Every finding on record at Sunset Drive - a Prospera Community

Based on observations, review of facility policy, and staff interviews, the facility failed to ensure sanitization of dishware (utensils, dishes, pots/pans) used to serve residents, staff, and visitors for 2 of 5 dishwashers (main kitchen and Edgewater). Failure to ensure the mechanical dishwashing machine maintains the correct hot water temperature to destroy pathogens may result in the spread of illness and/or foodborne illness to residents, staff, or visitors. During the on-site recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 07/08/26 at 12:55 p.m. when the dishwasher rinse cycle failed to reach 160 degrees Fahrenheit (F) at plate level. The survey team consulted with the State Survey Agency (SSA) and determined an IJ situation existed. *07/08/26 at 1:55 p.m. - The survey team notified the administrator of the IJ situation, provided the IJ template, and requested a plan for removal for the IJ. *07/08/26 at 3:55 p.m. - The SSA received and accepted the IJ removal plan. The removal plan contained the following:*Edgewater unit and main kitchen dishwashers removed from service.*Repair technician on-site to repair or replace affected dishwashers.*Dish Machine Temperature Log implemented.*All dishes from Edgewater unit rewashed on Grandview unit and manually.*Paper products utilized on Edgewater unit until dishwasher repaired.*Educated all dietary staff working on 07/08/26 and all on-coming staff.*Educated all dietary staff with in-person training on Warewashing Mechanical and Manual Policy and completed mechanical ware washing competency checklist. *07/09/26 at 11:46 a.m. - The survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at a F scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Warewashing-Mechanical and Manual - Food and Nutrition occurred on 07/08/26. This policy, dated 02/13/26, stated, . f. If temperatures/chemicals are outside acceptable parameters, employees notify the DFN (director of food and nutrition services) . or maintenance before proceeding with ware washing. Per the food code, when hot water mechanical ware washing is in use, an irreversible registering temperature indicator shall be readily accessible for measuring the surface temperature to ensure 160 degrees Fahrenheit (F) is reached in the rinse cycle. Observation of dish washer temperatures, using an irreversible registering temperature indicator (i.e., thermometer), showed the following: -07/07/26 at 10:04 a.m., the thermometer used in the dishwasher on the Edgewater unit showed 158 degrees F. -07/08/26 at 9:54 a.m., the thermometer used in the dishwasher in the main kitchen showed 148 degrees F and 146 degrees F. -07/08/26 at 10:49 a.m., a different thermometer showed the dishwasher in the main kitchen measure 150.9 F. A facility color-indicator test strip also showed the dishwasher failed to reach the appropriate temperature. Facility staff members (#15 and #16) verified the temperature and test strip were below requirements. During an interview on 07/08/26 at 10:49 a.m., a dietary administrative staff member (#16) confirmed the rinse temperature, failed to reach160 degrees F.

Based on record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 8 sampled resident (Resident #81) with weight loss. Failure to document post-dialyzed weights, complete a dietary assessment, and identify/implement nutritional interventions for a resident at nutritional risk, resulted in a significant weight loss.Findings include: Review of facility policy titled Nutrition and Hydration - Food and Nutrition occurred on 07/09/26. This policy, dated 04/27/26, stated, . Accurately and consistently assess a resident's nutritional status on admission and as needed. Identify a resident at nutritional risk . Provide nutritional care . consistent with the resident's comprehensive assessments and periodic reassessments. Monitor weight . Review of Resident #81's medical record occurred on all days of survey. Diagnosis included end stage renal disease and dependance on renal dialysis. A physician order, dated 06/04/26, stated, Collect weight at dialysis for accuracy- compare 'dry' [post-dialysis] weight for nutritional determinations. Liberal Renal Diet, Regular texture, Thin consistency . The current care plan stated, . NUTRITION: [Resident's name] is at risk for nutritional problem d/t [due to] ESRD [end-stage renal disease], CHF [congestive heart failure], DM [diabetes mellitus] and depression. Monitor for weight loss d/t being at risk for malnutrition . Provide resident with a calm, quiet setting at meal times with adequate eating time. The resident needs hemodialysis R/T [related to] Stage 4 [four] chronic kidney disease . Dialysis . three days a week. During an interview on 07/08/26 at 2:43 p.m., a certified nurse aide (CNA) (#7) confirmed Resident #81 receives dialysis on Monday, Wednesday, and Fridays. Review of Resident #81's weights identified the following: *06/04/26 (admission) (Thursday) at 2:54 p.m. - 121.0 lbs [pounds]*06/11/26 (Thursday) at 2:02 p.m. - 122.0 lbs *06/12/26 (Friday) at 4:30 a.m. - 117.9 lbs (pre-dialyzed weight)*06/12/26 (Friday) at 6:19 p.m. - 112.8 lbs (post-dialyzed weight) *06/13/26 (Saturday) at 1:50 p.m. - 112.9 lbs*06/23/26 (Tuesday) at 2:36 p.m. - 108.4 lbs*06/26/26 (Friday) at 12:20 p.m. - 110.2 lbs (post-dialyzed weight) Review of a facility document titled Dialysis Communication, dated 07/03/26, stated, . Post-Dialysis . Weight 47.1 kg [kilograms] (103.8lbs). During an interview the afternoon of 07/07/26, a nurse (#4) confirmed staff enter vital signs and weights, including dry weights, obtained post dialysis into electronic health record (EHR). Review of the EHR showed the facility failed to document Resident #81's weight from June 14 - 22, 2026 and from June 26 - July 9, 2026 including eight post dialysis weights. Resident #81's calculated weight loss percentage from June 4 - July 3, 2026, identified a weight loss of 14.21%. Observation on 07/06/26 at 11:56 a.m., showed Resident #81 seated in a wheelchair in her room. When asked if the resident planned to each lunch, CNA (#24) stated, the resident just came back from dialysis and frequently refuses to eat. When asked if the staff offer nutritional supplements, the CNA stated, I don't think we give her those. During an interview on 07/09/26 at 12:33 p.m., a facility dietician (#23) confirmed the facility failed to complete a comprehensive dietary admission assessment and implement nutritional interventions for Resident #81's weight loss. The facility failed to: *Document all post dialysis weights in the EHR. *Complete a comprehensive dietary assessment upon admission. *Implement nutritional interventions to maintain weight and/or prevent weight loss. *Follow physician orders related to documentation of post-dialysis weights.

Based on observation and staff interview, the facility failed to ensure emergency equipment remained in operating condition on 4 of 4 resident care units (Sunset, Edgewater, Grandview, and [NAME]). Failure to ensure the suction machines are identifiable and ready for use may result in delayed emergency airway and suctioning treatment for all residents. Findings include: Observation of the Edgewood unit occurred on 07/08/26 at 3:48 p.m. with a nurse (#10) and showed the emergency suction machine boxed and not assembled in the clean utility room. The nurse stated the assembly of the suction machine would slow the response time in the event of an emergency. Observation of the Sunset unit occurred on 07/08/26 at 4:08 p.m. with a staff member (#27). When asked the location of the emergency suction machine, the staff member went to the clean utility room. When unable to locate the suction machine, this staff member asked an unidentified nurse where it is stored, and the nurse confirmed in the clean utility room. The staff member (#27) returned to the clean utility room, moved boxes, and located the suction machine. The unidentified nurse stated the last time she tried to use the suction machine, it did not work. Observation of the [NAME] unit occurred on 07/08/26 at 4:33 p.m. with a staff member (#28). When asked about a suction machine, the staff member went to the clean utility room but failed to identify the box that contained the emergency suction machine. Observation of the Grandview unit occurred on 07/08/26 at 4:49 p.m. with a staff nurse (#29) and a staff member (#30). When asked about the suction machine, the staff member (#30) located the emergency suction machine in the clean utility room. The nurse (#29) confirmed unpacking and setting up the suction machine would increase the response time in the event of an emergency. During an interview on 07/08/26 at 5:07 p.m., two administrative staff members (#2 and #3) confirmed the location of the suction machines and/or the unassembled machines would not be helpful during an emergency.

Based on observation, review of facility policy, and resident representative and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 3 of 4 days of survey (July 6, 7, and 9). Failure to maintain a safe, clean, sanitary environment may result in falls and does not provide a homelike living area for residents. Findings include: Review of the facility policy titled Housekeeping, Resource Packet occurred on 07/09/26. This policy, dated 8/21/25, stated, . Environmental cleaning plays an important role in an infection control program . All staff members play a role and should be aware of the general principles of environmental cleaning and safety.Standard or Light Cleaning - Rehabilitation/Skilled Care . To provide procedures for the proper, daily cleaning of resident rooms . Standard or light cleaning should occur on a daily basis in occupied rooms. Damp wipe with a neutral cleaner or mild disinfectant, non-critical items and areas within the resident living space . empty . trash containers . Sweep all hard surface flooring and damp mop as needed. -Observation on 07/06/26 showed the following: *10:33 a.m., a fan in Resident #26's room covered in dust. *10:39 a.m., Resident #48 lying in bed watching TV with no bedding on the bed.*10:45 a.m., dust/debris and food crumbs all over the floor in Resident #71's room.*10:50 a.m., a sticky floor and water on the floor in Resident #82 room. *11:06 a.m., food debris on the over the bed table and an odor in Resident #113's room. Observation showed the same findings on 07/07/26 at 10:20 a.m. *11:12 a.m., a garbage bag containing a soiled brief on the wheelchair seat in Resident #100's room. *11:13 a.m., Resident #1 seated in a recliner and a garbage bag containing a soiled brief sitting on the seat of the resident's electric scooter. Observation showed the same findings on 07/07/26 at 12:19 p.m. *11:42 a.m., Resident #95's bathroom garbage full of incontinence products. The resident stated, I need to ask for the trash to be emptied and have had a full trash bin since Friday. *1:05 p.m., a full garbage can, food crumbs and food wrappers, and a dried substance on the floor in Resident #58's room. The resident stated, The bathroom hasn't been cleaned recently.*1:18 p.m., Resident #87 stated, They lack at getting the toilet cleaned, it's not done regularly, and I do it myself sometimes.*1:36 p.m., food particles and dust/debris on floor and under Resident #19's bed. *2:02 p.m., food debris and garbage next to Resident #113's bed. *2:21 p.m., dust/debris on the floor in front of Resident #1's bathroom. -Observation of the [NAME] unit kitchenette on 07/09/26 at 8:52 a.m. showed particles of food debris, dust, and debris, a wet substance on the floor, and a sticky floor. A dietary aide (#15) agreed the floor needed cleaning. During an interview on 07/06/26 at 2:16 p.m., a family member (#1) stated, the kitchen floors are gross in reference to the [NAME] Unit kitchenette. During an interview on 07/07/26 at 4:20 p.m., an administrative staff member (#1) stated the facility contracted with a cleaning company to provide housekeeping services and expected all staff to clean resident rooms as needed and to take the trash to soiled utility room and not leave it in the room. During an interview on 07/09/26 at 11:18 a.m., a dietary supervisor (#16) provided a POD [unit] Housekeeping Checklist, dated 06/24/26, which stated the housekeeping staff are expected to sweep floors after every meal and mop floors daily and as needed.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the residents' current status for 6 of 25 sampled residents (Resident #6, #8, #12, #13, #80 and #119). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident.Findings include: Review of the facility policy titled Comprehensive Care Plan and Care Conferences occurred on 07/09/26. This policy, dated 12/29/25, stated, . The care plan is driven by identified resident issues/conditions and their unique characteristics, strengths and needs. care plans must be revised as the resident's needs/status changes. - Observation on 07/06/26 at 11:41 a.m. showed Resident #6 seated in a wheelchair in his room and his right lower leg wrapped in a dressing. The resident stated facility staff change the dressing weekly because the areas leaked, and also identified an open area on to his buttocks. Review of Resident #6's medical record occurred on all days of survey. Current physician's orders included dressing changes to right buttock on Monday, Wednesday and Friday, wraps to right lower leg for a venous stasis ulcer changed weekly, and a 1800 milliliter (mL) fluid restriction per day. The current care plan stated, . INFECTION: The resident has urinary tract infection [UTI] . FLUID RESTRICTION 1500 ml's/day . PRESSURE ULCERS: The resident has potential for pressure ulcer development . The care plan failed to include the problems, goals, and interventions related to the venous ulcer and treatment and the open area to his buttocks. During an interview on 07/07/26 at 9:45 a.m., a nurse (#34) identified the open area to Resident #6's buttock as a stage two pressure ulcer. During an interview on 07/09/26 at 8:33 a.m., an administrative nurse (#9) confirmed Resident #6 completed treatment for a UTI on 05/15/26 and confirmed the resident should have enhanced barrier precautions in place due to the open wounds to the right leg. During an interview on 07/09/26 at 4:05 p.m., two administrative nurses (#9 and #17) confirmed Resident #6's care plan enhanced barrier precautions and the open wounds and agreed staff failed to update the care plan related to the fluid restriction amount and the resolved UTI. - Review of Resident #8's medical record occurred on all days of survey. The physician order, dated 01/22/26, stated, . Buttocks: Cleanse with peri-wipes apply triad paste BID [twice a day] and PRN [as needed]. The care plan stated, . Buttocks: Cleanse with peri-wipes apply triad paste BID and PRN per orders . A provider communication form, dated 06/29/26, identified the provider changed the order from Triad to calmoseptine. The facility failed to update the care plan with the new provider order. - Review of Resident #12 medical record occurred on all days of survey. A physician's order, dated 10/01/25, stated, Spironolactone [diuretic] Oral Tablet Give 50 mg [milligrams] three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. The care plan failed to include problems, goals, and interventions related to the diuretic medication. - Review of Resident #13's medical record occurred on all days of survey. Diagnoses included mixed incontinence, need for assistance with personal care, and cognitive communication deficit. Resident #13's care plan stated, . has impaired cognitive function. She does have a hard time understanding things or the importance of cares. TOILET USE: Continent of bowel and bladder resident toilets independently Occasionally incontinent of bladder and often with [sic] wears multiple briefs . Review of Resident #13's progress notes included the following: *06/07/26 at 5:38 p.m., . resident is upset with her bladder incontinence and was noted hitting herself in the lower abdomen stating 'what is wrong with me, why cant [sic] I help myself'. [sic] Staff assisted to change her linen and her clothes . *07/01/26 at 5:54 p.m., . Does need increased monitoring and assistance as she is incontinent bladder [sic] and does become agitated when she is not able to control her bladder. staff [sic] able to get her bed changed and remove all of the soiled clothing in her room . Staff need to offer to assist her with her cares and her needs. During an interview on 07/08/26 at 8:28 a.m., an administrative staff member (#3) confirmed Resident #13's care plan failed to identify incontinence and current toileting status/needs. - Review of Resident #80's medical record occurred on all days of survey. The current care plan stated, . Documented Pressure Ulcer . During interviews on 07/09/26 at 12:25 p.m. and 4:02 p.m., an administrative nurse (#9) confirmed Resident #80 had no open areas and agreed the care plan was incorrect. - Review of Resident #119's medical record occurred on 07/09/26. The current care plan stated, The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] LLE [left lower extremity] fracture E/B surgery with brace in place. AMBULATION: x [times] 1 with FWW [front wheeled walker] in her room. Resident requires 2 assist with toileting. Transfer Between Surfaces: 2 X staff assist, with non-mechanical lift NWB [non-weight bearing] LLE. Observation on 07/09/26 at 6:09, p.m. showed two nurses (#5 and #6) assisted Resident #119 onto the toilet using a pivot transfer from a wheelchair. During an interview on 07/09/26 at 6:21 p.m., the nurse (#6) confirmed Resident #119's transfer status had changed to a two-person pivot, and he/she does not ambulate with a front wheeled walker. The facility failed to update the care plan to reflect the current mobility status for Resident #119.

Based on observation, review of facility documents, and staff interview the facility failed to ensure the environment remained free of hazards for 2 of 2 dryers in the main laundry room. Failure to clean dryer lint from the behind the machines may result in fires and places all residents at risk for injury.Findings include:-Review of the facility document Laundry, Resource Packet, occurred on 07/09/26. This undated document stated, An important aspect of a laundry service program is the maintenance and use of the laundry room(s). it is crucial that frequent cleaning, disinfecting and inspections of the laundry room occur. It is also equally important that the equipment is well maintained . Observation of the laundry room occurred on 07/09/26 at 9:20 a. m. with laundry staff members (#20 and #21) and showed the back of the dryers with lint build-up on the top, around the openings at the top, on the gas lines, and into the machines' openings, and through these openings the gas dryer flames were visible. When asked, the staff stated no one cleans the behind of the dryers; they clean the floor and what they can reach.

Based on observation, record review, review of facility policy, staff, resident and family interviews, the facility failed to ensure sufficient nursing staff and related services are available to meet the residents' needs for 3 of 25 sampled residents (Resident #8, #44, and #81) and 2 supplemental residents (Resident #106 and #116) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents. Findings include: Review of facility policy titled Call light occurred on 07/09/26. This policy, dated 07/08/25, stated, . To ensure residents always have a method of calling for assistance . To promptly answer resident's call light . When resident's call light is observed/heard, go to resident's room promptly. Respond to request as soon as possible. During an interview on 07/07/26 at 12:05 p.m., Resident #8's family member stated, Staff lack to answer call lights. The family member stated the resident had waited for 2 hours for staff to assist him with cares. The family member also stated the resident has called them three times since admission and stated her ventilator was not attached. Review of call light report showed wait times up to 43 minutes. - Review of Resident #44's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified dependent on staff for showering/bathing and intact cognition. A progress note dated 07/04/26 at 3:09 p.m. stated, . Resident upset as he was not able to get a shower this morning. Discussed he did not get his shower yesterday and wanted his shower today. Writer discussed that there were not enough staff scheduled this shift and could not pull both of the staff off the floor for his shower as he required two staff in the shower . Review of Resident #44's call light report showed wait times up to 45 minutes. - Review of Resident #81's medical record occurred on all days of survey. The admission MDS, dated [DATE], identified substantial/maximum assistance required for shower/bathing and moderately impaired cognition. During an interview on 07/08/26 at 2:43 p.m., Resident #81, teary eyed, stated she did not know when she had last received a shower. During an interview on 07/09/26 at 8:25 a.m., a bath aide (#14) stated she was unaware of the last time Resident #81 received a shower or a bed bath. The bath aide stated the resident frequently refuses. The documentation from June 10 - July 8, 2026 lacked documentation of resident refusals. - Review of Resident #106's medical record occurred on all days of survey. An admission MDS, dated [DATE], identified partial/moderate assistance required for shower/bathing and intact cognition. During an interview on 07/06/26 at 1:42 p.m., Resident #106 stated he had not received a bath since admission [DATE]). The resident pointed at a package of wet wipes and stated, I have been using these. The resident reported he requested to have bed linens changed, and stated, The bedding was only changed because I asked them to. -During an interview on 07/06/26 at 11:25 a.m., Resident #116 stated call light response times vary between five minutes and an hour. She further stated staff will answer the call light and say they will be back, but do not come back. She said staff say, We're feeding or busy or don't have time. She stated she uses the bed pan for toileting and has been incontinent due to the long wait times. Review of Resident #116's call light report identified call light response times of 21 and 27 minutes. During an interview on 07/07/26 at 8:15 a.m., a nurse (#4) voiced concerns regarding the amount of staffing for Edgewater unit, and stated, Edgewater unit has a higher acuity of residents than the other units. The nurse stated Edgewater had a call in for the morning shift, leaving one certified nurse aide (CNA) to 33 residents from 6 a.m. to 7 a.m. During an interview on 07/07/26 8:19 a.m., a CNA (#15) working on the Edgewater unit stated only two CNA's working on the unit this shift. When asked how many CNAs are typically on the schedule for Edgewater, the CNA stated normal staffing is four CNAs. During an interview on 07/09/26 at 4:12 p.m., an administrative staff member (#1) confirmed that staff are expected to answer call lights promptly.

Based on observation, record review, review of facility policy and staff interviews, the facility failed to follow standards of infection control and prevention for 4 of 25 sampled residents (#1, #6, #81, and #86) and two supplemental residents (#9 and #36) observed during cares. Failure to practice infection control standards related to hand hygiene, glove use, enhanced barrier precautions (EBP), and personal protective equipment (PPE) with transmission-based precautions (TBP) has the potential to spread infection throughout the facility. Findings include: Review of facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 07/09/26. This policy, dated 04/30/26, stated, . To prevent the spread of infection and communicable diseases to residents . Enhanced barrier precautions . used for residents with chronic wounds (i.e. pressure wounds . ) and residents with indwelling medical devices (i.e. hemodialysis catheters, indwelling urinary catheters .) . Post clear signage indicating the type of precautions . Transmission-based precautions . Contact precautions . For residents/patients on contact precautions with signs and symptoms of a gastrointestinal illness (i.e. diarrhea), employees must perform hand hygiene via handwashing only . Post clear signage on the door or wall outside of the resident/patient room . apply gown and gloves before contact with the resident/patient or their environment. Review of facility policy titled Hand Hygiene occurred on 07/09/26. This policy, dated 06/08/26, stated, . When to wash with soap and water . During the care of residents . with suspected/confirmed C. Difficile [Clostridium difficile a bacterium that causes severe inflammation of the colon and watery diarrhea]. Hand hygiene should be performed by employees: Before contact with a resident . Before performing a clean/aseptic task . After removal of personal protective equipment/gloves . After contact with a resident . surroundings . Gloves are not a substitute for hand hygiene. If a task requires gloves, perform hand hygiene before donning [applying] gloves and touching the resident . Perform hand hygiene after removing gloves . -Observation on 07/06/26 at 2:21 p.m. showed Resident #1 in a recliner. Two certified nurse aides (CNAs) (#31 and #32) performed hand hygiene, applied gloves and transferred the resident from the recliner to the bathroom with a sit-to-stand lift. The CNA (#32) removed Resident #1's soiled brief and sat the resident on the toilet. Both CNAs removed the soiled gloves, and without hand hygiene, applied new gloves, and assisted Resident #1 to stand. The CNA (#32) performed perineal cares, applied a clean brief, adjusted the resident's pants, and both CNAs transferred the resident to the recliner. Without removing the soiled gloves or performing hand hygiene, the CNA (#32) adjusted the side table and moved the resident's scooter closer. Without removing the soiled gloves, the CNA (#31) disinfected the lift, then removed the soiled gloves, and without performing hand hygiene, transferred the lift from the resident's room, down the hallway, and into the storage room. The CNA (#32) gathered the garbage bag, removed the soiled gloves, and without performing hand hygiene, exited the room. The CNAs (#31 and #32) failed to remove soiled gloves and perform hand hygiene before performing other tasks, and failed to perform hand hygiene after removing gloves and before exiting the room. -Observation on 07/06/26 at 11:41 a.m. showed Resident #6 seated in a wheelchair in his room and his right lower leg wrapped in a dressing. The resident stated facility staff change the dressing weekly, the bandaged areas leaked, and identified an open area on his buttocks. Observations on all day of survey showed no sign for EBP or PPE supplies outside Resident #6's door. During an interview on 07/09/26 at 8:33 a.m., an administrative nurse (#9) confirmed the facility failed to initiate EBP for Resident #6. -Observation on 07/06/26 at 1:44 p.m. showed a CNA (#33) assisted Resident #9 from the dining room to her room via wheelchair. The CNA left the room and returned with a mechanical lift. Without performing hand hygiene, the CNA applied gloves, transferred Resident #9 to the bathroom, removed the soiled gloves, pulled down the resident's skirt and brief, seated the resident on the toilet, and turned off the chair alarm. Without performing hand hygiene, the CNA applied new gloves, removed the soiled brief, and applied a clean brief. Wearing the same gloves the CNA touched her own nose and face. The CNA (#33) removed the soiled gloves, and without hand hygiene, assisted the resident to stand, applied new gloves, performed perineal cares, and adjusted the brief and skirt, and removed the soiled gloves. Without performing hand hygiene, the CNA moved the chair alarm from the wheelchair to the recliner, transferred the resident from the bathroom to the recliner, adjusted the resident with a blanket and placed the call light within reach. The CNA (#33) failed to perform hand hygiene prior to entering and exiting the resident room, after removing soiled gloves and before applying clean gloves, and before performing other tasks. -Observation on 07/07/26 at 9:10 a.m. showed a CNA (#25) assist Resident #36 with toileting. The CNA performed perineal care and without removing the soiled gloves or performing hand hygiene, transferred the resident back to their wheelchair and turned on the faucet so the resident could wash their hands. The CNA (#25) failed to remove their soiled gloves and perform hand hygiene before changing tasks. -Review of Resident #81's medical record occurred on all days of survey. Diagnoses included enterocolitis due to clostridium difficile (C. difficile), recurrent. The current care plan stated, . Enhanced Barrier Precautions (EBP) D/T [due to] indwelling medical device (dialysis catheter) . [NAME] [apply] gown and gloves when performing high contact care activities . INFECTION: The resident has C. difficile. CONTACT PRECAUTIONS: Wear gowns and masks when changing contaminated linens. Observation on 07/08/26 at 2:43 p.m. showed a Contact Precautions sign on Resident #81's door. A nurse (#10) entered the room without wearing a gown, gloves, or mask. A CNA (#7) prompted the nurse (#10) to apply PPE. The nurse exited the room, applied a gown, entered the room with a medication cup, handed the medication cup to the resident, provided water, removed the gown, and performed hand hygiene with hand sanitizer. The nurse (#10) failed to wear appropriate PPE and failed to wash their hands with soap and water. -Review of Resident #86's medical record occurred on all days of survey. The current care plan stated, .EBP: The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] indwelling urinary catheter. [NAME] gown and gloves when . transferring . Observation on 07/06/26 showed no EBP signage or PPE outside of Resident #86's door. A nurse (#4) and CNA (#14) assisted the resident to transfer with a full-body mechanical lift from the wheelchair to the bed. The nurse and CNA failed to apply PPE when performing high-contact resident care activities for a resident on EBP enhanced barrier precautions. During an interview on 07/09/26 at 11:10 a.m., an administrative staff member (#9) confirmed staff are expected to follow the infection control precautions.

Based on record review, review of a facility reported incident (FRI), review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 supplemental residents (Resident #96) who experienced unwanted sexual contact from another resident (Resident #43). Failure to protect residents from sexual abuse placed Resident #96 and all residents at risk for mental and emotional distress. Findings include: Review of a facility policy titled Abuse and Neglect occurred on 07/09/26. This policy revised 04/07/25, stated, The resident/client has the right to be free from abuse. must not be subjected to abuse by anyone, including . other residents/clients. Review of the final FRI, dated 06/22/26, stated, Resident [Resident #43] returned from outing intoxicated and smelling of alcohol . Resident kissed another Resident [Resident #96]. - Review of Resident #43's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified intact cognition. The progress notes identified the following:*06/20/26 at 6:48 a.m., Health Status Note Text: Late entry for 6/19/26: Resident returned from outing intoxicated and smelling like alcohol. Resident not usual self . Answering questions appropriately and kissed another Resident. During an interview on 07/08/26 at 6:14 p.m., Resident #43 confirmed being intoxicated on 06/19/26. The resident could not recall encountering Resident #96. - Review of Resident #96's medical record occurred on all days of survey and included a diagnosis of dementia. The MDS, dated [DATE], identified severely impaired cognition. The progress notes identified the following:*06/21/26 at 4:35 a.m., Health Status Note Text: Late entry for 6/19/26: CNA reported seeing Resident being kissed by a resident while reaching her arms out to him in the hallway. Both Residents redirected, on call nurse aware and she notified DON. No other behaviors observed or reported. During an interview on 07/09/26 at 1:02 p.m., an administrative staff member (#1) confirmed a sexual incident occurred between Resident #43 and #96 on 06/19/26.

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 25 sampled residents (Residents #11, #80, and #113). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2025 pages M-4 through M-6, stated, . M0210: Unhealed Pressure Ulcers/Injuries . Steps for Assessment . Review the medical record . Speak with direct care staff and the treatment nurse to confirm conclusions form the medical record review. Examine the resident and determine whether any skin ulcers/injuries are present. If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do not code the ulcer/injury on the assessment. Review of Resident #80's medical record occurred on all days of survey. A Pressure ulcer/Injury Evaluation History, dated 03/18/26, identified a Stage 3 pressure injury to resident's right plantar first digit. The medical record lacked additional documentation of a pressure ulcer. A quarterly MDS, dated [DATE], identified one Stage 3 pressure ulcer. During an interview on 07/09/26 at 12:25 p.m., an administrative nurse (#17) stated Resident #80 had no open areas and the medical record lacked documentation of a pressure ulcer past 03/25/26 even though the Pressure ulcer/Injury Evaluation History showed the wound as active. During an interview on the afternoon of 07/09/26, an administrative nurse (#11) stated she failed to confirm the presence of a pressure injury through interview or assessment and relied solely on the active wound in the Pressure ulcer/Injury Evaluation History. The nurse agreed the facility coded Resident #80's MDS incorrectly. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2025 pages N-4 and N-6, stated, . N0415: HIGH-RISK DRUG CLASSES: Uses and Indication . Coding Instructions. Code all high-risk drug class medications . Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period . Review of Resident #113's medical record occurred on all days of survey. A physician's order stated, Eliquis [an anticoagulant] oral tablet 5 MG [milligram] . by mouth two times a day . A quarterly MDS, dated [DATE], showed the facility failed to code section N0415, an anticoagulant. During an interview on 07/09/26 at 1:19 p.m., an administrative nurse (#11) confirmed the facility failed to code the resident's MDS for anticoagulant use. SECTION P: PHYSICAL RESTRAINTSThe Long-Term Care Facility RAI User's Manual, revised October 2025 page P-3, stated, . P0100: Physical Restraints . Consult the nursing staff to determine the resident's cognitive and physical status/limitations. the decision about coding any manual method or physical or mechanical device . as a restraint depends on the effect it has on the resident.Resident #11's medical record occurred on all days. Diagnoses included epilepsy and seizures. A quarterly MDS, dated [DATE], identified dependent on staff for all activities of daily living and mobility and a trunk restraint used daily. A physical device and/or restraint evaluation and review, dated 05/25/26, stated, . Harness and positioning aid will provide the ability for the resident to sit upright in her wheelchair, as she has no core control and falls forward and to the side and has fallen out of her wheelchair. This harness/chest strap, will allow her to eat in the dining room and attend events without safety issues and injury. Observation of Resident #11 on all days of survey showed the resident unable to move arms/legs and a chest vest in place when seated in the wheelchair. During an interview on 07/09/26 at 2:03 p.m., an administrative staff member (#36) confirmed the resident's chest vest did not meet the definition of a restraint and the facility coded Resident #11's MDS correctly.

Based on record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 2 of 25 sampled residents (Resident #44 and #81) and 1 supplemental resident (Resident #106) who required staff assistance for bathing. Failure to provide assistance to residents who cannot perform the bathing task independently may result in poor hygiene, skin issues and decreased self-esteem.Findings include: Review of the facility policy titled Bathing occurred on 07/09/26. This policy, dated 12/22/25, stated, . Purpose . To ensure cleanliness and general hygiene . promote comfort, relaxation, and well-being . assist resident with personal care .Bed Bath . provide bedridden resident with personal care in bathing . -Review of Resident #44's medical record occurred on all days of survey. Diagnoses include quadriplegia, and immobility syndrome. The quarterly Minimum Data Set (MDS), dated [DATE], identified dependent of staff for showering/bathing and cognitively intact. The current care plan stated, Bathing . requires 2 staff assist with total lift . scheduled . Monday and Friday . A physician's order, dated 10/03/25, stated, . bathing three days a week – two showers and a bed bath . Review of Resident #44's bathing record dated June 9 - July 6, 2026, identified the facility provided two showers and 12 sponge baths.The record lacked documentation of resident refusals of all showers. A progress note, dated 07/04/26 at 3:09 p.m., stated, . Resident [Resident #44] upset as he was not able to get a shower this morning. Discussed he did not get his shower yesterday and wanted his shower today. Writer discussed that there were not enough staff scheduled this shift and could not pull both of the staff off the floor for his shower as he required two staff in the shower. agreed due to only having two staff on shift it would be impossible to pull staff off the floor and tie them up for a shower. Resident continues to be frustrated. Writer did give a sponge down for resident. Resident states he is not receiving pericare [sic] on a routine basis . The facility failed to provide a shower/bath as care planned and ordered by Resident #44's physician. -Review of Resident #81's medical record occurred on all days of survey and identifed dialysis three times a week, muscle weakness and pain. The admission MDS, dated [DATE], identified substantial/maximum assistance required for shower/bathing and moderately impaired cognition. The current care plan stated, Bathing: Resident requires assist x [times] 1 for all bathing . Minimum one bed bath or shower each week. Prefers to wear hats at this time due to matting to hair . Review of Resident #81's bathing record, dated June 10 - July 8, 2026, showed the facility provided one shower, one bed bath and 16 sponge baths. An interview with Resident #81 occurred on 07/08/26 at 2:43 p.m. when asked Resident #81 when their last shower occurred, the resident responded, teary eyed, responded with, I don't know. Observation showed the resident's hair was matted. During an interview on 07/09/26 at 8:25 a.m., a bath aide (#14) stated she was unaware the last time Resident #81 received a shower or a bed bath. The bath aide stated, the resident frequently refuses. The medical record lacked documentation of refusals. The facility failed to provide a bed bath or shower as care planned for Resident #81. -Review of Resident #106's medical record occurred on all days of survey. Diagnoses included a fracture of left femur, chronic pain, and muscle weakness. The admission MDS, dated [DATE], identified partial/moderate assist with shower/bathing and cognitively intact. The current care plan stated, . Bathing: Resident requires staff assist x [times] 1 for shower . The care plan failed to include how often to shower. Review of Resident #106's bathing record dated June 10 - July 7, 2026, showed staff only provided sponge. During an interview on 07/06/26 at 1:42 p.m., Resident #106 noted he had not received a bath since admission [DATE]). The resident pointed at a package of wet wipes and stated, I have been using these. The resident stated he made requests to change bed linens, stating that the bedding was only changed because I asked them to. The facility failed to provide scheduled showers for Resident #106. During an interview on 07/08/26 at 3:15 p.m., a CNA (#31) stated, I honestly do not know the difference between a sponge bath and a bed bath. During an interview on 07/09/26 at 11:10 a.m., an administrative nurse (#9) stated she expected staff to provide cares, including showers and bed baths, per the care plan and to document refusals.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to provide care and services in accordance with physician's orders for 1 of 25 sampled residents (Resident #8) and one close record (Resident #127). Failure to follow physician orders for daily weights and verify significant weight differences, may result in adverse health effects for the residents. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 189, 507 and 736, stated, . Definitive treatment of the condition requires both medical and nursing interventions. Vital signs should be evaluated with reference to clients' present and prior health status . Ordered vital sign measurements . should be considered the minimum . In addition to cleaning the skin, bathing also stimulates circulation. produces a sense of well-being . frequently improves morale, appearance, and self-concept . Review of the facility policy titled Weight and Height occurred on 07/09/26. This policy, dated 09/30/26, stated, . Purpose: . To report changes in a resident's clinical condition (significant weight change) to physician . To accurately measure weigh . To monitor weight loss or gain in a resident . If weight varies by more than three percent, reweigh resident and document. Report weight to licensed nurse. -Review of Resident #80's medical record occurred on all days of survey. Diagnoses included congestive heart failure and edema. A quarterly Minimum Data Set (MDS), dated [DATE], identified a significant weight loss with current weight of 195 pounds. Current physician's orders stated, Daily weight - reweigh immediately if weight is 5# [five pounds] greater or lower than previous weight obtained. If weight 3# [three pounds] or greater in 1 day or greater than 5# in a week - contact provider and Furosemide [a diuretic] Oral Tablet 20 MG [milligram] . Give 60 mg by mouth in the morning. Review of Resident #80's weight record and medication administration records April 1 - July 9, 2026 showed the facility failed to obtain daily weights: *Four times in April. *Six times in May. *Nine times in June. *Once in July. Review of weights obtained in June showed the facility failed to reweight the resident on 06/18/26 when the weight showed a loss of 10 pounds from the previous day (205 to 195.3 pounds); and again on 06/19/26 when the weight showed an 11-pound weight gain (195.3 to 206.1 pounds). During an interview on 07/08/26 at 2:40 p.m., an administrative nurse (#3) stated staff see a flag if weight loss/gain is three percent or greater and she expected staff to re-weigh and document in the health record. During an interview on 07/09/26 at 3:55 p.m., an administrative nurse (#6) confirmed she expected staff to obtain weights as ordered. Facility staff failed to obtain daily weights and reweigh when indicated per physician's orders. -Review of Resident #127's medical record occurred on July 8-9, 2026 and identified an admission date of 06/25/26. Diagnoses included congestive heart failure. Physician's orders included daily weight. Review of Resident #127's weights showed the facility failed to obtain daily weights on five of eight days.

Based on record review, review of facility policy, and staff interview, the facility failed to provide care and services to prevent nutritional deficits for 1 of 2 sampled residents (#8) reviewed for tube feedings. Failure to provide nutritional needs as ordered may lead to malnutrition, dehydration, and other complications. Findings include: Review of facility policy titled Enteral Nutrition (Tube Feeding) occurred on 07/09/26. This policy, dated 06/24/26, stated, . Enteral nutrition (EN) may be necessary for residents who are unable to consume enough calories orally to meet their nutritional needs. A resident who is fed via EN receives appropriate treatment and services .Review of Resident #8's medical record occurred on all days of survey. Diagnosis included a feeding tube and a vitamin deficiency. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. Resident #8's current care plan stated, . NUTRITION: The resident has nutritional problem R/T [related to] diagnosis but not limited to dysphagia with need for PEG [percutaneous endoscopic gastrostomy] tube feeding for 100% nutrition and hydration needs . vitamin deficiency. Need for additional vitamin and/or mineral supplementation. Diet: NPO, Resident has order [sic] enteral feeding by feeding tube. Review of Resident #8's June 1 - July 7, 2026, electronic medication administration record (eMAR) identified the following:*Flush enteral tubing with 250 cubic centimeters of additional water three times a day (44 missed administrations).*Okay to give 1/2 (one half) of bolus feed, monitor tolerance and give other 1/2 of carton as tolerated until resident able to tolerate entire carton for bolus feed two times a day (28 missed administrations).* Complete Peptide continuous tube feeding to run at 50 milliliters (mL) per hour over 10 hours to run 8 p.m. to 6 a.m. Flush with 60 mL water before and after feedings. Use three cartons of formula for continuous feeding (16 missed administrations).*Three bolus feeds by feeding tube daily. 250 mL carton Complete Peptide three times daily at 9 a.m., 1 p.m., and 5 p.m. Flush with 60 mL water before and after feeding - may use scheduled water boluses for flushes. Administer over 10-15 minutes or more as tolerated to ensure resident is able to take entire carton as tolerated (46 missed administrations).The facility was unable to provide a nutritional or dietary assessment upon request for Resident #8. During an interview on the afternoon of 07/09/26, an administrative nurse (#3) confirmed that the facility is unable to provide documented information regarding the missed administrations.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 1 of 4 sampled residents (Resident #80) reviewed for antipsychotic medications. Failure to establish a baseline by assessing for abnormal involuntary movements before starting an antipsychotic and to monitor periodically while on the medication may result in the resident experiencing adverse consequences related to the antipsychotic medication. Findings include: Review of the facility policy titled Psychotropic Medications occurred on 07/09/26. This policy, dated 12/09/25, stated, . DEFINITIONS: Psychotropic Medication: Any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to . anti-psychotics . POLICY: . Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: . without adequate monitoring . PROCEDURE: . If a resident is admitted on psychotropic medications . the following must be completed: . If the medication is an antipsychotic, a registered nurse must complete the Abnormal Involuntary Movement Scale [AIMS]. Review of Resident #80's medical record occurred on 07/09/26 and showed an admission date in March 2026. Diagnoses included vascular dementia with anxiety and hallucinations. Medications included Olanzapine [antipsychotic] 2.5 milligrams twice daily on admission related to vascular dementia with anxiety and decreased to daily at bedtime on 06/16/26. Resident #80's record lacked an AIMS assessment on admission. During an interview on 07/09/26 at 2:54 p.m., a nurse manager (#17) confirmed staff failed to complete an AIMS assessment on admission.

Based on observations, record review, review of facility policy and resident and staff interviews, the facility failed to store drugs and biologicals securely for 2 of 2 sampled residents (Resident #8 and #76) with medications at the bedside. Failure to securely store medications may result in unauthorized use, adverse reactions, or ineffective treatment. Findings include: Review of facility policy titled Medication: Administration occurred on 07/09/26. This policy, dated 03/30/26, stated, . Pre-setting medications is not an acceptable practice. The resident has the right to self-administer medications if the interdisciplinary team determines that this practice is safe for the individual resident and is documented in the care plan. An order from the provider is required for this activity. Do not leave medications at the bedside . unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. If the resident has not been assessed for safety of self-administration and there is not a physician order to leave the medication with the resident, stay with the resident until the medication is taken and you observe the resident swallow. -Review of Resident #8's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact. Observation on 06/06/26 and 06/07/26 of Resident #8's private room showed two overflowing baskets of various creams and ointments on a bed-side table at the end of the bed, some contained pharmacy labels and a medication cup of a light pink creamy substance also located on the bed side table. Review of Resident #8's medical record lacked a self-administration assessment and a physician's order to keep creams at bedside. -Review of Resident #76's medical record occurred on all days of survey and identified a Resident Self-Administration of Medication assessment, dated 11/25/25, which stated, Resident is not approved for self-administration. Observations on 07/06/26 at 12:10 p.m. and 07/07/26 at 12:30 p.m. showed medications in cups located on the windowsill. The resident reported they were his noon medications, and he would take them later. In an interview on 07/08/26 at 4:30 p.m., a nurse (#22) confirmed Resident #76 is not approved for self-administration of medications.

Based on observation, review of facility policy, resident and family interviews, the facility failed to ensure a safe, clean, comfortable, homelike environment for 4 of 14 sampled residents (Resident #2, #3, #8. and #17) and 9 supplemental residents (Resident #30, #31, #32, #33, #34, #35, #36, #37, and #39) observed during survey. Failure to maintain a clean, comfortable, and sanitary environment does not provide a homelike environment for residents and fails to promote dignity. Review of the facility policy titled Environmental Cleaning Principles occurred on 05/28/26. This undated policy, stated, . Environmental cleaning plays an important role in an infection control program. the spread of infections from contaminated surfaces is significant and supports the need for good procedures and practices related to cleaning and disinfecting of surfaces. There should be an emphasis of frequently cleaning and disinfection [sic] high touch areas . Observations on all days of survey showed the followed: * 05/26/26 at 2:36 p.m., Resident #35's floor showed visible food debris, dust accumulation, and a dried known residue. Resident #35 reported a strong urine smell in the bathroom and wished the housekeeping staff cleaned the floor better. * 05/26/26 at 2:52 p.m., Resident #34's floor showed visible dirt and dust accumulation and scuff marks.* 05/26/26 at 2:52 p.m., Resident #36's floor showed residue spots and dust debris.* 05/26/26 at 2:55 p.m., Resident #39's floor showed visible dust debris, food crumbs, a packet of jelly, and small pieces of paper on the floor. There was a strong urine smell in the bathroom. Resident #39 stated she had not received housekeeping for well over a week. * 05/26/26 at 3:52 p.m., Resident #30's floor showed visible dirt and dust accumulation. * 05/26/26 at 4:32 p.m., Resident #8's bathroom showed the floor (near toilet) smeared with fecal matter. * 05/26/26 at 4:56 p.m., Resident #31's fall mat soiled with a dried liquid residue. * 05/26/26 at 5:09 p.m., Resident #32's room showed visible dirt and dust accumulation on the floor. The flooring was sticky throughout the bedroom/bathroom. * 05/27/26 at 8:48 a.m., Resident #37's floor showed food debris, paper, wrapper garbage, and a dried liquid residue. Wrappers and empty cans of Coke were collected on the bedroom and bathroom countertops. Resident #37 stated housekeeping staff had not cleaned much lately. * 05/27/26 at 9:10 a.m., Resident #2's floor showed sticky flooring throughout the bedroom/bathroom, numerous black/brown particles on the bathroom floor, and a soiled toilet. * 05/27/26 at 9:18 a.m., Resident #33's floor showed dark stains and area of dried unknown residue. - During an interview on 05/27/26 at 9:34 a.m., Resident #3 stated, They don't really clean well. They don't clean the bathroom good enough. Garbage piles up. - During an interview on 05/27/26 at 10:25 a.m., Resident #17 reported concerns with housekeeping services, stating the facility and their room were not consistently maintained in a clean condition and a family member cleaned their room on multiple occasions. - During an interview on 05/27/26 at 4:35 p.m., a family member (A) stated, The room was always dirty, the bed wouldn't be made until after 1:00 p.m., and the mess from the night before would still be there the following night. - During an interview on 05/28/26 at 3:01 p.m., an environmental staff member (#7) confirmed the housekeeping department is short staffed.

Based on record review, review of facility policy, and resident representative interview, the facility failed to notify the resident's representative of a discharge for 1 of 1 sampled resident (Resident #19) who left the facility and did not return. Failure to notify a resident's representative of a discharge does not allow the representative to make informed decisions regarding the resident's care.Findings include:Review of the facility policy titled Notification of Change- R/S, LTC [rehab/skilled and Long Term Care] occurred on 05/28/26. This policy, dated 12/12/25, stated, . A facility must immediately inform . the resident representative(s) when there is: . A decision to transfer or discharge the resident from the facility . Review of Resident #19's medical record occurred on all days of survey and identified family member #B as the resident's guardian over the person, financial and property, effective 03/19/26.Review of Resident #19's progress notes identified the following:*03/28/2026 at 9:47 p.m., Resident left AMA [against medical advice].*03/28/26 at 9:55 p.m., Resident not in her room since this nurse came around 1800 [6:00 p.m.] until this time. Called [family member C] and asked about her mother and told this nurse that 'My mom wants me to take care of her in our house' and dropped the phone. Resident left AMA in the facility without notifying staff and without signing the sign out sheet.During an interview on 05/26/26 at 4:19 p.m., family member B confirmed the facility did not call her when the resident left the facility and did not return and stated the administrative staff member (#4) and an unknown nurse received the guardianship paperwork on 03/26/26.The facility failed to notify the guardian after Resident #19 left the facility.

Based on record review, review of the facility reported incident (FRI), facility policy review, staff interview, and family interview, the facility failed to thoroughly investigate a fall for 1 of 1 closed resident record (Resident #20) reviewed who reported a fall and injury. Failure to thoroughly investigate Resident #20's reported fall from a mechanical lift and potential causes of a compression fracture, placed Resident #20 and all residents at risk for possible neglect and/or injury.Findings include: Review of the facility policy title Fall Prevention And Management- Rehab/Skilled, Therapy & Rehab occurred on 05/28/26. This policy, dated 03/31/26, stated, . Procedure . Notify the physician and resident representative of the incident. If resident is stable, call available employees to the scene of the fall and begin the investigation . Review of the FRI, submitted to the state survey agency (SSA) on 04/28/26, identified a moderate injury and compression to the T8 (thoracic vertebrae number 8). The report stated [Resident #20] states she was dropped from mechanical lift, staff deny incident no one notified. When PA [physician's assistant] was told on 4/27 x-rays ordered. Resident has significant hs [history] of back pain . Review or Resident#20's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. The current care plan stated, . has an ADL [activities of daily living] self care performance deficit R/T [related to] weakness . needs assistance for transfers . Transfer - sit to stand assist x 1 [one person assist]. Review of Resident 20's nurses' notes identified the following: *04/26/26 at 18:24 (3:15 p.m.), stated, The [family member D] called and said that the resident is telling that he (sic) had a fall on Friday -04/24/2026 from the sling of the lift. *04/27/26 at 10:09 a.m., stated, [provider's name] here and informed of resident stating that she had fallen on friday (sic) and c/o [complains of] severe pain all over. no record of resident falling friday (sic) or c/o pain. new order for thoracic/lumbar/spine x-ray. During an interview on 05/28/26 at 8:36 a.m., a family member D stated she called the facility on Saturday, 04/25/26, and asked the nurse about Resident #20's report of a fall. The nurse told family member D there were no reported falls. Family member D stated she called the facility again on Sunday, 04/26/26, and told a nurse Resident #20 complained of pain and said she fell. The nurse told family member D the resident could not have fallen. During an interview on 05/28/26 at 12:04 p.m., an administrative nurse (#6) stated facility staff informed her of the fall on 04/024/26 but Resident #20 could not recall when it happened. The fall did not seem real therefore, the facility did not conduct an investigation. The facility failed to investigate Resident #20's reported fall from a mechanical lift or the cause of the compression fracture to her T8 vertebrae.

Based on observation, record review, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 1 sampled resident (Resident #2) observed without wheelchair footrests. Failure to use the wheelchair footrests placed the resident at risk for falls and/or injury. Findings include: Review of the facility's policy titled, Wheelchair, Use of, LTC, occurred on 05/28/26. This policy, revised 09/30/25, stated, . To provide mobility for the non-ambulatory resident with safety and comfort. Lower foot rests and place resident's feet on foot rests . Assist resident to the area of the facility desired. Observation on 05/27/26 at 9:10 a.m., an unidentified certified nurse aide (CNA) approached Resident #2, who was seated in his wheelchair. The CNA brought Resident #2 back to his room to assist with dressing. During the transport, the resident's legs/feet bounced along the floor. The CNA failed to place the footrests on the wheelchair and failed to cue the resident to raise his legs/feet.

Based on record review, review of facility policy, and staff interview, the facility failed to provide respiratory services consistent with professional standards of practice for 1 of 1 closed record (Resident #18) who received oxygen therapy. Failure to clarify physician's orders regarding oxygen administration and failure to adequately monitor respiratory status have contributed to Resident #'s compromised respiratory status and subsequent hospitalization.Findings include: Review of facility policy titled Oxygen Administration, Safety, Mask Types occurred on 05/28/26. This policy, revised 07/30/25, stated, Oxygen administration is carried out only with a medical provider order. Oxygen Cylinder. Verify physician order. Assess resident for at least first 15 to 30 minutes after beginning therapy and at regular intervals depending on resident's condition. Review of Resident #18's medical record occurred on all days of survey and identified an admission from the hospital to the facility on [DATE]. Diagnoses included interstitial pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The resident's baseline care plan lacked problems, goals or interventions related to respiratory diagnoses. Review of a pulmonary inpatient consultation note, dated 04/20/26 (prior to admission to the facility), stated, . began to require supplemental oxygen earlier this year. currently using about 3 L [liters]/min [minute]. A chest CT scan during this admission showed interstitial lung disease . CT [computed tomography] scan shows progression. Recommendations. increase her oxygen to the maximum before she exerts herself. Plan includes supportive care, symptom management, and rehabilitation at a nursing facility for breathing therapy. Review of Resident #18's discharge summary note, dated 05/01/26 stated, Discharge Diagnoses . Dependence on supplemental oxygen . Hypoxia. Pulmonology consulted . recommend increasing her oxygen to maximum over 4 she exerts herself. history of chronic hypoxic respiratory failure, interstitial lung disease, pulmonary hypertension at baseline 3-1/2 L to 4 L O2 [oxygen] . Review of Resident #18's progress notes identified the following: *05/01/2026 at 5:03 p.m., . O2 90% [oxygen saturation percent] . Method: Room Air. Resident reported Shortness of breath (while lying flat). Nurse observed Shortness of breath (upon exertion). *05/05/2026 at 8:19 a.m., CNA alerted writer that [resident name] was having shortness of breath. visibly short of breath, anxious, posture was leaned forward. O2 SAT [saturation] 76% on 2L. [resident stated] 'I have been crying most of the night.' NOC [night] nurse did not report this. Unaware if she placed call light to report . TO [telephone order] to transfer to ER [emergency room] . *05/05/2026 at 9:02 a.m., Writer does recall the night nurses reporting she had placed resident on a concentrator as the oxygen did not seem to be working. The facility failed to clarify post hospitalization orders and whether Resident #18 required oxygen, and if so, at what flow rate; and failed to assess and/or address the resident's change in respiratory status. These failures may have contributed to Resident #18's rehospitalization just four days after admission to the facility. During an interview on 05/28/27 at 12:49 p.m., an administrative staff member (#1) confirmed staff failed to obtain a physician's order for oxygen therapy and monitoring.

Based on review of facility policy and resident and staff interviews, the facility failed to ensure residents remained free from accident hazards during 2 of 2 severe weather events (06/20/25 and 06/27/25). Failure to ensure facility staff took appropriate action/precautions to protect residents during severe weather events placed all residents at risk for physical and emotional harm. During an on-site complaint survey, the survey team consulted with the State Survey Agency (SSA) on 07/24/25 and determined an Immediate Jeopardy (IJ) situation existed on 06/20/25. The facility failed to implement their emergency plan when tornado warnings were issued which placed residents at risk for injury.* 07/24/25 at 5:24 p.m., the survey team notified the acting administrator (#1) and the director of nursing (DON) (#2) of the IJ situation, provided the IJ template, and requested the facility's removal plan for the IJ.* 07/25/25 at 1:41 p.m., the State Agency (SA) reviewed and accepted the removal plan.* 07/28/25 at 3:11 p.m., the survey team verified the implementation of the removal plan as of 07/25/25 and the IJ removal. The deficient practice remained at a F scope and severity following the removal of the IJ.The facility completed the following steps to remove the immediacy and correct the deficient practice:*Completed a comprehensive review of the emergency management resource packet/binder and the policy and procedure for tornado watches and warnings.*Completed a tabletop tornado drill on all four units for leadership, employees, and ancillary/dietary staff working on 07/24/25. *Ordered five new electric/battery powered weather radios on 07/24/25 to be located on each unit and at the main floor reception desk. *Ensured current weather radios were present and working on Units 1 and 3 on 07/24/25. Unit 3 is designated to listen to weather updates and notify Units 1, 2, and 4 when to implement and end the tornado watch and tornado warning protocols. *Educated all staff via OnShift (the facility's text/telephone messaging system) with the education to be completed during their shift and/or prior to their next shift. *Assigned all employees computer training for Workplace Emergencies and Natural Disasters. Findings include:Review of the facility policy titled Tornados occurred on 07/24/25. This undated policy stated, . Each center should have a national weather service radio with an audible alarm in accessible common area. In case of a tornado or threat of tornado, tune into local weather radio or television for information and advice from the National Weather Service and public safety agencies. A WATCH indicates that conditions exist wherein a tornado may develop. 1. Close drapes in resident rooms and common areas. 2. Gather flashlights in case of power failure. 3. Alert all on-duty staff to the potential for a tornado 4. Continue to monitor local TV/radio stations for weather updates. A WARNING indicates a tornado has been sighted or indicated by radar. Upon notification that a tornado had been sighted . the following additional procedures should be implemented: 1. Alert staff that a tornado has been sighted. 2. Move residents/clients, staff, and visitors into first floor interior hallways, bathrooms, or areas away from windows or skylights. Close doors after residents have been evacuated. 3. Charge nurse must have a roster of residents/clients and keep them together. 4. If possible, place resident near protective walls with arms over head. Provide blankets and pillows for protection. If there is no time to get residents to protected areas, have them lie flat on the floor, face down. 5. Use beds, bed covers or mattresses as protection against flying glass and debris where applicable. 7. Stand by for the ALL CLEAR. Stay in the building until the storm has passed.Review of the SEVERE WEATHER ALERT protocol stated, After Hours and Weekends. Unit 3 nurse is the designated leader to listen to weather updates. You will notify Units 1, 2 and 4 when to implement the Tornado Watch or Tornado Warning Policy. Unit 3 nurse will be the leader to notify other units when to end the watch or warning. Weather radios are in MDS [Minimum Data Set] nurses office, 1 for each unit if needed - instructions are also there. Instructions to go to each unit when taking radio the [sic] the unit.During confidential resident interviews on 07/23/25 and 07/24/25, the residents stated the following:*Resident A, Branches hitting my window woke me up. The resident confirmed he remained in his bed with the window blinds and room door open.*Resident B, Notified of everything [severe weather and tornado] on TV [television], They [staff] did nothing, I sat [in a recliner in his room] and waited it out, No one came in when the sirens on the TV went off [to tell me] if it was the real thing. If it was okay, and I am concerned about fire. How will they do this. The resident confirmed the room blinds remained open.*Resident C, Notified of the severe weather from the TV. Staff didn't say a word [about a tornado warning]. The resident confirmed the room door and blinds remained open.*Resident D, I was sleeping. It [weather] woke me up. and I was not aware of any tornados. They [staff] did not tell me one was near. The resident confirmed she remained in bed with the room blinds open.*Resident E, I remember waking up to it [weather] and confirmed she remained in her bed.*Resident F, They [staff] told me nothing about the storm and confirmed she remained in her bed.*Resident G, Confirmed only the TV alerted her to a tornado warning and she remained in her room.*Resident H, I learned of the bad weather on TV, I was watching the trees bend over. I was not aware a tornado was near, and They [staff] just shut the door and said stay in your room.*Resident I, Notified of the severe weather by the TV and she remained lying in bed.*Resident J, Slept during the storm and confirmed he remained in his room lying in his bed.*Resident K, Confirmed she remained in her bed located beside/under her room window with the blinds closed.*Resident L, Notified of the severe weather by the TV. There were so many tornados so close. I didn't feel safe. Nobody cared. and At least they [staff] could have moved me to the first floor. The resident confirmed she remained in her bed located beside/under her window with the blinds closed. I wonder what they would do if there was a fire. Just leave me lay here in my bed?* Resident M, I was asleep and confirmed he remained in his bed with the window blinds and room door open.*Resident N, The only way we [resident's and staff] knew what was going on was on the TV. and We [the residents] were telling them [staff] there was a [tornado] warning.*Residents located on Unit 2 stated staff came in to close their blinds. Residents on Units 1, 3, and 4 stated their blinds remained open and/or they always keep their blinds closed.During an interview on 07/23/25 at 11:30 a.m., a maintenance staff member (#3) stated all units have a binder at the nurse's station which contains the tornado watch and warning protocols. During an interview on 07/24/25 at 2:22 p.m., a management nurse (#2) stated the weather radio located on Unit 3 did not go off because it was not plugged in. That's why they [staff] did not know there was a tornado [warning].The facility failed to take appropriate action/precautions to protect residents during two issued tornado warnings.

Based on record review, review of the facility reported incident (FRI) and investigation, and resident and staff interviews, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 sampled resident (Resident #55) injured during a facility van transport. Failure to ensure the power control to the motorized scooter (wheelchair) is turned off during transport resulted in an injury to Resident #55's foot and placed all residents with motorized wheelchairs at risk for injury during transports. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 02/28/25. The facility implemented and completed corrective action on 03/05/25. Review of Resident #55's medical record occurred on all days of survey. Diagnoses included quadriplegia, immobility, and right foot fracture. The care plan stated, . AMBULATION: Does not ambulate at this time. Resident has proven sufficient in steering his motorized wheelchair independently. Review of the FRI, dated 02/28/25 at 2:20 p.m., stated, Van driver [name] stated that while transferring resident in [the] transportation van, resident was seated in a motorized scooter, in locked position and strapped/seat belted appropriately. The motorized scooter power was not shut off. While van was in motion, the van slowed down, the chair was propelled forward by resident accidentally hitting the forward button causing the chair to move slightly forward. The motorized scooter foot board hit the chair in front of the resident and slightly lifted up toward the resident causing it to hit the resident's right foot. The resident then moved his foot off the foot board and rested it on the van wall ledge. When the resident arrived to his scheduled appointment at the clinic he stated to them his pain of his right foot and what had occurred. The clinic ordered an xray [sic] to be completed and was completed on 02/28/27 [sic]. The xray [sic] finalized 3/4/25 and released with findings inconclusive stating unable to tell if non-displaced [foot bones remain in place] fracture vs [versus] advance bone demineralization. and would require further testing. Provider [name] notified and has no additional orders on 3/4/25. [Provider name] stated she would see resident on 3/5/25 for further evaluation. Review of the x-ray results, completed on 03/09/25, identified a healing change to the first metatarsal head [foot bones] fracture, fracture line remains visible. The facility final report investigation stated, Staff [van driver's name] failed to ensure that the motorized wheelchair power was turned off after she securely buckled/hooked the motorized scooter in place before she put the van in motion. [Van driver's name] was educated immediately after this was reported to administration when she returned to the facility after dropping [Resident #55's name] off for his appointment. All Staff who operate the van were immediately educated and weekly audits will be performed. Resident is able to turn on and off his motorized scooter and utilize his scooter independently . During an interview on 05/12/25 at 3:50 p.m., Resident #55 stated, She [van driver] did nothing negligent. It was an accident. The facility failed to ensure Resident #55's motorized wheelchair control was in the off position prior to transporting the resident. Based on the following information, non-compliance is considered past non-compliance. The facility implemented corrective actions for other residents who may be affected by the deficient practice as follows: * Completed an investigation in Resident's #55's incident and injury. * Provided immediate education to van driver (#27) involved in the incident on 02/28/25. * Educated all van drivers, either in person or by telephone, prior to operation of the van. Last person educated on 03/05/25. * Competency for all van drivers reviewed and in place, dated 07/30/24 through 01/02/25. * Implemented audits for van transports with motorized wheelchairs.

1. Based on observation, record review, review of facility policy, review of professional literature, and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #36 and #90) observed in an inclined/reclined position during meals received the care and services necessary to attain the highest degree of safety possible. Failure to ensure staff properly positioned and/or supervised residents with dysphagia (difficulty swallowing food and/or liquids) (Resident #36 and #90) or known aspiration (breathing food and/or liquids into the airway) (Resident #90) during meals resulted in Resident #90 aspirating and placed Resident #36 at risk of aspiration. Findings include: The facility policy titled Resident-Assisted Dining-Rehab/Skilled, revised 04/16/21, stated, . Elevate the head of the bed, or assist the resident to a sitting position . Place the meal in the line of sight of the resident . Encourage resident in feeding self, assisting as needed . [NAME] B. Swigert's The Source for Dysphagia; Third Edition, LinguiSystems, Inc., Illinois, 2007, page 125 and educational handouts identified, . During the oral intake of . foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. This position must be maintained during and following the meal. Repositioning is frequently required during the meal. Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue. Signs and symptoms of aspiration: Coughing . Throat clearing, Wet gurgling voice after swallowing . - Observations showed the following: * 02/01/22 at 8:25 a.m., Resident #90 laid in bed with the head of his bed positioned at an approximate 20-degree angle. Staff left his breakfast tray sitting on the bedside table to his right. Resident #90 used his left hand to feed himself. On two occasions, he spilt thickened juice on his neck/upper chest while attempting to drink from the glass. Resident #90 cleared his throat twice, coughed twice, and presented with a wet vocal quality after drinking from the glass. Resident #90 had difficulty placing the glass back on the table, stating, My arm and shoulder are bad. * 02/01/22 at 11:59 a.m., A certified nursing assistant (CNA) (#7) raised the head of Resident #90's bed to an approximate 75-degree angle. She set-up the tray and supervised him throughout the meal. After Resident #90 coughed a third time, the CNA (#7) raised the head of his bed approximately five more degrees. * 02/02/22 at 12:15 p.m., Resident #90 fed himself as he lay in bed, with the head of his bed positioned at an approximate 60-degree angle. He coughed three times during the observation. A managerial nurse (#8) stood next to Resident #90's bed watching him. The managerial nurse (#8) identified she needed to watch the resident eat as he is a one-to-one supervision when he is in the room. This conflicts with the observation made on 02/01/22 at 8:25 a.m., when Resident #90 fed himself in his room without staff supervision/assistance. Review of Resident #90's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognitive skills and extensive assistance of one person required for eating. The current physician orders, care plan, and diet order notification (swallow/safe feeding guide) identified Florajen 3 capsule (probiotic) and Vitamin C tablet for aspiration pneumonia, minced textured foods, mildly (nectar) thick fluids, direct supervision, sit upright/as close to 90 degrees as possible when eating/drinking, and do not lie down for 30 minutes after meals. The progress notes identified the following: * 01/08/22 at 9:53 a.m., Resident not feeling well, resident seemed to have sputum in his lungs that he could not expel . resident was sent to the hospital for weakness, altered mental status, possible pneumonia. * 01/10/22 at 11:31 a.m., . admitted to [hospital] on 1/8/2022 w [with]/ respiratory failure/[CONDITION(S)] [oxygen deficiency]/aspiration pneumonia, [CONDITION(S)] [urinary tract infection]. Currently on a pureed diet w/ honey thick liquids. Needs to be spoon fed and is a 1:1 [one-to-one] assist due to aspiration. Will have a video swallow while inpatient . * 01/11/22 at 2:56 p.m. Swallow eval [evaluation] done today . He is also On [MEDICATION(S)] [an antibiotic] x [times] 7 days for Pneumonia . An Xray Video Swallow with Fluoro [flouroscopy (imaging technique)] report, dated 01/11/22, identified, . Video swallow study was performed . Penetration [food or liquid enters the airway, but not below the true vocal folds] seen with nectar consistency and frank [unmistakable/clinically evident] aspiration occurred with thin liquids. During an interview on the morning of 02/03/22, when asked questions pertaining to Resident #90's swallow guide recommendations, a therapist (#9) responded, He should be at 90 degrees and midline. He needs pillows on each side to prop him up. It's written on all the notes and on the swallow guide. He had a video [modified [MEDICATION(S)] swallow study] and therapy. He came back [from the hospital] with COVID [coronavirus] and was a one-on-one in his room [and] direct supervision in the dining room. He is very high risk. He could aspirate again. He is on thick liquids and no straws. The facility failed to position Resident #90 as close to 90 degrees as possible prior to serving each meal, ensure each tray is placed within his line of sight, provide one-on-one supervision throughout each meal, and/or further raise the head of his bed if/when he began coughing. Failure to implement these interventions resulted in the resident aspirating during meals. - Observation on 02/01/22 at 11:37 a.m. showed a managerial activity staff member (#10) feeding Resident #36 in the dining room. Resident #36 leaned to her right side with her head resting on edge of the wheelchair. Review of Resident #36's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified severely impaired cognitive skills and extensive assistance of one person required for eating. The current physician orders, care plan, and diet order notification (swallow/safe feeding guide) identified pureed textured foods, regular fluids, one-on-one supervision, sit upright/as close to 90 degrees as possible when eating/drinking, and do not lie down for 30 minutes after meals. An Xray Video Swallow with Fluoro report, dated 03/03/21, identified, . Cookie was swallowed with some residual in the mouth [pocketing food] that was cleared by thin liquid. No evidence of gross aspiration or penetration when drinking and eating various materials as mentioned above. During an interview on the morning of 02/03/22, when asked questions pertaining to Resident #36's swallow guide recommendations, a therapist (#9) responded, [Resident #36] should be repositioned to midline [if she is leaning to the side.] The facility failed to position Resident #36 as close to midline as possible prior to serving the meal and/or reposition her during the meal. Failure to implement the above interventions placed Resident #36 at risk of pocketing food and/or aspiration. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care and services to ensure proper skin care for 1 of 4 sampled residents (Resident #66) with skin impairments. Failure to complete weekly skin assessments, follow physician's orders related to skin impairments, and monitor residents with an identified skin condition may cause continued pain, worsening skin impairments, and delay changes in treatment. Findings include: Review of the facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation occurred on 02/03/22. This policy, dated April 2021, stated, . PURPOSE: To systemically assess residents with regard to risk of skin breakdown . To accurately document observations and assessments of residents . 5. A systemic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. The medical record identified the following orders on the current Physician Order Summary Report: * 1-30-22- Cleans (sic) with Warm Water and apply Aloe Vista (sic) + [MEDICATION(S)] Cream (skin protectant ointments) To scattered Skin fold stage 1 Wound every 12 hours and As Needed. Until Resolved. * 12-6-21- Complete skin assessment UDA [User Defined Assessment] every night shift every Tue [Tuesday] for skin observation. The current care plan stated, . The resident has actual impairment to skin integrity R/T [related to] redness/moisture E/B [evidenced by] resident has multiple skin folds requiring cleaning, drying, and intradry (a moisture wicking dressing). Weekly skin observation by licensed nurse. Keep skin clean and dry. The record lacked evidence of a current order for intradry and failed to include the current intervention of Aloe [MEDICATION(S)] and [MEDICATION(S)] cream. The record showed the facility failed to complete weekly skin assessments for the weeks of December 7, 21, and 28, 2021, and January 4, 2022. Observation on 02/02/22 at 10:10 a.m. during Resident #66's partial bath showed the following: * Red, raw, rashy skin impairments to the left abdominal fold and under the bilateral breasts and several other areas of mild redness to Resident #66's skin folds. The certified nurse aide (CNA) (#1) called the nurse to bring intradry to the room. The nurse (#14) entered the room, cut ten strips of intradry, and exited the room. The CNAs (#1, #2, #3, and #4) applied the intradry dressing to the resident's various skin folds. Staff failed to apply treatment to the resident's skin folds as per current physician's order. * Bleeding around the resident's rectal area. The resident cried out in pain while the CNA (#3) cleansed the rectum. The CNA (#3) mixed [MEDICATION(S)] cream and aloe [MEDICATION(S)] cream and applied to the resident's rectum. The staff failed to report the bleeding, red raw rectum to the nurse to assess. * During the partial bath the CNA (#1) found a wooden back scratcher under the resident's left side with the tongs pointing up into the resident's skin, leaving a reddened mark on the resident's skin approximately 1.5 centimeters in length. The staff failed to report the reddened area to the nurse. * During perineal cares, observation showed dried bowel movement to Resident #66's perineal area and lower abdomen. * Observation showed the resident's bottom sheet and pressure relieving mattress wet and soiled with urine. The CNAs changed the soiled sheet but failed to clean and dry the soiled pressure relieving mattress. This surveyor pointed out the mattress to the CNA. The CNA (#1) stated, Yes, it is, we need to put a towel down under the sheet. The CNAs (#1, #2, #3, and #4) then used a hand towel and attempted to dry the pressure relieving mattress, and put another hand towel over the visibly wet and soiled mattress and then applied the fitted sheet. During an interview on 02/03/22 at 12:10 p.m., an administrative nurse (#6) agreed nursing staff failed to follow physician orders, failed to update Resident #66's care plan, and failed to complete/document weekly skin assessments. The nurse (#6) stated, staff altered the pressure relieving mattress' integrity by placing a hand towel between the mattress and the sheet.

1. Based on observation, record review and staff interview, the facility failed to provide the necessary care and services to manage pain for 1 of 1 sampled resident (Resident #5) who expressed pain/discomfort related to her mattress. Failure to attempt interventions to improve Resident #5's comfort resulted in unresolved pain, skin breakdown, and the use of prn (as needed) antianxiety medications. Findings include: Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current medications included [MEDICATION NAME] (a narcotic pain reliever) four times per day (started 07/30/13). Discontinued medications included [MEDICATION NAME] (an antianxiety medication) prn (discontinued 12/19/13) and [MEDICATION NAME] prn (discontinued 03/18/14). The current Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. Resident #5's current care plan stated, ". . . Positioning . . . Egg crate cushion over mattress d/t (due to) initial c/o (complains of) discomfort from pressure relief mattress. Mattress pad over eggcrate per family request for foot comfort. . . . Edited 04/12/2013 . . ." Observations throughout the survey showed Resident #5 asleep in her recliner. Nurses' notes from 04/04/13 through 03/12/14 included multiple entries identifying Resident #5's back pain and difficulty sleeping in her bed, including the following: *04/04/13 at 3:27 a.m.: ". . . Resident in good spirits but c/o bed being to (sic) hard. Staff had adjusted her bed but she voiced cant (sic) get into comfortable position. Up in recliner at 2400 (midnight) . . ." *04/11/13 at 12:43 a.m.: ". . . Res (resident) voiced that she hates sleeping in this bed. . . ." *08/08/13 at 3:33 a.m.: ". . . Res. had been sleeping well until assisted up to the bathroom when resident started crying about her pain. Res. stated that the pain was 'In my back, and my arms, oh it is all over". Prn (as needed) [MEDICATION NAME] given. . . ." *08/18/13 at 4:45 a.m.: ". . . resident yelling and crying 'theres (sic) something behind my back' not anything there; don't touch my arm, don't touch my gown; gave PRN [MEDICATION NAME] for crying 'it hurts'; insisted to get into recliner and out of bed . . ." *08/26/13 at 3:47 a.m.: ". . . 0323 (3:23 a.m.) gave scheduled [MEDICATION NAME] early for c/o back pain in that bed! toileted, positioned higher in bed with HOB (head of bed) elevated, stating that felt much better. . . ." *09/08/13 at 1:36 a.m.: ". . . Resident attempted to sleep in bed tonight but then later refused and requested to sleep in recliner due to back pain. . . ." *10/06/13 at 10:13 a.m.: ". . . Noted small abrasion to mid right buttock, area cleaned with normal saline and measures 1 x 0.8 cm (centimeters), redness noted around the open area. . . ." *10/08/13 at 3:27 a.m.: ". . . Refuses to sleep in bed. 'It makes my back hurt so much worse. I am not sleeping in it.' . . ." *10/08/13 at 3:43 p.m.: ". . . Open area observed, remains present to edge of R (right) mid buttocks area. . . ." *10/15/13 at 2:50 p.m.: ". . . Spoke with resident this afternoon about nursing staff concern related to resident refusal to sleep in her bed anymore. . . . Explained that the healing abrasion she now has on her outer buttocks fold is probably from being in her recliner so much. . . . States her chair: 'Feels better'. . . ." *10/16/13 at 2:30 a.m.: ". . . Resident sitting up at edge of bed, alarms sounding. Res. crying with c/o back pain and wanting to get out of the bed. . . ." *10/21/13 at 6:09 a.m.: ". . . Resident stayed in bed from 2000 (8:00 p.m.) until 2200 (10:00 p.m.) when she was sitting on side of bed crying, 'It hurts my back too much. I can't stand to be in it.' Tried to educate on importance of changing positions and keeping pressure off of her buttocks and back area. 'I am not staying in that thing. Even if you elevate my head. No way.' Then resident slept in recliner rest of night. . . ." *11/04/13 at 2:36 a.m.: ". . . Resident sat in recliner from 1830-2230 (6:30 p.m. until 10:30 p.m.). 'I am not sleeping in that thing. It makes my back hurt so bad.' Then resident started crying, 'Why do I have to sleep in that thing. Why are you torturing me so much?' Offered to rub resident's back. Offered resident a warm blanket. Did offer resident water. Interventions were not effective. Gave resident time to calm on own. Also assisted resident to bathroom. Interventions continue to be not effective. Did give resident [MEDICATION NAME]; which was effective. . . ." *11/11/13 at 12:52 a.m.: ". . . Resident would only stay in her bed from 2200 until 0000 (10:00 p.m. until midnight). Was trying to get out of bed. Assisted to the bathroom with assist of 2, gait belt, and walker. Refused to go back into bed. Crying with c/o back pain. Scheduled [MEDICATION NAME] had been given at 2100 (9:00 p.m.). Resident repositioned into her recliner. . . ." *11/21/14 at 2:25 a.m.: ". . . Resident has been awake multiple times tonight, 'oh, my back hurts. It hurts so bad. Why do I have to sleep in this damn thing?' Did give resident a PRN for pain and repositioned her in bed. Resident awake again and saying, 'I can't stand this. I want to sleep somewhere else.' Resident assisted to bathroom. Interventions were not effective. Did assist resident to recliner which she refused. 'I'm nervous now. I can't settle down.' Offered resident a snack and a warm blanket. Interventions were not effective. Did give resident [MEDICATION NAME]; which was effective. . . ." The Medication Administration Record [REDACTED] *12/14/13 at 11:53 p.m.: ". . . gave PRN [MEDICATION NAME] at 21:35 (9:35 p.m.) for anxiety, yelling, crying; earlier wanted to go to bed; changed her mind and became very upset when hs cares completed and requested she go into bed; took [MEDICATION NAME] and at present is sleeping in bed . . ." *12/18/13 at 3:46 a.m.: ". . . Resident was very agitated and crying, 'oh my back. I can't stay in that bed. It makes it so bad.' Resident was asssisted (sic) to the bathroom. Resident also offered fluids and food. Did also give resident a warm blanket and turned on TV for music. Interventions were not effective. Did give resident [MEDICATION NAME]; medication was effective. . . ." *12/20/13 at 1:10 a.m.: ". . . Resident awoke at 0015 (12:15 a.m.), 'my back my back oh it hurts. Pull that thing out of here.' Then resident attempted to remove bed protector. . . . Also, did give resident PRN for pain and rubbed her back. Resident awake at 0100 (1:00 a.m.) crying, 'I'm not staying in that thing. It hurts my back too much.' . . ." *01/02/14 1:50 a.m.: ". . . Refused to go back to bed, 'That thing hurts my back way too much. I am not going back.' . . ." *02/23/14 5:14 a.m.: ". . . Resident slept in her recliner the entire night. Staff and nurse encouraged her to go into bed but she refused. Now when scheduled medication given, resident complaining of her butt and back hurting. Upon exam butt is red and nurse explained the importance of getting into bed and off the buttocks. Resident replied 'I am not sleeping in that bed'. . ." *03/06/14 at 5:26 a.m.: ". . . resident slept in recliner all noc (night); would not even attempt to sleep in bed. . . ." *03/12/14 at 5:46 a.m.: ". . . refused to sleep in bed thru noc . . ." A Physical Therapy Screen, dated 02/17/14, stated, ". . . Resident has started sleeping in recliner. Staff is encouraging resident to sleep in bed but she refuses. Gave resident ROHO (a type of pressure-relieving cushion) cushion for recliner. . . ." Record review first identified skin breakdown to Resident #5's buttocks in October 2013, as well redness in February 2014. The facility failed to provide/attempt effective interventions in response to Resident #5's continued complaints of back pain related to her bed. The care plan identified staff added an egg crate mattress in April 2013, but lacked further interventions since that time. During an interview on the afternoon of 03/19/14, a supervisory nurse (#2) identified the facility tried other mattresses; however, they provided no evidence of these alternative measures. 2. Based on record review and staff interview, the facility failed to provide the necessary care and services to manage behavioral symptoms for 1 of 6 sampled residents (Resident #10) who received antipsychotic medications. Failure to identify target behaviors, assess the reason/causative factor(s) for behaviors, implement appropriate interventions (including non-pharmacological interventions), and establish accurate on-going monitoring of the behaviors has the potential for residents to not obtain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of Resident #10's medical record occurred during all days of survey. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. Review of Resident #10's current plan of care identified, "Problem: . . . Behaviors: . . . Resident room is cleaned daily, tv (television) and lamp removed from room. Resident has hx (history) of breaking utensils. . . Approach: Do not leave Sani Cloths Germicidal Wipes in resident room for safety. Educate resident re: safety measures with behaviors as needed. . . . Resident is not redirectable, allow time and space in a safe environment. Notify (physician's name) of increased behaviors. Allow resident as many choices as possible." Review of Resident #10's physician's orders [REDACTED]. * [MEDICATION NAME] (an antipsychotic) dose increased to 1 milligram (mg) daily, started 08/20/13 * [MEDICATION NAME] continue 1 mg daily, 10/08/13 * [MEDICATION NAME] increase to 1.5 mg daily, started 01/14/14 * [MEDICATION NAME] (an antidepressant) dose increased to 50 mg daily, started 01/28/14 * [MEDICATION NAME] 1.5 mg continue - move to pm (evening), started 01/28/14 * [MEDICATION NAME] increase to 2 mg in the evening, started 03/04/14 * [MEDICATION NAME] increase to 75 mg daily, started 03/04/14 Review of Resident #10's Progress Notes identified the following: * 08/01/13 at 5:42 a.m.,"resident has been messing with the TV I had turned it off around 2100, CNA noted Nursing that he had it back on and kept turning the screen toward the wall. Turned it off at 0400, and told resident to leave it off, it is broken, he said, "ok." * 08/02/13 at 3:57 p.m.,"Staff report noting observations of resident pushing on television screen, pushing on window and even pushing on mirror. Staff also report this AM (morning) resident had large amount of urine on his floor. . ." * 08/05/13 at 1:15 p.m., "Staff report resident observed to be "pushing" on window, window blinds, television, mirror and wall mounted light fixture broke via resident. Television screen also broke via resident. Updated (physician's name) re: (regarding) above behaviors. . ." * 08/16/13 at 5:50 p.m.,"Resident noted to have behaviors this morning before lunch. Resident was noted to be looking thru the kitchen cupboards and drawers. Resident asked if he needed help with something or if he was still hungry. Resident would not respond. . . No other behaviors noted since." * 08/20/13 at 11:53 a.m., "Resident was seen by (physician's name) today with new orders received. . ." * 12/06/13 at 12:20 p.m., "Resident has slept through breakfast and lunch today. Resident has been approached a few times from different staff members. At one time he acted like he was going to choke a staff member by reaching towards her throat. . ." * 12/08/13 at 11:28 a.m., "Resident once again slept through breakfast. . . . He also would not let housekeeping clean his room Friday 12/6." * 12/31/13 at 1:55 p.m., "Resident observed via SNF (skilled nursing facility) staff to be picking at left upper forehead throughout day today. Resident profusely picks on this area. (physician's name) here for rounds. . . . During evaluation of skin condition, resident suddenly showed aggression towards (physician's name), attempted to "throw a fist punch" at MD (medical doctor). When MD backed up away from resident, resident attempted to swing cane at MD. . ." * 01/02/14 at 11:48 a.m., "Update re: recent aggressive behavior sent to (psychiatrist's name) via fax on 12/31/13." * 01/28/14 at 10:39 a.m., "Resident was seen by (physician's name) today with new orders received. . ." * 02/05/14 at 3:17 p.m., "Staff reported to nursing today resident cane was found in resident room broken. When staff asked resident about cane, he was unable to provide staff with explanation on how cane broke. . ." * 02/18/14 at 10:48 a.m.,"Staff have been challenged via resident ongoing refusals for baths due to unpredictable sleep pattern. . ." Review of Resident #10's Nursing Home Progress Notes (psychiatry appointment notes) identified the following: * 08/20/13, ". . . Behavior: Staff report pushing on various items resulting in breakage, agitation. . . .Comments: . . . Mood 'ok' Affect [MEDICATION NAME]. Concrete. Not able to answer questions re: psychotic sx (symptoms) but appears internally preoccupied. No obs (observation) suicidal ideation. . . start [MEDICATION NAME] . . ." * 10/08/13, ". . . Behavior: Staff report no problems. . . . Comments: . . . Mood 'ok.' Affect [MEDICATION NAME] - pleasant. Concrete Denies psychotic sx. No obs suicidal ideation. Continue [MEDICATION NAME]. . ." * 01/28/14, ". . . Behavior: Staff report picking @ (at) skin & significant agitation, isolation to room . . . Comments: . . .good - abrasion on R (right) cheek. Good eye contact. . . Mood 'ok" affect [MEDICATION NAME]- superficially pleasant. Concrete. Denies psychotic sx or suicidal ideation. . . Start [MEDICATION NAME] . . ." * 03/04/14, ". . . Behavior: Staff report pt. (patient) not redirectable & refuses direction. Last nt (night) pt. pointing finger (like gun) @ peers in dining rm (room). . . Comments: . . . Brief answers - appears to be talking to self @ times. Mild psychomotor agitation - fidgety. Mood 'ok' Affect [MEDICATION NAME] - pleasant. Concrete. No obs. Psychotic sx or suicidal ideation. . . Increase [MEDICATION NAME]. . . Increase [MEDICATION NAME]. . ." During an interview on the afternoon of 03/20/14, a unit nurse (#16) confirmed staff failed to document or attempt any non-pharmacological interventions attempted prior to seeking increases to Resident #10's [MEDICAL CONDITION] medications. Failure to attempt non-pharmacological interventions and monitor the effectiveness of those interventions prior to administering or increasing the dose of an anti-anxiety/anti-psychotic medication does not allow staff to evaluate what interventions were most effective for Resident #10's behavior and may lead to the use of unnecessary medications.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistance necessary to prevent accidents for 4 of 14 sampled residents (Resident #2, #5, #15, and #17) with a history of falls. Failure to ensure Resident #5's safety by providing appropriate supervision and adequate assistance resulted in an unwitnessed fall with a hip fracture. Failure to provide necessary assistance to residents who experienced staff-assisted falls (Resident #2, #15, and #17) and re-evaluate the appropriateness of their care may result in further falls and injuries. Findings include: Review of the facility policy, titled "Incidents of Unknown Origin/Incident/Accident Reporting" occurred on 03/20/14. This policy, revised October 1999, stated, "PURPOSE: 1. To provide proper documentation of incidents/accidents that occur to residents, regardless if of (sic) known or unknown origin 2. To provide information for the Safety Committee, All CQI (Continuous Quality Improvement) committees, Nursing Administration, and Administrator . . . 4. To enhance the quality of resident care and to assist in providing a safe environment for that care. PROCEDURE: When an incident or accident occurs . . . to residents . . . the appropriate forms must be completed. An event is defined as 'an event is any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. It might be an accident or a situation which may result in an injury. . .' Complete investigation of how incident occurred. Complete corrective action taken for resident and interventions put into place to prevent reoccurrence of incident . . ." Review of the facility policy titled "Fall Assessment Program" occurred on 03/20/14. This policy, revised 05/10/11, stated, ". . . If a fall occurs, a Fall Event is completed prior to the end of the shift on which it occurred. . . . Nursing refers this resident to the restraint team and or fall committee for further evaluation and interventions. . . ." - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's current Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment, and extensive assistance from one person for transfers, ambulation, and locomotion. Observations throughout the survey showed Resident #5 ambulated to and from meals with a walker and assistance from one staff person with a gait belt. The resident used a wheelchair for longer distances. Nurses' notes identified the following: *05/03/13 at 6:59 p.m.: ". . . Resident c/o (complains of) elbow pain this am (morning) when nurse arrived at 0630 (6:30 a.m.). . . . When resident was seen by (provider name) mid morning for the elbow pain she told her she hit it against the wall. When CNA (certified nursing assistant) went to get resident for supper she stated she had fallen and hurt her elbow. Resident said she fell early this afternoon and that is how she hurt her elbow. Unsure if resident fell or not, will continue to monitor. . . ." *05/06/13 at 3:01 p.m.: ". . . Resident fall event occurred at 12:10 today. Resident not out to lunch, when checked on, room door closed and upon opening it, resident appears very distressed facially & is confused in manner & movement. States 'I just fell and hurt my arm.' . . . cannot recall specifically how she fell . . . Stated, 'I just went down'. . . . Ambulated to dining room (with) gait belt, 1 staff assist d/t (due to) visibly shaken by event. . . ." *05/08/13 9:49 a.m.: ". . . Fall Comm (committee) Rev (review): Discussion of unwitnessed resident reported fall event on 5-6-13. Nurse from 5-3-13, reports resident stated the (sic) had fallen and hurt her arm on Friday 5-3. Staff continue to monitor her behavior for increased confusional episodes noted at the time of this event. . . ." *07/20/13 at 4:30 p.m.: ". . . Received call from CNA that resident had fell (sic)in the elevator, resident was observed on elevator floor laying on her left side, with head near the wall, resident is crying and would not let treatment nurse touch her left leg. Resident was holding onto railing to help relieve (sic) pressure on the hip. Refusing to roll to her back, noted no shortening of the leg but unusual positioning of the leg and internal rotation. . . ." *07/20/13 at 5:42 p.m.: ". . . (Resident #5) was found lying in the elevator on the floor and then son . . . notified . . . (physician name) . . . called @ 1640 (4:40 p.m.) and orders received to send resident to ER (emergency room ). . . ." *07/20/13 at 7:29 p.m.: ". . . Called placed to (hospital name) and resident was sent to (room number) and admitted with left hip fracture. . . ." *07/22/13 at 10:27 a.m.: ". . . Fall Comm (committee) Review: Resident fall reviewed by comm members. Resident had fractured L (left) hip and had hip repair surgery on 7-21-13. Resident remains in the hospital for post-operative care at this time. . . ." The MDS dated [DATE] (effective at the time of Resident #5's fall) identified severe cognitive impairment, a previous fall with an injury, and supervision required for transfers, ambulation, and locomotion. Resident #5's care plan (in effect at the the time of the fall with a hip fracture) stated, ". . . Problem (created 04/12/13) . . . High risk for falls related to Dx (diagnosis) of Osteoarthritis, Osteoporosis, Foot Drop & Gout. . . . Goal . . . Minimize frequency of falls and decrease severity of injury if falls occur. . . . Protect from falls with assist of 1, gait belt; by intervening if resident has periods of unsteadiness or weakness. . . . Problem . . . Unable/able to complete own cares due to: Dx (diagnosis) of Alzheimer's Dis (disease) . . . Osteoporosis, Osteoarthrosis . . . Approach . . . Transfers: (created 04/11/13) Per PT/OT (physical therapy/occupational therapy) resident is able to transfer independently with FWW & stand-by directional assistance by staff . . . Locomotion: (created 04/11/13) Locomotion in the hallway, to dining room & off unit independently with FWW. staff directional assistance of 1 may be required PRN . . ." Resident #5's fall risk assessment, dated 04/03/13, identified a final score of 19 (any number over 10 indicated a high risk for falls). The fall risk assessment dated [DATE] identified a final score of 21 (indicating an increased fall risk since the prior assessment). When asked to see the facility's investigation into the fall that occurred on 07/20/13, the facility provided an incident report. The report contained a copy of the nurses' note dated 07/20/13 and the following entry: ". . . Resident Outcome . . . Additional hospitalization . . . Fall Comm. (committee) Rev (review): Resident sent to hosp (hospital); had surgery for [REDACTED]. . . ." The report also identified the fall was a discovered fall, it occurred on the floor of the elevator when the resident was ambulating, the resident was alert, received an injury, and had a fall risk score of 21. Staff failed to record further documentation regarding this incident. A Fall Event Report, recorded 07/22/13 (two days after the fall occurred), stated, ". . . Description . . . Fall in elevator causing unusual positioning of leg & internal rotation of L (left) leg. . . . Evaluation notes . . . Resident placed in hospital post event with Fx hip. Treatment program completed (with) no additional interventions required at this time. . . ." The remainder of the event report was not completed by the staff, except a set a vital signs which were dated 09/03/13 at 10:29 p.m. (over a month after the fall) During an interview on the morning of 03/20/14, a supervisory nurse (#6) stated the incident report is the facility's investigation. Both the incident report and the fall event report lacked further investigation as to how the event occurred (including interviews with staff and any monitoring of Resident #5's whereabouts prior to the fall), corrective action taken for the the resident, and any recommendations from the fall committee to prevent reoccurrence of this type of incident. During an interview on 03/18/14 at 4:40 p.m., a nurse (#5) stated staff did not witness Resident #5's fall on 07/20/13, and a CNA found the resident in the elevator. The nurse thought Resident #5 was downstairs playing cards in the main event room, but was unsure. Review of the activity calendars for this day identified no events scheduled in the main event room. The nurse further stated staff allowed Resident #5 to go in the elevator unsupervised, as she was independent. During an interview on 03/19/14 at 4:27 p.m., a supervisory nurse (#6) stated a CNA heard Resident #5 yelling from inside the elevator. The nurse was unsure how long or why the resident was in the elevator. She stated staff did not monitor Resident #5's whereabouts as she was "independent." The facility staff allowed Resident #5 to ambulate unsupervised throughout the facility. Resident #5 required supervision with transfers and ambulation, experienced two falls (05/03/13 and 05/06/13; one with an injury) prior to the fall with a hip fracture in July, and had severe cognitive impairment. The resident's care plan contained contradictory interventions addressing transfers and ambulation. Although record review identified Resident #5 reported two falls prior to her fall on 07/20/13; the facility failed to attempt additional interventions or re-evaluate the level of assistance/supervision required in order to prevent future falls. The facility staff failed to thoroughly investigate the circumstances surrounding Resident #5's fall, which limited their ability to determine causative factors and implement corrective actions to prevent future occurrences for this resident as well as other residents. Although the resident experienced falls in her room and the facility's fall risk assessment showed Resident #5's risk for falling had increased, staff failed to implement appropriate supervision/staff assistance necessary to prevent future falls. As a result, Resident #5 experienced an unwitnessed fall in the elevator with a subsequent hip fracture and deterioration in her ability to perform activities of daily living. - Review of Resident #17's medical record occurred on March 19-20, 2014. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified severe cognitive impairment, extensive assistance from two or more people for transfers, and two or more falls without injury. Resident #17's care plan stated, ". . . Transfers: (created 09/25/13) with 1-2, gait belt and pivot transfer to Rt (right) lower extremity. Resident self transfers frequently with hx (history) of falls. . . . Ambulation: (created 06/19/09) Resident ambulates with restorative therapy. Brace for Left leg/kept in restorative therapy. . . ." Resident #17's fall risk assessment, dated 12/18/13, identified a score of 20 (indicating high risk). The next assessment, dated 03/19/14, identified a score of 24 (indicating an increased risk for falls since the prior assessment). Observation on 03/19/14 at 5:05 p.m. showed a CNA (#7) assisted Resident #17 to stand from her wheelchair and pivot to the toilet. The resident's knees buckled, and the CNA stated, "I need you to stand tall." The resident stated, "I don't have that brace on my leg," and "I usually wear it, see, and when I don't my leg just gives out." The CNA responded, "They haven't had you wear that lately." Resident #17's nurses' notes stated the following: *12/24/13 at 9:30 p.m.: ". . . Resident lowered to floor by CNA, while resident was attempting to transfer to toilet from wheelchair. . . . Resident started to slide down on chair and CNA lowered to floor. . . ." *02/01/14 at 12:20 p.m.: ". . . Called to resident's room by CNA with report of fall. Nurse found resident sitting on floor with CNA behind her; gaitbelt in place . . . When lifted to standing position with assist of 3, no injuries or bruising noted . . . CNA reported that resident was assisted to floor after wheelchair moved away from resident while in the locked position and she was attempting to sit down after toileting. Maintenance called and was here to fix floose (sic) brake. . . ." *03/07/14 at 7:15 p.m.: ". . . CNA was walking resident to the bathroom. Resident lost her balance and CNA lowered her to the ground. . . ." Fall event reports for the above falls stated: *Recorded on 12/24/13 at 11:57 p.m.: ". . . Evaluation notes: Fall committee reviewed. . . ." *Recorded on 02/01/14 at 2:47 p.m.: ". . . Evaluation notes: Brakes repaired by maintenance staff. No further interventions required at this time. Re-check by Maintenance staff on 2-3-14. . . ." *Recorded on 03/07/14 at 7:16 p.m.: ". . . Evaluation notes: Staff educated and resident's walker put in closet. . . ." Record review identified Resident #17's most recent PT evaluation occurred on 12/18/12 and her most recent OT evaluation occurred on 07/18/12. Resident #17 experienced three falls in less than three months with staff "assisting" her to the floor; however, staff failed to re-evaluate the level of assistance Resident #17 required and failed to implement interventions in an attempt to prevent future falls. Resident #17 continued to be a 1-2 staff assist for transfers, although she had three falls (which required her to be "assisted" to the floor) with 1 staff member present. Observation on 03/19/14 showed Resident #17 was unsteady during the transfer, and only 1 staff person assisted her. During an interview on 03/20/14 at 1:38 p.m., a supervisory nurse (#6) stated (regarding Resident #17's fall on 03/07/14) the CNA did not follow Resident #17's care plan, as the resident is only supposed to ambulate with restorative therapy. - Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified severe cognitive impairment, extensive assistance from two or more people for transfers, and two or more falls without injury. Resident #2's previous care plan (in effect at the time of her falls) stated, ". . . Transfers: (created 11/07/13) Staff transfer with assist of 1-2, gait belt, FWW, platform walker by positioning it in front of (Resident #2) . . . Wheelchair for long distance transport . . . Ambulation: (created 11/07/13) Assistance from 1-2 staff daily & prn -- ambulates with FWW or platform walker & gait belt. Resident to walk to all meals (with) 1-2 assist. 2 when resident is weakened or having problems (with) stepping through. . . ." Resident #2's fall risk report, dated 01/24/14, identified a score of 21 (indicating a high risk for falls). A PT screen, dated 12/09/13, stated, ". . . Nursing staff questioning safety (with) amb. (ambulation)/transfers. State she (Resident #2) is hardly able to stand when meds (medications) needed to reduce behaviors. Observed resident transfer (with) staff from toilet (and) amb. to chair (with) FWW. Also, (with) platform walker from dining room. Resident required cueing to avoid side sitting into chair. . . . Recommendations: Cue resident to make full turn when moving to sit. Use PAL when resident is not cognitively able to perform pivot transfers/amb. prn. . . ." Nurses' notes identified the following: *11/05/13 at 1:20 p.m.: ". . . Resident out to lunch and returned to room (with) staff, gait belt & platform walker. Taken to BR and after toileting, when stepping through to turn around in front of her recliner, her shuffling gait caused her to lose her balance and fall to the floor on her L side. Calling out repeatedly, 'Get me up, Get me up.' . . . 3 staff and Hoyer lift (a full-body mechanical lift) used to mechanically lift her up into her recliner chair. . . ." *11/20/13 at 6:30 p.m.: ". . . Resident walking in hallway with CNA, she was attempting to sit down saying, 'I can't go any farther.' several attempts made at encouraging her to continue walking but she sat on my thigh as we put a chair under her. . . ." *11/23/13 at 1:34 p.m.: ". . . Resident was refusing to stand up to go to her room from the dining room chair. Two staff members were needed to stand her up and to walk with her back to her room due to weakness and shuffling of her feet. . . ." *11/26/13 at 9:00 a.m.: ". . . CNA's reporting resident having increased difficulty walking in room and to dining room; also reporting very difficult to stand needed 3 people to assist her to stand walk for breakfast; needed WC (wheelchair) . . ." *11/29/13 at 5:55 p.m.: ". . . Resident walked to the dining room about half way each time. Posture is poor and resident is shuffling feet. . . ." *12/19/13 at 8:15 p.m.: ". . . Resident was ambulating to bathroom, 'Catch me' her knees started to buckle and her walker tipped to the side. CNA guided to floor. . . ." *12/19/13 at 9:13 p.m.: ". . . CNA's report that when taking resident to bathroom; she stated, 'get me in there quickly or I'm falling to the floor on you.' CNA's requested to use at least two staff for all transfers and ambulation until further instruction. . . ." *12/20/13 at 1:50 p.m.: ". . . Fall Comm Rev: Discussion of fall event (with) committee members. When resident has weakness, she is careplanned for two to assist (with) transfers. Will continue to monitor. . . ." Fall Event Reports for Resident #2's falls identified the following: *Recorded on 11/05/13 at 1:21 p.m.: ". . . Description: Resident fell to ground while transferring with a CNA . . . Notes: . . . 11/6/2013 09:47 (a.m.) Fall Comm Rev: Resident has increased fall risk d/t increased weakness at times & greater inability to correct positioning (with) pivot turning d/t shuffling gait. Consideration given to walking (with) 2 staff during times of weakness. . . ." *Recorded on 12/19/13 at 8:09 p.m.: ". . . Description: Resident assisted to floor in bathroom . . . Evaluation: fall committee reviewed . . ." *Recorded on 01/24/14 at 3:16 p.m.: ". . . Description: JFall (sic) in resident's room. No injuries at 1400 (2:00 p.m.) . . . What was resident doing just prior to fall? walking with FWW and 1 assist to her WC from recliner. . . . Notes: . . . Called to resident's room with reports of fall; assessed resident- noted she was on floor lying on her right side beside the bed and recliner . . . assisted to recliner via hoyer and assist of 3 . . . CNA reported, She was starting to walk to wc and sat down too soon and missed her chair. Resident was assisted to the floor and gaitbelt was on. . . ." Although nurses' notes and a PT evaluation identified Resident #2's increasing difficulty with transfers and ambulation, the facility failed to implement additional interventions in an attempt to prevent future falls. The facility allowed Resident #2 to remain a 1-2 person transfer (as per the CNA's discretion) even after she experienced two falls with 1 staff person assisting her. Failure to implement additional interventions/re-evaluate the level of care that Resident #2 required may have resulted in avoidable falls and injuries. During an interview on the morning of 03/20/14, a supervisory nurse (#2) agreed CNAs should not be responsible to assess whether Resident #2 and Resident #17 need 1 or 2 staff members for transfers. - Record review for Resident #15 occurred on March 19-20, 2014. The care plan problem addressing activities of daily living (ADLs) contained an approach for toileting, dated 01/20/14, which stated, ". . .May ambulate to the BR with hand hold and assist of 2 staff." Resident Progress Notes identified the following: * 02/26/14 at 12:09 a.m. "Resident ambulated to toilet with assist of one. CNA required assistance to get resident off toilet to bed due to weakness and resident unable to hold self up and walk at the same time. . . ." * 03/07/14 at 2:46 p.m., Stated, "CNA walking him to BR using a gait belt, and trying to get him to turn to sit on the toilet, when his knees gave out. She tried to hold resident up but did lower him to the floor. . . ." Failure to follow the care plan of using two staff to assist Resident #15 to the bathroom, placed the resident at a greater risk of falling, injury, or pain. 2. Based on record review and staff interview, the facility failed to evaluate and analyze the hazards and risks associated with 1 of 1 sampled resident (Resident #16) with a history of being found in a stairwell and identified as an elopement risk. Failure to evaluate and analyze the conditions resulting in Resident #16 wandering into unsafe/unsupervised areas (a stairwell in this multi-story facility) placed Resident #16 and other wandering residents at risk for severe injury/harm. Findings include: Review of Resident #16's medical record occurred on March 19-20, 2014. The facility admitted Resident #16 in November, 2013. Resident #16's [DIAGNOSES REDACTED]. Review of Resident #16's Care Plan, dated 12/19/13, stated ". . . At risk for elopement . . . ." Review of a Progress Note dated 01/24/2014 at 3:23 p.m., stated, "Resident found in north unit stairwell when (name of staff registered nurse) and (name of staff licensed practical nurse) entered stairwell this p.m. (at) approximately (2:00 p.m.). Resident returned to unit by these nurses. Administrator notified. Resident has been seen standing at the door trying the latches several times today. . . ." The facility revised Resident #16's Care Plan following this incident. During interview on 03/20/14 at 8:46 a.m., an administrative nurse (#2) stated the facility did not complete an incident report following Resident #16 being found in the 2nd floor stairwell. When asked what circumstances led to Resident #16's ability to access the stairwell unattended, the duration of time Resident #16 was in the stairwell without supervision, and other environmental factors (door to stairwell not properly latched, alarm on stairwell door malfunctioned) which may have contributed to this incident, this administrative staff member stated the facility changed the code to the stairwell door immediately following the incident. On 03/20/14 at 11:10 a.m., the surveyor requested additional information to ensure the facility thoroughly investigated the potential causes for Resident #16's unsupervised access to the stairwell and what systemic changes were considered and/or implemented in response to this incident. Administrative staff members (#8, #2, #6, and #9) provided a hand-written note from the 01/27/14 "Daily Stand-Up" meeting (a facility wide meeting held to discuss concerns from the previous day) which stated, "(Resident #16's name) was in staircase (stairwell) - she knew code? follow someone in there?" This note failed to ensure the facility thoroughly investigated and analyzed the stairwell incident involving Resident #16 and, if indicated, implemented systemic corrective actions to ensure the safety of all wandering residents who have the potential to gain unsupervised access to the facility's stairwells.