Every finding on record at Sweet Memorial Nursing Home

Based on observation, interview, and record review, the facility failed to routinely monitor and document a resident's weight in the resident's record, failed to ensure comprehensive quarterly nutritional assessments were completed timely to analyze and evaluate related factors for a severe weight loss, and failed to revise a residents care plan to prevent an avoidable weight loss for 2 (#s 15 and 20) of 20 residents sampled. Resident #15 had a severe 9.75% weight loss in the last three months, and 17% in the last six months. Resident #20 had a severe 6% weight loss in 29 days, and a severe 8% weight loss of her body weight in 92 days. This deficient practice had the potential to affect all residents at risk for nutritional deficit. Findings include:1. During an observation on 1/27/26 at 8:44 a.m., resident #15 was sleeping in bed during breakfast. During an observation on 1/27/26 at 9:23 a.m., resident #15 was sitting on a dining chair along the wall by the nurses' station. Her dentures were notably oversized in her mouth when trying to speak. During an interview on 1/28/26 at 11:53 a.m., staff member B stated that the facility management had recently begun monitoring weight loss in the weekly care plan meetings. Staff member B stated resident #15 was not noted to have a current weight loss, so she was not on the IDT lists for monitoring and interventions. During an interview on 1/28/26 at 3:27 p.m., staff member B brought in documents for resident #15 explaining in late 2024 she was placed on small portions by the provider due to weight gain up to 214 pounds, believed to have been from a psychotropic medication she had been on. Staff member B explained they asked to put her back on regular portions, but the provider denied to order it and ordered a supplement if the resident refused to eat a meal. During an interview on 1/28/26 at 3:52 p.m., staff member L stated the facility had two dieticians who rotated coming onsite monthly. Staff member L stated she would prepare a list of residents due for each dietician to review for regular assessments, weight changes, or difficulties eating. Staff member L stated that for any changes, the dieticians would give her a written recommendation to give to the provider to review and order what they determined was needed. The dieticians had access to the EHR offsite. Staff member L stated resident #15's family wanted her to lose weight after she had gained a lot of weight and would not get out of bed all day, so the provider placed her on small portions. During an interview on 1/29/26 at 11:16 a.m., staff member H stated that staff member L would provide her with a resident list for her visits, which were rotated monthly with another dietician. Staff member H stated they followed the care plan calendar for nutritional assessments, and if she had a recommendation, it would be written and given to the provider to write an order if they agreed. Staff member H stated that due to the limited onsite visits, she did not see the residents to do the evaluations and did not meet with the provider or participate in the facility IDT meetings. Staff member H stated neither dietician did care planning for the residents' nutritional needs. Staff member H stated that she been at the facility earlier in the month but could not recall resident #15 or any concerns with the resident. Review of resident #15's EHR weights, in pounds, for August 2025 to January 2026, showed a 17% weight loss in the last six months, with a 9.75% weight loss in the last three months. The weights in the medical record showed: - 8/4/25, 174.0 - 8/11/25, 173.0 - 8/18/25, 169.0 - 8/25/25, 170.0 - 9/1/25, 168.5 - 9/15/25, 168.5 - 10/6/25, 162.5 - 10/13/25, 159.5 - 10/27/25, 161.5 - 11/3/25, 159.5 - 11/24/25, 154.5 - 12/1/25, 156.0 - 12/15/25, 153.0 - 12/22/25, 154.0 - 12/29/25, 150.0 - 1/12/26, 150.5 - 1/19/26, 143.5 Review of resident #15's diet orders showed she had a regular diet with small portions. A supplement was to be offered if she did not eat a meal. Review of resident #15's Mini Nutritional Assessment, completed on 11/24/25, showed she was at risk of malnutrition. Review of resident #15's dietician written recommendation on 11/18/25 showed, 4 oz. supplement of choice TID at meals D/T significant weight loss of 14lbs over past quarter. Review of resident #15's Care Plan, last updated 6/5/25, showed a focus area for unplanned/unexpected weight loss due to sleeping and refusing to get out of bed, and there was a goal of maintaining a weight of 169 pounds through the 6/2/26 review. 2. During an observation on 1/27/26 at 2:00 p.m., resident #20 came out of her room and sat in a chair by her bedroom. The resident's face and arms appeared thin and gaunt and were prominent through her skin. During an observation and interview on 1/28/26 at 10:51 a.m., resident #20 was walking down the hallway with staff member Q. The resident stated she had not had breakfast. The resident was offered a sandwich and a cola, but was not offered a nutritional supplement. Review of resident #20's weights from 9/10/25 to 1/28/26 showed the resident weighed 108 pounds on 9/10/25 and 99 pounds on 12/10/25. The resident had an 8% weight loss of her body weight in 92 days. On 12/3/25, the resident weighed 106 pounds, and on 12/31/25, the resident weighed 99 pounds. The resident lost 6% of her body weight in 29 days. Both were severe weight losses. a. Monitoring Review of resident #20's weights from 9/10/25 to 1/29/26, showed: - 9/10/25: 108.7 lbs. - 10/1/25: 102.5 lbs. - 10/8/25: 109.5 lbs. - 10/15/25: 107.0 lbs. - 11/19/25: 108.5 lbs. - 12/3/25: 106 lbs. - 12/10/25: 99 lbs. - 12/18/25: 103.5 lbs. - 12/31/25: 99.5 lbs. Weights were not obtained or documented weekly in September and November 2025, and there were no documented weights from 12/31/25 to 1/28/26. Review of resident #20's Dietitian Weight Graph document showed one weight recorded for September, which was on 9/10/25 for 108.7 pounds. No additional comments were noted about the missing weekly weights in September. For October, three weights were recorded on 10/1/25 for 102 pounds, 10/8/25 for 109 pounds, and 10/15/25 for 107 pounds. For 10/22/25 and 10/29/25, there was no weight' for those dates. For November, one weight was documented on 11/19/25 for 108 pounds. There were no weights documented for 11/5/25, 11/12/25, and 11/26/25. For December, one weight was documented for 12/3/25 for 106 pounds. There were no other weights or notes documented on the Weight Graph after 12/3/25. Review of resident #20's Provider Progress Note, titled, Dietary Consultation, dated 10/7/25, showed, The dietitian notes 'offer highest calorie supplement available.' She recommended that we add higher calorie foods to her foods and beverages such as heavy whipping cream and extra butter. [Resident #20] has been noted to have weight loss '11.2% in six months with BMI of 18.' This has been known since her fall and hip fracture. She is actually doing better with regard to her hip fracture, however. She is able to ambulate around and is less frustrated by life in general, it seems. Review of resident #20's Provider Progress Note, dated 12/30/25, showed, . [Resident #20] has not wanted to eat recently. She says today that she is not hungry and tears down a peanut butter and jelly sandwich. Staff noted she did not want to get up for breakfast. The assessment and Plan did not address the resident's weight loss. A review of the Provider Progress Notes, from 10/7/25 to 1/28/26, did not show any additional information for resident #20's severe weight loss in December 2025. b. Nutritional Assessments Review of resident #20's comprehensive Annual Nutrition Assessment, dated 8/2/25, showed, admit date : [DATE]. [height]: 65 [inches] Current weight: 115 [pounds on] 7/28, 6/23: 119 [pounds] [Ideal body weight]: 125 [pounds] (92%) Admit weight: 116 [pounds] and [Body Mass Index] 19. Current diet order: regular with supplement of choice between meals/bedtime. Extra butter/cream to appropriate foods. Meal intakes: 0-100%, needs supervision. Drinking 60-240 cc of supplement. Resident is at high nutritional risk due to dementia and recent fall with fractures. Weight is down 4 pounds in a month or 3%. [Body mass index] is low/normal range. Recommend supplement of choice [three times a day] with meals as well due to resident's new hip/wrist fracture. She does seem to like the supplements most of the time. [sic] Review of resident #20's Quarterly Mini Nutritional Assessment, dated 9/26/25, showed the resident's weight on 9/10/25 was 108 pounds. The resident had a moderate decrease in food intake, with a weight loss greater than 6.6 pounds over the last three months, and a BMI of less than 19. The evaluation showed the resident was malnourished with a score of 3. Review of resident #20's comprehensive Nutritional Quarterly Review note, dated 9/30/25, showed Resident eats independently. Meal intake: usually 76-100%. Diet order: regular diet with ground meat texture. Orders also include Ensure with meals and [bedtime]. Weight: 108.7# BMI 18. August weight 108.5 [pounds] March weight: 122.5 [pounds] Weight loss of 11.2% in 6 months is significant. Weight loss and BMI of 18 places patient at increased nutritional risk. Recommend offer highest calorie supplement available. Add extra butter / heavy whipping cream to appropriate foods/beverages. Review of resident #20's Quarterly Mini Nutritional assessment dated [DATE], showed the resident's weight on 12/18/25 was 103 pounds. The resident had a moderate decrease in food intake, with a weight loss between 2.2 and 6.6 pounds in the last 3 months, and a BMI of less than 19. The evaluation showed the resident was malnourished with a score of 5. A review of resident #20's electronic and paper medical record did not show any further comprehensive quarterly nutritional assessments were completed after 9/30/25, besides the mini nutritional assessment on 12/22/25. On 1/28/26 at 3:30 p.m., a document request for dietary evaluations and/or assessments, including IDT notes for weight loss in the last six months, was provided to the facility. No further nutritional assessments or evaluations by the dietitians after 9/30/25 were provided by the facility by the end of the survey, 1/29/26. The facility failed to provide a nutritional assessment completed by the dietitian for resident #20 in December 2025 and or January 2026 to analyze and evaluate related factors for the severe weight loss in one month. c. Care Plan Revision Review of resident #20's Care Plan, with an initiation date of 9/27/24, and a revision date of 12/5/25, showed: Focus: The resident had unplanned/unexpected weight loss related to poor food intake after her recent pelvic and wrist fracture, and the weight loss was an ongoing problem. Goal: The resident will consume 100 percent of two of three meals/day, which was initiated on 9/27/24 and revised on 9/27/24. The resident's weight was also to return to the baseline weight range between 125 and 130 pounds by the review date. This goal was initiated on 9/27/24, with a revision on 8/1/25. The Interventions/Tasks showed the following for resident #20: - Current weight is 103 pounds. Date Initiated: 09/27/24 Revision on: 10/2/25. - Dietician will evaluate resident 8/2/25. Date Initiated: 8/1/25. - High calorie supplement after meals and at bedtime. Date Initiated: 12/5/25. - If weight decline persists, contact physician and dietician immediately. Date Initiated: 9/27/24. - Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Date Initiated: 9/27/24. - Monitor and record food intake at each meal. Date Initiated: 9/27/24. - Offer snacks between meals. Date Initiated: 8/1/2025. - Regular diet Date Initiated: 3/27/25. - Resident needs her meats mechanically altered. Date Initiated: 10/2/25. - Supplement of choice if resident skips a meal, add extra butter and heavy whipping cream to appropriate foods. Date Initiated: 11/6/24. Revision on: 3/27/25 - Weigh at same time of day and record: morning before breakfast once a week. Date Initiated: 9/27/24. During an interview on 1/28/26 at 11:39 a.m., staff member B stated that the dietitians review the residents for weight loss based on the list provided to them every month. After they complete the assessments, they provide staff member L with any recommendations or interventions, and staff member L notifies the provider of any order changes. Staff member B stated that staff member L would complete any care plan updates recommended by the dietitians. She stated that weight losses were monitored during the monthly care plan meetings. She stated the dietitians did not attend the care plan meetings. During an interview on 1/28/26 at 12:08 p.m., staff member L stated there were two dietitians who visited the facility once a month, and they rotate between them every other month. She stated that she would prepare a list of residents for the dietitians to review each month. She stated she had a book in which she tracks information on residents regarding weight changes. Staff member L stated that once the dietitians were done with their evaluations, if they had any recommendations, she would take those to the provider for orders. She stated she was not sure why resident #20 was not reviewed for a nutritional assessment by the dietitians for December 2025 or January 2026, other than she did not show as nutrition at risk. During an interview on 1/28/26 at 3:41 p.m., staff member B stated resident #20's weight had been stable, and the (EHR) system did not flag the resident for nutrition at risk. She stated every resident should be weighed weekly and the weights should be documented in the EHR. Staff member B stated she had asked staff member M about weights for resident #20 and was told by staff member M that he had seen resident #20 being weighed by the aide last week, but did not know why it was not documented in the resident's chart. Staff member B also stated they had two registered dietitians who rotated every other month, so one dietitian was at the facility each month. Staff member B said it was the expectation for the annual nutritional assessments to be completed yearly by the dietitians, and the quarterly nutritional assessments were to be completed by the dietitians at least every three months. She stated she was not certain why resident #20 did not have a comprehensive nutritional assessment by a dietitian in either December 2025 or January 2026. She stated that staff member H visited the facility in both December and January. Staff member B stated they have IDT meetings weekly and stated they discuss resident #20's nutritional concerns at those meetings, stating resident #20's weight had been stable. During an interview on 1/29/26 at 11:15 a.m., staff member H stated she had been to the facility once in December 2025 and again in January 2026. She stated she came once a month to complete nutritional reviews of residents. She stated that staff member L compiles the list of residents to be reviewed each month. Staff member H stated they completed annual and quarterly nutritional assessments for residents based on the information provided to them by staff member L. She stated she did not communicate directly with the provider. She stated after an assessment that if she had any recommendations, she would inform staff member L who would then notify the provider to obtain any physician order changes. She stated she did not write dietary orders. Staff member H stated she did not call to speak with the resident's family members regarding weight loss concerns, but would discuss any concerns if the family member was at the facility. She stated if she had any concerns regarding a resident, she would speak with staff member H, stating staff member L usually had a good idea what was going on with each resident, and would also review resident notes for information regarding the resident. She stated staff member L would notify her if there were any issues or concerns regarding a resident's nutritional status. Staff member H stated if a significant weight loss was identified, she would review a resident's percentage of weight lost in one, three, and six months and make recommendations and suggest interventions based on the weight loss. She stated she monitored the resident's weights based on her communication with staff member L and then reviewed weights in the EHR. She stated she reviewed resident weights at least monthly, and if recent weights were not available, she would request the resident be reweighed as soon as possible. She stated she could not say if she reviewed resident #20's weight loss in December 2025 or January 2026 without looking at their EHR, and she did not have access at that time to review the information. Staff member H stated she did not attend the facility IDT meeting, the Nutrition at Risk meeting, any resident care conferences, or QAPI meetings. She stated she did not complete any care plan updates; those were completed by staff member L. Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, last revised 9/2017, showed: 3.a. Dietary restrictions are not always essential, and they may even be unnecessary or harmful. In some instances the risk of continued weight loss and hydration deficits may outweigh other considerations that such restrictions are meant to address. Monitoring 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example additional weight gain or loss. 2. When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident/patient's responses.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans for the use side rails for 2 (#4 and #8); failed to comprehensively care plan the use of enhanced barrier precautions for 1 (#7); and failed to implement care plan interventions to address an identified weight loss 1 (#6) of 20 sampled residents. The deficient practices increased the risk of negatively impacting the residents' quality of life. Findings include:1. During an observation on 1/26/26 at 4:20 p.m., a side rail was observed on the right side of resident #4's bed.Review of resident #4's comprehensive care plan, with an admission date of 9/11/25, failed to identify the use of side rails or include any related interventions, risks, or monitoring.2. During an observation on 1/26/26 at 4:19 p.m., two side rails were observed on resident #8's bed.Review of resident #8's comprehensive care plan, with an admission date of 10/16/25, failed to identify the use of side rails or include any related interventions, risks, or monitoring.During an interview on 1/28/26 at 11:44 a.m., staff member B said the use of side rails required a physician's order and side rails should be on the resident's care plan.3. During an observation and interview on 1/27/26 at 12:03 p.m., no personal protective equipment supplies or signage indicating infection control precautions were observed outside or inside resident #7's room. Resident #7 stated he did have a catheter in place.Review of resident #7's comprehensive care plan, with an admission date of 12/22/14, failed to identify the need for enhanced barrier precautions related to catheter use.During an interview on 1/29/26 at 10:50 a.m., staff member F stated that the use of enhanced barrier precautions should have been reflected on a resident's care plan.4. During an interview on 1/27/26 at 9:27 a.m., NF1 said he had a concern related to resident #6's intake and ongoing weight loss. NF1 stated he communicated these concerns to facility staff and requested that a nutritional supplement be provided to address the weight loss.During an interview on 1/28/26 at 10:52 a.m., staff member M stated that the kitchen distributed supplements and charted the intakes.During an interview on 1/28/26 at 11:29 a.m., staff member J said she was just informed of the physician's order for resident #6's supplement and revealed that before today, they were unaware she had an order for a supplement, and the resident had not been receiving the supplement.Review of resident #6's EHR revealed a nutrition/dietary progress note, dated 9/30/25, that documented the resident had experienced weight loss. The progress notes further showed NF1 requested a protein supplement due to the noted weight loss. The kitchen was made aware of the supplement, and supplements were to be implemented, with a recommendation to offer the highest-calorie supplement.Review of resident #6's physician orders showed, Dietary recommendations: Offer highest calorie supplement available, revised on 10/7/25.Review of resident #6's comprehensive care plan with an admission date of 11/15/15 showed, .Focus: The resident has nutritional problem or potential nutritional problem, history of obesity with weight loss. Resident has had an unplanned weight loss. Revision on: 5/2/24. Goal: The resident will not lose any more weight .Resident will return to 165 pounds as her goal weight, Revision on 5/2/24.Interventions/Tasks: .offer highest calorie supplement. Date Initiated: 12/5/25.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, not dated, showed, Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure a Medication Aide II (MAII) in training had direct supervision of a licensed nurse while passing medications; and failed to ensure staff administered medications following the professional standards of medication administration rights for 3 (#s 1, 10 and 31) of 20 residents sampled. This deficient practice increased the risk of medication administration errors. Findings include: 1. Medication Aide II CertificationDuring an interview on 1/28/26 at 8:23 a.m., staff member N stated she was currently a CNA and had completed an online course for MAII. She stated she had not yet completed the test to be a MAII and was not yet certified.During an interview on 1/28/26 at 10:35 a.m., staff member N stated staff member M was the supervising nurse that day while she completed the medication pass. She stated she was allowed to administer medications without the direct supervision of a licensed nurse. Staff member N stated she was not sure exactly where staff member M was, stating, He could be anywhere at this point.During an interview on 1/28/26 at 10:39 a.m., staff member M stated he was the charge nurse for the day and would try to make himself available should staff member N need any assistance with their medication pass. He stated he was not given any direction on the need for direct supervision of staff member N.During an interview on 1/28/26 at 11:39 a.m., staff member B stated staff member N was currently in training for the MAII certification. She stated that while an aide was enrolled in the MAII curriculum, a nurse needed to be there to supervise them, but it was not necessary to stand over them while they completed their medication pass. Staff member B stated staff member N had not yet taken and/or passed the certifying test for the MAII certification.A facility document request for staff member N's Medication Aide II Certification was requested on 1/28/26 at 11:20 a.m. The document was not provided by the end of the survey.During an interview on 1/28/26 at 2:00 p.m., staff member A stated staff member N did not have a current MAII certification and was scheduled to take the certification testing on 1/29/26.2. Professional Standards of Medication AdministrationDuring an observation and interview on 1/28/26 at 8:23 a.m., staff member N poured a powder medication of MiraLAX in a small medication cup for resident #10. Staff member N then poured the powder medication into the resident's gray plastic drinking mug which was sitting on the resident's bedside table. She then stirred it with a straw and replaced the gray plastic lid. Staff member N stated the water mug was about one third of the way full of water. She could not state how much water in ounces was in the water mug1. Staff member N stated she would mix resident's MiraLAX in a resident's water mug or other beverage, stating, it's the best place to put it. Staff member N stated she would return every so often to make sure the resident had finished drinking the MiraLAX.During an observation on 1/28/26 at 8:44 a.m., staff member N entered the dining room during the breakfast meal. She poured a white powdered medication into resident #1's red colored juice and mixed in the medicated powder. Staff member N left the dining room and did not complete observing resident #1 to determine if she finished drinking all of the juice the white powdered medication was mixed in. During an observation and interview on 1/28/26 at 9:03 a.m., staff member N poured a white powdered medication into resident #31's honey thickened orange juice and stirred it. The honey thickened orange juice became thicker to the consistency of pudding. A bottle of Thick-it was on the dining room table. Staff member N stated she gave resident #31 his MiraLAX in the orange juice. She stated the MiraLAX can sometimes make a drink thicker. Staff member N left the dining room and did not ensure resident #31 finished drinking all the orange juice the MiraLAX was mixed in. During an interview on 1/28/26 at 10:39 a.m., staff member M stated MiraLAX could be mixed into water or juice and should usually be mixed with and administered with eight ounces of fluid. Staff member M stated it was important to ensure a resident completed medications before leaving. Staff member N stated the water mugs in the resident rooms should not be used for mixing medications.During an interview on 1/28/26 at 11:39 a.m., staff member B stated MiraLAX should be mixed with the appropriate amount of fluid. She stated if the nurse was uncertain if a resident could finish the drink with the medication mixed in, the nurse should watch the resident to ensure they finished the medication. Staff member B stated it would not be recommended to mix MiraLAX into the resident's water mugs because it would be hard to monitor if they finished taking all of the medication. Staff member B stated if a resident was on a modified diet which required thickened liquids for swallowing, the nurse administering the MiraLAX would need to ensure the liquid was thickened to the prescribed thickness. Review of the facility's policy and procedure titled, Administering Medications, with no revision date, showed: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.1 MiraLAX Dosage Guide. Drugs.com, www.drugs.com/dosage/miralax.html. stir and dissolve one packet of powder (17 g) in any 4 to 8 ounces of beverage (cold, hot or room temperature) then drink.

Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was reviewed at least annually and failed to ensure current standards of practice were followed when enhanced barrier precautions were not implemented for residents with suprapubic indwelling catheters for 2 (#s 7 and 26) of 20 sampled residents. This deficient practice failed to ensure the current standards of practice were followed to prevent and control infections, and it increased the risk of transmission of multidrug-resistant organisms. Findings include:1. Annual Review A review of the facility's infection prevention and control program policies and procedures showed there was no documentation of an annual review. During an interview on 1/29/26 at 10:50 a.m., staff member F stated the policy review dates were reflected in the policy headers and showed that the Med Pass policies were the most recently reviewed. During an interview on 1/29/26 at 10:55 a.m., staff member A stated the Med Pass policies were reviewed when implemented in June of 2024. Staff member A stated that the infection control program policies had not been reviewed annually. 2. Enhanced Barrier Precautions a. During an observation and interview on 1/27/26 at 12:03 p.m., resident #7's room lacked signage indicating enhanced barrier precautions and personal protective equipment (PPE) outside or inside the room. Resident #7 stated he did have a catheter, and staff did not wear gowns when providing catheter care or any other care. During an interview on 1/28/26 at 9:25 a.m., staff member M stated that resident #7's catheter got clogged a lot. Staff member M stated standard precautions were used for resident #7's catheter care and required only the use of gloves. During an interview on 1/28/26 at 9:37 a.m., staff member Q stated resident #7 required assistance with draining his catheter bag, and the personal protective equipment (PPE) required included gloves and alcohol pads; gowns were not required. When asked about what personal protective equipment was required for the use of enhanced barrier precautions, staff member Q stated, What's that? During an interview on 1/29/26 at 10:50 a.m., staff member F said there was only one resident at the facility who required precautions, and the individual required precautions for MRSA (methicillin-resistant Staphylococcus aureus). Staff member F said enhanced barrier precautions were used for MRSA and required the use of gowns, face shield, and gloves. Staff member F said personal protective equipment should be used when providing any direct care to the residents. Staff member F gave examples of high contact care, such as dressing, bathing, nail care, direct contact, and transferring. Staff member F said personal protective equipment should be used anytime the resident who required enhanced barrier precautions was touched. Staff member F did not identify resident #7 as requiring enhanced barrier precautions despite his indwelling catheter. Review of resident #7's treatment administration record for January 2026 showed his suprapubic catheter was to be changed on the day shift every four weeks on Fridays for long-term catheter use, and daily catheter flushes were ordered as needed. Resident #7's physician orders lacked any order addressing enhanced barrier precautions for the indwelling catheter. Review of resident #7's comprehensive care plan, with an admission date of 12/22/14, showed, .Focus: The resident has (indwelling Suprapubic) Catheter: r/t urinary retention as evidenced by urinary retention. Date Initiated 3/21/22. b. During an observation on 1/27/26 at 8:29 a.m., there were no enhanced barrier precaution signage or supplies posted outside of resident #26's room. Staff members P and Q were assisting resident #26 with toileting, utilizing a sit-to-stand lift. The resident had an indwelling catheter. Staff members P and Q were only wearing gloves; they were not wearing any additional PPE. During an interview on 1/27/26 at 9:29 a.m., staff member P stated she was not aware of any additional PPE needed when caring for a resident with an indwelling catheter. During an interview on 1/28/26 at 3:15 p.m., staff member Q stated she was not aware of any additional PPE needed when caring for a resident with an indwelling catheter. Review of resident 26's Physician Orders, dated 12/24/25, showed, Urinary Catheter Care- perform per-care with Redi cleanse peri wipes [every]shift and after [bowel movement]. Urinary Catheter supra pubic 16 [French] 10 [milliliter] bulb as needed for Occlusion or Leakage As Needed. Urinary Catheter supra pubic 16 [French] 10 [milliliter] bulb every day shift every 2 weeks on Wed change catheter bag with catheter change and every 2 [weeks]. Urinary Catheter supra pubic 16 [French] 10 [milliliter] bulb every day shift every 4 weeks on [Wednesday] Change catheter and bag every 4 weeks. [sic] Review of resident #26's Care Plan showed interventions for a suprapubic indwelling catheter but failed to address enhanced barrier precautions for the catheter care. Review of the facility's policy titled, Infection Control: Isolation Precautions, reviewed 2/22/24, showed, Purpose: To outline Isolation types and when to initiate isolation for a resident within the facility. To facilitate proper equipment, use, and implementation of isolation precautions. Staff need to recognize the type of isolation and appropriate personal protective equipment (PPE) by the signage used on resident doors. Enhanced Barrier Precautions: Enhanced barrier precautions (EBP) will be used in addition to standard precautions in the care of residents with indwelling medical devices or open wounds. EBP will not impede the movement of a resident within the facility and does not require a resident to remain in their room. Indwelling medical devices that may require the use of EBP include central venous catheters, Foley catheters, and suprapubic catheters. Open wounds that require wound care and dressing changes will require the use of EBP. EBP may be discontinued when the medical device is removed or the wound has resolved. PPE required for EBP: - Isolation gown - Gloves - Eye protection/face shield if irrigation is required. [sic]

Based on the observation, interview, and record review, the facility failed to ensure a physical restraint used for a resident with a seatbelt was used to treat a documented medical symptom, failed to assess the resident's ability to release the seatbelt, and failed to ensure the restraint was used for the least amount of time with appropriate monitoring and re-evaluation for 1 (#3) of 20 sampled residents. The deficient practice increased the risk for decreased mobility and injury. Findings include:During an interview on 1/27/26 at 10:45 a.m., NF2 stated resident #3's seat belt should be buckled when she was in the wheelchair. NF2 further stated, They say it's a restraint and that's what I want, I want her to stay off the floor.During an observation on 1/27/26 at 11:14 a.m., resident #3 was observed in a wheelchair positioned in a tilted backward/reclined position. A seat belt was present on the wheelchair; however, the belt was not fastened around the resident. The resident remained seated in the wheelchair during the observation.During an observation on 1/28/26 at 8:34 a.m., resident #3 was observed in a wheelchair positioned in a reclined/tilted backward position. A seat belt was fastened across resident #3's waist and secured to the wheelchair frame. The resident remained in the wheelchair and did not independently remove the belt during the observation.During an interview on 1/28/26 at 11:44 a.m., staff member B stated the seatbelt use for resident #3 was required for positioning and stated resident #3 had not been assessed for the ability to release the seatbelt independently and stated resident #3's hands were Not real strong.During an interview on 1/28/26 at 2:26 p.m., staff member K stated informed consents were obtained upon admission. Staff member K said there was no process in place to have the consents revisited if a resident experienced a decline or a change, or to monitor the effectiveness of the intervention of the informed consent.Review of resident #3's progress notes showed the following communication with family notes:7/1/25 at 3:01 p.m. - Call placed to [resident #3's family member] regarding [Resident #3's] wheelchair. Explained to [resident #3's family member] that the reason she needed the blue chair is because the Rock and Go does not accommodate her legs and feet. [Resident#3's family member] talked to this nurse regarding a Seat Belt. This nurse discouraged pursuit of that at this time. [Resident #3's family member] happy with the plan of care at this time. [sic]7/1/25 at 3:39 p.m. - New order to place seatbelt to rt's wheelchair d/t falls. Notified family member [name of resident #3's family member] and she is in agreement with this, will be here this afternoon to sign restraint consent. [sic]7/1/25 at 7:00 p.m. - [Name of resident #3's family member] in to sign Seat Belt restraint consent form and we also discussed prior order for OT for custom fit wheelchair. Pt. is private pay and family cannot afford the consult and new chair. They wish to decline at this time. Notified activities of cancelation plans. [sic]The progress notes show the family declined an occupational therapy assessment due to cost, and the seatbelt was implemented at the family's request without a documented safety or positioning assessment.Review of resident #3's acute physician visit progress note, dated 7/1/25, showed that resident #3 was seen for a fall on 6/28/25 when she fell out of a wheelchair. The progress note showed, We have been trying to find a more appropriate wheelchair for her, one that supports her feet and legs appropriately and that does not cause her to be leaning forward so much. Her family member is aware of this. Previous to that episode, we requested an OT consult for better fitting wheelchair for her.Plan: .Occupational therapy consult is needed for a better fitting wheelchair with foot supports for her. I will ask for a seatbelt to be used so she cannot fall forward again hopefully.Addendum: 1500 hours (3:00 p.m.) A little bit ago [Staff member O] with restorative physical therapy did bring by [Resident #3's] wheelchair. I asked specifically that foot supports be placed on her wheelchair every time it is used. I also asked that a seatbelt be placed.[Staff member E] would have to put a seatbelt on; she could not do that. I did ask that it be done. This is a safety issue related to fall. Again, I am hopeful that a formal occupational therapy and seating evaluation can be done for [Resident #3]. [sic]The progress note showed the seatbelt was placed by the order of the physician, without an occupational therapy assessment, secondary to the resident's fall on 6/28/25.Review of the facility's document titled, Informed Consent for use of physical restraints, dated 7/1/25, showed the identified medical symptom, which indicated the restraint use for resident #3 was Seatbelt to wheelchair (DX: Fall), [NF2] refused OT referral for WC positioning eval. The risks assessed were immobility and skin breakdown. The less restrictive restraints that were not effective were adaptive furniture, restorative care, frequent monitoring by staff to identify toileting, pain or comfort, and assisted toileting. Other alternatives attempted were to assess for physical illness, including pain and infection, increase activities during the day, and attempt to reorient, reassure, and distract the resident. The document further noted, [NF2] refusal OT referral for wheelchair positioning. Pre-existing conditions that may predispose the resident to injury, such as impaired cognition or fall history, were included in the list. No preexisting conditions that may predispose the resident to injury were checked in the document for resident #3. The document further showed I request, under the management and supervision of my doctor, the use of: seat belt on wheelchair for the medical conditions specified by my doctor. [sic]The document lacked the assessment of the resident's ability to release the seat belt independently, failed to identify impaired cognition and history of falls as predisposing risk factors, did not specify the duration or monitoring of the seatbelt, and lacked an appropriate medical symptom for the use of the seatbelt; showing the diagnosis for the use of the seatbelt was a Fall.Review of resident #3's physician's order, dated 7/1/25, showed . 2. Seat belt to WC (DX: falls). The order did not include the duration or monitoring parameters for the use of the seatbelt.Review of resident #3's physician orders and care task list lacked monitoring of the effectiveness of the use of resident #3's seatbelt.Review of resident #3's Minimum Data Set, with an assessment reference date of 5/20/25, showed resident #3 had a BIMS score of 3, reflecting severe cognitive impairment.Review of resident #3's Minimum Data Set with an assessment reference date of 8/19/25 showed resident #3 had a BIMS score of 3, reflecting a severe cognitive impairment.Review of resident #3's care plan, with an admission date of 2/18/20, showed: . Focus: The resident has history of falls d/t Poor Balance, Unsteady gait, Date Initiated 2/28/22Goal: The resident will continue usual activities without incidence of falls through the review date. Revised on 2/25/25Interventions/Tasks:. Seatbelt while in wheelchair d/t a history of falls from her wheelchair. (Family refused OT referral for seatbelt evaluation) Date Initiated: 7/1/25.The care plan failed to include how the seatbelt was monitored for effectiveness, how long the seatbelt was to be used for, or the resident's ability to self-release the seatbelt.Review of the facility's policy titled, Use of Restraints, not dated, showed: Policy Statement.Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls.When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to:a. treat the medical symptom;b. protect the resident's safety; andc. help the resident attain the highest level of his/her physical or psychological well-being.6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.9. The order shall include the following:c. The type of restraint, and period of time for the use of the restraint.16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination.[sic]The policy confirmed restraints are not to be used for fall prevention, require a documented medical symptom, pre-restraint assessment, the duration for the use of the restraint and on-going re-evaluation and monitoring of the restraint.

Based on observation, interview, and record review, the facility failed to ensure it did not use psychopharmacological medications as chemical restraints, ensure medications were prescribed for appropriate diagnosis management, or provide informed consent for the medications for 1 (#2) of 20 sampled residents. Findings include:During an interview on 1/27/26 at 1:32 p.m., staff member B stated resident #2 was not appropriate for the facility as she had behaviors they could not handle. Staff member B stated they had several medications they used for behaviors, including multiple PRN psychotropic orders for Ativan and hourly ABH gel. Staff member B stated the facility was still figuring out what combination was right for resident #2 to keep staff safe from her behaviors, which was why the PRN orders had ranges and multiple orders available for nurses. Staff member B stated she was more aggressive in giving the PRN medications and higher doses because it did not have much effect on resident #2, but the floor nurses were more apprehensive about using anything other than the lowest doses. Staff member B stated they could not give resident #2 too many medications because they barely affected her.During an observation on 1/28/26 at 9:08 a.m., resident #2 was in the dining room, unable to stay awake, rocking herself back and forth in her wheelchair.During an observation on 1/29/26 at 10:48 a.m., resident #2 was in her room sleeping.Review of resident #2's EHR showed that on admission in July 2025, she did not take any medications and had a primary diagnosis of dementia in other diseases classified elsewhere, unspecified severity with agitation.Review of resident #2's MAR/TAR for January 2026 showed psychopharmacological medications of:-Exelon Transdermal Patch 9.5MG/24 HR Apply 1 patch transdermally every night shift for Dementia with behaviors, with a start date of 1/14/26, increased from 4.5 started on 10/8/25.- Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) by mouth at bedtime for dementia, not before supper, with an updated date of 1/14/26, started on 10/28/25.- Ativan Oral Tablet 1MG (Lorazepam). Give 1 mg by mouth two times a day for Dementia with behaviors, anxiety, with a start date of 1/14/2026, prior to this date, it was three times a day with a start date of 10/28/25.-Namenda Oral Tablet 10 MG (Memantine HCl) given by mouth two times a day for dementia with an updated date of 1/13/26, started on 7/24/25.- ABH cream Apply to the inner forearm topically every 1 hour as needed for anxiety, agitation, aggressive behavior, lorazepam 1mg/ml; Haldol 2mg/ml, Benadryl 12.5mg/ml compounded cream in single-dose syringes, 1/2 ml dose with a start date of 8/28/25.- Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 4 hours as needed for agitation (may give 0.5 mg to 1 mg) with a start date of 10/21/25- Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 mg by mouth every 4 hours as needed for agitation 0.5 mg-1 mg with a start date of 10/21/25. A request was made on 1/29/26 for resident #2's psychoactive medication consents. The only documentation provided was a printout of a late entry progress note backdated to 1/28/26, entered into the EHR after the request was made, showing, . POA [Name] in attendance for family care conference. Discussed resident's behavior, mobility, weight, activity attendance, and current medications. POA in agreement with current plan of care with no concerns noted at this time.There was no medication consent showing the diagnosis with risks and benefits found or provided for resident #2's current medication ordersReview of the facility policy, Antipsychotic Medication Use, last revised July 2022, .16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use . not due to environmental stressors (e.g. hunger . excessive noise for that individual, inadequate or inappropriate staff response. or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g. the mistaken belief that this is not where he/she lives.

Based on interview and record review, the facility failed to update care plan goals and interventions for 1 (#2) for interventions for psychotropic medication use and 1 (#15) for severe weight changes of 20 sampled residents. Findings include:1. During an interview on 1/27/26 at 1:36 p.m., staff member B stated the facility had weekly care plan meetings and the facility had IDT meetings, however, resident #15 had not been identified as having a weight loss so she was not monitored by IDT or had an update in her care plan.Review of resident #15's EHR weights in pounds for August 2025 to January 2026, showed the resident has a severe weight loss of 17% in 6 months, with a 17% weight loss in the last six months and a 9.75% weight loss in the last three months. -8/4/25, 174.0-11/3/25, 159.5-1/19/26, 143.5Review of resident #15's Care Plan, last updated 6/5/25, showed a focus area for unplanned/unexpected weight loss due to sleeping and refusing to get out of bed, with a goal of maintaining a weight of 169 pounds through the 6/2/26 review.2. During an interview on 1/27/26 at 1:33 p.m., staff member B stated the facility had multiple PRN psychotropic medication orders to use in conjunction with scheduled medications to manage resident #2's behaviors. Staff member B stated the PRN Ativan had a range for nurses to use. The staff member could not explain what the parameters were for the nurses to determine which dose to use. Staff member B stated there was no ordered limit on the amount of PRN Ativan and PRN hourly ABH gel because the medications did not have much effect on resident #2.Record review of resident #2's Care Plan, last revised 10/25/25, showed a focus area of Daily use of antipsychotic medications r/t dementia behaviors affecting her safety. The goal was to have minimal behaviors regarding attempting to elope, and staff will be able to redirect the resident with inappropriate behaviors and exit-seeking. The only intervention listed was to monitor for side effects and the effectiveness of the medication.Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last revised March 2022: . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change.12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition;b. when the desired outcome is not met; at least quarterly.

Based on observation, interview, and record review, the facility failed to assess a resident for safety with smoking and failed to develop a smoking care plan for 1 (#20) of 20 residents sampled. This deficient practice had the potential to affect the safety of all residents who smoked. Findings include:During an interview on 1/28/26 at 4:07 p.m., staff member P stated resident #20 sometimes went out to smoke with her family when they visited. She stated resident #20 would also go out with the other residents during the designated smoking times. During an observation and interview on 1/29/26 at 4:10 p.m., staff member N stated resident #20 sometimes went out to smoke with the other residents who smoked during the supervised smoking times. Staff member N showed resident #20's cigarettes and lighter that were locked inside the medication cart. A document request for resident #20's smoking care plan and smoking safety assessment was submitted to the facility on 1/28/26 at 4:30 p.m. No documentation was provided by the end of the survey.During an interview on 1/29/26 at 9:04 a.m., staff member A stated she searched back to resident #20's admission [DATE]), and they did not have a smoking safety assessment or a smoking care plan for the resident. Staff member A stated resident #20 should have a smoking safety evaluation/assessment and a smoking care plan completed. She stated it was the expectation to complete a smoking risk assessment and care plan for any residents who smoke. A review of the facility's Smoking Policy - Residents, with a review date of 7/23/25, showed: .6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption. b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation.8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues .11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent triggers contributing to the overstimulation of the resident who had dementia; and implement the least restrictive and effective interventions for corresponding dementia behaviors, for 1 (#2) of 20 sampled residents. Findings include:During an observation and interview on 1/27/26 8:44 a.m., resident #2 was alone behind the nurses' station trying to reach the phone. Resident #2 attempted to stand to get the phone when a male resident who was vocally calling out was placed directly in front of the nurses' station with no staff present. Resident #2 was overwhelmed by the noise placing her head in her hands, shaking her head, and grumbling that she just needed to get away from the noise and she needed to call her mother so she could go home.During an observation on 1/27/26 at 8:57 a.m., resident #2 was behind the nurses' station attempting to reach and use the phone. Eight other residents were parked in the area, television on, with no staff present.During an observation on 1/27/26 at 9:09 a.m., in the dining room, resident #2's breakfast tray was on a table. There was one piece of buttered toast cut in half, open jam packet, coffee, water, juice, a sliced banana, and a bowl of soggy cereal that had begun to dry and had become crusty on top. The tray was later cleared without resident #2 having eaten breakfast. During an observation on 1/27/26 at 9:13 to 9:17 a.m., staff member G was sitting next to resident #2 behind the nurses' station. This surveyor inquired if resident #2 had eaten breakfast, and no staff answered; resident #2 could not recall. Resident #2 was asking to get help using the cordless phone in her hand, and staff member G was stating the phone was busy and they needed to give it a few minutes before trying to call again. When resident #2 asked again, staff member G told resident #2 she could go home on a bus in two hours if she wanted to take a catnap until then. Resident #2, in her wheelchair, then left the nurses' station, wandering past the queue of residents in wheelchairs and dining chairs, and set off the side exit door alarm. A different staff member walked to resident #2, stating 'What are you doing [Resident #2's name]?' Resident #2 stated she was trying to go home. The staff member began pushing resident #2 back to park her wheelchair at the nurses' station, and her feet were dragging on the floor.During an observation on 1/27/26 at 9:23 a.m., resident #2 was wandering at the nurses' station when a staff member gave her a bag of crackerjacks to eat and walked away. Resident #2 proceeded to eat the food while trying to pick up the dropped prize. No staff were present. Resident #2 was asking other residents about going home but was no longer wandering.During an observation on 1/27/26 at 4:27 p.m., resident #2 was wandering and set off the front entrance Wanderguard alarm. A staff member came down the hall to reset the alarm and wheel resident #2 back down the hallway.During an interview on 1/27/26 at 1:18 p.m., staff member B stated resident #2 was not appropriate for the facility, and they were not equipped for her behaviors of wandering and being aggressive. Staff member B stated the facility nurses did not have a limit on the amount of the PRN psychotropic medications to sue as they could not give resident #2 too much psychotropic medications due to the medications having little effect on her. Staff member B stated resident #2 wandered so much that the facility staff were now directed to let her get out of the doors and they followed her.Review of resident #2's Care Plan area of behavior problem., last updated 9/20/25, showed to:- anticipate and meet the resident's needs,- caregivers to provide opportunity for positive interaction, attention, and to stop and talk as passing by,- minimize potential for the resident's disruptive behaviors (combative behavior, elopement attempts, cursing, ramming others with wheelchair) by offering tasks which divert attention such as (looking at pictures, cup of coffee, walking),- monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes,- resident may go out the doors, if exit seeking persists, with the chaperone of one staff member. Other staff members need to be aware .- wander guard on at all times to prevent eloping .Review of facility policy titled, Dementia-Clinical Protocol, last revised 11/2018, showed, .The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia. staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated.

Based on observation, interview, and record review, the facility failed to ensure it did not use psychopharmacological medications as chemical restraints, ensure medications were prescribed for appropriate diagnosis management, and provide informed consent for the medications for 1 (#2) of 20 sampled residents. Findings include:During an interview on 1/27/26 at 1:13 p.m., staff member B stated the PRN antipsychotic renewal would be the responsibility of the charge nurse or nurse assigned to follow the provider on rounds to get them done that day. Staff member B stated the provider would normally write specific parameters for not giving specific medications concurrently or the maximum dose in a timeframe. The orders would be in the hard chart for each resident, as it was a lot to change the orders in the EHR every time. Staff member B stated for resident #2 the PRN ABH gel was probably due for renewal but in her case, there was not going to be an overdose or 'snow' cannot give her too much as they could barely manage her symptoms. The dose range and amount of PRN medications were due to the provider being unsure of the appropriate dosage to work for resident #2, and it should not be a range without parameters, but staff member B stated she had prescriptive authority. Staff member B stated the floor nurses could give either dose of the Ativan tablets, and in conjunction with the PRN ABH gel, but they usually used the lower dose as they were uncomfortable with going to the higher doses. During an observation on 1/28/26 at 8:10 a.m., staff member M prepared the following medications for resident #2. One lorazepam (Ativan) 1 mg tablet, one gabapentin (Neurontin) 600 mg tablet, and one memantine (Namenda) 10 mg tablet. Staff member M then approached resident #2, who was asleep, sitting in her wheelchair by the nurses' station. Staff member M attempted several times to wake resident #2 for her to take her medications. The resident would wake up for a second, look around, and fall back to sleep. Eventually, staff member M was able to rouse resident #2 to stay awake long enough to take the prepared medications. After taking the medications, the resident fell back to sleep while sitting in her wheelchair. Another staff member started to push the resident in her wheelchair to the dining room. The resident remained asleep.During an observation on 1/28/26 at 9:08 a.m., resident #2 was in the dining room unable to stay awake.During an interview on 1/29/26 at 10:37 a.m., staff member M stated he would try to use the least amount of PRN psychotropic medications for residents, especially resident #2, as he had experience in mental health centers and did not want to exacerbate behaviors. Staff member M stated that when he administered a PRN medication to a resident, he would watch the resident to make sure it was effective, but he did not document a progress note on the resident's behavior. Staff member M stated he believed the CNA charting was somehow linked to the medication use for behavior monitoring. Staff member M stated he only knew of Tylenol, or outside providers, putting specific parameters on medications to not give too much in a specific timeframe. When asked about administering ABH gel, staff member M stated he had never been provided guidance by the facility regarding other side effects or adverse reactions associated with anti-psychotics, or for monitoring the resident for adverse side effects after administering PRN psychotropic medications.Review of resident #2's MAR/TAR for January 2026 showed PRN psychotropic medications of:- ABH cream Apply to Inner forearm topically every 1 hours as needed for anxiety, agitation, aggressive behavior lorazepam 1mg/ml; Haldol 2 mg/ml, Benadryl 12.5 mg/ml compounded cream in single dose syringes. 1/2 ml dose with a start date of 8/28/25.- Ativan Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth every 4 hours as needed for agitation (may give 0.5 mg to 1mg) with a start date of 10/21/25.- Ativan Oral Tablet 0.5 mg (Lorazepam) Give 1 mg by mouth every 4 hours as needed for agitation 0.5mg-1mg with a start date of 10/21/25. - Resident #2 was given two ABH gel doses on 1/26/26 at 3:00 p.m., and 4:00 p.m., and 0.5 mg PRN Ativan at 6:34 p.m., by staff member B. Resident #2 was given two doses of ABH gel on 1/27/26 at 3:34 p.m., and 7:53 p.m. Observations of being overly sedated and hard to rouse were noted on 1/27/26, 1/28/26, observations.- There were no parameters for which dose or limit to give when combining with scheduled medications in a given timeframe. Review of resident #2's EHR showed that on admission in July 2025, she did not take any medications and had a primary diagnosis of dementia in other diseases classified elsewhere, unspecified severity with agitation. There were no other psychiatric diagnoses, anxiety, depression, or mood disorders.A request for psychotropic medication informed consents for resident #2 was requested on 1/28/26, and none were provided by the end of the survey.Review of the facility policy titled, Tapering Medications and Gradual Drug Dose Reduction, last revised July 2022, showed, 14. Attempted tapering of sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefitting from a medication or might benefit from a lower or less frequent dose. Tapering shall be done consistent with the following: a. For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer's recommendations for duration of use, the physician shall attempt to taper the medication at least quarterly unless clinically contraindicated. [sic]Review of the facility policy, Antipsychotic Medication Use, last revised July 2022, showed: .16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order.11. d. not due to environmental stressors (e.g. alteration in the residents customary location or daily routine, unfamiliar caregiver, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; and,e. not due to psychological stressors (e.g. loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g. the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed.Review of facility policy titled, Dementia-Clinical Protocol, last revised 11/2018, showed, .The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia. staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated.

Based on observation, interview, and record review, the facility failed to obtain routine dental care to meet the needs of a resident who had poorly fitted dentures for 1 (#8) of 20 sampled residents. This deficient practice resulted in the resident remaining without usable dentures and placed the resident at risk for decreased oral intake and weight loss. Findings include:During an observation and interview on 1/27/26 at 8:53 a.m., resident #8 was observed to be edentulous, with one natural tooth present and not wearing any dentures.During an interview on 1/28/26 at 12:50 p.m., staff members D and R stated they did not receive a referral for resident #8 to be seen by the dentist or denture clinic. Staff member D noted the denture clinic providers were in the facility on 1/12/26, seeing residents.During an interview on 1/28/26 at 1:24 p.m., staff member K was asked about resident #8's dentures and the status of the repair. Staff member K stated resident #8's family had her dentures, she had not been seen by the denture care clinic, and the staff would get her lined up for an appointment with the denture clinic. Staff member K said she had a hard time keeping in contact with family and reported that resident #8 went out with family on therapeutic leave. Staff member K stated resident #8's family would have to check in with the nursing department to get resident #8's medications and to check her out of the facility.During an observation and interview on 1/29/26 at 10:27 a.m., resident #8 nodded yes when she was asked if she wanted her dentures repaired. When asked if her dentures were with family, she nodded, no. Staff member O stated, I didn't know you had dentures, demonstrating a lack of staff knowledge regarding the resident's dental needs and equipment. Resident #8 motioned to her room, and staff member O went to resident #8's room and found the dentures beside the resident's sink.Review of resident #8's baseline care plan with an admission date of 4/10/25 showed resident #8 had dentures, and it was noted on the baseline care plan, Does not have with her though - family has for repairs. [sic]Review of resident #8's comprehensive care plan with an admission date of 10/16/25 showed, .Focus: The resident has a nutritional problem, is diabetic and has no teeth. Right sided CVA, Date initiated: 4/17/25.Goal: Resident will get her dentures fixed as soon as possible. Date Initiated 4/17/25.There were no interventions or tasks listed to complete the goal to get her dentures fixed as soon as possible, as it related to resident #8's nutritional problem.Review of the facility's document titled [Facility Name] Nutrition Report, for the week of 1/27/26, showed resident #8 had decreased intake and a weight loss of 3.5 lbs.Review of resident #8's Minimum Data Set with an Assessment Reference Date of 4/16/25 showed, Section L0200 Dental, A. Broken or loosely fitting full or partial denture, the box was checked yes.Review of resident #8's Minimum Data Set, with an Assessment Reference Date of 1/13/26, showed under Section L0200 Dental, A. Broken or loosely fitting full or partial denture, the box was checked no.A request was made for resident #8's dental appointment and dental progress notes on 1/28/26 at 4:22 p.m. No documentation was provided before the end of the survey.Review of the facility's policy titled, Dental Services, not dated, showed, Routine and Emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.Policy Interpretation and Implementation1. Routine and 24-hour emergency dental services are provided to our residents through:a. a contract agreement with a licensed dentist that comes to the facility monthly;b. referral to the resident's personal dentist;c. referral to community dentists; ord. referral to other health care organizations that provide dental services.6. Social services representatives will assist resident with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.10. If dentures are damaged or lost, resident will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. [sic]Review of the facility's policy titled, Dental Examination/Assessment, not dated, showed, Policy Statement, Each resident shall undergo a dental assessment prior to or within ninety (90) days of admission.Policy Interpretation and Implementation,1. Resident shall be offered dental services as needed.2. Dental Examinations will be made by the resident's personal dentist or by the facility's consultant dentist.3. Records of dental care provided shall be made a part of the resident's medical record.4. Upon conducting a dental examination, a resident needing dental services will promptly referred to a dentist. [sic]

Based on observation, interview, and record review, the facility failed to ensure an occupational therapy evaluation was completed to assess wheelchair positioning and the need for a seatbelt following resident falls and instead implemented a seatbelt without the proper evaluation when the family declined therapy due to the cost, for 1 (#3) of 20 sampled residents. The deficient practice resulted in the use of a positioning device without an appropriate assessment to ensure the resident's safety and effectiveness. Findings include:During an interview on 1/27/26 at 10:45 a.m., NF2 stated resident #3's seat belt should be buckled when she is in the wheelchair. NF2 further stated, They say it's a restraint and that's what I want, I want her to stay off the floor.During an observation on 1/27/26 at 11:14 a.m., resident #3 was observed in a wheelchair positioned in a tilted backward/reclined position. A seat belt was present on the wheelchair; however, the belt was not fastened around the resident. The resident remained seated in the wheelchair during the observation.During an observation on 1/28/26 at 8:34 a.m., resident #3 was observed in a wheelchair positioned in a reclined/tilted backward position. A seat belt was fastened across resident #3's waist and secured to the wheelchair frame. The resident remained in the wheelchair and did not independently remove the belt during the observation.During an interview on 1/28/26 at 8:52 a.m., when staff member A was asked about resident #3's need for an occupational therapy referral, she stated the evaluation was not a billable expense through Medicare and the resident was private pay; therefore, the family would have to pay out of pocket for the occupational therapy evaluation.The facility failed to obtain the necessary occupational therapy services despite the resident's payor or insurance, and the facility relied on family refusal rather than ensuring the resident's clinical needs were assessed and addressed.Review of an email addressed to staff member B from staff member U, dated 6/11/25 at 11:00 a.m., showed, an order was received from the physician for resident #3's wheelchair evaluation. The email further showed, Doesn't look like she has Medicaid but wanted to double check with you. Just so you know for future, if a LTC patient does not have Medicaid, it will not be covered under Insurance. If family is interested in private pay-we need to talk to them prior to setting up an eval. Documented on the copy of the email was a handwritten note showing resident #3's family requested to cancel the occupational therapy appointment.Review of resident #3's progress notes showed the following communication with family:7/1/25 at 3:01 p.m. - Call placed to [#3's Family member] regarding [Resident #3's] wheelchair. Explained to [Family member] that the reason she needed the blue chair is because the Rock and Go does not accommodate her legs and feet. [Resident#3's family member] talked to this nurse regarding a Seat Belt. This nurse discouraged pursuit of that at this time. [Resident #3's daughter] happy with the plan of care at this time. [sic]7/1/25 at 3:39 p.m. - New order to place seatbelt to rt's wheelchair d/t falls. Notified daughter [name of resident #3's daughter] and she is in agreement with this, will be here this afternoon to sign restraint consent. [sic]7/1/25 at 7:00 p.m. - [#3's Family member] in to sign Seat Belt restraint consent form and we also discussed prior order for OT for custom fit wheelchair. Pt. is private pay and family cannot afford the consult and new chair. They wish to decline at this time. Notified activities of cancelation plans. [sic]The progress notes show the family declined an occupational therapy assessment due to cost and the seatbelt was implemented at the family's request without a documented safety or positioning assessment.Review of resident #3's acute physician visit progress note, dated 7/1/25, showed that resident #3 was seen for a fall on 6/28/25 when she fell out of a wheelchair. The progress note showed, We have been trying to find a more appropriate wheelchair for her, one that supports her feet and legs appropriately and that does not cause her to be leaning forward so much. Her daughter is aware of this. Previous to that episode, we requested an OT consult for better fitting wheelchair for her. Plan: .Occupational therapy consult is needed for a better fitting wheelchair with foot supports for her. I will ask for a seatbelt to be used so she cannot fall forward again hopefully. Addendum: [3:00 p.m.] A little bit ago [staff member O] with restorative physical therapy did bring by [Resident #3's] wheelchair. I asked specifically that foot supports be placed on her wheelchair every time it is used. I also asked that a seatbelt be placed. [Staff member O] noted that [staff member E] would have to put a seatbelt on; she could not do that. I did ask that it be done. This is a safety issue related to fall. Again, I am hopeful that a formal occupational therapy and seating evaluation can be done for [Resident #3]. [sic]Despite the lack of an occupational therapy evaluation, a seatbelt was placed on the resident's wheelchair by order of the physician. No documented assessment addressed the proper fit and positioning, the impact on the resident's mobility, or the resident's ability to tolerate or safely use the device. The seatbelt was implemented without the specialized clinical assessment required to determine appropriateness. The facility failed to obtain the necessary occupational therapy services despite the resident's payor or insurance, and the facility relied on the family's refusal rather than ensuring the resident's clinical needs were assessed and addressed.

Based on interview and record review, the facility failed to ensure the Facility Assessment was reviewed and updated annually, and when necessary to update memorandums of understandings for laboratory services, and emergency operations plan. This deficient practice increased the risk of negative outcomes for residents residing at the facility. Findings include:Review of the facility's Facility Assessment updates showed: - 10/2025: [staff member G] to help review/update.- 12/2025: name updates, [etcetera].- 1/2026: [staff member G] suggested updated [NAME] with [name of local hospital] for lab. Also, need updated [NAME] for EOP evacuation to [name of local hospital].Review of the facility's Facility Assessment did not show the facility's assessment was updated since September 2024 and suggested updates for 2025 and 2026 were not completed.During an interview on 1/29/26 at 8:13 a.m., staff member A stated she needed some help on updating the Facility Assessment. She stated staff member G had reviewed the assessment and made some suggestions, but they have not been able to complete the facility assessment for 2025.

Based on interview and record review, the facility failed to ensure vulnerable residents were free from physical abuse by another resident for 5 (#s 9, 13, 34, 73, and 98); and protect residents from misappropriation of medications for four (#s 34, 40, 57 and 67) of 16 sampled residents. Resident #9 was involved in 5 resident-to-resident altercations within the last five months. Findings include:1. Resident to Resident Abuse Events:a. Review of resident #13's nursing progress notes, dated 7/27/25, showed that resident #13 was crying and upset. Resident #9 had grabbed #13's face and would not let it go. The nurse intervened and removed resident #9, but resident #13 was instantly upset. The progress notes did not contain any information regarding interventions for the prevention of abuse for #13, by resident #9. During an interview on 8/7/25 at 8:20 a.m., staff member B said the event between residents #9 and #13 was not reported to the State Survey Agency as abuse. Staff member B said resident #13 is either usually very happy or she cries. The staff thought her crying was just part of her usual behavior. The facility did not identify this event as reportable event or put safety interventions in place for future prevention of abuse by #9.Review of Facility-Reported Incidents, dated 3/11/25 through 6/11/25, submitted to the State Survey Agency, showed resident #9 was responsible for three resident-to-resident altercations in which resident #9 was the aggressor and one altercation where resident #9, was the victim, due to her wandering into another resident's room. b. Review of resident #34's nursing progress notes, dated 6/18/25 at 5:08 p.m., showed the nurse reported another resident (#9) attempted to choke resident #34. The note showed this altercation had happened the week prior, when there was a singing activity in the activity room. Resident #9 initially had her hands on resident #34's shoulders, but when the staff asked her to stop, resident #9 put her hands around resident #34's neck. Review of resident #34's progress notes showed no further actions were taken to prevent abuse or altercations between the two residents to ensure #34 was safe. During an interview on 8/5/25 at 2:10 p.m., staff member H said she was in the activity area when resident #9 had her hands on resident #34's throat. Staff member H said she asked the resident to remove her hands, but resident #9 wouldn't let go. Staff member H said she had the certified nurse assistant help the residents. Staff member H said she reported to the charge nurse on duty. The nurse in charge told her to mind her own business. Staff member H said she did not tell anyone else and did not make a report. Staff member H was unaware who was designated as the facility abuse coordinator. During an interview on 8/6/25 at 8:37 a.m., staff member J said a report was given to the nurse regarding resident #9 choking resident #34 in the activity room. Staff member J could not identify the date the event occurred. Staff member J said the activity was a movie. Staff member J said resident #34 was sitting in a chair, and resident #9 was standing behind her, rubbing her shoulders. Resident #9 then began rubbing the front of #34's neck. Staff member J said she heard resident #34 say, Don't you're choking me. Record review of a Facility-Reported Incident, dated 6/11/25, submitted to the State Survey Agency, showed resident #34 was at an activity when resident #9 came up behind #34 and put her hands on resident #34's shoulders. When resident #9 was asked to stop, she put her hands around resident #34's neck and grasped her firmly by the neck. c. Review of the Facility Reported Incident, submitted 3/18/25, to the State Survey Agency, showed resident #9 was in resident #98's room. Resident #98 was upset with resident #9 taking things out of her room, and resident #9 was hit on the head by the door. Review of the investigative files for the incidents noted above, showed the facility failed to identify any possible triggers for the physical abuse perpetrated by resident #9. 2. Review of a Facility-Reported Incident, dated 6/11/25, submitted to the State Survey Agency, showed resident #13 wandered into resident #73's room. Resident #13 yelled at resident #73. Resident #73 then slapped resident #13. The Facility Reported Incident, with the section of the report showing corrective actions taken, was blank. There were no interventions put into place to prevent further abuse or altercations or for the protection of either resident involved. During an interview on 8/5/25 at 11:00 a.m., staff member B said if the staff observed the residents and saw what was happening, there would not be any further investigation. Staff member B said the facility event reports are the only documentation the facility uses for investigations. Staff member B said a review of the resident event reports is only completed once a week. 3. Misappropriation of Drugs: During an interview on 8/5/25 at 9:11 a.m., staff members B and C were present for the interview. Staff member B said starting in May 2025, resident #46 ran out of Seroquel about 14 days earlier than she should have. This was the first missing medication identified. Staff member B said she emailed the Drug Enforcement Agency for guidance but has not received any feedback from them. The investigation for the missing medications continued through 7/30/25. No prevention for the misappropriation or diversion of the drugs was initiated during the investigation. The resident's representative was not notified of the medications missing, which were paid for privately by the representative. Staff member B said the common denominator with all the missing medication was a nurse, and she was not terminated until 7/30/25. During the interview, it was reported that the nurse refused to write a statement related to the diversion for the facility. Review of a drug investigation packet, provided to the surveyor, showed potential drug diversion, with the investigation starting in May 2025. Refer to F609 Abuse Reporting

Based on interviews and record reviews, the facility failed to report initial allegations or final summaries of abuse or misappropriation of property to the State Survey Agency in the required timelines established by the federal regulations, to meet the initial or final summary reporting requirements, for 7 (#s 5, 9, 13, 21, 34, 73, and 98) of 16 sampled residents. Findings include: 1. Review of a drug investigation packet, provided to the surveyor by the facility, showed that potential drug diversion occurred with resident medications, with the investigation starting in May 2025. The facility did not report the allegation or suspicion of drug diversion immediately at the time of the event. A review of the facility's Facility Reported Events showed they reported the drug diversion to the State Survey Agency on 7/30/25; they were delayed in reporting. During an interview on 8/5/25 at 9:11 a.m., with staff members B and C, staff member B said that starting in May 2025, resident #46 ran out of Seroquel, which was about 14 days earlier than she should have. These were the first missing medications, and the facility began investigating the situation. Staff member B said she emailed the Drug Enforcement Agency for guidance, but has not received any feedback from them as of the survey. Staff member B said she had not called the local law enforcement agency. Staff member B said the facility wanted to complete its medication audit before reporting anything to the police or the State Survey Agency. The facility did not report this information through a Facility Reported Incident to the State Survey Agency at the time of the initial allegation or suspicion of diversion. The facility did report the event to the State Survey Agency on 7/30/25. Review of a final drug diversion report the facility submitted to the State Survey Agency, on 8/8/25, showed the local police department was not contacted until 8/7/25, and the board of nursing was contacted on 8/7/25. 2. Review of the Facility Reported Incident, submitted to the State Survey Agency on 3/18/25, showed residents #9 and #98 were involved in a physical altercation. The final summary was not submitted until 3/26/25, eight days later, which did not meet the timely reporting requirements. 3. Review of the Facility Reported Incident, submitted to the State Survey Agency, on 5/3/25, showed residents #9 and #73 were involved in a resident-to-resident altercation. The final summary report was not submitted to the state survey agency until 5/12/25, but should have been sent in by 5/9/25. 4. Review of Facility Reported Incident, submitted to the State Survey Agency on 6/11/25, showed residents #13 and #73 had a physical altercation. This abuse report showed the altercation took place on 6/2/25, nine days before the report was submitted to the State Survey Agency, so the abuse event was not reported timely.5. Review of Facility Reported Incident, submitted on 6/16/25, to the State Survey Agency, showed residents #9 and #34 had an altercation on 6/11/25. The initial report of abuse was submitted to the State Survey Agency five days after the altercation. Therefore, the allegation was not reported timely per the federal regulations. 6. Review of an untitled facility report dated 6/11/25, showed resident #5 had a bruise of unknown origin on her left foot, right thigh, and left upper calf. Review of the Facility Reported Events for the facility showed the initial report for #5's bruising was submitted on 6/11/25 to the State Survey Agency. The final summary was not submitted until 6/19/25. During an interview on 8/5/25 at 1:50 p.m., staff member B said she talked to resident #5's son, and he said the resident always bruised easily. Staff member B said there were no further actions taken on the investigation into the causes of the bruising. Staff member B said she did not know why the final summary report sent to the State Survey Agency was late in being finalized.

Based on observation, interview, and record review, the facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, for 5 (#s 9, 13, 34, 73, and 98) and failed to investigate bruising of unknown origin, for 1 (#5) of 16 sampled. Findings include:1. Review of an untitled facility report, dated 6/11/25, showed resident #5 had a bruise on her left foot, right thigh, and left upper calf. The bruises were of an unknown origin. A Facility Reported Incident was submitted on 6/11/25 to the State Survey Agency.Review of Resident #5's nursing progress notes showed there was no progress note written to clearly identify or describe the bruises or the causes for them in resident #5's medical record. During an interview on 8/5/25 at 1:50 p.m., staff member B said she had talked to resident #5's family member, and he said the resident always bruised easily. Staff member B said there was no further investigation completed as to the cause of the bruises. A thorough investigation into potential causes or interventions to prevent the unknown bruising or potential abuse was not completed. 2. Review of a Facility-Reported Incident, dated 6/2/25 and submitted to the State Survey Agency, showed that resident #73 yelled at and slapped resident #13. The incident findings, reported on 6/11/25, failed to show what the potential causes were for #73 slapping and yelling at #9, and there were no interventions to prevent future abuse. 3. Review of Facility-Reported Incidents showed abuse events involving resident #9 and other residents, including: a. The 3/11/25 incident showed resident #9 sprayed alcohol and sanitizer on resident #34's face. The investigation failed to show observations of resident #9's interactions with other residents, interviews with other residents and staff regarding the incident, and or any other similar interactions, or corrective actions implemented to protect resident #34 and other vulnerable residents from abuse. The medical record did not show the responsible party was notified. b. Review of Facility-Reported Incidents, dated 3/18/25, showed a physical altercation which occurred between resident #9 and resident #98. Resident #98 hit resident #9. The untitled facility risk report did not show the root causes, interviews obtained from staff or other residents, or any actions taken to investigate this event.c. Review of the Facility Reported Incident, submitted on 5/3/25, showed resident #9 punched resident #73 in her back. The facility provided an untitled risk event report, which was said to be the only investigation for the abuse event. The facility failed to investigate further to identify root causes or precipitating factors for the abuse, or to identify or implement interventions for future prevention of abuse. d. The 6/11/25 incident showed resident #9 choked resident #34. The investigation failed to show interviews with residents and staff regarding the incident, or any corrective actions or interventions implemented to protect resident #34 and other vulnerable residents from abuse by resident #9. e. Review of the Facility-Reported Incident, dated 6/11/25, submitted to the State Survey Agency, showed resident #9 came up behind resident #34 and put her hands on resident #34's shoulders and choked her.Review of resident #9's nursing progress notes, dated 6/11/25, showed no progress note was written for the resident on this day. A request was made on 8/4/25 for an investigation into the event between #9 and #34, and no investigation was received by the end of the survey. f. Review of resident #13's nurse progress notes dated 7/27/25 showed resident #13 crying and upset. Resident #9 grabbed her face and would not let it go. The nurse intervened and removed resident #9, but resident #13 was instantly upset. The progress notes did not contain information regarding precipitating factors or interventions for the prevention of further abuse. During an interview on 8/5/25 at 11:00 a.m., staff member B said, Well, if the staff observed the residents and saw what was happening, there would not be any further investigation. Staff member B said the facility reviews the event reports every week, and the event reports are what the facility uses for investigations. There isn't anything else for investigations, as the facility uses the risk management forms. During an interview on 8/7/25 at 8:20 a.m., staff member B said resident #13 is either usually very happy or she cries. The staff members thought her crying was just part of her usual behavior.

Based on interview and record review, the facility failed to revise and individualize comprehensive care plans to reflect the individualized needs or interventions to protect residents, for 6 (#s 5, 9, 13, 34, 73, 98) of 16 sampled residents, and the staff responsible for updating the care plans were not aware of what to add to the care plans for resident concerns related to abuse or protecting the resident. Findings include: 1. Review of resident #98's nursing progress notes, dated 7/5/25 at 3:34 p.m., showed the resident was found on the floor in the bathroom. Review of #98's untitled facility risk management report for the fall failed to show that a root cause was identified. The resident sustained a laceration to her face. The fall was not investigated for a cause, and there was no evidence that the facility reviewed the fall to prevent further falls. Review of resident #98's care plan with a revision date of 6/16/25, failed to show if the care plan was reviewed or updated related to the fall with injury on 7/5/25, or if interventions were identified to prevent future falls. 2. A review of resident #34's medical record showed the resident was the recipient of a physical assault by another resident on 3/11/25 and again on 6/11/25. Review of resident #34's care plan failed to show if any interventions were identified or added by the facility staff to ensure the protection of the resident, or if the resident was vulnerable to other residents for specific reasons. During an interview on 8/5/25 at 1:00 p.m., resident #73 said the resident who had been coming into her room does not bother her as much anymore, since she moved downstairs (to another wing of the facility). Resident #73 said the other resident threw alcohol on her face, and it got into her eyes, and she thinks her vision is blurrier since that time. Resident #34 said she feels more isolated in the new room, but she likes her own company. The resident's care plan had not been updated to address her vulnerability related to abuse and the physical aggression, or the isolation resident #34 is feeling since she moved rooms. 3. Review Facility-Reported Incident, dated 6/11/25, was submitted to the State Survey Agency, and it showed resident #5 had bruising of unknown origin to her her left foot, her right thigh and her left upper calf. A review of the resident's current care plan failed to include the risk factors for bruising and the interventions for managing the potential for bruising. During an interview on 8/5/25 at 1:50 p.m., staff member B said the care plan for #5 should have been updated. 4. Review of Facility-Reported Incident, dated 6/2/25, and submitted to the State Survey Agency on 6/11/25, showed residents #13 and #73 were involved in a physical altercation. Review of resident #13's care plan was not updated and did not show any potential problems with resident-to-resident altercations, either as the aggressor or the resident being personally abused.5. Review of resident #9's nursing progress notes, dated 5/25/25 at 6:21 p.m., showed resident #9 was observed coming back into the building after she eloped. The nursing note showed the staff observed resident #9 leave the building at 5:10 p.m., as well. Resident #9's care plan failed to include interventions to prevent elopement when attempting to follow her family or other people through the exit door, and the resident is cognitively impaired. 5. Review of the Facility Reported Incident, dated 5/2/25, and submitted to the State Survey Agency on 5/3/25, showed that resident #73 was involved in a physical altercation. Review of resident #73's care plan showed there were no interventions to prevent resident #73 from continuing to be involved in physical altercations. During an interview on 8/5/25 at 11:00 a.m., staff member B said the facility talked about making changes to the care plans during shift reports, but the care plans may not have been updated. Staff member B said she was not sure what could be done as there were many residents with dementia and the facility could not just restrain them. During an interview on 8/5/25 at 12:47 p.m., staff member D said she works part-time doing MDS assessments and care plans. Staff member D said the nurses will reach out to her when a care plan need to be updated. Staff member D said she also checks notes and incident reports weekly to identify things that need to have care plan updates on, and she will update care plans as needed. Staff member D said she believes she always gets notified when a care plan needs to be updated, and the care plans should be current. During an interview of 8/5/25 at 1:43 p.m., staff member E said she completed the behaviors, mood, psychosocial, communication, and dietary areas on the resident care plans. Staff member E said she only adds to the care plan to separate the residents if there has been an altercation. Staff member E said she did not know what to put on a care plan for the prevention of resident-to-resident abuse altercations. Staff member E said the interdisciplinary team does not work on the care plans as a group. Staff member E said half the time she is not in the facility when an altercation occurs, and she is not always informed of the issues. During an interview on 8/5/25 at 3:21 p.m., staff member I said investigations should occur after incidents to determine the cause of the event Staff member I said the investigations should include interviews with other residents and other staff. Staff member I said the care plans are updated by the MDS (minimum data set-care plan) nurse. Staff member I was not sure what other disciplines helped and what parts of the care plans those staff completed.

Based on interview, and record review, the facility failed to maintain a system to store and monitor controlled drugs was in a manner to contain sufficient detail to enable an accurate reconciliation; and prevent diversion for 5 (#'s 34, 40, 46, 57, and 67) of 16 sampled residents. 1. Review of a facility investigation file showed the facility began an investigation for missing medications in May of 2025. 2. During an interview on 8/5/25 at 9:11 a.m., staff members B and C were present for the interview. Staff member B said beginning in May 2025, resident #46 ran out of Seroquel about 14 days earlier than she should have. This was the first missing medication identified. Staff member B said she emailed the Drug Enforcement Agency for guidance but has not received any feedback from them. 3. During an interview on 8/5/25 at 12:32 p.m., staff member B said the investigation continued through 7/ 30/25. Staff member B said the common denominator with all the missing medication was NF5. Staff nurse NF5 continued working and signing for narcotics until she was terminated 7/30/25, over two months after the first narcotic was missing. NF5 refused to write a statement for the facility. 4. Review of the narcotic sheets showed the facility used three-hole punched loose-leaf paper placed in a binder for the tracking log. The pages were not numbered chronologically and did not correspond to the card of narcotics. The process did not provide a security check. This system allowed the card of medication to be removed from the secured medication cart, and the notebook paper was easily removed. 5. The facility completed its investigation and found: - Resident #46 was missing Seroquel of unknown quantity, - Resident # 40 was missing 3 tablets of Alprazolam, - Resident #57 was missing 17 tablets of Mirtazapine,- Resident #67 was missing 73 tablets of Tramadol, and- Resident #24 was missing 153 tablets of Norco. 6. Review of a final drug diversion report the facility submitted to the survey agency on 8/8/25, showed the local police department was not contacted until 8/7/25, and the board of nursing was contacted on 8/7/25. 7. During an interview on 8/5/25 at 4:04 p.m., staff member M said she was the consultant pharmacist for the facility. She said she was made aware of the drug diversion only a couple of weeks ago but did not remember the exact date. Staff member M said she did not assist the facility in any way with the drug diversion investigation. Staff member M said she does not look at assessments to determine if residents are experiencing freedom from pain. Staff member M said the facility used to be pretty good, and they would call her, and she would help with narcotics destruction. This had changed, and now the facility uses two people to destroy narcotics. Staff member M said she did not monitor any narcotics reconciliation logs because there are two nurses counting and signing off between shifts. 8. The facility policy titled Controlled Substances from MED-PASS, revised November 2022, was provided. The policy showed, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection and follow-up.If a major discrepancy or pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the and administrator and consultant pharmacist immediately. The administrator, consultant pharmacist, and /or the director of nursing services determine whether other actions are needed, e.g. notification of police or other enforcement personnel. the medication regimen of residents using medications that have discrepancies are reviewed to assure the resident has received all medications order and the goal of therapy is met (example: a resident receiving a pain medication complaints of unrelieved pain). The consultant pharmacist or designee routinely monitors controlled substance storage records.

Based on interview and record review, the facility failed to ensure the residents' highest practicable level of physical and psychosocial well-being was met for 2 (#s 13 and 34) related to medically related social services, of 16 sampled residents. Resident #34 felt isolated after her move, and #13 was upset over an abuse event; neither resident had a social service follow-up after the abuse event. Findings include:During an interview on 8/5/25 at 1:00 p.m., resident #34 said she did have some problems with another resident coming into her room. Resident #34 said the other resident was in her room, and stated, She squirted my eyes with some hand sanitizer. Resident #34 said she is still having problems with her left eye being blurry. Resident #34 said it made her feel very vulnerable. Resident #34 said she was moved to another area of the building, and she feels isolated now. Review of resident #34's progress notes showed no additional interventions related to social services or the resident's emotional well-being, following the physical abuse by resident #9. A review of Facility Reported Events showed resident #9 acted out on #34 on two occasions, on 3/11/25 and 6/11/25. During an interview on 8/6/25 at 12:09 p.m., staff member E said she was not even aware of resident #9 squirting hand sanitizer in resident #34's eyes. Staff member E said she only assesses the residents quarterly, or as needed, if she thinks it is necessary. Review of resident #34's medical record showed resident #34 had a (PHQ-9) Patient Health Questionnaire-9 completed on 1/7/25 and 7/1/25. The assessment was not completed quarterly, as stated by staff member D. The PHQ-9 is used to assess the resident for depression. 2. Review of resident #13's nursing progress notes dated 7/27/25 showed resident #13 was crying and upset. Resident #9 grabbed #13's face and and would not let it go. The nurse intervened and removed resident #9, but resident #13 was upset. The progress notes did not contain any information regarding interventions for the prevention of abuse or to address the resident being upset.During an interview on 8/7/25 at 8:20 a.m., staff member B said resident #13 is either usually very happy or she cries. The staff thought her crying was just part of her usual behavior, and did not correlate it to the other resident grabbing her face. Review of resident #13's progress notes reflected that there was no documentation to show the resident's psychosocial or emotional health was assessed specifically following the abuse that caused her to cry and become upset.

Based on observation, interview, and record review, the facility failed to thoroughly investigate resident to resident altercations, alleged to be abuse, for 3 (#s 19, 29, and 30) of 19 sampled and supplemental residents. Findings include: 1. During an interview on 12/4/24 at 2:50 p.m., staff member A stated she submitted the initial report and findings for the incident, which occurred on 10/17/24. The incident involved an injury of unkown orgin for resident #19. Staff member A felt the injury of unknown origin found on resident #19's forehead was not from an unwitnessed fall. Staff member A stated if resident #19 had fallen, she would not have been able to get back in her wheelchair without assistance. Staff member A stated there were no reports of any unwitnessed falls for resident #19. Staff member A stated resident #19 and resident #29 were roommates on 10/17/24 when resident #29 was observed being the aggressor in an altercation with another resident. Staff member A stated she felt there was a possibility the injury to resident #19 was sustained during an unwitnessed altercation between resident #19 and resident #29. Resident #19 would not have been able to defend herself due to her physical and cognitive limitations. Staff member A stated resident #19 was moved to a different room, away from resident #29. Review of a Facility-Reported Incident, dated 10/17/24 and submitted to the State Survey Agency, showed resident #19 was found to have a new bruise on her forehead, above her left eye. The incident findings, reported on 10/22/24, failed to show what the potential causes were for the injury to resident #19, including staff member A's feeling the injury may have been caused by resident #19's roommate, resident #29. The report submitted also failed to show resident #19 was moved to a different room for her safety. 2. Review of two Facility-Reported Incidents, dated 10/17/24 and 10/24/24, showed the physical altercations which occurred between resident #29 and resident #30. The 10/17/24 incident showed resident #29 was seen punching resident #30 in the right shoulder. The investigation failed to show observations of resident #29's interactions with other residents, interviews with other residents and staff regarding the incident and any other similar interactions, and corrective actions implemented to protect resident #30 and other vulnerable residents from abuse. The second incident occurred on 10/24/24 and showed resident #29 hit resident #30 on the top of the head and pulled her hair. The investigation failed to show interviews with residents and staff regarding the incident or any corrective actions implemented to protect resident #30 and other vulnerable residents from abuse by resident #29. During an interview on 12/04/24 at 2:27 p.m., staff member B stated she investigated the altercation which occurred on 10/24/24. Staff member B stated both residents were cognitively impaired, and therefore it was only mistreatment rather than abuse by resident #29. Staff member B was not able to describe how residents were protected from abuse other than monitoring residents and separating residents if any incidents occur. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, not dated, showed the follow-up investigation report contained sufficient information to describe the incident and any corrective action taken. The policy failed to show what was done when the incident involved residents rather than staff and residents.

Based on observation, interview, and record review, the facility failed to prevent a resident from eloping and wandering the facility from the facility for 1 (#12) failed to implement interventions for #12's wandering behaviors causing resident's to be upset, for 2 (#s 12 and 15) of 4 sampled residents. Findings include: Review of a facility reported incident regarding resident #12, dated 6/3/22, showed, Facility under COVID outbreak lockdown since Tuesday 5/31/22. Residents are all a little out of sorts being isolated to their rooms. Also, this resident is normally quite busy and does roam around the facility, occasionally trying to open the doors. When staff have been busy with other residents, there has just not been anyone available to redirect resident before she is able to get outside. Our wander guard system is functioning properly, but if you hold the exit bar long enough, even when the alarm is sounding, the door eventually opens - It is a safety feature. Some residents hold onto the exit bar long enough for this to happen. If the alleged violation(s) was verified, what corrective action has been taken? Staff are doing more one on one with resident as able .Incident Description: Elopement - resident once again able to get out the north door. All staff were assisting other residents when the door alarm sounded. Resident was found standing in the parking lot looking around and easily came back in. Review of a facility reported incident regarding resident #12, dated 11/7/22, showed, .Incident Description: Un-witnessed elopement - Resident entered building through Kitchen door. Method of elopement unknown. Wanderguard in place and functioning properly. Wanderguard doors checked and functioning properly, service doors checked and locked as appropriate. Facility document titled, Elopement for resident #12's elopement, dated 11/6/22, showed, .Nursing Description: Notified by Kitchen staff member that resident had come in to kitchen from outside and was cold. Unsure how resident left the building as wanderguard was on and had been functioning prior to the Incident .Assisted resident to nurses station provided warm blanket to resident comfort. Confirmed wanderguard placement. Family and DON notified of incident. [sic] Review of a facility document titled, Manager's Agenda dated, 11/9/22 showed, .[Resident #12] elopement -out kitchen door? Wanderguard on kitchen door that hasn't been working, other doors that go outside that don't have alarm *lock hallway door all the time. [sic] There was not any documentation provided which showed the investigation of how the resident exited the facility or for how long the resident was outside the building. During an interview on 12/6/22 at 1:38 p.m., staff member K stated resident #12 has eloped out of the facility multiple times. She stated resident #12 will try to go out any time and any door. There does not seem to be any pattern at all. Staff member K stated she did have a wander guard on her ankle. When a resident with a wander guard went up to an exit door, the door will lock, and the electrical panel at the nurses station would indicate a resident with a wander guard was at the door with a blinking red light. If the resident pushed on the door long enough the door would eventually unlock and the door alarm would sound. Staff member K stated resident #12 often pushed on the door long enough to exit the facility. If staff saw resident #12 trying to get out of the building, they were instructed to redirect her. Staff member K stated there was not anything that kept the resident busy. Resident #12 would also wander into other residents' rooms and take their things or move their stuff to other resident's rooms. Some of the residents get pretty upset by this, and staff redirect her and return the items she had taken or moved. During an interview on 12/6/22 at 2:09 p.m., staff member L stated, resident #12 wandered and was exit seeking all day long, she was very busy. Staff member L stated she was constantly going into other resident rooms. If staff noticed this, they redirect her. Staff member L stated last week resident #12 took the entire water fountain off of the hallway wall. Staff member L stated she was hard for staff to redirect, but it usually worked if a male staff member redirects her. During an observation on 12/6/22 at 4:12 p.m., staff members were busy taking residents to the dining room for dinner. Resident #12 was wandering the north hall by resident #1's room. Resident #12 started to push and knock on resident #1's door, which had a wooden 1/2 door in front of the main door. Resident #10 yelled at resident #12 to not go in that room, and to stop banging on the door. Resident #12 walked away from the door and proceeded to attempt to exit the facility out of the east hallway exit door. Resident #12 pushed on the door until it unlatched. Staff member J stopped her before she exited the facility. During an observation on 12/6/22 at 4:19 p.m., resident #12 got up from a chair in the hallway by the nurse's station, walked over to the TV, and picked up the rack of TV stands and carried them to the middle of the hallway. Staff member J grabbed them from resident #12 and put them back under the TV. During an interview on 12/7/22 at 8:50 a.m., staff member M stated, the 1/2 wooden doors that are in front of some resident rooms are to keep resident #12 from entering their room. Staff member M stated she thought it helped. During an observation and interview on 12/7/22 at 9:55 a.m., resident #15 had a 1/2 wooden door on the entrance of her room. She stated it was so resident #12 did not go in her room. Resident #15 stated there was one time resident #12 wandered in her room in the middle of the night and fell asleep on her couch. Resident #15 stated it scared her because she woke up in the middle of the night, and she did not know who it was right away. She stated it felt unsettling to know that the resident was able to go in her room without her knowing, and fall asleep on her couch. Resident #15 stated there was another time resident #12 came in her room and tried to take her things. During an observation on 12/7/22 at 2:03 p.m., resident #12 attempted to elope out of the main entrance from the facility. The door alarm went off and the resident was able to open the first set of doors. Resident #12 was stopped before she exited the facility. Review of resident #12's care plan showed: Focus: The resident is an elopement risk/wanderer, r/t Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities Date Initiated: 2/8/22 . Goal: The resident's safety will be maintained through the review date. Target Date: 1/31/22 The resident will not leave facility unattended through the review date. Target date of 1/23/22 .Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 2/8/22 Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate Date Initiated: 2/8/22 .WANDER ALERT: Resident will have wander guard on at all times to prevent eloping. Date Initiated: 2/8/22.

Based on interview and record review, the facility failed to protect 1 (#32) from resident to resident abuse with injury by resident (#82); failed to protect 1 (#7) from alleged abuse with injury; and failed to protect 1 (#00) from neglect, of 5 sampled and supplemental residents. Findings include: 1. Record review of resident #82's Care Plan, dated 2/14/20, showed a concern for: Behavioral Symptoms: Angry outbursts, inappropriate physical behavior and inappropriate verbal behavior. Evidenced by: No concept of what is dangerous, left family while on a (sic) outing and ended up hurt and in jail. Punched a CNA in the face while trying to elope. Curses and yells at residents and staff. Threatened resident that he would kill her after she provoked him . Approaches: Monitor resident for aggressiveness. Restart [MEDICATION(S)]. Offer a cappuccino. Assist him to help call his sister. The care plan did not include interventions to protect other residents or staff from the resident. Record review of a Facility Reported Incident, dated 8/26/20, at 1:20 p.m., showed, On August 26, 2020 at 1:30 p.m. [staff member K] notified [staff member B], of an altercation in the hallway she overheard from her office. [Staff member B] and [Staff member A] reviewed the video this morning (8/27/20) to verify. [Resident #82] and [resident #7] were in the hallway near the dining room doors, in their wheelchairs, passing each other going opposite directions. [Resident #82] propels his wheelchair with his feet sporadically at times and it appears that the two residents' wheelchairs became intertwined. It is unclear from the video if words were exchanged, but it is clear to see that [resident #82] reached over and grabbed at [resident #7], then also grabbed her right arm and bent it back and held on to it. [resident #7] was starting to get away by backing herself away from [resident #82], and it was at this time that [staff member K] came out of her office to assist. [Resident #82] ended up also having possession of [resident #7's] glasses and left a small scratch below her eye where the glasses had rubbed as [resident #82] took them off her face. The scratch below [resident #7's] eye is not major and did not need much treatment. But as of this morning her hand was swollen so she was taken to the hospital for an X-ray. Her family was notified of the incident and will be notified of the results of the X-ray. Two bones in one of her fingers are broken, per the X-ray results. [Resident #7] will have a brace on that hand. [Resident #82] has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #82] has been involved in a number of incidents with residents in the last few months. Record review of a facility document, titled Type of Visit: Brief, dated 8/31/20, signed by the physician, showed: [Resident #82] is noted to have recently twisted another resident's hand and gave her some small fractures in her hand. [Resident #82's] behaviors have been somewhat better controlled with the use of [MEDICATION(S)]. We had cut back on his [MEDICATION(S)] due to sedation. It seems that a relatively sedated [Resident #82] would be safer to have than an un-sedated [Resident #82] now that he has injured someone else . Use of [MEDICATION(S)] is thought safer for both [Resident #82] and everyone else in the facility presently and we will accept a little bit of sedation in exchange for resident and staff safety. The physician note did not include any behavior modification interventions for resident safety. Record review of a facility document, titled Type of Visit: Routine, dated 9/21/20 signed by the physcian, showed, under the subjective heading: . There was another concern voiced in that he (resident #82) has 'hurt three women residents,' but it has been in the past several weeks. The incidents are about a month ago he grabbed someone's hand and caused a significant skin tear on the dorsal left hand (having checked on that patient today too, the wound is completely healed). A second incident he grabbed another woman patient's hand, kind of twisted it and caused her some fractures. She is currently in a cast, which will be rechecked at the end of this month. The third incident just over the weekend apparently. He got upset when someone told him that another woman patient 'wasn't his,' and he started waving his arms and I believe rather inadvertently but still hit this woman in the face, broke her glasses, knocked them off, did not cause any other significant injury to the patient. Under the O heading of the same document, it showed: . I specifically asked [Resident #82] if he understood that hurting other people was not okay. To that question, he answered clearly 'yeah,' and nodded his head in the affirmative . Behavior is frankly dangerous to other residents at this facility at this time. Under the plan heading of the same document it showed: . We will try the increased [MEDICATION(S)], managing his bowels even better, I think we will also add [MEDICATION(S)] to his regimen. It will certainly help any GI problems but in using it for its anti-adrogenic effect perhaps it will help as well since most of his aggressions seem to have been against female residents here recently. During an interview on 9/2/21 at 8:59 a.m., staff member A stated the facility discussed resident #82's behaviors at least weekly. She stated he was not purposeful in his wheelchair, but did not want people in his way. 2. Review of a Facility Reported Incident, dated 5/8/21, showed resident #32 told a staff member she did not want staff member J caring for her. She stated staff member J was transferring her, and she received a skin tear from 'bumping her arm.' Resident #32 reported she believed staff member J contributed or caused her injury. An x-ray revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the investigation showed resident #32 had [CONDITION(S)]. Staff member B interviewed staff member J regarding the injury, and staff member C spoke with staff member J on 5/17/21. The physician stated the fracture is consistent with the resident putting her hand out and 'not really to [sic] turning.' The incident showed the facility did not believe this was abuse or mistreatment. The findings from staff member J's interviews were not documented. No other residents were interviewed for further care concerns with staff member J. During an interview on 9/1/21 at 3:01 p.m., staff member C was asked about the lack of the interview documentation with staff member J and how the interviews could more clearly show how abuse was not substantiated, and she replied Gotcha. She stated staff member J was no longer working at the facility, as of 5/8/21. Resident #32 was no longer in the facility and unable to be interviewed regarding the incident. 3. Review of the facility file for 'Grievances' showed a typed statement, untitled, dated August 5, 2021: A family member was 'very upset' that resident #00 had not received care for 4 hours, and had not received her lunch. Staff member B explained to the family member that resident #00's CNA, staff member H, had been giving a bath to an out-patient, and it had taken longer than expected. Staff member H did not realize the resident had not been given her tray for lunch. This was discussed with the CNA and a message was sent to all the CNAs stating that this resident no longer has a catheter and needs to be toileted before and after meals. During an interview on 8/31/21 at 3:05 p.m., staff member B stated the alleged neglect was not 'intentional' neglect by the CNA, and the family member understood the situation, so staff member B did not feel it was a reportable incident or neglect. Staff member B stated she did investigate the allegation, but it was not thoroughly documented. Staff member H continued to work at the facility, and no other residents were interviewed for further concerns of neglect. Resident #00 was no longer residing in the facility and was not able to be interviewed.

Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in multiple falls with injury; failed to implement interventions, and failed to adequately identify root causes for the prevention of falls for 2 (#s 15 and 28); and failed to prevent a fracture from range of motion with no current physical therapy plan for 1 (#1) of 21 sampled residents. Findings include: 1. During an observation on 10/30/19 at 1:58 p.m., resident #15 was observed walking with two person assistance, with a staggering and uncoordinated gait. Review of resident #15's Incident Report: Falls, dated 11/29/18, showed the resident fell in the hallway, hit his head, and had rib pain. An x-ray at the ER showed six fractured ribs and a popped lung. The fall was unwitnessed. The Investigation portion of the report showed none. No root cause analysis was identified. No new interventions were noted on the Care Plan. Review of resident #15's Care Plan, with a review date of 11/14/19, did not identify the fall with injury or new interventions to prevent further falls. Review of resident #15's Incident Report: Falls, dated 9/9/19, showed the resident had an unwitnessed fall at the south door. No fall precautions or root cause were identified. Review of resident #15's Incident Report: Falls, dated 9/10/19, showed the staff heard a crash and saw the resident sitting on his bottom in front the bathroom door. The fall was unwitnessed. No bruising was noted, but he did receive a skin tear on his right forearm. No root cause or investigation was completed. Review of resident #15's Incident Report: Falls, dated 9/12/19, showed the roommate was coming out of the bathroom when resident #15 was on the floor. He hit his head, a bloody mess. No root cause or interventions were identified. Review of resident #15's Incident Report: Falls, dated 9/18/19, showed staff heard a noise and found the resident sitting on the floor scooting to the bathroom. No root cause or interventions were identified to prevent further falls. Review of resident #15's Incident Report: Falls, dated 9/22/19, showed the resident fell in his room on the way to the bathroom. Reopened scrape to left knee. No root cause or interventions were identified or implemented. Review of resident #15's Incident Report: Falls, dated 9/24/19, showed the resident was in his wheelchair tried to open the door, and fell out of the chair. The fall was unwitnessed, with no fall interventions implemented. Review of resident #15's Incident Report: Falls, dated 10/20/19, showed the resident fell out of bed. The fall was unwitnessed. The apparent cause of current problem is: didn't have gripper socks on, was barefoot and was unable to stand up. Measure to be implemented to prevent future similar problem; try to get him to wear gripper socks. Review of resident #15's Care Plan, dated 11/14/19, did not include gripper socks as a fall intervention. Review of resident #15's Incident Report: Falls, dated 10/29/19, showed an unwitnessed fall out of bed. No investigation or root cause was identified, and no interventions were implemented. During an interview on 10/29/19 at 4:53 p.m., staff member G stated she was aware of resident #15's falls, and they had decreased since he started to use a wheel chair. She stated his bed was in the low position, and the staff had increased his supervision, by checking his room. She said the resident was impatient and could not use his call light. She stated she was not aware of any other interventions, or anything on the Care Plan, or his Care Plan sheet. During an interview on 10/30/19 at 4:28 p.m., staff member H stated she did not know anything about resident #15's falls or interventions. Staff member H regularly worked on the same hall where resident #15 was located. During an interview on 10/31/19 at 10:28 a.m., staff member I stated the staff kept resident #15's door open so they could hear him when he began to move. She stated the bed was low, and the resident could move quickly. She stated walks outside seemed to help prevent falls. Review of resident #15's Fall Care Plan, with a review date of 11/14/19, showed no falls had occurred or that walking outside might be helpful to prevent falls. During an interview on 10/31/19 at 10:28 a.m., staff member C stated the facility did not put falls on the Care Plan. She stated the CNAs should know the fall interventions because they are on the Care Plan. No new fall interventions were on resident #15's Fall Care Plan, because the facility implemented the Century brake for the wheel chair. Review of resident #15's Fall Care Plan showed the following interventions: Century brake to back of wheelchair - 3/27/19. Anti tip bars to back of wheelchair - 3/27/19. Ambulate with assistance - 8/14/19. Encourage participation with Restorative Care - 8/14/19. Resident #15's Fall Care Plan did not include fall interventions or increased supervision after seven unwitnessed falls from 9/9/19 through 10/20/19. During an interview on 10/31/19 at 11:26 a.m., staff member [NAME] stated they tried to update the Care Plans, as incidents occurred, and not just on a quarterly basis. She stated the facility did not do a root cause analysis for falls. Review of resident #15's CNA Care Plan Sheet did not include fall prevention interventions. Review of the facility Falling Star Program Worksheet for (MONTH) 2019, did not show root causes or fall prevention interventions for resident #15. During an interview on 10/31/19 at 11:26 a.m., staff member [NAME] stated the facility used the Worksheet to discuss falls, and what interventions might be helpful. This information was not documented. 2. During an interview on 10/31/19 at 11:51 a.m., staff member J stated she would typically get a restorative flow sheet from the Physical Therapy department. She did not receive a flow sheet for resident #1 because she had worked with him before for range of motion for his fingers. She said he asked her to work with his arm. Review of a typed written note submitted by staff member E, dated 2/28/19, showed (Resident #1) sustained a fracture in his arm. He was getting passive range of motion by rehab aide. Staff member J came to the nurse's station immediately when it happened. Staff member J was in tears and said that she was pretty sure his arm broke while she doing range of motion. Resident #1 was sent by ambulance to the ER for evaluation directly. Review of resident #1's Nursing Progress Note, dated 2/28/19, showed he had a fractured left humerus. Review of resident #1's Nursing Progress note, dated 2/28/19, showed staff member J was doing passive range of motion this a.m., which had recently been restarted due to stiffness, when she heard a snap while working with the left arm. During an interview on 10/31/19 at 11:55 a.m., staff member D stated there was no Physical Therapy evaluation for resident #1 to restart passive range of motion for the arm. During an interview on 10/31/19 at 12:07 p.m., staff member [NAME] stated resident #1 should have had a Physical Therapy evaluation, in hindsight, but staff member J had been working with resident #1's fingers for quite a while, and the resident had requested more work with his arms. 3. During an observation on 10/28/19 at 4:30 p.m., resident #28 had a dark purple, round bruise on her chin, measuring approximately one inch in diameter and had a wander guard device affixed to the back of her shirt. Staff were assisting other residents as resident #28 wandered in and out of the dining room. During an interview on 10/31/19 at 7:58 a.m., staff member D stated, We look at falls every week in care plan meetings and change the care plan looking at the times and where the falls happen. We also take a lot of residents that have a history of falls. We educate the staff not to be afraid to lower the bed, put the resident on a toileting program, add more frequent checks, and continue to try to change things. Staff member D was asked if a root cause is completed on every fall and stated, No, I don't do a root cause analysis on every fall. This is a very small facility and we know what is going on. There is no tracking except to pull every fall and see what had happened. New interventions are conveyed to the staff verbally, on the CNA care sheet, email, and sometimes it makes it to the report sheet also. Review of resident #28's Fall Risk Assessment, dated 9/5/19, showed the resident scored a 60, which placed the resident at a very high risk for falls. Review of facility Incident Reports for resident #28, showed the resident had three falls between the admission date of [DATE] and 10/31/19. a. Review of resident #28's Incident Report for the fall on 10/2/19 at 11:15 p.m., showed resident #28 was found in her room, sitting on the floor, next to the bed. The incident report showed a CNA had helped the resident into a recliner, prior to the fall, and had the foot rest up. The foot rest was still up when the resident was found on the floor. No investigation or root cause was completed for this fall. b. Review of resident #28's Incident Report for the fall on 10/24/19 at 2:30 p.m., showed resident #28 was found in her room, sitting on the floor, in front of the bed. The incident report showed no contributing factors were identified related to the fall, documentation showed resident #28 had wraps on her legs and was wearing socks. Resident #28 had injuries which included a bump on the back of her head, a bruised upper lip and lower lip, and a bruised chin. No investigation or root cause was completed for this fall. c. Review of resident #28's Incident Report for the fall on 10/29/19 at 12:30 a.m., showed resident #28 was found sitting on the floor, in the bathroom, after staff heard her yelling. The investigation of resident #28's fall showed: -Floor dry, light on in bathroom, -walked to bathroom without walker or wheelchair, she normally walks all over building without anything, -no medication since HS, -missed the toilet, -she had her pants and pullup pulled down, -she did have her shoes on, -Measure to be implemented to prevent future similar problem: was assisted to bathroom earlier at beginning of shift. Review of resident #28's Admission MDS, with an ARD of 9/10/19, showed: -rarely/never understands others, -severely impaired, -one person physical assist for transfers, bed mobility, walk in room, walk in corridor, locomotion on and off unit, -Non-Alzheimer's dementia, depression, dementia with behavioral disturbances, -fall history in last month prior to admission, -care area triggered in Care Area Assessment as falls. Review of resident #28's Care Plan, dated 9/17/19, showed under cognitive loss: -Inability follow instructions, -no concept of what is dangerous, trys (sic) to elope, -unable to remember task long enough to complete, -salad speech. Review of resident #28's Care Plan, dated, 9/17/19, showed risk of falls approaches: -Assess clothing and footwear daily for any safety hazard, -assess fatigue and tolerance to activity, -encourage use of wheelchair with increased fatigue. Review of resident #28's Care Plan, updated 10/15/19, under fall approaches, showed, Encourage use of walker for ambulation. Review of resident #28's ADL Care Plan Sheet, with admission date of [DATE], showed fall risk as high. During an interview on 10/31/19 at 9:11 a.m., resident #28 stated when asked about the bruise on her chin, Someone hit me, but I can't remember. When resident #28 was asked if she had ever fallen, she stated, No, I don't fall, I don't remember. During an interview on 10/31/19 at 9:20 a.m., staff member C stated the process for documenting interventions for falls was to discuss the falls in the care plan meetings, and if the resident continued to fall, they looked at different options. During an interview on 10/31/19 at 9:36 a.m., staff member I stated she was always watching a resident that was at risk for falling and received information on the fall risk from the charts and the ADL sheet for CNAs. During an interview on 10/31/19 at 10:08 a.m., staff member K stated she knew if a resident was a fall risk by looking in their charts and the unit report books. Staff member K stated, You should always keep your eyes on them and use the gait belt. During an interview on 10/31/19 at 10:40 a.m., staff member A stated, We make resident #28 use her walker, try to get her in a wheelchair, but we mainly try to have her sit at the nurse's station so we can watch her. During an interview on 10/31/19 at 10:44 a.m., staff member [NAME] stated the administrative team goes over falls every week. Staff member [NAME] stated, We implement things such as using Century brakes, lower the resident's beds, and we have our falling star program. Review of the facility's policy titled Falling Star Program, dated 11/2009, showed: -Residents who incur a fall will be put on the Falling Star Program on the shift that the fall occurs, -residents who incur a fall will be monitored and assessed in order to implement and develop an individualized plan of care to address the fall, -the resident will remain on the Falling Star Program for at least 30 days, -communicate to all staff members the residents that are at risk for falls by a falling star on his/her door. During on observation on 10/31/19 at 11:00 a.m., resident #28's room door did not have a falling star program emblem adhered to the door.

Based on observation, interview, and record review, the facility failed to ensure a resident received continued monitoring and care according to professional standards of practice for a resident who had respiratory distress, needed to go to the ER (emergency room ), and the resident was admitted to the hospital, and was required to be intubated and placed on a ventilator, for 1 (#33) of 14 sampled residents. Findings include: During an observation and interview on 10/2/18 at 2:14 p.m., resident #33 was in physical therapy exercising. Resident #33 said she would be finished shortly and return to her room. The resident was wearing oxygen per a nasal cannula. During an interview on 10/2/18 at 2:15 p.m., resident #33 said The first Saturday in March, staff member C 'dilly dallied' when I had pneumonia. Resident #33 said, (Staff name) sent me to the hospital by the facility van instead of by ambulance. The resident said, (Staff name) thought I was 'joking' (referring to her medical status). Resident #33 stated, At the hospital they had intubated me and placed me on a ventilator. I was in the hospital for ten days. The resident said, I worry that it could happen again to me or others. During an interview on 10/2/18 at 1:47 p.m., staff member C said, A CNA got me out of report as resident #33's color was bad and she was having a hard time breathing. Staff member C said she placed oxygen on resident #33, got her in a wheel chair, and called the doctor. The doctor said to send her to the ER. Staff member C said the activity person transported the resident by Van. Review of resident #33's ER report titled History and Physical Report, dated 3/3/18, showed resident #33 was admitted on [DATE]. The report showed the resident was brought to the ER for fever, low oxygen, and lung congestion. The resident's vitals, taken in ER, showed a temperature of 101.1 Fahrenheit, and an oxygen saturation of 79% on 5 liters of oxygen per nasal cannula. Resident #33 was intubated in the ER, and placed on a ventilator. Under the title of Assessment, showed acute hypoxic [MEDICAL CONDITION], ventilator dependent, likely secondary to #2, possibly due to pneumonia as well 2. [MEDICAL CONDITIONS] 8. Prognosis: Guarded. Resident #33 was discharged back to the facility from the hospital on [DATE]. Review of resident #33's typed, unsigned note from the facility, dated 3/13/18, showed resident #33's family member reported his concern that the resident had been transported to the ER by the facility van, and not by an ambulance. The typed note also showed that, According to the charting, the resident was alert and talking to staff and although having some 'respiratory distress' and her oxygen was 79% on 5 L/NC, she was not impaired cognitively. Review of resident #33's typed, unsigned note from the facility, dated 4/17/18 showed, staff member C was on duty when the resident went to the hospital. The note showed that staff member C had heard in report that she (resident 33) wasn't feeling that well. The note reflected that staff member C wished she had sent the resident by ambulance, knowing the resident was intubated shortly after she arrived at the ER.

Based on observation, interview, and record review, the facility failed to address a significant weight loss of 5.5% in less than 30 days, for a resident who had already lost a significant amount of weight since his admission, for 1 (#3) of 14 sampled residents. Findings include: During an observation on 10/1/18 at 12:15 p.m., resident #3 was seated at a dining table. His wife was seated next to him. Resident #3 was served his food. The resident's wife cut up his ham and assisted him with eating. During an interview on 10/3/18 at 3:05 p.m., NF1 said she was concerned about resident #3's continued weight loss. NF1 said the resident ate well at most meals, and he did have liquid supplements for his weight loss. NF1 said resident #3 did drink his supplements most of the time. NF1 said she did not understand why resident #3 continued to lose weight. NF1 said she was at the facility with resident #3 every day. Review of resident #3's Weights and Heights report showed the resident weighed: - 7/25/18 weighed 145.2 pounds, and - 8/22/18 weighed 137.2 pounds, for an unidentified, significant weight loss of 5.51% in less than 30 days. Review of resident #3's nursing notes, from 7/10/18 to 8/28/18, failed to show the physician was notified of the significant weight loss between 7/25/18 to 8/22/18. A nursing note, dated 8/19/18, a late entry for 8/16/18, showed staff member B had a conversation with NF1 regarding resident #3's weight loss. The nursing note did not identify resident #3 had a significant weight loss of 5.51%, from 7/25/18 to 8/22/18, to NF1. Review of resident #3's physician progress notes [REDACTED]. The physician's progress note, dated 8/7/18, showed, Weight on 8/1/18 was 141 lbs, a year ago reported as 149 lbs. He is recovering some of his weight. Review of resident #3's physician progress notes [REDACTED]. The note did not discuss the resident's weight loss. Review of resident #3's care plan, titled In facility weight loss, showed the resident had a 5.80% weight loss in 11 days, and it was noted, on 6/20/18, his weight was increasing. The goal for the resident's weight loss was, Resident will get strong and put on some weight. The approaches or interventions, noted on the care plan were, Weigh before breakfast in nightclothes once a week. Assist resident at beginning of meal by {cutting meat, opening packages, buttering bread, arranging food}. Monitor intake of each meal for two weeks. and 60 cc two cal TID with med pass, supp (sic) of choice bid. This care plan had a goal date of 12/20/18, and was last reviewed on 9/20/18. The care plan had not identified, or addressed the significant weight loss of 5.51%, between 7/25/18 and 8/22/18. No new goals or approaches were added to the weight loss care plan at that time. During an interview on 10/3/18 at 4:31 p.m., staff member B said staff member E did the dietary care plans. During an interview on 10/4/18 at 11:15 a.m., staff member E said she did the weight loss care plans. Staff member E said she also monitored the resident weights for weight loss. Staff member E said if a resident was identified with a weight loss she would notify the RD and get an order for [REDACTED]. Staff member E said if a resident had a continued weight loss, she would consult with the RD to try different interventions to prevent further weight loss. Staff member E said she would write a note in the nursing notes, notify the charge nurse, and update the care plan immediately for any changes related to a resident. She said the charge nurse and the RD would notify the physician of resident significant or severe weight loss. Staff member E asked to review resident #3's Weights and Heights Report, specifically the weights recorded from 7/25/18 to 8/22/18. Staff member E said the CNA staff have frequently entered incorrect weights for residents, and she had tried to correct them as that happened. Staff member E said the CNAs were not supposed to enter weights with a decimal point. She said they were supposed to enter a whole number. Staff member E asked if using a whole number would make a difference in the percentage of weight loss for resident #3. A demonstration was provided to her and the resultant loss was the same amount. Staff member E provided a copy of the RD's current dietary note for resident #3. The note was dated 8/22/18 and showed, wt: 137.2# indicates a 4% loss in one month and 8% loss since March. BMI currently 21.7. Reviewed note written on 8/19 regarding food preferences. Recommend staff visit resident to obtain a detailed food prefence (sic) list. Also, recommend add 3 tsp butter or margarine to appropriate foods at each meal. Also, recommend add 2 Tbsp heavy whipping cream to appropriate foods/beverages to increase calorie density of foods. Staff member E did not know what weight the RD had used as a starting weight to determine the 4% weight loss.

Based on observation, interview, and record review, the facility failed to maintain the resident's highest well being, by ensuring the facility had signed physician orders to treat a resident, failed to have timely access to a physician in an emergency for a resident who had a fall, who had pain, and who had an injury which required a higher level of care for the treatment of [REDACTED].#7) of 10 sampled residents. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 06/05/07 at 2:50 p.m., resident #7 was visiting a family member. He was able to ambulate down the hall with use of a cane. During an observation and interview on 06/07/17 at 8:20 a.m., resident #7 was sitting on a low bed and expressed how upset he was. He stated that he didn't have a good night as he had slipped on liquid on the floor in the bathroom around 4:00 a.m. Resident #7 also stated he hurt his left ankle, which was swollen. The ankle had been wrapped and his sock placed over it. He also stated he was a diabetic, he had not eaten and he did not have any of his medications yet and was waiting for a wheel chair to go eat. Resident #7 did not know if the doctor was notified or not regarding the injury. He did not know what the staff were doing relating to the injury. During an interview on 06/07/17 at 8:45 a.m., staff member G stated resident #7 fell in his bathroom, and slipped on liquid. Resident #7 told her his left foot was sore, and I wrapped it for support. Staff member G also stated that she did not know for sure if the doctor or family was notified yet of the fall and injury. She also added that the resident could have a stress fracture. During an interview on 06/07/17 at 9:20 a.m., NF1 stated family had not been notified of his fall, and I was not notified until I got here this morning. She also stated it was almost 10:00 a.m., and He hasn't had his medications, he is diabetic, and on insulin. NF1 said that the resident told her he fell around 4:00 a.m. She also said the resident would not stay there if this is how it is. NF1 was told by the medication nurse that she would call about his medications. During this same interview, resident #7 said his left ankle hurts like hell, it is throbbing, and they need to do their job. During an interview on 06/07/17 at 9:30 a.m., staff member D stated the resident took himself to the bathroom and slipped around 4:00 a.m., and said I told (NF1) about 10 minutes ago that we don't notify the doctor right away. The resident did complain of left ankle pain. At this time, the fall and injury had occurred approximately four and a half hours earlier. During an interview on 06/07/17 at 1:25 p.m., NF2 stated there were no physician orders for resident #7, and he had also checked with the consultant for the facility. He stated that the facility was going to admit the resident last week but didn't, and Usually, we have admit orders by now. I will contact (staff member A) to check on admit orders. Due to this, the resident was treated without signed physician orders. See F281 Professional Standards. Review of the facility's LN Report Chart, the note written by night staff dated 06/07/17 at 4:00 a.m., showed the resident fell coming from the bathroom, {liquid} on the floor, and complained of left ankle pain. The doctor will be here on rounds and will be notified this morning. During an interview on 06/07/17 at 9:50 a.m., staff member B stated We don't call the doctor or family after 9:00 p.m., unless it is serious such as a head injury or obvious hip dislocation. If a resident complained of pain after a fall, and if severe, yeah we will call during the night. Staff member B stated the doctor hadn't been notified. The covering doctor was expected to be at the facility on 06/08/17, and arriving from out of town. Review of the resident's nursing notes, dated 06/07/17 at 5:34 a.m., showed that resident #7 had a fall at 4:00 a.m. and complained of left ankle pain. It also showed the resident's family was not notified, and the physician will be here for rounds today, will notify her then and have her check his left ankle. Review of another nurse's note in resident #7's record, which was a late entry, written on 06/07/17 at 1:11 p.m., showed when the resident's left ankle was examined by staff member G that there was some swelling of the left ankle, slight discoloration, and no actual bruising. Forward and backward ROM was performed by staff member G on the left ankle and was done without complaints of pain. Internal and external ROM was done with minimal complaints of pain. The note also showed that resident #7, when asked to stand and bear weight, was able to do as requested. Resident #7 was able to take approximately two steps forward, pivot, and take two steps back, before sitting down. It was noted by staff member G that he only put partial weight on the left foot when taking steps and was using a cane. Review of the resident's nursing note, dated 06/07/17 at 3:56 p.m., showed staff member D recorded that resident #7 was complaining of pain, his left ankle seemed more swollen, and the doctor would be notified. Staff member D documented that the doctor did not return a call back right away, and staff member D started writing an order since she felt the resident's situation seemed more serious. The doctor returned a call and ordered the resident to be transported to the ER. The resident was transported by the activities van at 10:30 a.m. Review of the resident's nursing note on 06/07/17 at 4:34 p.m., showed staff returned from the hospital and stated the resident was staying overnight and would have surgery in the morning for a fracture. During an interview on 06/07/17 at 4:00 p.m., staff member B stated that a family member from the hospital called, and resident #7 had broke his ankle and would undergo surgery.

Based on interview and record review, the facility failed to obtain signed physician orders [REDACTED].#7) of 10 sampled residents; and, the resident required an emergency transfer to a hospital after a fall with injury and pain that resulted in a fracture. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 06/07/17 at 11:26 a.m., staff member D stated the resident's medical record did not include signed physician orders. Staff member D stated she would call staff member B to check on the orders. Staff member B provided the form the facility used for the admission orders [REDACTED]. Review of the resident's Sweet Memorial Nursing Home Physicians Admitting Order sheet showed the form was dated 06/06/17. The orders did not include who the admitting physician was, or the signature by the admitting physician for the resident's admission, medications, or ongoing care needs. Some handwritten entries had been added to the form, by the facility staff. The information added to the form was followed by a list of the resident's medications and treatments that were also hand written on the form, and the form was signed by Staff member A. Staff member A dated the form 06/06/17 at 3:50 p.m. (1550). Review of resident #7's nursing notes, dated 06/06/17 at 4:54 p.m., showed resident #7 was admitted from home, and the resident was an insulin dependent diabetic and the facility was waiting for progress notes from a local health clinic. The note was signed off by staff member B. Review of another nurse's progress note, dated 06/07/17 at 5:34 a.m., showed resident #7 had an unwitnessed fall around 4:00 a.m The resident complained of left ankle pain, and the family was to be notified in the morning. The physician would be there for rounds that day. During an interview on 06/07/17 at 9:50 a.m., staff member B stated that the doctor would not be at the facility until 06/08/17, and the doctor had not been notified of the resident's fall and injury. The doctor was coming from out of town and was covering for the regular physician. During an interview on 06/07/17 at 1:25 p.m., NF2 stated they had no admission orders [REDACTED]. Refer to F309 - Maintaining the Highest Well Being for more information on the injury for resident #7.

Based on record review, observation, and interview, the facility failed to maintain the highest level of well-being for 1(#5) of 10 sampled residents. Specifically, the facility did not get medical treatment for [REDACTED]. Findings include: Review of resident #5's Nursing Notes showed the resident had one fall with a major injury but the date was unclear due to the number of falls resident #5 had in March 2016. Review of the MDS sections J0400 and J0600A, dated 1/26/16, showed resident #5 scored a 3 for having occasional pain rated at a 3-severe. Review of the Nursing Note dated 3/27/16 at 12:52 a.m., showed that resident #5 had a witnessed fall on 3/26/16 at 7:00 p.m. The note described the resident falling over another resident's wheelchair foot rest. Resident #5 landed on her side on the floor. The note stated that resident #5 was holding her right rib area and stated it was sore after the fall. The note showed that the physician would be notified during the next visit. Review of Nursing Note dated 3/27/16 at 9:41 a.m., showed resident #5 was holding onto the door frame and attempted to walk but was showing visual signs of pain. The note stated that she winced loudly in pain and grabbed her right side. The note showed she was having pain in the area just below her posterior/lateral right rib cage. The nurse palpated the area causing the resident to wince loudly in pain, made a grimacing face, and stated she was in so much pain and it was causing her to be nauseous. The note described the resident holding on tightly to arms and the edge of the chair, gripping very tightly while wincing and grimacing. The resident continued to state that the pain was making her nauseous. She was given a pain pill and about 1 hour later, she was receiving assistance to change her sitting position, and she continued to wince and grimace and state she was nauseated from pain. Resident #5 stated that her right side felt better lying down. Review of the Nursing Notes dated 3/27/16 at 11:44 a.m., showed resident #5 was given another pain pill at 10:20 a.m. At 11:00 a.m., she continued to report pain with any movement, crying, and asking for medical help. The physician was notified and ordered the resident be given another [MEDICATION NAME]/APAP 5/325 mg. at the time of call and ordered a PRN of the medication every 2 to 4 hours for the day. The note stated that the resident was unwilling to get out of bed or get dressed. Review of the Nursing Notes dated 3/27/16 at 1:46 p.m., showed resident #5 continued to wince in pain if she moved wrong. Review of the Nursing Notes dated 3/27/16 at 11:46 p.m., showed resident #5 had difficulty walking during the shift due the amount of pain that her right side and rib pain was causing. The note showed that the resident cried, complained of pain, and was unable to walk. She was holding her hand on her right side and back. Nursing staff gave resident #5 her scheduled [MEDICATION NAME]. The note described her struggles to sit for any length of time and being so uncomfortable that she would be up and down from sitting. The note stated that the resident was unable to ambulate even with assistance. The note showed that resident had a tabs alert on in bed at the time of the note. The facility did not list any additional interventions for resident #5 at the conclusion of the note. Review of the a Nursing Note dated 3/28/16 at 3:58 a.m., showed resident #5 had an unwitnessed fall in her bedroom. The alarm that was placed on her was going off and the CNA found her sitting on the floor in front of her bed. The note described her resting her head on her right forearm and unable to recall what happened or how she fell . Resident #5 continued to complain of rib pain after the fall. The note showed that the physician would be notified of the fall in the morning. Review of Nursing Note dated 3/28/16 at 7:00 a.m., showed a CNA found resident #5 sitting on the floor beside her bed. The note reflected staff checked on her at 3:00 a.m. and she was in bed, but her alarm was going off at 3:40 a.m. The staff found the resident laying on her right side and assisted her back to bed. The facility did not classify this incident as a fall in the nursing notes. No assessments or interventions were completed according to the review of this note. Review of a Nursing Note dated 3/28/16 at 12:50 p.m., resident #5 was having right sided pain underneath her rib cage. The note showed the pain was increased with palpitation. Resident #5 did not eat anything for breakfast and was complaining about her back/rib area being in pain. Resident #5 reported feeling nauseous and stated, I am going to throw up. Review of a Nursing Note dated 3/28/16 at 11:42 p.m., showed resident #5 crying because her back hurt so badly. The note showed that resident #5 continued to state she was feeling like she was going to throw up. The note indicated that she had her tabs alarm on to alert staff if she was to get up. Review of a Nursing Note dated 3/29/16 at 5:55 a.m., showed that resident #5 continued to complain of lower abdominal pain and was on the physicians list to be seen. Review of the physician's orders [REDACTED]. Review of a Nursing Note dated 3/29/16 at 3:00 p.m., showed that resident #5 was found lying sideways in bed, awake and grimacing with pain. She complained of her right side hurting. She was given medication for the pain at 7:30 a.m., and continued to have pain at 8:30 a.m. The note described resident #5 being doubled over due to her pain level and stating Oh! It hurts so bad, and complained of pain for the entire shift. The note states that the nurse requested that resident #5 go to the hospital to get x-rays of her right side. Review of the Nursing Note dated 3/29/16 at 4:45 p.m., showed that the results of the x-rays revealed a fractured right rib. Review of a Nursing Note dated 3/30/16 at 3:59 p.m., showed resident #5 was in so much pain she was banging on the wall and would jump and grimace with any movement. She was given PRN's for pain. Review Nursing Notes dated 3/31/16 showed that resident #5 was found on the floor in her doorway. She reported that she crawled to the door after she slid off her bed. She stated that her pain was so bad she crawled to the door. The note described resident #5 crying and stating that her pain was bad and was asking staff to please help her. Review of physician's orders [REDACTED].#5 may use abdominal binder for back and rib pain. Review of a Nursing Note dated 4/4/16, showed that the resident was crawling down the halls and was crying stating she had pain in her back and side. During an observation on 4/11/16 around 12:20 p.m., resident #5 was holding her back and walking hunched over complaining of pain. She did not have an abdominal binder on her. During an interview on 4/13/16 at 9:10 a.m., staff member B explained that resident #5 had a history of [REDACTED]. Staff member B stated that after the pain was not going away, they made the decision to get her into to get x-rays. Review of a Nursing Note dated 4/1/16 showed the ace wrap placed on resident #5 ribs for support. Review of a Nursing Note dated 4/2/16, showed that the resident did not have the ace bandage on despite continued complaints of pain. Review of a Nursing Note dated 4/4/16, showed that the resident was crawling down the halls and was crying stating she had pain in her back and side.