Every finding on record at The Atrium of Bellmead

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (R#1) of 5 residents.The facility failed to ensure staff notified R#1's Physician, Hospice Physician and NP when R#1 fell during a 1-person transfer without a gait belt on 7/14/26, 7/19/26, and 7/20/26. R#1 cried, said her buttocks was hurting, and complained of right hip pain after the fall on 7/19/26. R#1 also cried and said her right hand was hurting and she hit her leg after the fall on 7/20/26. This failure could place residents at risk of falls and injuries.Findings include:Review of R#1's admission Record, dated 7/21/26, reflected she was admitted to the facility on [DATE]. R#1 also had medical diagnoses that included late onset Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), dementia (a decline in mental ability severe enough to interfere with daily life), muscle wasting and atrophy, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders.Review of R#1's Quarterly MDS Assessment, dated 6/25/26, reflected staff were unable to interview her for BIMS. R#1 also had no falls since admission. R#1 was dependent on staff assistance with transfers.Review of R#1's Care Plan, revised 4/23/26, reflected she was at risk for falls. Staff were required to use 1-person assistance with R#1's transfers.Review of R#1's Fall Risk Assessment, dated 4/20/26, reflected she was a high fall risk.Review of R#1's Fall Event Nurses' Note, created by RN A on 7/14/26 at 11:13 p.m., reflected, CNA notifies this charge nurse that resident is on the floor. Patient was sitting on the floor with her back against her recliner. CNA stated, 'I attempted to move patient from her recliner to the bed, but she didn't stand up as well as she normally does. She sat back down at the edge of the recliner. When she attempted to scoot back in the chair, the chair moved, and she fell on her buttocks.' R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included a floor mat and walker. R#1's Hospice Nurse was notified. Review of R#1's Fall Event Nurse's Note, created by RN B on 7/19/26 at 1:06 p.m., reflected, CNA attempted to transfer resident into her recliner using a walker. Her legs gave out and resident was assisted to the floor. Denies hitting her head. Denies pain. No swelling noted. R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. R#1's statement reflected she fell. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included educating the CNA on transferring R#1 with 2-person assistance. R#1's Physician and Hospice Nurse was notified. Review of R#1's Fall Event Nurse's Note, created by LVN C on 7/20/26 at 2:20 p.m., reflected, Resident transferring with CNA from wheelchair to recliner when her knee started to hurt so resident went to sit down and missed seat of recliner, resident then slide to bottom on the floor in front of the recliner. R#1 didn't receive an injury from the fall. R#1 appeared and stated to be in pain to her right knee. There were no interventions in place prior to this fall and no new interventions initiated in response to this fall. R#1's Hospice Nurse was notified. Review of R#1's POC for July 2026 reflected staff documented they provided 1-person assistance with transfers on 7/14/26 at 1:59 p.m. and 3:18 p.m. and 7/19/26 at 1:44 p.m.Review of Video Footage, dated 7/19/26 at 1:02 p.m., reflected R#1 was sitting in her wheelchair. CNA D entered the room and explained to R#1 that she was going to put her in her recliner so she could put her feet up. CNA D took off the foot pedals from R#1's wheelchair, pushed the wheelchair in front of the recliner, locked the wheelchair wheels, held R#1's left hand with her left hand, held onto R#1's left Tricep with her right arm as she tried to pull R#1 forward and towards the recliner. R#1 didn't move in her wheelchair, CNA D backed the wheelchair from the recliner, placed R#1's walker in front of R#1, and the gait belt hung on the walker. CNA D placed both R#1's hands on the walker, held onto R#1's left arm using her left arm, pulled on R#1's gown up and lifted R#1 with her left arm. R#1 fell forward and over her walker, and her knees landed on the floor as she tried to hold onto the recliner with her upper body. R#1 also cried and told staff to look at her buttocks because it was hurting a little bit when they asked her if she was hurting anywhere.Review of Video Footage, dated 7/20/26 at 2:16 p.m., reflected R#1 was sitting in her wheelchair. CNA E held onto R#1's left arm using her right arm, pulled R#1 up and towards the walker in front of her, pushed the wheelchair away from R#1, pivoted R#1 and the walker as R#1 held onto it until R#1's back faced the recliner. R#1 fell backwards, hit her right arm on the window sill and her back on the wall, slid down, landed on her buttocks on the floor, started to cry, and said, Ow my leg. There was no gait belt. R#1 also told staff her right hand was hurting and she hit her leg when they asked her if she was hurting. Review of the facility's Incident Log, from 6/1/26 through 7/21/26, reflected R#1 had a fall on 7/14/26 at 9:45 p.m. There were no other falls for R#1 documented on the log.Review of the facility's In-Services, from 7/1/26 through 7/21/26, reflected the ADON presented the in-service regarding R#1's to 22 staff on 7/20/26. Staff were taught to use two CNAs at all times, gait belt, walker, and talk to R#1 through the process when transferring her. CNA D did not sign the in-service. LVN C, CNA E, CNA F, CNA G, CNA H and LVN I signed the in-service.During a telephone interview with R#1's RP on 7/21/26 at 10:53 a.m., she said R#1 had no falls before her admission to the facility. She also said R#1 had dementia. She said RN A called and notified her on 7/14/26 that R#1 fell and CNA F was involved. She did not know and was not explained how R#1 fell on 7/14/26. She also said she notified the ADON, who told her that she would investigate the fall. She said she attended care plan meetings and asked staff to ensure R#1 had her walker and used 2-person assistance and a gait belt when transferring her. She said her family notified her on 7/19/26 that R#1 fell again. She also said she spoke with the ADON and RN B, who confirmed R#1 fell on 7/19/26. She said RN B told her that she did not know what happened on 7/19/26 and did not know what R#1's transfer protocols were. She also said R#1 complained of right hip pain after the fall on 7/19/26. She said she observed R#1 fall on 7/20/26 and went to the facility. She also said the ADON was not aware R#1 fell on 7/20/26 and she notified the DON on unknown date.During an interview with R#2 on 7/21/26 at 12:03 p.m., she said R#1 fell when CNA E did not properly sit R#1 down on 7/20/26. She said staff were required to transfer R#1 using 2-person assistance and a gait belt.During an observation and interview of R#1 on 7/21/26 at 12:04 p.m., R#1 was sitting in her wheelchair in front of the nurse's station. The surveyor attempted to interview R#1, but R#1 was unable to recall the falls and provide additional information.During an interview with CNA G on 7/21/26 at 1:10 p.m., she said she was not in-serviced on transfers prior to 7/21/26. She also said she read and signed an in-service regarding R#1 on 7/21/26 around 7:00 a.m. She said CNAs and the ADON transferred residents. She said her and CNA H transferred R#1 all the time. She said she also transferred R#1 by herself. She said R#1's family and other CNAs also transferred R#1 without a gait belt. She said LVN I asked her and CNA H to transfer R#1 on 7/21/26 because CNA F refused to go into R#1's room. She explained that her and CNA H transferred R#1 without a gait belt. She said R#1's family told her and CNA H that she told the staff and management about the issue with staff not using a gait belt when transferring R#1. She said she was aware that she did not transfer R#1 with a gait belt. She said she did not transfer R#1 with a gait belt because she did not think anything of it and never did before. She explained she was not told before 7/21/26 that a gait belt was required when transferring R#1 and was placed as an intervention on 7/21/26. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, Proper transferring is going to ensure fall risk residents did not fall and that they did not lose balance.During an interview with CNA H on 7/21/26 at 1:37 p.m., he said he was not in-serviced on transfers before 7/20/26. He said the ADON had him read and sign an in-service regarding R#1 on 7/20/26. He said he did not read the in-service. He said CNAs, nurses and therapy staff transferred residents. He said he never had to transfer R#1. He explained CNA G asked him to help her transfer R#1 on 7/21/26. He said he and CNA H were on each side of R#1, stood R#1 up, and placed her in the chair. He also said he and CNA H did not use a gait belt when they transferred R#1. He said R#1's family walked in and informed him and CNA H that they informed RN J that anyone who transferred R#1 needed to use 2-person assistance with the gait belt. He explained he did not know anything about the interventions until after he and CNA H transferred R#1 without the gait belt. He said he knew it was important to accommodate by transferring the resident with a gait belt and said, For safety of resident and staff. Residents could be at risk of falling and could sustain injuries depending on how staff were grabbing the resident.During an interview with the ADON on 7/21/26 at 1:53 p.m., she said the nurse managers in-serviced staff. She said she provided staff with the in-service to read and sign on paydays and case by case. She couldn't remember when she most recently in-serviced staff on falls. She said CNAs and nurses transferred residents. She explained CNAs primarily transferred residents. She said R#1 needed more assistance with transfers in the last couple of days because R#1 had weakness and her legs would buckle. She said R#1 required 2-person assistance with a gait belt for transfers. She said she was working when R#1 fell on 7/14/26 and could not remember how R#1 fell. She said RN B notified her on 7/19/26 that R#1 had a witnessed fall, did not complain of pain, and did not sustain any injuries. She explained CNA D tried to transfer R#1 without a gait belt and by herself. She put R#1's walker in front of her, tried to assist her up but R#1's knees buckled, and she fell on 7/19/26. She said R#1's family provided her with the video footage. She said the IDT met on 7/20/26 and decided to in-service the staff. She said she put out an in-service about talking to R#1 through and using the gait belt and walker on 7/20/26 because of the fall R#1 had the night of 7/19/26. She said R#1's family notified her that CNA E tried to stand R#1 up by herself, tried to transfer R#1 into the recliner, R#1's legs buckled, and R#1 fell on 7/20/26. She said she investigated the incident. She said CNA E told her that she reviewed and signed the in-service. She said the IDT did not meet after R#1's 7/20/26 fall because the ADM and DON were not at the facility on 7/21/26, RN B was working as a floor nurse until 2:00 p.m. and her and RN B did not do clinical review. She said she was aware CNA G and CNA H transferred R#1 without a gait belt on 7/21/26. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, To protect the resident and yourself. Residents could be at risk of injury.During an interview with LVN I on 7/21/26 at 2:18 p.m., she said she was in-serviced on gait belt safety use with 2-person assistance either on 7/20/26 or earlier on 7/21/26. CNAs and nurses transferred residents. She said R#1 used to require 1-person assistance and a gait belt with transfers. She said R#1's family recently expressed wanting staff to transfer R#1 using 2-person assistance and a gait belt. She said R#1 fell over the weekend. She said CNA E told her that she tried to transfer R#1 by herself on 7/20/26. She did not know whether or not CNA E used a gait belt when she tried to transfer R#1 by herself on 7/20/26. She said R#1's family told her that CNA G and CNA H transferred R#1 without a gait belt on 7/21/26. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, for their safety. That's number one. Safety always come first. Residents could be at risk of getting hurt from the fall, hurt their arms, and we must use what is recommended for that person as well for us.During a telephone interview with the Physician on 7/21/26 at 3:22 p.m., he said he expected staff to use a Hoyer lift when transferring R#1, but R#1's family did not want them to use the device. He said a gait belt could be used to transfer R#1. He said he was aware that R#1 fell a couple times. He said staff did not notify him about R#1's fall on 7/14/26. He said RN B notified him that R#1 fell on 7/19/26. He also said staff did not notify him that R#1 fell on 7/20/26. He advised to call the NP for additional information.The surveyor attempted to call and interview the Hospice Physician on 7/21/26 3:42 p.m. A voicemail and call back number was left. R#1's Hospice Physician did not return the call before exit on 7/22/26.During a telephone interview with the NP on 7/21/26 at 4:05 p.m., she said she was not notified of R#1's falls on 7/14/26, 7/19/26 and 7/20/26.During an interview with CNA F on 7/22/26 at 11:21 a.m., she said she was recently in-serviced on transfers this past week. She explained she received, reviewed and signed the in-service. She said she could not remember if she worked with R#1 on 7/14/26, 7/19/26, and 7/20/26. She said she was notified that R#1 fell within this past week or two weeks. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, We do not want residents falling. It's important to have a gait belt to be used and behind them because residents could have moments of losing balance and need to have something to hold onto.During a telephone interview with LVN C on 7/22/26 at 12:26 p.m., she said CNAs, nurses, and therapy staff transferred residents. She said she knew how to use a gait belt when a resident was a fall risk, required 1-2 person assistance, and was an increased fall risk. She said R#1 required 2-person assistance with a gait belt for transfers. She said R#1's family told her in the past on unknown date how they wanted R#1 properly transferred. She said CNA E told her on 7/20/26 that she moved R#1 towards the seat, R#1 missed the seat and fell. She said she did not know whether or not CNA E transferred R#1 by herself. She said she was in-serviced on transfers for R#1 on 7/21/26. She said she learned to use the gait belt, verbally guide R#1, and ensure R#1 held onto her walker when transferring her. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, To prevent injuries, falls and trauma to the resident and staff. Residents could be at risk of getting hurt when assistive devices and appropriate number of staff weren't used during transfers.During a telephone interview with CNA E on 7/22/26 at 12:48 p.m., she said she could not remember when she was most recently in-serviced on transfers. She also said CNAs must use a gait belt during transfers and did not have to when a resident could stand up. She said she did not read the entire in-service on 7/20/26 because she was assisting another resident when staff handed the in-service to her. She said she did not use 2-person assistance and a gait belt when she tried to transfer R#1 because R#1 was doing good without the gait belt. She said she did not know R#1 required 2-person assistance with transfers and, It's my fault. She explained R#1 slipped from her walker that was placed in front of her recliner, fell on her knees, then turned over and fell on her buttocks, did not hit her head, did not complain of pain, and she notified LVN C and another nurse. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, To guarantee safety of residents. Residents could be at risk of safety and falls when appropriate number of staff and assistive devices aren't used during a transfer.During a telephone interview with CNA D on 7/22/26 at 1:08 p.m., she said she could not remember when she was most recently in-serviced on falls and transfers. She said CNAs transferred residents. She said R#1 required 1-person assistance with transfers, could pivot, and was independent. She said she worked with R#1 when R#1 fell on 7/19/26. She explained R#1 tried to stand up with the walker in front of her, she could not turn and her knees gave out. She lowered R#1 to the ground because she could not lift R#1, and notified RN B. She said R#1 told RN B that her buttocks hurt.During a telephone interview with RN K on 7/22/26 at 1:24 p.m., she said the ADON in-serviced her on transferring R#1 with 1-2 person assistance and a gait belt before 7/20/26. She said CNA E notified her that R#1 fell and did not explain how on 7/20/26. She said CNA E told LVN C that she was trying to transfer R#1 and her legs gave out. R#1 slid onto her buttocks, and did not hit her head. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, So residents didn't fall and get hurt. Residents could have a fracture or break something when not using appropriate number of people and assistive devices.During an interview with RN A on 7/22/26 at 2:17 p.m., he said he could not remember when he was most recently in-serviced on transfers. He said R#1 required a gait belt when transferring her. He said CNA F notified him that R#1 fell on 7/14/26. He explained CNA F told him that she was transferring R#1 from the recliner and R#1 fell. He said CNA F was by herself when he entered R#1's room. He said CNA F did not tell him whether or not there were two people in the room when she transferred R#1. He said he knew it was important to accommodate by transferring the resident with a gait belt and said, It's safe to use gait belt during transfers. It's for safety and to follow procedure and for your own safety. Residents could be at risk of falling and sustaining injuries. During a telephone interview with RN B on 7/22/26 at 5:00 p.m., she said she was not in-serviced after R#1's fall on 7/19/26 because she did not return to the facility after the incident. She said R#1 required 1-person assistance with transfers at the time on 7/19/26. She said CNA D notified her that R#1 fell on 7/19/26. She said CNA D told her that she tried to transfer R#1 to the walker by herself and R#1's legs became weak, and R#1 fell. She said she did not know whether or not CNA D used a gait belt when she tried to transfer R#1 by herself. She said she knew it was important to accommodate by transferring the resident with a gait belt and said, To prevent fractures, injuries and death.During a telephone interview with the ADM on 7/22/26 at 5:13 p.m., she said nurse managers in-serviced staff on transfers routinely and annually. She said she could not remember when staff were most recently in-serviced on transfers. She said she expected CNAs to transfer residents according to their transfer status in their EHR. She said she could not remember exact details for R#1's falls on 7/14/26, 7/19/26 and 7/20/26. She also said she was unaware that staff did not use a gait belt when they transferred R#1 on those dates. She said the ADON notified her that CNA G and CNA H did not use a gait belt when they transferred R#1 on 7/21/26. During a telephone interview with the DON on 7/22/26 at 6:04 p.m., she said she expected staff to transfer residents according to their transfer status in the EHR. She said R#1 required a gait belt when being transferred. She said she expected staff to use 2-person assistance with transfers. She said she was notified R#1 fell during a transfer on 7/14/26. She said RN B notified her on 7/19/26 that R#1 fell during a transfer and recommended 2-person assistance. She said she could not remember whether or not a gait belt was used when R#1 fell during a transfer on 7/19/26. She said she had staff initiate in-services on falls. She said the ADON notified her on 7/20/26 that CNA E attempted to transfer R#1 by herself, did not use a gait belt and did not ask for help. Review of the facility's Notifying the Physician of Change in Status, 2003, reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention .The nurse will notify the physician immediately with significant change in status.

Based on observation, interview, and record review, the facility failed to ensure 1 (R#1) of 5 residents were provided with pain management.The facility failed to accurately assess R#1's pain after her falls on 7/19/26 and 7/20/26. R#1 cried, said her buttocks was hurting, and complained of right hip pain after the fall on 7/19/26. R#1 also cried and said her right hand was hurting and she hit her leg after the fall on 7/20/26. This failure could place residents at risk of not having pain treated and change in condition.Findings include:Review of R#1's admission Record, dated 7/21/26, reflected she was admitted to the facility on [DATE]. R#1 also had medical diagnoses that included late onset Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), dementia (a decline in mental ability severe enough to interfere with daily life), muscle wasting and atrophy, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders.Review of R#1's Quarterly MDS Assessment, dated 6/25/26, reflected staff were unable to interview her for BIMS. R#1 also had no falls since admission. R#1 was dependent on staff assistance with transfers.Review of R#1's Care Plan, revised 4/23/26, reflected she was at risk for falls. Staff were required to use 1-person assistance with R#1's transfers. There were no revised interventions regarding staff being required to use 2-person assistance and a gait belt when transferring R#1 prior to 7/21/26.Review of R#1's Fall Event Nurse's Note, created by RN B on 7/19/26 at 1:06 p.m., reflected, CNA attempted to transfer resident into her recliner using a walker. Her legs gave out and resident was assisted to the floor. Denies hitting her head. Denies pain. No swelling noted. R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. R#1's statement reflected she fell. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included educating the CNA on transferring R#1 with 2-person assistance.Review of R#1's Fall Event Nurse's Note, created by LVN C on 7/20/26 at 2:20 p.m., reflected, Resident transferring with CNA from wheelchair to recliner when her knee started to hurt so resident went to sit down and missed seat of recliner, resident then slide to bottom on the floor in front of the recliner. R#1 didn't receive an injury from the fall. R#1 appeared and stated to be in pain to her right knee. There were no interventions in place prior to this fall and no new interventions initiated in response to this fall. Review of Video Footage, dated 7/19/26 at 1:02 p.m., reflected R#1 was sitting in her wheelchair. CNA D entered the room and explained to R#1 that she was going to put her in her recliner so she could put her feet up. CNA D took off the foot pedals from R#1's wheelchair, pushed the wheelchair in front of the recliner, locked the wheelchair wheels, held R#1's left hand with her left hand, held onto R#1's left Tricep with her right arm as she tried to pull R#1 forward and towards the recliner, R#1 didn't move in her wheelchair, backed the wheelchair from the recliner, placed R#1's walker in front of R#1, the gait belt hung on the walker, placed both R#1's hands on the walker, held onto R#1's left arm using her left arm, pulled on R#1's gown up and she lifted R#1 with her left arm and R#1 fell forward and over her walker, and her knees landed on the floor as she tried to hold onto the recliner with her upper body. R#1 also cried and told staff to look at her buttocks because it was hurting a little bit when they asked her if she was hurting anywhere.Review of Video Footage, dated 7/20/26 at 2:16 p.m., reflected R#1 was sitting in her wheelchair. CNA E held onto R#1's left arm using her right arm, pulled R#1 up and towards the walker in front of her, pushed the wheelchair away from R#1, pivoted R#1 and the walker as R#1 held onto it until R#1's back faced the recliner, R#1 fell backwards, hit her right arm on the window sill and her back on the wall, slid down, landed on her buttocks on the floor, started to cry, and said, Ow my leg. There was no gait belt. R#1 also told staff her right hand was hurting and she hit her leg when they asked her if she was hurting. Review of R#1's Pain Level Summary, as of 7/21/26, reflected staff previously used a Pain Ad (non-verbal) to assess R#1 for pain until 3/12/26. Staff started to use a pain numerical scale to assess R#1's pain from 4/3/26 through 5/14/26, which was the most recent documented entry. There were no other entries.During a telephone interview with R#1's RP on 7/21/26 at 10:53 a.m., she said R#1 had no falls before her admission to the facility. She also said R#1 had dementia. She said she attended care plan meetings and asked staff to ensure R#1 had her walker and used 2-person assistance and a gait belt when transferring her. She said her family notified her before the staff on 7/19/26 that R#1 fell again. She also said she spoke with the ADON and RN B, who confirmed R#1 fell on 7/19/26. She said RN B told her that she did not know what happened on 7/19/26 and did not know what R#1's transfer protocols were. She said staff did not mention anything about sending R#1 to the hospital for further evaluation after the fall. She also said R#1 complained of right hip pain after the fall on 7/19/26. She said she did not report R#1's c/o pain to the staff. She said she observed R#1 fall on 7/20/26 on the electronic monitoring system and went to the facility. She also said the ADON was not aware R#1 fell on 7/20/26. She said she had staff send R#1 to the hospital after the fall. She said R#1 returned from the hospital the night of 7/20/26 and had negative results for any injuries. She said she notified the DON on unknown date of the results and the DON did not respond back to her.During an interview with R#2 on 7/21/26 at 12:03 p.m., she said R#1 fell when CNA E did not properly sit R#1 down on 7/20/26. She said R#1 did not complain of pain, but the staff also did not come and evaluate her or help CNA E after the fall. She said R#1 went to the hospital on 7/20/26, came back and was fine. She also said staff were required to transfer R#1 using 2-person assistance and a gait belt.During an observation and interview of R#1 on 7/21/26 at 12:04 p.m., R#1 was sitting in her wheelchair in front of the nurse's station. R#1 wore a hospital band around on of her wrists. The surveyor attempted to interview R#1, but R#1 was unable to recall the falls and provide additional information.During an interview with CNA G on 7/21/26 at 1:10 p.m., she said R#1 could not verbalize her pain levels. She explained nurses would need to use a Pain Ad scale to determine whether or not R#1 was in pain.During an interview with the ADON on 7/21/26 at 1:53 p.m., she said she taught staff to assess residents after a fall and determine whether or not they needed to be sent to the hospital. She said she expected the nurses to assess the resident after a fall. R#1 needed more assistance with transfers in the last couple of days because R#1 had weakness and her legs would buckle. She said R#1 required 2-person assistance with a gait belt for transfers. She said RN B notified her on 7/19/26 that R#1 had a witnessed fall, did not complain of pain, and did not sustain any injuries. She explained CNA D tried to transfer R#1 without a gait belt and by herself, put R#1's walker in front of her, tried to assist her up, R#1's knees buckled, and she fell on 7/19/26. She said R#1's family provided her with the video footage. She said the IDT met on 7/20/26 and decided to in-service the staff. She said she put out an in-service about talking to R#1 through and using the gait belt and walker on 7/20/26 because of the fall R#1 had the night of 7/19/26. She said R#1's family notified her that CNA E tried to stand R#1 up by herself, tried to transfer R#1 into the recliner, R#1's legs buckled, and R#1 fell on 7/20/26. She said she investigated the incident. She said CNA E told her that she reviewed and signed the in-service. She said the IDT did not meet after R#1's 7/20/26 fall because the ADM and DON were not at the facility on 7/21/26, RN B was working as a floor nurse until 2:00 p.m. and her and RN B did not do clinical review. She said R#1's family wanted her to go out to the hospital, R#1 was sent out, and returned with no injuries. She said R#1 could let staff know when she was in pain. She said she used a Pain Ad scale when assessing R#1's pain. She explained she would look for signs and symptoms, such as hollering and facial grimacing, to determine whether or not R#1 was in pain.During a telephone interview with the Physician on 7/21/26 at 3:22 p.m., he said a gait belt could be used to transfer R#1. He said he was aware that R#1 fell a couple times. He said RN B notified him that R#1 fell on 7/19/26. He also said staff did not notify him that R#1 fell on 7/20/26. He said he would not have expected staff to send R#1 out to the emergency room unless she experienced pain. He expected staff to notify him if there was a fall and injury, if the resident complained of pain, and ensure resident was checked on and there were no complaints of pain. He advised to call the NP for additional information.The surveyor attempted to call and interview the Hospice Physician on 7/21/26 3:42 p.m. A voicemail and call back number was left. R#1's Hospice Physician did not return the call before exit on 7/22/26.During a telephone interview with the NP on 7/21/26 at 4:05 p.m., she said she was not notified of R#1's falls on 7/19/26 and 7/20/26 and expected staff to notify the resident's primary care staff.During an interview with the MDS Coordinator on 7/22/26 at 10:48 a.m., she said staff must take residents pain at the cognitive status of where they are at right now. She explained staff used a numerical scale if they can when assessing a resident's pain. She went on to explain that staff used a Pain Ad scale if they cannot assess a resident's pain with the pain numerical scale. She said she knew it was important to accurately assess residents' pain and said, Because pain is a big deal and we want to make sure we help with their pain because it impacts their (residents') behaviors, moods, and eating and we notify the physician of any changes.During an interview with CNA F on 7/22/26 at 11:21 a.m., she said she revised residents' EHR to determine what their transfer status was. She said she could not remember if she worked with R#1 on 7/14/26, 7/19/26, and 7/20/26. She said she was notified that R#1 fell within this past week or two weeks. She said charge nurses evaluated residents' pain. She said she would determine R#1 was in pain based on R#1's nonverbal cues, signs and symptoms of pain, and after evaluating her skin. She explained staff could not use a pain numerical scale to assess R#1's pain levels because she could not provide a response.During a telephone interview with LVN C on 7/22/26 at 12:26 p.m., she said R#1 required 2-person assistance with a gait belt for transfers. She said R#1's family told her in the past on unknown date how they wanted R#1 properly transferred. She said she was coming over for shift change when CNA E notified her that R#1 fell. She said CNA E told her on 7/20/26 that she moved R#1 towards the seat, R#1 missed the seat and fell. She said she did not know whether or not CNA E transferred R#1 by herself. She said she asked R#1 if she had any pain. She said RN K took R#1's vitals and she returned to the hallway she was assigned to. She said R#1 had periods of lucidity (clarity of thought, clearness of expression, or a temporary state of mental sanity), but the staff were required to use a Paid Ad scale to evaluate her pain because she was nonverbal. She said she did not know a pain numerical scale was used to assess R#1 and believed a Pain Ad nonverbal scale should be used. She said she knew it was important to accurately assess residents' pain levels and said, It helps gives symptoms to physician to make better judgement and help with treatment plan and adequately monitor resident.During a telephone interview with CNA E on 7/22/26 at 12:48 p.m., she said she did not use 2-person assistance and a gait belt when she tried to transfer R#1 because R#1 was doing good without the gait belt. She said she did not know R#1 required 2-person assistance with transfers and said, It's my fault. She explained R#1 slipped from her walker in front of her recliner, fell on her knees, fell on her buttocks, did not hit her head, did not complain of pain, and she notified LVN C and another nurse. She said RN K asked R#1 if she was hurt and R#1 expressed her knee was hurting. She said nurses were expected to ask R#1 what parts of her body were hurt and observe for nonverbal cues. She said she knew it was important to accurately assess residents' pain levels and said, To get an accurate pain assessment of what's going on with the resident. Residents could be at risk of not having their pain treated.During a telephone interview with CNA D on 7/22/26 at 1:08 p.m., she said R#1 required 1-person assistance with transfers, could pivot, and was independent. She said she worked with R#1 when R#1 fell on 7/19/26. She explained R#1 tried to stand up with the walker in front of her, could not turn, knees gave out, she lowered R#1 to the ground because she could not lift R#1, and notified RN B. She said R#1 told RN B that her buttocks hurt. She said the nurses evaluated resident post-fall for pain and injuries. She said RN B was aware R#1 could not articulate the severity of her pain. She said the RN B asked R#1 open ended questions about her pain and R#1 told her that her buttocks hurt. She said staff were expected to look for nonverbal cues for pain. She said she knew it was important to accurately assess residents' pain levels and said, Because the nonverbal resident isn't capable of speaking for themselves. Residents could be at risk of not having pain evaluated properly. During a telephone interview with RN K on 7/22/26 at 1:24 p.m., she said CNA E notified her that R#1 fell and did not explain how on 7/20/26. She said CNA E told LVN C that she was trying to transfer R#1, R#1's legs gave out, R#1 slid onto her buttocks, and did not hit her head. She said she observed R#1 was leaning up against the recliner. She said LVN C assessed R#1. She said nurses assessed residents after fall. She said LVN C used pain numerical scale when assessing R#1's pain. She said she did not know what the facility's guideline was for evaluating nonverbal residents' pain because she only worked for the facility since 7/9/26. She said staff could ask where R#1 was hurting, but R#1 could not give a numerical pain value. She said she knew it was important to accurately assess residents' pain levels and said, Because we need to know if the resident needed pain medication and to keep them comfortable. Residents could be at risk of not having pain treated and comforted.During an interview with RN A on 7/22/26 at 2:17 p.m., he said R#1 required a gait belt when transferring her. He said all staff were responsible for resident care. He said R#1 could tell staff where she was hurting at times. He said nurses were expected to evaluate pain. He said staff were expected to use a Pain Ad scale when R#1 could not tell staff where she was hurting. He said R#1 would not be able to tell staff how severe her pain level was. He said it was important to accurately assess residents' pain levels and said, Its important because we must use observation of nonverbal cues because resident is not that alert. It's also a greater impact on getting pain identified and treated.During a telephone interview with RN B on 7/22/26 at 5:00 p.m., she said R#1 required 1-person assistance with transfers at the time on 7/19/26. She said CNA D notified her that R#1 fell on 7/19/26. She said CNA D told her that she tried to transfer R#1 to the walker by herself, R#1's legs became weak, and R#1 fell. She said she did not know whether or not CNA D used a gait belt when she tried to transfer R#1 by herself. She said the DON and IDT investigated falls and reviewed and revised residents' care plans after a fall. She said R#1 did not complain of pain. She said she touched R#1 all over the body and asked her if she had any pain and R#1 told her no. She said she normally assessed residents' pain this way. She said staff were supposed to use a Pain Ad scale and look for non-verbal cues for pain. She said R#1 would not have been able to tell her the severity of her pain. She said it was important to accurately assess residents' pain levels and said, It's important to make sure resident didn't have any injuries and obvious injuries. Residents could be at risk of pain not being treated.During a telephone interview with the ADM on 7/22/26 at 5:13 p.m., she said she reviewed falls during clinical meetings. She said her staff in-serviced the staff to her understanding. She said she expected CNAs to transfer residents according to their transfer status in their EHR. She also expected staff to notify the charge nurse whenever residents' level of assistance changed and said, For the safety of residents and staff. She said she could not remember exact details for R#1's falls on 7/19/26 and 7/20/26. She also said she was unaware that staff did not use a gait belt when they transferred R#1 on those dates. She said she discussed interventions with staff. She said she expected nurses to use their scope of practice to assess residents' pain. She said she did not know how staff were required to assess R#1's pain. She said R#1 had dementia and she expected staff to document how they evaluated R#1's pain. She sad it was important to accurately assess residents' pain levels and said, Because we want resident's pain to be addressed.During a telephone interview with the DON on 7/22/26 at 6:04 p.m., she said she expected staff to transfer residents according to their transfer status in the care plan and EHR and said, For the safety of the resident and staff. Residents could be at risk of injury. She said R#1 required a gait belt when being transferred. She said she expected staff to use 2-person assistance with R#1's transfers. She said RN B notified her on 7/19/26 that R#1 fell during a transfer and recommended 2-person assistance. She said she could not remember whether or not a gait belt was used when R#1 fell during a transfer on 7/19/26. She said she had staff initiate in-services on falls. She said the ADON notified her on 7/20/26 that CNA E attempted to transfer R#1 by herself, did not use a gait belt and did not ask for help. She said she expected staff to use a pain assessment that was appropriate for the resident at the time. She said it was important to accurately assess residents' pain levels and said, To get the correct pain level for them.Review of the facility's Pain Management Assessment Scale policy, undated, reflected, Procedure: If a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAINAD assessment.Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain.

Based on observation, interview, and record review, the facility failed to ensure 1 (R#1) of 5 residents received adequate supervision and assistance devices to prevent accidents.1. The facility failed to ensure staff used a gait belt and 2-person assistance when transferring R#1 on 7/14/26, 7/19/26 and 7/20/26. R#1 fell on 7/14/26, 7/19/26, and 7/20/26. R#1 cried, said her buttocks was hurting, and complained of right hip pain after the fall on 7/19/26. R#1 also cried and said her right hand was hurting and she hit her leg after the fall on 7/20/26. 2. The facility failed to ensure staff used a gait belt when transferring R#1 on 7/21/26.This failure could place residents at risk of falls, injuries, and change in condition.Findings include:Review of R#1's admission Record, dated 7/21/26, reflected she was admitted to the facility on [DATE]. R#1 also had medical diagnoses that included late onset Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), dementia (a decline in mental ability severe enough to interfere with daily life), muscle wasting and atrophy, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders.Review of R#1's Quarterly MDS Assessment, dated 6/25/26, reflected staff were unable to interview her for BIMS. R#1 also had no falls since admission. R#1 was dependent on staff assistance with transfers.Review of R#1's Care Plan, revised 4/23/26, reflected she was at risk for falls. Staff were required to use 1-person assistance with R#1's transfers. There were no revised interventions regarding staff being required to use 2-person assistance and a gait belt when transferring R#1 prior to 7/21/26.Review of R#1's Fall Risk Assessment, dated 4/20/26, reflected she was a high fall risk.Review of R#1's Fall Event Nurses' Note, created by RN A on 7/14/26 at 11:13 p.m., reflected, CNA notifies this charge nurse that resident is on the floor. Patient was sitting on the floor with her back against her recliner. CNA stated, 'I attempted to move patient from her recliner to the bed, but she didn't stand up as well as she normally does. She sat back down at the edge of the recliner. When she attempted to scoot back in the chair, the chair moved, and she fell on her buttocks.' R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included a floor mat and walker.Review of R#1's Fall Event Nurse's Note, created by RN B on 7/19/26 at 1:06 p.m., reflected, CNA attempted to transfer resident into her recliner using a walker. Her legs gave out and resident was assisted to the floor. Denies hitting her head. Denies pain. No swelling noted. R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. R#1's statement reflected she fell. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included educating the CNA on transferring R#1 with 2-person assistance.Review of R#1's Fall Event Nurse's Note, created by LVN C on 7/20/26 at 2:20 p.m., reflected, Resident transferring with CNA from wheelchair to recliner when her knee started to hurt so resident went to sit down and missed seat of recliner, resident then slide to bottom on the floor in front of the recliner. R#1 didn't receive an injury from the fall. R#1 appeared and stated to be in pain to her right knee. There were no interventions in place prior to this fall and no new interventions initiated in response to this fall. Review of R#1's POC for July 2026 reflected staff documented they provided 1-person assistance with transfers on 7/14/26 at 1:59 p.m. and 3:18 p.m. and 7/19/26 at 1:44 p.m.Review of Video Footage, dated 7/19/26 at 1:02 p.m., reflected R#1 was sitting in her wheelchair. CNA D entered the room and explained to R#1 that she was going to put her in her recliner so she could put her feet up. CNA D took off the foot pedals from R#1's wheelchair, pushed the wheelchair in front of the recliner, locked the wheelchair wheels, held R#1's left hand with her left hand, held onto R#1's left Tricep with her right arm as she tried to pull R#1 forward and towards the recliner, R#1 didn't move in her wheelchair, backed the wheelchair from the recliner, placed R#1's walker in front of R#1, the gait belt hung on the walker, placed both R#1's hands on the walker, held onto R#1's left arm using her left arm, pulled on R#1's gown up and she lifted R#1 with her left arm and R#1 fell forward and over her walker, and her knees landed on the floor as she tried to hold onto the recliner with her upper body. R#1 also cried and told staff to look at her buttocks because it was hurting a little bit when they asked her if she was hurting anywhere.Review of Video Footage, dated 7/20/26 at 2:16 p.m., reflected R#1 was sitting in her wheelchair. CNA E held onto R#1's left arm using her right arm, pulled R#1 up and towards the walker in front of her, pushed the wheelchair away from R#1, pivoted R#1 and the walker as R#1 held onto it until R#1's back faced the recliner, R#1 fell backwards, hit her right arm on the window sill and her back on the wall, slid down, landed on her buttocks on the floor, started to cry, and said, Ow my leg. There was no gait belt. R#1 also told staff her right hand was hurting and she hit her leg when they asked her if she was hurting. Review of the facility's Incident Log, from 6/1/26 through 7/21/26, reflected R#1 had a fall on 7/14/26 at 9:45 p.m. There were no other falls for R#1 documented on the log.Review of the facility's In-Services, from 7/1/26 through 7/21/26, reflected the ADON presented the in-service regarding R#1's to 22 staff on 7/20/26. Staff were taught to use two CNAs at all times, gait belt, walker, and talk to R#1 through the process when transferring her. CNA D did not sign the in-service. LVN C, CNA E, CNA F, CNA G, CNA H and LVN I signed the in-service.During a telephone interview with R#1's RP on 7/21/26 at 10:53 a.m., she said R#1 had no falls before her admission to the facility. She also said R#1 had dementia. She said RN A called and notified her on 7/14/26 that R#1 fell and CNA F was involved. She did not know and was not explained how R#1 fell on 7/14/26. She also said she notified the ADON, who told her that she would investigate the fall. She said she attended care plan meetings and asked staff to ensure R#1 had her walker and used 2-person assistance and a gait belt when transferring her. She said her family notified her before staff on 7/19/26 that R#1 fell again. She also said she spoke with the ADON and RN B, who confirmed R#1 fell on 7/19/26. She said RN B told her that she did not know what happened on 7/19/26 and did not know what R#1's transfer protocols were. She also said R#1 complained of right hip pain after the fall on 7/19/26. She said she observed R#1 fall on 7/20/26 and went to the facility. She also said the ADON was not aware R#1 fell on 7/20/26 and she notified the DON on unknown date. During an interview with R#2 on 7/21/26 at 12:03 p.m., she said R#1 fell when CNA E did not properly sit R#1 down on 7/20/26. She also said staff were required to transfer R#1 using 2-person assistance and a gait belt. She said R#1 went to the hospital on 7/20/26 and returned.During an observation and interview of R#1 on 7/21/26 at 12:04 p.m., R#1 was sitting in her wheelchair in front of the nurse's station. The surveyor attempted to interview R#1, but R#1 was unable to recall the falls and provide additional information.During an interview with CNA G on 7/21/26 at 1:10 p.m., she said she was not in-serviced on transfers prior to 7/21/26. She also said she read and signed an in-service regarding R#1 on 7/21/26 around 7:00 a.m. She said CNAs and the ADON transferred residents. She said some residents could be transferred with a gait belt using one or two person assistance. She also said her and CNA H transferred R#1 all the time. She said she also transferred R#1 by herself. She also said R#1's family and other CNAs also transferred R#1 without a gait belt. She said LVN I asked her and CNA H to transfer R#1 on 7/21/26 because CNA F refused to go into R#1's room. She explained that her and CNA H transferred R#1 without a gait belt. She said R#1's family told her and CNA H that she told the staff and management about the issue with staff not using a gait belt when transferring R#1. She also said she was aware that she did not transfer R#1 with a gait belt. She said she did not transfer R#1 with a gait belt because she did not think anything of it and never did before. She explained she was not told before 7/21/26 that a gait belt was required when transferring R#1 and was placed as an intervention on 7/21/26. She said she knew it was important to transfer the resident with a gait belt and said, Proper transferring is going to ensure fall risk residents did not fall and that they did not lose balance.During an interview with CNA H on 7/21/26 at 1:37 p.m., he said he was not in-serviced on transfers before 7/20/26. He said the ADON had him read and sign an in-service regarding R#1 on 7/20/26. He also said he did not read the in-service. He said CNAs, nurses and therapy staff transferred residents. He said he was expected to transfer residents with 2-person assistance and a gait bely. He said he never had to transfer R#1. He explained CNA G asked him to help her transfer R#1 on 7/21/26. He said he and CNA H were on each side of R#1, stood R#1 up, and placed her in the chair. He also said he and CNA H did not use a gait belt when they transferred R#1. He said R#1's family walked in and informed him and CNA H that they informed RN J that anyone who transferred R#1 needed to use 2-person assistance with the gait belt. He explained he did not know anything about the interventions until after he and CNA H transferred R#1 without the gait belt and because he did not really transfer residents. He said he knew it was important to transfer residents with a gait belt and said, For safety of resident and staff. Residents could be at risk of falling and could sustain injuries depending on how staff were grabbing the resident.During an interview with the ADON on 7/21/26 at 1:53 p.m., she said the nurse managers in-serviced staff. She also said she provided staff with the in-service to read and sign on paydays and case by case. She couldn't remember when she most recently in-serviced staff on falls. She said CNAs and nurses transferred residents. She explained CNAs primarily transferred residents. She said R#1 needed more assistance with transfers in the last couple of days because R#1 had weakness and her legs would buckle. She also said R#1 required 2-person assistance with a gait belt for transfers. She said she was working when R#1 fell on 7/14/26 and could not remember how R#1 fell. She also said RN B notified her on 7/19/26 that R#1 had a witnessed fall, did not complain of pain, and did not sustain any injuries. She explained CNA D tried to transfer R#1 without a gait belt and by herself, put R#1's walker in front of her, tried to assist her up, R#1's knees buckled, and she fell on 7/19/26. She said R#1's family provided her with the video footage. She said the IDT met on 7/20/26 and decided to in-service the staff. She said she put out an in-service about talking to R#1 through and using the gait belt and walker on 7/20/26 because of the fall R#1 had the night of 7/19/26. She said R#1's family notified her that CNA E tried to stand R#1 up by herself, tried to transfer R#1 into the recliner, R#1's legs buckled, and R#1 fell on 7/20/26. She said she investigated the incident. She said CNA E told her that she reviewed and signed the in-service. She said the IDT did not meet after R#1's 7/20/26 fall because the ADM and DON were not at the facility on 7/21/26, RN B was working as a floor nurse until 2:00 p.m. and her and RN B did not do clinical review. She said she was aware CNA G and CNA H transferred R#1 without a gait belt on 7/21/26. She said she knew it was important to transfer residents with a gait belt and said, To protect the resident and yourself. Residents could be at risk of injury.During an interview with LVN I on 7/21/26 at 2:18 p.m., she said she was in-serviced on gait belt safety use with 2-person assistance either on 7/20/26 or earlier on 7/21/26. CNAs and nurses transferred residents. She said R#1 used to require 1-person assistance and a gait belt with transfers. She also said R#1's family recently expressed wanting staff to transfer R#1 using 2-person assistance and a gait belt. She said R#1 fell over the weekend. She said CNA E told her that she tried to transfer R#1 by herself on 7/20/26. She did not know whether or not CNA E used a gait belt when she tried to transfer R#1 by herself on 7/20/26. She said R#1's family told her that CNA G and CNA H transferred R#1 without a gait belt on 7/21/26. She said she knew it was important to transfer residents with a gait belt and said, For their safety. That's number one. Safety always come first. Residents could be at risk of getting hurt from the fall, hurt their arms, and we must use what is recommended for that person as well for us.During a telephone interview with the Physician on 7/21/26 at 3:22 p.m., he said he expected staff to use a Hoyer lift when transferring R#1, but R#1's family did not want them to use the assistive device. He said a gait belt could be used to transfer R#1. He said he was aware that R#1 fell a couple times. He said staff did not notify him about R#1's fall on 7/14/26 and he expected staff to notify him whenever there was a fall. He said he did not attend or was notified about any IDT meeting after R#1's fall on 7/14/26 and was usually involved if the staff determined he needed to be. He said RN B notified him that R#1 fell on 7/19/26. He also said staff did not notify him that R#1 fell on 7/20/26. He advised to call the NP for additional information.The surveyor attempted to call and interview the Hospice Physician on 7/21/26 3:42 p.m. A voicemail and call back number was left. R#1's Hospice Physician did not return the call before exit on 7/22/26.During a telephone interview with the NP on 7/21/26 at 4:05 p.m., she said she was not notified of R#1's falls on 7/14/26, 7/19/26 and 7/20/26 and expected staff to notify residents' physician team.During an interview with the MDS Coordinator on 7/22/26 at 10:48 a.m., she said she reviewed and revised residents' care plans after morning meeting report, falls, and when reviewing residents' medications. She said she usually revised residents' care plans the morning of the fall. She said she was not at the facility on 7/20/26 and 7/21/26. She said the DON and ADM were her designees in the event she was absent and residents' care plans needed to be revised. She said her and the DON were absent on 7/21/26. She said she was notified the morning of 7/22/26 that R#1's care plan was not revised timely. She said the gait belt did not need to be in R#1's care plan because it was part of the uniform. She also said she was unaware staff did not use the gait belt when transferring R#1 on 7/14/26, 7/19/26, 7/20/26, and 7/21/26. She said the staff were required to comply with residents' transfer requirements.During an interview with CNA F on 7/22/26 at 11:21 a.m., she said she was recently in-serviced on transfers this past week. She explained she received, reviewed and signed the in-service. She said she had access to the residents' EHR to determine their transfer status. She said she could not remember if she worked with R#1 on 7/14/26, 7/19/26, and 7/20/26. She said she was notified that R#1 fell within this past week or two weeks. She said she knew it was important to transfer residents with a gait belt and said, We do not want residents falling. It's important to have a gait belt to be used and behind them because residents could have moments of losing balance and need to have something to hold onto.During a telephone interview with LVN C on 7/22/26 at 12:26 p.m., she said CNAs, nurses, and therapy staff transferred residents. She said she knew how to use a gait belt when a resident was a fall risk, required 1-2 person assistance, and was an increased fall risk. She said there were no instances in which staff could not use the gait belt when transferring a resident. She said she had access to residents' care plan and EHR to determine transfer status. She said R#1 required 2-person assistance with a gait belt for transfers. She said R#1's family told her in the past on unknown date how they wanted R#1 properly transferred. She said CNA E told her on 7/20/26 that she moved R#1 towards the seat, R#1 missed the seat and fell. She said she did not know whether or not CNA E transferred R#1 by herself. She said she was in-serviced on transfers for R#1 on 7/21/26. She said she learned to use the gait belt, verbally guide R#1, and ensure R#1 held onto her walker when transferring her. She said the DON investigated falls and identified contributing factors and said, To help prevent future falls and to figure out what was causing the falls. She said she knew it was important to transfer residents with a gait belt and said, To prevent injuries, falls and trauma to the resident and staff. Residents could be at risk of getting hurt when assistive devices and appropriate number of staff weren't used during transfers.During a telephone interview with CNA E on 7/22/26 at 12:48 p.m., she said she could not remember when she was most recently in-serviced on transfers. She also said CNAs must use a gait belt during transfers and did not have to when a resident could stand up. She said she did not read the entire in-service on 7/20/26 because she was assisting another residents when staff handed the in-service to her. She also said she did not use 2-person assistance and a gait belt when she tried to transfer R#1 because R#1 was doing good without the gait belt. She said she did not know R#1 required 2-person assistance with transfers and said, It's my fault. She explained R#1 slipped from her walker in front of her recliner, fell on her knees, fell on her buttocks, did not hit her head, did not complain of pain, and she notified LVN C and another nurse. She said she knew it was important to transfer residents with a gait belt and said, To guarantee safety of residents. Residents could be at risk of safety and falls when appropriate number of staff and assistive devices aren't used during a transfer.During a telephone interview with CNA D on 7/22/26 at 1:08 p.m., she said she could not remember when she was most recently in-serviced on falls and transfers. She also said CNAs transferred residents. She said she had access to residents' EHR to determine transfer status. She said R#1 required 1-person assistance with transfers, could pivot, and was independent. She said she worked with R#1 when R#1 fell on 7/19/26. She explained R#1 tried to stand up with the walker in front of her, could not turn, knees gave out, she lowered R#1 to the ground because she could not lift R#1, and notified RN B. She said R#1 told RN B that her buttocks hurt.During a telephone interview with RN K on 7/22/26 at 1:24 p.m., she said the ADON in-serviced her on transferring R#1 with 1-2 person assistance and a gait belt before 7/20/26. She said she had access to residents' care plan and EHR to determine transfer status. She said the ADON reviewed and revised residents' care plans after a fall. She said CNA E notified her that R#1 fell and did not explain how on 7/20/26. She said CNA E told LVN C that she was trying to transfer R#1, R#1's legs gave out, R#1 slid onto her buttocks, and did not hit her head. She said she knew it was important to transfer residents with a gait belt and said, So residents didn't fall and get hurt. Residents could have a fracture or break something when not using appropriate number of people and assistive devices.During an interview with RN A on 7/22/26 at 2:17 p.m., he said he could not remember when he was most recently in-serviced on transfers. He said all staff were responsible for resident care and he had access to residents' assessments and EHR to determine transfer status. He said he did not know who reviewed and revised residents' care plans after a fall. He said R#1 required a gait belt when transferring her. He said CNA F notified him that R#1 fell on 7/14/26. He explained CNA F told him that she was transferring R#1 from the recliner and R#1 fell. He said CNA F was by herself when he entered R#1's room. He also said CNA F did not tell him whether or not there were two people in the room when she transferred R#1. He said he knew it was important to transfer residents with a gait belt and said, It's safe to use gait belt during transfers. It's for safety and to follow procedure and for your own safety. Residents could be at risk of falling and sustaining injuries. During a telephone interview with RN B on 7/22/26 at 5:00 p.m., she said she was not in-serviced after R#1's fall on 7/19/26 because she did not return to the facility after the incident. She said R#1 required 1-person assistance with transfers at the time on 7/19/26. She said she did not know whether R#1 require a gait belt for transfers at the time of her fall on 7/19/26. She said CNA D notified her that R#1 fell on 7/19/26. She said CNA D told her that she tried to transfer R#1 to the walker by herself, R#1's legs became weak, and R#1 fell. She said she did not know whether or not CNA D used a gait belt when she tried to transfer R#1 by herself. She said the DON and IDT investigated falls and reviewed and revised residents' care plans after a fall. She said she knew it was important to transfer residents with a gait belt and said, To prevent fractures, injuries and death.During a telephone interview with the ADM on 7/22/26 at 5:13 p.m., she said she reviewed falls during clinical meetings. She said nurse managers in-serviced staff on transfers routinely and annually. She said she could not remember when staff were most recently in-serviced on transfers. She said her staff in-serviced the staff to her understanding. She said she expected CNAs to transfer residents according to their transfer status in their EHR. She also expected staff to notify the charge nurse whenever residents' level of assistance changed and said, For the safety of residents and staff. She said she could not remember exact details for R#1's falls on 7/14/26, 7/19/26 and 7/20/26. She also said she was unaware that staff did not use a gait belt when they transferred R#1 on those dates. She said the ADON notified her that CNA G and CNA H did not use a gait belt when they transferred R#1 on 7/21/26. She said she discussed interventions with staff. She said the DON reviewed incident reports from falls, assessed the need for new interventions, and determined whether current interventions were effective or ineffective. She said the DON also reviewed and revised residents' care plans after a fall.During a telephone interview with the DON on 7/22/26 at 6:04 p.m., she said she expected staff to transfer residents according to their transfer status in the care plan and EHR and said, For the safety of the resident and staff. Residents could be at risk of injury. She said R#1 required a gait belt when being transferred. She said she expected staff to use 2-person assistance with transfers. She said she was notified R#1 fell during a transfer on 7/14/26. She said she expected staff to assess residents' fall risk assessments and fall event notes at the time the fall occurred. She said her, the ADON and therapy reviewed falls during morning meetings and identified contributing factors for falls and said, To prevent falls from reoccurring. She said she investigated R#1's 7/14/26 fall and determined the incident occurred during a transfer. She said she implemented new interventions after the fall. She said her, the MDS Coordinator or the ADON reviewed and revised residents' care plans after a fall. She said she could not remember whether or not R#1's care plan was reviewed and revised after 7/14/26. She said she knew it was important to review and revise residents' care plans after a fall and said, To help prevent injuries to the resident. She also said RN B notified her on 7/19/26 that R#1 fell during a transfer and recommended 2-person assistance. She said she could not remember whether or not a gait belt was used when R#1 fell during a transfer on 7/19/26. She said she had staff initiate in-services on falls. She said the ADON notified her on 7/20/26 that CNA E attempted to transfer R#1 by herself, did not use a gait belt and did not ask for help.Review of the facility's Moving a Resident, Bed to Chair/Chair to Bed policy, 2023, reflected, The purpose of this are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident.This procedure may require two (2) persons.h. Position a gait belt around the resident's waist and clasp it.i. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.Review of the facility's Preventive Strategies to Reduce Fall Risk policy, revised 10/5/16, reflected, The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining and improving residents' mobility.5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s).Review of the facility's Event Reporting: Completion of policy, undated, reflected, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events of the reported Event including persons, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent events and signatures of the individuals as indicated on the form.Interventions: Include and care plan any required interventions or supervision to help prevent further occurrence of the event.

Based on observation, interview, and record review, the facility failed to review and revise 1 (R#1) of 5 residents' care plans.The facility failed to review and revise R#1's care plan to reflect she required a gait belt and 2-person assistance with transfers after she fell during a 1-person transfer without a gait belt on 7/14/26, 7/19/26, and 7/20/26.This failure could place residents at risk of not having their care and service needs met.Findings include:Review of R#1's admission Record, dated 7/21/26, reflected she was admitted to the facility on [DATE]. R#1 also had medical diagnoses that included late onset Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), dementia (a decline in mental ability severe enough to interfere with daily life), muscle wasting and atrophy, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders.Review of R#1's Quarterly MDS Assessment, dated 6/25/26, reflected staff were unable to interview her for BIMS. R#1 also had no falls since admission. R#1 was dependent on staff assistance with transfers.Review of R#1's Care Plan, revised 4/23/26, reflected she was at risk for falls. Staff were required to use 1-person assistance with R#1's transfers. There were no revised interventions regarding staff being required to use 2-person assistance and a gait belt when transferring R#1 prior to 7/21/26.Review of R#1's Fall Event Nurses' Note, created by RN A on 7/14/26 at 11:13 p.m., reflected, CNA notifies this charge nurse that resident is on the floor. Patient was sitting on the floor with her back against her recliner. CNA stated, 'I attempted to move patient from her recliner to the bed, but she didn't stand up as well as she normally does. She sat back down at the edge of the recliner. When she attempted to scoot back in the chair, the chair moved, and she fell on her buttocks.' R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included a floor mat and walker.Review of R#1's Fall Event Nurse's Note, created by RN B on 7/19/26 at 1:06 p.m., reflected, CNA attempted to transfer resident into her recliner using a walker. Her legs gave out and resident was assisted to the floor. Denies hitting her head. Denies pain. No swelling noted. R#1 didn't receive an injury from the fall and didn't appear or state to be in pain. R#1's statement reflected she fell. There were no interventions in place prior to this fall. Interventions that were initiated in response to the fall included educating the CNA on transferring R#1 with 2-person assistance.Review of R#1's Fall Event Nurse's Note, created by LVN C on 7/20/26 at 2:20 p.m., reflected, Resident transferring with CNA from wheelchair to recliner when her knee started to hurt so resident went to sit down and missed seat of recliner, resident then slide to bottom on the floor in front of the recliner. R#1 didn't receive an injury from the fall. R#1 appeared and stated to be in pain to her right knee. There were no interventions in place prior to this fall and no new interventions initiated in response to this fall. Review of R#1's POC for July 2026 reflected staff documented they provided 1-person assistance with transfers on 7/14/26 at 1:59 p.m. and 3:18 p.m. and 7/19/26 at 1:44 p.m.Review of Video Footage, dated 7/19/26 at 1:02 p.m., reflected R#1 was sitting in her wheelchair. CNA D entered the room and explained to R#1 that she was going to put her in her recliner so she could put her feet up. CNA D took off the foot pedals from R#1's wheelchair, pushed the wheelchair in front of the recliner, locked the wheelchair wheels, held R#1's left hand with her left hand, held onto R#1's left Tricep with her right arm as she tried to pull R#1 forward and towards the recliner, R#1 didn't move in her wheelchair, backed the wheelchair from the recliner, placed R#1's walker in front of R#1, the gait belt hung on the walker, placed both R#1's hands on the walker, held onto R#1's left arm using her left arm, pulled on R#1's gown up and she lifted R#1 with her left arm and R#1 fell forward and over her walker, and her knees landed on the floor as she tried to hold onto the recliner with her upper body. R#1 also cried and told staff to look at her buttocks because it was hurting a little bit when they asked her if she was hurting anywhere.Review of Video Footage, dated 7/20/26 at 2:16 p.m., reflected R#1 was sitting in her wheelchair. CNA E held onto R#1's left arm using her right arm, pulled R#1 up and towards the walker in front of her, pushed the wheelchair away from R#1, pivoted R#1 and the walker as R#1 held onto it until R#1's back faced the recliner, R#1 fell backwards, hit her right arm on the window sill and her back on the wall, slid down, landed on her buttocks on the floor, started to cry, and said, Ow my leg. There was no gait belt. R#1 also told staff her right hand was hurting and she hit her leg when they asked her if she was hurting. During a telephone interview with R#1's RP on 7/21/26 at 10:53 a.m., she said R#1 had no falls before her admission to the facility. She also said R#1 had dementia. She said RN A called and notified her on 7/14/26 that R#1 fell and CNA F was involved. She did not know and was not explained how R#1 fell on 7/14/26. She also said she notified the ADON, who told her that she would investigate the fall. She said she attended care plan meetings and asked staff to ensure R#1 had her walker and used 2-person assistance and a gait belt when transferring her. She said her family notified her on 7/19/26 that R#1 fell again. She also said she spoke with the ADON and RN B, who confirmed R#1 fell on 7/19/26. She said RN B told her that she did not know what happened on 7/19/26 and did not know what R#1's transfer protocols were. She also said R#1 complained of right hip pain after the fall on 7/19/26. She said she observed R#1 fall on 7/20/26 and went to the facility. She also said the ADON was not aware R#1 fell on 7/20/26 and she notified the DON on unknown date.During an interview with R#2 on 7/21/26 at 12:03 p.m., she said R#1 fell when CNA E did not properly sit R#1 down on 7/20/26. She also said staff were required to transfer R#1 using 2-person assistance and a gait belt.During an observation and interview of R#1 on 7/21/26 at 12:04 p.m., R#1 was sitting in her wheelchair in front of the nurse's station. The surveyor attempted to interview R#1, but R#1 was unable to recall the falls and provide additional information.During an interview with CNA G on 7/21/26 at 1:10 p.m., she said CNAs and the ADON transferred residents. She also said her and CNA H transferred R#1 all the time. She said she also transferred R#1 by herself. She also said R#1's family and other CNAs also transferred R#1 without a gait belt. She said LVN I asked her and CNA H to transfer R#1 on 7/21/26 because CNA F refused to go into R#1's room. She explained that her and CNA H transferred R#1 without a gait belt. She said R#1's family told her and CNA H that she told the staff and management about the issue with staff not using a gait belt when transferring R#1. She also said she was aware that she did not transfer R#1 with a gait belt. She said she did not transfer R#1 with a gait belt because she did not think anything of it and never did before. She explained she was not told before 7/21/26 that a gait belt was required when transferring R#1 and was placed as an intervention on 7/21/26.During an interview with CNA H on 7/21/26 at 1:37 p.m., he said CNAs, nurses and therapy staff transferred residents. He said he never had to transfer R#1. He explained CNA G asked him to help her transfer R#1 on 7/21/26. He said he and CNA H were on each side of R#1, stood R#1 up, and placed her in the chair. He also said he and CNA H did not use a gait belt when they transferred R#1. He said R#1's family walked in and informed him and CNA H that they informed RN J that anyone who transferred R#1 needed to use 2-person assistance with the gait belt. He explained he did not know anything about the interventions until after he and CNA H transferred R#1 without the gait belt.During an interview with the ADON on 7/21/26 at 1:53 p.m., she said CNAs and nurses transferred residents. She explained CNAs primarily transferred residents. She said R#1 needed more assistance with transfers in the last couple of days because R#1 had weakness and her legs would buckle. She also said R#1 required 2-person assistance with a gait belt for transfers. She said she was working when R#1 fell on 7/14/26 and could not remember how R#1 fell. She also said RN B notified her on 7/19/26 that R#1 had a witnessed fall, did not complain of pain, and did not sustain any injuries. She explained CNA D tried to transfer R#1 without a gait belt and by herself, put R#1's walker in front of her, tried to assist her up, R#1's knees buckled, and she fell on 7/19/26. She said R#1's family provided her with the video footage. She said R#1's family notified her that CNA E tried to stand R#1 up by herself, tried to transfer R#1 into the recliner, R#1's legs buckled, and R#1 fell on 7/20/26. She said she investigated the incident. She said the IDT did not meet after R#1's 7/20/26 fall because the ADM and DON were not at the facility on 7/21/26, RN B was working as a floor nurse until 2:00 p.m. and her and RN B did not do clinical review. She said she was aware CNA G and CNA H transferred R#1 without a gait belt on 7/21/26.During an interview with LVN I on 7/21/26 at 2:18 p.m., she said CNAs and nurses transferred residents. She said R#1 used to require 1-person assistance and a gait belt with transfers. She also said R#1's family recently expressed wanting staff to transfer R#1 using 2-person assistance and a gait belt. She said R#1 fell over the weekend. She said CNA E told her that she tried to transfer R#1 by herself on 7/20/26. She did not know whether or not CNA E used a gait belt when she tried to transfer R#1 by herself on 7/20/26. She said R#1's family told her that CNA G and CNA H transferred R#1 without a gait belt on 7/21/26.During a telephone interview with the Physician on 7/21/26 at 3:22 p.m., he said he expected staff to use a Hoyer lift when transferring R#1, but R#1's family did not want them to use the device. He said a gait belt could be used to transfer R#1. He said he was aware that R#1 fell a couple times. He said staff did not notify him about R#1's fall on 7/14/26 and 7/20/26. He said RN B notified him that R#1 fell on 7/19/26. He advised to call the NP for additional information.The surveyor attempted to call and interview the Hospice Physician on 7/21/26 3:42 p.m. A voicemail and call back number was left. R#1's Hospice Physician did not return the call before exit on 7/22/26.During an interview with the MDS Coordinator on 7/22/26 at 10:48 a.m., she said she reviewed and revised residents' care plans after morning meeting and falls and when reviewing residents' medications. She said she usually revised residents' care plans the morning of the fall. She explained she was not at the facility on 7/20/26 and 7/21/26. She said the DON and ADM were designated to review and revise residents' care plans whenever she was unavailable and staff needed care plans revised. She said her and the DON were absent on 7/21/26. She said she was notified the morning of 7/22/26 that R#1's care plan was not revised in a timely manner. She said gait belt did not need to be documented in R#1's care plan because it was part of uniform. She said it was important to review and revise residents' care plans timely and said, To provide the best quality of care and to provide safety to the resident. Residents could be at risk if care plans were not accurate and revised in a timely manner. During an interview with CNA F on 7/22/26 at 11:21 a.m., she said she revised residents' EHR to determine what their transfer status was. She said she could not remember if she worked with R#1 on 7/14/26, 7/19/26, and 7/20/26. She said she was notified that R#1 fell within this past week or two weeks.During a telephone interview with LVN C on 7/22/26 at 12:26 p.m., she said CNAs, nurses, and therapy staff transferred residents. She said she had access to residents' care plans and EHR to determine transfer status. She said she did not know who reviewed and revised residents' care plans after falls. She said R#1 required 2-person assistance with a gait belt for transfers. She said R#1's family told her in the past on unknown date how they wanted R#1 properly transferred. She said CNA E told her on 7/20/26 that she moved R#1 towards the seat, R#1 missed the seat and fell. She said she did not know whether or not CNA E transferred R#1 by herself.During a telephone interview with CNA E on 7/22/26 at 12:48 p.m., she said she had access to residents' EHR to determine their transfer status. She said CNAs must use a gait belt during transfers and did not have to when a resident could stand up. She said she did not use 2-person assistance and a gait belt when she tried to transfer R#1 because R#1 was doing good without the gait belt. She said she did not know R#1 required 2-person assistance with transfers and, It's my fault. She explained R#1 slipped from her walker in front of her recliner, fell on her knees, fell on her buttocks, did not hit her head, did not complain of pain, and she notified LVN C and another nurse.During a telephone interview with CNA D on 7/22/26 at 1:08 p.m., she said CNAs transferred residents. She said she had access to residents' EHR and care plan to determine transfer status. She said R#1 required 1-person assistance with transfers, could pivot, and was independent. She said she worked with R#1 when R#1 fell on 7/19/26. She explained R#1 tried to stand up with the walker in front of her, could not turn, knees gave out, she lowered R#1 to the ground because she could not lift R#1, and notified RN B. She said R#1 told RN B that her buttocks hurt.During a telephone interview with RN K on 7/22/26 at 1:24 p.m., she said she had access to residents' EHR and care plans to determine their transfer status. She said CNA E notified her that R#1 fell and did not explain how on 7/20/26. She said CNA E told LVN C that she was trying to transfer R#1, R#1's legs gave out, R#1 slid onto her buttocks, and did not hit her head. During an interview with RN A on 7/22/26 at 2:17 p.m., he said he had access to residents' care plans and EHR to determine their transfer status. He said R#1 required a gait belt when transferring her. He said CNA F notified him that R#1 fell on 7/14/26. He explained CNA F told him that she was transferring R#1 from the recliner and R#1 fell. He said CNA F was by herself when he entered R#1's room. He also said CNA F did not tell him whether or not there were two people in the room when she transferred R#1. He said he did not know who reviewed and revised residents' care plans after a fall.During a telephone interview with RN B on 7/22/26 at 5:00 p.m., she said she had access to residents' care plans to determine their transfer status. She said R#1 required 1-person assistance with transfers at the time on 7/19/26. She said CNA D notified her that R#1 fell on 7/19/26. She said CNA D told her that she tried to transfer R#1 to the walker by herself, R#1's legs became weak, and R#1 fell. She said she did not know whether or not CNA D used a gait belt when she tried to transfer R#1 by herself. She said the MDS Coordinator and DON reviewed and revised residents' care plans after a fall.During a telephone interview with the ADM on 7/22/26 at 5:13 p.m., she said she expected CNAs to transfer residents according to their transfer status in their EHR. She said she expected staff to identify residents' transfer status using their EHR. She said the DON reviews residents' fall incident reports, assessed the need for new interventions, and determines whether current interventions were effective or ineffective. She also said the DON reviewed and revised residents' care plans. She said she could not remember exact details for R#1's falls on 7/14/26, 7/19/26 and 7/20/26. She also said she was unaware that staff did not use a gait belt when they transferred R#1 on those dates. She said the ADON notified her that CNA G and CNA H did not use a gait belt when they transferred R#1 on 7/21/26. During a telephone interview with the DON on 7/22/26 at 6:04 p.m., she said she expected staff to transfer residents according to their transfer status in the care plan and EHR and said, For safety of resident and staff. Residents could be at risk of injury. She said her, the MDS Coordinator, and ADON reviewed and revised residents' care plans. She said R#1 required a gait belt when being transferred. She said she expected staff to use 2-person assistance with transfers. She said she was notified R#1 fell during a transfer on 7/14/26. She said she could not remember whether or not R#1's care plan was reviewed and revised after the 7/14/26 fall. She also said RN B notified her on 7/19/26 that R#1 fell during a transfer and recommended 2-person assistance. She said she could not remember whether or not a gait belt was used when R#1 fell during a transfer on 7/19/26. She said the ADON notified her on 7/20/26 that CNA E attempted to transfer R#1 by herself, did not use a gait belt and did not ask for help. Review of the facility's Comprehensive Care Planning policy, undated, reflected, In situations where a resident's choice to decline care or treatment poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the IDT to educate the resident and the representative as appropriate. The facility's attempts to find alternative means to address the identify risk/need should be documents in the care plan.Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.The resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to ensure 1 (R#3) of 5 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.The facility failed to follow hospital discharge orders and ensure R#3's physician followed up with her within a week after she returned from the hospital with an acute kidney injury on 7/10/26.This failure could place residents at risk of falls, injuries, and change in condition.Findings include:Review of R#3's admission Record, dated 7/22/26, reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. She had medical diagnoses that included Parkinson's disease (a progressive neurological disorder that primarily affects movement), age-related cognitive decline, and chronic congestive heart failure (a chronic, progressive condition where the heart's muscle weakens or stiffens).Review of R#3's Quarterly MDS, dated [DATE], reflected she had a 13/15 BIMS score, which indicated she was cognitively intact.Review of R#3's Care Plan, revised 7/22/26, reflected she had potential fluid deficit. Staff were required to obtain and monitor lab/diagnostic work as ordered, report results to the MD and follow-up as indicated.Review of R#3's Progress Notes, from 7/1/26 through 7/22/26, reflected:-LVN L created a note on 7/7/26 at 7:57 p.m., Resident returned to the facility from OOP with [family member] and [family member's] reports noticing a change in mental status last night.and requested this nurse to reach out to have a UA run.Received orders to have a UA done.-RN M created a note on 7/8/26 at 9:36 a.m., This nurse contacted NP to notify resident was having SOB and received new order for chest x-ray.-LVN N created a note on 7/9/26 at 12:17 p.m., While awaiting arrival of EMS resident admitted that she had c/p a couple of times yesterday and that she did not tell anyone. She also said that when she has laid down in the evenings and became SOB that she did not report this to anyone.-LVN N created a note on 7/10/26 at 6:37 a.m., Resident admitted to [hospital] with AKI.-LVN O created a note on 7/10/26 at 10:51 p.m., Resident returned from the hospital.-LVN N created a note on 7/12/26 at 2:39 p.m., Noted that hospital instructions and f/u appts.There were no progress notes from the physician after R#3 returned from the hospital on 7/10/26. Review of R#3's Hospital After Visit Summary Discharge Orders, dated 7/10/26, reflected, Follow-up with [Physician] in 1 week.Review of the facility's admission and Discharge Report, from 7/1/26 through 7/21/26, reflected R#3 was discharged to the hospital on 7/9/26 and returned 7/10/26.During a telephone interview with the Physician on 7/21/26 at 3:22 p.m., he said he had not seen R#3 in a couple of months. He said the NP visited residents once or twice a week. He said he visited residents who were new admissions and who went out to the emergency room. He reviewed the physician progress notes and said the most recent note he sees was from 6/18/26.During a telephone interview with the NP on 7/21/26 at 4:05 p.m., she said she had not seen R#3 since June 2026. She said she visited residents once a month and as needed. She said she could not remember whether or not she visited and followed-up with R#3 after she returned from the hospital on 7/10/26.During an interview with the MDS Coordinator on 7/22/26 at 10:48 a.m., she said R#3 was not feeling well, started to exhibit signs and symptoms of a change in condition, had respiratory issues and shortness of breath, was sent to the hospital on 7/9/26, and diagnosed with pneumonia and dehydration. She said the physician visited residents weekly, monthly, annually and as requested.During a telephone interview with R#3's RP on 7/22/26 at 1:39 p.m., she said staff notified her on 7/9/26 that R#3 was being sent out to the hospital. She said R#3 returned from the hospital on 7/10/26. She said the Physician and MP did not follow-up with R#3 after she returned from the hospital. She said she emailed the DON and, asked who R#3's Physician was and never received a response. She said the NP told her that she saw R#3 and did not.Record review of an email from the ADM on 7/22/26 at 2:45 p.m., and read, Physician notes for [R#3] for July should be in the progress notes, but the NP notes may be in medical records. I sent messages to both [Physician] and [NP] to see if either have seen her [R#3] in July. [Physician] just messaged me in response to my call, 'She was on [NP's] list in 7/20, but [R#3] was not in facility. She is in my list for tomorrow [7/23/26].'During an interview with R#3 on 7/22/26 at 3:51 p.m., she said the Physician did not visit her and never saw her after she returned from the hospital on 7/10/26.During a telephone interview with LVN L on 7/22/26 at 4:01 p.m., she said she was expected to review residents' discharge orders and enter them into the EHR. She said she also had to reach out to the Physician/NP about any appointments. She knew it was important to follow orders and said, It's health. There's a change for the reason. Must enter physician orders. Residents could be at risk of anything when discharge orders not followed.During a telephone interview with RN P on 7/22/26 at 4:13 p.m., she said the readmission nurses were expected to notify the physician that the resident was back from the hospital and to review the orders. She knew it was important to follow orders and said, You have to communicate with the physician because medications could be stopped from the hospital. Residents could be at risk of not being looked at or followed-up on. There might be medications on hold that need to be restarted. Labs could also not end up being entered. Residents could face a decline.During a telephone interview with LVN N on 7/22/26 at 4:33 p.m., she said R#3 returned from the hospital on 7/10/26. She said nurse managers were expected to enter discharge orders. She said she knew it was important to follow orders and said, To prevent delay in care. Residents could be at risk of unfavorable outcomes and encounter delay in treatments.During a telephone interview with the ADM on 7/22/26 at 5:13 p.m., she said R#3 was sent out to the hospital on 7/9/26. She said she expected nurse managers to review residents' discharge orders. She also said the charge nurse would enter orders. She said she expected charge nurses to enter the orders by the end of their shift. She said R#3's hospital discharge summary including Physician follow-up within one week was, Discharge stuff with the hospital that is generic. They are not instructions. Just orders.During a telephone interview with the DON on 7/22/26 at 6:04 p.m., she said she was notified that R#3 was sent out to the hospital on 7/9/26. She said staff were expected to enter orders in EHR. She said the readmission nurse also relays notifications to the physician at the time. She said she knew it was important to follow orders and said, That way they (Physicians) can do it.Review of the facility's Physician Progress Notes policy, 2023, reflected, Regulation states that a resident must be seen by a physician on a specific timeline after admission. After admission, a resident must be seen within the first 30 days, then every 30 days there after to complete the first 90 days of the stay. After the 90-day time frame the resident must then be seen every 60 days. A. The physician does have the option to delegate these visits to the physician assistance or the nurse practitioner. However, within the first 90 days after an admission the attending physician themselves must at least alternate visits with the NP during any Medicare admission. 2. It is our responsibility to notify the physician when a physician's progress note is due. Routine clinical chart audits alert you which physician needs to be notified.Physician visits must confirm to the following scheduled: (B) A physician visit is considered timely if it occurs not later than ten days after the date the visit is required.

Based on interview, and record review, the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 8 of 8 resident.The facility failed to provide continued care for 8 of 8 residents (Resident #1, Resident # 2, Resident # 3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8) after being treated by podiatry.This failure resulted in Resident #1 developing Gangrene which lead to toe amputation.An Immediate Jeopardy (IJ) was identified on 06/17/2026 at 5:14PM. The initial IJ template was provided to the facility on [DATE] at 5:14PM. While the IJ was removed on 06/18/2026 at 7:42PM, the facility remained out of compliance at the scope of pattern and severity of no actual harm due to the facility's need to train all staff. Findings Included:An interview was conducted on 06/16/2026 at 12:45PM with family member for Resident #1 who stated Resident #1 was being seen for issues of her toenails growing weird. A family member stated there were no concerns regarding the resident's toe condition prior to the amputation of the toe. They could not state what caused the amputation of their loved ones' toe.An interview was conducted on 06/16/2026 at 12:50PM with Resident #1 but she could not state what happened to her toe. She stated she had no concerns regarding her care.An interview was conducted on 06/16/2026 at 1:07PM with ADON A revealing that Resident #1 did not have any concerns regarding her toe condition before 06/08/2026. ADON A stated the podiatrist made a visit with Resident #1 on 06/05/2026 and completed an incision and drainage, including a toenail removal. ADON A stated the podiatrist did not leave the orders with a nurse, but at the business office. ADON A stated the facility staff was not aware of the orders until 06/08/2026. ADON A stated on 06/08/2026 Resident #1 had c/o pain in her toe. ADON A took resident to her bedroom and noticed a bandage on Resident #1's right toe. ADON A described the bandage as yellow, which was not a color used at the facility. ADON A stated the bandage appeared tightly wrapped and required soaking of the bandage to be able to remove it from Resident #1's toe. ADON A stated when they removed the bandage, the toe was black and was smaller on the tip. ADON A stated it appeared that Resident #1's toe had lost a lot of blood circulation. ADON A sent Resident #1 to the hospital. ADON A stated that the ADON B had removed the bandage on 06/06/2026 and reapplied he same bandage to the toe. ADON A stated staff were not aware of this being done until 06/09/2026. ADON A stated Resident #1 had circulation issues and believed that the dressing was placed on too tight.An interview was conducted on 06/16/2026 at 1:38PM with MDSC revealed that during the morning meeting on 06/09/2026 it was discussed that a nurse had unwrapped Resident #1's dressing, looked at the toe, and continued with her rounds on 06/06/2026. MDSC stated that the nurse was ADON B, who stated that the podiatrist had done some work on the resident's toe, and ADON B wrapped it back up.An interview was conducted on 06/16/2026 at 3:07PM with ADON B who stated that she was not aware of any orders for Resident #1 following the podiatry appointment on 06/05/2026. ADON B stated that when she made rounds on Resident #1 and observed the dressings on Resident #1's toe on 06/06/2026, she did not check for orders. ADON B stated that the providers would leave orders with the nursing staff. She stated that she did not observe any concerns and did not feel she needed to check the orders.An interview on 06/16/2026 at 3:28PM was conducted with the BOM who stated she would not typically receive orders from providers, but stated she would give them to a nurse or DON if they were present. The BOM stated she was working on 0605/2026. She stated that the podiatrist handed her a stack of paperwork and that she needed to leave it for the social worker. She said that the podiatrist did not specify what it was. She said that she did not take a look at the documents because it was just stack. She said she put them on her desk for the social worker to take a look at on Monday because the social worker was gone. She said that the podiatrist made the copies of the orders by herself. BOM stated that she was not aware that they were orders for the residents and would not have been able to tell just by looking at the documents that they could have been orders.An interview was conducted on 06/16/2026 at 5:05PM with ADON A who stated when she received the orders she had gone to each resident to take a look at the toes and feet that the orders were written on. She stated that in the progress note she acknowledged what the order was and when it was received. She stated she believed that this was on Tuesday 06/09/2026. She said there were only 2 that needed monitoring, but the rest had been healed. ADON A stated that Resident #1's skin assessment that was completed on 06/07/2026 should have reflected bandages on the resident's toes.An interview was conducted on 06/16/2026 at 5:15PM with the RADM revealed that ADON B was the facility's acting wound care nurse and completed wound care.An interview was conducted on 06/17/2026 at 1:18 PM with the RDN. The RDN stated that skin assessments would note if there were concerning conditions. The RDN stated if a bandage was observed on the resident, it should be noted in a skin assessment if there were scheduled skin assessments.An interview on 06/17/2026 at 2:25PM with the podiatrist. She stated that the orders she placed would be to remove the dressing in 24 hours. Confirmed the note on the order sheet that a total nail avulsion was done. She confirmed the orders on the back of the page. She stated that she went to check out with the call nurse, who stated they do not enter orders. She said there was urgent orders who also required a bandage to be removed within 24 hours. She said she left copies of those and left them under the DON door with the intention that the nurse was going to notify the DON per their statement. If the facility had not followed the orders it could have resulted in gangrene and the amputation of the toe. When you remove the toenail it could bleed, so there was a tight dressing to prevent excessive bleeding. She said it could strangulate the toe and lead to necrosis and infection because it is impeding blood flow. She stated that the facility had not followed these orders that it could result in the amputation of the resident's toe. She stated that the abscess under the nail would not have noticed by the facility staff unless you look closely at the foot. She said you can see fluid under the nail after thinning the toe nail. She stated that she leaves orders almost every single time at a facility, she said that it is typically put in when the nurse was given. She said that she tried to text the social worker the next day notifying them of the orders being placed under the door at the DON office. She stated she did not leave the orders at the copy machine. She said she gave all the copies of the notes to the business office because the DON had left for the day.RR of podiatry visit orders revealed that 8 residents were seen by podiatry on 06/05/2026 with new orders for continued care for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8.RR of Resident #1's face sheet revealed an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses of gangrene and acquired absence of one right toe.RR of hospital records indicated that Resident #1 presented to the ER on [DATE] for necrosis (tissue death) of the toe with a diagnoses of Gangrene (the death of body tissue caused by a loss of blood supply or a severe bacterial infection), which resulted in amputation of the toe.RR of resident's nurse notes indicated Resident #1 had a skin check completed on 06/06/2026 with no issues or concerns noted.RR of podiatrist order dated 06/05/2026 revealed Resident #1 required the dressing to be removed after 24 hours and apply ointment for 4 days following. The order also stated wound care as needed.RR of Resident #1's podiatry order as of 06/05/2026 indicated to remove the bandage in 24 hours bilateral feet, triple antibiotic ointment followed by bandage daily x4 days, and have wound care follow if necessary. RR of Resident #2's face sheet revealed a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of type II diabetes and unsteadiness on feedt.RR of Resident #2's podiatry order as of 06/05/2026 indicated to remove bandage to right foot in 24-48 hours.RR of Resident #3's face sheet revealed an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses of type II diabetes (chronic condition where your body becomes resistant to insulin or cannot produce enough of it, leading to high blood sugar) and end stage renal disease (the final stage of chronic kidney disease).RR of Resident #3's podiatry order as of 06/05/2026 indicated to remove bandage in 24-48 hours on right first toe.RR of Resident #4's face sheet revealed an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses of unspecified protein calorie malnutrition and unsteadiness on feet. RR of Resident #4's podiatry order as of 06/05/2026 indicated remove bandage to right foot in 24 hours, triple antibiotic ointment followed by bandage daily x3 days, and have wound care follow if needed.RR of Resident #5's face sheet revealed a [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses of type II diabetes and unspecified sequelae of cerebral infarction (medical term for lingering, post-stroke effects that are present but not detailed in clinical notes).RR of Resident #5's podiatry order as of 06/05/2026 indicated remove bandage bilateral toes x2 in 24-48 hours.RR of Resident #6's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of type II diabetes and unsteadiness on feet.RR of Resident #6's podiatry order as of 06/05/2026 indicated ketoconazole 2% lotion to bilateral feel daily x4 weeks.RR of Resident #7's face sheet revealed an [AGE] year-old woman who admitted to the facility 02/02/2026 with a diagnoses of peripheral vascular disease (a slow, progressive circulation disorder that narrows, blocks, or spasms blood vessels outside the heart and brain) and unsteadiness on feet.RR of Resident #7's podiatry order as of 06/05/2026 indicated triple antibiotic ointment followed by bandage daily x2 days, have wound care follow as needed.RR of Resident #8's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of unsteadiness on feet and muscle wasting atrophy (the loss or thinning of muscle tissue, leading to decreased mass and strength). RR of Resident #8's podiatry order as of 06/05/2026 indicated unilateral edema of right lower extremity, please alert PCP to risk of deep vein thrombosis (serious medical condition that occurs when a blood clot (thrombus) forms in a deep vein, typically in the legs or pelvis) if not already aware and triple antibiotic ointment followed by bandage to left 1st toe and right 3rd toe daily x3 days. RR of undated policy titled Skin Assessment revealed the followingAny open areas will be treated according to physician orders. Notify DON and responsible family member. Documentation will then be entered into the resident's chart with the following information.1. Skin problem noted, and treatment completed.2. Skin problem appearance including size, color of tissue, perimeters, color and amount of drainage, odors, etc.3. Resident with or without pain/discomfort at the site.4. Signs and symptoms of infection.5. Notification completed (physician, family, Treatment Nurse/designee, etc.) RR of undated policy titled Medication Orders revealed the following:New Handwritten Orders signed by the prescriber. The charge nurse on duty at the time the order is received, notes the order and enters it on the physician order sheet if not written there by the prescriber. If necessary, the order is clarified before the prescriber leaves the nursing station whenever possible.THE POR WAS AS FOLLOWS:On 06/16/2026 an investigation was initiated at the facility. An Immediate Jeopardy (IJ) was identified on 06/17/2026 at 5:14PM. On 06/17/2026 the surveyor provided an IJ Template notification that the Regulatory Services had determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The POR was requested on 06/17/2026 at 5:20PM and approved on 06/18/2026 at 8:54AM.The notification of Immediate Jeopardy stated as follows: The facility failed to ensure that proper foot care was provided for Resident #1 to maintain mobility and good foot health to prevent complications from the resident's medical condition, for 1 of 1 resident. All residents receiving services from podiatrist could be affected.Immediate ActionsResident #1 was assessed by the ADONs and Charge Nurses on 6/9/2026. No further skin issues were identified. Physician orders were reviewed by the Regional Compliance Nurse to ensure all orders were implemented and followed. Completed 6/17/2026.All residents seen by the Podiatrist on 6/5/2026 (residents #1-8) were assessed by the ADONs and Charge Nurses on 6/17/2026. No additional skin issues were identified. All physician orders were reviewed by Regional Compliance Nurse to ensure all were implemented and followed. Completed 6/17/2026.Skin assessments on all residents in the facility were completed by the ADON and Charge Nurse to ensure accuracy. Completed as of 6/17/2026. All skin assessments are current. No additional skin issues were identified.An audit of all podiatry visits and physician consults from the previous 30 days was completed to verify that all orders had been received, entered into PCC (cloud-based Electronic Health Record and healthcare software platform designed specifically for the long-term and post-acute care) and implemented. Completed by the Regional Compliance and ADONs on 6/17/2026.Effective immediately, the DON, ADONs or Treatment Nurse will conduct an entrance conference with the provider (podiatrist). The Treatment Nurse or ADON will be designated to round with the provider (podiatrist) with every visit. The Treatment Nurse and/or ADON will exit with the provider (podiatrist) and enter all orders into PCC to ensure that the treatment orders are implemented. If the provider (podiatrist) does not exit, the Treatment Nurse or ADON will call the provider directly for orders and instructions. The Administrator, DON, ADONs, and Treatment Nurses were in-serviced 1:1 on this process by the Regional Compliance Nurse on 6/17/2026.The medical director was notified of the immediate jeopardy on 6/17/2026.An ADHOC QAPI was completed with the Interdisciplinary team as of 6/17/2026.EducationThe following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all staff. All staff who are not present or in-serviced as of 6/17/2026 would not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in- serviced prior to assuming their next assignment. Competency will be verified with a post-test. Completion date 6/18/2026. Abuse and Neglect PolicyPressure Prevention PolicySkin Assessment PolicyProvider Process- If a provider (podiatrist) gives staff any paperwork, the staff member will take the paperwork to the DON or ADON immediately. If the DON and ADON cannot be located, the staff member will call the DON directly.THE POR WAS MONITORED AS FOLLOWS:An interview was conducted on 06/18/2026 at 3:47 PM with MA C, stated the in-service for 06/18/26 covered abuse and neglect, pressure prevention policy, skin assessment policy and the provider process. She stated that if a provider gave paperwork to staff, they would give it to the ADON or DON immediately. She would call the DON immediately if she could not find them. She said the DON's phone number was posted on the wall next to her office door. She said she took a competency test and if she did not make 100, she had to be in-serviced again. She stated that ADON, charge nurses, DON, and wound care doctors completed all skin assessments.An interview was conducted on 06/18/2026 at 4:13 PM with ADON B who stated the ADONs, and Charge Nurse completed another skin assessment on 06/17/26 for all residents seen by the podiatrist on 06/05/26. She stated there were not any new skin issues. ADON B said that the podiatry provider would no longer be allowed in the facility and that no other providers have been there since 06/10/26. ADON B said she was in-serviced on having an entrance and exit conference with all providers effective 06/17/2026. She said either she or a treatment nurse would complete the rounds with the provider. She stated that the provider would give her, the treatment nurse, or the DON all the orders and paperwork and they would enter all orders in the system (PCC). If the provider did not complete an exit conference with them, she said she would call them immediately for orders and instructions. She stated she met with the RDN by herself and was in-serviced on 06/17/2026. She said she had to take a competency test and make a 100 or she would have had to be in-serviced and tested again until she made a 100. She stated she, the DON, RDN, and the ADM administered an Inservice to all staff on:1. Abuse and neglect policy2. Pressure prevention policy -turning every 2 hours and notification if one saw redness3. Skin Assessment policy - when removing dressing, make sure they measured and described everything they saw. CNA's were to report changes to Nurses. Nurse would then go and assess.4. Provider process - if providers gave staff any paperwork, they were to notify and take it to the ADON or DON immediately. Staff would call the DON directly.She stated that the DON's phone number was posted by her office. She stated that everyone signed the in-service and took a competency test. She stated that staff were not allowed to clock in until the in-services were completed. She advised that no one left until that was done. She advised the RDN called the PRN staff and told them they would have to complete the in-service and the test before they would be able to clock in. They had to take a competency test. You had to make a 100 on the test or you would be in-serviced again.An interview was conducted on 06/18/2026 at 4:40 PM with CMA D, who stated the in-service for 06/18/2026 covered abuse and neglect, pressure prevention policy, skin assessment policy and the provider process. She stated that if a provider gave paperwork to staff, they would give it to the ADON or DON immediately. She would call the DON immediately if she could not find them. She said the DON's phone number was posted on the wall next to her office door. She said she took a competency test and if she did not make 100, she had to be in-serviced again. She stated that ADON, charge nurses, DON, and wound care doctors completed all skin assessments.An interview was conducted on 06/18/2026 at 4:55 PM with CNA E, who stated the in-service for 06/18/2026 covered abuse and neglect, pressure prevention policy, skin assessment policy and the provider process. She stated that if a provider gave paperwork to staff, they would give it to the ADON or DON immediately. She would call the DON immediately if she could not find them. She said the DON's phone number was posted on the wall next to her office door. She said she took a competency test and if she did not make 100, she had to be in-serviced again. She stated that ADON, charge nurses, DON, and wound care doctors completed all skin assessments.An interview was conducted on 06/18/2026 at 5:23 PM with RDN, who advised that she reviewed the physician orders in PCC on 06/17/26 for all Residents seen by the Provider on 06/05/2026 to ensure all MD orders were implemented and followed. She advised there were no additional skin issues identified. RDN stated the old podiatrist would not be allowed in the building anymore. She said that no providers have been in the building since 06/10/2026. RDN said she conducted an in-service with the ADM, DON, ADON and the treatment nurse, individually, on 06/17/2026 regarding the provider process. She said either the DON, ADON, or the treatment nurse would conduct an entrance and exit conference with all providers. She said the ADON, or the treatment nurse would round (check on residents) with the provider at every visit and would also exit with them. She said the ADON, or the treatment nurse would enter all orders in PCC to make sure all orders were implemented. She said if the provider left the facility without completing an exit conference with them, the ADON or treatment nurse would call them to get the orders and instructions. RDN said the ADM, DON, ADON, and treatment nurse signed their in-service on 06/17/2026. RDN said the DON was not there, but she sent her a picture of the in-service by text message and the DON acknowledged it by responding to the text. RDN said the DON would sign the in-service when she returned. RDN advised she and RADM completed the Root cause analysis on 06/17/2026. RDN advised the root cause analysis determined that the podiatry orders were provided to a non-clinical department head rather than a licensed nurse responsible for implementation. She said the facility failed to obtain the orders, and they did not ask for them. Additionally, the facility failed to identify the new bandage on Resident#1, verify and implement the provider's orders, monitor and track the resident's condition, and document the issue on the weekly skin assessment as required. RDN stated an ADHOC QAPI was completed with the Interdisciplinary team on 06/17/2026. RDN said she, the ADM, DON and ADON completed the following in-services with staff:Abuse and neglect policyPressure Prevention policySkin Assessment PolicyProvider processRDN said there was a post competency test completed for staff who were in-serviced. They had to make a grade of 100 or they would be in-serviced and had to re-take the test until they passed. She said no one could work a shift until they were in-serviced and took the test. If they were in-serviced by phone, they would have to sign the in-service and take the test before starting their next shift. RDN stated the MD was notified of the IJ on 06/17/2026. RDN said an ADHOC QAPI was completed with Interdisciplinary team on 06/17/2026. An interview was conducted on 06/18/2026 at 5:46 PM with CNA F who said she was not working on 06/17/2026, but she signed the in-service and completed the competency test before she started her shift on 06/18/26. She said she had to score 100 or she would have had to take the in-service and take the test again until she had got a perfect score. She said the in-service covered the following areas:Abuse - she said it meant anything that harmed the resident; and neglect - she said it meant not taking care of the residents' needs on purposePressure PreventionSkin AssessingProvider process- she stated that if a provider gave her any paperwork, she would immediately give it to the ADON. If she did not see the ADON or the DON, she would call the DON immediately. She said the DON's number was posted on the outside of her doorShe stated that the nurses completed the skin assessments and the pressure ulcer assessments.An interview was conducted on 06/18/2026 at 6:00PM with WCN who said he completed skin assessments on 06/17/2026 on all residents seen by the provider on 06/05/2026. He said there were no new skin issues reported, and all assessments were current.He said he was in-serviced by the ADM, DON, and ADON on the following:Provider process - if a provider gave any paperwork work to a staff member, they were to give it to the DON or the ADON immediately. If DON was not around, they had to call her immediately and that her number was posted outside of her office.Abuse and neglect policySkin assessment policyPressure ulcer policyWCN stated he was in-serviced by the RDN on 06/17/2026 regarding an entrance and exit conference with all providers effective 06/17/2026. He stated he would complete rounds with the provider. He stated they had to have an entrance conference with the provider to discuss what they were going to do and what the plan would be. He said they would also have an exit conference. WCN said if the provider left the building without an exit, he would call them to get the orders and instructions. He advised he took a competency test and had to make a 100 or had to be re-in- serviced and take another test until he made a 100.An interview was conducted on 06/18/2026 at 6:24 PM with ADM who stated the ADONS, DON, and charge nurses completed skin assessments on 06/17/2026 for all residents who the provider saw on 06/05/2026. She said there were no new skin issues reported. She said all orders were reviewed for accuracy by the RDN on 06/17/2026. ADM said the old podiatrist would not be allowed in the building anymore due to not providing nurse staff with the orders. She stated that they were still contracted with the same company but requested a different person. She said there were no audits completed after 06/10/26 because no other providers had been there. She said the in-service for 06/18/2026 covered abuse and neglect, pressure prevention policy, skin assessment policy and provider process. She stated that if a provider gave paperwork to staff, they would give it to the ADON or DON immediately. She would call the DON immediately if she could not find her. The ADM had to take a competency test. She stated that if you did not make a 100, you had to be in-serviced again. ADM stated the DON, ADONs, and treatment Nurses were in-serviced by the RDN on 06/17/2026 regarding an entrance and exit conference with the providers effective 06/17/2026. She said they would have the entrance conference to discuss what they were there for and what the plan would be and then either the ADON or a treatment nurse would round with them while they were there. ADM said they would also have an exit conference with the provider and enter all information and orders into the system. She said if the provider left the building without an exit, either the ADON or treatment nurse would call them to get the orders and instructions. She advised they took a competency test and had to make a 100 or had to be re-in serviced and take another test until they scored a 100. ADM said a root cause analysis was completed between the RDN and RADM on 06/17/2026 to determine the cause of the systemic breakdown. She said the provider gave paperwork and orders to non-clinical staff and there was no follow-up process completed by staff. ADM stated the medical director was notified of the immediate jeopardy. ADM said she in-serviced the provider on 6/10/2026. She said the in-service included that the provider would communicate with clinical leadership when visiting the building. She said the provider would conduct an entrance conference and exit conference with the treatment Nurse or ADON and theywould conduct resident rounds with them. She said the provider would give the treatment Nurse or the ADON all orders and paperwork and would conduct an exit conference and discuss details about the visit rounds before they left the facility. She stated the provider electronically signed the Provider Acknowledgement section of the in-service to verify they understood. She stated that they wanted to ensure that the provider gave the orders to the appropriate person.ADM said she, RADM, DON and the ADON completed the following in-services with staff on 06/17/2026:Abuse and neglect policyPressure Prevention policySkin Assessment PolicyProvider processADM said staff who were in-serviced completed a competency test. She said they had to make a grade of 100 or they would be in-serviced again and had to re-take the test until they passed. She said no one could work a shift until they were in-serviced and took the test. If they were in-serviced by phone, they would have to sign the in-service and take the test before starting their next shift.An interview was conducted on 06/18/2026 at 6:54 PM with the FP who stated he was contacted about the IJ on 06/17/2026.RR of skin assessments for all residents who had a podiatry appointment on 06/05/26 revealed there were no additional skin breakdowns as of 06/17/2026.RR of training titled DON, ADON, or treatment Nurse rounding with podiatrist provided on 06/17/26 at 8:00 PM by RDN revealed the following: Effective immediately, the DON, ADON, or Treatment nurse will conduct an entrance conference with the Provider. The Treatment Nurse or ADON will be designated to round with the provider with every visit. The treatment nurse and/or ADON will exit with the provider and enter all orders into PCC to ensure that the treatment orders are implemented. If the provider does not exit, the treatment nurse or ADON will call the provider directly for orders and instructions. Five staff members signed the in-service and there were 5 competency tests with a score of 100.RR of the Root cause Analysis dated 06/17/26, revealed it was conducted by the RDON and RADM. It consisted of the event summary, root cause, contributing factors, and conclusion. It stated the deficient practice occurred due to a system failure in the facility's order-management and communication processes. The lack of a defined procedure for routing, verifying, and implementing physician orders resulted in podiatry orders not being communicated to licensed nursing staff and therefore not implemented in a timely manner.RR revealed there were 73 competency tests with a score of 100 from the in-service completed on 06/17/29 facilitated by the RDN, ADM, DON, and ADON.An Immediate Jeopardy (IJ) was identified on 06/17/2026 at 5:14PM. The initial IJ template was provided to the facility on [DATE] at 5:14PM. While the IJ was removed on 06/18/2026 at 7:42PM, the facility remained out of compliance at the scope of pattern and severity of no actual harm due to the facility's need to train all staff.The IJ was lifted on 06/18/2026 at 7:42PM

Based on observation, interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #64) of 5 residents reviewed for unnecessary medications.The facility failed to ensure Resident #64's PRN prescription of Ativan (a medication used to treat the symptoms of anxiety) was discontinued after 14 days. The facility did not document a rationale for the continued provision of the medication.This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included:Review of Resident #64's significant change in status MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: neurocognitive disorder with Lewy bodies (a type of progressive brain disease that impairs thinking, movement, behavior, and mood), psychotic disorder with hallucinations, muscle wasting, and difficulty walking. She had a BIMS score of 9, indicating moderate cognitive impairment.Review of Resident #64's comprehensive care plan dated 09/09/2024 reflected The resident uses anti-anxiety medicationfor dx of anxiety. Interventions included Give anti-anxiety medications ordered by physician. Monitor/document side effectsand effectiveness. Antianxiety side effects: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision.Record review of Resident #64's active physician order report dated 02/12/2026 reflected an order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/ agitation/ restlessness dated 01/25/2026.Record review of Resident #64's Medication Administration Record for the month of February 2026 reflected there had been no administration of Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/ agitation/ restlessness.In an interview and observation on 02/10/2026 at 2:12 p.m. Resident #64 was found to be awake and alert. She stated she was well taken care of. Resident #64 was talking about the Baptist church when inquiring about her care.In an interview on 02/12/2026 at 11:19 a.m. the ADON stated usually there was a 14 day stop date for all as needed psychoactive medications. She stated the ADONs run a report daily and review it to observe for current and discontinued medications to look and correct discrepancies within the orders. She stated she was not sure why Resident #64 did not have a stop date on her Ativan. It just must have been missed. The ADON stated a risk for residents for not having a stop date on as needed psychotropics could be over sedation.In an interview on 02/12/2026 at 11:39 a.m. the DON stated as needed psychotropic meds were to have a 14 day stop date. If the medication were to be continued the facility would get an extended letter from the physician. She stated the ADON and DON do order listing reports each morning and if they found a PRN medication without a stop date, they would contact the doctor and get clarification on the order. The DON stated risk to the resident for not having stop dates on as needed psychotropic medications was that the resident could continue to get medication used when it is not necessarily needed.Record review of facility policy titled Psychotropic Medication dated 2/12/2025 reflected Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for antidepressant, hypnotic, and antianxiety drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document the rational in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on interview and record review, the facility failed to provide pharmaceutical services that assures the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 5 residents reviewed for pharmacy services, in that: The facility failed to ensure Resident #1's narcotic medications were recorded in the EMR, showing they had been administered on 10/3/2025, 10/5/2025, 10/6/2025, and 10/8/2025. This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization.Findings included:Review of Resident #1's face sheet dated 10/14/2025 reflected she was an [AGE] year-old-female admitted on [DATE] with diagnosis that included: acute respiratory failure (condition where the lungs cannot properly exchange gases), Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that cause long term breathing problems), atrial fibrillation (an abnormal heart rhythm), congestive heart failure (condition where the heart is weakened and cannot pump effectively), and hypertension (high blood pressure). Review of Resident #1's admission MDS assessment dated [DATE] reflected she had a BIMS score of 13 suggesting no cognitive impairment. Review of Resident #1's orders reflected an order dated 10/2/2025: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain DNE 3G/24HR. Review of Resident #1's narcotic count sheet for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) reflected that she had been given 1 tablet on the following dates and times:10/3/2025 at 10:00 am10/5/2025 at 3:00 pm10/5/2025 at 8:07 pm10/6/2025 at 2:15 pm10/8/2025 at 6:00 pm Review of Resident #1's October MAR reflected no administration entries for the following dates and times: 10/3/2025 at 10:00 am10/5/2025 at 3:00 pm10/5/2025 at 8:07 pm10/6/2025 at 2:15 pm10/8/2025 at 6:00 pm During an interview on 10/14/2025 at 1:00 pm, the ADM stated her expectation was that staff would do both parts for medication administration - click off the MAR and sign out in the narcotic book. She stated their policy stated staff were supposed to click off in the MAR when medications were administered. She stated if the MAR was not signed off, medication would be given too soon, and the facility would not have an accurate record of when medications are being given. During an interview on 10/14/2025 at 2:10 pm, the DON stated she had worked on the floor on 10/3/2025, and she had administered Resident #1 her narcotic medications at 10:00 am. She confirmed the signature on the narcotic count for 10/3/2025 was her signature. She stated she signed the medication out on the narcotic count sheet, but forgot to sign it off on the MAR. She stated she got pulled into a room where Resident #1 had requested medication before therapy, so she rushed it down to her without taking her medication cart with her. When she got back to her cart, another resident was already asking for something, and she forgot to document the administration on the computer in Resident #1's MAR. She stated her expectation as the DON was that staff - including herself - would document in the MAR and the narcotic count sheet when the medication was given. She stated if staff did not document in the MAR, a medication error could happen, staff could get medication at the wrong time, and it could cause the patient to not have their pain controlled effectively or they could get too much medication. During an interview on 10/14/2025 at 2:22 pm, LVN A stated she had worked on 10/5/2025 and 10/8/2025 and had administered narcotic medication to Resident #1 as it was recorded on the narcotic count sheet. She confirmed the signature on the narcotic count for 10/5/2025 and 10/8/2025 were her signatures. She stated she had signed the medication out on the narcotic count sheet but forgot to sign it off on the MAR. She stated she was supposed to sign off on the MAR and narcotic count sheet as soon as the person took the medication. She stated by not signing off the medication on the MAR, it looked like they may not have gotten it and could lead to a medication error. She stated if staff went by the MAR alone, a resident could get a double dose and it could cause respiratory depression, which could cause them to stop breathing and possible kill them. She stated the reason she forgot to document in the MAR was because she had a load of 42 residents and [SH1] [LP2] got pulled left and right that day and she had to complete a bunch of assessments and just forgot. During an interview on 10/14/2025 at 2:50 pm, LVN B stated she had worked on 10/6/2025 ,and had administered narcotic medication to Resident #1 at 2:15 pm. She confirmed she had signed the narcotic count sheet. She stated they were supposed to sign off the MAR when they gave the medication and stated the reason she did not sign off the administration on the MAR as I might have had something come up with another resident, and got distracted. She stated if a medication was not signed off in the MAR, it could lead to a med error as the next nurse might not recognize the medication had been given. She stated she was not sure what would happen if there was a medication error, but maybe it could cause drowsiness. Review of the facility's policy Medication Administration and Guidelines dated v3-2025 reflected: 11. The resident's MAR is initialed by the person administering a medication, in the space provided under the date and on the line for that specific medication dose administration. Or if utilizing an Electronic Medical Record, the initials of the nurse are electronically stamped into the record. All licensed personnel / nurses will be assigned a secure password which will not be shared or given out to other personnel. Checklist for completing proper steps in the administration of medications Washes hands using proper technique Does not handle pills with bare hands Ensures identity of the right resident Explains the administration procedure to the resident Adheres to the 6 Rights of Medication Administration: 1) Right Dose 2) Right Route 3) Right Resident 4) Right Medication 5) Right Time 6) Right Documentation Observes the resident take the medications Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: 1) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 2) Dietary staff failed to effectively label items in in freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 11/04/2024 at 09:11 AM the following was observed: The walk-in refrigerator contained what appeared to be cabbage in a clear opened plastic bag that was exposed to air and not labeled or dated. The freezer contained what appeared to be croissants in a clear plastic bag with no label. Interview with the Dietary Manager on 11/05/24 at 11:05am, the DM stated all items in the refrigerators and freezers should be sealed, labeled, and dated. The DM stated if an item was not sealed properly the item could spoil or there would be a cross contamination issues. The DM stated if an item was not labeled then someone would not know what the item was. The DM stated it was the cook or aide who opened the items responsibility to ensure they were labeled, dated, and properly sealed. Interview with the ADM on 11/05/24 at 11:50am, the ADM stated all items should be sealed, labeled, and dated. The ADM stated that if food was not sealed properly the food would not be safe to serve and would not be palatable. The ADM stated that if an item was not labeled then it may not be identified correctly. The ADM stated whoever opened the item would be responsible for ensuring it was sealed, labeled and date properly. Record review of the facility's Food Storage and Supplies policy, dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedures: 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when open . Record review of the facility's Storage Refrigerators policy, dated 2012, revealed All storage refrigerator shall be maintained clean and have a proper temperature for food storage and ensure a proper environment and temperature for food storage. Procedures: 5. Food must be covered when stored, with a date label identifying what is in the container .

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 6 residents (Resident #144) reviewed for resident rights. The facility failed to ensure Resident #144's call light was within reach on 11/04/24. This failure could place residents at risk of needs not being met. Findings included: Record Review of Resident #144's medical diagnosis dated 11/06/24 reflected the resident was an [AGE] year-old male admitted on [DATE]. His diagnoses included diabetes (a group of diseases that result in too much sugar in the blood), ischemia and infarction of the kidney (conditions that occur when the kidney's blood supply is blocked, leading to tissue damage), atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), and congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). Record review of Resident #144's quarterly MDS dated [DATE] reflected the resident's BIMS was not completed due to being a new admit and BIMS score was not due yet. The MDS reflected it was in progress and required assistance section was not completed. Record review of Resident #144's care plan dated 10/31/24 reflected: Focus: Resident #144 was at risk for falls. Goals: The resident will be free of falls through the review date. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach). In an observation and interview on 11/04/24 at 11:55 AM Resident #144 was lying in bed with the call light lying on the floor on the right side of Resident #144's bed and out of Resident #144's reach. Resident #144's door was open. Resident #144 stated he could not reach his call light at that time and if he needed his call light, he would not try to reach it if it was on the floor because he knew he would fall. He stated he would yell out for help if he needed help and sometimes it took a while for staff to answer his light if he could reach it to call for them. In an observation on 11/04/24 at 12:25 PM Resident #144 was lying in bed with the call light lying on the floor on the right side of his bed and out of Resident #144's reach. Resident #144's door was open, and Resident #144 was not showing any sign of pain or distress. In an interview on 11/04/24 at 12:22 PM CNA C stated she had worked in the facility for about 2 years. She stated she had not seen Resident #144's call light on the floor or out of his reach. She stated Resident #144 could not have reached the call light where it was on the floor, and he probably had gotten up to go to the bathroom and it fell on the floor. She stated she had been in-serviced on call lights being within residents reach. She stated residents call lights should have been in residents reach at all times and if a residents call light was out of reach, it could cause a fall. In an interview on 11/06/24 at 10:54 AM, the DON stated residents call lights should be in all residents reach at all times. She stated all nursing staff and any other staff that entered a residents room were responsible for ensuring call lights were in residents reach at all times and all staff had been in-serviced on call light placement. She stated if a residents call light was not in reach, it could have caused a delay in care or assistance. In an interview on 11/06/24 at 11:02 AM, the ADM stated she stated residents call lights should be in all residents reach at all times. She stated all staff were responsible for ensuring call lights were in residents reach at all times and all staff had been in-serviced on call light placement. She stated if a residents call light was not in reach, it could have caused a resident to possibly not have their needs met. In an interview on 11/06/24 at 11:08 AM a policy for call lights or call light placement was requested from the ADM. The ADM stated there was no policy from the facility for call lights or call light placement. The ADM stated it was their expectations for all call lights to be in place and to answered in a timely manner.

Based on observation, interview, and record review the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to ensure 3 expired Central Line Dressing Change Kits, 3 expired I.V. Start Kits and 1 Pack of 30 expired syringes of Ativan/Benadryl 1-25mg/ml medications were removed from the medication storage room located near Nurse's Station 2. There were no active orders for the medication. These failures could place residents who needed intravenous medications at risk to have contaminated dressings or contaminated I.V. lines started. This would put them at risk of infection. The failure to removed expired medications could put residents at risk of receiving ineffective medications. Use of these expired supplies and medications would not meet acceptable standards of medical practice and could result in resident's harm. Findings include: Observation on 11/05/2024 at 2:37 pm of the Medication Room on Station 2 revealed the following items with expired Manufacturer/Supplier dates: #3 HTo3-7600 Dressing Change Central Line Kit by Cardinal Health Expired 10/1/24. #3 IV Start Kit with/Chloraprep App by Medline Item # DYND74260 Expired 7/31/24. #1-Pack of 30 1ml syringes Ativan/Benadryl 1-25 mg/ml Lipo Topical Expired 10/27/24. In an interview on 11/6/24 at 10:55 am, the DON stated the policy on expired items in the medication storage room was for them to be destroyed and placed in the destroyed bin and reordered. She stated the nurses, and the medication aides were responsible for this and that they have been given in-services on this. The DON stated the potential outcome if this was not done, would be that expired medications and supplies could cause harm like infections to residents. In an interview on 11/6/24 at 11:00 am, the ADM stated the policy on expired items in the medication storage room was for them to be destroyed. The ADM stated that anyone who has access to the medication room was responsible for doing that, including nursing and nursing management. She stated that they have been in-serviced on this. She also stated the potential outcome if not done was that expired medications may not have the correct effectiveness and expired supplies may not have the original integrity. A lack of integrity for supplies could cause a break in a sterile field, which would create a potential risk for infection. She stated a prudent nurse would not use expired items. In an interview on 11/6/24 at 12:18 pm, LVN-A stated the policy on expired items in the medication storage room was to put them into the hazardous bin, sign-off on them, and then the DON can dispose of them later. She said nurses and medication aides were responsible for doing this and that they have been in-serviced on this. She stated the potential negative outcome if this was not done, and expired meds or supplies were used was that expired medications may not be effective and expired supplies could break and allow bacteria in to cause infections. In an interview on 11/6/24 at 12:20 pm, MA-B stated the policy on expired items in the medication storage room would be to put them in the discontinued box or if it was a narcotic, then give it to the DON. She stated the medication aides, and the nurses were responsible for doing this and they have been in-serviced on it. MA-B stated the potential negative outcome if this was not done, and expired meds or supplies are used is that expired medications lose their effectiveness and expired supplies could also not be effective. Record review of the facility policy dated 2003 and titled, Pharmacy Policy and Procedure Manual Policy-Storage of Medication reflected, Medications and biologicals are stored safely, and properly following manufacturer recommendations or those of the supplier.

Based on interview, and record review the facility failed to keep residents free from physical and verbal abuse for 1 (Resident # 1) of 4 residents reviewed for abuse. The facility did not ensure Resident # 1 was free from abuse, as a result Resident # 1 was physically assaulted by Resident # 2 and was injured. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: Record review of Resident # 1's admission face sheet dated 08/06/2024, revealed Resident # 1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance (A group of thinking and social symptoms that interferes with daily functioning), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), hypertension (high blood pressure), anemia (A condition in which the blood doesn't have enough healthy red blood cells), depression (A group of conditions associated with the elevation or lowering of a person's mood), lymphocytosis (An increase in the number or proportion of lymphocytes in the blood), protein calorie malnutrition, and personal history of transient ischemic attack (A brief interruption of blood flow to the brain that causes stroke like symptoms) and cerebral infarction(An ischemic stroke which occurs as a result of disrupted blood flow to the brain). Record review of the MDS assessment dated [DATE] revealed Resident # 1 had clear speech and was understood by staff. The MDS revealed Resident # 1 usually understands others. The MDS revealed Resident # 1 had a BIMS score of 6, which indicated mild cognitive impairment. The MDS reflected Resident # 1 had no behaviors or refusal of care. Record review of the care plan, initiated on 01/11/2023 and revised on 01/15/2024 revealed Resident # 1 is risk for falls. Interventions included be sure the residents call light is within reach and encourage resident to use it when needed. Resident # 1 has an ADL self-care performance deficit. Interventions included Resident # 1 is a 1 person staff assist with bed mobility, transfers, toileting, dressing, and bathing. Record review of a nursing progress note dated 08/01/2024 revealed LVN A documented: As I walked into room [ROOM NUMBER], I heard Resident # 2 tell Resident # 1 you are a lazy b Resident # 1 responded she doesn't bother anybody, and that Resident # 2 had kicked her. Upon completing a physical assessment of both residents Resident # 1 had a skin tear approx. 5 cm by 1 cm to her lower left leg. Family notified for Resident # 2 at 2020 (8:20 pm) and received a return call from Resident # 1family at 2105 (9:05 pm). Skin tear cleansed with w/c and wrapped with kerlix to stop bleeding. Record review of a nursing progress note dated 08/02/2024 revealed SW met with Resident # 1 in her room. Resident # 1 in her bed appeared to be resting. SW asked Resident # 1 how she was doing this morning and she replied ok. SW asked Resident # 1 if she feels safe and she replied yes. SW asked Resident # 1 if she feels afraid and resident replied no. SW asked resident what happened to cause altercation between her and her roommate. Resident # 1 replied that her roommate just kept yelling at her that she was lazy and couldn't do for herself. Resident # 1 said she likes to take up for herself and when she did her roommate kicked her in the leg. SW asked Resident # 1 if she slapped her roommate and Resident # 1 replied no. Resident # 1 expressed, she is glad she moved to her new room. SW has assessed Resident #1 for fearfulness or distress related to this occurrence. Currently Resident #1 is not showing any signs or fearfulness or distress and feels safe. Record review of Resident # 2's admission face sheet dated 08/06/2024, revealed Resident # 2 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of personal history of transient ischemic attack (A brief interruption of blood flow to the brain that causes stroke like symptoms) and cerebral infarction (An ischemic stroke which occurs as a result of disrupted blood flow to the brain), permanent atrial fibrillation (An irregular often rapid heart rate that commonly causes poor blood flow), hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wear down), chronic kidney disease stage 3 (When the kidneys have moderate damage and are less able to filter waste and fluid from the blood), dementia with other behavioral disturbance (A group of thinking and social symptoms that interferes with daily functioning). Record review of the MDS assessment dated [DATE] revealed Resident # 2 had clear speech and was understood by staff. The MDS revealed Resident # 2 usually understands others. The MDS revealed Resident # 2 had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS reflected Resident # 2 had no behaviors or refusal of care. Record review of the care plan, initiated on 12/12/2023 revealed Resident # 2 has impaired cognitive function/dementia or impaired thought processes. Interventions included monitor/document/report to MD any changes in cognitive function specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Record review of care plan, initiated on 05/20/2024 revealed Resident #2 has potential to demonstrate physical behaviors and has potential for injury related to will strike out at staff when attempting to provide care. Resident # 2 goal stated the resident will not harm self or others thru review date. Interventions included if resident has physical behaviors towards another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Record review of the nursing progress notes dated 08/01/2024 at 20:51 (8:51 pm) revealed LVN A documented: As I walked into room [ROOM NUMBER], I heard Resident # 2 tell Resident # 1 you are a lazy b Resident # 1 responded she doesn't bother anybody, and that Resident # 2 had kicked her. Upon completing a physical assessment of both residents Resident # 1 had a skin tear approx. 5 cm by 1 cm to her lower left leg. No injuries noted on Resident # 2. Residents were immediately separated. Family notified for Resident # 2 at 2020 and received a return call from Resident # 1family at 2105. Resident # 2 said Resident # 1 is a lazy b . that she needed to get up and that she doesn't try hard enough. DON and NP notified of event. Record review of the nursing progress notes dated 08/02/2024 at 9:20 am revealed SW met with Resident # 2 in SW office to assess how Resident # 2 is doing this morning after the altercation with her roommate last night. SW asked Resident # 2 if she felt safe and Resident # 2 replied yes. SW asked Resident # 2 if they were afraid, and Resident # 2 replied no. SW asked Resident # 2 what happened. Resident # 2 stated they were in bed last night and her roommate Resident # 1 kept yelling for an aide to help her to the bathroom. Resident # 2 said she put her call light on to try and help her roommate but Resident # 1 kept keeping Resident # 2 up and Resident # 2 became agitated. Resident # 2 then said Resident # 1 slapped her. SW asked Resident # 2 how Resident # 1slapped her if they were in bed. Resident # 2 said that's right we were in our wheelchairs and then Resident # 1 slapped me and I then kicked her in the leg, but it was already hurt. SW asked Resident # 2 why she kicked Resident # 1 and Resident # 2 responded I was taught to defend myself and if you grew up the way I did with a bunch of siblings you would too. Resident # 2 then expressed she can take herself to the bathroom and do things for herself and that her roommate Resident # 1 is always needing help and can't do for herself and that bothers her. SW explained that not everyone is the same and some need the help of staff and those that don't are very lucky. SW discussed with Resident # 2 that her roommate Resident # 1 has moved to another room and Resident # 2 replied that's a good thing and might be for the best. SW educated Resident # 2 about not physically using her arms or legs to hurt another resident, even if she is upset, and that going forward she should notify staff using her call light to prevent any other altercations with other residents. SW completed a SLUMS with Resident # 2 and she scored a 9 which, a score of 1-20 indicates dementia. SW has assessed Resident # 2 for fearfulness or distress related to the occurrence and at this time Resident # 2 appears safe, calm, and unafraid. SW did discover the root cause of Resident # 2 agitation. Resident # 2 feels that at her age you should be able to do for yourself and not ask for help from others. SW feels that Resident # 2 lashed out at her roommate Resident # 1 because she needs assistance with ADL's and uses her call light to get that assistance. Record review of the nursing progress notes dated 08/02/2024 at 10:50 am SW notified RP of Resident # 2 that due to the altercation with Resident # 1 last night the SW recommends a referral to psych services and RP agreed to psych services. Record review of the nursing progress notes dated 08/02/2024 at 12:38 pm revealed SW sent referral for psych services for urgent telehealth visit. Record review of the nursing progress notes dated 08/02/2024 at 13:14 (1:14 pm) revealed SW contacted Resident # 2 RP about psych not knowing Resident # 2 prior and recommends that Resident # 2 be sent out to a psych hospital for evaluation. SW explained to RP at this time Resident # 2 is not showing signs of frustration or aggression, Resident # 1 has been moved, neither resident feels afraid nor distressed at this time. RP said he feels sending Resident # 2 to the psych hospital would be extreme and does not want Resident # 2 sent out. SW agreed and let RP know that the SW would continue to monitor the situation. Record review of the nursing progress notes dated 08/05/2024 at 11:04 am revealed SW followed up with Resident # 2 this morning. SW asked Resident # 2 how she was doing, and Resident # 2 said she was doing good. No aggression or frustration noted. Resident is adjusting to having a new roommate and SW encouraged Resident # 2 that it will take time to get to know each other. SW asked Resident # 2 if she told her new roommate that she didn't belong in the room and Resident # 2 responded no. Resident # 2 then said her new roommate stays in bed all day and she does not. SW reminded Resident # 2 that they share a room and if her roommate wants to stay in bed all day then she can. Record review of the nursing progress notes dated 08/06/2024 15:27 (3:27 pm) revealed it was reported to SW that Resident # 2 was being verbally aggressive to her new roommate. To minimize any further behavior Resident # 2 RP was contacted and agreed to Resident # 2 moving to a room without a roommate. Record review of the nursing progress notes dated 08/06/2024 16:18 (4:18 pm) revealed SW noted Resident # 2 will be seen on 08/08/2024 at 11:00 am for psych evaluation via telehealth. Record review of email dated 8/2/24 at 12:30 pm SW sent to psych facility for referral for Resident # 2 for evaluation. Observation/Interview on 8/6/24 at 1:15 pm with Resident # 1 revealed Resident # 1 said they feel safe, and staff take good care of them. Resident # 1 said they were happy they moved rooms and had no concerns with their new roommate. Resident # 1 said her prior roommate Resident # 2 was upset with her and had injured her legs. Resident # 1 said she was not sure why Resident # 2 was upset with her and that she was not afraid of her as she did not see her anymore. Resident # 1 said her prior roommate got upset with her anytime she called for help. Resident # 1 said she only called for help when she needed it. Resident # 1said her leg was bleeding and hurt after her roommate kicked her. Resident # 1would not answer as to how the incident made her feel. Resident # 1 said she did not want to get anybody in trouble and since she moved rooms it was not a problem now. Interview on 8/6/24 at 1:28 pm with Resident # 2 revealed Resident # 2 said they feel safe, and that staff do the best they can to assist. Resident # 2 could not recall the altercation that had happened with Resident # 1. Resident # 2 said they do not use their call light as they do for themselves. Interview on 8/6/24 at 4:04 pm with the SW revealed SW said she had met with each resident after the altercation occurred. The SW said the interventions that had been put in place was to separate the residents immediately, have Resident # 1 move rooms, and contact psych services for an evaluation. The SW said after the allegation of Resident # 2 verbally abusing her current roommate the intervention of moving Resident # 2 to a room without a roommate and continued monitoring until the psych evaluation could be completed and the recommendations received from psych services. The SW said this intervention had been put into place for the safety of the other residents and the resident herself. Interview on 8/6/24 at 6:19 pm with the AD revealed the AD said abuse can be mental, physical, or sexual. The AD said abuse was any willful or intentional harm of someone. The AD said yes abuse can occur between residents. The AD said negative outcomes of abuse can be physical harm, being fearful, scared, intimidated, uncomfortable in their own home. The AD said the procedure for a resident-to-resident altercation was to immediately separate the residents, perform a physical and emotional assessment of each resident, notify MD and RP, establish what interventions are needed for both parties involved, complete the self-report, train, and educate staff, monitor for behaviors, and review during the facility QAPI meeting. AD was asked if Resident # 2 had hurt any other residents in the past and AD responded no they had not. AD said they felt like the proper interventions had been put in place after the incident with Resident #1 and Resident #2. AD said the facility investigation of this incident confirmed this incident occurred. AD would not directly answer if this incident was abuse. AD said staff have received in-service/training on resident-to-resident behaviors, abuse/neglect/misappropriation, change of condition, answering call lights, Q-2-hour resident rounds. Record review of in-services with topics of: Resident to resident behavior dated 8/1/24 revealed 25 staff in attendance, Abuse/Neglect/Misappropriation 8/1/24 with 28 staff in attendance, Q-2-hour resident rounds 7/31/24 with 12 staff in attendance, answering call lights 7/31/24 with 14 staff in attendance, Change of condition 7/29/24 with 28 staff in attendance, Record review of the facility investigation for intake 522101 included resident safe surveys conducted, staff questionnaire about resident-to-resident monitoring for behaviors, progress notes, and residents head to toe assessments completed. Record review of the Abuse policy with a revision date 08/2019 revealed under heading policy: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form and to report in accordance with the law any incidents/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Under heading procedure 6. Protection c. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the home's primary concern.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of communicable disease and infections for 1 of 1 staff (CMA A) reviewed for the following: 1. CMA A failed to sanitize a blood pressure monitor between uses on Resident #1, #2 and #3. Findings included: 1. Observation on 09/11/22 at 9:10 AM, revealed CMA A took blood pressure on Resident #1 with the use of wrist cuff blood pressure monitor and returned to the med cart and did not disinfect the blood pressure monitor. CMA A then charted the result into the computer, performed hand hygiene with sanitizer and began to prepare medication for Resident#1. CMA A administered medication to Resident #1 and performed hand hygiene using soap and water. Observation on 09/11/22 at 9:31 AM, revealed CMA A returned to the med pass after administered medications to Resident#1, grabbed the used wrist cuff blood pressure monitor and entered Resident #2 to check blood pressure. CMA A returned to med cart after taking the blood pressure on Resident #2, did not clean the blood pressure monitor and placed the blood pressure monitor on top of the med cart. CMA A charted the results into the computer, performed hand hygiene with use of sanitizer and began to prepare medication for Resident #2. CMA administered medications to Resident #2 and performed hand washing with use of soap and water. CMA A did not clean the wrist cuff blood pressure monitor between Resident #1 and Resident #2. Observation on 09/11/22 at 9:53 AM, revealed CMA A returned to the med pass after administered medications to Resident#2, grabbed the used wrist cuff blood pressure monitor and entered Resident #3 to check blood pressure. CMA A returned to med cart after taking the blood pressure on Resident #3, did not clean the blood pressure monitor and placed the blood pressure monitor on top of the med cart. CMA A charted the results into the computer, performed hand hygiene with use of sanitizer and began to prepare medication for Resident #3. CMA administered medications to Resident #3 and performed hand washing with use of soap and water. CMA A did not clean the wrist cuff blood pressure monitor between Resident #2 and Resident #3. An interview on 09/11/22 at 10:07 AM, CMA A stated that she forgot to wipe the blood pressure monitor down with the purple-topped disinfectant wipes. CMA A stated she normally does wipe it down between resident care and pulled out the purple-topped disinfectant wipes from the bottom of the medication cart. CMA A stated this action of failure can result in spread of germs. CMA A reported she had in-service on sanitizing equipment conducted by DON. An interview on 09/13/22 at 11:26 AM, DON stated, staff should be sanitizing blood pressure machine in between resident use. The DON stated, A failure can result in infection material that could possibly be transferred to another person and could fall somewhere in the chain of infection. Record review of facility's policy Infection Control Plan: Overview dated 2016, states: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Resident care equipment and articles: Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures placed the resident at risk of not receiving adequate care and services, poor self-esteem and self-worth and decreased quality of life. Findings include: Review of the face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the annual minimum data set (MDS) for Resident #1 dated 10/4/2021 reflected a brief interview for mental status (BIMS) score of 12, indicating resident had moderately impaired cognition. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One time only for tremors related to Neuroleptic induced parkinsonism for 10 days. The order had a start date of 12/20/21 and an end date of 12/30/21. Further record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facilities policy and procedures entitled 'Physicians Orders', from the Medical Records Manual 2015, revealed: Purpose: to monitor and ensure the accuracy and completeness of the medication orders, treatment orders and ADL order for each resident. It further revealed under the section entitled 'Written orders by the Physician or Nurse Practitioner', #4 the receiving nurse will contact any other department or external facilities as required, i.e., dietary department, pharmacy, lab provider, x-ray provider, etc. Observation on 1/5/22 at 11:43 AM revealed Resident #1 sitting up in bed requesting help cutting off a bandage on her right wrist. Both of the resident's hands were shaking with tremors. Resident stated she had trouble eating if her hands were shaking really bad. She stated it bothered her that her hands shook and she wasn't able to do things for herself. Observation on 1/5/22 at 12:49 PM revealed LVN B in Resident #1's room. The resident's mouth was going up and down involuntarily and her left hand was shaking slightly with tremors. Observation on 1/6/22 at 1:04PM revealed Resident #1 was sitting at bedside working with therapist and resident's hands were moderately shaking with tremors. During an interview on 1/5/22 at 10:11 AM with Resident #1's family member revealed she had concerns about the increase in tremors in Resident #1. She stated they had recently gotten worse, She asked the facility for a neurology consult about 3 weeks ago. She further stated the tremors were decreasing Resident #1's quality of life and making her more anxious and they wanted them looked into. She stated, She has gone from being a pretty independent [AGE] year-old woman to almost bedridden. She stated her and another family member noticed an increase in her tremors about 2 weeks before Thanksgiving. She said the facility had not followed through on the neurology consult. During an interview on 1/5/22 at 11:24 AM CNA A revealed she was the transport coordinator and also sets up all of the appointments for the residents. She stated once the order was confirmed, it was printed out by the nurse and put in a folder at the nurses' station. She stated there were 2 nurses' stations and a folder at each station. She stated she checks these folders every day, Monday through Friday. CNA A stated she never saw a confirmed order in either folder for a Neurology referral for Resident #1. During an interview on 1/5/22 at 12:16 PM DON stated the facility has two (2) ADON's that review all orders from the previous 2-3 days. She stated, They go through and make sure things have been done and that orders were put in correctly. She stated it was her expectation that the ADON's review the orders and make sure the orders were carried out. She states they follow up on x-rays, labs and referrals to be sure they were completed. She stated it was her understanding that the referral was still not made because the transport coordinator had not received any information for an appointment. During a phone interview on 1/5/22 at 12:21 PM, LVN A stated, I know I didn't print it out - that actually never occurred She further stated CNA A didn't get the order because I didn't print it out. I don't even remember confirming the order. We don't have many referrals so I should have remembered this one. I would have remembered it if I had printed it out. She further stated, I'm pretty good about locking out or signing off on the computer and I don't let others use my ID on the computer. There is no chance that someone else confirmed this order under my ID. This is all on me. During an interview on 1/5/22 at 12:49 PM with LVN B she stated resident was currently having tremors to her left hand and her mouth was going up and down involuntarily. She stated, some days it's worse than others, some days its both hands. She stated resident was going to be starting a new medication trial to see if would help the tremors. During an interview on 1/5/22 at 1:18 PM ADON #1 stated the neurology referral for Resident #1 came through from the NP (Nurse Practitioner). ADON #1 stated she saw the order in PCC and faxed it over to the neurologist's office. She stated she also called, but they were closed so she left messages. She stated, I don't document when I fax and call and was unable to provide dates and times when the fax and call was completed. She stated as of today, 1/05/22, the appointment still has not been made Not that I am aware of. She further stated she had no notes as to when she called the neurologist's office and left messages. She stated she called before Christmas and to follow up after her hospital visit early this week - a day or two ago. During a phone interview on 1/5/22 at 1:35 PM the referral coordinator at the Neurologist's office stated she had not seen a fax or received a voice messages regarding a referral for Resident #1. She further stated she had checked with everyone in their office, and no one had heard of Resident #1 nor received a fax or voice message regarding a referral. She stated, We don't have any referrals for this patient. I have checked both our scheduling cue and our new patient cue and there is nothing there. If we would have received it, she would have been scheduled. We are scheduling out to March right now. She also stated if there was a problem with scheduling an appointment it would have shown up and there is nothing in our unable to schedule cue. During an interview on 1/5/22 at 2:00 PM the DON stated, If the nurse misses something and the ADON misses something the NP will ask about orders and things that are pending when she is in the building She stated the NP was in the building 4-5 days a week. She further stated it was her expectations that the nurse that confirms the order will print it out and put it in the folder for the CNA to schedule. She stated it is her expectation that the ADONs will review the orders within about a week or so and that they review orders and insure they are followed up She also stated, I don't know why this order for the referral has not been done and fell through the cracks. She stated per their policy, the nurse is responsible for making sure the orders are carried out.

Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of * resident reviewed for pain management. (Resident #54) The facility failed to ensure a triplicate prescription was completed timely to avoid a lapse in pain medication for Resident #54. The facility failed to ensure Resident #54's pain medication was available when she needed it. The facility did not assess Resident #54 for pain on 7/20/21 while her medication was not available. This facility failure could place residents on pain management at risk for unnecessary pain, discomfort and decreased quality of life. Findings include: Record review of a Resident Face Sheet dated 07/28/21 revealed Resident #54 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment dated [DATE] revealed Resident #54's cognition was not impaired, with the highest BIMS score of 15. Record review of MAR for Resident #54 revealed she had an allergy to [MEDICATION(S)], [MEDICATION(S)] and related. She was prescribed scheduled and PRN pain medication. MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MAR for Resident #54 reveals that no pain medication was provided for 7/20/21. Record review of electronic pain assessments for Resident #54 revealed she experienced moderate pain occasionally and no pain assessment was documented on 7/20/21. Record review of progress notes for Resident #54 revealed on 7/22/21, a note was entered to state the resident did not attend [CONDITION(S)] on Tuesday, which was 7/20/21, on the day she did not receive any pain medication. Record review of the Care Plan revised 01/13/2021 revealed Resident #54 was at risk for uncontrolled pain and was on pain medication therapy. Interventions included anticipating the resident's need for pain relief, evaluating the effectiveness of pain interventions, identifying, recording and treating conditions which may increase pain, monitor/document for side effects of pain medication, monitor/record pain characteristics, monitor/record/report to nurse complaints of pain or requests for pain treatment, notify physician if interventions are unsuccessful, administer medication as ordered, ask physician to review medication if side effects persist. During an interview on 07/26/21 at 2:56 PM, Resident #54 stated she went several days without her regular pain medication. She stated she was in too much pain to attend [CONDITION(S)] one of those days. She is not aware why she did not have her medication available. During an interview on 07/28/21 at 9:28 AM, MD stated [MEDICATION(S)] and [MEDICATION(S)] were related and he would suggest trying [MEDICATION(S)] first and go from there. He stated they used the E-scribe system to fill triplicate prescriptions. He stated there could possibly be a delay if there was insurance changes or other types of issues. He stated if a resident were to run out of pain medication, the facility would notify him and he would get it completed as quickly as possible. He stated if [MEDICATION(S)] was not available and [MEDICATION(S)] was used in place of [MEDICATION(S)] his expectation would be that pain levels would be assessed to ensure alternate methods of pain management were effective. During an interview on 07/28/21 at 11:19 AM, Resident #54 stated she had pain at a 5 to 8, on a 0-10 scale, during the days her [MEDICATION(S)] medication was not available. She stated she notified the staff that the Tylenol #3 was not helping her pain and refused to take it after the second day. She stated she also had taken [MEDICATION(S)] and it helped a little bit, but her [MEDICATION(S)] was not given on one day. She stated she has drug allergies to [MEDICATION(S)] that caused GI upset following her gastric by-pass, and she has an allergy to [MEDICATION(S)] that caused a severe headache. She stated that [MEDICATION(S)] made her itch. During an interview on 07/28/21 at 03:38 PM, DON she stated the facility notified the NP on 7/8/21, that a refill order would be needed for Resident #54's [MEDICATION(S)] medication. She felt it was easier to contact the NP and have the NP determine which Primary Care Physician would need to write the order. Record review revealed there was no follow up after that date. The DON stated alternate pain management was addressed, by the facility medical director, for Resident #54 to use Tylenol #3 in place of the [MEDICATION(S)] until the primary care physician could be contacted. She stated, per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #3 was first given on 7/21/21 at 11:00 am. She stated [MEDICATION(S)] was given for pain management but not as a replacement for [MEDICATION(S)]. The PRN [MEDICATION(S)] was also not given on 7/20/21 the day that the [MEDICATION(S)] was not available. She stated there was no pain assessment completed on 7/20/21. Facility policy for Pain Management was not provided prior to exit.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 3 (Residents #9, #58 and #219) of 18 residents reviewed for care plans in that: 1. Resident #9's comprehensive care plan did not reflect puree diet with nectar consistency. 2. Resident #58's comprehensive care plan did not reflect fall on [DATE], [DATE] or floor mats proceeding two falls. 3. Resident #219's comprehensive care plan inaccurately reflected full code status when resident had a DNR code status. These deficient practices could affect all residents who reside at the facility and could result in missed or inaccurate care. The findings were: 1. Record review of Resident #9's electronic face sheet dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's physician orders dated [DATE] reflected Regular Diet pureed texture, Nectar consistency with a start date of [DATE]. Record review of Resident #9's Comprehensive Care Plan dated [DATE] reflected resident has a swallowing problem related to CVA (Cerebral Vascular Accident) with an intervention of follow diet as prescribed. Diet for puree consistency and puree was not found in Comprehensive Care Plan review. During an interview on [DATE] at 12:10 PM, MDS Nurse A stated that the comprehensive care plan should reflect specification for diets to include puree and thickened or nectar fluids. During an interview on [DATE] at 12:15 PM, MDS Nurse B stated that a person-centered comprehensive care plan should include anything specific for a resident, including diet specifications. During an interview on [DATE] at 2:55 PM, the DON stated that it was her expectation to see specialized diets in the comprehensive care plans. DON stated that the care plan did not state puree consistency. 2. Record review of Resident #58's face sheet dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #58's electronic Nursing Progress Notes dated [DATE] and signed by LVN A, reflected that resident was found on her right side of the bed and assisted back into bed by 2 unnamed CNAs and LVN A. Record review of Resident #58's electronic Fall Nurses note dated [DATE] reflected a fall on [DATE] with no injury. Record review of Resident #58's electronic Nursing Progress Notes dated [DATE] and signed by LVN B reflected that resident had a fall the night of [DATE]. Record review of Resident #58's electronic Fall Nurse's note with an effective date of [DATE] at 12:15 PM, signed by LVN B reflected a fall note with fall intervention of low bed and floor mat. Record review of Resident #58's electronic Fall Nurse's note with an effective date of [DATE] at 4:15 AM, signed by LVN C reflected a fall note with fall intervention of low bed and floor mat. Record review of Resident #58's electronic Fall Nurse's note with an effective date of [DATE] at 8:15 PM, signed by LVN D reflected a fall note with fall intervention of low bed and floor mat. Record review of Resident #58's comprehensive care plan, revision date [DATE] reflected the care plan did not address actual falls or intervention for falls that occurred on [DATE] and [DATE]. Record review of Resident #58's incident accident report #536 Fall reflected a date of [DATE] at 4:15 AM. During an observation on [DATE] at 9:31 AM, Resident #58 was observed asleep in bed, with bed approximately at hip level of surveyor that is 5 foot 2 inches tall. Resident #58 was sitting at an approximate 75-degree angle leaning to right side. No floor mat observed. During an observation on [DATE] at 10:10 AM, Resident #58 was observed asleep in bed, with bed approximately at mid-calf level of surveyor that is 5 foot 2 inches tall, with resident leaning to right side. No floor mat observed. During an observation on [DATE] at 8:23 AM, Resident #58 was observed awake in bed, with bed approximately at thigh level of surveyor that is 5 foot 2 inches tall, with resident leaning to right side. No floor mat observed. During an observation on [DATE] at 9:46 AM, Resident #58 was observed asleep in bed, with bed approximately at thigh level of surveyor that is 5 foot 2 inches tall, with resident leaning to right side. No floor mat observed. During an interview on [DATE] at 9:18 AM, Resident #27 stated that she was Resident #58's room-mate and had noticed that she leaned to the right side often. She stated that Resident #58 had a fall and she had called the nurse to assist and that she had fallen while sleeping and leaning to the right side. During an interview on [DATE] at 8:59 AM, FM A stated that on [DATE] FM A reported to LVN D that Resident #58 was going to fall out of the bed due to Resident #58 leaning so far to the right and the bed not at a low position. FM A stated that no floor mat or low bed was implemented at that time. FM A stated this was observed at approximately 6 pm on [DATE]. FM A stated the facility notified FM A of fall at approximately 4:00 AM on [DATE]. FM A stated that she believed the fall could have been prevented with a low bed and floor mat. During an interview on [DATE] at 11:54 AM, CNA A stated that a low bed for falls should be at ankle height and as low as the bed will go. During an interview on [DATE] at 12:01 PM, CNA B stated that a low bed for falls should be as low as the bed will go and at least ankle height from the floor. She stated that the bed should be at low height anytime that a resident is in the bed when the intervention of low bed has been placed. During an interview on [DATE] at 12:10 PM, LVN E stated that if a resident is a fall risk they should be in a low bed. She stated that a low bed is with the bed in the lowest position possible. During an interview on [DATE] at 12:19 PM, MDS A stated the bed should be in the lowest position for a resident that is a fall risk. During an interview on [DATE] at 12:20 PM, MDS B stated low beds are lowered to the lowest position the bed will go. During an interview on [DATE] at 2:55 PM, DON stated that a low bed means the bed is in the lowest position it will go. She stated that hip level is not a low position. She stated that fall interventions were entered into the comprehensive care plans by the DON. She stated that if a fall note had a floor mat intervention then she would expect there to be a floor mat in place. She stated she would not remove the floor mat if it was listed as an intervention. 3. Record review of Resident #219's face sheet dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #219's Physician Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #219's BIMS revealed a Summary Score of 08, dated [DATE]. Record review of Resident #219's Advanced Directives revealed a signed Out-Of-Hospital Do-Not-Resuscitate Order, dated [DATE]. Record review of Resident #219's Comprehensive Care Plan initiated on [DATE] revealed the resident is a Full Code and that CPR is to be initiated. During an interview on [DATE] at 10:26 AM, MD stated his evaluation and assessment of Resident #219 was that the resident is competent to make his own end-of-life decisions and sign DNR forms for himself. During an interview on [DATE] at 3:40 PM, the DON stated it was her expectation that the Care Plan reflect the accurate code status of whether Resident #219 is DNR or Full Code. Review of the facility policy Comprehensive Care Planning, undated, revealed in part .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical and psychosocial needs.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Review of facility policy Fall Risk Assessment, dated [DATE], revealed in part .4. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. 7. After risk is assessed, individualized plans of care will be implemented to prevent falls. The resident and the family members are educated on methods to prevent falls. 8. Interventions will focus on manipulating the environment, educating the resident and family, implementing rehabilitation programs to improve functional abilities in ADL's and careful monitoring of medication side effects.10. Environmental interventions include keeping beds in the lowest position with brakes on, grab bars in the bathroom, nightlights, and nonskid wax on floors.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (Residents #9 and #58) of 17 residents reviewed accidents and hazards. 1. Resident #9 did not have the ordered and care planned fall/floor mat placed when resident was in bed for 3 out of 3 days observed to help protect from injury due to previous fall history. 2. Resident #58's bed was not at a low position and no fall/floor mat was placed for 3 out of 3 days observed to help protect from injury due to previous fall history. This deficient practice could place all residents with falls at risk for pain and injury. The findings were: 1. Record review of Resident #9's electronic face sheet dated 7/27/21 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Essential Hypertension, History of Falling, Gastro-[CONDITION(S)] Reflux Disease without Esophagitis, Dysphagia following Cerebral Infarction, [CONDITION(S)] and Recurrent Depressive Disorders. Record review of Resident #9's Physician Orders dated 7/27/21 reflected an order with a start date of 1/11/21 for a floor mat when resident is in bed. Monitor q (every) shift related to history of falling. Record review of Resident #9's comprehensive care plan revised on 5/4/21 reflected actual falls on 9/18/2020, 9/23/2020, 9/25/2020, 10/13/2020, 10/13/2020, 10/27/2020, 11/3/2020, 11/20/2020, 2/3/21, 4/17/21 and 4/29/21. Interventions dated 11/20/2020 include floor mats. Record review of Resident #9's Quarterly MDS Section C Cognitive Patterns, dated 5/12/21 reflected a BIMS (Brief Interview Mental Status) of 3, which indicated severe cognitive impairment in daily decision-making skills. Record review of Resident #9'a most current Fall Risk assessment dated [DATE] reflected a score of 12, which indicated high risk for falls. During an observation on 7/26/21 at 9:33 AM, Resident #9 was in bed awake but not interview-able. Fall mat was folded in half, up against the left-hand wall, away from resident. During an observation on 7/26/21 at 3:32 PM, Resident #9 was asleep in bed with fall mat folded up against the left-hand wall, away from resident. During an observation on 7/27/21 at 12:23 PM, Resident #9 was asleep in bed with fall mat folded up against the left-hand wall, away from resident. During an observation on 7/28/21 at 9:40 AM, Resident #9 was asleep in bed with fall mat folded up against the left-hand wall, away from resident. During an interview on 7/28/21 at 11:54 AM, CNA A stated that fall/floor mats should be under the resident when they are in the bed if a fall/floor mat is ordered, care planned, or an intervention placed for high fall risk residents. During an interview on 7/28/21 at 12:01 PM, CNA B stated that Resident #9 should have had a fall/floor mat beside the bed if she was in the bed. She stated that she had seen the fall/floor mat against the wall. During an interview on 7/28/21 at 12:10 PM, LVN E stated if a fall/floor mat is ordered or care planned it should be beside the resident, when the resident is in the bed. During an interview on 7/28/21 at 2:55 PM, the DON stated a fall/floor mat should be down if the resident is in the bed. 2. Record review of Resident #58's face sheet dated 7/27/21 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Unspecified Heart Failure, [CONDITION(S)], Pressure Ulcer of Sacral Region Stage 2, Cognitive Communication Deficit, Unspecified [CONDITION(S)], Muscle Weakness (Generalized), Muscle Wasting and Atrophy, Difficulty in Walking, Unsteadiness on Feet, Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus without Complications, Essential (Primary) Hypertension, Gastro-[CONDITION(S)] Reflux Disease without Esophagitis and [CONDITION(S)] (Unspecified). Record Review of Resident #58's Quarterly MDS Section C Cognitive Patterns, dated 6/13/21 reflected a BIMS (Brief Interview Mental Status) of 8, which indicated moderate cognitive impairment in daily decision-making skills. Record review of Resident #58's Fall Risk assessment dated [DATE] reflected a score of 10, which indicated high risk for falls. Record Review of Resident 58's Fall Risk assessment dated [DATE] reflected a score of 16, which indicated high risk for falls. Record review of Resident #58's electronic Nursing Progress Notes dated 4/3/21 and signed by LVN A, reflected that resident was found on her right side of the bed and assisted back into bed by 2 unnamed CNAs and LVN A. Record review of Resident #58's electronic Fall Nurses note dated 4/3/21 reflected a fall on 4/3/21 with no injury. Record review of Resident #58's electronic Nursing Progress Notes dated 7/16/21 and signed by LVN B reflected that resident had a fall the night of 7/15/21. Record review of Resident 58's electronic Fall Nurse's note with an effective date of 7/16/21 at 12:15 PM signed by LVN B reflected a fall note with fall intervention of low bed and floor mat. Record review of Resident #58's electronic Fall Nurse's note with an effective date of 7/17/21 at 4:15 AM signed by LVN C reflected a fall note with fall intervention of low bed and floor mat. Record review of Resident #58's electronic Fall Nurse's note with an effective date of 7/17/21 at 8:15 PM signed by LVN D reflected a fall note with fall intervention of low bed and floor mat. Record review of Resident #58's incident accident report #536 Fall reflected a date of 7/15/21 at 4:15 AM. During an observation on 7/26/21 at 9:31 AM, Resident #58 was observed asleep in bed, with bed approximately at hip level of surveyor that is 5 foot 2 inches tall. Resident #58 was sitting at an approximate 75-degree angle leaning to right side. No floor mat observed. During an observation on 7/27/21 at 10:10 AM, Resident #58 was observed asleep in bed, with bed approximately at mid-calf level of surveyor that is 5 foot 2 inches tall, with resident leaning to right side. No floor mat observed. During an observation on 7/28/21 at 8:23 AM, Resident #58 was observed awake in bed, with bed approximately at thigh level of surveyor that is 5 foot 2 inches tall, with resident leaning to right side. No floor mat observed. During an observation on 7/28/21 at 9:46 AM, Resident #58 was observed asleep in bed, with bed approximately at thigh level of surveyor that is 5 foot 2 inches tall, with resident leaning to right side. No floor mat observed. During an interview on 7/26/21 at 9:18 AM, Resident #27 stated that she was Resident #58's room-mate and had noticed that she leaned to right side often. She stated that Resident #58 had a fall and she had called the nurse to assist and that she had fallen while sleeping and leaning to the right side. During an interview on 7/27/21 at 8:59 AM, FM A stated that on 7/14/21 FM A reported to LVN D that Resident #58 was going to fall out of the bed due to Resident #58 leaning so far to the right and the bed not at a low position. FM A stated that no floor mat or low bed was implemented at that time. FM A stated this was observed at approximately 6pm on 7/14/21. FM A stated the facility notified FM A of fall at approximately 4:00 AM on 7/15/21. FM A stated that she believed the fall could have been prevented with a low bed and floor mat. During an interview on 7/28/21 at 11:54 AM, CNA A stated that a low bed for falls should be at ankle height and as low as the bed will go. During an interview on 7/28/21 at 12:01 PM, CNA B stated that a low bed for falls should be as low as the bed will go and at least ankle height from the floor. She stated that the bed should be at low height anytime that a resident is in the bed when the intervention of low bed has been placed. During an interview on 7/28/21 at 12:10 PM, LVN E stated that if a resident is a fall risk they should be in a low bed. She stated that a low bed is with the bed in the lowest position possible. During an interview on 7/28/21 at 12:19 PM, MDS A stated the bed should be in the lowest position for a resident that is a fall risk. During an interview on 7/28/21 at 12:20 PM, MDS B stated low beds are lowered to the lowest position the bed will go. During an interview on 7/28/21 at 2:55 PM, the DON stated that a low bed means the bed is in the lowest position it will go. She stated that hip level is not a low position. She stated that fall interventions were entered into the comprehensive care plans by the DON. She stated that if a fall note had a floor mat intervention then she would expect there to be a floor mat in place. She stated she would not remove the floor mat if it was listed as an intervention. Review of facility policy Fall Risk Assessment, dated 2/1/2007, revealed in part .4. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. 7. After risk is assessed, individualized plans of care will be implemented to prevent falls. The resident and the family members are educated on methods to prevent falls. 8. Interventions will focus on manipulating the environment, educating the resident and family, implementing rehabilitation programs to improve functional abilities in ADL's and careful monitoring of medication side effects.10. Environmental interventions include keeping beds in the lowest position with brakes on, grab bars in the bathroom, nightlights, and nonskid wax on floors.

Based on observation, interview and record review the facility failed to ensure storage of drugs and biologicals used in the facility for one (1) of three (3) medication carts. Two (2) of two (2) medication room cabinets, containing discontinued medications were not locked. The facility failed to ensure expired medications were removed from the medication carts once expired. The facility failed to keep discontinued medications secured. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications. Unlocked cabinets made discontinued medications accessible. Findings Included: During an observation on 07/27/21 at 3:47 PM of one (1) of two (2) medication rooms revealed an unlocked cabinet containing discontinued prescription medications. This medication room was located by the nurse station close to the rehab hall. During an observation on 07/27/21 at 4:04 PM of unlabeled nurse cart containing medications, the cart contained a bottle of [MEDICATION(S)] (Guaifenesin 400mg). The lid of the bottle had been marked that it was opened 4/20 and the back label of the bottle revealed and expiration date of 06/21. This cart was being pushed by LVN F, on the long-term hall. During an observation on 07/27/21 at 4:12 PM of two (2) of two (2) medication rooms revealed an unlocked cabinet containing discontinued prescription medications. This medication room was located by the nure station close to the long-term hall. During an interview on 07/27/21 at 4:08 PM LVN F agreed the [MEDICATION(S)] medication was expired and stated the expired bottle should have been placed with old medications in the cabinet of the medication room. He then removed the medication from the cart. During an interview on 7/28/21 at 3:38 PM the DON stated it was her expectation that expired medications be removed from all medication carts. She stated she was aware that an expired bottle of medication had been discovered and they must have missed it when they checked the carts. Record Review of the Facility's policy Discontinued Medications dated 2003 reflected The medication will be locked in the cabinet with medications to be destroyed. No policies were provided for expired medications on medication carts by exit.

Based on interview and record review, the facility failed to ensure irregularities reported by the pharmacist were acted on in a timely manner for one of five residents reviewed for drug regimen reviews. (Resident # 61) The facility failed to address Pharmacy recommendations dated 1/25/21 for Resident #61 for GDR (Gradual Dose Reduction) of [MEDICATION(S)] (Anti-Anxiety). This facility failure could place all residents who received [CONDITION(S)] medications at risk for adverse drug reactions. Findings include: Record review of Resident #61's Face Sheet dated 7/28/21 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of: Muscle Wasting and Atrophy, Unsteadiness on Feet, [CONDITION(S)] in other Chronic Diseases Classified Elsewhere, Unspecified Lack of Coordination, Resistance to Multiple Antibiotics, Heartburn, Pressure Ulcer of Sacral Region Stage 2, [CONDITION(S)] [CONDITION(S)] Secondary to Blood Loss (Chronic), Unspecified Protein-Calorie Malnutrition, Pain in Right Hip, Muscle Weakness (Generalized), Cognitive Communication Deficit, Weakness, Rash and other Nonspecific Skin Eruption, Repeated Falls, Other Abnormalities of Gait and Mobility, Unstable [CONDITION(S)], Vitamin Deficiency Unspecified, Restless Leg Syndrome, Urinary Tract Infection Unspecified, Anxiety Disorder Unspecified, Other Forms of [CONDITION(S)] Pectoris, Functional Dyspepsia, [CONDITION(S)] without Behavioral Disturbance, Allergic Rhinitis, cough, [CONDITION(S)], Type 2 Diabetes Mellitus without Complications, Major Depressive Disorder Single Episode Unspecified, [CONDITION(S)] Unspecified, essential (Primary) Hypertension, Unspecified Constipation, Shortness of Breath and Unspecified Pain. Record review of Consultant Pharmacist's Medication Regimen Review Recommendations Pending a Final Response dated 1/25/21 reflected Resident #61 recommendation This resident has been taking [MEDICATION(S)] 20mg QHS [every night] and [MEDICATION(S)] 0.25 mg Q [daily] 1PM since 2018. Please evaluate the current dose and consider a dose reduction. IMPORTANT: Please add resident specific documentation to support the above action or check below if information as added to physician progress notes. No information was filled out on form. Record review of Pharmacy Recommendations reflected no other recommendations for Resident #61 from January 2021 through 7/28/21. Review of Resident #61's current physician orders dated 7/28/2021 [MEDICATION(S)] Tablet 0.5 MG (Lorazepam) Give 0.5 tablet by mouth one time a day for anxiety ½ tablet = 0.25 mg with an order date of 8/9/2018 and start date of 11/15/2019. Review of Resident #61's Electronic Medical Record on 7/28/21 did not reflect any progress notes from MD for contraindications for GDR of Resident #61's [MEDICATION(S)]. During an interview on 7/28/21 at 2:55 PM the DON stated that she had started at the facility on 3/17/21. She reviewed Resident #61's electronic medical record and found that on 7/27/20 physician reviewed and did not change order. She stated that she did not find any other documentation on Resident #61's [MEDICATION(S)]. She stated that she would check with her Corporate Consultant that had been assigned the facility during that time. During a follow up interview on 7/28/21 at 3:59 PM the DON stated that the Corporate Consultant could not find any follow up documentation and had stated that is one of the reasons the previous DON was let go. No further documentation or information was provided during survey. Record review of facility policy titled [CONDITION(S)] Drugs revised 10/25/2017 reflected the following 2. Residents who use [CONDITION(S)] drugs receive gradual dose reductions, and behavioral interventions, unless contraindicated, in an effort to discontinue these drugs; The policy further states under subtitle Gradual Dose Reduction for [CONDITION(S)] Medication . During the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medication; When evaluating the resident's progress the attending physician or prescribing practitioner reviews the total plan of care, orders, the resident's response to medication(s) , and determines whether to continue, modify, or stop a medication; and . Within the first year in which a resident is admitted on a [CONDITION(S)] medication or after the prescribing practitioner has initiated a [CONDITION(S)] medication, the facility must attempt a GDR in two separate quarters (within at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of eight (8) staff reviewed for infection control. The facility failed to ensure CNA A doff gown when exiting isolation rooms # 101, 102, 103,104,105,106, 107 and 108. These failures could lead to the transmission of communicable diseases and infections and at risk for contracting COVID-19. Findings Include: Observation on 08/22/2020 at 8:55 AM - 9:15 AM revealed all residents on the isolation unit were on droplet precautions. Information regarding Droplet Precautions and PPE were posted on each resident's door. Observation on 08/22/2020 at 8:55 AM - 9:40 AM revealed CNA A not doffing gown when exiting and entering isolation rooms: #101, 102, 103, 104, 105, 106, 107 and 108. Interview on 8/22/2020 at 9:43 AM the cna stated, I didn't know to remove my gown after I left each room. When we had COVID unit we wore our gowns and never changed them until the end of the shift. It is posted on the doors of this isolation hall about removing gowns before leaving the isolation room. The Director of Nurses told us every resident on this isolation hall is on droplet precautions. I can't recall if anything was mentioned about removing gowns after leaving each room. In an interview on 8/22/2020 at 10:45 AM the DON stated, All staff working on the isolation hall are required to doff gowns after they exit each room and donn a new gown prior to entering another room. In an interview on 8/22/2020 at 11:15 AM the Area Director of Operations stated, Everyone working on the isolation unit is expected to donn a new gown prior to entering isolation room and doff gown upon exiting the same room. The residents on the isolation unit are all on droplet precautions. Facility Droplet Precautions posted on each isolation room stated, Donn gloves, mask and gown outside of the resident's room. Remove gown and observe hand hygiene before leaving the patient-care environment. Facility Policy on PPE use when Positive COVID Residents are in the Facility states, 1. Area of Facility without COVID * All staff must wear: Gown, Gloves and N95 if available, if not surgical mask. * You can continue to wear the same mask and gown unless you encounter a resident on contact or droplet precautions. If you interact with a resident with contact and droplet precautions you must change gown and gloves before and after the interaction.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #1) of 14 residents reviewed for significant medication errors. The facility failed to obtain a new medication (Xarelto, blood thinner) for Resident #1 who was to receive it daily. Resident #1 was without this medication for 7 days. Due this significant medication error Resident #1 [MEDICAL CONDITION] transferred to the hospital and died . This failure resulted in an Immediate Jeopardy situation identified on [DATE]. While the IJ was removed on [DATE] at 4:45 PM, the facility remained out of compliance at a level of actual harm that is not immediate with a scope identified as pattern due to a need for ongoing monitoring. This failure placed residents receiving medications at risk for harm and/or death. Findings include: Review of Face Sheet of Resident #1 reflected an admitted [DATE] and an [AGE] year-old male with [DIAGNOSES REDACTED]. Review of care plan initiated [DATE] indicated Resident #1 has Altered Cardiovascular Status r/t Arrhythmia's/ AFIB. Review of MDS dated [DATE] indicated Resident #1 was impaired cognitively with a BIMS score of 9 which indicates moderately impaired. Resident #1 needed stand by assistance with all his ADL's, able to walk but is weak due to recent hospitalization . Review of Resident # 1's Medication Administration Record [REDACTED]. Review of MAR indicated [REDACTED] Initials are in the box for [DATE], [DATE], [DATE], [DATE] and a 9 is written, which indicates see nurses' notes. On [DATE], [DATE] of same record MA C was working and she also indicated to see nurses' note and on [DATE] of same record MA B was working and she indicated by a check mark the med had been given. Review of Resident #1's Medication Administration Record [REDACTED]. A provider incident report dated [DATE] indicated this incident occurred on [DATE] at 7:14 p.m. and was reported to the state on [DATE]. The report alleged following Resident #1 discharge to the hospital on [DATE], during review of chart it was discovered that a blood thinner had been ordered on [DATE] to be started on [DATE]. Chart/Medication Administration Record [REDACTED]. Resident #1 was transferred to the hospital on [DATE] following a change of condition indicative of a stroke. Investigation summary of Provider Report reveals the Nurse Practitioner(NP) ordered a blood thinning medication on [DATE] to start on [DATE]. The NP placed the order in the computer, which populated the medication to the Medication Administration Record [REDACTED]. A third MA B marked the medication was given but when interviewed she stated she had mistakenly checked the box and didn't know how to electronically remove it, but she reported to her supervisor what happened. The Pharmacy indicates that the medication was not ordered/filled/delivered to the facility. This medication is also not stocked in the facility Emergency-kit. Therefore, it is determined that the medication was not given as ordered. However, it is inconclusive as to whether this omission was contributing factor to Resident #1's change of condition. An interview on [DATE] 12:55 pm with DON, revealed it is the policy of this facility to notify the immediate supervisor, herself or Administrator if a medication is not in the medication box when attempting to administer. An interview on [DATE] at 12:57 pm with MA A stated in MA training that on the second day you let someone know it is not on cart. When asked if she let anyone know she stated Noand said she didn't know why. An interview on [DATE] at 1:22 pm with MA C stated was taught in MA training that you could let it go until the second day if the medication not in the cart, she stated the charge nurse was notified on [DATE] (LVN A). An interview on [DATE] at 1:15 pm was attempted with MA B but couldn't understand due to Spanish speaking. On [DATE] around 1:00 pm a Spanish speaking person translated MA B and discovered the check mark was an error, but didn't know how to get it taken off, but notified the supervisor (RN A). An interview on [DATE] 1:30 pm NP confirmed ordering Resident #1 Rivaroxaban ( Xarelto), a med given for [MEDICAL CONDITION] Fibrillation due to [MEDICAL CONDITION]. She went to the facility site on-line and ordered this med. She did not know it wouldn't trigger a notice either to the pharmacy or the facility like most of her facilities on electronic records. It was never ordered from the pharmacy, but it printed out on the Medication Administration Report (MAR). An interview on [DATE] 1:50 pm with Pharmacist, which revealed there had not been any blood thinner ordered for Resident #1. An interview on [DATE] at 1:45 pm with LVN A, charge nurse on skilled unit, stated she was not aware of a new order for Resident #1 or that it was not available to be administered. She had not been notified by MA C the med was not in the medication cart. An interview on [DATE] at 1:00 pm with RN A she stated she knew nothing about the order for Xarelto or that is was on the MAR but not in the medication box. Review of all in-services on [DATE] that the facility provided there were none on medication administration or medication not available. The survey was re-opened on [DATE]. Review of Resident #1 emergency room records dated [DATE] around 8:02 pm. The statement dictated is: [MEDICAL CONDITION] Discussed with Tele-stroke, not a candidate for tissue Plasminogen Activator (tPA) ( a clot dissolving medicine) secondary to Xarelto use. Review of In-house Hospice notes for Resident #1 revealed he expired on [DATE] from an [MEDICAL CONDITION]([MEDICAL CONDITION] Review of of facility's Medication Administration Procedure dated [DATE] on number 6 It states: 6. If a dose of scheduled medication is withheld or refused, the nurse is to initial and circle the front of the MAR indicated [REDACTED]. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy. The Administrator was notified and received the IJ template on [DATE] at 5:00 PM that an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator and approved by the Program Manager on [DATE] at 6:34pm. Plan of Removal [DATE] 100% MAR indicated [REDACTED] All anticoagulants will now be given by nurses only and counted beginning [DATE] Medication error report completed by [DATE] DON and ADON in-serviced on morning start up completed on [DATE] The following in-services were initiated by the DON, ADON and Regional Nurse. Any member not present or in-serviced on [DATE], will not be allowed to assume their duties until in-serviced. Licensed Nurses and Medication Aides: Abuse/Neglect In-services were completed [DATE]. Notification of DON/ADON if medication is unavailable In-services completed [DATE]. Notification of Physician if medication is unavailable In-services completed on [DATE]. Notification of Physician with a change of condition (COC) in-services administered on [DATE], to be completed on [DATE]. In-services with nurses and medication aides stating they are not to document medication not available without first calling the DON/Admin In-services completed on [DATE]. Initial dosing of medications In-services completed on [DATE]. In-service done with Medical Director and Nurse Practitioner regarding the need to write telephone orders for all orders and not putting them into PCC as we currently do not have policy and procedures or checks and balances for this. In-service completed [DATE]. The medical director was notified of the immediate jeopardy situation on [DATE] at 5:25 pm. Monitoring The DON/designee will monitor Electronic Medication Medication Report (EMAR) daily to ensure all meds were given as ordered. Monitoring began, [DATE] and is ongoing. The DON/designee will audit all medication carts weekly to ensure all medications are in the house. Monitoring began [DATE] and is ongoing. The DON/designee will ask 10 nurse/medication aides per week what would they do if a medication is unavailable. Monitoring began [DATE] and ongoing. DON/designee will monitor the 24-hour report daily to ensure any change of condition (COC) has been reported to the Physician. Monitoring started [DATE] and is ongoing. The QA committee will review findings monthly and make changes as needed. On [DATE] a monitoring visit was conducted: Interviewed 50% of staff, 5 Nurses, 5 MA's and 4 C N A's, DON and Corporate Nurse. All were asked if they were in-serviced to the items that were designated by the Administration's Plan of Removal. All interviews indicated they had been in-serviced to all tasks. They all stated the DON/designee was monitoring carts, checking EMAR daily. Review of all In-services for medication errors, significant medication errors, reporting of changes in condition (COC) to MD, and Abuse/Neglect/Exploitation revealed appropriate documentation for response to the Immediate Jeopardy citation. This failure resulted in an Immediate Jeopardy situation identified on [DATE]. While the IJ was removed on [DATE] at 4:45 PM, the facility remained out of compliance at a level of actual harm that is not immediate with a scope identified as pattern due to a need for ongoing monitoring. Exited the facility at 5:00 pm.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the ordering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 14 residents reviewed for medication administration. The facility failed to obtain a new medication (Xarelto, blood thinner) for Resident #1 who was to receive it daily. Resident #1 was without this medication for 7 days Resident #1 transferred to the hospital and died . This failure resulted in an Immediate Jeopardy situation identified on [DATE]. While the IJ was removed on [DATE] at 4:45 PM, the facility remained out of compliance at a level of actual harm that is not immediate with a scope identified as pattern due to a need for ongoing monitoring. The failure placed residents receiving medication at risk of harm and/or death. Findings include: Review of Face Sheet of Resident #1 reflected an admitted [DATE] and an [AGE] year-old male with [DIAGNOSES REDACTED]. Review of care plan initiated [DATE] indicated Resident #1 has Altered Cardiovascular Status r/t Arrhythmia's/ AFIB. Review of MDS dated [DATE] indicated Resident #1 was impaired cognitively with a BIMS score of 9 which indicates moderately impaired. Resident #1 needed stand by assistance with all his ADL's, able to walk but is weak due to recent hospitalization . Review of Resident # 1's Medication Administration Record (MAR) reflected an order written [REDACTED]. Review of Resident #1's Medication Administration Record dated [DATE]-[DATE] of Resident #1 reveals MA A's Initials are in the box for ,[DATE], ,[DATE], ,[DATE], ,[DATE] and a 9 is written, which indicates see nurses' notes. On [DATE], [DATE] of same record MA C was working and she also indicated to see nurses' note and on [DATE] of same record MA B was working and she indicated by a check mark the medication had been given. Review of Resident #1's Medication Administration Record (MAR) revealed [DATE], [DATE], [DATE], and [DATE] MA A documented in progress notes on Order and on [DATE] and [DATE] MA C documented pending delivery and on [DATE] MA B checked she had given the medication. A provider incident report dated [DATE] indicated this incident occurred on [DATE] at 7:14 p.m. and was reported to the state on [DATE]. The report alleged following Resident #1 discharge to the hospital on [DATE], during review of chart it was discovered that a blood thinner had been ordered on [DATE] to be started on [DATE]. Chart/Medication Administration Record indicated medication not available according to the documentation of Medication Aide. Resident #1 was transferred to the hospital on [DATE] following a change of condition indicative of a stroke. Investigation summary of Provider Report reveals the Nurse Practitioner(NP) ordered a blood thinning medication on [DATE] to start on [DATE]. The NP placed the order in the computer, which populated the medication to the Medication Administration Record (MAR), between [DATE]--[DATE] two (2) Medication Aides (MA) MA A and MA C documented that the medication was on order or pending delivery; however, neither informed their nurse. A third MA B marked the medication was given but when interviewed she stated she had mistakenly checked the box and didn't know how to electronically remove it, but she reported to her supervisor what happened. The Pharmacy indicates that the medication was not ordered/filled/delivered to the facility. This medication is also not stocked in the facility Emergency-kit. Therefore, it is determined that the medication was not given as ordered. However, it is inconclusive as to whether this omission was contributing factor to Resident #1's change of condition. An interview on [DATE] 12:55 pm with DON, revealed it is the policy of this facility to notify the immediate supervisor, herself or Administrator if a medication is not in the medication box when attempting to administer. An interview on [DATE] at 12:57 pm with MA A stated in MA training that on the second day you let someone know it is not on the cart. When asked if she let anyone know she stated No and said she didn't know why. An interview on [DATE] at 1:15 pm was attempted with MA B but couldn't understand due to Spanish speaking. On [DATE] around 1:00 pm a Spanish speaking person translated MA B and discovered the check mark was an error, but didn't know how to get it taken off, but notified the supervisor RN A. An interview on [DATE] at 1:22 pm with MA C stated was taught in MA training that you could let it go until the second day if the medication was not on the cart, she stated the charge nurse was notified on [DATE]. LVN A An interview on [DATE] 1:30 pm NP confirmed ordering Resident #1 Rivaroxaban ( Xarelto), a medication given for [MEDICAL CONDITION] Fibrillation due to [MEDICAL CONDITION]. She went to the facility site on-line and ordered this medication. She did not know it wouldn't trigger a notice either to the pharmacy or the facility like most of her facilities on electronic records. It was never ordered from the pharmacy, but it printed out on the Medication Administration Report (MAR). An interview on [DATE] at 1:45 pm with LVN A, charge nurse on skilled unit, stated she was not aware of a new order for Resident #1 or that it was not available to be administered. She had not been notified by MA C the medication was not on the medication cart. An interview on [DATE] 1:50 pm with Pharmacist, which revealed there had not been any blood thinner ordered for Resident #1. An interview on [DATE] at 1:45 pm with LVN A she explained ordering medications usually consist of the Doctor or NP writes a order on a short form, its given to the nurse and she orders it from the pharmacy and makes sure it is on the MAR and the cart. When a telephone order is received the nurse taking the order will write it on a short form and send to the pharmacy and wait until the Doctor or NP comes in the facility to sign but the medication is on the cart and the MAR usually the next day. An interview on [DATE] at 1:00 pm with RN A she stated she knew nothing about the order for Xarelto or that is was on the MAR but not in the medication box. Review of all in-services on [DATE] that the facility provided there were none on medication administration or medication not available. The survey was re-opened on [DATE]. Review of Resident #1 emergency room records dated [DATE] around 8:02 pm. The statement dictated is: [MEDICAL CONDITION] Discussed with Tele-stroke, not a candidate for tissue Plasminogen Activator (tPA) ( a clot dissolving medicine) secondary to Xarelto use. Review of In-house Hospice notes for Resident #1 revealed he expired on [DATE] from an [MEDICAL CONDITION] Review of facility's Medication Administration Procedure dated [DATE] on number 6 It states: 6. If a dose of scheduled medication is withheld or refused, the nurse is to initial and circle the front of the MAR in space provided for that dosage administration and an explanatory note to be entered in the nursing notes or in the PRN section of the MAR. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy. Review of facility's Ordering Medications procedure/policy 2003: 1. Medication orders are phoned or faxed to the pharmacy and written on a medication order form provided by the pharmacy for that purpose or the Physician order [REDACTED]. Receiving a New Medication: The nurse that receives a new medication order, should be responsible for the following: Order received is accurate and includes necessary information Document the resident's condition justifies a need for the new order Family/Responsible party should ne notified of the change of condition of the resident Order transcribed accurately to the MAR sheet MAR contains proper times scheduled with arrows for start times and duration of therapy if needed. Medication ordered from the pharmacy timely. The Administrator was notified and received the IJ template on [DATE] at 5:00 PM that an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator and approved by the Program Manager on [DATE] at 6:34pm. Plan of Removal [DATE] 100% MAR to Med cart audit All anticoagulants will now be given by nurses only and counted beginning [DATE] Medication error report completed by [DATE] DON and ADON in-serviced on morning start up completed on [DATE] The following in-services were initiated by the DON, ADON and Regional Nurse. Any member not present or in-serviced on [DATE], will not be allowed to assume their duties until in-serviced. Licensed Nurses and Medication Aides Abuse/Neglect In-services were completed [DATE]. Notification of DON/ADON if medication is unavailable In-services completed [DATE]. Notification of Physician if medication is unavailable In-services completed on [DATE]. Notification of Physician with a change of condition (COC) in-services administered on [DATE], to be completed on [DATE]. In-services with nurses and medication aides stating they are not to document medication not available without first calling the DON/Admin In-services completed on [DATE]. Initial dosing of medications In-services completed on [DATE]. In-service done with Medical Director and Nurse Practitioner regarding the need to write telephone orders for all orders and not putting them into PCC as we currently do not have policy and procedures or checks and balances for this. In-service completed [DATE]. The medical director was notified of the immediate jeopardy situation on [DATE] at 5:25 pm. Monitoring The DON/designee will monitor EMAR daily to ensure all medications were given as ordered. Monitoring began [DATE] and is ongoing. The DON/designee will audit all medication carts weekly to ensure all medications are in the house. Monitoring began [DATE] and is ongoing. The DON/designee will ask 10 nurse/medication aides per week what would they do if a medication is unavailable. Monitoring began [DATE] and ongoing. DON/designee will monitor the 24-hour report daily to ensure any change of condition (COC) has been reported to the Physician. Monitoring started [DATE] and is ongoing. The QA committee will review findings monthly and make changes as needed. On [DATE] a monitoring visit was conducted: Interviewed 50% of staff, 5 Nurses, 5 MA's and 4 C N A's, DON and Corporate Nurse. All were asked if they were in-serviced to the items that were designated by the Administration's Plan of Removal. All interviews indicated they had been in-serviced to all tasks. They all stated the DON/designee was monitoring carts, checking EMAR daily. Review of all In-services for medication errors, significant medication errors, reporting of changes to MD, and Abuse/Neglect/Exploitation revealed appropriate documentation for response to the Immediate Jeopardy citation. This failure resulted in an Immediate Jeopardy situation identified on [DATE]. While the IJ was removed on [DATE] at 4:45 PM, the facility remained out of compliance at a level of actual harm that is not immediate with a scope identified as pattern due to a need for ongoing monitoring

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #8) Certified Nurse Aides (CNA) A and CNA B failed to utilize a safe method for providing incontinent care to Resident #8 resulting in a fall which caused a Left Femoral Diaphyseal Fracture (a bone break that occurs along the shaft of a long bone like the femur). This facility failure resulted in injury to one resident and could potentially harm 67 residents who rely on staff assistance for incontinent care. Findings Include: Review of Resident #8's Face Sheet reflected an admission date of [DATE] with the following Diagnoses: [REDACTED].>[MEDICAL CONDITION] Disease, Open Wound of Right Forearm, Nausea with Vomiting, [MEDICAL CONDITION]. Review of Resident #8's Comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) score of twelve (12) with (15) being the highest score. The assessment also reflected a functional status for transfers at a three (3) indicating assistance with two (2) or more individuals required. Review of Resident #8's Care Plan dated 02/12/2018 reflected Falls. Resident at risk for falling related to weakness. Interventions included: Encourage resident to use environmental devices such as hand grips and hand rails, etc. Activities of Daily Living Functional/Rehabilitation, Resident is limited in ability to transfer self r/t [DIAGNOSES REDACTED]. Review of a facility generated incident report dated 04/30/2018 reflected a statement from the Administrator: This resident (Resident #8) told CNA A that she needed to be changed. CNA A asked CNA B to assist her. They took the resident to her room and stood her up next to her bed, one on each side. The resident stood while her brief was removed. Upon removal the aides noticed the resident had a bowel movement. They were attempting to provide incontinent care while the resident was standing. The resident was not able to stand for a long period of time and her legs started to buckle. She weighs 239.4 lbs Resident landed on her knee with leg slightly under her. The nurse aides notified the charge nurse that resident had fallen. Charge nurse assessed resident. She was lifted from the floor with a Hoyer Lift (mechanical Lift). Resident complained of knee pain. Dr. notified and resident was sent to emergency room (ER) for evaluation. It was reported back to the facility the resident had a femur fracture and would need surgery. Review of a mobile imaging report dated 4/30/2018 reflected Exam of Left Femur, Hip and Knee. Findings were: Oblique Displaced and Angulated Mid Diaphyseal Fracture evident. Left femoral Diaphyseal Fracture. In interview on 8/17/2018 at 3:00 p.m., the Nurse Practitioner (NP) stated if she had gone by a doorway and witnessed anyone standing a resident up to conduct incontinent care she would have to tell them that is unsafe practice. In an interview on 08/14/2018 at 1:48 p.m. CNA A described the event on 4/30/2018 with Resident #8 as it was a hectic day and she had the unit by herself. She was trying to take Resident #8 to the dining room when she noticed she was soiled. CNA B came in to help her change Resident #8 and they leaned her up against the bedside table to change her. Resident #8's knees started buckling and she was assisted to the ground by the both of them. CNA A stated she tried to straighten her leg out but Resident #8 kept saying OW,OW OW. CNA A stated they got the nurse and Resident #8 was sent to the emergency room (ER). CNA A stated she knew she should not have changed the resident without putting her back in bed, but that she had done this before with this resident. In interview on 8/17/18 at 9:00 a.m. with CNA B she stated that she was helping to change Resident #8. She stated that she and CNA A had the resident stand up and when they removed her brief her legs began to buckle. She stated she could hold her up so they lowered her to the floor. She stated her leg was twisted and CNA A straightened her leg out before going to get the nurse. She stated she did not remember using a bedside table. She stated she had never worked with this patient before and knew nothing about her. She stated CNA A worked with her often, and was aware of her assistance needs. She stated that she understood it was not correct procedure to stand a resident up to provide incontinent care. In interview on 8/17/2018 at 9:25 a.m. with Licensed Vocational Nurse (LVN) A, she stated that she was notified by CNA B that Resident #8 had a fall. LVN A stated that as she entered the room she found the patient on the floor with her feet at the foot of the bed, and the wheelchair behind the resident's head. She stated she would never stand the resident up to do incontinent care because she did not believe the resident could stand for any extended time. LVN A stated that the resident had not been ambulatory for a very long time and that she had gained significant weight. In interview on 8/17/18 at 10:15 a.m., Assistant Director of Nurses (ADON) A stated he was not very familiar with the incident that happened on 4/30/2018. When asked if he was familiar with the resident he stated somewhat. When asked if the resident could stand up he stated, she could, but doesn't know if she could be changed while standing up. He stated that it did not follow their policy and procedure for providing incontinent care to a resident. He stated he did not remember hearing anything about use of a bedside table. In interview on 8/17/18 at 10:30 a.m., the Administrator stated that the CNA's changed their story many times during her investigation but she did not recall them ever saying anything about using a bedside table. She believed they had her at the end of the bed and changed the resident while standing up. She stated the resident is a 2-person with all ADLs due to behaviors. She stated that they did not have a gait belt on, and that they had her under the arms. She stated that the resident wanted to go to the dining room and CNA A was in a hurry. She stated CNA A did not start the transfer or incontinent care until CNA B was able to assist her. Review of facility policy dated 8/2016 titled: Incontinent Care/Perineal Care With or Without a Catheter reflected the following elements: It is the policy of this facility to provide incontinent care to residents in a manner which promotes privacy, promotes dignity and ensures no cross contamination. Procedure: 1. Beginnings steps g. Provide safety as appropriate, such as use of good body mechanics The facility Administrator provided a CMS 672 form that reflected 67 residents require incontinent care by facility staff.