the General Acute Care Hospital (GACH) at 5:55 a.m. A review of the GACH History and Physical notes, dated [DATE] revealed Resident 1 was having shortness of breath, was comatose and unresponsive. The resident's blood pressure was ,[DATE] mm/dl, with respiratory rate of 37 breaths per minute. The laboratory results revealed the blood urea nitrogen (test to detect how well the liver and kidneys are working) was 40 mg/dl (normal 7 to 20 mg/dL) which indicated severe dehydration. The white blood count (the cells that help fight infection) was very high at 36.2 1000/mcl (normal 4.0 - 11.0 x 1000/mcl) with bacterial growth of eschericha coli (bacteria found in lower intestines) and [DIAGNOSES REDACTED] pneumoniae (blood infection). The resident was given [MEDICATION NAME] 1.25 gram (strong antibiotic) and [MEDICATION NAME] 3.375 (strong antibiotic) intravenous ((IV) in the vein) antibiotic along with three liters of IV hydration to replenish fluids and electrolytes due to the [MEDICAL CONDITION] (a life-threatening complication of an infection), lactic acidosis (excessive acid accumulates due to a problem with the body's metabolism) and [MEDICAL CONDITION] (abnormal low blood pressure) caused by dehydration and infection. On the same day at 4:09 the resident was pronounced dead because there was no pulse and no respirations. During a telephone interview on [DATE] at 10:07 am, LVN 1 stated as he was making rounds on [DATE] between 1 to 2 a.m., Resident 1's O2 Sat was between 88 - 90 %. LVN 1 stated he raised the HOB and administered oxygen at 2 L/min. The resident's O2 Sat increased to 95 - 96 %. LVN 1 stated he notified the Registered Nurse (RN 1) and was told to continue administer the oxygen. LVN 1 stated at around 4 - 5 am., the resident was noticed to get worse so RN 1 was called to assess the residents vital sings and 911 (emergency response team was called). On [DATE] at 3:55 a.m., during a telephone interview, RN 1 stated they were alerted about Resident 1 around 5 or 6 a.m., who was having SOB. RN 1 stated the resident was seen around around 5:15 a.m., but she was not able to wake him up. RN 1 stated the lungs were checked, the oxygen was increased, placed on a non-rebreather mask and 911 was called. On [DATE] at 11 a.m., during a telephone interview the DON stated according to her investigation, LVN 1 only told RN 1 about Resident 1 being administered oxygen. LVN 1 told RN 1 the resident's O2 Sat was raised but not about a true change of condition. The DON stated LVN 1 never rechecked the resident until 5:15 a.m., that was when RN 1 stepped in and assessed the resident. The DON stated upon interview with LVN 1, aside from the O2 Sat, the resident's other vital signs was never obtained. The DON stated at 3 a.m., LVN 1 told her he just looked the resident but never actually touched the resident. The DON acknowledged LVN 1, at the minimum should had obtained the resident's vital sign, including his lung sounds. The DON also stated RN 1 should have been notified of LVN 1's findings after obtaining the resident's vital sign. A review of the Resident 1's Certificate of Death, dated [DATE] indicated the immediate cause of death was [MEDICAL CONDITION]. According to the facility's policy and procedures titled Change of Condition, revised [DATE], indicated the policy was to ensure the proper assessment and follow through for any resident with a condition change. The policy indicated the change of condition is a sudden and marked change in vital signs, behavior (changed to: lethargic, agitated, anxiety, refusing care, non-responsive), output (low urine output, vomiting), congestion or shortness of breath, and change in level of consciousness. The general documentation guidelines indicated to observe the resident's findings, emergency care provided, notification of the physician and document the observation of the resident until condition is stable.

Based on observation, interview and record review, the facility's nursing staff failed to prevent an actual fall for one of 24 residents(8) and potential falls for two of 24 sampled residents (4, and 13). Resident 8, who required one-person physical assistance with toilet use and does not have the capacity to understand and make decision, was left on a toilet by herself on September 19, 2015. As a result, at 11:35 a.m., Resident 8 was found on the floor with severe pain, and was transferred to a general acute care hospital (GACH) on the same date. On September 22, 2015, Resident 8 had an operation to her right hip intertrochanteric-subtrochanteric fracture, comminuted (is a fracture in which the bone involved in the fracture is broken into several pieces) intertrochanteric with displacement, and readmitted back to facility on September 26, 2015. Resident 4, who required two-plus persons-physical assist, was transferred by one certified nursing assistant using a mechanical lift (a device used to move heavy immobile resident). Resident 13, who was assessed as a high risk for fall was using a high gel wheelchair cushion that caused the resident pelvis (sitting bone, lower part of the trunk) to be higher than her knees, cause the resident to lean forward and increase the risk for falls. Findings: a. A review of Resident 8's Admission Records indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment care screening tool), dated June 2, 2015, indicated Resident 8 required limited one-person physical assist for toilet use (how a resident uses the toilet room, bedpan, transfers on/off toilet; cleanses self after elimination). The resident was assessed with [REDACTED]. A History and Physical, dated September 6, 2015, indicated Resident 8 does not have the capacity to understand and make decisions. A Fall Risk assessment dated , August 24, 2015, indicated Resident 8 scored 20 (total score of 10 or above represents high risk). A physician's orders [REDACTED]. 1. Low bed 2. Apply bed alarm to alarm staff when resident attempts to get out of bed unassisted due to dementia. Nurses Progress Notes, dated September 19, 2015, at 11:35 a.m., documented by registered nurse 2 (RN 2) indicated while preparing lunch medication at the nursing station, she heard a crying sound, went to Resident 8's room and found the resident sitting on the floor in severe pain. The documentation indicated the resident was alert, awake and verbally responsive. There was no bleeding, no skin breakdown and the resident was able to wiggle her toes on both lower extremities. The documentation indicated the writer asked the certified nursing assistant (CNA) to remain with the resident for safety, and left to call the registered nurse supervisor. At 11:40 a.m., the Nurses Progress Notes indicated the RN supervisor was called and notified about the incident. The notes indicated the writer went back to the resident's room and two CNAs were assisting resident back to bed. At 11:43 a.m., the Nurses Progress Notes, documented by registered nurse 4 (RN 4) indicated the resident was found on the bed, crying in pain. The resident pointed to her right leg, RN 4 lifted her pants and the right thigh was found with swelling, no skin break, no bleeding. The resident was unable to move right leg. On November 10, 2015, at 11:32 a.m., during an interview, the physical therapy rehabilitation director (PTRD) stated Resident 8 had a short leg with a boost in her shoe. The resident was able to ambulate independently with a front wheel walker prior to the fall incident, however her gait was unsteady and required support assistance. PTRD stated someone should have been walking with the resident and she should not have been left alone on the toilet. A GACH x-ray report, dated September 19, 2015, indicated Resident 8 had a comminuted intertrochanteric right hip fracture. A Report of Operation, from the GACH, dated September 22, 2015, indicated the following: Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure: Right hip open reduction and internal fixation (ORIF, a surgical procedure to repair a hip fracture). A discharge summary, from the GACH, dated September 25, 2015, indicated Resident 8 was admitted to the hospital with [REDACTED]. She was seen by an orthopedic surgeon who performed an ORIF. On November 5, 2015, at 9:40 a.m., during an interview, Resident 8's family member stated prior to the resident's fall (September 19, 2015), the resident was able and wanted to walk; and did walk using a FWW. He stated since the fall and fracture, the resident is unable to walk and is more confused at times. At the time of this interview, the resident was observed lying in bed, awake and alert but would only stare; she would not answer questions or speak. On November 19, 2015, at 6:23 a.m., during a telephone interview, registered nurse 2 (RN 2) stated she was working as a charge nurse, passing medication, the day of Resident 8's incident, when she heard a crying sound. RN 2 stated she entered the resident's room and saw the resident sitting on the bed and CNA 2 was standing next to her. RN 2 stated she did not know what had happened but the resident was crying and agitated so she went to her cart to retrieve her stethoscope. No one told her the resident had fallen but the resident kept pointing to her leg saying it hurts, it hurts. The resident spoke only her native language they could not understand her so they got a housekeeping staff to interpret. The resident was so upset and agitated they still could not understand her. RN 2 stated she called RN 4. On November 19, 215, at 3:17 p.m., during a telephone interview, RN 4 stated she was called to evaluate Resident 8, because of a fall. When she arrived to the resident's room the resident was sitting on the bed and both CNA 2 and RN 2 was in the room. She was told by both that the resident had fallen. RN 4 stated during her assessment she lifted the resident's pants and saw the resident's right leg was twisted to the right. She stated the resident was screaming in pain, so she called 911 (emergency number). RN 4 stated she was told by CNA 2 that she assisted the resident to the bathroom but left the resident in the toilet because she had to help another resident. On her way back to the resident's room, CNA 2 heard a noise and found the resident on the floor. RN 4 stated prior to the fall incident, the resident was able to ambulate with a front wheel walker, however, she has never seen her walk completely alone and always has someone next to her. On November 26, 2015, at 10:33 a.m., during a telephone interview, CNA 2 stated she heard Resident 8's bed alarm go off; she went to the resident's room and found the resident trying to get out of bed unassisted, stating she had to go to the restroom. She assisted the resident to the restroom and placed her on the toilet. CNA 2 stated she had to assist another resident in another room because everyone else was busy but instructed Resident 8 not to get up and to call her (via the call light in the bathroom) when she was finished. When she was on her way back to Resident 8's room she heard a clunking sound and the resident crying, when she entered the room she saw the resident on the floor next to the foot of her bed. She stated her and another CNA assisted the resident back to bed and called RN 2 to the room. CNA 2 stated the resident was able to ambulate with a FWW prior to the fall incident but she knows that someone should be with her when she is walking. CNA 2 stated she should not have left the resident on the toilet, and should not have put her back in bed before she called a licensed nurse to assess her. b. On November 5, 2015, at 11:30 a.m., Resident 13 was observed sitting in her wheelchair. The resident was observed leaning slightly forward and to the right. The cushion in the seat of the wheelchair appeared to be several inches high. On November 9, 2015, at 11:40 a.m., Resident 13 was observed sitting in her wheelchair. The arm rest on the left was placed on backwards without an area for Resident 13 to rest her elbow. While sitting on a high seat cushion in the wheelchair, Resident 13 was observed leaning slightly forward. A review of the admission record indicated Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A resident care plan dated April 27, 2015, addressed Resident 13 being at risk for falls. The goals included minimizing the occurrence of falls and keeping the resident free from falls. A Fall Risk Evaluation dated April 27, 2015, indicated Resident 13 score was 20, which was considered a high risk for falls. A review of the Nurses Progress Notes dated October 6, 2015, at 8:55 pm, indicated Resident 13 was found down on her bathroom floor. Resident 13 was observed with slight swelling, redness and bleeding from her nose. A resident care plan dated October 6, 2015, addressed Resident 13's actual fall. The nursing interventions included identifying factors contributing to the fall and to intervene appropriately. A status [REDACTED]. A Therapy Progress Note dated November 9, 2015, indicated Resident 13 was screened for better wheelchair sitting options. The notes indicated Resident 13 may benefit from a thinner wheelchair cushion to obtain lower positioning of her hips. On November 9, 2015, at 11:40 am, during an interview and observation of Resident 13 ' s wheelchair cushion, the director of rehabilitation stated the high gel cushion in the seat of Resident 13's wheelchair caused her pelvis to be higher than her knees. He stated the resident's pelvis being higher than her knees could cause the resident to lean forward and increase the risk for falls. c. Resident 4's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, is a standardized resident assessment and screening tool) dated on October 7, 2015, indicated resident's cognitive skills for daily decision making were severely impaired. The resident was assessed as totally dependent from the staff with two person-assist during transfer. During an observation on November 4, 2015, at 1:20 p.m., in Resident 4's room, certified nurse assistant 4 (CNA 4) was observed using the mechanical lift by herself. CNA 4 hooked four corners of mechanical lift slings and transferred Resident 4 from wheelchair to bed. During an interview with director staff developer (DSD) on November 10, 2015, at 8:18 a.m., DSD stated all mechanical lift must be use by two persons.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards and failed to provide supervision, assistance and assistive devices to three of 24 sampled residents (8, 9, and 10). These deficient practices resulted in Residents 8, 9, and 10 suffering falls and sustaining injuries which may have been prevented. For Resident 9, who was high risk for fall due to her diagnoses, had fallen from her bed during her original admission process, on July 15, 2011, by leaving the resident alone with the bed in a high position and side rail down sustaining facial bone fracture. The facility continued failing to provide adequate supervision and safety devices as care planned. The resident had another fall, on November 27, 2011, four months after, while in her wheelchair and was found without a soft belt as ordered sustaining facial bruising and right elbow abrasion. For Resident 8, who had a tab alarm to alert staff of unassisted movement by the resident, the facility failed to provide appropriate supervision and safety devices to prevent a fall and head injury. For Resident 10, who was rehabilitating after a recent hip surgery and had history of falls, the facility failed to lock the resident's wheelchair and provided supervision while the resident was on the commode. The facility failed to prevent a fall and failed to revise the plan of care addressing the cause of the fall and specifying the assistance/supervision the resident needed to prevent further falls and injury. Findings: 1. a. Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 9 suffered a fall from her bed on July 15, 2011, around 6:05 p.m., according to their Event/Incident Report, while the resident was left unattended during the admission process. The facility could not provide documented evidence of a physician's orders [REDACTED]. No documentation of the level of supervision the resident required nor what safety measures should have been in place at the time of the fall and injury. A facility policy and procedure titled "Assessment of Patients' Nursing Care Needs" undated, indicated patient nursing needs assessments record the presence or absence of the patient's ability to function within that person's physical, social, psychological and even spiritual environment. Initial nursing assessment at the facility begins at the time of a patient's admission and is completed within 7-14 days. According to a Fall Event/Incident Report dated July 15, 2011, Resident 9 was found lying, face down, on the floor in her room and was sent to the acute hospital at 6:40 p.m. The incident report indicated Certified Nursing Assistant (CNA) 6 served Resident 9 her dinner tray at 5:30 p.m. The report indicated CNA 6 raised the resident's bed to a mid-high level off the floor, lowered the right side rail, and positioned the over bed table so the food tray was placed in front of the resident, then raised the head of the bed so that the resident was in a sitting position for her meal. CNA 6 stated she then left the room as the resident began to eat. Sometime after 6:05 p.m., the incident report indicated CNA 7 stated she went to Resident 9's room and found the resident face down on the floor. She stated she immediately called for help. Licensed Nurse (LN) 5, who was the charge nurse, stated in the report she entered the resident's room at approximately 6:15 p.m. and observed Resident 9 on the floor face down. Both her arms were underneath her and both her legs were lying on top of the over bed table's legs. LN 5 stated the resident was bleeding from her nostril and there was blood on the carpet. The right side rail was down and the bed was in a high position. Abrasions to the resident's right eye orbit and right cheek were noted at that time. The resident denied pain and was able to move both lower extremities. Her vital signs were taken and the physician was notified. Resident 9 was transferred to the acute hospital on July 15, 2011 at 18:40 p.m. (6:40 p.m.), and returned to the facility 3 days later with a [DIAGNOSES REDACTED]. During an interview with CNA 6 on December 10, 2011 at 4 p.m., she stated both of Resident 9's side rails were up when she delivered the resident's dinner tray. She stated she lowered the right side rail and placed the resident's over bed table across the bed so the resident could eat. She stated she was not aware of how much assistance the resident required. She stated she then left the room to continue passing the meal trays. A facility policy and procedure titled "Care Plan Process-General" dated April 2004 indicated the Interdisciplinary Team (IDT) will coordinate with the resident/family a care plan appropriate for his/her needs or wishes based on the assessment and reassessment process within the required time frame. Based upon the physician's orders [REDACTED]. The Interim Care Plan facilitates care until the Interdisciplinary Care Plan is developed. A facility policy and procedure titled "Fall Prevention-General" dated April 2004 indicated it was the policy of the facility that residents shall receive appropriate supervision and assistance devices to prevent accidents. Residents shall be assessed for fall risk upon admission. Based on the assessed level of risk, residents shall be provided with assistance devices and care measures to prevent falls and accidents. These policies were not followed. b. Resident 9 was readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool), dated July 25, 2011, the resident sometimes understood others and was sometimes able to make herself understood, and had moderately impaired cognitive skills for daily decision-making. The resident required extensive one-person assistance with all her activities of daily living and was incontinent of bowel and bladder. Resident 9 was observed numerous times during the survey sitting in her wheelchair with a soft seat belt and pommel cushion (wedge foam seat cushion with pommel or raised area at the front) in place. The resident was alert but did not respond appropriately to simple questions. The clinical record for Resident 9 was reviewed on December 9-10, 2011. A Nursing History and Assessment, dated July 18, 2011, indicated the resident had altered mental status, was disoriented to time and place, had poor hearing and vision, was dependent on staff assistance for eating/nutrition, and required one-person assist with transfers and two-person assist with ambulation. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. A Resident Care Plan for "Falls" initiated July 18, 2011, indicated Resident 9 was at risk for falls due to poor safety awareness, impaired short term memory, psychotropic drug use, incontinence, unsteady gait, and [DIAGNOSES REDACTED] (one-sided weakness). Interventions included applying soft belt when in wheelchair for safety. A Resident Care Plan for "Devices" initiated July 18, 2011, indicated use of a soft belt in wheelchair for safety due to history of frequent falls. The "Activity of Daily Living" initiated on July 19, 2011, indicated the resident required extensive assistance with all activities of daily living and among the interventions listed included to monitor frequently and anticipate resident's needs. A Resident Care Plan titled "Risk for Repeated Falls" as evidenced by: History of Falls, along with the 3 previously mentioned care plans, was not reviewed/revised following the resident's fall on November 27, 2011. A Nursing Progress Note, dated November 27, 2011 at 8:30 p.m., indicated Resident 9 was found face down on the floor in her room by a CNA. The resident was lying "by the bedside table without soft belt applied while resident on wheelchair." The note further indicated the resident was able to move all extremities without pain and had a right elbow abrasion and redness on the bridge of her nose. The physician was notified and ordered an ice pack applied to the resident's nose and treatment for [REDACTED]. The responsible party arrived to visit the resident and x-rays were ordered for the following day. According to an Event/Incident Report, dated November 27, 2011, Resident 9 was found lying face down on the floor in her room at 8:15 p.m. The incident report indicated a physical assessment was done; the resident was able to move all extremities without pain, and was observed to have redness on the bridge of her nose. Facial x-rays were ordered on November 28, 2011. According to a Diagnostic Imaging Report, dated November 28, 2011, no fracture was seen. Review of the Skin Tear/Abrasion Assessment, dated November 27, 2011, indicated Resident 9 had a right elbow abrasion. The assessment form indicated the resident had been sitting in her wheelchair in her room and the seatbelt on her wheelchair was not applied. The Summary of Causative Factors indicated "Resident on wheelchair, while on wheelchair no soft belt applied." The physician ordered an ice pack to the bridge of the resident's nose and to clean the right elbow abrasion and apply triple antibiotic ointment. The Fall Risk Assessment, dated July 18, 2011, indicated Resident 9 had intermittent confusion, 1-2 falls in the past 3 months, was chair bound, had poor vision, was unable to walk, and had a history of [REDACTED]. The Fall Risk Assessment was not reviewed/revised following the resident's fall on November 27, 2011. The Physical Therapy (PT) Daily Progress Note, dated November 28, 2011, indicated Resident 9 had a fall from her wheelchair on November 27, 2011. The note indicated the resident did not have her seat belt on and fell out of her wheelchair, and that the resident "continues to need seat belt to control unsafe transfers." During an interview with CNA 6 on December 10, 2011, she stated she was Resident 9's caregiver on November 27, 2011 (the night of the incident). She stated she went on break and another CNA was covering her residents. Resident 9 was in her wheelchair with her soft seatbelt on when she went on break. She stated the resident was not able to remove the seatbelt herself and she could not explain what happened. A facility policy and procedure titled "Fall Prevention-General" dated April 2004 indicated it was the policy of the facility that residents shall receive appropriate supervision and assistance devices to prevent accidents. Residents shall be assessed for fall risk upon admission. Based on the assessed level of risk, residents shall be provided with assistance devices and care measures to prevent falls and accidents. This policy was not followed. 2. Resident 8 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the MDS, dated [DATE], Resident 8 was sometimes able to make herself understood and sometimes understood others. The resident's cognitive status for daily decision-making was moderately impaired and she required cues and supervision. She required extensive assistance with one or two person assist with all her activities of daily living and was always incontinent of bowel and bladder. During the initial tour of the facility on December 8, 2011 at 6:20 p.m., Resident 8 was observed sitting in her wheelchair in her room. The resident responded slowly and inappropriately to simple questions. The clinical record for Resident 8 was reviewed on December 9, 2011. The Nursing Progress Notes, dated August 22, 2011, indicated the resident was found on the floor in her room. The resident was in a seated position on the floor with a CNA next to her. The resident was not wearing her gown; it was on the floor with the tab alarm still attached. The resident was noted to have a bump on her left forehead area. The physician was notified and issued orders to transport the resident to the acute hospital for further evaluation. Resident 8 was transported to the acute hospital at 12:36 a.m. and returned to the facility at 5:15 a.m. Results of the CAT scan (a form of x-ray) to the left forehead hematoma (solid swelling of clotted blood within the tissues) and spine were negative for fracture. Review of the facility's Event/Incident Report revealed Resident 8 got up from her bed towards the end of the bed and while walking unassisted, fell and hit her head. The Skin Tear/Abrasion Assessment, dated August 22, 2011, indicated at 11 p.m., the resident was found on the floor in her room after standing up from bed and walking independently. The resident had a purple bump on her left forehead. The assessment indicated the resident had unsteady gait and was trying to get up unassisted. It indicated the resident had a tab alarm on (attached to the resident's gown), but the gown, it was connected to, was removed with the tab alarm still in place. Two Investigative Statements were documented regarding the incident. Neither staff member was available for interview during the survey. Neither statement mentioned the fact that the resident's gown had been removed without setting off the tab alarm by a resident who required extensive one person assistance with dressing. The licensed vocational nurse's (LVN) statement indicated the resident was lying on the floor on her right side next to the CNA. The Nursing Progress Notes, dated August 22, 2011, indicated the resident was seated next to the CNA when the LVN arrived. A facility policy and procedure titled "Fall Prevention-General" dated April 2004 indicated it was the policy of the facility that residents shall receive appropriate supervision and assistance devices to prevent accidents. Residents shall be assessed for fall risk upon admission. Based on the assessed level of risk, residents shall be provided with assistance devices and care measures to prevent falls and accidents. This policy was not followed. 3. Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Nursing History and Assessment, dated December 6, 2011, Resident 10 was alert but disoriented to person, required total assist for transfers, was non-weight bearing, and required 2-person assistance for ambulation. The resident was totally dependent on staff assistance for all activities of daily living. During an observation on December 10, 2011 at 12:30 p.m., Resident 10 was sitting in bed eating her lunch. She was alert and answered questions appropriately. There was a tab alarm in place. The clinical record for Resident 10 was reviewed on December 9-10, 2011. An undated Physical Restraint Assessment indicated the resident was alert and oriented and the use of the tab alarm was to alert the resident not to get up unassisted and the raised side rails were used as enablers, not restraints. A Fall Risk Assessment, dated December 6, 2011, indicated the resident had history of falls, was chair-bound and required assistance with elimination, and was considered a high risk for falls. The Fall Event/Incident Report, dated December 8, 2011 at 4:45 a.m., indicated CNA 8 assisted Resident 10 to the bathroom and assisted the resident onto a raised commode seat. CNA 8 stated in the report that she instructed the resident to call her when she was done, and exited the bathroom. CNA 8 stated she heard a noise and returned to the bathroom and found the resident on the floor in a seated position. The report further indicated the resident was noted with periods of confusion, and the resident indicated that she had tried to get up by herself, just to see if she could do it alone. The resident complained of left hip pain and at 6:35 a.m., was transferred to the acute hospital for follow-up. (The resident returned to the facility the same day at 2:30 p.m., x-rays were negative for fractures). According to Nursing Progress Notes, dated December 8, 2011 at 4:45 a.m., CNA 8 reported to the supervisor and charge nurse that Resident 10 was found on the floor inside her bathroom. The resident was assisted back to bed by the CNA at which time a body check was done by the supervisor and charge nurse. The note further indicated the resident stated she had tried to get up by herself (transferring from the commode seat to her wheelchair). The note indicated the resident was having periods of confusion, and was medicated for complaints of left hip pain. At 8:30 a.m., the resident again complained of pain and pain medication was given as ordered. At 9:15 a.m., the resident left via ambulance for the acute hospital for follow-up. The facility's interview with CNA 8 was merely date December 8, 2011, and did not specify any time frames. The CNA did not specify how she transferred the resident to the bathroom, and how she transferred her back to bed. The statement indicated the supervisor and charge nurse "checked and interviewed the resident", but failed to specify when and where. During an interview with CNA 8 on December 11, 2011 at 2 p.m., she stated on December 8, 2011 at 8 a.m., Resident 10 asked to go to the bathroom. CNA 8 stated she did not know the resident's condition but that the resident asked where she was and requested assistance to the bathroom. The CNA stated she took the resident to the bathroom via wheelchair and assisted her onto the raised commode seat. She then instructed the resident to call her when she was done and left the resident unattended. CNA 8 then heard a noise and returned to the bathroom to find the resident on the floor next to her wheelchair. CNA 8 stated she called another CNA for assistance and together, they put the resident in her wheelchair, and then transferred her back to bed. Then the supervisor and charge nurse were notified and came to the resident's room and assessed her condition. During an interview with Resident 10 and her son on December 11, 2011 at 2 p.m., the resident stated at the time of the fall, the CNA had transferred her to the bathroom via wheelchair and assisted her onto the raised commode seat. She stated that after 5-7 minutes, she decided to try to get back into the wheelchair by herself, just to see if she could do it. She stated she assumed that the wheels on the wheelchair were locked, but they were not, and when she tried to hold onto the chair to get up, it rolled away and she fell . The resident's son reiterated the wheels of the wheelchair were not locked. He further stated the resident had no practice to transfer and was not able to transfer herself. A care plan titled "Incontinent of Bowel and Bladder Function" initiated on December 7, 2011, failed to indicate any type of toileting plan other than to check and change incontinent pads. A care plan titled "ADL (activities of daily living) Functioning" initiated on December 6, 2011, indicated the resident had self-care deficits related to cognitive deficits, poor safety awareness, unsteady gait, poor balance, and joint limitations. Interventions included providing incontinent care as needed and assisting with ADLs as needed. A care plan titled "Falls" initiated on December 6, 2011, indicated the resident was at risk for falls/injury related to poor body balance/control, poor safety awareness/judgment, and history of falls. Interventions included to visibly observe resident frequently and to provide a safe and clutter-free environment. An entry on the care plan, dated December 8, 2011, indicated the resident had an actual fall on December 8, 2011. However, the interventions section was left blank and the care plan was not revised to address the cause of the fall and attempts at measures to prevent recurrence of falls. And even after the resident's fall, the tab alarm was not listed on the care plan. A facility policy and procedure titled "Fall Prevention-General" dated April 2004 indicated it was the policy of the facility that residents shall receive appropriate supervision and assistance devices to prevent accidents. Residents shall be assessed for fall risk upon admission. Based on the assessed level of risk, residents shall be provided with assistance devices and care measures to prevent falls and accidents. This policy was not followed. Policies and procedures regarding resident transfer, assessment/reassessment after fall incidents, detailed care plans, and incident investigative reports were requested but not by the facility.

Based on observation, interview, and record review, the facility staff failed to ensure bed side rails were properly padded for one of 15 sampled residents (Resident 12). This deficient practice placed Resident 12 at risk for injury during seizure activity. The facility staff also failed to lock the medication cart while left unattended along the hallway. This deficient practice had the potential to result in unauthorized access to medications by residents, visitors and staff, predisposing them to possible overdose, unauthorized use of medications, adverse reactions and drug to drug interactions for 12 confused residents that were in their wheelchairs on the third floor wing. Findings: a. On March 8, 2012 at 7:30 p.m., during the initial tour, Resident 12 was observed in bed, with the head of the bed elevated. Both bed side rails were padded. However, both pads were hanging from the bed exposing the upper metal bar of the bed. During an interview with Licensed Vocational Nurse 2 (LVN 2) at that time, stated the pads should have covered the entire side rails to prevent injury. On Mach 10, 2012 at 10:30 a.m., the side rail pads were observed hanging from the bed exposing the upper metal bar. A review of Resident 12's clinical record indicated she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated December 23, 2011, indicated Resident 12 was unable to make her needs known and required total assistance with her activities of daily living. There was a physician's orders [REDACTED]. The nursing care plan, dated July 23, 2010, indicated Resident 12's side rails be padded to prevent injury during seizures. This was not followed. On March 11, 2012 at 10:30 a.m., the director of nursing was informed of the observation and stated all staff will be re-educated regarding resident's safety. b. On 3/9/12 at 5:30 p.m., during the medication pass, the medication cart was parked next to Room 312, along the hallway, was left unlocked, was unattended, and was out of sight of the licensed nurse. During an interview with Licensed Vocational Nurse 1 on 3/11/12 at 9:20 a.m., she stated she forgot to lock her medication chart while attending to a resident. According to the facility's undated policy and procedure titled, "Medication Administration" when administering medications, the medication cart is kept closed and locked when out of sight of the medication nurse.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with the necessary nutritional care to maintain acceptable body weight and protein levels for two of 24 sampled residents (5 and 8). For Resident 5, who was identified by the facility requiring supervision during eating, had weight loss of 14 pounds (10.85%) in six months starting from admission on June 2011 to December 2011, the facility failed to assess the cause(s) of the weight loss until the resident had 13 pounds weight loss in September 2011; failed to implement physician's orders [REDACTED]. preferences to add fortified cereal at breakfast, extra gravy and fortified soup at lunch and dinner, and to be placed on weekly/feeding program which resulted in continued unplanned weight loss resulting in a severe weight loss (10.85%) in six months. According to State Operations Manual, Appendix PP, severe weight loss is greater than 10% in six months. For Resident 8, the facility failed to provide dietary care according to assessed needs and plan of care by failing to provide assistance and encouragement with eating, accurate monitoring of food intake, and reporting significant changes to the physician. Resident 8 was observed sitting in her wheelchair with a full tray because she could not put the food on her fork. She did not eat anything. The facility also failed to address Resident 8's low [MEDICATION NAME] levels as identified on four laboratory tests, for a period of three months, dated August 30, 2011, September 19, 2011, October 10, 2011, and November 21, 2011. These deficient practices resulted in Resident 8 suffering severe weight loss of 10 pounds (6.9 %) in one month (according to the State Operations Manual Appendix PP, severe weight loss is greater than 5% in one month) and ongoing, untreated [MEDICATION NAME] levels of 2.5-2.6 grams (g)/deciliter (dl). Normal [MEDICATION NAME] level range=3.5-5.0 g/dl. ([MEDICATION NAME] is a protein manufactured by the liver. In [MEDICAL CONDITION], there is not enough protein in the resident's diet for the liver to make new [MEDICATION NAME] from. If [MEDICATION NAME] gets very low, swelling can occur in the ankles ([MEDICAL CONDITION]) and fluid can begin to accumulate in the abdomen (ascites) and in the lungs (pulmonary [MEDICAL CONDITION])). Findings: 1. During an observation on December 10, 2011, at 7:35 a.m., Resident 5, a thin elderly lady who was sitting in her bed, was applying her lower dentures, and getting ready to have her breakfast. Resident 5 requested her glasses from the certified nursing assistant (CNA). The surveyor asked Resident 5's CNA to verify the breakfast card. The CNA stated regular diet and small portions. On December 10, 2011, a review of the admission face sheet indicated Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent (quarterly) Minimum Data Set (MDS, an assessment tool), dated September 13, 2011, identified the resident as usually understood and had the ability to sometimes understand others. She required supervision from the staff for eating. The MDS, Section K, Height and Weight, indicated 60 inches and 122 pounds (lbs). The MDS, dated [DATE], Section K, Height and Weight, indicated 60 inches and 129 pounds, a weight difference of 7 lbs. During an interview with the director of nursing (DON) on December 9, 2011, at 2:10 p.m., he reviewed the Nursing Progress Notes, dated November 16, 2011, (no time indicated) and stated, "It looks like the staff did not follow up with the physician." The surveyor reviewed the Nursing Progress (NP) Notes. The NP Notes indicated "Resident observed with downward trend of weight lost over last six months, resident with only 1 pound weight loss since last month. However, has a total of 13 pounds weight loss since June 7, 2011, left message to the physician for request of 4 ounces of high protein nutrition (HPN) twice a day per dietician's recommendations, and awaiting call back from the physician." The DON further stated there was no documented evidence of the implementation of the dietician's recommendations. During interviews with the dietary service supervisor (DSS) and the dietary aide, on December 10, 2011, at 8:50 a.m., the DSS reviewed the Interdisciplinary Weight Management (IDWM) Care Plan, dated November 11, 2011, and stated the team's recommendations included 4 ounces of HPN twice a day at 10 a.m. and 2 p.m. The DSS read the additional comments which included 13 pounds in 5 months, has dentation problems schedule to see dentist, and will notify family and the physician of weight loss. The surveyor reviewed the IDWM Care Plan and asked the DSS to verify the notification of Resident 5's family and the physician. The DSS stated per the documentation on the IDWM Care Plan "No, the family and the physician were not notified of the weight loss." The DSS further stated the licensed nurses were responsible to complete a communication slip for diet changes and submitted to the dietary department. "If I don't get the slip, how do I know the resident has changes?" The DSS reviewed Resident 5's Monthly Record of vital signs (V/S) and Weights. The DSS used her cell phone's calculator and stated "Yes, Resident 5 had significant weight loss." The DSS asked the dietary aide, had she recommended daily weights, the dietary aide stated, "No." The staff's approaches as indicated in the IDWM Care Plan included to report to the physician any weight change of 3 pounds or more, encourage adequate nutritional intake of 75% -100%, and assess for food preferences and provide within reason. There was no documentation that indicated the licensed nursing staff had informed the physician of the weight loss per the IDWM plan of care. An Interdisciplinary Team Conference (consisting of nursing, activity, dietary, and social service personnels' signatures), dated September 13, 2011, indicated dietary went over current weight. Resident's gradual weight loss was due to not tolerating diet and went over options including snacks in between meals. The IDT Weight Variance Committee Meeting Minutes, dated November 11, 2011, had IDT Recommendations (consisting of nursing and dietary personnels' signatures) which included notifying family and physician of the weight loss and recommended 4oz HPN twice a day at 10 a.m. and 2 p.m. The Nursing Progress Notes, dated November 16, 2011, indicated a weight loss of 13 pounds total since June 7, 2011. "The physician was notified and message left." However, further review of the record did not indicate a follow up with the physician to ensure he/she was aware of the IDT Recommendations. There was no documentation in the resident's record that indicated the licensed nursing staff addressed the resident's weight loss and notified the physician. The nutritional screening completed by the registered dietician (RD) on June 1, 2011, indicated the resident had a weight and height of 129 pounds and 60 inches respectively. The RD estimated her nutritional needs as 1470 calories, 54-59 grams of protein, and 1770 cubic centimeters (cc) of fluid. The quarterly review, dated September 13, 2011, indicated on September 122 lbs, August 123 lbs, July 125 lbs, June 129 lbs, and the resident's diet was regular with small portions. On October 10, 2011, the RD indicated the resident was triggered with continued weight loss upon admission; June 129 lbs, July 125 lbs, September 122 lbs, and October 122 lbs, 6.4 % loss in 3 months and 5 lbs or 4.1% loss in 1 month. The diet ordered was mechanical soft, small portions, offer snacks at hours of sleep. Met with the resident-will continue to honor the resident's request for small portion, add fortified cereal at breakfast, extra gravy and fortified soup at lunch and dinner, and place on weekly/feeding program. On November 7, 2011, the RD indicated history of 10.1 % loss in 5 months and 5.7 % loss in 3 months. The recommendation again was fortified cereal and soup, and on December 6, 2011, indicated weight stable 116 lbs, 6.5% loss in 3 months. However, a review of the resident's clinical record revealed there was no documented evidence that indicated the RD's recommendations were brought to the attention of the attending physician. A review of the physician's monthly recapitulation of orders, dated December 2011, indicated mechanical soft diet with small portions and a dietary supplement of a snack at hours of sleep. There was no documentation that indicated the licensed nursing staff had informed the physician of the RD's recommendations or the resident's weight loss. The care plan titled, "Nutritional and Hydration", dated June 2, 2011, indicated the resident's goal was to maintain weight at 129 lbs. The staff's approaches included encouraging the resident to consume 75% of each meal, monitor weight and report significant changes to the physician/responsible party, and monitor labs. The Physician's Progress Notes, dated July 29, 2011, indicated the resident lost 4 lbs in 1 month and the plan was to continue with treatment. September 30, 2011, indicated the resident lost 7 lbs in 3 months and the plan was to continue with treatment. On October 30, 2011, the resident does not eat much and lost 12 lbs and drinks some of the protein nourishment. Continue with treatment. On November 28, 2011, indicated the resident lost 13 lbs in 5 months and continue with treatment plan. A review of the resident's weight record indicated the following: On June 7, 2011, 129 pounds (lbs) On July 4, 2011, 125 lbs, resident lost 4 lbs On July 31, 2011, 123 lbs, resident lost 2 lbs On September 1, 2011, 122 lbs, resident lost 1 lb On October 1, 2011, 117 lbs, resident lost 5 lbs On November 1, 2011, 116 lbs, resident lost 1 lb On December 8, 2011, 115 lbs, resident lost 1 lb (A total weight loss of 14 lbs) On December 8, 2011, the resident weighed 115 pounds. This was a significant weight loss of a total of 14 lbs. While Resident 5 was losing weight, the licensed nursing staff did not address the cause(s) of the weight loss, provide additional nourishments, and assist the resident with eating. There were systemic failures of the facility in the management of Resident 5's nutritional status. These included the failure of the staff to provide the required supervision during eating, failure to assess and identify the cause(s) of continuous weight loss and the failure to communicate the RD's recommendations to the physician which resulted in severe weight loss of 14 pounds. 2. a. Resident 8 was originally admitted to the facility August 9, 2011, and was readmitted [DATE], with [DIAGNOSES REDACTED]. (one form of dementia, loss of brain function, that gradually gets worse over time), and dementia (a loss of brain function affecting memory, thinking, and behavior). According to the Minimum Data Set (MDS, an assessment tool), dated November 21, 2011, Resident 8 was sometimes able to make herself understood and sometimes understood others. The resident's cognitive status for daily decision-making was moderately impaired and she required cues and supervision. She required extensive assistance with one or two person assist with all her activities of daily living and was always incontinent of bowel and bladder. During the initial tour of the facility on December 8, 2011 at 6:20 p.m., Resident 8 was observed sitting in her wheelchair inside her room. Her dinner tray was on the over bed table in front of her. The food on the tray had been disturbed by the resident's attempts to eat it, but the tray remained full and the food was uneaten, since she was incapable of placing food on the fork and raising it to her mouth. The resident's roommates' trays had already been returned to the cart. The charge nurse observed the resident attempting to feed herself unsuccessfully, and called for the certified nursing assistant (CNA) to assist the resident. During an observation on December 10, 2011 at 8:15 a.m., Resident 8 was seen seated in the same position with her breakfast tray in front of her. She was observed from the nurse's station which was just outside her room. She was left alone with her breakfast tray and no assistance with eating was provided by any staff member. The tray was removed from her room and placed on the cart. It was 100% uneaten by the resident. The resident was served her lunch tray also in her room at 1 p.m. Observation revealed the resident was provided no assistance by staff. The resident was observed attempting to place food on her fork and raise it to her mouth, but she was not able to eat as much as 10 % of her meal. Her tray was picked up and placed back on the cart at 1:40 p.m. December 10, 2011, Resident 8 consumed 51-75% of her breakfast and 76-100% of her lunch. The flow sheets, dated September and October 2011, indicated the resident required moderate or maximum physical help in eating and required one person physical assistance with eating. The clinical record for Resident 8 was reviewed on December 9, 2011. A Monthly Record of Vital Signs and Weights form indicated the following weights for Resident 8: August 9, 2011, (admission) 143 lbs; August 30, 2011, 144 lbs; September 29, 2011, 145 lbs; November 1, 2011, 135 lbs; December 7, 2011, 135 lbs. A Nutritional Screening and Data Collection Form, dated November 18, 2011, indicated the resident was receiving moderate assistance with meals and was able to make her needs known. The MDS, dated [DATE], indicated the resident required extensive one person physical assistance with eating. This assessment indicated a decline in functioning compared to the MDS, dated [DATE], which indicated the resident only required supervision/cueing with eating. No documentation in the clinical record to indicate when and why the decline in the resident's functioning occurred and the timing/cause of the decline could not be explained by the DON. A care plan titled, "Nutrition and Hydration" initiated on August 23, 2011, and last reviewed on November 11, 2011, did not address Resident 8's severe weight loss and was not revised to address the weight loss. The care plan indicated the resident's "variable intake" risk had been resolved, but no date of resolution was provided. Approaches (interventions) included to encourage the resident to consume 75% of each meal and monitor, provide dining assistance for the resident, and monitor weight and report significant changes to the physician/responsible party. An Interdisciplinary Weight Management Care Plan, dated November 17, 2011, was only signed by dietary staff; no other discipline had signed the care plan to indicate coordination of care. The care plan addressed the resident ' s recent weight loss of 10 pounds in one month. However, the care plan failed to identify whether the weight loss was expected, planned, or beneficial. It indicated the weight loss was unavoidable secondary to [MEDICAL CONDITION]. The care plan indicated diagnoses/conditions that placed the resident at risk for unavoidable weight loss included Alzheimer's/dementia, [MEDICAL CONDITION], and diuretic use. However, the resident was documented as having gained 1 pound while receiving [MEDICATION NAME] 40 milligrams (mg) (a diuretic ordered on August 29, 2011, to treat the resident's high blood pressure). On September 12, 2011, [MEDICATION NAME] was increased to 60 mg and the resident gained 1 pound. On October 9, 2011, [MEDICATION NAME] was increased to 80 mg. On November 1, 2011, 23 days later, the resident had lost 10 pounds. Aside from the resident's [DIAGNOSES REDACTED]. No assessment of increased or decreased [MEDICAL CONDITION] was in evidence to determine if the diuretic was responsible for the weight loss. There was no documentation of measurements of the resident's legs in order to determine if the [MEDICAL CONDITION] was stable, increased, or decreased. The care plan indicated to monitor weight as ordered and to record, to report to the physician any weight change of 3 pounds or more, obtain laboratory studies as ordered and report to physician as indicated. The care plan clearly indicated the resident's physician was not notified. The care plan recommended informing the physician of the weight loss and to follow-up with laboratory tests when available. There was no documented evidence in the clinical record to indicate the resident's physician was notified of the severe weight loss and the low [MEDICATION NAME] level results. There was no documented evidence in the clinical record the facility took action to correct the issues and develop a plan to prevent reoccurrence. During an interview on December 10, 2011 at 1:50 p.m., the DON stated Resident 8's condition had declined to the extent that she was unable to feed herself and was not able to make her needs known. He further stated he would place her on the restorative nursing assistant (RNA) feeding program. During an interview with the dietary technician on December 10, 2011 at 3:40 p.m., she stated she depended on the CNAs to accurately document the residents' intake in order to formulate dietary plans for the individual residents. During an interview with CNA 5 on December 10, 2011 at 4 p.m., she stated Resident 8 needed a lot of help with eating and that she did assist Resident 8 with her meals. She further stated she thought she had recorded the resident's meal intake accurately. The facility's policy and procedure titled "Unintended Weight Loss" undated, indicated to determine if weight loss is 5% in the last 30 days or 10% in the past 6 months. Notify the primary physician and the responsible party regarding the weight loss. Assess and evaluate all aspects of the resident's nutritional status. Identify clinical conditions that (created) the risk for unintended weight loss. Determine appropriate nutritional interventions that are consistent with the resident's nutritional status, overall medical condition and personal preferences. Laboratory tests to determine status of hydration and RNA dining program. Charge Nurse will monitor intake of residents with significant weight loss. Collaborate with dietary consultant re: management for significant weight loss and follow-up their recommendations. Develop a nursing care plan and interdisciplinary documentation to identify the potential problems and to develop goals and methods to address these problems. These procedures were not followed. b. Resident 8's [MEDICATION NAME] levels were reviewed on December 10, 2011. A lab report from the acute hospital, dated August 16, 2011, indicated a level of 3.3 g/dl (Normal [MEDICATION NAME] level range 3.5-5 g/dl). The following levels were obtained after the resident returned to the facility: August 30, 2011 2.7 g/dl September 19, 2011 2.5 g/dl October 10, 2011 2.6 g/dl November 21, 2011 2.6 g/dl. A care plan titled "Nutrition and Hydration" initiated August 23, 2011, and last reviewed November 11, 2011, listed the 3.3 g/dl [MEDICATION NAME] level from August 16, 2011, and the 2.7 g/dl level from August 30, 2011. No further levels were listed on the care plan. The care plan was not revised to reflect the continued low [MEDICATION NAME] levels and no approaches/interventions were included beyond the original ones listed: to encourage resident to consume 75% of each meal and monitor, provide dining assistance for the resident, and monitor weight and report significant changes to physician/responsible party. The care plan listed options such as: encourage compliance with diet, appetite stimulants, snacks, and Nepro-like supplements. However, there was no documetation that these options were implemented. A Nutritional Screening and Data Collection Form, dated August 23, 2011, indicated Resident 8's [MEDICATION NAME] level was 3.3 g/dl. An entry on the form, dated August 23, 2011, indicated mildly decreased [MEDICATION NAME] level. An entry dated September 8, 2011, indicated moderately decreased [MEDICATION NAME] level of 2.7 g/dl (partly due to [MEDICAL CONDITION]). A "snack" was recommended by the RD. On November 18, 2011, an entry was written by the dietary technician (DT). The DT documented the resident had lost weight of 10 pounds or 6.9% in one month (which is considered a severe weight loss). She stated she was unaware of the resident's low [MEDICATION NAME] levels of 2.5 g/dl on September 19, 2011, 2.6 g/dl on October 10, 2011, and 2.6 g/dl on November 21, 2011. The DT concluded her entry by writing the resident's responsible party was informed of the resident's 10 pound weight loss during the care plan meeting. She indicated she had visited the resident prior to the interdisciplinary team meeting (IDT) to go over food preferences and that the resident was currently being followed by the weight variance committee due to weight loss. She indicated, will refer to RD. However, as of December 10, 2011, no documentation of further follow-up by the RD was in evidence in the clinical record. During an interview with the dietary technician on December 10, 2011 at 3:40 p.m., she stated as a result of Resident 8's weight loss, an additional snack and fortified soup were ordered for the resident. She was asked what was being done regarding the resident's [MEDICATION NAME] levels, she stated there were supplements that could be ordered, such as Nepro (Nepro is a therapeutic nutrition specifically designed to help meet the nutritional needs of residents with [MEDICAL CONDITION], and was shown in studies to increase [MEDICATION NAME] and pre-[MEDICATION NAME] levels in those residents). She stated she would inform the RD of the resident's [MEDICATION NAME] levels. The facility's policy and procedure titled "Job Description: Dietary Technician (DT)" undated, indicated that, under the supervision of the Dietary Supervisor and Registered Dietician, the DT participates in meal rounds, observes resident intake, and participates in the management of resident nutritional needs such as nutritional assessment of each resident including dietary input into resident care plan. The facility's policy and procedure titled "Weight Committee" dated May 2010, indicated residents with significant weight changes, or gradual weight variance trends will be reviewed at the Weight Committee meeting to help maintain acceptable parameters of nutritional status. An Interdisciplinary Team (IDT) meets regularly to review residents identified to be at nutritional risk due to weight changes. The IDT may include the following members: Dietary Manager, Registered Dietician, Nursing, Activities and Social Services, representatives from the therapy department and/or others as facility designates. Identified residents are reviewed by the IDT to determine the reason for weight variance, plan interventions to prevent further weight change, and improve weight status. A new MDS may be triggered due to significant, unplanned weight change. The plan of care is updated to reflect weight changes, with appropriate goals and approaches/interventions listed. As necessary, each discipline is responsible for documenting the results of the meeting in the appropriate section of the medical record. These procedures were not followed.