Every finding on record at Sunny View Care Center

Based on clinical record review, staff interview and facility policy review, the facility failed to ensure the 5 rights of medication administration were followed resulting in 1 of 1 residents receiving another resident's medications (Resident #6) in addition to the resident's own medication which required an admission to the hospital due to sinus bradycardia (resting heart rate that is slower than normal) requiring further hemodynamic (blood flow movement and circulation through the heart and blood vessels) monitoring. The facility reported a census of 92 residents.Findings include: Review of Resident #6's census in the Electronic Health Record (EHR) revealed the resident was hospitalized [DATE] to 3/23/26. Review of the Minimum Data Set (MDS) assessment for Resident #6, dated 2/24/26 revealed a list of diagnoses which included hypertension, Alzheimer's disease and toxic encephalopathy (change in how the brain functions). The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of Resident #6's March 2026 Medication Administration Record (MAR) revealed the resident received the following ordered medications on 3/22/26 during the morning medication pass:a. Aspirin 81 milligrams (MG) 1 [NAME]. Calcium Carbonate 600 MG 1 tabc. Vitamin C 500 MG 1 tabd. Vitamin D 25 micrograms (MCG) 1 tabe. Fluoxetine 20 MG 1 tab f. Furosemide 40 MG 1 tab (medication to pull excess fluid off the body)g. Galantamine Hydrobromide 12 MG 1 tabh. Lidocaine external patch 4% (topical pain medication)i. Memantine Hydrochloride (HCL) 10 MG 1 tab (medication to decrease anxiety, and or mood disturbance)j. Acetaminophen 325 MG 2 tabsk. Oxycodone HCL 5 MG 0.5 tab as needed (prn) (opioid class used for moderate to severe pain)Review of facility Incident Report (IR) #2275 dated 3/22/26 at 10:10 AM prepared by Staff A, Licensed Practical Nurse (LPN) revealed Resident #6 was in the dining room when the resident was given the wrong medications. Staff A notified the nurse on-call and the doctor was notified. The IR documented the resident to be oriented to person only. Review of the EHR revealed a Nurse's Progress Note entered 3/22/26 at 11:04 AM documented Resident #6 was giving another resident's medications which included the following: a. Metoprolol 60 MG ( medication to lower heart rate)b. Lyrica 75 MG (narcotic medication used to calm overactive nerves)c. Oxycodone 7.5/325 MG (opioid class of medication for moderate to severe pain)d. Furosemide 40 MG (medication used to pull excess fluid off the body)e. Celebrex 100 MG ( nonsteroidal anti-inflammatory drug for reducing pain, for example arthritis, acute pain, and menstrual pain)f. Prozac 60 MG (anti-depressant known for it's long extended release factor)g. Hydroxyzine 10 MG (can be used for sedative, anti-anxiety, and anti- itch)h. Cetirizine 10 MG (allergy medication)i. Neuriva j. Protonix 20 MG k. Potassium + 99 MG l. Multivitamin m. Vitamin D3 The Progress Note dated 3/22/26 at 11:04 PM further revealed these medications were given in addition to the resident's regular morning medications including a as needed (prn) Oxycodone that were given around 8:00 AM. The resident's blood pressure (BP) was originally 100/50, then 85/48 and 73/48. The resident complained of not feeling well and was increasingly fatigued. Staff A informed the on-call provider and was given orders to send the resident to the emergency room (ER) for treatment and evaluation. The Power of Attorney (POA) was notified, emergency services were contacted and the resident was transported out of the facility at 11:00 AM to a local ER. Review of Nurse's Progress Notes dated 3/22/26 at 5:29 PM revealed the ER was contacted for an update on Resident #6's condition. The resident had been hypotensive (low blood pressure) upon admission and had required two (2) bags of fluid to increase the residents blood pressure (BP). Review of the History & Physical (H&P) hospital notes dated 3/22/26 at 9:30 PM revealed the chief complaint as drug overdose after accidental ingestion of another resident's multiple medications in addition to the resident's own medications. Poison control was contacted and provided recommendations which were executed in the ER. However, after the recommended observation the resident continued to have sinus bradycardia and thus was recommended for admission for further hemodynamic monitoring. During a phone interview 4/29/26 at 11:10 AM Staff A, LPN reported Resident #6 had been screaming and yelling and she didn't realize there had been two (2) residents with the same first name in the back hallway. Staff A reported it was her first time working in the back hallway after her training was completed. Staff A acknowledged there were pictures in the EHR to help identify the residents but felt they were small. Staff A stated she didn't know the residents but realized it right away when she gave medications to the wrong resident and contacted the physician. Staff A reported the physician was only concerned about the BP meds and directed staff to monitor Resident #6's BP and if it went down to transfer the resident out which they did. Review of facility policy titled, Medication Management, dated 2023 directed staff to identify the resident before administering medication. Review of employee records for Staff A, LPN revealed the following: Date of Hire: 12/31/25Termination Date: 3/23/26Review of facility form titled, Medication Occurrence Report Form, dated 1/20/26 revealed Staff A administered the wrong medications including Lasix (Furosemide), and potassium to a resident. Review of facility form titled, Employee Warning Notice, dated 2/6/26 revealed Staff A received a final warning related to unprofessional and inappropriate conduct toward residents and their family members. Staff A documented not being familiar with residents due it being the 2nd time on the cart and as a measure to prevent reoccurrence to ask staff in not sure.Review of facility form titled, Employee Warning Notice, dated 3/23/26 revealed Staff A received notification of termination related to substandard work including a medication error that resulted in a resident being hospitalized . Description of Infraction: Inadvertently gave a resident another resident's medication which resulted in the resident having to be hospitalized for hypotension. Failed to follow the 5 rights of medication pass to ensure resident safety while administering resident medications. Pictures of both residents were available in the EHR for reference. Plan for Improvement: Staff A had a previous medication error, disciplinary documents in Staff A's file on 1/20/26 and had been counseled on medication administration expectations. Consequences of Further Infractions: The facility elected to terminate Staff A's employment effective immediately due to the significant medication error infraction. Staff A had given a 2 week notice voluntary resignation however the facility accepted it immediately. On 4/28/26 at 1:29 PM the Administrator revealed any education provided to Staff A, LPN would have been in the attachment of Staff A's disciplinary action. The Administrator further revealed Staff A did not have an orientation checklist and a Quality Assurance Performance Improvement (QAPI) had been started on orientation checklists.

Based on clinical record review, resident interview, family interview, staff interview and policy review, the facility failed to complete a comprehensive assessment and evaluation of a resident for readmission to the facility, and failed to have the appropriate documentation in the medical record prior to issuing an involuntary discharge to 1 of 3 residents reviewed for discharge (Resident #1). This failure caused the resident to experience a negative impact on her psycho-social well being. The facility further failed to have the resident or the resident representative sign the discharge summary. The facility reported a census of 91 residents. Findings include:According to the Minimum Data Set (MDS), dated [DATE], Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident had diagnoses to include progressive neurological conditions, Multiple Sclerosis (MS), anxiety disorder, depression and functional quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). The MDS documented the resident had verbal behavioral symptoms directed toward others 1 to 3 days in the look back period. This behavior did not: put the resident at significant risk for physical illness or injury, significantly interfere with the resident's care or the residents participation in activities or social interactions. This behavior did not: put others at significant risk for physical injury, significantly intrude on the privacy of others or significantly disrupt care or living environment. The MDS documented the resident's current behavior status was the same compared to the prior assessment. The MDS indicated the resident was taking an antipsychotic, an antianxiety and an antidepressant medication. The Care Plan, with a target date of [DATE], included a focus area Resident #1 planned to stay at the facility long term as her children are not in the area and her husband is deceased , with a goal of the resident voicing contentment with her stay. Interventions under this focus area included monthly meetings initiated [DATE] and an entry on [DATE] of a monthly meeting where the resident reported things are going well and documentation the resident has had no untoward behaviors and is attending activities and doing very well. An entry under this same focus area on [DATE] of resident voicing daily her discontent in staying at the facility and the facility offered multiple times to help her seek alternate placement and she declined. Under this same entry, as of [DATE] resident new required 2 people for all cares and conversations due to vaping marijuana in her room and escalating behaviors. The Care Plan further included a focus area resident had chronic pain due to muscle spasms from MS. Resident uses medical marijuana off of property. An intervention initiated on [DATE] documented the resident was found to have three unidentifiable pills in her bed which resident later confessed as Marinol (a synthetic man-made form of THC - THC is a crystaline compound that is the main active ingredient of cannabis), resident was educated she could not bring in medications that were not prescribed to her due to the potential side effects. Another entry under this focus area for an intervention was initiated [DATE] and documented resident was noted to have a marijuana pen in her bag and admitted to the charge nurse she had given another resident a few hits off of it. Resident was re-educated that she could not have any illicit/illegal substances on the property and could not give it to other residents as it could potentially cause a severe reaction up to and including death. An additional intervention under this focus area was initiated on [DATE] and documented the resident has been repeatedly educated/counseled regarding the use of illegal substances and vaping in the facility. The facility has a zero tolerance for illicit drugs being brought in and used at the facility for the health and safety of her and other residents who reside in the facility. Therefore, an Emergency involuntary discharge notice has been delivered to the resident at the hospital. Review of the Electronic Health Record (EHR) revealed Resident #1 was transferred to the hospital on [DATE]. Nurse Progress Note dated [DATE] at 11:01PM documented the following; Call from Hospital emergency room updated this nurse on patient, nurse stated that so far they had discovered that the resident had a urinary tract infection (UTI), and wanted to confirm that the resident was caught with THC earlier in the week. The nurse stated they would call back with any other pertinent information, but wanted to confirm that the facility could treat the UTI.Review of the EHR revealed the following Progress Notes:a. Progress Note dated [DATE] at 2:59 PM, titled Nurse's Progress Note: At 1:30PM this writer (Administrator) and witness, facility Social Worker (SW), went to the hospital and delivered by hand an involuntary discharge letter to Resident #1 for the reason of vaping marijuana in her room on Friday, [DATE]th, 2026. This writer also met with the social worker at the hospital assigned to Becky's case and explained reason for the emergency discharge letter. b. Progress Note dated [DATE] at 4:19 PM, titled Nurse's Progress Note: At approx. 3:30 pm this writer (Administrator) and witness, Assistant Director of Nursing (ADON), went to the hospital and delivered by hand an involuntary discharge letter to Resident #1. c. Progress Note dated [DATE] at 8:28 AM, titled Nurse's Progress Note: At approx. 5:30PM on 01.22.2026, this writer (Administrator) and witness, facility SW, went to the hospital and delivered by hand an involuntary discharge letter to Resident #1. d. Progress Note dated [DATE] at 12:42 PM, titled Nurse's Progress Note: Received a letter/notice from facility Medical Director (MD) yesterday, that Resident #1 is a danger to herself and others and should not be allowed to return to the facility. See letter/notice scanned into Point Click Care (PCC) documents. Copy of the letter also placed in her hard chart. The Progress Notes lacked documentation that the facility completed a comprehensive assessment of the resident for readmission to the facility after being notified that the resident was able to be discharged from the hospital, and wanted to return. During an interview [DATE] at 3:15 PM, Resident #1 stated she had remained in a hospital setting since the 18th of January, 2026. She believed she was medically ready to discharge around the 22nd of January, however the facility would not take her back. Resident #1 stated she was admitted to the hospital on the 18th of January due to a Urinary Tract Infection (UTI) and had an altered mental status. She believed the facility told the hospital they confiscated a marijuana vape pen from her earlier in the week, however she said that is not true. The facility filed an emergency discharge while she was at the hospital and she appealed. Resident #1 stated the appeal hearing had taken place and she won the appeal, however the facility continued to say they would not take her back and they are appealing the decision by the Administrative Law Judge ( ALJ). Resident #1 stated she did not have symptoms of a UTI prior to her admission to the hospital and stated she had a history of UTI's. Resident #1 stated she had limited feeling below her neck. She stated she was very tired on the 18th and that could have been attributed to a UTI. Resident #1 stated the Administrator and the facility Social Worker (SW) came to the hospital on the 20th of January and handed her a letter of involuntary discharge. The letter did not have the correct verbiage and the Administrator and the ADON returned on the 21st of January and handed her another letter of involuntary discharge, which was still incorrect. The Administrator and the SW returned to the hospital on the 22nd and handed her another letter of involuntary discharge, which had the correct verbiage. Resident #1 stated she was emotionally impacted by the involuntary discharge, she had felt unsure of what was going to happen to her and scared, she reported increased anxiety. The Administrator did not say anything to her when she handed the letters to her, just that she had a letter for her. The letter said she had 7 days to remove her belongings from the facility. Resident #1 said she just cried each time she opened the letters. She immediately called for an appeal hearing all three times of being given the involuntary discharge. The ALJ sent his decision the previous Thursday and overturned the discharge, however the facility said they were appealing the decision and did not have to take her back while appealing. Resident #1 stated she is just stuck at the hospital. She said the involuntary discharge had devastated her. She stated she liked the facility and wanted to remain at the facility. She stated it felt vindictive from the facility because she filed a complaint on them in December of 2025. Resident #1 became teary at times while talking and would then become angry and upset. During an interview [DATE] at 3:40 PM, the hospital SW stated Resident #1 arrived at the hospital on the 18th of January of 2026 and still remained at the hospital. On the 20th of January the hospital coordinator called the facility to discuss arrangements for the resident to return to the facility as the resident would be medically ready for discharge the next day. Facility staff arrived at the hospital later that day on the 20th of January to serve the resident emergency discharge paperwork and the Administrator stopped in the SW's office to say the facility would not be taking the resident back. The paperwork said 30 days for discharge and facility staff returned the next day with what they believed to be corrected discharge paperwork and ended up returning three times to serve the resident emergency discharge paperwork. The resident became scared of what was going to happen to her and to her belongings and she was anxious about the discharge. The hospital coordinator called the facility after getting the ALJ decision which overturned the discharge and the facility said they would not be taking the resident back. Inquired if the resident had any medication changes for her mental health and the SW advised the resident was already on anti anxiety medication when she arrived at the hospital and this was not changed. During an interview [DATE] at 9:15 AM, the Administrator and the Chief Nursing Officer (CNO) stated Resident #1 violated the facility's zero tolerance policy for illegal substances. The first time this was violated was on [DATE] when the resident had a vape pen in her room and gave another resident a hit of the vape pen, which was believed to have marijuana in it. The CNO stated Staff A, Registered Nurse (RN) went into the resident's room on that date and witnessed the resident give another resident a hit out of the vape pen. The resident later admitted it was a vape pen with marijuana. The resident would not give the facility staff the vape pen. The CNO stated the facility had an interim Administrator in September and the Administrator re-educated the resident on the facility's zero tolerance policy. The resident signed this agreement for zero tolerance back in her admission in 2022. The CNO stated their interventions at that time were to educate the resident and the Care Plan was updated. The CNO, was in this position in September of 2025, stated no interventions or assessments were completed with the other resident. The CNO stated on [DATE] Resident #1 was found with 3 unidentified pills in her bed, which were later identified as Marinol, a derivative of THC. A friend had visited the resident that day. The facility destroyed the pills. The CNO stated the pharmacist identified the pills and the resident denied knowing what they were. The intervention at that time was staff had re-educated the resident again about not taking medication without prescription and zero tolerance. The CNO stated the next incident happened on [DATE], when Staff A went into the resident's room and there was smoke coming out of the resident's mouth. The resident tried to hide the vape pen under her covers and told Staff A it was a nicotine pen. That same day Staff B, business manager, and Staff A went in to interview the resident, they requested the vape pen and the resident said she no longer had it. She said she gave it to her friend who was visiting at that time. Resident #1 was impaired, her speech was slurred and her eyes were rolling back in her head. Resident #1 finally admitted it was marijuana. Their interventions at that time included monitored the resident's vital signs and notified the local police department who came out, however the resident would not give them any information and the police department had closed their case with no charges. The facility also put the resident back on the 2 person rule, two staff with her during care and contact. Facility staff continued to monitor her vital signs after the 16th. On the 18th of January, the resident became unresponsive and her speech was slurred. The resident was transported to the hospital. She had a UTI, which was complicated by her THC use (believed this is what the hospital report documented). We locked her door to be sure everything was safe in her room, that her belongings were safe after she went to the hospital. The CNO stated conversations took place with the facility's legal department about discharging the resident and they came to the conclusion that the facility needed to do an emergency discharge as they felt she was not safe to herself or others. The CNO stated the facility issued the first emergency discharge on the 20th, it had the wrong verbiage, it said a 30 day discharge. The facility updated the paperwork and delivered a second one on the 21st, however this was still not correct. The 3rd and final notice of emergency involuntary discharge was delivered on the 22nd to the resident at the hospital. Inquired if the facility conducted an evaluation or assessment of the resident after her transfer to the hospital and the CNO stated the facility used the medical records as their assessment and evaluation, and did not conduct their own assessment or evaluation of the resident at the hospital. The CNO stated the facility had the resident's mom sign the discharge summary. The CNO was not sure if the resident's mom was her Power of Attorney (POA) or guardian. The CNO stated the facility admitted another resident into Resident #1's room on [DATE]. The CNO advised the resident appealed the discharge and the hearing had taken place in which the ALJ reversed the emergency discharge, however the facility is going to appeal the decision and will not take the resident back. The CNO stated the attorneys are working on the appeal. The CNO stated a belief that the resident was not safe to return to the facility. The facility Medical Director (MD) wrote a letter on [DATE] which documented the resident was not safe at the facility. The facility MD was not the resident's primary care physician (PCP), however the MD is familiar with the resident. The CNO stated the facility never offered substance abuse counseling or a substance abuse assessment/evaluation to the resident. The CNO stated the facility did not initiate emergency involuntary discharge with the resident after the September incident or after the December incident. The CNO stated she felt the facility tried to work with her and needed to do the emergency discharge due to safety concerns. During this interview the Administrator stated she delivered all 3 letters of emergency involuntary discharge to the resident at the hospital. She told the resident she had a letter to give her and gave her the letter and left. The 2nd time her parents were in the room and she told the resident she had another letter for her and put it on her bedside table and left. The 3rd time she told her she had another letter, she gave her the letter and left. The Administrator did not discuss the letter or complete an evaluation/assessment of the resident. The Administrator stated she had a witness each time, the first time the facility Social Worker (SW) went with her, the second time the Assistant Director of Nursing (ADON) went with her and the 3rd time the SW went with her. In the last letter served it contained the discharge letter, the summary of events and the discharge summary. She did not have the resident sign the discharge summary. During an interview [DATE] at 10:15 AM, the hospital coordinator stated she called the facility on the 20th of January at around 11:20 AM to discuss discharge planning for Resident #1 as she would be medically ready to discharge from the hospital the following day. The admissions person who answered the phone stated she did not think the resident would be returning to the facility. The hospital coordinator did not speak with any other facility staff. Facility staff arrived at the hospital on the 20th of January at around 1:40 PM to give the resident emergency discharge paperwork. The hospital coordinator stated the hospital SW became involved at that time to assist the resident. She stated the resident had been calm and cooperative with her, but tearful about the circumstances and scared of what would happen. During an interview [DATE] at 11:30 AM the hospital SW stated she talked to the resident the previous night and the resident was tearful and said everything was hitting her all at once and she is finally realizing what had happened. The hospital SW stated the resident has not had any suicidal thoughts or ideations, or changes in her appetite or sleep, however the resident is tearful and has had increased anxiety about what has happened and what will happen. The resident had been afraid and scared. During an interview [DATE] at 11:40 AM, Resident #1 said she felt shredded by what the facility had done regarding her discharge. Inquired from the resident about having a vape pen. The resident stated when she first admitted to the facility in 2022 she was allowed to use her vape pen in her room with the door shut. Then the Administrator left and the new Administrator told her she could not use her vape pen at the facility. Her parents would come and pick her up and take her off the facility grounds to use her vape pen and then return her to the facility. Resident #1 stated she had a medical card for medical marijuana use. She had a THC cartridge and would use this in her vape pen while off the facility grounds with her parents. Her parents stopped doing this last summer as they were getting older and it became more difficult for them. When asked if she used her vape pen at the facility since last summer when her parents stopped taking her off the grounds, Resident #1 stated she would not answer any more questions about this. When asked if she used marijuana at the facility, or had illegal substances at the facility, the resident said she would not answer the question. Review of the hospital (Psychiatry Consultation) record for Resident #1, dated [DATE], documented resident arrived to the hospital emergency department on [DATE] due to being found lethargic and sleepy. While in the hospital resident was given an emergent discharge from the facility due to being found with a THC pen. Resident has court tomorrow after filling an appeal against her emergent discharge. Psychiatry was consulted due to the resident's increased anxiety and depression. Resident reported her mood is anxious. Resident felt that her psychiatric medications were working well prior to this added situational stress. The assessment/plan was to continue with already prescribed psychiatric medications. Review of Resident #1's EHR lacked documentation of an assessment or evaluation completed by the facility after the resident's transfer to the hospital on [DATE] and prior to the facility serving the resident involuntary discharge paperwork. The EHR lacked documentation by the resident's Primary Care Physician (PCP) or the facility's Medical Director (MD) of the resident being a risk to herself or others at the facility prior to the facility serving the resident involuntary discharge paperwork. During an interview [DATE] at 8:00 AM, the family member of Resident #1 stated he had a medical Power of Attorney (POA) for the resident and the resident is her own responsible person. He stated the facility called him on the 18th of January and asked if he wanted to hold the bed for the resident while she was at the hospital, which he said yes he did. The facility did not speak with him regarding the involuntary discharge of Resident #1. The POA stated it had been hard on the family to have to arrange to pick up the resident's belongings and to have to make arrangements so quickly. The POA stated he came to the facility to pick up the resident's belongings and the facility did not ask him to sign the discharge summary. The family member stated Resident #1 is exhausted with all of this, she did not know what she was going to do when she was served the emergency discharge paperwork. During an interview [DATE] at 9:10 AM, Staff A, RN, stated in September of last year she was given a report by another staff member Resident #1 had smoked marijuana with her vape pen and gave it to another resident. Staff A stated this did not happen on her shift, she was given the information at shift change. Staff A stated she and another nurse went into the resident's room and Staff A asked the resident if she had a vape pen and if she used it. Resident #1 told her it was a hemp pen and said her marijuana pen was at home. Resident #1 admitted to giving some to another resident. Staff A talked to the other resident who reported using the vape pen with Resident #1. Resident #1's family came and picked up the vape pen. Staff A reported this to the Director of Nursing (DON). Resident #1 told Staff A she would probably get kicked out. Staff A stated she was not aware of any changes in the resident's care plan or changes with care after this incident in September of 2025. Staff A stated in December of 2025, the night nurse said they were doing something with the resident's blankets and found 3 unidentified pills in her bed. The night nurse gave them the pills to Staff A when she came on shift in the morning and Staff A gave them to the DON. Staff A asked the resident if she knew what the pills were and she said no. Staff A stated on the 16th of January, this year, she knocked on the resident's door and then went inside. The resident had something in her hands and went to hide it and smoke came out of her mouth. Her room smelled like marijuana. Staff A told her you know you cannot smoke marijuana in the building, she said it was nicotine. Staff A reported this to Staff B, Business Manager, who was the only manager in the building. Staff B talked to corporate who said to remove the vape pen from the resident's room. Resident #1 would not give Staff A the vape pen. Resident #1 appeared impaired, she was assessed every shift for the next day and a 2 person rule was put in place, two staff with her with every care. During an interview [DATE] at 12:05 PM, Staff C, Social Worker, stated she accompanied the Administrator the first time and the last time to the hospital to give the resident the notice of discharge. The Administrator gave Resident #1 the paperwork and told the resident she had paperwork for her, handed her the envelope and they left. Staff C stated an evaluation or assessment of the resident did not take place and no other conversation took place. The last time, she and the Administrator walked in and the Administrator handed the resident the envelope and the resident said wow you guys are putting a lot of miles on your car, the Administrator said yes we are. No evaluation or assessment was completed with the resident. Staff C stated the facility wanted her to go as a witness. During an interview [DATE] at 12:15 PM, the DON stated in December of 2025 the pills were found in Resident #1's bed in the early morning shift and were given to the next shift nurse and then given to the DON. The DON called the pharmacist and they could not identify what the pills were. The DON also did some research and could not find what they were. These three pills did not match any pills for the resident or any other resident. The DON stated he destroyed the pills as they could not be identified. Staff talked to the resident who said she had no idea what they were. There were three pills in total, all three the same. The DON instructed all of the staff to keep an eye out for any pills unidentified or loose, there were no other interventions at that time. During an interview [DATE] at 8:43 AM, Staff D, Admissions, stated she took mail to the resident at the hospital on the previous Thursday evening, the resident said she was the first person from the facility to visit her and appear welcoming. Staff D explained who she was and that she was dropping off mail. The resident became teary and said it was really hard what happened. The resident stated she knew the facility tried hard to please her. During an interview [DATE] at 9:40 AM, the Administrator and the CNO acknowledged an in person assessment/evaluation of Resident #1 after she transferred to the hospital on [DATE] did not take place, and an assessment/evaluation through conversations with the hospital did not take place prior to serving the resident the involuntary discharge. The Administrator and the CNO acknowledged the facility MD wrote a letter on the 9th of February, 2026, which documented a belief the resident was a danger to herself and others. Both acknowledged prior to this letter on the 9th of February, there is no documentation in the resident's medical record from the MD or from the resident's PCP regarding the resident being a danger to herself or others. The Administrator and the CNO acknowledged the facility had the resident's mother sign the discharge summary, and did not have the resident's POA or the resident sign the discharge summary. Review of the facility Admission, Transfer and Discharge policy, undated, documented:Upon admission, the resident/representative will be informed that if/when the resident is transferred to another health care facility, transferred within this facility, or discharged from this facility, the resident or his/her representative will be informed about the Facility Admission/Transfer/Discharge policies in addition to assurance of comparable care, treatment and services regardless of the resident's payer source If/when facility staff mandates a transfer out of the facility or discharge from the facility, staff will document the reason(s) for and conditions under which the resident is mandated to transfer out of the facility or be discharged and the method(s) for transitioning the responsibility for the resident's care from one clinician, organization, program or service to another. In addition, the following documentation requirements include:The clinical record documentation includes the provision of and response to medical treatment and care, and changes in the residents' condition by the resident's attending physician:The basis of the transferThe specific resident need(s) that cannot be met at the facilityFacility attempts to meet the residents' needs Services available at the receiving facility to meet those needsThe resident's response to medical treatment and careadmission informationAdmitting diagnosisCurrent medical findingsDiet prescribedThe resident's functional status at the time of admission and at the time of dischargeMedical observations and recommendations made after the initial medical assessment, as well as progress notes that are reported at the time of observation and that describe significant changes in the resident's conditionProgress notes recorded at each visit Complete transfer form and discharge summaryEvidence that the attending physician has reviewed the consulting physician's orders for consistency with the interdisciplinary plan of careFacility staff will document in the clinical record discharge information provided to the resident and the receiving organization, if applicable:The basis for the transferSpecific resident need(s) that cannot be met by this facilityFacility attempts to meet the needs of the residentThe reason for transfer, discharge or referralTreatment provided, diet, medication orders, and orders for the residents' immediate careReferrals provided to the resident, the referring licensed independent practitioner's name, address, and telephone number, and the name of the licensed independent practitioner who has agreed to be responsible for the resident's medical care and treatment, if this person is someone other than the referring licensed independent practitionerMedical findings and diagnosis; a summary of the care, treatment, and services provided and progress reached toward goalsInformation about the residents' behavior, ambulation, nutrition, physical status, psychosocial status, and potential for rehabilitationNursing information that is useful in the resident's careAny advanced directivesInstruction provided to the resident and/or surrogate decision-maker before discharge.

Based on observations, staff interview and policy review the facility staff failed to provide care for a resident in an environment that maintained or enhanced dignity for two of five residents observed and required assistance for eating. The facility reported a census of 81 residents.Findings include: Observations on 1/12/2026 at 9AM revealed the following: Staff H, Certified Nurse Aide (CNA) in the dining room (DR) sitting beside a resident with but not interacting with the resident, having a personal conversation with Staff G, [NAME] as she walked around the DR cleaning up tables. Staff H would provide the resident a bite of food and continue to observe and talk to Staff G. Staff F, CNA was sitting between 2 residents, feeding 1 resident while the other resident independently fed herself. Staff F proceeded to engage in conversation with the independent resident, provide the other resident a bite of food and then proceed back to the conversation with the other resident. Staff F would only look at the resident when she provided him a bite of food and then the resident would have to wait 2-3 minutes after finishing the bite before receiving another bite of food as Staff F was talking with the other resident and not watching the resident she was feeding. Facility Resident Rights policy, undated, revealed each resident will be treated with dignity. Interview on 1/14/2026 at 9:30 AM, the Chief Nursing Officer stated expectation for staff to engage with and observe the resident while they are feeding the resident.

Based on interviews, providers' orders review and IPOST review, the facility failed to have the updated IPOST (Iowa Physician Orders for Scope of Treatment) for 1 out of 24 residents reviewed (Resident #8). Resident had a provider's order directing the code status for Resident #8 was Do Not Resuscitate (DNR) and an IPOST directing the code status for Resident #8 was CPR (Cardiopulmonary Resuscitation)/Attempt Resuscitation. The facility reported a census of 82 residents Findings include: An IPOST dated [DATE], directed staff to perform CPR on Resident #8 in the absence of breathing and a heart beat. On [DATE] on 2:34 p.m., Staff A, Registered Nurse (RN), stated to check a resident's code status she would look in the electronic health record (EHR). When asked if it would be anywhere else, she said 'you could look in their chart too.' On [DATE] at 10:15 a.m., it was noted that Resident #8 had a Dr's order for DNR in his EHR, but in his hard chart the IPOST directed CPR. On [DATE] at 10: 45 a.m., Staff B, Licensed Practical Nurse (LPN), stated she is in training. When asked if she had been trained or shown where to look for a resident's code status, she stated yes. She was sitting at the nurses' station and pulled the EHR up on the computer and said she would check there. At the same time of the above interview, Staff C, RN, was sitting at the nurses' station. She overheard the conversation and said she would check in the residents' hard chart (EHR) as that is where the IPOST is. She stated she would check the IPOST as she has worked at other places where the EHR was wrong, so it was best to check the IPOST. On [DATE] at 10:50 p.m., Staff D, LPN stated she would check code status in the hard chart by looking at the IPOST. At the same time Staff E, RN, stated she would go to the electronic health record. Staff E then pulled a resident's record up and pointed to the code status. On [DATE] at 11:00 a.m., Staff C looked at Resident #8's EHR and verified Resident #8's code status was DNR. She then looked at the IPOST in the EHR, and verified code status was a full code. She had dialogue with staff around her and it was determined that this resident was in Hospice. Staff C then went to the Hospice book and the IPOST was not in the Hospice book. When asked who is responsible to get the correct IPOST in the hard chart, Staff C stated she was going to reach out to Hospice and see if they have the order for the change. On [DATE] at 11:00 a.m., Staff C stated she got a hold of Hospice and they will be getting the updated DNR IPOST to the facility.On [DATE] at 4:00 p.m., The Administrator and the ADON acknowledged the above concern regarding Resident #8's IPOST was not correct with the doctor's order. A Cardiopulmonary Resuscitation policy dated 12/2021, directed the following: Purpose: To provide guidelines on the facility CPR procedures and the emergency procedures associated with providing CPR.Policy: Sunny View Care Center has systems in place to ensure resident desires for CPR are obtained, CPR status is communicated to staff, consistent trainings are completed for staff and these systems are audited.Procedure:1 . Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness).2. Resident code status will be determined upon admission as communicated by the resident or the resident's decision maker.3. Resident code status will be documented in the resident's medical chart on the Iowa Physician Orders Sheet for Scope of Treatment ('POST).4. In the event that a resident or the resident's decision maker decides that their treatment will include CPR the resident will be a FULL-CODE.5. Identification of resident's that have selected CPR as part of their treatment will be identified by the following means:a. Medical Chart will have a name label that is green in color.b. FULL-CODE resident list posted at the nursing station and on the crash cartc. Purple dot on the label on the medical chartd. Purple dot on resident name platee. Purple dot on resident call light plate6. The care plan team will review resident CPR status with resident or resident's decision maker at least quarterly during the scheduled care plan review meeting.7. All licensed staff (RN/LPN) must have and maintain CPR/BLS certification from the American Red Cross or American Heart Association (AHA) prior to and during their employment.8. Upon hire all CPR/BLS certified staff will receive as part of their orientation training on the facility CPR]FULL-CODE procedures. Includes but not limited to:a. Identification of FULL-CODE resident(s)b. Crash cart locationc. CPR kit locationd. FULL-CODE/CPR Standard Work [NAME]. IPOST Form9. At least annually the facility will provide a CPR/BLS course that is certified by the American Red Cross, AHA or an on-tine option when in-person training can't be accommodated.10. The facility will conduct at least quarterly, mock code simulations.1 1 . Annually, the facility will conduct an in-service focused on facility CPR/BLS procedures and code status identification.12. Facility will monitor systems for compliance that include a minimum of:a. Crash Cartb. CPR Kitsc. Purple Dot Identification on name plates and call-light platesd. FULL CODE liste. FULL CODE chart labelf. Resident roster list13. Monitoring will be conducted by the Director of Nursing or as designated by the Director of Nursing.Emergency Procedure - Cardiopulmonary Resuscitation1. The facility's procedure for administering CPR shall incorporate the steps covered in the current American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material.2. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, ainNay, breathing).3. If a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order exists that prohibits CPR from being initiated.4. Upon identifying that the resident is a FULL-CODE activate the emergency response by call CODE-PURPLE and location across the walkie-talkie system or yelling it. Additionally, pull call light cord.a. All available CPR/BLS certified staff respond to CODE-PURPLE locationb. Responding staff obtain crash cart and deliver to CODE-PURPLE locationc. One (1) staff member contact 91 1 and inform dispatch CPR is in process (After call is made, wait for EMS to arrive and assist responders to FULL-CODE area)d. One (1) CPR/BLS certified staff member Assist with two (2) person CPRe. One (1) CPR/BLS certified staff member take notes and assist with CPR as needed (IF AVAILABLE)5. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing.6. Delivering high-quality chest compressions is essential:1. Push hard to a depth of at least 2 inches (5 cm) at a rate of at [NAME] 100 compressions per minute.2. Allow full chest recoil after each compression.3. Minimize interruptions in chest compressions.4. Position resident on a hard surface (Floor, deflated air mattress, CPR board)7. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.8. Continue CPR/BLS until relieved by EMS

Based on record review, staff interview and policy review, the facility failed to provide the required Center for Medicare Services (CMS) Notice of Medicare Non-Coverage (NOMNC) forms to address beneficiary appeals and liability notice for one of three residents reviewed for advanced beneficiary notices (ABN) (Resident #72). The facility reported a census of 81 residents. Findings include: Record review revealed Resident #72 had skilled services 11/18/25 to 11/22/25 and remained in the facility. The record also revealed the facility issued the Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) CMS form #10055 and obtained verbal consent from the Power Of Attorney on 11/20/25 for therapy services that ended 11/22/25. However, the facility failed to issue a Notice of Medicare Non Coverage (NOMNC) CMS Form #10123 regarding the right to appeal further skilled therapy services within the required 48 hours of skilled serviced ending on 11/22/25. In an interview 1/14/26 at 7:30 AM, the Social Worker reported she provided the SNF ABN forms whenever skilled services were ending for residents. She was not aware there were two forms to provide and only provided one form (form 10055) when Resident #72's services were ending. An email on 1/14/26 at 7:31 AM, the Administrator wrote the SW was unaware that both the ABN and NOMNC were to be issued. The SW was educated and a cheat sheet given that explained when both are to be issued so she can reference that in the future. An undated Medicare Denial Notice (Advanced Benefit Notification-ABN) policy revealed the facility will inform each resident periodically during the resident's stay of services and charges for those services including any charges for services not covered under Medicare. The facility will provide written notification to residents with necessary information to decide whether or not to appeal a decision to terminate Medicare care and services at least three days prior to the planned change in payor status or discharge.

Based on interview, observations, and record review, the facility failed to ensure 1 out of 3 residents' property was inventoried and failed to replace his personal property after he reported that it was missing (Resident #81). The facility reported a census of 82 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #81 included COPD (Chronic Obstructive Pulmonary Disease), anxiety and depression. A Brief Interview for Mental Status (BIMS), revealed a score of 13 out of 15, which indicated intact cognition. On 1/11/26 at 2:40 p.m., Resident #81 stated his only concern is that he is missing some of his things from when he moved to his current room from another room. He stated he was missing a narrow cabinet that also was an instrument from [NAME], 2 large books from [NAME] and Noble, and a statue about 1 1/2 feet tall (showed height with his hands). He said he would appreciate this being looked into. A Grievance Log provided by the facility showed a list of residents who reported having missing items from 3/27/25 to 1/10/26. Resident #81's name was not on this list.On 1/14/26 at 10:30 a.m., the Social Worker (SW), stated Resident #81 did report some items missing. When asked when this was reported she said Monday (1/12/26). She stated he reported 2 books, a statue and a dresser that was also an instrument of some kind. When asked what she did with the information, she stated she had reported it to housekeeping. The SW provided: a Complaint/Grievance Report dated 1/7/26. This report documented Resident #81 verbally communicated he was missing the following items: dresser/instrument, ceramic (statue), and anatomy books. The SW documented she notified housekeeping of missing items. An Inventory of Personal Effects dated 4/26/24. The sheet listed no items and had written on the top that (the facility) would do this resident's laundry. Both of these items were signed by the SW. On 1/14/25 at 11:25 p.m., this resident gave permission for the surveyor to reach out to his sister and ask about the missing items. He stated it was months ago when the items went missing. He repeated the items went missing when he had moved from a room down the hall to the room he presently was in. He stated he did not report the items the day of the move but he did a few days after the move when he noticed them missing. He reported it to the staff across the hall from him a few months ago. (SW's office). He said several people have looked for the items but all he has heard back was that nobody has found them. He stated he wants to know when the facility was going to replace them. On 1/14/25 at 11:33 p.m., Resident #81's sister stated she had not seen the dresser that was also an instrument. It was not in the items she had brought from home. She stated if he had something like that it must have been given to him after he was admitted to the facility. Same with the [NAME] and Noble books. He would not have gone to [NAME] and Noble after his admission, so someone must have given those to him. She did verify the Indian nation statue was with his things when he admitted to the facility on [DATE] at 11:40 p.m., the SW stated she did not know why the inventory was not taken when he was admitted . She said she is the one responsible to take inventory and she signed it but she must have been doing other things that day because she did not get it done. She stated the first time Resident #81 reported the missing items was last week. She had not heard anything about the missing items prior to this. This SW stated she had been employed at this facility for approximately 2 years. On 1/14/25 at 4:00 p.m., the Administrator and DON acknowledged the concern with missing items were reported per Resident #81 shortly after he had moved rooms to the person across the hall. They acknowledged the SW's office was directly across the hall from his current room. They acknowledged concerns that the inventory sheet was not done. They acknowledged the Grievance Log provided by the facility did not include Resident #81's items and they acknowledged no attempt had been made to replace the items. An undated MISSING ITEMS policy, directed the following:The Missing Items Report is used when attempting to locate any resident's, visitor's, or others' belongings determined to be missing or allegedly stolen.POLICYNursing personnel are responsible for completing the resident's Inventory Sheet on admission, when items are detivered to or removed from a resident's room, and updating it at least annuallyNursing personnel are responsible for filing the grievance and any other appropriate reports regarding missing items with the Administrator immediately and/or social worker o The department managers and others, as designated by the facility administrator, will begin an immediate investigation of the missing item. Any missing items located will be returned to the resident immediately upon the location of the item.PROCEDURES When an item is reported missing by a resident, the supervisor of the facility will initiate a search of the unit for the item The Director of Nursing, or facility administrator, is responsible for notifying the resident and/or family immediately if the item is not found at the time of the initial search.If the location of the missing item cannot be found in a reasonable time frame, the facility will replace the item at facility cost.Staff Responsible: All

Based on clinical record review, policy review, and staff interview the facility failed to complete upon discharge the recapitulation for a resident's stay for 1 of 3 residents reviewed (Resident #95). The facility reported a census of 81 residents. The Discharge Minimum Data Set for Resident #95, dated 12/1/25, revealed the resident was admitted to the facility on [DATE] and discharged to home/community on 12/1/25. Review of Resident #95's clinical record lacked a recapitulation of stay. Facility Discharge Policy with Criteria, undated, instructed the facility staff will develop a post-discharge plan of care and a discharge recapitulation form will be completed. Interview on 01/14/2026 at 1:19 PM, the Director of Nursing stated he was unable to find that a recapitulation of the resident's stay was completed. Interview on 1/14/2026 at 1:20 PM, the Chief Nursing Officer stated her expectation for a recapitulation of the resident's stay to be initiated by the social worker and then completed by each department assigned when a resident is discharged .

Based on observations, interviews, and record review, the facility failed to ensure 1 out of 1 resident reviewed received his prescribed medication upon a hospital return (Resident #8). Resident #8 returned from the hospital on [DATE] and did not receive the majority of his medications until 1/2/26 and 1/3/26. The facility reported a census of 82 residents. Findings include:A Minimum Data Set (MDS), dated [DATE], documented diagnoses for Resident #8 included hypertension (high blood pressure), diabetes, arthritis, non-Alzheimer's dementia, Post Traumatic Stress Disorder (PTSD), obesity, and low back pain. A Brief Interview of Mental Status (BIMS), revealed a score of 13 out of 15 which indicated intact cognition. This MDS indicated that Resident #8 was taking antipsychotic, antidepressant, diuretic, antiplatelet, hypoglycemic (including insulin) and anticonvulsant medications. A Nurse's Progress Note dated 12/31/25 at 2:57 p.m., documented that at 1:30 p.m., Resident #8 arrived from hospital after a lengthy stay and was treated for Urinary Tract Infection (UTI). Additional diagnosis as follows: Type II Diabetes mellitus (Insulin dependent), Chronic kidney disease Stage 4. Dementia, sleep apnea, HTN, Hyperlipidemia, Dyspnea, ETOH abuse, Chronic post-traumatic stress disorder, glucose intolerance, chronic pain. Upon hospital return assessment Resident #8 presented as very ill in appearance. He was difficult to arouse. This speaker (the author of this note) had to adjust tone very loud to get him to open his eyes. No verbal communication. Will occasionally shake head to yes or no questions. Shakes head No when asked if he is in pain. Conjunctiva (thin membrane that covers the eyelids and whites of eyes) pale bilaterally. Nares patent without drainage. Hard of hearing. Moderate signs/symptoms of dehydration noted. Orbits sunken, skin turgor poor. Skin warm and dry without cyanosis (bluish color of skin) or diaphoresis (perspiration). Tongue coated with very thick white substance. Per hospital report, this resident has not been eating and taking small amounts of fluid only in which he generally let's run out of his mouth. He is on full liquid diet only. Lung sounds essentially clear with decreased breath sounds in Right Lower Lobe. Moist sounding cough but not productive. Abdomen soft non-tender to palpation. Bowel sounds present. Has very strong body odor upon hospital return. Smearing soft brown stool from rectum. Briefs in place. Per history from hospital, this resident was treated for a fecal impaction while at the hospital. Foley catheter patent draining light yellow urine. No sediment noted. Catheter anchored to leg. EBP (Enhanced Barrier Precautions) in place secondary to catheter. 2+ pitting pedal edema (swelling) to bilateral feet and ankles. Had a right heel wound and a left heel wound. Wife contacted regarding grave condition upon hospital return and the inability to consume much fluid or any nutrition. Spoke with the Advanced Registered Nurse Practitioner (ARNP) who gave order for Hospice consult. Facility social worker working with wife on setting up hospice of her choice. Resident #8 repositioned for comfort and resting with shallow respirations as noted above. This note was documented by the Chief Nursing Officer.A Nurse's Progress Note dated 1/1/26 at 9:18 p.m., documented Resident is extremely antsy and attempting to walk most of the evening. His medications still have not arrived from the pharmacy. (the author) left a 2nd voicemail with the pharmacy requesting that the medications be delivered As Soon As Possible (ASAP) tomorrow so that staff can get his medications to him. Resident #8 is able to be redirected easily with 1:1 care. This note was documented by Staff Q, Licensed Practical Nurse (LPN). A Nurse's Progress Note dated 1/2/26 at 8:22 a.m., Resident #8 hasn't had routine medications since his return on 12/31/25. Pharmacy stated they will deliver the medications on their 10:00 am run. This resident is unsettled and hasn't slept all night. This resident will not stay in his wheelchair and had to be continually redirected and is not redirectable at times. Notified the Administrator. This note was documented by Staff K, Registered Nurse (RN).A Nurse's Progress Note dated 1/2/26 at 10:30 p.m., documented this resident was restless and antsy most of shift. He is ambulating without assistance and being non-compliant with using assistive devices. He is dragging foley cath on the floor while walking. This writer put a leg strap on the residents catheter (tubing) to help with tension at insertion point and resident removed thigh strap. Another strap was placed and resident removed it again. Resident is pleasant and easily redirected but does not stay in one place for long. This note was documented by Staff Q. There were no further progress notes documenting that most of this resident's medications did not arrive until 1/3/26. On 1/13/26 at 1:30 p.m., the pharmacy's Director of Operations (DOO), on a phone call over speaker with the Administrator, Director of Nursing (DON) , and the Chief Nursing Officer (CNO), the DOO stated the pharmacists enter the doctor's orders into the electronic health record (PCC) for the facility. He stated that on 12/31/25 the pharmacy closed early at 4:00 p.m., on that day for New Year's Eve. The pharmacist working that day entered the first half of the doctor's orders, The DOO stated nobody finished the 2nd half of the job and the fault was on them. He stated after the pharmacy closed on 12/31/25 until they opened again on 1/2/25, two on call pharmacists were working. The DOO stated that he talked with both of the on call pharmacists and neither of them received a call regarding Resident #8 from during the time they were on call. The DOO stated it looked like a terrible timing thing and it's an error on their part. The DON stated directly after the above call that the nurses fax the orders to the pharmacy and then the pharmacy enters the orders into PCC. The nurse then checks PCC against the faxed orders to ensure the orders are correct. The pharmacy has access to all of this facility residents' PCC records. On 1/13/26 at 1:40 p.m., the Administrator acknowledged that the nurses should have done more to ensure the medications got to the facility. On 1/14/26 at 10:50 a.m., Staff K stated that she was working in the back on 12/31/25 and 1/1/25. On 1/2/25 she covered the middle of the facility where Resident #8 (R#8) lived. She stated she found out R#8 didn't have his medications since he returned on 12/31/25 from the hospital. She stated this was ridiculous. She phoned Staff L, Advanced Registered Nurse Practitioner (ARNP), to let her know. Staff K called the pharmacy and let them know she needed the medications STAT (right away). When Staff K let Staff L know about this resident not receiving his medications since he returned from the hospital, they both thought the pharmacy would deliver all of the medications the facility had not yet received. Staff K stated that she found out later that when the pharmacy came to deliver the medications they only brought 2 medications with them. Staff K stated they had been able to give a few medications as his Insulins were still in the cart from prior to the hospitalizations and maybe some others. She stated she did not know if anyone tried to give him medications from their eKit (locked supply of medications at the facility accessed when needed). On 1/14/26 at 11:00 a.m., Staff L stated she found out that Resident #8 had not had the majority of his medications on 1/2/25 when Staff K told her. She stated at that time the pharmacy had been contacted and the medications were to be on their way. Staff L said that if someone would have contacted her to let her know that his medications were not in house earlier, she would have told them to keep trying the pharmacy. Staff L stated she assessed REsident #8 on the day he returned from the hospital and she was mostly concerned about getting him a Hospice consult as he was lethargic and not responding. She stated that he has perked up since then. An email sent by the Administrator on 1/14/26 at 11:04 AM, documented the following: After evaluating administration logs, charting, and progress notes the affected medications are listed below. An email sent by the Administrator on 1/14/26 at 11:04 AM, documented the following: After evaluating administration logs, charting, and progress notes the affected medications (medications that were prescribed but not available for this resident) are listed below. Melatonin 5mg (milligrams) (a hormone that affects sleep wake cycles)Not in E-KitRisperidone 1mg (antipsychotic)Not in E-kitTamsulosin HCL 0.4mg (relaxes smooth muscles in the prostate and bladder neck)Not in E-kitTrazodone HCL 50mg (antidepressant)In E-Kit but requires access code provided by pharmacy to pull a doseClonidine HCL 0.3mg (blood pressure medication)Not in E-KitCyclosporine Ophthalmic Emulsion 0.05% (increases tear production in dry eyes)Not in E-KitNystatin Mouth/Throat Suspension (antifungal for oral thrush)Not in E-KitAmlodipine 5mg (blood pressure medication)Not in E-KitAspirin 81mg (prevention of heart attack and stroke)Not in E-KitCholecalciferol 50 mcg (micrograms) (vitamin D)Not in E-kitFamotidine 40mg (reduces stomach acid)Not in E-KitFinasteride 5mg (treat symptoms associated with enlarged prostate)Not in E-KitFluconazole 100mg (treats yeast infection)Not in E-KitFluoxetine HCL 40mg (antidepressant)Not in E-Kit Hydralazine 100mg (blood pressure medication)Not in E-kitPartial delivery received mid-day on January 2ndGabapentin 300mg (treats partial seizures and nerve pain)100mg capsules in E-KitWas not pulled (facility had this medication available but did not get it out of their E-Kit to administer it to him.) Unaffected medications (these medications were available upon Resident #8's return to the facility):Insulin AspartInsulin GlargineTylenolBisacodyl suppository (treats constipation)Milk of Magnesia (treats constipation)Nitrostat (for chest pain) An email sent on 1/14/25 at 11:49 AM, requested clarification for the following: The evening doses on the 2nd for Rispridone, Trazadone, and Melatonin were signed as given, were they delivered by pharmacy along with the hydralazine? Were the Lidoderm external patches left in the cart while he was in the hospital?An email prepared by the Director of Nursing and sent on 1/14/26 at 1:51 PM, documented the following:On 1/2/2026 at 1036 a delivery was received containingResperidone (2nd dose) delivered and administeredTrazodone delivered and administeredMelatonin delivered and administeredHydralazine delivered and administered Lidoderm external patches were in the cart from prior to his hospitalization. An undated Medication Ordering and Receiving from Pharmacy Provider policy, directed the following:Policy Medications will be delivered to the facility in packaging to facilitate proper administration of the medication.Procedures The Administrator, Director of Nursing, and provider pharmacy establish a daily delivery and pick-up for medication orders. The schedule lists the pharmacy's regular and after business hours, applicable telephone numbers, and routine medication order and delivery times, and other pertinent information, such as the poison control center telephone number. The dispensing pharmacy shall have an on-call system available for after-hours to deliver medications as needed. This includes weekends and Holidays. On-call hours for the pharmacy will be posted to obtain the medications in a timely manner. Solid oral medication forms (tablets and capsules) are supplied by the provider pharmacy in packing strips, which are delivered each evening to be placed in the respective medication carts. Medication packages are labeled by the provider pharmacy and placed in the medication storage system for each resident. Veterans may receive medications from an approved VA pharmacy provider in bulk bottles of medications if the medications are appropriately labeled per pharmaceutical regulations. Daily strips are available for each resident that are in pill form that includes each medication listed on the packing strip. Liquid medications will be labeled according to pharmaceutical standards. Any problems noted with the packaging of a medication shall be reported immediately to the provider pharmacy. If a medication is ordered and is not available in a timely manner (within 24-hours) of the physician's order, the nursing staff will notify the pharmacy of the needed medication. The physician may clarify the order to indicate the medication may be started when the medication is available; OR the physician may clarify the order to indicate the medication is required to be given now or stat and the dispensing pharmacy will be responsible for communicating with the ordering physician and locating an alternate source for the medication; OR the physician may discontinue the order and order a medication that is available within the facility's E-kit or is available for stat delivery from the dispensing pharmacy. The consultant pharmacist who completes the drug regimen review will communicate with the dispensing pharmacy any significant irregularities identified during the monthly consultation. The Director of Nursing and/or facility administrator may request the dispensing pharmacist to attend meetings as requested at the facility to review any irregularities noted in service.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 2 of 3 residents reviewed (Resident #44 and Resident #68). The facility failed to ensure use of enhanced barrier precautions (EBP) when required. The facility reported a census of 81 residents. Findings include:1.The Minimum Data Set (MDS) for Resident #44, dated 12/3/25, included diagnoses of Non-Alzheimer's Dementia and retention of urine. The MDS identified the resident was dependent on staff for toilet hygiene. The MDS indicated the resident had a indwelling catheter (tube into bladder to drain the urine from the bladder). The MDS indicated the resident had a BIMS score of 2, indicating severe cognitive impairment. Resident #44's Care Plan with target date 3/3/26, documented the resident had an indwelling catheter and intervention to utilize enhanced barrier precautions per policy related to the foley catheter. Observation on 1/12/26 at 1:47 PM, Staff I, Certified Nurse Aide (CNA) and Staff J, CNA entered Resident #44's room and applied gloves only. Staff I and Staff J proceeded to transfer the resident from the wheelchair to the bed and provided peri care, catheter care, and emptied the catheter. Interview on 1/12/26 at 2PM, Staff I stated Resident #44 was on EBP due to the catheter and she should have worn a gown for the resident's cares. Interview on 1/12/26 at 3:30 PM, the Director of Nursing stated training had previously been provided to all staff regarding EBP and the expectation to use EBP (gown and gloves) when providing care to a resident with a catheter. 2. The MDS assessment dated [DATE] revealed Resident #68 had diagnosis of a Stage 3 pressure ulcer, dermatitis, and excoriation skin picking disorder. The MDS documented the resident had a Brief Interview for Mental Status score of 6, indicating severely impaired cognition. The MDS revealed the resident had incontinence. The Care Plan revised 11/25/25 revealed the resident had an altered skin integrity related to incontinence, immobility, MASD (moisture associated skin disorder), and a Stage 3 pressure ulcer on the coccyx. The Care Plan directed staff to to provide good peri-care after each incontinence episode to prevent skin breakdown or infection. The Care Plan lacked info about EBP's. The Back North Hallway Biosheet updated 10/22/25 revealed under Other Information that Resident #68 was on EBP's due to wound care. The Order Summary revealed an order for silvadene cream to the coccyx and buttocks topically two times a day for wound care started 12/23/25 and doxycycline (an antibiotic) by mouth two times a day for cellulitis to buttocks for 10 Days started on 1/12/26. A skin assessment dated [DATE] revealed the resident had an unstageable pressure ulcer to the coccyx and her left heel. Observations revealed the following: a. On 1/12/26 at 9:09 AM, Staff N, CNA, entered the room, washed her hands, and donned a pair of gloves. Staff M, CNA, and Staff N used a mechanical lift and transferred the resident from a wheelchair to bed. At 9:13 AM, Staff M, donned a pair of gloves, removed the resident's pants and brief, and provided incontinence care. Staff N assisted the resident to roll onto her side and assisted Staff M with cares. b. On 1/13/26 at 7:48 AM Staff P, CNA, wore gloves and removed foam boots from the resident's feet. A dark black pressure area was observed on the left heel. Staff P provided incontinence care then placed a sling under the resident. Staff P did not wear a gown before or during cares. At 8:05 AM, Staff P and Staff O, CNA, connected the sling to a mechanical lift and transferred the resident from the bed to the wheelchair. Staff P and Staff O did not wear a gown when they transferred the resident. In an interview 1/13/26 at 7:55 AM, Staff P, CNA, reported the resident had a sore on her heel and her bottom. In an interview 1/13/26 at 8:15 AM, Staff O, CNA, reported she did not think Resident #68 was on EBP. The EBP sign on door was from another resident that was in that room. Staff O reported EBP's required anytime a resident had a catheter or a skin condition. Staff O confirmed a gown and gloves should be worn whenever a resident on EBP's. In an interview 1/13/26 at 8:20 AM, Staff P reported a gown and gloves worn whenever she provided cares to residents on EBP's. Staff P acknowledged she forgot to wear the gown when she provided cares for Resident #68. Staff P reported she got nervous with State watching her and she just forgot to put the gown on. In an interview 1/14/26 at 1:05 PM, the Assistant Director of Nursing (ADON) reported EBP required for residents with a wound or catheter. The ADON reported she expected staff wear a gown and gloves whenever staff performed cares or transferred a resident that was on EBP's. An undated Enhanced Barrier Precautions policy revealed the facility followed recommendations and guidance from the Center for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI), such as multi-drug resistant organisms (MDRO). EBP are implemented as one intervention to reduce the transmission of resistant organisms and employed the use of Personal Protective Equipment (PPE) during high contact resident care activities. A gown and gloves worn prior to and during high-contact care activities including whenever staff toileted a resident or changed their briefs, provided catheter care, and whenever transferred a resident who had a wound or indwelling medical device such as a catheter.

Based on observations, interviews, and record review, the facility failed to maintain mechanical and electrical patient care equipment in safe operating condition for 5 out of 5 residents reviewed (Residents #1, #7, #10, #11, and #12). Resident's #1 and #12 had care delayed related to batteries not working in stand lifts. Resident #7's bed would raise but not lower (beds in low position are a standard of safety). During separate observations of Residents #10 and #11 it was observed that 1 of the 4 wheels on the mechanical lift used to transfer the residents came off of the ground during the transfer. The facility reported a census of 86 residents. Findings include: 1. The Annual Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included multiple sclerosis (MS), anxiety and depression. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognition. This resident was dependent on staff for toilet transfers, sit to stand, and for chair/bed to chair transfers. A Care Plan for Resident #1 had the following interventions: -Toileting: Assist Resident #1 to the stool with use of sit to stand (lift) and 2 assist. On [DATE] at 10:59 AM, Resident #1 stated that the battery dies a lot on the lifts. She said when they get the stand lift to the room, much of the time the battery dies. She voiced frustration, as she has to wait for staff before she can transfer to the toilet. She said the machines are so old the batteries don't stay charged. On [DATE] at 11:12 AM , Staff D, Certified Nurse Aide (CNA) returned to this resident's room with the stand lift. She stated Staff E, Certified Medication Aide (CMA)/CNA will come in to help. On [DATE] at 11:18 AM, they started to transfer this resident but the battery died. Staff E left the room with the battery. She stated she would be right back. Staff D confirmed the battery had died. She stated they just had charged the battery. On [DATE] at 11:20 AM, Staff E returned to the room with a different battery. She placed the battery on the EZ stand and the battery did not work. On [DATE] at 11:29 AM, Staff E returned with a different stand lift and transferred this resident to the toilet. On [DATE] at 2:35 PM, the Chief Nursing Officer (CNO), Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), acknowledged this concern regarding the battery dying, delaying the resident being able to use the toilet. 2. The Quarterly MDS dated [DATE], documented diagnoses for Resident #12 included Parkinson's, depression, and chronic pain. A BIMS documented a score of 15 out of 15, which indicated intact cognition. This resident was dependent on staff for toilet transfers, sit to stand, and for chair/bed to chair transfers. On [DATE] at 12:55 PM, this resident verified staff transferred her with the stand lift. When asked if she had any concerns with her transfers, she stated the only problem is the batteries. They will die and the staff have to run and get another battery. She said she has been left standing there on the machine while they go and get another battery. This resident stated she didn't know if they don't have enough batteries, or the chargers are not working or what, but it happens a lot. On [DATE] at 2:35 PM, Nurse consultant, LHNA, and DON, acknowledged this concern regarding the battery dying while resident was in the standing position and with the resident not liking being left in the standing position. On [DATE] at 10:43 AM the Director of Operations verified they have had issues with batteries and charges holding on the facility lifts. We have found that staff were not plugging them in to charge. If we need to replace them we do. He stated staff are to charge the batteries overnight and if the batteries do not work then the batteries are pitched and replaced. The Director of Operations acknowledged concerns regarding Resident #1 and Resident #12. The Resident Council minutes dated [DATE], documented that an EZ Stand was out of commission. 3. The Quarterly MDS assessment dated [DATE] revealed Resident #7 with a BIMS score of 5, indicating severe cognitive impairment with disorganized thinking and difficulty focusing attention. Resident #7 has a cerebrovascular accident (stroke) diagnosis and dependent on staff for chair/bed to chair transfers. The Care Plan with a target date of [DATE] listed Focus Areas related to communication problem and Activities of Daily Living (ADL) self-care performance deficit related to limited mobility and stroke. Interventions include the use of a mechanical lift to/from wheelchair with the assist of 2 staff members and keeping bed in a low position with wheels locked. During on observation on [DATE] at 1:20 PM Staff H, CNA, completed personal cares on Resident #7 in bed, which was in a higher position. Staff H voiced the resident's bed is broken as it does not lower down. Staff H was not sure how long the bed had been broken. During an interview on [DATE] at 10:25 AM Staff G, CNA, acknowledged Resident #7's bed not working properly. Explained the head and foot bed can be adjusted but the up and down function does not. Staff G estimated this has been on-going for a week/week and a half and had been reported. During an interview on [DATE] at 10:35 AM, Staff I, CNA, acknowledged Resident #7's bed not working properly. They explained it had not been working since late last week. During an interview on [DATE] at 10:45 AM, Staff J, CMA (certified medication aide)/CNA, acknowledged Resident #7's bed not working properly as it does not go down to a lower position. They believe it wasn't working over the weekend and unsure how long it has not worked properly. During an interview on [DATE] at 10:50 AM, Staff L, Maintenance, voiced this morning was the first they had received a work order regarding Resident #7's bed not working. They suspect it may be an issue with the remote but will asses the situation. During an interview on [DATE] at 11:30 AM, Staff K, CNA, acknowledged Resident #7's bed not working properly as does not go up/down. They believe the bed was this way when last worked the hallway three days ago. Staff K explained Resident #7 likes her bed in a higher position so she may see the television better. During an interview on [DATE] at 10:05 AM, Staff L acknowledged Resident #7's bed was not working properly as it did not go down to a lower position. The remote was changed out and it is working properly. Staff L explained the bed work order was placed by the Quality Assurance nurse on [DATE]. Staff L along with the LNHA voiced any staff member (aides, housekeeping) can enter a work order electronically through the TELS maintenance program. Routine bed maintenance completed monthly. 4. The Quarterly MDS assessment dated [DATE] revealed Resident #10 with a BIMS score of 5 indicating severe cognitive deficits. Diagnoses include cerebral ischemia (reduced blood flow to the brain) and non-Alzheimer's dementia. Resident #10 dependent on facility staff for chair/bed to chair transfers. The Care Plan with a target date of [DATE] listed a Focus Area related to Activities of Daily Living (ADL) self-care performance deficit due to impaired balanced, limited mobility and chronic pain. Interventions include the use of a mechanical lift to/from wheelchair with the assist of 2 staff members. During an observation on [DATE] at 12:00 PM, Staff I, CNA, and Staff J, CNA, transferred Resident #10 from the bed to a wheelchair utilizing a mechanical lift labeled #4. At the beginning of the transfer, all four wheels of the lift were on the ground. During the transfer, while Resident #10 was in the air, the lift's back-left wheel was seen off the ground approximately 1-2 inches. The other three wheels remained on the ground. The front part of the mechanical lift dipped down during this time. Once Resident #10 was transferred and seated into the wheelchair, the back-left wheel returned to the ground. 5. The Quarterly MDS assessment dated [DATE] revealed Resident #11 with a BIMS score of 13 indicating intact cognition. Diagnoses include coronary artery disease, heart failure, morbid obesity, and peripheral vascular disease. Resident #11 dependent on facility staff for chair/bed to chair transfers. The Care Plan with a target date of [DATE] listed a Focus Area related to Activities of Daily Living (ADL) self-care performance deficit due to weakness, acute on chronic health conditions, debility and cognition. Interventions include the use of a mechanical lift between surfaces with the assist of 2 staff members. During an observation on [DATE] at 11:45 AM, Staff I, CNA, and Staff J, CNA, transferred Resident #11 from the bed to a wheelchair utilizing a mechanical lift labeled #4. At the beginning of the transfer, all four wheels of the lift were on the ground. During the transfer, while Resident #11 was in the air, the lift's back-left wheel was seen off the ground approximately 1-2 inches. The other three wheels remained on the ground. The front part of the mechanical lift dipped down during this time. Once Resident #11 was transferred and seated into the wheelchair, the back-left wheel returned to the ground. During an interview on [DATE] at 11:30 AM, Staff K, CNA, explained the mechanical lift used for the front hallways typically will tilt during transfers. Staff will have to stand on it so it doesn't tip. Staff K stated the lift tips up on the left side. No timeframe provided on how long this had been happening. During an interview on [DATE] at 11:55 AM, Staff I and Staff J both acknowledged the back-left wheel of the mechanical lift coming off the ground. Neither staff could recall how long this had been happening. Staff I voiced it had been called-in. During an interview on [DATE] at 10:05 AM, Staff L, Maintenance explained they were not aware of the left-back wheel lifting up off the ground until yesterday. Staff L examined the mechanical lift, without a resident/not actively in-use, and could not see where the wheel was off the ground. It was further explained that the wheel came up when residents were in the sling, in the air, and being transferred. The facility Work Order #16 was the only Work Order related to mechanical lifts (standing or sitting) identified within the past six months. Work Order #16, created [DATE], was for a Hoyer lift not functioning on North (2). No further details provided. The Work Order was closed out [DATE]. A facility document summarizing Work Orders from [DATE]-[DATE] documented Resident #7's bed not working properly. The entry did not specify the date the Work Order was submitted or closed out. The undated policy Preventative Maintenance and Inspections outlined the following: a. Preventive Maintenance is completed in accordance with the defined procedure. When manufacturer's guidelines are available, Preventive maintenance is completed in accordance with the manufacturer's guidelines b. Record Keeping (1). Documents will be uploaded to the TELS system by the environmental supervisor and/or designee in his/her absence. (2). In the event that maintenance cannot be completed, the reason is noted along with the action plan for completion (3). Records are retained for five (5) years unless a different requirement has been established by state/federal regulations and statutes c. Inspections (1). Inspections verify that all equipment and furnishings are in working order, esthetically pleasant, clean and free from safety hazards (2). Each resident's room will be inspected routinely and through the Guardian Angel Program. Work orders shall be completed and uploaded to TELS. d. A system for work orders is established among all staff, residents, and employees that provides rapid communication regarding equipment problems. The work order system includes documentation of: (1). The problem (2). Date the problem was identified (3). Correction action (servicing, repair or replacement) (4)Completion date e. Work orders are written and uploaded to TELS (The facilities electronic system for environmental services) for the environmental supervisor to complete. The environmental supervisor is responsible for prioritizing work orders which always include safety concerns first. f. The Environmental supervisor will document the completion of work orders into TELS.

Based on observations, interviews, and record review, the facility failed to ensure dignity was promoted for 2 out of 2 residents (Resident #1 and Resident #12). The facility had ongoing issues with batteries not staying charged in stand lifts used for daily transferring of residents. Resident #1 waited 30 minutes after staff answered her call light to toilet her related to 2 different batteries not working and the need to go get another stand lift from the other side of the building. A stand lift battery died after staff raised Resident #12 to a standing position and could not lower her due to the lift's battery dying. She remained in the standing position until staff could retrieve another battery. The facility reported a census of 86 residents. Findings include: 1. A Annual Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included Multiple Sclerosis (MS), anxiety and depression. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognition. This resident was dependent on staff for toilet transfers, sit to stand, and for chair/bed to chair transfers. A Care Plan for Resident #1 had the following interventions: -assist Resident #1 to toilet upon request revised on [DATE]. -Toileting: Assist Resident #1 to the stool with use of sit to stand and 2 assist. She requests to not have staff be in the bathroom when she is toileting. Crack the door open to her bathroom for observation to ensure safety and to maintain her privacy as much as possible. Staff to make sure needed personal supplies are within reach. Wheelchair positioned as she requests. Initiated on [DATE] and revised on [DATE]. -if aides are unable to toilet this resident at a specific time she desires, Resident #1 is to notify administrator or other available management staff member. Corporate nurse if in the facility for an additional intervention. Revised on [DATE]. On [DATE] at 10:59 a.m., Resident #1's call light was on. Staff D, Certified Nurse Aide (CNA), shut off the call light at 11:00 a.m., Staff D stated she was going to get a second person and the lift stand. After Staff D left the room, Resident #1, who was sitting in her wheel chair, stated that there is one thing that she forgot to mention. She stated there are not enough lifts in the facility. She stated that the battery dies a lot on them. She said when they get the stand lift to the room, much of the time the battery dies. She voiced frustration, as she has to wait for staff before she can transfer to the toilet. She said the machines are so old the batteries don't stay charged. On [DATE] at 11:12 a.m., Staff D returned to this resident's room with the stand lift. She stated Staff E, Certified Medication Aide (CMA)/CNA will come in to help. On [DATE] at 11:15 a.m., Staff E came in to the room and asked if Resident #1's legs were too tired from doing the exercise and she said no. On [DATE] at 11:18 a.m., they started to transfer this resident but the battery died. Staff E left the room with the battery. She stated she would be right back. Staff D confirmed the battery had died. She stated they just had charged the battery. On [DATE] at 11:20 a.m., Staff E returned to the room with a different battery. She placed the battery on the EZ stand, washed her hands and grabbed new gloves. The battery did not work. Staff E said We probably are going to have to use the (non-standing lift) . They removed the sling used with the stand lift from behind Resident #1. Staff E stated she could run up to the front end of the building and grab the other stand lift. Staff E stated there were 2 stand lifts in the building. Staff E appeared upset. Resident #1 stated it's not your fault (Staff E). On [DATE] at 11:23, Staff E left and said she would be right back. Resident #1 stated If it would have happened (the lift worked) the first time it would have been a shock, that's the way it works. On [DATE] at 11:29 a.m., Staff E returned with a different stand lift. Resident #1's feet were placed on the stand and sling placed behind her and under her arms. They raised this resident off her wheelchair. Resident holding on to the stand lift handles, and they transferred this resident to the toilet. This resident's adult brief was removed and disposed of while resident was still standing in the lift prior to lowering her to the toilet. The adult brief was saturated and drooped under the weight of its contents. Staff D and Staff E stepped outside of the bathroom into the bedroom to allow privacy for this resident. When asked if this happens often with the battery dying, they both were hesitant to answer, but then said it hadn't happened recently with the battery, but it was happening though. Staff D and E both said they thought it had been fixed. On [DATE] at 3:04 p.m., Staff E stated they have had problems with the batteries off and on for months. The maintenance man fixes it right away when he finds out, but they just keep not working. Staff E stated she felt bad for the residents. She stated for example what happened with Resident #1 today. It's frustrating for them to have to sit in soiled clothing. The residents that are cognizant have been getting frustrated with this ongoing situation. On [DATE] at 2:35 p.m., the Chief Nursing Officer (CNO), Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), acknowledged this concern regarding the battery dying, delaying the resident being able to use the toilet. 2. The Quarterly MDS dated [DATE], documented diagnoses for Resident #12 included Parkinson's, depression, and chronic pain. A BIMS documented a score of 15 out of 15, which indicated intact cognition. This resident was dependent on staff for toilet transfers, sit to stand, and for chair/bed to chair transfers. On [DATE] at 12:55 a.m., This resident verified staff transferred her with the stand lift. When asked if she had any concerns with her transfers, she said staff do a great job. She stated the only problem is the batteries. They will die and the staff have to run and get another battery. She said your kind of standing there on the machine like you are in outer space or something. When asked how that made her feel, Resident #12 stated she doesn't like the feeling when that happens. She stated she didn't know if they don't have enough batteries, or the chargers are not working or what, but it happens a lot. On [DATE] at 2:35 p.m., Nurse consultant, LHNA, and DON, acknowledged this concern regarding the battery dying while resident was in the standing position and with the resident not liking being left in the standing position. On [DATE] at 10:43 a.m., the Director of Operations verified they have had issues with batteries and charges holding on the facility lifts. We have found that staff were not plugging them in to charge. If we need to replace them we do. He stated staff are to charge the batteries overnight and if the batteries do not work then the batteries are pitched and replaced. The Director of Operations acknowledged concerns regarding Resident #1 and Resident #12. The Resident Council minutes dated [DATE], documented that an EZ Stand was out of commission. An undated Right to Dignity policy, directed the following: Policy: This facility will promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the elder's individuality. Procedure: Residents will be groomed as they wish including hair care and styled, facial hair shaved/trimmed as the resident wishes, nail care as the resident chooses. Each resident will be encouraged and assisted to dress in his/her own clothing appropriate to the time of day and the individual's preferences. Unless specifically requested by the resident and/or Responsible Party. The resident will always be addressed by the name preferred by the resident and staff will not call the resident by terms such as sweetie, honey, grandma, etc,. without the permission of the resident and/or Responsible Party. If the residents prefer and choose to be called by a term of endearment, the practice will be included in the residents individualized comprehensive plan of care. Each resident will be provided and will be encouraged to attend activities of his/her own choosing. Clothing and personal items will be labeled in a manner that respects the resident dignity by placing all labeling on the inside of shoes and all clothing items. Each resident will be provided with independence and dignity during dining experiences regardless of the amount of assistance the resident requires Bibs (clothing protectors) will be used if the resident desires to have one. Each resident requiring staff assistance or encouragement with eating will be provided with that assistance by staff being seated next to the resident, at eye level, facing the same direction as the resident. Staff assisting any resident with a meal will interact/converse with the resident. Staff members will respect each resident's private space and property at all times Staff will knock on the door and wait for permission to enter when entering the elder's personal space. Staff will close doors and utilize privacy curtains during provision of care. Staff will not move or inspect the personal possessions without permission of the elder. Staff will exhibit respect for each resident. Staff will speak respectfully to each resident. Staff will address the residents by the name of the resident choice. Staff will not label residents i.e., diagnosis, feeder, etc. Staff will not exclude residents from conversations or discussing residents in community settings in which others can overhear private information. Staff will provide dignity to each resident by maintaining the residents' privacy of body including: Keep the resident covered while transporting residents outside the residents room All staff will refrain from any practice which could be considered demeaning to a resident including: Urinary catheter bags uncovered Refusing to comply with a resident's request for toileting assistance during meals Restricting residents from use of common areas open to the public such as lobbies and restrooms unless the residents is restricted related to an infective process or are restricted according to the resident care-planned needs Failure to focus on the resident as individuals when talking with the resident or failure to address the resident as an individual during care and services

Based on observations, interviews, and record review, the facility failed to follow document and/or carry out physician orders for 2 of 16 residents reviewed (Resident #2 and Resident #3). Resident #2 had an order to check her oxygen saturation (POx) once per shift. She had a second PRN (as needed order) to apply oxygen if the oxygen saturation was below 90%. There was no documentation of oxygen application for oxygen saturation below 90%. Resident #3 had an order to check Hgb A1c (a test that measures the average blood sugar) every 6 months. This was not done. The facility reported a census of 86 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) dated [DATE], documented Resident #2's diagnoses included heart failure and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 4 out of 15, which indicated severely impaired cognition. This resident received oxygen treatment. A Treatment Administration Record (TAR) for June 2025 and printed on 6/25/25 at 3:33 p.m., directed to check spo (oxygen saturation level) every shift for shortness of breath. It documented that on 6/21/25 on the evening shift her oxygen saturation was 89%. It documented that on 6/25/25 on the day shift Resident #2's oxygen saturation was at 89%. Both of these entries were initialed/signed by Staff A, Licensed Practical Nurse (LPN). A Doctor's Order dated 10/6/24, directed to apply oxygen at 2 liters via nasal prongs to keep oxygen saturations above 90% as needed related to heart failure. The June 2025 TAR lacked staff initials documenting the administration of oxygen on 6/21/25 and 6/25/25. On 6/25/25 at 2:00 p.m., it was noted that this resident had not been observed having any oxygen administered up to this point of the survey. The survey was initiated on 6/23/25. On 6/25/25 at 4:00 p.m., Staff A stated on this morning Resident #2's POx was 89% and the CNA put O2 on her. She stated they always do if Resident #2's POx was lower than 90%. When told there wasn't an observation this morning with this resident having oxygen administered via nasal cannula, this LPN stated that's because Resident #2 takes the oxygen off all the time. When this LPN was asked about the order for PRN oxygen on the TAR not being signed, she stated she didn't even know there was an order. This LPN acknowledged the POX readings of 89% on 6/21/25 evening shift and on 6/25/25 day shift were signed by her. Staff A acknowledged that she did not sign for PRN oxygen on 6/21/25 nor did she sign for PRN oxygen for this morning 6/25/25. On 6/25/25 at 4:31 p.m., Staff B, Certified Medication Aide (CMA), stated that Staff A had asked Staff B to check Resident #2's oxygen saturation as Staff A was busy. Staff B stated she went and checked the oxygen saturation with the POx and it was 88%. Staff B stated she then put oxygen on Resident #2. Staff B stated she did not know there was a PRN order for oxygen. She stated they were told to put oxygen on Resident #2 whenever her POx reading was below 90% because her O2 levels fluctuated during the dayshift. Staff B did not know when they were told to do this but a bunch of CMAs and nurses were told to do this for Resident #2. A late entry Progress Note dated 6/25/25 at 9:49 a.m., documented 'Late Entry' Resident was at 89 % on room air, prn oxygen applied. This entry was not in the progress notes prior to the above 2 interviews. The TAR dated 7/1/25 on the day shift, documented Resident #2's oxygen saturation was at 81%. The PRN oxygen was not signed for as being applied. Progress Notes from 6/2/25 to 72/25, revealed that no nursing assessment was documented on 7/1/25 nor on 6/21/25. On 7/2/25 at 10 a.m., the Director of Clinical Services stated that nurses could put oxygen on without doctor's orders per nursing assessment and based on their clinical assessments. She stated that staff should be documenting when PRN oxygen is applied. She and the DON acknowledged that the oxygen saturation was documented at 81% and felt it must have been done in error. The Director of Clinical Services asked if this should be addressed further. 2. The Quarterly MDS Assessment, dated 5/23/25, revealed Resident #3 with a BIMS of 9, indicating moderate cognitive impairment. Diagnoses included diabetes mellitus, hyperlipidemia, hypertension, and non-Alzheimer's dementia. The Order Summary Report, obtained on 6/25/25, included a lab order for a Hemoglobin (Hbg) A1c to be obtained every 6 months on the 10th day related to Type 2 Diabetes. This was initiated on 5/2/22. Review of diabetic medication history revealed the following: a. Glargine insulin was initiated on 5/3/22 and discontinued on 8/2/24 b. Metformin HCl 500mg twice daily was initiated on 5/24/25 c. Glargine insulin 10 units in the morning was initiated on 5/28/25 Review of TARs revealed the following: a. May'24 a Hgb A1c was due on the 10th of the month, Staff documented as complete b. Jun'24-Oct'24 indicated a Hgb A1c was not due in these months c. Nov'24 indicated a Hgb A1c was due on the 10th of the month. No staff documentation identified on the TAR or in Progress Notes if the lab had been drawn or not d. Dec'24-Apr'25 indicated a Hgb A1c was not due in these months e. May'25 indicated a Hgb A1c was due on the 10th of the months. No staff documentation identified on the TAR or in Progress Notes if the lab had been drawn or not Paper health record review documented a Hgb A1c 5.8 on 5/10/24 and 9.1 on 5/21/25, which was obtained during Resident #3's hospitalization. No further Hgb A1c were identified during this timeframe. During an interview on 6/25/25 at 1:45 PM, the Chief Nursing Officer explained the floor nurses would see lab draw orders as they are listed out on the TARs. It would be the Charge Nurse responsibility to ensure the labs were drawn. During an interview on 6/26/25 at 9:15 AM, Staff F, LPN, explained after the provider writes a lab order, the nurse completes the first order check, write the lab in the Lab Order Book, and enter into MARS/TARS. The nursing staff complete the Double and Triple order check to ensure the order is processed. Night shift nursing review the Lab Order book for labs needed on the upcoming day shift. Lab requisitions completed. The day shift obtains the lab and sends out. All nursing staff should see lab orders as they print out on the MAR/TAR and any nurse can address. Staff F obtained the Lab Order book and discussed the book is divided up by months/days. Jun'25 and Jul'25 were in the book but no lab sheets identified for future month/lab needs. Past months lab sheet/request are not kept and ultimately placed in the confidential shred bin. The undated policy Physician Orders for Medications and Treatments stated all medications will be administered as ordered by a health care professional authorized by the state to order medications.

Based on observations, interviews and record review, the facility failed to ensure doctor's orders for oxygen (O2) were being followed for 3 out of 3 residents reviewed (Residents #2, #8 and #9. Resident #2 had an order for PRN (as needed) oxygen to be placed when her oxygen saturation was below 90%. Documentation showed she had a least 2 occasions when her oxygen saturation read by a pulse oximeter (Pox) was 89% and oxygen was not documented as being applied. Staff reported not knowing there was an order for PRN oxygen, but they were applying oxygen without clarifying the order. Residents #8 and #9 were observed to have oxygen administered at flow rates that differed from their doctor ordered oxygen flow rates. The facility was not documenting what the liter flow was for oxygen saturation readings on an oxygen order that was to be titrated between 2 and 4 liters(L) per Resident #8's needs. The facility reported a census of 86 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) dated [DATE], documented Resident #2's diagnoses included heart failure and non-Alzheimer's dementia. A brief Interview for Mental Status (BIMS) documented a score of 4 out of 15, which indicated severely impaired cognition. This resident received oxygen treatment. A Treatment Administration Record (TAR) for June 2025 and printed on 6/25/25 at 3:33 p.m., directed to check pox every shift for shortness of breath. It documented that on 6/21/25 on the evening shift her oxygen saturation was 89%. It documented that on 6/25/25 on the day shift Resident #2's oxygen saturation was at 89%. Both of these entries were initialed/signed by Staff A, Licensed Practical Nurse (LPN). A Doctor's Order dated 10/6/24, directed to apply oxygen at 2 liters via nasal prongs to keep oxygen saturations above 90% as needed related to heart failure. The June 2025 TAR lacked staff initials documenting the administration of oxygen on 6/21/25 and 6/25/25. On 6/25/25 at 2:00 p.m., it was noted that this resident had not been observed having any oxygen administered up to this point of the survey. The survey was initiated on 6/23/25. On 6/25/25 at 4:00 p.m., Staff A stated on this morning Resident #2's POx was 89% and the CNA put O2 on her. She stated they always do if Resident #2's POx was lower than 90%. When told there wasn't an observation this morning with this resident having oxygen administered via nasal cannula, this LPN stated that's because Resident #2 takes the oxygen off all the time. When this LPN was asked about the order for PRN oxygen on the TAR not being signed, she stated she didn't even know there was an order. This LPN acknowledged the POX readings of 89% on 6/21/25 evening shift and on 6/25/25 day shift were signed by her. Staff A acknowledged that she did not sign for PRN oxygen on 6/21/25 nor did she sign for PRN oxygen for this morning 6/25/25. On 6/25/25 at 4:31 p.m., Staff B, Certified Medication Aide (CMA), stated that Staff A had asked Staff B to check Resident #2's oxygen saturation as Staff A was busy. Staff B stated she went and checked the oxygen saturation with the POx and it was 88%. Staff B stated she then put oxygen on Resident #2. Staff B stated she did not know there was a PRN order for oxygen. She stated they were told to put oxygen on Resident #2 whenever her POx reading was below 90% because her O2 levels fluctuated during the dayshift. Staff B did not know when they were told to do this but a bunch of CMAs and nurses were told to do this for Resident #2. On 7/2/25 at 10 a.m., the Director of Clinical Services stated that nurses could put oxygen on without doctor's orders per nursing assessment and based on their clinical assessments. She stated that staff should be documenting when PRN oxygen is applied. 2. A Quarterly MDS dated [DATE], documented Resident #8's diagnoses included cancer, schizophrenia, chronic obstructive pulmonary disease (COPD), and Chronic respiratory failure with hypoxia (low oxygen levels in your body tissues). A BIMS documented a score of 5 out of 15, which indicated this resident's cognition was severely impaired. Resident #2 had shortness of breath or trouble breathing with exertion. This resident received oxygen therapy. A Doctor's Order initiated on 4/9/25, directed that Resident #8 was to have oxygen at 2L per nasal cannula every shift for oxygenation. On 6/23/25 at 2:19 p.m., an oxygen sign was noted hanging outside Resident #8's door. This resident was not wearing oxygen. Staff C, Certified Nurse Aide (CNA), stated that Resident #8 takes his oxygen off all of the time. She stated that he will probably get mad at her because she constantly was putting the oxygen back on him. This CNA went into Resident #8's room and talked with him, he allowed her to put the oxygen via nasal cannula back on him. When Resident #8 was asked if he takes the oxygen tubing off, he stated 'yeah, I really don't like it'. Resident stated that he really didn't like the breathing treatments either but the oxygen (administration) was okay. This resident stated that he liked to keep the oxygen (liter flow) at 2. It was noted at that time the oxygen liter flow was on between 3.5 and 4 liters. After leaving the room, this CNA stated that Resident #8 was going through chemotherapy and had been confused. On 6/23/25 at 3:15 p.m., noted Resident #8's oxygen liter flow was still at 3.5 to 4 liters. Asked the MDS Nurse what oxygen flow liter rate should this resident have oxygen administered. This MDS Nurse looked this up in Resident #8's chart then stated it should be at 2 liters. When told the doctor's order directed that it be at 2 liters, this nurse said okay. This MDS Nurse was then asked if she would verify the liter flow. This nurse went into this resident's room and stated the oxygen flow rate was at 4 liters. She then turned the oxygen rate down to 2 L. This nurse then checked his oxygen saturation and it was at 90%. She asked the resident if he was short of breath and he denied being short of breath. She stated Resident #8 had lung cancer and was being treated for it. On 6/23/25 at 3:30 p.m., the Chief Nursing Officer stated Resident #8 changes the setting (liter flow) on the oxygen concentrator. She added that they put a note on the concentrator to remind him not to change it. She acknowledged the concern. ON 6/24/25 at 10:32 a.m., Resident was lying in bed. Oxygen tubing on the floor. He stated he took it off as he wanted to take a nap. Sign on concentrator reads: (Resident's name) Please do NOT adjust your oxygen! Please ask your nurse for help with any oxygen needs! Your order is for 2-4 liters. Oxygen was at 2 Liters. A Doctor's Order dated 6/23/25, directed that oxygen via nasal cannula 2-4L continuously. May titrate to keep pulse ox above 90%. The previous Doctor's Order for oxygen to be administered at 2L was discontinued on 6/23/25. The June TAR had Resident #8's oxygen titration order on it with signature spaces for Pox readings and a signature box for each shift. There was no place to document the oxygen liter flow. On 6/25/25 at 2:48 p.m., the Chief Nursing Officer stated they got the order for titration of oxygen as Resident #8 changed his oxygen liter flow all the time and they just wanted to make sure they could cover it. She agreed that Resident #8 had confusion and stated she couldn't say for sure if he was turning it up because he felt like he needed more oxygen. When asked about the liter flow not being documented on the TAR, she stated the facility had never done that. She stated she understood why the liter flow should be recorded with the titration of oxygen. The Chief Nursing Officer stated she understood the concern and stated she would get this changed. 3. The 5-day scheduled MDS assessment dated [DATE] revealed Resident #9 with a BIMS score of 12 indicating moderate cognitive impairment. Diagnoses include coronary artery disease, chronic obstructive pulmonary disease with acute exacerbation, heart failure, hemiplegia, and non-Alzheimer's dementia. The Order Summary Report, obtained on 6/24/25, documented Resident #9 with an order for oxygen at 2 liters (L) via nasal cannula; May titrate to keep oxygen saturation levels above 90%. This was initiated on 6/12/25. During an observation and interview on 6/24/25 at 1:05 PM, Resident #9 sat in a wheelchair in the dining room with oxygen. The portable oxygen tank, placed in the back of the wheelchair, was set at 1.5 L. Staff G, CMA/CNA, acknowledged the oxygen was set at 1.5 L and voiced it should be set at 2 L. Staff G increased the oxygen setting to 2 L. During an observation and interview at 6/24/25 at 2:15 PM, Resident #9 was asleep in their recliner with oxygen. The portable oxygen concentrator was located several feet away from the resident. The oxygen was set at 1.5 L. Staff F, LPN, was present in the room, acknowledged the oxygen setting, and voiced it was incorrect. Staff F increased the oxygen setting to 2 L, as per order. Staff F explained the oxygen was at 2 L earlier in the morning and was not aware of the change. Staff F would expect the aides to alert nursing of any breathing or medical concerns which may need a nursing assessment and oxygen adjustment. The undated policy Administration of Oxygen stated the initiation of oxygen therapy will be performed by a licensed nurse. Direct care staff may reapply the nasal cannula and replace distilled water in the humidifier. Oxygen therapy will be administered or supplied on prescription from the resident's primary care physician and will be administered as prescribed with full details recorded in each resident's clinic record.

Based on clinical record review, staff interviews and facility policy review, the facility failed to maintain complete and accurate medical records for 2 of 3 residents reviewed for discharge planning (Resident #15 and Resident #16). The facility reported a census of 86. Findings include: 1. The Quarterly Minimum Data Set (MDS) of Resident #15 dated 4/8/25 recorded a Brief Interview for Mental Status (BIMS) Score of 12, which indicated moderate cognitive impairment. The Care Plan, last reviewed on 4/22/25, failed to reflect a discharge plan for Resident #15. The Care Conference Review Notes dated 1/10/25 recorded the presence of the social services representative at the care conference. The Notes revealed Resident #15's daughter requested a referral to be made to another facility in the resident's home town for the resident to move to. The Care Conference Review Notes dated 4/15/25 recorded the presence of the social services representative at the care conference. The Notes revealed Resident #15's daughter requested a second referral to be made to an additional facility in the same town as the last request. Review of the Progress Notes of the resident, performed on 7/1/25, revealed no progress notes had ever been entered by the facility Social Services Representative since his admission in June of 2024. On 7/1/25 at 2:33 PM, the Social Services Representative stated sometime in mid to late June, she had reached out to an out of town facility to place a referral for transfer per the request of Resident #15's family member. She stated the transfer was denied due to financial issues and she notified the Business Office Manager of this. On 7/1/25 at 2:40 PM, the Social Services Representative stated she had never documented anywhere on Resident #15 since his admission. She stated she does not document when a resident or resident representative requests to transfer out of the facility and unless a big event occurs, she does not document anywhere in the resident's electronic health record (EHR) at all. On 7/1/25 at 3:17 PM, the Social Services Representative supplied emails she had exchanged with Res #15's daughter regarding her request for assistance to transfer the resident to another facility. Three emails in June of 2025 were provided. No communication prior to June was provided. 2. The Annual MDS assessment dated [DATE] revealed Resident #16 with a BIMS score of 11 indicating moderate cognitive impairment. The Care Conference Review Note dated 6/11/25 recorded the presence of the social services representative, the MDS Coordinator, and Resident #16's sister at the Care Conference. The notes revealed a discussion of Resident #16 transferring to a smoking facility. The Social Services Representative would assist the sister in search and paperwork. During an interview on 7/1/25 at 1:35 PM, Resident #16's sister confirmed having conversations with the facility's Social Services Representative since June's care conference regarding a possible change in facility. The last contact occurred 1-2 weeks ago. Review of Progress Notes for Resident #16, performed on 7/1/25, revealed no Progress Note had been entered by the facility Social Services Representative summarizing conversations with the sister regarding updates on a facility transfer. The last Progress Note identified was from 8/19/24 notifying the sister of a room change. During an interview on 7/1/25 at 2:20 PM, the Social Services Representative acknowledged Resident #16's desire to move to a different facility and keeps in touch with the sister. The Social Services Representative stated she typically does not document resident or family interactions in the EHR unless it is something big. During an interview on 7/1/25 at 4:15 PM, the Chief Nursing Officer acknowledged the lack of Social Services Representative EHR documentation. The Chief Nursing Officer noted all resident and family interactions be recorded in the EHR. The undated policy Documentation noted the following under Procedure: As needed to provide care, treatment and services, the clinical record will contain: a. Any advance directive b. Order, renewal of orders, and documentation that resuscitative services are to be withheld or life-sustaining treatment withdrawn c. Any informed consent, when required (Antipsychotic/psychoactive medications; Side rails and other potential restraints; Signed declination of recommended vaccinations) d. Any records of communication with the resident and/or surrogate decision-maker such as telephone calls or email communication e. Any resident-generated information such as choices, habits, and routines f. Referrals or communication made to external or internal care providers and community agencies g. Any physician's summary and final diagnosis when the resident is admitted either from a hospital or from another health care organization h. The discharge plan or the reason for lack of an on-going plan when discharge potential does not exist

Based on clinical record review, staff interview, and facility policy/procedures the facility failed to clarify a medication when a resident was admitted on [DATE] for which delayed the resident getting the medication as directed until 4/7/25. (Resident #1). The facility reported a census of 82 residents. Finding include: The Admission Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 4/7/25, documented diagnoses for which included anemia, hypertension, benign prostate hyperplasia (BPH) and arthritis. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no memory impairments and requiring partial to moderate assistance with Activities of Daily Living (ADL). The MDS documented no mood disorders and able to be understood and understand others. The Plan of Care with an initiated date of 4/4/25, had a focus area of ADL Care-Resident requires assistance with ADL's secondary to lumbar spine fusion procedure. Intervention include: *Toileting: Assist of one staff. Provide good peri-care after each toileting and/or incontinent episode to prevent infection/skin breakdown. (Date Initiated: 04/11/25) *Transfers/Ambulation. My wife will often assist me with ambulation/transfers despite frequent reminders not to do so which places resident at a greater risk for falls. If you see wife transferring/ambulating gently remind her that staff needs to perform these ADL's as to prevent a fall. (Date Initiated: 04/07/25) *Administer medications as ordered. Notify Medical Doctor of possible side effects. example(weight changes, sleep pattern disturbances,headaches, sweating, constipation, diarrhea, confusion, palpitations. (Date Initiated: 04/11/25) *Routine Social Worker visits to address any concerns and address any needs. (Date Initiated: 04/11/25) The Active Outpatient Medication list dated 4/3/25, documented to give Pyridostigmine Bromide (medication to treat muscle spasms) 60 milligrams (mg), Take one tablet by mouth as directed up to four times daily. The Medication and Treatment Record dated 4/1/25-4//30/25, documented to give Pyridostigmine Bromide Oral Tablet 60 MG. Give 1 tablet by mouth every 6 hours as needed for muscle spasms with a start date-04/02/2025 The Progress Notes documented on the following dates and times: *4/3/2025 at 11:40 a.m., Note Text: This order is outside of the recommended dose or frequency. Pyridostigmine Bromide Oral Tablet 60 mg Give 1 tablet by mouth every 6 hours as needed for muscle spasms-The frequency of daily is below the usual frequency of 2 to 8 times per day. *4/4/2025 at 5:32 p.m., Note Text: resident requested a copy of his medications due to he feels he should be taking a medication for my muscles and he can't remember the name. This nurse asked if it was the Pyridostigmine 60 mg. resident order states Pyridostigmine 60 mg take as directed up to four times a day. pharmacy wants clarification as well before sending. put in request to clarify orders. awaiting reply and resident notified as well *4/4/2025 at 5:50 p.m., Note Text: resident continues to hyperfixate on what medications he thinks he should be on and what the doctor ordered. this nurse explained I was clarifying the order and went into resident room and he had medications out that were brought from home. this nurse took medications and put in med room. *4/5/2025 at 9:17 p.m., Note Text: called to resident room for 2nd time to discuss the number of pills given. resident hyper fixates on medication no matter what time it is or what he is given. this nurse administered his hour of sleep medications and also gave two as needed Tylenol for back pain. resident had no questions or concerns at that time and now continues to call nurse down to room to say he didn't get enough. Resident has been told on numerous occasions with his spouse present that we are giving him what the doctor prescribed and he was provided a medication list. Also if he feels its in correct he can speak to the doctor. *4/6/2025 at 9:00 a.m., Note Text: resident continues to hyper fixate on his medications. am medications administered and resident wanted to know what all the medications were, and this nurse gave resident the list of medication and informed him of the stock medications as well. A Physician Communication Form dated 4/4/25, documented, Please clarify order for Pyridostigmine 60 mg, the order states to take up to four times a day and resident states he takes three times a day to help keep his eyes open. Please advise. The Advanced Registered Nurse Practitioner signed and dated 4/7/25, Ok to make Three times a day per his preference/home regimen. Interview on 4/22/25 at 1:13 p.m., the facility Director of Nursing confirmed and verified that the residents medication needed to be clarified upon admit and that the expectation is to make sure any questions in regards to medications needed to be clarified per the policy/procedures. Interview on 4/23/25 at 9:40 a.m., the facility Advanced Registered Nurse Practitioner stated that since the resident wanted the medication to be given three times a day an order would of been given on 4/4/25, and the resident would not of had to go until 4/7/25 to receive the medication. The Physician Orders for Medications and Treatments with no date documented the policy is that all medications will be administered as ordered by a health care professional authorized by the state to order medications. All physician orders will be signed and dated, including the facility standing order. Procedure: *All medications administered to residents in the facility will be ordered by health care professionals who have the authority to order medications under state law. *All orders for medications and treatments will be written, dated and signed by the health professional with authority to write medication and treatments orders. *Verbal orders of medications and treatments may be communicated only to licensed nurses employed by the facility, a registered therapist employed by the facility, a pharmacist, another physician, an advance registered nurse practitioner or a physician assistant. *Once the order is received the nurse will then enter the order into the facilities electronic medical record. It is the expectation that orders will be followed accordingly. *If the prescribing physician has not returned signed order a call will be placed to him/her by the Director of Nursing or assistant director of nursing, *If prescribing physician does not return call and orders are not signed within a respectable time the Medical Director will be notified for order clarification.

Based on observations, staff interview, and facility cleaning procedures, the facility failed to ensure resident rooms were free of odors to create a home-like environment for 1 of 59 resident rooms (Resident #71). The facility reported a census of 82. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #71 with a Brief Interview for Mental Status score of 14, which indicated intact cognition. Diagnoses on the MDS include anxiety, cerebrovascular accident (stroke), chronic pain syndrome, depression, diabetes, hemiplegia, non-Alzheimer dementia, Parkinsons, and prostate cancer. The MDS noted Resident #17 utilizes either a walker or wheelchair for mobility. The Care Plan with a completion date of 12/2/24 indicated Resident #71 has had falls with minor injury due to poor balance. Interventions included staff to check urinal frequently and empty if needed to prevent spills. During an observation on 2/10/25 at 11:10 AM, an ammonia odor was present in the hallway from Resident #71's room. During a room observation on 2/10/25 at 2:05 PM, an ammonia odor was detected in Resident #71's room despite the presence of an odor diffuser. The carpet had a spongy, sticky feel when walking around the room, especially near the bed. During an interview on 2/10/25 at 2:05 PM, Resident #71 stated his preference to use a urinal while in bed. Resident #71 prefers the urinal to hang on the trash can next to the bed instead of a bed rail. When on the bed rail, the urinal is typically near the head of the bed. Resident #71 explained they do not wish to be that close to see or smell it. Resident #71 voiced when the urinal is full, there are times when it spills, either when placing it back onto the trash can or when trying to get to the bathroom himself to empty it in the toilet. In an interview on 2/11/25 at 12:35 PM, Staff H, Housekeeping, explained resident rooms are vacuumed and dusted daily. Carpets can be cleaned as needed. In an interview on 2/11/25 at 12:45 PM Staff G, Environmental Supervisor, noted that resident room carpets can be cleaned as needed. Especially after urinary or bowel incontinent events. Staff G acknowledged the frequency to which Resident #71 spills the urinal. There is no extra scheduled carpet cleaning of the room. Environmental Services rely on staff to inform if the room carpet needs cleaning due to odors. In a follow-up interview on 2/13/25 at 1:45 PM, Staff G discussed routine carpet cleaning addressed as part of the resident room's deep cleaning checklist. Staff G voice the goal is to complete 6 deep clean resident rooms per day. At this time, Staff G estimates environmental staff deep cleans only 3 rooms daily. Review of the document Environmental Services Checklist and Goals of Department, dated 2021, indicated each room shall be deep cleaned monthly with 6 rooms are deep cleaned daily. The Deep Clean Checklist outlined staff to extract carpet or use carpet spotter for stains.

Based on observation, family and staff interviews, and clinical record review, the facility failed to follow the physician's orders for 1 of 20 residents (#32). The facility reported a census of 82 residents. Findings include: 1. On 2/10/25 at 3:56 PM, Resident #32's visitor stated the resident missed several doses of Calcium Carbonate (Tums) during the last week of October 2024. She also stated there were several occasions when the resident's Voltaren External gel (topical analgesic used to treat pain and inflammation) was not given until after the prescribed time. On 2/10/25 at 5:29 PM, the resident's relative stated the resident received the Tums to provide calcium for a previously fractured T12 vertebrae. She also stated the Volteran gel was to be applied for the same reason. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed a Brief Interview for Mental Status (BIMS) score was not obtained because the resident was rarely/never understood. It included diagnoses of Heart Failure, Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), chronic pain, and spinal stenosis (narrowed spinal canal). It also revealed the resident required setup assistance with eating, supervision with oral and personal hygiene, maximal assistance with toileting hygiene and bathing, and was dependent with all other aspects of Activities of Daily Living (ADLs). The Electronic Health Record (EHR) included a physician order dated 2/15/22 for Calcium Carbonate Tablet chewable 500 mg; give two (2) tablet by mouth in the morning for indigestion. The EHR also included a physician order dated 9/27/24 for Voltaren External Gel 1% (Diclofenac Sodium (Topical)); apply to lower back 4 gm topically two (2) times a day for back pain after patch removed at 9 AM and apply at 2 PM. The Medication Administration Record (MAR) dated October 2024 revealed Staff A, Registered Nurse (RN) documented the resident did not receive the Calcium Carbonate on 10/25/24, 10/28/24, 10/29/24, and 10/31/24. The Progress Notes indicated the Calcium Carbonate was given on 10/26/24, 10/27/24, and 10/30/24 but was not on hand on 10/25/24 or 10/31/24. It also indicated the facility was waiting for a delivery on 10/28/24. There was no progress note entry for the resident's Calcium Carbonate omission on 10/29/24. On 2/13/25 at 7:20 AM, Staff B, Licensed Practical Nurse (LPN), stated nurses check other medication carts for stock medications if their cart doesn't have it. She also stated the nurses notify Staff C, Central Supply staff (CS) by text, even on weekends if they run out of a stock medication. She added they also notify the physician and document it in the progress notes. Staff A, RN was not available for an interview. At 2:32 PM, Staff C (CS), stated she was not in the current role in October and didn't have any method to check whether the facility ran out of stock medications at that time. The Care Plan revised 4/05/23 did not include interventions for Calcium Carbonate. On 2/13/25 at 3:20 PM, the Director of Nursing (DON) stated the staff should notify the pharmacy if stock medications are not available. 2. The Electronic Health Record (EHR) included a physician order dated 9/27/24 for Voltaren External Gel 1% (Diclofenac Sodium (Topical)); apply to lower back 4 gm topically two (2) times a day for back pain after patch removed at 9 AM and apply at 2 PM. On 2/12/25 at 7:36 AM, Resident #32 was observed asleep in her bed. The Medication Administration Record (MAR) indicated the resident's pain patch had been removed. At 7:54 AM, Staff D, Certified Nurse Aide (CNA), assisted Resident #32 to the dining room. She also revealed the resident's patch was removed but no topical gel was noted on the resident's back. At 10:01 AM, the Treatment Administration Record (TAR) indicated the resident had not received the Voltaren Topical gel to her back. At 10:06 AM, the resident was observed sleeping in her bed. At 10:33 AM, Staff E, Registered Nurse (RN), stated nurses apply the medicated cream (Voltaren) to the residents. She said the medicated lotion is scheduled at medication pass but if it is scheduled for a specified time, there is a 1-hour window before and after the scheduled time for medication administration. She also stated the Voltaren should be documented on the MAR. She said the process is to check the MAR during medication pass then check the TAR for medications that are timed. At 11:25 AM, Staff E, RN, stated if the resident refuses the medication, it is documented as refused and a subsequent progress note is documented. She also stated the refusal is entered into the communication book for the physician. She stated she had not applied the Voltaren because she was waiting for the resident to get back to her room. The Care Plan directed staff to administer analgesic medications as order by physician. The Administration Record History (ARH) revealed the Voltaren was administered over one (1) hour after the scheduled administration time on 2/04/25, 2/05/25, 2/06/25, 2/10/25, and 2/12/25. On 2/13/25 at 3:20 PM, the Director of Nursing (DON) stated it was unusual for topical medications to be scheduled for specific times but staff should administer medications within 1 hour before of after the scheduled dose. The facility did not have a policy specific to following physician's orders.

Based on health record review, facility document review, and staff interviews, the facility failed to communicate throughout departments current resident staff assistance level for 1 of 5 residents reviewed for nursing supervision (Resident #71). The facility reported a census of 82. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 with a Brief Interview for Mental Status score of 14, which indicated intact cognition. Diagnoses on the MDS include anxiety, cerebrovascular accident (stroke), chronic pain syndrome, depression, diabetes, hemiplegia, non-Alzheimer dementia, and Parkinsons. The MDS noted Resident #17 utilizes either a walker or wheelchair for mobility. The MDS revealed Resident #71 is independent with chair/bed-to-chair transfers, toilet transfers, and walk 10 feet. The MDS recorded no falls since prior assessment. The Care Plan with a completion date of 12/2/24 indicated Resident #71 has a self-care performance deficit related to stroke with left-sided weakness. Interventions indicated Resident #71 independent with stand pivot transfers from wheelchair level to/from toilet and bed (initiated on 7/8/24), utilizes a wheelchair for primary mobility inside room (revised on 7/30/24), and independent to perform toileting tasks (revised on 7/15/24). Electronic health record review revealed Resident #71 has experienced 7 falls since the MDS was completed on 11/19/24. Falls occurred on 12/20/24, 12/14/24, 12/15/24, 1/13/25, 1/16/25, 1/23/25, and 2/2/25. Paper chart review revealed the following Activity Level and Recommendations Form from therapy, which was located in the Rehab and Therapy tab: 1. On 5/16/24: Staff assist of 2 for transfers with a hemi-walker 2. On 6/14/24: Changed from a staff assist of 2 to a staff assist of 1 for transfers using a hemi-walker 3. On 7/16/24: Staff walk to dine with wheelchair follow as tolerated No further recommendations from therapy found, paper or electronic, which indicated Resident #71 was changed from an assist of 1 to independent, as outlined on the Care Plan interventions from July'24. Paper chart review revealed a Fall and Safety Management Program form, dated 11/7/24, revealed Resident #71 as independent with transfers and ambulation status. This form was located in the Risk Assessment tab of the chart. The Physical Therapy Evaluation and Plan of Treatment, for the date of service 9/17/24-11/12/24, recommended Resident #71 perform transfers with stand-by staff assistance. The Physical Therapy Discharge Summary, for the date of service 11/27/24-1/10/25, recommended Resident #71 perform transfers with stand-by staff assistance. During an interview on 2/11/25 at 2:00 PM, Staff I, Certified Nursing Assistant, and Staff J, Licensed Practical Nurse, both unable to explain Resident #71's current staff assistance level. Staff J stated this information would be found in the Bio Worksheet Binder. Upon review of the binder, which was last updated on 2/12/25, Resident #71 listed as independent with stand pivot transfers to and from bed to toilet to wheelchair. During an interview on 2/13/25, Staff L, Licensed Practical Nurse, voiced Resident #71 not needing much assistance now as mainly in bed. Staff L believes Resident #71 has been a staff assistance of 1 since October. During an interview on 2/13/25 at 1:00 PM, the MDS Coordinator explained therapy will provide a copy of Activity Level and Recommendations Form. The MDS Coordinator will update the Care Plan and the Bio Worksheet. During an interview on 2/13/25 at 1:30 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated Resident #71's independent status is reflective of their current status. Resident #71 typically does not wait for staff help or will refuse assistance. During an interview on 2/13/25 at 2:00 PM, the Director of Rehab (DOR), did not feel the information on the Bio Worksheet reflected Resident #71's current status given the increase in falls. Upon review of the most recent Physical Therapy notes, the DOR indicated Resident #71 should have staff present during transfers. The DOR could not explain or provide documentation when Resident #71 became independent, as outlined on the Care Plan. The DOR could not explain the inconsistency between the Physical Therapy recommendations for stand-by staff assistance (from September'24 and January '25) and the Risk Assessment stating an independent level of assistance in November'24. The policy Care Plan Development Process, dated 2022, indicated the Care Plan will be reviewed and amended as needed.

Based on observations and resident and staff interviews, the facility failed to provide resident assistance or follow-up with medical equipment for 1 of 2 residents reviewed for respiratory care (Resident #235). The facility reported a census of 82. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #235 with a Brief Interview for Mental Status score of 15, which indicated intact cognition. Diagnoses on the MDS include anemia, atrial fibrillation, hip fracture, obstruction sleep apnea, and osteoporosis. The facility admitted documented as 1/28/25. The Care Plan revised on 2/11/25, indicated Resident #235 had a self-care performance deficit due to right shoulder fracture and left femur fracture. Interventions include staff assist of 1 with a hemi-walker for transfer inside the room, weight-bearing as tolerated to left lower extremity, and staff assist of 1 to turn and reposition in bed. The Care Plan indicated Resident #235 is a fall risk due to weakness, decreased mobility, fall history, weight-bearing restrictions, and opioid medication use. During a room observation on 2/10/25 at 3:00 PM, a Continuous Positive Airway Pressure (CPAP) machine was sitting in Resident #235's bedside nightstand. During an interview on 2/12/25 at 1:10 PM, Resident #235 explained the CPAP is their own personal equipment. Family brought the machine to the facility shortly after admission. Resident #235 stated they could use the CPAP independently but needed help filling and emptying the water chamber. At least 2 one-gallon jugs of distilled water were seen sitting on the floor behind the bedside nightstand. Resident #235 voiced a desire to wear the CPAP while at the facility. Resident #235 explained asking facility staff for assistance but was told they could not as there is not a current physician order for the CPAP. Since that time, staff had not followed-up with Resident #235 regarding the CPAP nor provided any assistance. During brief interview on 2/12/25 at 9:00 AM, Staff M, Registered Nurse, was not aware of Resident #235's CPAP as this is typically worn at night. Staff M stated they work during the daytime. Staff M could not answer specific questions regarding the CPAP. During an interview on 2/12/25 at 2:30 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were not aware of the CPAP machine. Both acknowledged the lack of physician order for the machine. The DON confirmed without a current order, staff unable to assist Resident #235 with the machine. During this time, the ADON placed a call to Staff N, Registered Nurse, via speaker, who typically works the overnight shift. Staff N confirmed the presence of the CPAP machine and observed Resident #235 wearing it at least one time. Staff N stated no assistance was provided and no orders were signed off. During an interview on 2/13/25 at 9:45 AM, Staff O, Registered Nurse, acknowledged the presence of the CPAP machine on the bedside night stand. Staff O unable to recall how may nights they had seen it nor when if was first seen. On 2/12/25 at 2:30 PM, the ADON voiced an expectation for staff to acknowledge the presence of medical equipment and to ensure physician orders are in place. In an email response, the Chief Nursing Officer reported there is not a facility policy addressing resident personal medical equipment.

Based on record review, staff interview, and policy review, the facility failed to ensure a yearly psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was attempted or appropriately declined for 3 of 3 resident (#32, #44, & #66). The facility reported a census of 82. Findings included 1. On 2/11/25 at 11:00 AM, Resident #32 was identified as a resident who received psychotropic medications. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed a Brief Interview for Mental Status (BIMS) score was not obtained because the resident was rarely/never understood. It included diagnoses of Heart Failure, Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), chronic pain, anxiety, and spinal stenosis (narrowed spinal canal). It also revealed the resident required setup assistance with eating, supervision with oral and personal hygiene, maximal assistance with toileting hygiene and bathing, and was dependent with all other aspects of Activities of Daily Living (ADLs). The Electronic Health Record (EHR) included a physician's three (3) orders for a) Alprazolam 0.5 mg; give 1 tablet by mouth at bedtime for insomnia and give 1 tablet by mouth every 24 hours as needed for anxiety dated 2/14/22; b) Buspirone Hydrochloride (HCL) tablet 15 mg; give 1 tablet by mouth two times a day for anxiety related to anxiety disorder dated 2/14/22; and c) Escitalopram Oxalate (medication use; anxiety, depression, obsessive compulsive disorder) 10 mg tablet; take 1 tablet by mouth every morning dated 11/16/22. The EHR also included an order dated 8/22/22 for Behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care every shift. The Progress Notes included documentation the resident exhibited monitored behaviors on 8/16/24, 11/30/24, and 12/25/24. The Care Plan revised 3/07/22 directed staff to consult with pharmacy and the MD to consider dosage reduction when clinically appropriate at least quarterly. A GDR for alprazolam dated 10/24/24 indicated the clinician documented anxiety as a clinical rationale for continued use. A GDR for Buspirone dated 11/20/24 indicated the clinician documented no change with no included clinical rationale. A GDR for alprazolam dated 2/13/25 indicated the clinician documented no change with no included clinical rationale. No other GDR's were located in the resident's EHR. The Treatment Administration Record (TAR) revealed the resident exhibited behaviors on 8/16/24, 11/30/24, and 12/25/24. No behaviors were documented since 12/25/24. On 2/12/25 at 2:13 PM, Staff E, Registered Nurse (RN) stated target behaviors are documented in Progress Notes if observed. 2. On 2/11/25 at 11:00 AM, Resident #44 was identified as a resident who received psychotropic medications. The Minimum Data Set (MDS) dated [DATE] for Resident #44 revealed a Brief Interview for Mental Status (BIMS) score was documented as 99 which indicated the resident was not able to complete the assessment. It included diagnoses of Non-Alzheimer's dementia, Chronic Kidney Disease (CKD), anxiety, depression, bipolar disorder, and psychotic disorder. It also revealed the resident was dependent with all aspects of Activities of Daily Living (ADLs). The Electronic Health Record (EHR) included a physician's three (3) orders for a) Mirtazapine 7.5 mg tablet; take 3 tablets (22.5 mg) by mouth every night at bedtime for depression dated 10/26/23; b) Risperidone 0.25 mg tablet; give 1 tablet by mouth every morning and every night at bedtime related to bipolar disorder, current episode depressed, severe with psychotic features dated 1/22/24; and c) Sertraline Hydrochloride (HCL) 25 mg; take 1 tablet by mouth every morning dated 4/30/24. (Sertraline HCL can be used to treat depression, and also sometimes, panic attacks, obsessive compulsive disorder, and post-traumatic stress disorder.) The EHR also included an order dated 10/26/22 for Behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care every shift. The Progress Notes included documentation dated 9/01/24 which indicated the resident exhibited monitored behaviors. The Care Plan dated 2/06/24 directed staff to consult with pharmacy and the MD to consider dosage reduction when clinically appropriate at least quarterly. A GDR for Sertraline dated 9/26/24 indicated the clinician documented no change - may increase target symptoms suggest she see <named psyche provider group> for delusional with no included clinical rationale. A GDR for Risperidone dated 2/12/25 indicated the clinician documented do not recommend GDR as she continues to hallucinations, delusions. GDR may exacerbate symptoms. No other GDRs were located in the resident's EHR. The Treatment Administration Record (TAR) revealed the resident had no documented behaviors since 9/01/24. On 2/12/25 at 3:03 PM, Staff F, Licensed Practical Nurse (LPN) stated the TAR is where resident target behaviors are documented if observed. 3. On 2/11/25 at 11:00 AM, Resident #66 was identified as a resident who received psychotropic medications. The Annual Minimum Data Set (MDS) dated [DATE] for Resident #66 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. It included diagnoses of Parkinson's Disease, Diabetes Mellitus (DM), depression, Post Traumatic Stress Disorder (PTSD), and alcohol dependence. It also revealed the resident was independent with eating, oral and personal hygiene, and required moderate assistance with all other aspects of Activities of Daily Living (ADLs). The Electronic Health Record (EHR) included a Physician's Order for Escitalopram Oxalate oral tablet 5 mg; give 1 tablet by mouth in the morning related to depression for 1 week AND give 2 tablets by mouth in the morning related depression. The EHR did not include a physician order to monitor for behaviors nor a progress note which indicated observed resident-specific behaviors. The Care Plan dated 1/08/24 included antidepressant medication use, but did not provide any directives regarding dose reductions. A GDR for Escitalopram (Lexapro) dated 2/12/25 indicated the clinician documented no GDR per POA request for fear of increase in symptoms. No other GDR's were located in the resident's EHR. On 2/12/25 at 2:01 PM, Staff B, Licensed Practical Nurse (LPN) stated the TAR included to monitor for side effects behaviors noted. She stated she did not see where his target behavior was documented and was not aware of any other place to document these other than the progress notes. On 2/13/25 at 3:20 PM, the Director of Nursing (DON) and the Director of Clinical Services stated the Powers-of-Attorney for Resident #32 and Resident #66 declined to allow the facility to reduce the residents' psychotropic medications. It was not included on the completed GDR's. The facility did not provide a policy specific to Gradual Dose Reductions.

Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision to prevent falls and provide a safe environment for two of five residents (Residents #40 and #79) reviewed for falls. The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #79 recorded diagnoses that included arthritis, Non-Alzheimer's dementia, anxiety disorder and a history of COVID 19. The MDS documented the resident had severely impaired memory and cognition and was totally dependent on two staff for bed mobility and transfers. The MDS also recorded she fell twice and sustained non-major injuries since the prior assessment. Resident #79 received antianxiety medication one day out of seven and an opioid medication two days out of seven during the look back period Review of the resident's Care Plan, initiated on 6/3/13, revealed she had a risk for falls related to confusion, unawareness of safety needs and being very unsteady at times. The Care Plan directed staff to keep her bed in the lowest position with the left side rail in place, place a padded side rail for safety, use a low bed, and place a mattress by the bed. Care Plan interventions added on 5/5/21 included a sign in the room to leave her bed in the lowest position before staff left the room and removal of a table from the room to allow staff room to prevent injuries from falls. The Bio Sheet (pocket care plan for staff) revealed Resident #79 needed bilateral side rails, but lacked other fall interventions prior to resident's fall. The Bio Sheet dated 5/5/21 at 9:00 AM documented Resident #79 as at high risk for falls. Staff directives included to ensure the bed was in its lowest position, placement of a floor mat next to the bed while in bed, and bilateral side rails up. The Side Rail assessment dated [DATE] revealed resident had a left side rail to promote her safety and independence. The Morse Fall Scale assessment dated [DATE] revealed the resident had a high risk for falls and a history of falls. In a communication to the physician on 4/16/21, staff documented Resident #79 found lying on her abdomen next to the bed on the floor. Staff initiated fall follow up with neurological (neuro) checks. Communication to the physician on 5/4/21 recorded Resident #79 had unwitnessed fall out of bed. The resident's left knee and leg appeared more rotated than usual and she screamed out with touch to her left knee and left hip. Staff obtained an order to send Resident #79 to the emergency room for evaluation. The resident's Nurse's Notes revealed the following information: a. On 3/27/21 at 10:21 AM, staff found Resident #79 on the floor at 6:15 AM sitting up with her back against the end of the bed. Assessment revealed red/purple discoloration. Nobody witnessed the fall and staff initiated neuro checks. b. On 4/16/21 at 4:30 AM, a Certified Nursing Assistant (CNA) found the resident lying on floor on her stomach next to the bed. A CNA saw the resident approximately 1/2 hour before. Assessment revealed a skin tear and bruising to her left arm by the elbow. Staff completed an incident report and obtained witness statements. Staff initiated fall follow up and neuro checks. c. On 4/30/21 at 9:50 PM, staff found Resident #79 on the floor around 9:15 PM. Assessment revealed no injuries and staff would continue to monitor. d. On 5/4/2021 at 8:34 PM, Resident #79 had an unwitnessed fall out of bed and a CNA found her upon passing the room. Resident #79 lay with her head toward the door and her left leg bent at a 90 degree angle next to end table. The resident's knee appeared rotated further inward and resident yelled out in pain when her knee and left hip were touched. The resident's left knee appeared dislocated with a possible left hip injury. Her vital signs measured BP (blood pressure) 159/67, P (pulse) 65 and R (respirations) 20. Another nurse assessed the resident's leg and believed an injury occurred. Staff notified family members and Resident #79 transferred to the hospital for evaluation. e. On 5/5/21 Hospital staff informed facility staff Resident #79 fractured both femurs and had a urinary tract infection. f. On 5/5/21 at 6:14 PM, Resident #79 returned to facility via ambulance at approximately 5:45 pm. The resident had bilateral femur breaks and immobilizers on her legs to be worn at all times. The resident returned with orders for [MEDICATION(S)] every 2 hours as needed for pain, [MEDICATION(S)] every 4 hours as needed for anxiety, and [MEDICATION(S)] (antibiotic) daily for five days. Resident #79 yelled out in pain when rolled onto her side. Staff positioned her bed in the lowest position and placed a floor mat. Resident #79 was extremely agitated and yelled out in pain when the nurse attempted to look at her legs; unable to assess the areas due to resident distress. g. On 5/12/21 at 4:15 AM, staff documented administration of [MEDICATION(S)] and [MEDICATION(S)] at 10:30 PM and 2:30 AM for restlessness and pain. The resident's left above the knee area had a hole about .5 cm (centimeter) round with drainage. Staff applied an ABD (dressing), but the resident removed the dressing and the area now measured one cm by .4 cm with bone seen in the hole. The nurse re-arranged the immobilizer to straighten the resident's leg and keep her bone from rubbing on the hole. The nursed notified Hospice notified and applied a new dressing. h. On 5/22/21 at 7:50 PM, staff changed the dressing to her left knee due to saturation through the gauze dressing and noted the bone appeared to be protruding more than usual. i. On 5/24/21 at 11:49 AM, staff summoned the nurse to the resident's room at 8:40 AM. Resident #79 had no respirations or heart rate. The Quality Assurance Condition Report dated 5/4/21 at 8:25 PM revealed Resident #79 as found by a CNA. The nurse evaluated the resident; her left leg bent at a 90 degree angle next to the end table and her left knee appeared rotated with pain to the left hip. The nurse called 911. The author added an intervention to the Bio Sheet/care plan for the resident's bed to be in its lowest position and a floor mat by the bed. Both interventions were not on the Bio sheet/care plan and education provided to CNAs. A Witness Statement dated 5/4/21 at 8:25 PM Staff O, CNA documented she last visualized the resident after supper when she laid her down and changed her. Staff O wrote the Bio sheet indicated Resident #79 needed to be on her side because of a wound on her coccyx but didn't say anything about her bed being in the lowest position or a mat on the floor and no signs detailing either of these interventions. Staff O heard the resident yelling for help and found her on the ground. Staff O got help and staff moved her into a lying position; the resident's leg looked wrong and she complained of pain. The Emergency Department physician's note dated 5/4/21 revealed resident fell out of bed and complained of bilateral leg and hip pain. X-ray of left and right knee revealed distal femur fractures. The Internal Medicine History and Physical dated 5/5/21 documented Resident #79 fell out of bed on 5/4/21. The resident complained of bilateral hip and leg pain. Per family, the resident had a low bed at nursing facility, pads on the floor and bed rails to prevent her from falling out. Somehow, the resident was found down on the ground by staff and were concerned about her lower extremity injuries. The physician documented the resident had acute bilateral distal femur fractures and consulted Orthopedics. The Orthopedic Consult note dated 5/5/21 documented the resident had closed bilateral periprosthetic distal femur fractures, left worse than right. Resident #79 was not a surgical candidate given her history. An Employee Warning Notice dated 5/4/21 recorded that Staff M, former Director of Nursing (DON) provided coaching to Staff O, CNA regarding leaving resident bed in the highest position. Resident crawled out of bed which resulted in injury. An Employee Warning Notice dated 5/5/21 documented Staff M provided coaching to Staff P, Licensed Practical Nurse (LPN) regarding failure to place an intervention on the Bio sheet and as a result the aides did not follow the intervention and Resident #79 fell . Staff M instructed that Staff P immediately will put all interventions on the Bio sheet. The resident's Skin Condition Report dated 5/12/21 revealed she had open area with red drainage and bone tip showing to her left leg above the knee. The resident wore an immobilizer to the knee area. In an interview on 9/23/21 at 9:45 AM, Staff M, Registered Nurse (RN), stated she worked as a RN since 2008 and worked at the facility since 2016. Staff M was familiar with residents and the care they required. Staff M used the pocket care plan for each individual to guide care; the pocket care plan provided knowledge of assistance needed and interventions. She referred to the pocket care plans as mini care plans set up for each resident and fall interventions are incorporated. Nurses complete follow up after falls that included vital signs and assessment (possibly neurological) every shift for 72 hours. She reported the facility completed huddles on each shift that updated nurses on changes. The Managers updated the pocket care plans, placed them on a drive, and printed them each morning. The pocket guides were placed in a binder for all staff to review. Staff M said changes made throughout the day were put on the master copy and entered in the system the next day. Licensed staff initiated fall interventions immediately after a fall. If management did not agree with the implemented intervention, they changed it back or initiated a different intervention and then updated the pocket care plan. Staff M reported the facility rarely used alarms and used alarms as a last resort. Staff M could not recall that any residents currently utilized alarms. She remembered Resident #79 and believed that she had an infrequent fall history. Staff M stated that Resident #79 came on and off Hospice. Staff M remembered the fall on 5/4/21 in which Resident #79 fell from her bed and fractured her femurs. The resident went to the hospital and returned on 5/5/21. On the evening of the fall in question, she thought Resident #79's bed was left in the high position and the side rails were up. She thought maybe Resident #79 climbed over the top of the side rails. Staff M did not know for sure if Resident #79 used a regular bed or a low bed; she received hospice services at the time of the fall. Staff M did not know whether or not the pocket care plan contained fall interventions that staff did not use at the time of the fall. Staff M reported she was the DON at the time of the incident and did not recall concerns with the fall or how staff handled the fall. Staff M stated Resident #79 had no alarm at the time of the fall. Staff M did not recall intervention put into place after the fall, but stated staff put interventions in place after every fall. The management team reviewed falls daily, planned interventions, and assisted with implementation. Staff M considered residents at risk for falls with any medication changes, anxiety, agitation, confusion, and behavior out of the norm, room changes or new admissions. Residents are assessed for fall risk upon admission and quarterly thereafter or with any physical or behavioral changes. Staff documented the assessments on the admission paperwork and in the electronic health record (EHR) or in the paper chart. Staff documented fall assessments in the progress notes. Staff M reported she monitored staff to ensure interventions were implemented and placed on Bio sheets. The management team reminded staff to sign off on changes made and discussion at shift report. In an interview on 9/23/21 at 11:40 AM, Staff O, CNA, stated she worked at the facility for three years and became familiar with the residents, cares needed, and how much assistance they needed by referring to the Bio sheets which had information about each resident. Staff O, stated fall interventions are located on the back of the Bio sheets (for example fall mats, low bed, wheelchair by bed), and the front of the Bio sheets indicated how much assistance each resident needed. Staff O stated the facility no longer utilized bed alarms. Resident #79 fell on [DATE] and Staff O reported she put the resident to bed that evening. Staff O reported she had not worked at the facility in a while, and did not know of the resident's change in cognition, her crawling out of bed, and recent fall. Staff O reported she had reviewed the Bio sheet prior to assisting Resident #79, and noted she had a body pillow on her bed but unsure of the reason. Staff O stated the Bio sheet lacked interventions related to falls. She received report but because she hadn't worked in a while, pertinent information related to Resident #79 was not shared. Staff O assisted the resident to bed and placed a body pillow and padded side rail. A couple of hours later she heard the resident yelling. Staff O found Resident #79 on the floor and noted an injury as her leg was crooked and she appeared in pain. Staff O notified the nurse for assistance. Staff O stated that after the fall, staff put interventions in place. Physical Therapy marked all the residents' walls at the level where the bed should be left after the incident. In an interview on 9/27/21 at 08:40 AM, Staff A, CNA, stated she had worked at the facility since 9/2020, and was familiar with the residents who resided in the front halls. Staff A reported she utilized the care plans or Bio sheets to know what cares the residents needed. The Bio sheets are located at the nurse's station and then they are printed daily for the staff to review. Staff A stated fall interventions are located next to the resident's name on the Bio sheet. The Bio sheet tells staff what type of supervision or assistance the resident needed. The CNAs and nurses provided information to management whenever new interventions were needed for a resident and placed these on the Bio sheet. Staff A reported Resident #79 had a history of falls. Staff A worked the evening of 5/4/21 when Resident #79 fell from her bed. Staff A and Staff O transferred Resident #79 into bed on 5/4/21. Staff A stated she believed the Bio sheet directed to have her side rails down but she could not state if other interventions were on the Bio sheet at that time. Staff A thought the resident had padded side rails at one point. In an interview on 9/27/21 at 11:26 AM, Staff R, Certified Medication Assistant (CMA), reported she had worked at the facility for four years and was familiar with Resident #79's cares. Staff R reported the resident used a 1/2 side rail on her bed, on the opposite side of the wall, and a body pillow against the side rail. Staff used the side rail anytime Resident #79 lay in bed. Staff R reported she knew to use the side rail by reviewing the Bio sheet. She also stated the side rails were used until the resident passed away. In an interview on 9/27/21 at 11:32 AM, Staff B reported she worked at the facility for one year and cared for Resident #79. Staff B recalled the resident used a side rail located in the middle of the bed and the pad placed against the side rail was longer than the side rail. She stated she knew to use the side rails per the Bio sheet. She stated Resident #79 utilized the side rails until the time of her death. In an interview on 9/27/21 at 11:38 AM, Staff Q, CNA, reported she worked at the facility for four years. Staff Q reported Resident #79 utilized side rails while in bed, a fall mat on the floor opposite the wall, and her bed in its lowest position. Staff Q reported the Bio sheets listed the interventions. In an interview on 9/30/21 at 10:53 AM, Staff H, Corporate Nurse, reported the facility had no policy related to falls besides the Resident Safety Policy. At 11:21 AM, Staff H reported there are no other fall policies utilized at the facility. Review of the Resident Safety Policy, dated 2016, revealed following a resident fall, section 2.k. directed staff to document any corrective action taken and section 2.l. directed to documented follow-up information. The policy contained no specific instruction to update resident Care Plans. 2. The admission MDS assessment dated [DATE] documented Resident #40 entered the facility on 5/31/18. The resident had diagnoses of a right above the knee amputation, traumatic brain injury (TBI), depression, [CONDITION(S)] and arthritis. The MDS recorded the resident had a brief interview for mental status (BIMS) score of 13, which indicated intact memory and cognition. The MDS documented Resident #40 required the extensive assistance of two for bed mobility and toilet use, total dependence on two for transfers, and partial/moderate assistance to roll left and right. The MDS documented Resident #40 fell on ce without injury since her prior assessment. The facility Quality Assurance Condition Report dated 6/23/21 at 6:00 AM documented Staff K, CNA stated Resident #40 rolled out of bed and hit the back of her head on the bedside table while Staff K completed a linen change. Resident #40 reported her right stump was sore and slightly red. No side rails were in use at the time of the incident. Staff L, LPN completed the report, documented environmental concerns, and wrote resident needed side rails. Initiated interventions included counseling of Staff K and the resident. The witness statement report dated 6/23/21 documented during the process of changing the resident, Staff K, CNA told the resident to roll. As Staff K removed wipes and a bedpan from area, Resident # 40 rolled out of bed onto the floor. On 6/28/21 Staff L, LPN added to the report that staff were educated on Resident # 40's fall and instructed to take all items needed to the bedside when changing Resident #40. Staff K, CNA added she had everything next to her. She stepped back an inch and removed the package of wipes out of her way. During that moment, the resident rolled out of bed. She also noted Resident #40 rolled by herself and Staff K just cued her. In an interview on 9/15/21 at 3:15 PM Resident #40 reported while staff assisted her with incontinence care, an aide told her to roll over. The side rail on the bed was down and she rolled off the bed onto the floor causing broken ribs and a punctured lung. In a follow up interview on 9/20/21 at 3:15 PM, Resident #40 stated she fell out of bed while staff assisted her with incontinence care. She stated staff told her to roll to one side of the bed and then roll back toward them. When she rolled back to staff, no one was there and Resident #40 fell off the bed. Resident #40 blamed staff for the fall out of the bed. She stated there was only one staff member in the room. During this interview, Resident #40 reported her only injury was bruising to the stump of her amputated leg. She further stated she had a different fall where she broke her ribs a very long time ago. In a joint interview on 9/21/21 at 12:11 PM, the Administrator and Staff H, Director of Clinical Services reported that Staff K received counseling for Resident #40's fall. Education completed regarding turning and having resident turn into your body. In an interview on 9/22/21 at 2:30 PM, Staff K reported she was assisting Resident #40 to change depends (incontinence briefs) and asked the resident to roll towards her. Staff K stated she stepped back maybe one inch to grab a wipe and Resident #40 rolled onto floor. Staff K denied stepping several feet away from the resident. In an interview on 9/22/21 at 2:48 PM, Staff L, LPN stated Staff K reported she turned Resident #40 and asked Resident #40 to roll towards her. When Resident #40 rolled, the CNA thought Resident #40 had stopped rolling and she turned to grab a wipe. Resident #40 continued to roll and rolled onto the floor. Staff L thought the fall was preventable, but she did not witness the fall. Staff L felt the CNA needed to make sure Resident #40 was stable before she grabbed the wipes. At the request of the DON, Resident #40 re-interviewed on 9/29/21 at 9:39 AM regarding her fall on 6/23/21. Resident #40 stated she felt the CNA was at fault for her fall. Resident #40 reported the CNA had Resident #40 turn to the wall. The CNA removed her brief and then told Resident #40 to roll back toward her. Resident #40 said when she rolled back toward the CNA, she rolled onto the floor because the CNA was over by the door to the room. Resident #40 said the trash can held the door open and the CNA went to throw away her brief. Resident #40 reported a minor injury of bruising to her right above the knee amputation stump. The resident's Care Plan, updated 4/23/21, reflected Resident #40 at a moderate risk for falls and had activities of daily living (ADL) self-care performance deficit related to amputation above the right knee. The resident required assistance of two for bed mobility when repositioning the head of the bed, otherwise the assistance of one for turning. The Care Plan identified Resident # 40 used a bedpan, and usually had incontinence episodes daily.

Based on clinical record review, observation, and staff interview, the facility failed to follow care interventions to prevent falls for 1 resident with a fall resulting in [MEDICAL CONDITION] (Resident #73). The facility reported a census of 86 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] (prior to fall) documented Resident #73 had [DIAGNOSES REDACTED]. The MDS documented the resident scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating mild cognitive impairment. The MDS documented the resident required extensive assistance of 1 staff member for bed mobility, transfers, walking, and total dependence of 1 staff for toilet use. The MDS documented the resident had no falls. The care plan revised on 11/15/18 (prior to fall) directed staff to use extensive assistance of 1 staff member for transfers. The resident had a history of [REDACTED]. Anticipate and meet my needs. First down after supper Be sure call light is within reach and encourage/remind me to use it Dycem in wheelchair Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility Ensure bed remote is in holder Ensure I am wearing appropriate footwear such as soles with a sole or non-skid socks when ambulating/transferring or mobilizing in my wheelchair I participate in the walk to dine program as I allow Physical therapy evaluate and treat as ordered or as needed Staff to not leave in bathroom unattended Staff to offer to sit in recliner before leaving the room The MDS dated [DATE] (after the fall) documented the resident had BIMS score of 10 indicating moderate cognitive impairment. The MDS documented the resident required extensive assistance of 1 staff member for bed mobility, extensive assistance of 2 staff members for transfers, total dependence on 2 staff members for toilet use, and did not walk. The MDS documented the resident has occasional bladder incontinence and always continent of bowel. The MDS documented the resident had no falls. The care revised on 12/4/18 (after the fall) directed staff to use extensive assistance of 2 staff for toilet use and do not leave me on the toilet alone. The facility had fall interventions including: Anticipate and meet my needs. First down after supper Be sure call light is within reach and encourage/remind me to use it Dycem in wheelchair Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility Ensure bed remote is in holder Ensure I am wearing appropriate footwear such as soles with a sole or non-skid socks when ambulating/transferring or mobilizing in my wheelchair Physical therapy evaluate and treat as ordered or as needed Staff to not leave in bathroom unattended Staff to offer to sit in recliner before leaving the room The resident had the following falls: 1/24/18 8:00 p.m. fell off toilet. intervention do not leave unattended in the bathroom 2/16/18 15:30 p.m. in bathroom resident let go off grab bar 6/11/18 1:45 p.m. sitting on buttocks. dycem to w/c 7/7/18 6:35 p.m. leaning to pick up bed control. keep bed control and call light close 11/27/18 4:45 p.m. fell off toilet. transfer to hospital The Nurse's Notes dated 11/27/18 at 4:45 p.m. observed the resident on the bathroom floor. Another neighbor resident had activated the call light to obtain assistance. An x-ray dated 11/27/18 documented an acute right femur neck fracture. The Bio-sheets or pocket care plan as described by the facility policy as a detailed specific tool used to provide care for each resident. During an interview on 1/15/19 at 9:43 a.m. Staff P, Certified Medication Aide/Certified Nurse Aide, (CMA/CNA), worked with Staff W, CNA, on 11/27/18 for 2-10 p.m. shift. Staff P learned in orientation to carry the biosheet at all times. Staff P stated the biosheet directed staff to use 2 staff and the pivot disc for transfers. Staff P stated the charge nurse prints a new biosheet everyday. She learned in orientation not to leave the resident unattended on the toilet. During an interview on 1/15/19 at 9:52 a.m. Staff Q, licensed practical nurse (LPN) night shift prints biosheets out for 6-2 shift. Staff Q, stated the resident had a fall from the toilet before and the intervention directed staff not to leave the resident unattended on the toilet. During an interview on 1/15/19 at 11:45 a.m. Staff R, CNA, worked 2-5 on date of incident 11/27/18 in the back of new southwest and new northwest. Staff R received the biosheet once on duty which directs the resident's care. She went to the break room for supper break and Staff AA, CNA, went to the break room for a supper break. Staff O, LPN, entered the room to say to Staff AA that she had left the resident on the toilet and she fell with a possible fracture. During an interview on 1/15/19 2:55 p.m. Staff S, CNA, (from staffing agency) worked 2-10 in the new northwest and new southwest skilled hall. Staff S stated she heard about the incident the next day. Staff S stated the CNAs use a pocket care plans to direct care for the resident. She will not attempt any cares without facility staff. She did not quite understand why resident needed supervision on the toilet. She could be in her wheelchair or recliner without supervision. During an interview on 1/15/19 at 4:06 p.m. Staff T, CNA, stated he usually works up front and unfamiliar with the resident, Staff T used the biosheet. given to him at the beginning of the shift. Staff T checked the biosheet and it directed to use 2 assist with pivot disc and gait belt. During an interview on 1/15/19 at 4:12 p.m. Staff U, CNA, (from staffing agency). Staff U stated she worked up front primarily. Staff U stated being from a staffing agency, she depends on the biosheets to give directions for the resident care. Staff U she did know the resident cannot be left alone on the toilet. Staff U stated the resident has panic attacks and does not like to be left alone. During an interview on 1/15/19 at 4:20 p.m. Staff O, LPN, printed out biosheets for the 2-10 p.m. shift the day of the incident. Staff AA had a copy of the biosheet on 11/27/18. Staff O stated the biosheet directed staff not to leave the resident alone on the toilet. Staff O stated Staff AA went on break and did not tell the other CNAs that she put the resident on the toilet. Staff W alerted Staff O that the resident fell off the toilet. Staff O stated she assessed the resident and sent the reside to the emergency room for possible [MEDICAL CONDITION]. Staff O stated the resident was a fall risk and very impulsive. During an interview on 1/15/19 at 4:26 p.m. Staff V, CNA, stated she always carried the biosheet. Staff V stated it tells everything you need to know to care for that resident. The facility had made it mandatory to carry the biosheet at all times. During an interview on 1/16/19 at 8:40 a.m. Staff W CMA via phone call. stated on 11/27/18 she had an orintee Staff P. Staff W stated that they came back from break then Staff AA and Staff BB, CNA, went to break. Staff AA did not tell her she put the resident on the toilet. Staff W stated they answered the bathroom light and observed the resident on the floor in bathroom. Staff W stated she had Staff P stay with resident while she get the nurse Staff O. During an interview on 1/16/19 at 9:27 a.m. Staff X, RN, stated approximately 35 residents on back and new SW/NW with 10 residents that require 2 assist. Staff X stated for sufficient staffing for the 2-10 p.m. shift sufficient staffing 4 CNAs. Staff X stated 2 CNAs go on break leaving 2 CNAs to manage all 4 halls. During an interview on 1/16/19 at 9:35 a.m. Staff Y, physical therapist assistant, stated the resident had improved to 1 assist with front wheeled walker. Staff Y discontinued the pivot disc on 1/14/19 and updated the biosheet. Staff AA in a written statement dated 11/27/18 at 4:45 p.m. Staff AA wrote she had helped the resident to bed once about 3 weeks ago. Staff AA stated she had observed other CNAs leave the resident on the toilet unattended. Staff AA stated she sits in her room alone and wanders the facility independently. The surveyor attempts to contact Staff AA proved unsuccessful. During initial tour of the facility on 1/13/19 at 11:25 a.m. the resident sat in recliner with feet up. The surveyor whet to introduce self to the resident. The resident indicated she needed to use the bathroom by pointing to the bathroom door. The call light was under the bed where the resident could not reach The resident hard to understand but will answer yes no questions. The resident recalled the fall but unable to give any details. Staff CC, CNA, and Staff N, RN, to assist with the transfer. At 11:45 a.m. gait belt applied. and assisted the resident to stand and pivot to the wheelchair. Staff wheeled the resident into the bathroom and assisted the resident to stand and pivot to the toilet. The resident had a dry depend. Staff assisted the resident to stand and use grab rails to pull up depend and pants then another stand pivot transfer to the wheelchair. Staff did not use a pivot disc.

Based on observation, record review and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazardous side rails and wheelchair foot pedals which caused tears to the skin of Resident #2 and Resident #3. The sample consisted of 6 residents and the facility reported a census of 88 residents. Findings include: 1. A document titled Admission Record, dated 10/20/17, identified Resident#2 had [DIAGNOSES REDACTED]. Resident #2 had a MDS (Minimum Data Set) assessment, with a reference date of 10/19/17. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15. A score of 6 identified the resident had cognitive problems. The MDS indicated the resident required extensive assistance of staff members for bed mobility, transfers, dressing, toilet use and hygiene. The MDS identified the resident as not ambulatory. A Care Plan with focus areas dated 10/20/17 identified the resident as wheelchair bound. The interventions directed the staff the resident could propel self a short distance but staff assist for all other mobility. The interventions indicated the resident required 2 staff for transfers. The Care Plan identified the resident at risk for skin breakdown related to impaired cognition, incontinence and a history of pressure ulcers. The interventions included and directed staff to monitor skin weekly per protocol, during showers and when providing cares; Report any areas of concern to the nurse. The Nurse's Notes dated 11/7/17 at 1:00 a.m. indicated the resident had a right lower extremity skin tear area. The nurse cleansed the area with normal saline and covered the area with [MEDICATION NAME] The nurse documented a ½ C skin tear that the resident thinks she hit on the wheelchair pedal when being put to bed. The Skin Condition Report dated 11/7/17 indicated a 3 cm (centimeter) by 1 cm by .1 cm depth and located on the right outer calf. The report described the area as a C shaped skin tear with a small amount of drainage. The Skin Report indicated assessments daily from 11/9 through 11/12/17 and then on 11/17/17, 11/24/17 and 12/1/17. The last report on 12/1/17 indicated the area measured 2 cm by 0.5 cm and scabbed. The Quality Assurance Condition Report dated 11/7/17, identified an intervention for staff to remove the wheelchair foot pedals with all transfers. The Skin Condition Report dated 11/14/17, identified another skin tear which measured .5 cm by .5 cm and bleeding. The cause of the skin tear was from transferring to a wheelchair. On 11/15/17 the area measured 2.4 by 0.8. The report indicated on 12/1/17, the area measured 1 cm by 0.3 cm and scabbed. The Quality Assurance Condition Report identified the area on the right lower leg and next to the old previous skin tear. The intervention initiated was to pad the wheelchair. The Skin Condition Report dated 12/3/17 identified a skin tear located on the right upper extremity that measured 2.0 by 2.0 cm and full thickness. The report identified the cause of the skin tear was the resident had increased anxiety with the transfers and had fragile skin. The intervention to prevent further skin tears directed the staff to apply Geri Sleeves to the resident's arms and to monitor anxious behaviors for 1 week for possible medication review. Observation on 12/5/17 at 3:25 p.m. identified no plastic insert on the lower side-rail, closest to the door. On 12/4/17 at 12:55 p.m., the resident indicated the 2nd skin tear occurred when she scrapped her right leg on the bottom part of the side rail without a plastic protector in the circle. An observation at the same time revealed no plastic insert in the circular area on the bottom portion of the side rail closest to the door. On 12/6/17 at 1:20 p.m., observation identified Staff A, Licensed Practical Nurse (LPN), conducted an interview with the resident. The resident stated she received the 2nd skin tear from the side rail closest to the door as she reached down and touched the side rail and stated from this circle thing that does not have a cap on it. On 12/6/17 at 1:26 p.m., Staff A was interviewed and confirmed the above stated document. On 12/6/17 at 1:35 p.m., Staff L, Certified Nursing Assistant (CNA) was interviewed and stated the skin tear would have occurred when staff transferred the resident from the bed to the wheel chair. Staff L stated she didn't notice anything until she saw blood on the resident's pants. The staff member confirmed the resident as alert and oriented. Staff L stated the resident knew what was going on around her and she knew her (Staff L) by name. On 12/6/17 at 1:42 p.m. Staff M, Licensed Practical Nurse (LPN) was interviewed and stated when the 2nd skin tear occurred the resident had a Band-Aid over the 1st skin tear. The staff member confirmed the resident as alert and oriented. 2. Resident #3 had a MDS assessment with a reference date of 9/1/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 0. A score of 0 identified severely cognitive impairment. The MDS indicated the resident had fluctuating inattention and required extensive assistance of staff for bed mobility, transfers, locomotion, dressing, personal hygiene and non-ambulatory. A Care Plan with a focus areas initiated on 8/17/17, indicated the resident required assistance with all activities of daily living since his/her recent hospitalization for hip surgery and at risk for skin breakdown related to impaired cognition, impaired physical mobility and incontinence. The interventions directed the staff to do the following: Wheel chair used for mobility and propelled by staff. Two staff assistance and a front wheeled walker (FWW) and/or a Hoyer lift (mechanical) device for transfers. Geri sleeves to arms and lower extremities as allowed. Ace wraps from toe to knee (hand written and not dated). A document titled Quality Assurance Condition Report dated 9/11/17 at 8:15 a.m. indicated the resident received a skin tear to her right outer calf that measured 2 cm by 2.0 cm, no depth, dried blood present and staff had been unable to approximate the area (position the skin together). The Quality Assurance Condition Report dated 9/12/17 at 9:00 p.m. indicated the resident received a skin tear to her left calf. On 12/6/17 at 10:43 a.m. Staff C, Certified Medication Aide (CMA) was interviewed and stated when herself and Staff D, Certified Nursing Assistant (CNA) transferred the resident to bed she hit her leg on the bed but not the side rail. The staff noticed the area when they positioned the resident in bed so they reported it to the nurse who assessed the area and said the area had already been present it just re-opened. On 12/6/17 at 2:42 p.m., Staff E, Licensed Practical Nurse (LPN) indicated she had been unaware if the resident hit her leg or not but the above stated area had been scabbed and just re-opened. According to a form titled Witness Statements form dated 12/2/17 at 8:15 a.m., Staff H, CNA documented she removed the resident's geri sleeve from the resident's weeping and swollen leg and observed the skin tear. A Quality Assurance Condition Report form dated 10/29/17 at 7:30 p.m. indicated the resident received a Skin tear to her right lower extremity that measured 1.5 cm by 3.5 cm, with no depth and with red, moist scabbed edges. A Skin Condition Report form dated 11/17/17 indicated the resident received a skin tear to her left lower extremity that measured 6.5 cm by 3.5 cm and 2.0 cm deep with serosanguinous drainage and tissue exposure caused by a side rail. The facility staff then placed steri-strips to close the wound. The Nurse's Notes dated 11/17/17 at 7:15 p.m. contained the following documentation: A new 6.5 by 3.5 by 2.0 cm skin tear found to the left inner calf observed. The resident wore geri sleeves and had on pants. The resident's left calf hit the side rail while positioned in bed. The area was cleansed, 5 steri strips applied and covered with gauze. Wool to cover side rails and wheel chair legs initiated. On 12/5/17 at 1:40 p.m., Staff J, CNA, was interviewed and stated herself and Staff I, CNA transferred the resident from a wheel chair to bed while the resident wore leg protectors and pants. As the staff members sat the resident on the edge of the bed, the resident yelled out in pain. The staff members then laid the resident down in bed and she noticed fluid on the resident's pants and bed. This staff member stayed with the resident as Staff I informed the nurse. The staff member confirmed she knew the area came from the side rail because the skin tear had been at the same height and the rail had a jagged edge on the circle part of the rail that pointed towards the foot of the resident's bed and the skin tear tore down like the exposed circle on the rail. The staff member confirmed she felt along the rail and felt the jagged edges. On 12/5/17 at 4:34 p.m., Staff I CNA, confirmed herself and Staff J pivot transferred the resident from the wheelchair to bed and sat her on the edge of the bed. Staff J supported the resident's upper body while she swung the resident's legs onto the bed. The staff member stated once they put the resident in bed, she complained of pain, however, the resident didn't voice complaints while in the wheelchair. The staff members then lifted the resident's pant leg and noticed a geri sleeve in place with blood on the sleeve but she did not recall any tears or rip in the geri sleeve. The staff member then went to get the nurse while Staff J stayed with the resident. When the nurse arrived she left the resident's room and answered call lights. On 12/5/17 at 12:27 p.m. Staff K, Registered Nurse (RN) was interviewed and stated that night 2 staff members assisted the resident with hour of sleep (HS) cares. After the staff positioned the resident in bed, they informed her (Staff K) the resident hit leg on the side rail. When she entered the room, the resident laid in bed and wore calf length socks and geri sleeves; however, one had a cut through it. When she assessed the area, she noted a fairly deep cut that drained serosanguinous drainage. She placed a gauze, applied pressure, placed 6 steric strips as the area became well approximated, covered the area with a non-adherent dressing, wrapped the area with Kerlix and put the geri sleeves back over the area for pressure and protection of the leg. Review of an emergency room (ER) note dated 11/18/17 at 7:54 p.m., indicated the resident presented with a left posterior lower leg injury. Review of an Emergency Doctor (ED) Provider Notes form dated 11/18/17 at 8:02 p.m., documented per a Sunny View Nurse; the resident was transferred between the beds the day prior when her left calf caught the bed rail which caused the laceration. The area had been anchor shaped and measured 6.5 cm on the hook area and 4 cm on the top of the hook with the subcutaneous tissue exposed. The Physician applied 4 loose sutures and added steri-strips. A Quality Assurance Condition Report form dated 12/2/17 at 8:15 a.m. indicated the resident received a skin tear to her right shin. When the CNA's removed the resident's geri-sleeves on her legs, they noticed the area. The legs wept with 3 plus (+) [MEDICAL CONDITION]. A Skin Condition Report form dated 12/2/17 indicated the resident received a skin tear to her right shin that measured 4.5 cm by 0.3 cm. On 12/6/17 at 9:29 a.m. Staff F, LPN was interviewed and stated the skin tear on 12/2/17 resulted from removal of the geri sleeves. Observation on 12/5/17 at 3:25 p.m. identified 20 of the 49 beds checked with 1 or 2 side rails had missing 1 to 4 plastic inserts (caps) on the end of the side rails with 3 of those areas without plastic inserts confirmed as rough and jagged by the maintenance man. A Skin Condition Report form dated 10/2/17 indicated the resident received a skin tear to her right outer calf. One measured 1.5 cm by 1.5 cm and the other 1.0 cm by 1.0 cm.

Based on observation, record review and staff interview, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for one (1) of 5 (five) residents reviewed. Resident #1 eloped from the facility without staff knowledge. A nurse aide turned off the alarm without fully investigating what caused the alarm to activate. Resident #1 had an unwitnessed fall and a housekeeper personnel discovered the resident lying on the driveway. The findings constitute an immediate jeopardy to a resident's health and safety. The facility identified a census of 91 residents. 1. The Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED].#1. The same MDS documented a Brief Interview of Mental Status (BIMS) score of 7 which indicates moderate cognitive impairment, independent with bed mobility, transfer and ambulation. The care plan problem revised on 9/4/15 identified the resident as an elopement risk/wanderer related to the [DIAGNOSES REDACTED]. The care plan directed staff to distract the resident from wandering by offering pleasant diversions. The care plan revealed Resident #1 wears a Wanderguard device on his/her left ankle; and directed staff to check placement and functioning of the device every shift. The Fall Risk Assessment Form dated 11/18/15 documented a score of 13; a score of 10 or greater indicates a resident at high risk for falls. The Elopement Risk Assessment completed 11/18/15 documented a score of 8 yes answers, a score of 3 or more yes answers indicated the resident is at risk for elopement. The form documented the resident had a Wanderguard bracelet. Staff responded Yes to the assessment questions noting the resident showed the following concerns: disoriented to place, impaired decision making skills, resident made statement about going home, history of wandering, and displayed persistent anger at current placement. The Nurse's Notes entry dated 12/16/15 at 5:10 p.m. documented the resident exited out the south door of the facility at 4:56 p.m. The alarm sounded and staff turned off the alarm. The resident tripped over a piece of bark in the parking lot and fell to his/her knees. The resident had been assisted back into the building by 2 staff member. The Nurse's Notes entry at 5:10 p.m. documented staff performed a head-to-toe assessment of the resident and found a 6 centimeter (cm) x 4 cm bruise of the resident's left knee. The facility also initiated 15 minute checks and neurological checks per facility protocol of the resident at this time. After the incident, the facility performed a head count (of residents) and determined everyone had been accounted for. The Sunny View Daily Schedule Sheet documented Staff K, certified nursing assistant (CNA) assigned to the south hall of the facility on the 2:00 p.m-10:15 p.m., shift on 12/16/15. During interview on 12/23/15 at 3:49 p.m., Staff K had responded to the door alarm on 12/16/15 and stated she did not check outside the facility when she responded to the door alarm. Staff K further stated she could not recall being educated to the facility's elopement policy during orientation but had been educated on different codes needed to silence the alarm(s). Staff K documented on the witness report (undated) at 4:56 p.m., she heard an alarm go off at the South door and turned it off after looking out the window. Staff K documented it had been dark outside and she did not notify the nurse (after hearing the alarm). During interview on 12/22/15 at 2:00 p.m., the facility's housekeeping supervisor stated on 12/16/15 around 5:00 p.m. she heard a door alarm sound as she walked up the main hallway to clock out for the day. She stated she eyeballed the front door of the facility and then checked the service entrance door. She stated she then went to check the panel to see what door alarm was sounding, but the alarm ceased before she arrived at the panel. She then clocked out for the day and proceeded to her car located in the southeast driveway entrance. She stated she started her car and saw a resident lying on his/her back in the driveway entrance. The resident's walker lay on the ground next to his/her feet and the resident's head towards the middle of the driveway entrance. The housekeeping supervisor stated the resident tried to sit up and she supported the resident in a sitting position with her legs and called the facility on her cell phone for assistance. She stated the resident had no coat on and that it felt cool outside. The time clock report for the housekeeping supervisor documented she clocked out on 12/16/15 at 4:57 p.m. According to the State Climatologist the weather in Ankeny, IA on 12/16/15 at 5:00 p.m. was as follows: a temperature of 32 degrees Fahrenheit (F). with the wind from the west at 16-27 miles per hour (mph) making the wind chill temperature 22 degrees F, cloudy skies with no precipitation and the sunset occurred at 4:45 p.m. Observation on 12/22/15, at approximately 2:35 p.m., the location where staff found Resident #1 measured 140 feet from the south door of the facility and approximately 25 feet from the driveway entrance from the street. The speed limit on the street is front of the facility is posted as 30 miles per hour. A list provided by the facility identified 14 residents with Wanderguard bracelets in place. The facility's undated Wanderguard /Door Alarm policy directed staff on the following: Any resident determined at risk for elopement will wear a Wanderguard bracelet (an electronic device that signals an alarm on an exit door) to monitor the resident for safety. When a resident who wears a Wanderguard is near or attempting to exit a door, the louder alarm sounds to notify staff. There is a specific code that has to be entered when the alarm sounds due to a Wanderguard being near. If the Wanderguard code is used and a resident is seen by the staff member near the door, staff should assist the resident away from the door and provide distraction and redirection as needed. If there is no resident seen by the door, staff entering the code should alert the charge nurse immediately to begin a head count of all residents and should begin looking immediately outside the door that was alarming. A letter dated 12/17/15 from Staff K requested additional supports to prevent oversight and to improve her skills for resident's safety; and on 12/17/15, the facility educated Staff K on their policy. The facility abated the IJ on 12/18/15 when they educated all other staff members on responding per their protocol/policy when an alarm is sounding.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the health service supervisor failed to plan for and direct services for the implementation of safety interventions to reduce the residents risk for falls (Resident #4, #5). The sample consisted of 5 residents. The facility reported a census of 90 residents. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of [DATE], which identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long-term memory impairment, moderate cognitive impairment, signs of delirium which included inattention, disorganized thinking, altered level of consciousness and psychomotor retardation. The resident required total dependence for locomotion, dressing, eating, toilet use and personal hygiene. The resident sustained [REDACTED]. The Care Plan dated [DATE] and [DATE] identified the resident required extensive assistance with daily cares and transfers, a history of falls, dementia, anxiety and impaired mobility. The plan of care interventions directed the staff that the resident required 2 staff members to turn and reposition the resident in bed, and toileting ([DATE]). The Care Plan first identified the resident's impaired cognitive function/dementia or impaired thought processes on [DATE]. On [DATE] the plan of care first identified a history of falls and at great risk for falls due to dementia, occasionally uncooperative actions and impaired mobility. The interventions directed staff to: [DATE]-floor mat by bed, [DATE]-low bed and alarm in bed, [DATE]-do not leave on toilet alone, [DATE]- educated to use call light for assistance, [DATE]- educate family to call staff to assist resident to toilet, [DATE] (resident) turns off alarm Fall Risk Assessments performed on [DATE], [DATE] and [DATE] determined the resident at high risk for falls due to intermittent confusion, a history of falls, chair bound, medications, and predisposing diseases. An Occupational Therapy Evaluation dated [DATE] noted the resident was admitted the facility after two falls, the inability to walk, right hip pain, and right hip surgery on [DATE] and complaints of low back pain. The resident previously lived with his/her spouse and was independent with daily cares and walked with a walker. A Physical Therapy Plan of Treatment dated [DATE] noted the resident sustained [REDACTED]. The resident required moderate assistance of one person to roll side to side in bed, go from lying to sitting position and required the assistance of two persons to stand. The resident had fair static sitting balance and poor dynamic sitting balance. A Mini Care Plan last updated on [DATE] noted the resident required assistance with cares, required the assistance of two persons with transfers, and was alert with confusion/forgetfulness and combative at times. Nurse's Notes included: [DATE] at 5:00 p.m. resident was found lying on floor next to bathroom. [DATE] at 2:30 p.m. resident's roommate called staff to room, observed resident lying on the floor on right side. Resident stated, "I need the toilet!" PSA (alarm) in place on bed, turned on and blinking, but not sounding. Resident complained of pain everywhere. No sign of injury noted. [DATE] at 2:00 p.m. order received for physical therapy evaluation and treatment for [REDACTED]. [DATE] at 1:45 p.m. summoned to resident's room. Resident sitting on the floor by bathroom. Alarm sounding. Walker tipped over. Resident on the way to the bathroom. Resident stated, "I hit my head." Resident had a red area and bump on the back of head. Also noted a skin tear on left elbow with moderate amount of bleeding. (Communication to the physician dated [DATE] noted resident got self-up again, alarm went off, by the time staff reached the resident, resident on the floor in the bathroom leaning against the wall. Walker tipped over. Resident stated hit head. Red area with a bump on back of head. Also acquired skin tear to left elbow.) [DATE] at 11:30 a.m. gave resident a urinal and explained use. [DATE] at 7:30 p.m. resident in a bad mood this shift, refused to eat dinner after many attempts. [DATE] at 10:00 a.m. new order to increase Fentanyl patch at the request of the hospice nurse. [DATE] at 2:00 p.m. resident refused to get out of bed this shift. Resident irritable. [DATE] at 12:00 p.m. resident remains irritable, refused to get out of bed. Drank only glass of supplement. [DATE] at 9:30 p.m. resident up to bathroom multiple times. Voids very little each time. Resident had one large void of thick yellow mucous. Physician notified. [DATE] at 2:00 p.m. urine sample obtained, urine yellow, almost milky, can't see through it. [DATE] at 9:00 p.m. urine remained cloudy and frequency continued, resident showed increased confusion, resident attempted to get out of bed without assist. One on one supervision provided. [DATE] at 11:55 p.m. resident up in wheelchair in hall due to resident attempted to get out of bed. Resident then assisted back to bed. [DATE] at 6:20 a.m. nurse heard bed alarm, found resident lying on floor. Resident's head on the floor. [DATE] at 2:00 p.m. resident set off alarm several times trying to get up to the bathroom. Staff got to the resident each time. [DATE] at 3:10 p.m. staff discovered resident had transferred self from bed to bathroom and obtained a skin tear on right elbow. [DATE] at 5:05 a.m. resident out of bed, staff noted bleeding on mid-calf of right leg. (Communication sheet to the physician dated [DATE] noted resident did not wait for staff, got out of bed, scraped leg, bleeding) [DATE] at 6:30 p.m. resident had transferred self from bed to restroom five times by self. Educated resident. [DATE] at 6:00 p.m. resident tried to get up on own several times to go to the bathroom. Resident found in bathroom twice. Assisted back to bed with help. Resident educated on waiting for assistance. Non-compliant. [DATE] at 01:05 a.m. resident had been on call light very frequently since nurse arrived on duty. Nurse and nursing assistant assisted resident back to bed approximately every five minutes. Tramadol given for back pain. [DATE] at 1:30 a.m. resident has been out in dining room in wheelchair due to will not stay in bed. Hearing the alarm very often and need to check on resident immediately to prevent falls. [DATE] at 1:20 p.m. resident continued going to the bathroom frequently but not urinating every time. Has transferred self to bathroom a few times even though staff had explained several times to wait for assistance. [DATE] at 2:30 p.m. resident was trying to transfer self from bed to toilet. The resident's family was in the room and assisted the resident to the bathroom and bumped head on the wall. (Communication to the physician dated [DATE] noted resident transferred self to the bathroom, staff found resident lying on bathroom floor. Resident bumped head on wall.) [DATE] at 12:00 p.m. new order received from hospice for a catheter, waiting for okay from family. [DATE] at 6:30 p.m. resident up to bathroom with assistance approximately 10 times today. Urinates small amounts at a time. Awaiting family's okay to insert catheter. [DATE] at 10:00 a.m. resident transferred self to bathroom, alarm in place and sounding. [DATE] at 6:30 p.m. resident tried to transfer self approximately five times, one on one successful for short periods of time. [DATE] at 8:10 p.m. up to bathroom frequently, voids little or none. [DATE] at 11:30 a.m. hospice nurse here to see resident, contacted resident's family regarding a catheter due to urinary retention. Catheter inserted. [DATE] at 11:20 a.m. summoned to resident's room, resident found on floor, head hit the dresser. Resident lying alongside of bed, feet at end of bed. Resident tried to get up and go to the bathroom. Resident grabbed the walker and tripped and went to the floor. [DATE] at 5:30 p.m. resident extremely agitated, kicking and cursing at staff. Repeatedly trying to get out of bed, but wouldn't allow staff to assist. Tramadol given, hospice was contacted. Resident finally settled down with family visiting. [DATE] at 10:00 a.m. resident complained of right hip and leg pain. Described pain as achy. [DATE] at 8:50 a.m. resident fell this morning while taking self to bathroom, alarm was sounding. Walker was on top of resident. Re-educated resident to use the call light and wait for assistance. [DATE] at 7:00 a.m. resident on the floor between the bed and the bathroom, lying on back with walker on top of resident. Complained of left hip pain. Rated pain at a ten. Alarm was not sounding. Assessment completed and resident was left on the floor until transport to the hospital. [DATE] at 1:00 p.m. resident admitted to the hospital for a fractured left hip. [DATE] at 2:00 p.m. resident readmitted to the facility. Three incisions to left hip/thigh. [DATE] at 8:00 a.m. family at bedside, pulse faint and weak. Blood pressure faint. Roxanal given for comfort. [DATE] at 10:30 a.m. resident expired at 10:25 a.m. Nursing Home to Hospital Transfer Data List dated [DATE] noted resident sent to hospital [DATE] at 6:50 a.m. with cognitive impairment, fall and questionable fractured hip. The Biosheet for [DATE] instructed staff to use an alarm, use the side rail, transfer with assistance of one person, assistance of one with toileting/bathroom, oxygen on all day, resident dribbles, check every two hours, do not let sit on bed, sit up in wheelchair or recliner and pressure alarm. When interviewed on [DATE] at 7:35 a.m. CNA, Staff H stated she was not educated on the need or policy to check alarms during shift change rounds. On the day of this resident's fall, she performed rounds with the night shift aide, they did not enter this resident's room and did not check this resident's alarm. During report she was informed this resident was up and down all night, which was normal for this resident. She was not informed of any need to provide closer supervision for this resident. The resident normally wanted to go to the bathroom even though he/she had a catheter. The resident normally used the call light about ten times a shift. The resident was grumpy. A lot of the aides would blow the resident off. When the resident would say he/she needed to go to the bathroom they would always remind the resident he/she had a catheter and the resident would cuss and swear if they told him/her that he/she did not need to go to the bathroom. The resident was so determined to go to the bathroom even when they didn't want to help him/her. That morning she just looked into the room and he/she was sleeping. She did not check the resident's alarm. Staff H stated she should have checked the alarm (floor mat). The resident's alarm was an alarmed floor mat. No other alarms were utilized in bed. Normally if the Biosheet lists a clip alarm, she will place the clip alarm both in bed and in the wheelchair and if the Biosheet indicates a pad alarm she will place the pressure pad alarm in both the wheelchair and the bed. She had seen the resident one time that morning in bed, with the side rail along the side of the bed, and the floor mat next to the bed and the alarm box on the floor by the end of the floor mat. She was in another resident's bedroom assisting the other resident in the bathroom. She heard this resident yell hey which normally meant he/she wanted to go to the bathroom. She believed she had time to finish with the resident in the bathroom. She then heard the resident screaming help. She then knew something was wrong. She finished getting the other resident off the toilet and left the other resident in the resident's bedroom and then she approached this resident's bedroom. She observed the resident on the floor just inside the room by the bedroom door. The resident was yelling help and complaining of hip pain and she observed blood from the resident's elbow. She noticed no alarms were sounding. The bed rail was still in position along the resident's bed, the pad was next to the bed on the floor and the alarm box was still on the floor, next to the end of the mat. The floor mat alarm was turned off. She yelled for assistance. She does not believe the resident could have reached the alarm box without actually stepping on the floor mat. When interviewed on [DATE] at 1:10 p.m. a RN, Staff U stated utilized a fall mat on the floor next to the bed and a pressure alarm. She never knew the resident to turn off an alarm. She was just getting report from the night shift nurse when an aide stated the resident was on the floor. She went to the resident's room and found the resident on the floor, the resident had taken the walker and the catheter bag with him/her. The mat alarm was turned off. Staff stayed with the resident on the floor until the paramedics arrived and transported the resident to the hospital. When interviewed on [DATE] at 10:15 p.m. CNA Staff D stated the resident felt like he/she needed to go to the bathroom all the time. The resident knew how to unfasten the clip alarm. One time she knew the resident to turn off the floor mat alarm. She did not inform the nurse the resident knew how to turn off the mat alarm. She worked the night shift right before this resident fell and sustained a fractured hip. The resident had been up and down all night. She stated it is the policy the aides are to check the alarms during their between shift walk through rounds, however, the morning of this resident's fall/fracture, she did not check the resident's alarm during rounds. She stated shortly before 6:00 a.m. she had gone into the resident's room and turned off the alarm and assisted the resident. She believed she turned the alarm back on, however there is a chance she may have forgotten to turn the alarm back on and due to the fact they did not check the alarms during their walking report, she cannot say for sure the alarm was on when she left work that day. When she was home the nurse called her to ask if the resident's alarm was on and she told the nurse she was just sure it was on. She stated the resident was frequently up two or three times in an hour to the bathroom and she always used a gait belt due to the resident was unsteady When interviewed on [DATE] at 10:30 p.m. CNA Staff J stated sometimes she checks the alarms during between shift walk through rounds and sometimes she doesn't, it depends on how much she trusts the other aide. She knew this resident to turn off the alarm. She would try to place the alarm box in a place the resident could not see the box. When interviewed on [DATE] at 10:35 p.m. CNA Staff N stated sometimes she checks the alarms during between shift rounds and sometimes she does not. She stated the resident would turn off his/her alarm and get up out of bed alone. Some nights he/she would get up out of bed every five minutes. When interviewed on [DATE] at 10:40 p.m. CNA Staff A stated she did not go in and check the alarms during the 10:00 p.m. rounds. She stated they take turns checking the alarms. She stated normally at 6:00 a.m. walking report they do not normally check the alarms. She stated this resident frequently got up out of bed on the night shift. She never knew him/her to turn off the floor mat alarm. When interviewed on [DATE] at 1:30 p.m. CNA Staff E stated this resident was confused and wanted to be independent. She stated the resident had used the call light in the past, but not recently. The resident would use the floor mat alarm as a call light. The resident knew if he/she stepped on the mat, the alarm would sound and they would come quickly and take him/her to the bathroom. She would never trust the resident to walk alone due to poor balance. The shift had just begun when she saw Staff H in the hall waving. She went to the resident's room where she saw the resident on the floor. She noted blood from the resident's left elbow. The resident was stating he/she knew he/she should not have done that. The resident also stated he/she tried to call her but the thing wouldn't beep. The resident stated he/she had gone to the bathroom and was on the way back to the bed when he/she fell . She noted no alarm in the bed, only the floor mat which was turned off and not alarming. The resident again stated he/she tried to get them, but it wasn't beeping and he/she could not wait. She stated normally she would hide the mat alarm box. When interviewed on [DATE] at 12:30 p.m. the MDS/Care Plan Coordinator, Staff P described the resident has very forgetful and always trying to get up. The resident had multiple falls. The resident never used the call light. The resident always felt like he/she needed to go to the bathroom. She did not believe the resident could see well enough to be able to turn the alarm off. She stated the charge nurses were responsible for updating the care plans with any new approaches/interventions. They use Biosheets that instructed the aides about how to care for each resident. When interviewed on [DATE] at 10:45 p.m. the Corporate Nurse stated the staff had been educated on their expectations that all aides physically check each alarm during their change of shift aide to aide walk through rounds. This has been their policy and their expectations, however, they were aware this was not being done consistently and the staff had been educated regarding this practice prior to this resident's fall/fracture. 2. Resident #5 had an MDS with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The resident scored 11 out of 15 on cognitive testing. A score of 11 identified the resident had moderate impairment with cognition. The resident required supervision only for bed mobility, limited assistance of one person with transfers, walking in the hall and personal hygiene and extensive assistance of one person with dressing and toilet use. Testing of the resident's balance during transitions and walking revealed to be not steady, but able to stabilize without staff assistance with moving from a seated to a standing position, moving on and off the toilet and surface to surface transfers. The resident was not steady and only able to stabilize with staff assistance with walking and turning around. The resident and the staff believed he/she was capable of increased independence. The resident sustained [REDACTED]. The Care Plan dated [DATE], identified the resident's need for extensive assistance with cares related to weakness, unsteadiness, pneumonia and a history of Parkinson's Disease. The interventions instructed the staff to supervise the resident and provide assistance of one person with toileting, dressing and showers. The Care Plan also identified the resident had Parkinson's Disease with unsteady gait at times. The resident had not fallen and required a walker or wheelchair for steady gait and one staff assistance as needed. Another focus area noted the resident had continuous oxygen therapy related to a recent bout of pneumonia, hypoxia (low oxygen level). The interventions instructed the staff to provide oxygen at three liters continuously. An office visit pre-admission History and Physical dated [DATE] documented the resident required a physical to be admitted to the nursing home. The resident was falling more lately due to leg weakness. He/she had more weakness in the left leg. Rescue had been called to the apartment due to his/her falling and not being able to get up. Patient and family decided the resident required nursing home placement due to fall risk and he/she lived alone. Hospital Physical Therapy note dated [DATE] noted resident required minimal assistance of one person for transfers and gait belt with walker. Patient reported moving to a nursing home [DATE]. Therapist recommended 24 hour supervision at home until transition to nursing home. Hospital Patient Transfer Form dated [DATE] identified resident alert and confused and up with the assistance of one person. Nursing Home Admission Nursing assessment dated [DATE] assessed the resident without pain, transferred and walked independently. A Fall Risk assessment dated [DATE] assessed the resident at a high risk for falls due to intermittent confusion, (no fall history), chair bound, decreased muscular coordination and the use of medications. The Nurse's Notes included: [DATE] at 1:35 p.m. resident had been sitting on edge of bed, physical therapy instructed resident not to sit on bed, either up in the wheelchair or in recliner. Nurse notified staff. Oxygen needed to be on at all times and check as the resident would remove the oxygen. [DATE] at 1:00 p.m. resident transferred self from bed to bathroom on own. Did not use the call light. Nurse found resident in the bathroom. Instructed resident to use the call light and of the need for assistance. [DATE] at 7:00 p.m. resident found trying to transfer self. Educated resident on use of call light, verbalized understanding. [DATE] at 10:00 p.m. resident continued to transfer self, clip alarm placed at this time, explained to resident to use the call light for assistance. [DATE] at 7:15 a.m. resident up on own, standing in doorway of room, had removed clip alarm and oxygen. Instructed resident to use call light and to keep oxygen on and not to get up on own. Clip alarm in place. [DATE] at 7:00 p.m. resident continued to periodically remove nasal cannula, educated resident to keep on and resident reported understanding. Resident very forgetful. [DATE] at 1:30 a.m. staff reported resident did not have oxygen on when checked. Resident reminded to keep oxygen on. [DATE] at 10:00 a.m. resident removed clip alarm and was up on own. Now has pad alarm. Removed oxygen twice, and replaced by staff. [DATE] at 11:08 p.m. oxygen replaced due to resident removing oxygen. [DATE] at 7:00 p.m. resident had been transferring self throughout evening. SpO2 (oxygen saturation) 89% (normal ,[DATE]%), SpO2 tested 92% when on oxygen. Reinforced use of call light, resident remained non-compliant, taking off clip alarm. [DATE] at 11:50 p.m. upon entering room, resident lying in bed without oxygen which resident verified removing. SpO2 88%. Alarm reapplied. Resident appeared dyspnic (shortness of breath) when oxygen off. Resident non-compliant. [DATE] at 1:30 p.m. was called to resident's room by staff. Resident on the floor on his/her back and partially on right side. Resident stated he/she was headed to the bathroom and fell . Resident unable to raise right leg very far or put right leg down completely. Resident held pelvic area. Resident had removed oxygen. Resident alert to self only. The nurse called the physician, the resident's family and the ambulance. A written statement by nurse, Staff C dated [DATE] noted 30 minute checks performed, alarm on, checked due to resident liked to turn alarm off, and remove the alarm. A written statement by nurse, Staff V dated [DATE] noted resident is taken from dining room to bedroom and laid down in bed after meals. Resident wore a clip alarm on in wheelchair and used a pad alarm in bed. Today, resident was removed from the dining room and taken to his/her bedroom. Resident had a clip alarm on, and was left up in wheelchair in his/her bedroom. A SBAR Communication Form dated [DATE] noted resident fell . Resident non-compliant with wearing oxygen, increased weakness, dementia, wandering. Things that make the condition better were to increase staff to monitor. Treatment was place clip alarm. Resident fell related to confusion. Starting 30 minute checks related to resident non-compliance with wearing oxygen which caused increased confusion. A Nurse Practitioner's progress note dated [DATE] noted resident seen due to fall. Resident had COPD and was supposed to be on continuous oxygen, however resident non-compliant and then gets weak and fatigued. The resident also had Parkinson's Dementia and had frequent falls at home. Resident reported headaches and dizziness that would come and go. Assessment and plan included: fall secondary to Parkinson's Dementia, patient already alarmed, no residual injury. An Admission Order dated [DATE] noted resident readmitted to facility at 2:15 p.m. as a two-person assisted transfer, non-weight bearing, with a [DIAGNOSES REDACTED]. An Orthopedic Skilled Nursing Home Orders dated [DATE] included: Diagnosis: [REDACTED]. An undated Pain Assessment tool assessed resident with shooting pain due to right hip fracture. A Quality Assurance Condition Report dated [DATE] documented the resident fell at 2:55 a.m. in another resident's bedroom. A staff member answered a call light and found the resident sitting on the floor by the bathroom door in another resident's bedroom. The resident wore only a shirt. The resident was naked below the waist. Resident had removed his/her clip alarm. Resident confused at the time due to not having oxygen on. Intervention initiated: pad alarm placed and clip alarm removed, and performed 30 minute checks. When interviewed on [DATE] at 5:00 p.m. a licensed practical nurse, Staff F stated she was never aware of any 30 minute checks for this resident and did not know where it would be documented if they did do them. When interviewed on [DATE] at 5:10 p.m. a RN, Staff M stated she was unaware of any 30 minute checks for this resident. On [DATE] the facility provided documentation of 15 minute checks for this resident on [DATE] and [DATE]. A Quality Assurance Condition Report dated [DATE] documented resident fell at 1:30 p.m. in his/her bedroom. Resident was up independently. Resident turned off alarm and taken of oxygen. Resident fell by the sink. Resident stated he/she hit his/her head. Resident unable to straighten right leg. Resident wore socks. Resident's side rails on the bed were down. Intervention initiated: sent to hospital. Review of this resident's clinical record revealed the nurse on [DATE] at 10:00 a.m. failed to document the new intervention of a pad alarm. According to documentation in the clinic record the staff continued to use the clip alarm, and the resident continued to remove the alarm and attempt to walk independently and sustained a fall. Observation and interview on [DATE] at 9:15 a.m. revealed Resident #5 seated in a wheelchair with a lap buddy restraint, at a table in the back dining room. The resident visited freely. The resident talked of his/her long history of falls due to his/her Parkinson's Disease. The resident stated the Parkinson's caused him/her to fall backwards. The resident stated he/she broke his/her leg/hip when he/she walked unassisted to the bathroom and fell backwards. Observation revealed no oxygen in use for this resident at this time. Further observation revealed an oxygen tank on the back of the wheelchair with the oxygen tubing coiled up and in a plastic bag hung on the back of the wheelchair. Observation revealed resident wore a clip alarm at this time. Observation revealed the lack of a pressure alarm in this resident's wheelchair at this time. The Resident Biosheet for [DATE] for this resident, instructed the nursing assistants this resident utilized alarms, side rails, required the assistance of two persons for transferring and toileting, Oxygen at 3 liters, pad alarm/clip alarm, lap buddy and pivot disk for transfers. Observation on [DATE] at 9:30 a.m. revealed a certified nursing assistant, (CNA) Staff R pushed resident in his/her wheelchair from the dining room to his/her bedroom. Staff R verified she and Staff L assisted this resident up out of bed about 8:30 a.m. or 8:40 a.m. Staff R stated she removed this resident's oxygen when she assisted the resident that morning. She forgot to re-apply the oxygen after she assisted the resident into the wheelchair. Staff R and Staff L then assisted the resident to the bathroom. The staff removed the lap buddy from the wheelchair and unclipped the alarm from the resident prior to transferring the resident to the toilet. Observation revealed no pressure alarm in this resident's chair. Staff R stated she only used the pressure alarm in the resident's bed. Staff R then took a Biosheet from her pocket. Staff R stated normally she only used pressure alarms when residents were in bed. After providing toileting assistance, the staff then transferred the resident back into the wheelchair and then assisted the resident into bed. The staff utilized the pressure alarm in bed. The staff hung the box for the alarm and the side rail, near the resident's right hand. When interviewed on [DATE] at 10:05 a.m. Staff L stated he had assisted Resident #5 from the dining room to his/her bedroom on [DATE] after the noon meal. When he left the resident in the bedroom, the resident had a clip alarm fastened to the resident's shirt and the box to the alarm was hung on the wheelchair handle. He had known of the resident's history of removing his/her alarm. He left the resident in the wheelchair, next to the bed, facing the nightstand. The next time he passed this resident's room, he saw the EMS (ambulance crew) with the resident. When interviewed on [DATE] at 10:30 a.m. the Quality Assurance nurse, Staff T stated CNAs use the Biosheets to provide care to the residents. When asked if the Biosheet instructs the staff to use an alarm, such as a clip alarm or a pressure alarm, Staff T stated she would assume the pressure alarm would be used in the bed and the clip alarm would be used in the chair, however due to this resident utilized a lap buddy she did not believe they needed to use the clip alarm. When interviewed on [DATE] at 10:40 a.m. the Assistant Director of Nursing stated according to the Biosheet staff should use the pad alarm in the resident's bed and the clip alarm in the chair. She also stated when the Biosheet only stated clip alarm she would guess the staff would use the alarm in both the chair and the bed. When interviewed on [DATE] at 10:46 a.m. the Corporate Nurse, Staff K stated according to the Biosheet she would say the staff should use the clip alarm and the pressure alarm on this resident in both the bed and the chair. When interviewed on [DATE] at 11:10 a.m. the Director of Nursing stated she would expect the Biosheet to indicate the staff should use both alarms on this resident at all times, in the chair and in the bed. Based on review of the nurse's progress noted, the plan of care, the incident reports and the Biosheets, the facility did not specify when the staff should utilize which alarm(s) and different staff interpreted the Biosheet instructions differently resulting in inconsistent safety measures. When interviewed on [DATE] at 11:10 p.m. a registered nurse, Staff B stated Resident #5 would get up independently and go to the bathroom. They caught the resident unfastening the alarm so they added the pad/pressure alarm. The pad alarm worked better, however the resident would still get up, however at least they were alerted by the alarm when the resident was up. The nurse stated however they could not always hear the alarm if they were in a resident's bedroom or in a different hallway.

Based on clinical record review, observation, and staff interviews, the facility failed to provide supervision in order to prevent falls for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 85 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment with a reference date of [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 1 staff member for transfers, walking, dressing, and personal hygiene. The MDS documented the resident could go from a seated position to a standing position unsteadily but could stabilize without staff assistance. The resident could walk, turn around, moving on and off toilet, and surface resurface transfers unsteadily and could only stabilize with staff assistance. The MDS documented the resident had a history of [REDACTED]. A fall risk assessment dated [DATE] documented a score of 23. A score 10 or above identified the resident at a high risk for falls. The care plan dated [DATE] listed the following interventions for fall prevention: a. Ask yes/no questions in order to determine needs and give time to respond. b. Cue, reorient, and supervise as needed. c. Engage in simple, structured activities that avoid overly demanding tasks. d. Take for walks in the afternoon. e. Bring to a supervised area after activities. The nurse's notes dated [DATE] at 7:00 p.m. documented staff observed the resident on the floor by the nurse's station. The resident sustained [REDACTED]. The quality assurance condition report dated [DATE] at 7:00 p.m. documented the resident fell in front of the nurse's station. The resident sustained [REDACTED]. The nurse's notes dated [DATE] at 9:24 p.m. documented the resident's alarm sounded and staff observed the resident on the floor in the resident's room. The resident sustained [REDACTED]. The quality assurance condition report dated [DATE] at 11:00 a.m. documented staff heard the resident's alarm and saw the resident on the floor in the movie lounge. The resident sustained [REDACTED]. The intervention directed staff to take the resident to the nurse's station after activities. The nurse's notes dated [DATE] at 4:30 p.m. documented the resident sat at the nurse's station and had an unwitnessed fall. The nurse's notes documented the resident hit his/her head and complained of right hip pain. The staff sent the resident to the emergency room . An x-ray report dated [DATE] documented the resident had a minimally displaced fracture of the C7 vertebrae. An x-ray report dated [DATE] documented the resident had a minimally impacted right hip fracture. During an interview on [DATE] at 11:33 a.m. the Director of Nursing (DON) stated the nurse that completes the incident report after a fall, would write an intervention. The Quality Assurance Team reviewed the intervention for appropriateness. The DON stated the nurse's station would not be a supervised area if no one occupied the desk or immediate area and the resident required supervision at all times. The DON stated after the incident on [DATE], she gave an in-service for all the nurses regarding what constitutes a supervised area. During an interview on [DATE] on 12:32 p.m. the Assistant Director of Nursing (ADON) stated a supervised area would be a common room like the dining room where people walked around frequently. During an interview on [DATE] on 2:10 p.m. Staff B, certified nurse aide, stated he worked the 2:00 p.m. to 10:00 p.m. on [DATE]. Staff B stated he came out of a resident's room and saw Resident #1 on the floor. Staff B stated around 4:30 p.m. staff assisted the residents to get up for dinner and the nurses would be passing medications so the nurse's station lacked staff supervision. Staff B stated a supervised area would be an area where the resident could be seen at all times. During an interview on [DATE] at 2:21 p.m. the Activity Director stated the resident had a previous fall in the television room. After the incident, staff needed to place the resident in a supervised area where staff could see the resident at all times. The Activity Director stated she told her staff to place the resident at the nurse's station. During an interview on [DATE] at 2:37 p.m. Staff C, licensed practical nurse, stated she worked on [DATE] during the 2:00 to 10:00 p.m. shift. Staff C stated she was checking another resident's blood sugar in their room when she heard an alarm (personal resident alarm) sounding. Staff C stated she exited the room and observed the resident on the floor with Staff B. The resident usually sat at the corner of the nurse's station and the resident's family visited between 3:30 - 4:00 p.m. Staff C stated she considered the nurse's station a supervised area and thought activity personnel had put the resident at the nurse's station. Staff C stated the resident complained of hip pain and she called for an ambulance to take the resident to the emergency room . During an interview on [DATE] at 2:55 p.m. Staff C stated she reviewed the attendance records and the resident did not attend the 2:00 p.m. group activity. During an interview on [DATE] at 3:23 p.m. Staff J, activity assistant, remembered the resident siting at the nurse's station at 3:30 p.m. on [DATE] when she left for the day. Staff DJ stated her supervisor told her to leave the resident in a supervised area like the nurse's station. Staff J stated she knew the resident had to be visualized at all times and would not leave the resident at the nurse's station if staff did not occupy the desk. During an interview on [DATE] at 9:56 a.m. Staff F, CNA, stated she was the usual CNA down Resident #1's hallway. Staff F stated she worked 6:00 a.m. to 2:00 p.m. on [DATE]. Staff F described the resident as a fall risk and had a pressure alarm. Staff F stated the resident usually sat at the nurse's station and watched people. Staff F stated she would not leave the resident at the nurse's station if unoccupied by staff. Staff F stated she thought she assisted the resident to bed at change of shift on [DATE]. During an interview on [DATE] at 11:17 a.m. Staff D, corporate nurse, Staff E, registered nurse, and Staff K, quality assurance nurse, stated they collaborated to audit the care plans and are still in the process of rewriting them. All three of the staff stated they considered the nurse's station as a supervised area and Staff B witnessed the fall. Staff provided a map on the location of Staff B and the resident at the time of the fall. During an interview on [DATE] at 11:53 a.m. Staff H, CNA, stated she worked 2:00 to 10:00 p.m. on [DATE]. Staff H stated she assisted another resident to the bathroom and when she finished , she observed Resident#1 on the floor. Staff H stated the resident usually sat at the corner of the nurse's station and family would visit between 3:00 - 3:30 p.m. but the resident's family had left the building before the fall. Staff H stated at 4:30 p.m. at the time of the fall, staff busied themselves with other residents to get ready for dinner or assisting other resident's to the bathroom. Staff H stated she would consider the nurse's station to be a supervised area if staff occupied the desk. Staff H stated she would take the resident to the dining room or another area where staff could visualize the resident. During a second interview on [DATE] at 1:25 p.m. Staff B stated he exited another resident's room, observed Resident #1 take one step and then fell . Staff B stated it happened so fast and in a matter of seconds but then stated no other staff were in the vicinity of the nurse's station. The resident's family had left the building. During an interview on [DATE] at 1:40 p.m. the Administrator provided information about an in-service given to the nurses regarding supervised areas. The nurse's station would be a supervised area if staff occupied the area. During an interview on [DATE] at 1:54 p.m. Staff A, certified nurse aide, stated she worked 2:00 to 10:00 p.m. on [DATE]. Staff A stated she entered the storage room to get supplies from the refrigerator. Staff A stated she did not know the location of the nurse at the time. Staff A stated from the storage room, she heard an alarm sound and left the storage room to observe the Resident #1 stand then fall. Staff A knew the resident required supervision at all times but left the area for a short amount of time. Observation of the storage room on [DATE] at 2:30 p.m. revealed the room measured approximately 20 feet from the corner of the nurse's station where the resident usually sat. While standing at the refrigerator, the nurse's station could not be seen. During an interview on [DATE] at 2:05 p.m. Staff I, CNA, stated she worked [DATE] on the 2:00 to 10:00 p.m. shift. Staff I stated she assisted another resident when she heard an alarm beep twice then stop. Staff I stated she could not leave the resident and respond to the alarm. Staff I stated Resident #1 needed to be placed in a supervised area. If the nurse's station did not have staff in the area, she would lay the resident down or sit the resident in the dining room where staff could visualize the resident. The social progress notes dated [DATE] documented the resident died on [DATE].