Every finding on record at The Gardens Healthcare Center

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet their physical, mental, and psychosocial needs for one of three sampled residents (Resident 2). The facility failed to ensure Resident 2's vital signs (objective measurements of the body's most basic and essential physiological functions such as body temperature, blood pressure, heart rate, and breathing rate) were assessed after a fall incident. This failure had the potential to delay Resident 2's care and could negatively affect Resident 1' well-being.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/22/2026 with diagnoses including chronic osteomyelitis (long-lasting inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, type two diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a small open sore or wound), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/24/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2026, the MDS indicated Resident 2 had moderately impaired cognitive functioning. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) from facility staff with oral hygiene, personal hygiene, and upper body dressing. The MDS indicated Resident 2 required maximal assistance from facility staff with toileting hygiene and lower body dressing. During a review of Resident 2's Care Plan (CP), initiated on 8/18/2026, the CP indicated Resident 2 had an actual fall. The CP Interventions section indicated to complete full body check, assess resident for presence of pain, injury, change in range of motion, functional mobility and change in the level of consciousness. During a review of Resident 2's Change in Condition Evaluation (CIC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 8/18/2026, timed at 10:57 p.m., the CIC form indicated that on 8/18/2026, in the afternoon (time not indicated), Resident 2 had an episode of fall. The CIC form indicated Resident 2's vital signs evaluation was completed on 8/18/2026, and timed at 7:18 p.m. During a concurrent interview and record review on 8/31/2026 at 2:45 p.m. with the ADON, Resident 2's Progress Note, dated 8/18/2026, Post Fall Evaluation, dated 8/18/2026, CIC form, dated 8/18/2026, were reviewed. The Post Fall Evaluation indicated on 8/18/2026 at 4:30 p.m., Resident 2 had an unwitnessed fall. The ADON stated Resident 2's vital signs indicated on the CIC form dated 8/18/2026, were assessed at 7:18 p.m., approximately 2.5 hours after the fall incident. The ADON stated the facility staff failed to assess Resident 2's vital signs at the time of the fall incident. The ADON stated there was no documented evidence to indicate Resident 2's vital signs were assessed at the time of the fall incident, on 8/18/2026, at 4:30 p.m. The ADON stated failure to assess Resident 2's vital signs at the time of the incident had the potential for Resident 2 not to receive proper treatment and experience delay of care. During a review of the facility-provided policy and procedure (P&P) titled, Fall Prevention and Response, last reviewed on 1/12/2026, the P&P indicated, To assess fall risk factors and implement care and services in accordance with individualized level of risk to minimize likelihood of falls.8. Following a fall accident, a Licensed Nurse shall promptly respond and take actions, which may include: . d. Obtaining vital signs and conduct a physical assessment . h. Documenting assessment findings and actions.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who complained of pain, received treatment according to the physician orders. This failure had the potential for Resident 1 to experience unrelieved pain and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/21/2026, with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance that can cause confusion), depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), and generalized muscle weakness. During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/22/2026, the H&P indicated Resident 1 could make needs known but couldn't make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/24/2026, the MDS indicated Resident 1 had clear speech, was able to make self-understood, and had the ability to understand others. The MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) from the facility staff with toileting hygiene, personal hygiene, upper and lower body dressing. During a review of Resident 1's Care Plan Report (CP), initiated on 7/21/2026, the CP indicated Resident 1 had self-care deficit. The CP Interventions section indicated to assess for presence of pain and intervene accordingly. During a review of Resident 1's Order Summary Report, the Order Summery Report indicated the following physician's order:-7/31/2026: Acetaminophen (a medication to treat pain) oral tablet 325 milligram (mg - unit of measurement). Give two tablets by mouth every eight hours as needed for mild pain- one to three out of 10 (numeric pain rating scale, a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable] to quantify pain intensity). Not to exceed three grams a day. Non-pharmacological interventions: 1-Reposition,2- dim lights/quiet environment, 3-hot/cold applications, 4-relaxation Techniques, 5-distraction, 6-music, 7-massage, 8-other. Document the results/effectiveness of non-pharmacological interventions: E for effective and N for not effective. During a review of Resident 1's CP, initiated on 8/24/2026, the CP indicated Resident 1 had an actual fall when attempting to ambulate to the bathroom.During a review of Resident 1's Situation, Background, Assessment, and Recommendation Communication Form (SBAR-situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/24/2026, the SBAR Communication Form indicated that on 8/24/2026 Resident 1 had an episode of fall in his (Resident 1's) room. The SBAR Communication Form indicated Resident 1 reported hitting his head and had mild pain (three out of 10). During a concurrent interview and record review on 8/31/2026 at 2:45 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR), dated 8/2026, Resident 1's Progress Notes, dated 8/24/2026, and Resident 1's SBAR Communication Form, dated 8/24/2026, were reviewed. The ADON stated there was no documented evidence to indicate that Resident 1 received interventions to relieve her (Resident 1) headache on 8/24/2026 after the fall incident. The ADON stated Resident 1 had the potential to experience delayed care causing prolonged and intractable pain (severe, constant pain that does not go away with standard medical treatments or standard pain medications). During a review of the facility-provided policy and procedure (P&P) titled, Pain Assessment and Management, last reviewed on 1/12/2026, the P&P indicated, It is the facility policy to provide pain management to those who require such services, consistent with professional standards of practice, comprehensive care plan, and Resident's goals and preferences.3. Pain Management Interventions: Pain symptoms, whether reported, recognized, or anticipated shall be addressed promptly. Pain management will be individualized and implemented in accordance with practitioner orders, accepted standards of practice, and historical or known patterns.6. Documentation: Pain assessments, interventions, and responses will be documented in medical records.

Based on observation, interview, and record review, the facility failed to ensure Resident 1's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was dated for one out of three sampled resident (Resident 1).This deficient practice had the potential to result in contamination of Resident 1's care equipment and risk of transmission of bacteria that can lead to infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/27/2026, with diagnoses including encephalopathy (a disturbance of brain function) and chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/30/2026, the MDS indicated the resident had a moderate cognitive (the ability of the brain to think) impairment (loss of function or ability).During a review of Resident 1's Order Summary Report, dated 8/17/2026, the Report indicated an order for oxygen at 2 liters per minute via nasal cannula continuously every shift for pleural effusion (an abnormal buildup of excess fluid in the space between your lungs and your chest wall).During a concurrent observation and interview on 8/25/2026 at 11:10 a.m., with Certified Nursing Assistant 1 (CNA 1), Resident 1's nasal cannula was observed to be not dated. CNA 1 stated nasal cannula tubing was not dated. CNA 1 stated there was no way to know the last time the nasal cannula was changed and this could lead to contamination, and it could lead to infection of Resident 1. During a concurrent interview and record review on 8/25/2026 at 11:22 a.m. with the Director of Nursing (DON), stated that facility staff changes the nasal cannula once a week and they must indicate the date when the last time it was changed to know when it will be changed again. The DON stated that if the nasal cannula was not dated there was no way to know when it would be due to change the nasal cannula and this could lead to infection of the resident. During a review of the facility policy and procedure titled, Oxygen Administration, last reviewed date of 1/12/2026, the facility policy and procedures indicated Documentation after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: the date and time that the procedure was performedDuring a review of the facility policy and procedure titled, Infection Prevention & Control Program Policy, last reviewed date of 1/12/2026, the facility policy and procedures indicated established and maintained to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure that two medications namely Finasteride (use to treat enlarge prostate) and Tamsulosin (use to treat enlarge prostate) were not left above the medication cart unattended for one of three sampled residents (Resident 12).This deficient practice had the potential to place other residents at risk to take and misuse the medications. Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 8/13/2026 with diagnoses including diabetes mellitus (a chronic condition where the body has trouble regulating blood sugar (glucose) levels) and benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate gland {a small, walnut-sized gland found only in people with male reproductive organs}).During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 8/16/2026, the MDS indicated Resident 12 had moderate cognitive (the ability of the brain to think) impairment (loss of function or ability).During a review of Resident 12's Order Summary Report, dated 8/13/2026, the Report indicated an order to give Finasteride 5 mg (milligram - weight measurement) once a day for BPH and to give Tamsulosin 0.4 mg twice a day for BPH.During a concurrent observation and interview on 8/18/2026 at 12:30 p.m. with the Director of Nursing (DON) and License Vocational Nurse (LVN 1) in area 1. Observe that medication cart was unlocked, two pills were found on the top of the medication cart unattended. LVN 1 stated that the two pills were left unattended above medication cart namely Finasteride and Tamsulosin belonging to Resident 12. LVN 1 stated that Resident 12 refused the medications, and LVN 1 forgot to put the medications secure inside the medication cart. LVN 1 stated that she must put it inside the medication cart and lock it. LVN 1 stated medications should always be locked inside the cart because other residents could take it and might have allergies to medication and it was not safe for other residents. The DON stated observe the two pills on the top of medication cart.During a concurrent interview and record review on 8/25/2026 at 11:22 a.m. with the DON, the facility's policy and procedure titled, Medication Administration-General Guidelines, last reviewed on date 1/12/2026, was reviewed. The policy and procedures indicated During administration of medications, the medication cart kept closed, locked and secure. The medication cart needs to be secured and locked when unattended. The DON stated that the medication should always be secured all the time inside the medication cart because other resident could just easily take the medications and that could lead to adverse (unexpected result) effects to the resident.

Based on observation, interview, and record review, the facility failed to ensure that for one of three sampled residents (Resident 1), a change in condition assessment form was completed at the time Resident 1 experienced a change in condition, per facility policy and procedure.This failure had the potential to result in delayed patient care and interventions, which could negatively affect Resident 1's overall health, safety, and quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/6/2026 with the diagnosis including, but not limited to, fracture of left pubis (hip bone), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (elevated blood pressure), muscle weakness, and difficulty walking.During a review of Resident 1's Physician Progress Note, dated 8/7/2026, the Physician Progress Note indicated Resident 1 had the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Sheet (MDS - a resident assessment tool), dated 8/9/2026, the MDS indicated Resident 1 had moderately impaired cognitive function. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bath, lower body dressing, and personal hygiene.During a review of Resident 1's Telephone order, dated 8/6/2026, the Telephone order indicated, Baclofen (muscle relaxant) Oral Tablet 10 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Baclofen) Give 1 tablet by mouth three times a day for muscle spasms.During a review of Resident 1's Care Plan Report, initiated on 8/8/2026, the Care Plan Report indicated, alteration in comfort due to pain related to . Muscle Spasm. The interventions included Administer Baclofen . for Muscle Spasm (sudden painful tightening of a muscle) as ordered . Observe for side effects of pain medication such as . dizziness and intervene accordingly.During a concurrent interview and record review, on 8/24/2026, at 12:58 PM, with the Quality Assurance Nurse (QAN), the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 1/12/2026, was reviewed. The P&P indicated, Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR [Situation, Background, Assessment and Recommendation] Communication Form (a communication framework used by healthcare professionals to share critical resident information). The P&P indicated, If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. The QAN stated, the Interact SBAR Communication Form in this policy is referred to SBAR eINTERACT Change of Condition Evaluation V5 assessment form in the facility's electronic charting system.During a follow up interview on 8/24/2026, at 1:00 PM, with the QAN, the QAN stated that the SBAR eINTERACT Change of Condition Evaluation V5 assessment form was not completed to indicate the change in Resident 1's condition, such as being lethargic on 8/19/2026. The QAN stated the importance of completing this form is to document the full and complete head to toe assessment of the resident during the change in condition and the time of notification to the physician and resident's family. The QAN stated that if this form was not completed, the resident was not documented as fully assessed, and the necessary interventions were not be documented as having been completed.During an interview on 8/24/2026, at 1:20 PM, with Resident 1, Resident 1 stated, I was getting a medication that was making me tired and dizzy, but they stopped giving it to me a few days ago. Since they stopped that medication, I am not tired or dizzy anymore.During a review of Resident 1's Progress Notes, dated 8/12/2026, the Progress Notes indicated, On monitoring for reported dizziness and weakness yesterday. None reported during today's shift.During a review of Resident 1's Progress Notes, dated 8/17/2026, the Progress Notes indicated, resident complaint of sleepiness and dizziness.During a review of Resident 1's Progress Notes, dated 8/19/2026, the Progress Notes indicated, initial assessment pt [patient] appeared to be lethargic . reported my assessment to the md [medical doctor]. rcvd [received] new order.During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 1/12/2026, indicated, A 'significant change' of condition is a major decline or improvement in the resident's status that . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR [Situation, Background, Assessment and Recommendation] Communication Form (a communication framework used by healthcare professionals to share critical resident information).

Based on observation, interview, and record review, the facility failed to ensure that the care plan for one of three sampled residents (Resident 1) was revised according to the facility's policy and procedure.This failure had the potential to delay necessary care and interventions which could negatively affect Resident 1's health, safety and quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/6/2026 with diagnosis including, but not limited to, fracture of left pubis (hip bone), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (elevated blood pressure), muscle weakness, and difficulty walking.During a review of Resident 1's Physician Progress Note, dated 8/7/2026, the Physician Progress Note indicated Resident 1 had the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Sheet (MDS - a resident assessment tool), dated 8/9/2026, the MDS indicated Resident 1 had moderately impaired cognitive function. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bath, lower body dressing, and personal hygiene.During a review of Resident 1's Telephone order, dated 8/6/2026, the Telephone order indicated, Baclofen (muscle relaxant) Oral Tablet 10 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Baclofen) Give 1 tablet by mouth three times a day for muscle spasms.During a review of Resident 1's Telephone order, dated 8/19/2026, the Telephone order indicated, Baclofen Oral Tablet 10 MG (Baclofen) Give 1 tablet by mouth three times a day for muscle spasms medication order was discontinued on 8/19/2026 due to side effects.During a concurrent interview and record review, on 8/24/2026 at 11:27 AM, with the Quality Assurance Nurse (QAN), Resident 1's Care Plan Report, initiated on 8/8/2026, was reviewed. The Care Plan Report indicated, alteration in comfort due to pain related to . Muscle Spasm. The interventions include Administer Baclofen . for Muscle Spasm (sudden painful tightening of a muscle) as ordered . Observe for side effects of pain medication such as . dizziness and intervene accordingly. The QAN stated this care plan from 8/8/2026 should have been revised on 8/19/2026 to indicate the discontinuation of Baclofen and to monitor for drowsiness and sedation effects but it was not revised. The QAN stated that the risk of not having the care plan revised is that the facility will not be able to evaluate if the interventions were being effective and to know if the goals were being met.During an interview on 8/24/2026 at 12:27 PM with Registered Nurse 1 (RN 1), RN 1 stated Resident 1's care plan should have been revised due to the change of condition. RN 1 stated that the care plan was another form of communication about resident and if it is not updated, the most up to date information about the resident is not being communicated.During an interview on 8/24/2026, at 1:20 PM, with Resident 1, Resident 1 stated, I was getting a medication that was making me tired and dizzy, but they stopped giving it to me a few days ago. Since they stopped that medication, I am not tired or dizzy anymore.During a review of Resident 1's Progress Notes, dated 8/12/2026, the Progress Notes indicated, On monitoring for reported dizziness and weakness yesterday. None reported during today's shift.During a review of Resident 1's Progress Notes, dated 8/17/2026, the Progress Notes indicated, resident complaint of sleepiness and dizziness.During a review of Resident 1's Progress Notes, dated 8/19/2026, the Progress Notes indicated, initial assessment pt [patient] appeared to be lethargic . reported my assessment to the md [medical doctor]. rcvd [received] new order.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/12/2026, the P&P indicated, The comprehensive, person-centered care plan will . incorporate risk factors associated with identified problems; . aid in preventing or reducing decline in the resident's functional status and/or functional levels. The P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents' and the residents' conditions change.During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed on 1/12/2026, the P&P indicated, A 'significant change' of condition is a major decline or improvement in the resident's status that . requires interdisciplinary review and/or revision to the care plan.During a review of the facility's P&P titled, Charting and Documentation, last reviewed on 1/12/2026, the P&P indicated, All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documents in the resident's medical record.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 1) by failing to:Ensure Resident 1 had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 1 was provided with oxygen.Ensure Resident 1's oxygen tubing, oxygen supplies bag, and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.These deficient practices had the potential to create confusion in the delivery of care and services to Resident 1. Furthermore, these deficient practices had the potential for Resident 1 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 7/27/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways), pleural effusion (an abnormal build up of excess fluid in the narrow space between the lungs and the chest wall), and hypertensive heart disease with heart failure (occurs when the heart no longer pump blood well enough to meet the body's needs due to the damaged and weakened heart muscle from years of high blood pressure). During a review of Resident 1's Physician Progress Note, dated 7/29/2026, the Physician Progress Note indicated Resident 1 had chronic (long term) supplemental oxygen (a medical treatment that delivers extra oxygen to the body when the lungs cannot absorb enough from normal room air) two to three liters per minute (Lpm - unit of measurement). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/30/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was moderately impaired. During a review of Resident 1's Care Plan Report (CP) on respiratory status, initiated on 8/3/2026, the CP indicated Resident 1 was at risk for altered respiratory status and difficulty breathing related to pleural effusion. The CP indicated nursing staff to administer oxygen as ordered and apply oxygen tubing ear protector to prevent injury every shift. During a review of Resident 1's CP on oxygen, initiated on 8/4/2026, the CP indicated Resident 1 was on oxygen therapy related to the resident's pleural effusion. The CP indicated Resident 1 required oxygen via nasal cannula (a device used to deliver supplemental oxygen through the nostril [nose]) as ordered. During a concurrent observation and interview on 8/17/2026 at 2:55 p.m. with Registered Nurse (RN) 1 at the dining room patio, Resident 1 was observed with oxygen via nasal cannula connected to an oxygen tank. RN 1 stated Resident 1's nasal cannula was not dated. During a concurrent observation and interview on 8/17/2026 at 3:08 p.m. with RN 1 inside Resident 1's room, Resident 1's nasal cannula was observed inside an oxygen supplies bag and was connected to an oxygen concentrator (a device that provides extra oxygen). RN 1 stated Resident 1's nasal cannula was not dated. RN 1 stated Resident 1's oxygen supplies bag was dated 7/28/2026, 20 days ago. Resident 1's nasal cannula with extension tubing was observed on top of a chair with the resident's personal items. RN 1 stated Resident 1's oxygen therapy supplies should be inside a dated and labeled oxygen supplies bag when not in use. RN 1 could not state how often Resident 1's oxygen supplies should be dated and changed. RN 1 stated Resident 1's oxygen supplies could get dirty and had the potential to cause Resident 1 respiratory infections. During a concurrent interview and record review on 8/18/2026 at 2:58 p.m. with the Quality Assurance Nurse (QAN), Resident 1's Physician Orders were reviewed. The QAN stated Resident 1's Physician Orders did not indicate an order for oxygen therapy. The QAN stated Resident 1 received oxygen therapy since the resident's admission in the facility on 7/27/2026. The QAN stated providing oxygen treatment to Resident 1 without a physician's order could cause worsening of Resident 1's respiratory condition. The QAN acknowledged and stated the facility failed to ensure there was a physician's order before Resident 1 was provided with oxygen therapy. During a review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 1/12/2026, the PnP indicated the purpose to provide guidelines for safe oxygen administration. The PnP indicated to verify that there was a physician order for the procedure. During a review of the facility's PnP titled, Physician Orders, last reviewed on 1/12/2026, the PnP indicated treatment orders will include the following: a description of the treatment, including the treatment site. the frequency of treatment and duration of order.and condition/diagnosis for which the treatment is ordered. The PnP indicated .orders will include a description complete enough to ensure clarity of the physician's plan or care.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to ensure licensed nurses appropriately assessed and monitored Resident 1's fluid intake. Resident 1 was on 1500 milliliters (ml - unit of measurement) fluid restriction (limiting the total amount of liquids a person consumes each day to prevent extra water from building up in the body). This deficient practice had the potential to result in the failure to identify continued or worsening clinical deterioration thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the Resident 1 on 7/27/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways), pleural effusion (an abnormal buildup of excess fluid in the narrow space between the lungs and the chest wall), and hypertensive heart disease with heart failure (occurs when the heart no longer pump blood well enough to meet the body's needs due to the damaged and weakened heart muscle from years of high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/30/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was moderately impaired. During a review of Resident 1's Order Summary Report (OSR) for the active orders as of 8/18/2026, the OSR indicated Resident 1 had a fluid restriction of 1500 ml per day. The OSR indicated nursing staff to provide Resident 1 with 540 ml of fluids, divided into 200 ml in the morning shift (7 a.m. to 3 p.m.), 200 ml in the afternoon shift (3 p.m. to 11 p.m.), and 140 ml in the night shift (11 p.m. to 7 a.m.). The OSR indicated dietary staff to provide Resident 1 with 960 ml of fluids divided into 360 ml for breakfast, 360 ml for lunch, and 240 ml for dinner with an order date of 8/12/2026. During a review of Resident 1's Care Plan Report (CP) on fluid restriction, initiated on 8/13/2026, the CP indicated Resident 1 had the potential for fluid deficit due to the 1500 ml fluid restriction. The CP indicated nursing staff to observe decrease and refusal of fluid intake during mealtime. During an interview on 8/17/2026 at 2:35 p.m. with Resident 1's Representative (RR) 1, RR 1 stated on 8/16/2026 around 10 p.m., Resident 1 informed RR 1 that the facility staff did not provide the resident with water to drink. RR 1 stated Registered Nurse 2 reported that Resident 1 reached the allotted fluid for the 3 p.m. to 11 p.m. shift. RR 1 stated RN 2 refused to give Resident 1 water to drink. During a concurrent observation and interview on 8/17/2026 at 3:08 p.m. with Registered Nurse (RN) 1, Resident 1's supplement drink was observed on top of the table inside the resident's room. RN 1 stated the supplement drink was still sealed and unopened. RN 1 stated Resident 1's supplement drink was included in the resident's 1500 ml fluid restriction. RN 1 could not state when the supplement drink was provided to Resident 1. RN 1 could not state if Resident 1's supplement drink was documented as consumed. RN 1 could not state the effect on Resident 1 if documentation and monitoring of fluid intake was not done. During a concurrent interview and record review on 8/17/2026 at 4:43 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR), dated 8/1/2026 to 8/31/2026, were reviewed. LVN 1 stated Resident 1's MAR indicated on 8/16/2026, she gave 100 ml of fluid (out of the 200 ml allotted on the 3 p.m. to 11 p.m. shift) to Resident 1. LVN 1 stated at 10 p.m. on 8/16/2026, Certified Nursing Assistant (CNA) 1 reported to her that Resident 1 requested water. LVN 1 stated she instructed CNA 1 to give Resident 1 some water. LVN 1 stated she did not verify if CNA 1 gave Resident 1 the water. LVN 1 stated she did not follow up and documented the fluid she instructed CNA 1 to give Resident 1. LVN 1 stated failure to provide and document fluids provided to Resident 1 could cause fluid overload or dehydration. During a concurrent observation and interview on 8/18/2026 at 10:20 a.m. with the Dietary Manager (DM), the DM stated she observed two unopened and unlabeled supplement drinks on top of the table inside Resident 1's room. The DM stated the supplement drink provided to Resident 1 was included in the resident's dietary fluid limits. The DM stated the CNAs report to the licensed nurses the amount of fluid the resident consumed every meal or if the resident refused. The DM stated the licensed nurses report to her when a resident refused the supplement drink. The DM stated she was not informed that Resident 1 had refused the supplement drinks. During a telephone interview on 8/18/2026 at 11:27 a.m. with RN 2, RN 2 stated she was not aware Resident 1 was on fluid restriction until CNA 1 informed her about Resident 1's fluid restriction. RN 2 stated on 8/16/2026 at around 10 p.m., she gave Resident 1 one cup of water. RN 2 stated she did not verify with LVN 1, CNA 1, or in Resident 1's medical records, the amount of fluid the resident had already received. RN 2 stated she did not inform LVN 1 that she gave Resident 1 one cup of water. RN 2 stated she was not aware of the facility's procedure regarding resident's fluid restrictions. During a concurrent interview and record review on 8/18/2026 at 1:54 p.m. with the Quality Assurance Nurse (QAN), Resident 1's MAR, dated 8/1/2026 to 8/31/2026 were reviewed. The QAN stated on 8/15/2026 Resident 1's MAR indicated the resident received a total of 780 ml of fluid, 240 ml over the ordered fluid restriction. The QAN stated the licensed nurses provide and document the amount of fluid given to the residents on fluid restriction. The QAN stated the CNAs document the amount of fluid given to residents during mealtime. The QAN stated failure to monitor and document Resident 1's fluid intake could result in resident's dehydration or fluid overload. The QAN acknowledged and stated the facility failed to ensure Resident 1's fluid intake was calculated and documented accurately every shift. During a review of the facility's policy and procedure (PnP) titled, Encouraging and Restricting Fluids, last reviewed on 1/12/2026, the PnP indicated the purpose .to provide the resident with the amount of fluids necessary to maintain optimum health. The PnP indicated verify that there is a physician's order for this procedure. The PnP indicated .follow specific instructions concerning fluid intake or restrictions. be accurate when recording fluid intake. The PnP further indicated .information should be recorded in the resident's medical record.the amount (in ml) of fluid consumed by the resident during the shift.if the resident refused the treatment, the reason(s) why and the interventions taken. The PnP indicated to notify the supervisor if the resident refuses the procedure. During a review of the facility's PnP titled, Intake and Output Monitoring, last reviewed on 1/12/2026, the PnP indicated it is the facility's policy to provide appropriate monitoring and documentation of resident intake, output, hydration status and continence status consistent with physician orders and applicable standards of care.

Based on interview and record review, facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 1) when Resident 1 did not have an accurate assessment of the respiratory (organs and structures in the body that allow a person to breathe) treatments that was conducted on 7/30/2026. This deficient practice had the potential to result in a delay in Resident 1's necessary care and treatment.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 7/27/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways), pleural effusion (an abnormal buildup of excess fluid in the narrow space between the lungs and the chest wall), and hypertensive heart disease with heart failure (occurs when the heart no longer pump blood well enough to meet the body's needs due to the damaged and weakened heart muscle from years of high blood pressure). During a review of Resident 1's Physician Progress Note, dated 7/29/2026, the Physician Progress Note indicated Resident 1 had chronic (long term) supplemental oxygen (a medical treatment that delivers extra oxygen [an essential gas for life] to the body when the lungs cannot absorb enough from normal room air) two to three liters per minute (Lpm - unit of measurement). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/30/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was moderately impaired. The Special Treatments, Procedures, and Programs section of the MDS, under the Respiratory Treatment section, did not indicate Resident 1's use of supplemental oxygen therapy (a medical treatment that gives the body extra oxygen when the lungs cannot take in enough from the air on their own). During an interview on 8/18/2026 at 2:45 p.m. with Resident 1's Representative (RR) 1, RR 1 stated Resident 1 was on supplemental oxygen therapy at home, while in the General Acute Care Hospital (GACH), and since the resident was admitted to the facility. During a concurrent interview and record review on 8/18/2026 at 2:58 p.m. with the Quality Assurance Nurse (QAN), Resident 1's MDS, dated [DATE], was reviewed. The QAN stated Resident 1 was admitted to the facility with supplemental oxygen therapy. The QAN stated Resident 1's MDS data should come from the resident's medical records and physical assessment of the MDS nurse. The QAN stated Resident 1's MDS indicated the resident did not have supplemental oxygen therapy. The QAN stated Resident 1's MDS assessment on respiratory condition was inaccurate. During a telephone interview on 8/18/2026 at 3:31 p.m. with MDS Nurse (MDSN) 1, MDSN 1 stated he gathered Resident 1's data from the medical records to create the resident's MDS. MDSN 1 stated he did not meet the resident during the MDS assessment. MDSN 1 stated he did not have to physically see Resident 1 since the data he needed to complete his MDS sections were documented in the medical records. MDSN 1 stated Resident 1's MDS assessment on respiratory condition was inaccurate. During a follow up interview on 8/18/2026 at 4:01 p.m. with the QAN, the QAN stated Resident 1's MDS was one of the tools used to create the resident's care plan. The QAN stated failure to accurately assess and document Resident 1's respiratory condition in the MDS could result in an inaccurate resident care plan. The QAN acknowledged and stated the facility failed to accurately document Resident 1's respiratory conditions on the MDS assessment following the resident's admission. During a review of the facility's policy and procedure (PnP) titled, Comprehensive Assessment and the Care Delivery Process, last reviewed on 1/12/2026, the PnP indicated a comprehensive assessments will be conducted to assist in developing person-centered care plans. The PnP indicated .gather relevant information from multiple sources. (a) observation; (b) physical assessment. (d) resident and family interview. The PnP indicated the objective of the information collection (assessment)phase is to obtain, organize, and subsequently analyze information about a patient.

Based on observation, interview, and record review, the facility failed to initiate droplet isolation precautions (represent a specific category of transmission-based infection control interventions designed to prevent the transmission of pathogens and require specific personal protective equipment [PPE - a specialized clothing, goggles, and other garments designed to protect the wearer's body from spread of infection or illness) for one of three sampled residents (Resident 1) when Resident 1 was admitted from hospital on 7/25/2026. This deficient practice had the potential for ongoing risk of infectious disease transmission from Resident 1 spreading infection to other residents and staff.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/25/2026 with diagnoses including muscle weakness, hypertensive heart disease (a group of heart conditions caused by chronic blood pressure), dementia (a decline in mental ability severe enough to interfere with daily life), type 2 diabetes (a chronic condition where the body cannot use insulin), and human metapneumovirus pneumonia (a serious respiratory tract infection caused by the virus, requires droplet precautions [a set of interventions to block the spread of germs that travel through the air in respiratory droplets] combined with contact [a set of interventions to prevent spread of germs that are passed through direct or indirect physical contact] precautions in a healthcare setting).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/28/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired (resident has clear, measurable difficulties with memory and orientation).During a review of Resident 1's Physician Progress Notes, dated 7/27/2026, the Physician Progress Notes indicated Resident 1's did not have the capacity to understand and make decisions.During an interview on 8/6/2026 at 2 p.m. with Registered Nurse 1, (RN 1). RN 1 stated Resident 1 was admitted to the facility on [DATE] but droplet precautions were not placed until 7/27/2026. RN 1 stated the order for droplet precautions was missing and Resident 1 was not placed on droplet precautions right away which was against the facility's policy. RN 1 stated not placing Resident 1 on droplet isolation precautions upon admission could expose other residents to infection.During an interview on 8/6/2026 at 3 p.m. with the Administrator (AD), the AD stated the facility failed to follow its droplet precaution policy by not placing Resident 1 on droplet precautions on admission.During a review of the facility policy and procedure (P&P) titled, Isolation-Categories of Transmission-Based Precaution, last reviewed and approved on 1/12/2026, the P&P indicated:- Transmission-based precautions are initiated when a resident . arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.- 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne (a set of interventions to prevent the transmission of highly contagious germs that float on air currents and travel long distance).Droplet Precautions indicated:2. Resident on droplet precaution will be placed in a private room if possible3. Masks will be worn when entering room. 4. Gloves, gowns and googles should be worn if there is risk of spraying Respiratory secretions.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints (refers to means of purposely limiting or obstructing the freedom of a person's bodily movement) to one of three sampled residents (Resident 30) investigated under the physical restraints care area by failing to: - Obtain a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and developed and implemented a care plan on the use of low air loss mattress with bilateral bolsters (a soft foam pillow or wedge attached to a bed or chair that acts as a physical barrier to keep a resident from rolling out or sliding forward, but it becomes legally classified as an Physical Restraint Overview if the person cannot easily move or remove it themselves). - Assess the use/need of pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on the resident. These failures had the potential for Resident 30 not able to move around freely and at risk for further injuries. Cross-reference F726.Findings: During a review of Resident 30's admission Record, the admission record indicated the facility admitted the resident on 5/4/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial loss of control) following cerebral infarction (a type of ischemic stroke where a blocked blood vessel stops blood and oxygen from reaching an area of the brain, causing those brain cells to die), muscle weakness, and history of falling. During a review of Resident 30's History and Physical (H&P), dated 5/6/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 5/7/2026, the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes had the ability to understand others, and had impaired vision. The MDS indicated the resident had severely impaired cognitive skills (a major loss of mental function-such as memory, thinking, and reasoning-that completely stops a person from living on their own) and the resident was dependent to needing substantial/maximal assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had history of falls. During a review of Resident 30's Order Summary Report, dated 7/16/2026, the order summary report indicated an order for: - 5/12/2026 Sensor pad alarm while on bed secondary to alert staff when getting up unassisted. Monitor for function and placement. Document (Y) if functioning and in place and (N) if nonfunctioning or not in place every shift for fall precautions replace if nonfunctioning. - 5/12/2026 Sensor pad alarm while on wheelchair secondary to alert staff when getting up unassisted. Monitor for function and placement. Document (Y) if functioning and in place and (N) if nonfunctioning or not in place. Replace if nonfunctioning every shift for fall precautions. - 5/25/2026 Pressure Redistribution Mattress - Low Air Loss (LALM - a specialized medical bed that uses a continuous stream of air escaping through tiny holes to keep a person cool, dry, and free of bedsores) every shift for preventative. - The order summary report did not indicate an order for low air loss mattress with bilateral bolsters. During a review of Resident 30's Fall Risk Evaluation, dated 5/4/2026, the fall risk evaluation indicated the resident was at risk for falls. During a review of Resident 30's Physical Therapy Treatment Encounter, dated 7/13/2026, the physical therapy treatment encounter indicated Precautions: Fall risk, recent cerebrovascular accident (CVA, also known as a stroke, loss of blood flow to a part of the brain) affecting right (R) side, history of (h/o) recent fall. The physical therapy treatment encounter also indicated Bed Mobility = Set Up Level Surfaces = contact guard assistance (CGA - describes a level of physical assistance where the therapist maintains light, continuous contact with the resident to provide support, balance, or immediate physical intervention if they begin to lose their balance or stumble) (200 ft x 2 using small base quad cane (SBQC, it is a mobility aid used to provide more stability than a standard single-point cane) with wheelchair (w/c) to follow) Transfers = CGA Stairs = did not try (DNT). During a review of Resident 30's Care Plan (CP) Report titled, High risk for falls and injury related to recent fall in the last 30 days, bladder incontinence (the accidental loss of bladder control, which leads to the unwanted leakage of urine), bowel incontinence (a person cannot control when they pass solid waste, liquid waste, or gas), CVA with right sided weakness, aphasia (a disorder that makes it difficult to speak), gastrostomy (gt, a soft plastic tube placed directly through the skin of the belly into the stomach) status, infection, pressure redistribution mattress - low air loss every shift for preventative, last revised on 7/14/2026, the CP indicated a goal of risk factors will be managed to minimize falls and injury through the next review, with an intervention to use bed and wheelchair alarm to alert staff when resident is attempting to get out of bed unattended. The CP did not indicate the use of bilateral bolster on the low air loss mattress. During an observation on 7/13/2026 at 9:58 a.m., inside Resident 30's room, observed Resident 30 with a LALM with bolster on, bilateral grab bars, and bed/pad alarm on lying in bed and a Certified Nursing Assistant (CNA) was preparing the resident to transfer to a wheelchair. During a concurrent observation and interview on 7/14/2026 at 10:15 a.m. with Registered Nurse (RN) 2, inside Resident 30's room, observed the resident's bed on a low air loss mattress with elevated sides (bolster) combined with a grab bar, and a bed alarm in place. RN 2 stated he does not know what the purpose of the elevated sides of the resident's low air loss mattress and he will ask somebody what it is and its purpose. RN 2 stated the resident was a fall risk and had fallen before admission. RN 2 came back and stated the mattress is just a low air loss mattress. During an interview on 7/15/2026 at 11:56 a.m. with Low Air Loss Mattress Representative (LALM Rep) 1, LALM Rep 1 stated all the mattresses that they are delivering in the facility had bilateral bolsters on the side that they can inflate. During an interview on 7/15/2026 at 12:30 p.m. with LALM Rep 2, LALM Rep 2 stated all LALM had the ability to have inflated bolsters. During a concurrent interview and record review on 7/16/2026 at 11:03 a.m. with the Quality Assurance Nurse (QAN), Resident 30's Medical Diagnoses, Order Summary Report, Assessment for Restraints, Informed Consents, Care Plans, and policies and procedures (P&Ps). The QAN stated that she did not find a physician's order, informed consents, restraint assessment, and a care plan on the use of restraint low air loss mattress with bilateral bolsters. The QAN also stated she was not able to find a restraint assessment on the use of pad alarms. The QAN stated they were not using bolsters in the facility, that is why we will not be able to find the physician's order, informed consent, restraint assessment, and the care plan on the electronic healthcare record. The QAN stated the failure of the staff to obtain a physician's order, informed consent, restraint assessment, and develop a care plan on the use of restraint low air loss mattress with bilateral bolsters had the potential for residents to suffer from injuries such as bed entrapment (when a person gets accidentally caught, wedged, or tangled in the gaps around a bed) and falls. The QAN stated the application of the bilateral bed bolster had increased the likelihood of injury because the bolster increases the height of fall. The QAN also stated the facility failed to assess the use of the restraint pad alarm on the resident and had the potential for the resident to not move around in bed and cause deconditioning of the resident. The QAN stated they did not follow the P&Ps titled, Use of Restraints, Personal Alarms, Care Plans, Comprehensive Person-Centered, the facility provided Owner's Manual on the use of Pressure Alarm, and the manufacturer's specification on the use of LALM. During an interview on 7/17/2026 at 8:49 a.m. with the Director of Nursing (DON) and the QAN, the DON stated during the identification of the resident's fall risk status they applied appropriate interventions based on the resident's history of falls. The DON stated if the resident had fallen, it was not recommended to place a regular low air loss mattress so they applied special low air loss mattress (does not want to emphasize the elevated side of the mattress). The DON stated the fall assessment is followed depending on the needs of the resident. The DON stated the use of the bed/pad alarm should have an assessment on its use. The DON stated the facility uses bed/pad alarms for fall prevention and should have an assessment for safe use.During a review of the facility's recent P&P titled, Use of Restraints, last reviewed on 1/12/2026, the P&P indicated restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered as a restraint. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessments shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restraints shall only be used the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of restraint. 14. Residents and/or surrogate/ sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 16. Restraint individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms(s), but the underlying problems that may be causing the symptom(s). During a review of the facility's recent P&P titled, Personal Alarms, last reviewed on 1/12/2026, the P&P indicated it is facility policy to utilize resident alarms in limited circumstances, in accordance with Resident's needs, goals, and preferences, to attain or maintain highest practicable levels of physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines: 3. Identification of risk b. When alarms are in use or are under consideration, risks of adverse consequences related to the alarms shall be identified. 4. Evaluation and analysis of risk c. Interventions shall be developed to address root cause(s) of each risk. 5. Implementation of interventions b. Alarms shall be initiated only to address a specific medical symptom or unique risk, when the benefit of the alarm outweighs the risk associated with its use. 6. Monitoring and modification c. Ongoing assessment of Resident shall occur to identify changes in patters, routines, or medical symptoms of the Resident. Interventions shall be modified, as needed, to address changes. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/12/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. During a review of the facility's recent policy and procedure titled, Care Planning- Interdisciplinary Team, last reviewed on 1/12/2026, the P&P indicated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). During a review of the facility-provided Pad Alarm (PA) 1 Owner's Manual, undated, the owner's manual indicated: Warning- This device is not appropriate for all patients and residents. A caregiver should determine appropriateness as part of the resident's care plan and assessment. Warning- This device is not designed to replace good care giving practices including, but not limited to the following: -Direct resident supervision -Adequate care plans and training for staff personnel regarding fall prevention, patient repositioning and elopement -Inspection and testing before use

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for three of thirteen sampled residents (Resident 1, 2, and 26) investigated for care plans by failing to ensure:1. Resident 1's Continuous Glucose Monitoring (CGM - a wearable medical device that measures blood sugar levels in real-time via subcutaneous [beneath the skin] sensor) care plan was developed and implemented.This failure had the potential for inadequate care provided to Resident 1's wearable sensor and potential to cause infection.2. Resident 2 had a care plan on the use of the antibiotic (medication used to treat bacterial infections by killing bacteria or stopping them from growing) Amoxicillin-Pot Clavulanate (also known as Augmentin, a type of antibiotic) tablet 875-125 milligrams (mg - a unit of measure for weight). 3. Resident 26 had a care plan on the use of grab bars/bedrail (sturdy, securely anchored metal or plastic safety rails designed to help residents safely hold their weight, keep their balance, and prevent dangerous falls when sitting down, standing up, or moving around) and the use of antibiotic Cephalexin (a type of antibiotic) oral capsule 500 mg.These failures had the potential to deliver unnecessary care and services and subjecting residents to adverse effects (a harmful or abnormal result) of significant medications and equipment.Cross-reference F726.Findings: 1. During a review of Resident 1's admission Record, dated 7/16/2026, the admission record indicated the facility admitted Resident 1 on 4/24/2026 for aftercare following surgery on the digestive system (body parts system including mouth, throat, esophagus stomach and intestines), gastrostomy tube presence (a surgical opening fitted with a device [tube] to allow feedings and medication to be administered directly to the stomach common for people with swallowing problems), and diagnoses of pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit, bacterial pneumonia (infection of the lungs) , hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side (lack of effort or movement in arm and leg on one side of the body, caused by disrupted blood flow to the brain), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty in expressing self verbally and/or nonverbally, caused by disrupted brain functions such as memory, attention, or executive functioning), type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 4/26/2026, the MDS indicated Resident 1's cognitive function (brain's complex mental processes involved in gaining knowledge and comprehension) was severely impaired and Resident 1 never/rarely made decisions. The MDS indicated Resident 1 was dependent on assistance (helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with feeding, dressing, toileting, showering, transferring to wheelchair. During a concurrent observation and interview on 7/14/2026 at 12:13 pm with Resident 1's caregiver, the caregiver showed the continuous glucose monitoring (CGM) sensor attached to Resident 1's right upper arm above the elbow. Resident 1's caregiver stated the sensor needle is changed by nurses at the facility when Resident 1's wife brings the replacement of needle. During a concurrent interview and record review on 7/15/2026 at 2:07 p.m. with Registered Nurse (RN) 1, Resident 1's physician's order, dated 7/14/2026, were reviewed. The physician's orders indicated an order to monitor for skin breakdown at CGM and notify the physician if noted every shift and an order to monitor for the CGM placement every shift. RN 1 stated Resident 1 has CGM device. RN 1 stated the sensor needle should be changed every 30 days or so depending on the brand. RN 1 stated the family usually brings supplies to change the needle as needed or per family request. During a concurrent interview and record review on 7/15/2026 at 2:07 p.m. with RN 1, Resident 1's care plan titled, At risk for Skin breakdown secondary to presence of CGM on the skin, dated 7/14/2026, was reviewed. The care plan indicated interventions to monitor CGM placement every shift, observe for pain, swelling, redness, drainage. RN 1 stated there is no intervention or care plan to change the sensor needle. RN 1 stated there are no nurses' notes about needle change. RN 1 stated it is important to have a care plan because this device is foreign to the resident's body and skin infection can happen. RN 1 stated if no care plan is present, then no one will provide the care. RN 1 stated there should be a care plan and there should be documentation of when the needle was changed. During a concurrent interview and record review on 7/17/2026 at 4:40 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Continuous Glucose Monitoring, dated May 2026, was reviewed. The DON stated we are not responsible for change of the needle, it is family's responsibility, we don't use it in the facility for any glucose reading, and we don't replace implantable sensor needle. Our staff can monitor skin changes. The P&P indicated Replace sensors in accordance with manufacturer's recommendations or per physician's order; incorporate CGM use, monitoring parameters, and response protocols in plan of care. The DON stated the risk of having the implantable device in the skin is infection. 2. During a review of Resident 2's admission Record, the admission record indicated the facility admitted the resident on 4/21/2026, and readmitted the resident on 6/3/2026, with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract) and fracture (break in bone) of neck of left femur (thigh bone). During a review of Resident 2's History and Physical (H&P), dated 6/5/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a person has noticeable trouble with thinking and memory that actively disrupts daily independence). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 2's Order Summary Report, dated 5/29/2026, the order summary report indicated an order for Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give one tablet by mouth two times a day for UTI. For 10 Days start from emergency kit (EKIT - a backup box of urgent medications and life-saving supplies kept on hand for sudden medical crises when a pharmacy is closed or help cannot reach the building). During a concurrent interview and record review on 7/16/2026 at 9:45 a.m. with the Quality Assurance Nurse (QAN), Resident 2's Medical Diagnoses, Order Summary Report, Care Plans, and the facility's P&Ps were reviewed. The QAN stated the Amoxicillin-Pot Clavulanate Tablet 875-125 mg (Augmentin) was ordered for 10 days for UTI, and there was no care plan on its use. The QAN stated it was important to have a care plan on the use of Amoxicillin-Pot Clavulanate Tablet to ensure all interventions are implemented to meet their set goal for Resident 2. During an interview on 7/17/2026 at 8:49 a.m. with the DON, the DON stated the licensed staff should have developed and created a care plan on Resident 2's use of antibiotic Amoxicillin-Pot Clavulanate Tablet 875-125 mg to make sure that they follow the physician's order correctly and everything is in place. The DON stated the care plan was one of their tools to track the care of the resident and it was a part of standard antibiotic monitoring. 3. During a review of Resident 26's AR, the AR indicated the facility admitted the resident on 6/19/2026, with diagnoses including UTI, sepsis (a life-threatening blood infection), and muscle weakness. During a review of Resident 26's H&P, dated 6/22/2026, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 26's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment (a person has a major loss of mental function that stops them from living on their own). The MDS indicated the resident needed substantial to set up assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 26's Order Summary Report, the order summary report indicated an order for: 6/19/2026 Cephalexin Oral Capsule 500 mg (Cephalexin). Give one capsule by mouth two times a day for UTI for 10 Days. 6/26/2026 May have bilateral grab bars up as an aid to bed mobility, turning and repositioning, and to assist with transfers. Every shift. During a review of Resident 26's Bed Safety Assessment (BSA), dated 6/19/2026, the BSA indicated the resident had grab/transfer assist bars or rails. During a review of Resident 26's Fall Risk Evaluation (FRE), dated 6/19/2026, the FRE indicated the resident was at risk for falls. During a concurrent observation and interview on 7/14/2026 at 10:14 a.m. with RN 3, inside Resident 26's room, observed Resident 26 had bilateral grab bars on the bed. RN 3 stated the resident had grab bars for mobility. During a concurrent interview and record review on 7/16/2026 at 10:50 a.m. with the QAN, Resident 26's Medical Diagnoses, Order Summary Report, BSA, FRE, and the facility's P&Ps were reviewed. The QAN stated the order for Cephalexin Oral Capsule 500 mg, give one capsule by mouth two times a day for UTI for 10 Days, and the resident's use of grab bars did not have care plans. The QAN stated the licensed staff should have developed and implemented a care plan on the use of antibiotic Cephalexin Oral Capsule 500 mg and the resident's use of the grab bars to ensure the safe use of both interventions. The QAN stated it was important to have a care plan on the use of Amoxicillin-Pot Clavulanate Tablet and the grab bars to ensure all interventions are implemented to meet their set goal for Resident 26. The QAN stated the facility did not follow the P&P titled, Care Plans, Comprehensive Person-Centered, and Care Planning- Interdisciplinary Team. During an interview on 7/17/2026 at 8:49 a.m. with the DON, the DON stated the licensed staff should have developed and created a care plan for Resident 2's use of the antibiotic Amoxicillin-Pot Clavulanate tablet 875-125 mg and grab bars to make sure that they follow the physician's order correctly and everything is in place. The DON stated the care plan was one of their tools to track the care of the resident and it was a part of standard monitoring for resident care. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/12/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. During a review of the facility's recent P&P titled, Care Planning- Interdisciplinary Team, last reviewed on 1/12/2026, our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of three sampled residents (Residents 54, 4, and 53) reviewed under the pressure ulcer/injury care area by failing to ensure the facility set the residents' low air loss mattress (LALM - a medical bed that blows tiny amounts of air through microscopic holes to keep skin cool, dry, and free of bed sores) according to resident's weight. These failures had the potential for developing or worsening pressure injury on residents. Cross-reference F726.Findings: 1. During a review of Resident 54's admission Record (AR), the AR indicated the facility admitted the resident on 7/28/2021, and readmitted the resident on 7/4/2026, with diagnoses including severe protein-calorie malnutrition (a life-threatening medical condition where the body wastes away because it does not get enough food, calories, and protein), pressure-induced deep tissue damage/injury (DTI - a serious type of pressure sore where the deep muscle and soft tissue near a bone are damaged by too much squeezing or pressure, even though the top layer of skin may still look whole and closed) on the left heel and sacral region (the lower back area right above the tailbone and between the hip bones). During a review of Resident 54's History and Physical (H&P), dated 7/6/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 7/10/2026, the MDS indicated the resident usually had the ability to make self-understood and usually understands others and had severe cognitive impairment (a major loss of mental function, such as severe memory loss, confusion, and trouble reasoning, that makes a person completely unable to live independently). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) and was at risk for developing pressure ulcers/injuries. The MDS indicated that the resident had a one DTI that was present on admission and was on a pressure-reducing device for bed and on pressure ulcer/injury care. The MDS indicated the resident's latest weight of 91 pounds (lbs. - a unit of measure for weight weight) During a review of Resident 54's Order Summary Report (OSR), the OSR indicated an order for: 7/8/2026 Pressure Redistribution Mattress - Low Air Loss every shift for Wound Management. 7/13/2026 Left Heel DTI: Cleanse with normal saline (NS, a simple mixture of purified water and salt that matches the natural salt level of human blood), pat dry apply zinc oxide cream (a thick, white, over-the-counter skin protectant made from zinc and oxygen) every day shift for 14 Days. 7/7/2026 Sacrococcyx (an articulation between the apex of the sacrum and the base of the coccyx (tailbone)) DTI: Cleanse with NS, pat dry, apply zinc oxide cream every day shift for 14 Days. During a review of Resident 54's Braden Scale (BS) for Predicting Pressure Ulcer Risk Evaluation, dated 7/4/2026, the BS indicated the resident was at risk for pressure injury development. During a review of Resident 54's Care plan (CP) Report titled, Altered skin integrity related to DTI on Right Metatarsal Joint (toe knuckle), last revised on 7/10/2026, the CP indicated interventions of Pressure Redistribution Mattress - Low Air Loss every shift for Wound Management and Treatment as ordered. During an observation on 7/13/2026 at 9:27 a.m. inside Resident 54's room, observed Resident 54 lying in bed and the LALM was set at 220, alternating. During a concurrent observation and interview on 7/13/2026 at 9:33 a.m. with Registered Nurse (RN) 1, inside Resident 54's room, observed Resident 54's LALM was set at 220, alternating. RN 1 stated the LALM was set to 220 and was in alternating mode. RN 1 stated they set the bed according to the resident's weight and he does not think the resident weighs 220 lbs. RN 1 stated he checked the resident's latest weight and the resident was 91 lbs. on 7/4/2026. During a concurrent interview and record review on 7/16/2026 at 8:56 a.m. with the Quality Assurance Nurse (QAN), Resident 54's Medical Diagnoses, OSR, BS, CP, and the facility's policy and procedures (P&Ps) were reviewed. The QAN stated there was an order for LALM every shift for wound management and we set the LALM according to resident's weight. The QAN stated the failure of the staff to set the bed according to resident's weight had the potential of development or worsening of pressure injury on Resident 54. The QAN stated they did not follow the P&Ps titled, Support Surface Guidelines, Pressure Injury Prevention and Management, and the facility-provided low air loss mattress (LALM) 1 manufacturer's guidelines by not setting the bed according to resident's weight. During an interview on 7/17/2026 at 8:49 a.m. with the Director of Nursing (DON) and in the presence of the Administrator (ADM), the DON stated they follow the manufacturer's specification on the use of LALM in the facility. The DON stated the purpose of the LALM was to prevent skin breakdown on residents. The DON stated the setting on the LALM was incorrect. During a review of the facility's recent P&P titled, Support Surface Guidelines, last reviewed on 1/12/2026, the P&P indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Steps in the Procedure 2. Use a pressure ulcer risk scale such as the Braden Scale to help determine need for an appropriate type of pressure-relieving devices. Refer to bed selection algorithm for support surface selection. During a review of the facility's recent P&P titled, Pressure Injury Prevention and Management, last reviewed on 1/12/2026, the P&P indicated the facility is committed to preventing pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal a pressure injury, prevent infection, and avoid additional pressure ulcers. Policy Explanation and Compliance Guidelines 3. Interventions for Prevention and to Promote Healing c. Evidenced-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions may include, but are not limited to: iii. Provide appropriate, pressure-redistributing, support surfaces. During a review of the facility-provided LALM 1 Manufacturer's Guidelines, undated, under Product Function: Pump - Press Pressure Range (3) 26-65 mmHg adjustable pressure range selected by patient's weight guide listed on panel providing pressure range options. 2. During a review of Resident 4's AR, the AR indicated that the facility admitted the resident on 6/30/2026 with diagnoses including lumbar region (lower back) spinal stenosis (narrowing of the spinal canal compressing nerves) with neurogenic claudication (a syndrome characterized by leg pain, numbness, tingling, or heaviness brought on by standing upright or walking), dorsalgia (a broad medical term for back pain), and generalized muscle weakness. During a review of Resident 4's H&P, dated 7/1/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated that the resident has clear speech and adequate hearing and had the ability to understand others and makes self-understood. The MDS indicated that the resident with lower extremity impairment on both sides. The MDS indicated the resident needed substantial/maximal assistance (the helper does more than half the effort) with rolling left and right, sit to lying, and from lying to sitting on side of bed. During a review of Resident 4's physician order, the physician order indicated: - Pressure redistribution mattress – Low Air Loss every shift for preventative, order date 7/1/2026 and discontinued date 7/17/2026. - Pressure redistribution mattress – Low Air Loss every shift for wound management, order date 7/17/2026. During a review of Resident 4's CP titled, Risk for skin breakdown/further skin breakdown, dated 7/1/2026, the CP indicated that the resident will maintain skin integrity which included interventions of pressure redistribution mattress – Low Air Loss. During a review of Resident 4's Change in Condition, dated 7/14/2026, the Change in Condition indicated that the resident weighed 155 lbs. During an observation on 7/13/2026 at 8:54 a.m., inside Resident 4's room, Resident 4 laid in bed on his back with the LALM setting at 220 lbs. During a concurrent observation and interview on 7/13/2026 at 9:03 a.m. with Treatment Nurse (TN) 1, inside Resident 4's room, TN 1 stated Resident 4 has a LALM and the setting is at 220 lbs. and every 10 minutes alternate. TN 1 stated the LALM setting options starting at 90 lbs., 150 lbs., then 220 lbs. TN 1 stated Resident 4 weighs 155 lbs. and she rounds up to 220 lbs. TN 1 stated Resident 4 is on a LALM because the resident has a left heel deep tissue injury and a moisture-associated skin damage on the sacrococcyx (the buttocks area) for pressure ulcer prevention. During a concurrent observation and interview on 7/14/2026 at 10:40 a.m. with Certified Nursing Assistant (CNA) 8, inside Resident 4's room, Resident 4 laid in bed lying on his back with the LALM set at 220 lbs. CNA 8 stated the LALM setting is at 220 lbs. During an observation on 7/15/2026 at 7:58 a.m., inside Resident 4's room, Resident 4 laid in bed, lying on back with head of the bed up, eating breakfast, and the LALM setting at 220 lbs. During an observation on 7/15/2026 at 1:20 p.m., inside Resident 4's room, Resident 4 laid in bed on his back with the LALM set to 220 lbs. During an interview on 7/17/2026 at 8:16 a.m. with the DON, the DON stated for the LALM setting they follow the manufacturer's guidelines and set it accordingly to the resident's weight. The DON stated for Resident 4, who weighs 155 lbs., the LALM should be set at 150 lbs. The DON stated LALM are used to ensure there is no skin breakdown. The DON stated in general it is used to prevent pressure ulcer. When asked when Resident 4's LALM setting was set at 220 lbs. and observed on multiple days, the manufacturer's guidelines were not followed and the DON stated there is a potential for skin breakdown if they do not follow it. During a concurrent observation and interview on 7/17/2026 at 1:33 p.m. with CNA 9, inside Resident 4's room, Resident 4 laid in bed lying on his back with the LALM setting set to 220 lbs. CNA 9 stated she does not touch the LALM machine setting. During a review of the facility provided LALM 1 manufacturer's guidelines, undated, the manufacturer's guidelines indicated that the Press Pressure Range (3) 20-65 millimeters of mercury (mmHg-a unit of measurement) adjustable pressure range selected by patients weight guide listed on panel providing pressure range options. During a review of the facility's P&P titled, Pressure Injury Prevention and Management, last reviewed and approved on 1/12/2026, the P&P indicated that the Facility is committed to preventing pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal a pressure injury, prevent infection, and avoid additional pressure ulcers. 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Policy Explanation and Compliance Guidelines. 3. Interventions for Prevention and to Promote Healing. c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk who have a pressure injury present. Basic or routine care interventions may include, but are not limited to:. iii. Provide appropriate, pressure-redistributing, support surfaces;. During a review of the facility's P&P titled, Support Surface Guidelines, last reviewed and approved on 1/12/2026, the P&P indicated that the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Guidelines for Selecting Appropriate Pressure-Relieving Devices Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. 3. During a review of Resident 53's admission record, the admission record indicated the facility admitted Resident 53 on 7/2/2026 for aftercare following lumbar spine fusion surgery (surgical procedure that permanently joins two or more vertebrae in lower back to eliminate painful motion), and with diagnoses of acute pulmonary edema (fluid collection around lung tissues), depression (persistent sad mood, feeling of hopelessness, loss of interest or pleasure), legal blindness (severe vision loss, not a medical diagnosis of total blindness), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), presence of right artificial knee joint. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 was cognitive function (brain's complex mental processes involved in gaining knowledge and comprehension) was severely impaired (problem with thinking and memory). The MDS indicated Resident 53 required maximal assistance (helper does more than half of the effort to complete the activity) with dressing, toileting, bathing, standing up or transferring to wheelchair. During a review of Resident 53's electronic health records, dated 7/14/2026, the electronic health records indicated Resident 53 weighed 164 lbs. During a review of Resident 53's Order Summary Report, dated 7/16/2026, the order summary report indicated, Pressure Redistribution Mattress - Low Air Loss every shift for Preventative measures. During a concurrent observation and interview on 7/13/2026 at 10:02 a.m., inside Resident 53's bedroom, Resident 53 was resting on a special air type of mattress, grab bars on both sides, and awake. Resident 53 stated she broke her back and had surgery done with screws in her back. Resident 53 stated it was not convenient for her to get up from the mattress. During a concurrent observation and interview on 7/15/2026 at 9 a.m., inside Resident 53's room, Resident 53 sat in a wheelchair. Resident 53 stated she slept bad last night and could not be comfortable. Resident 53 stated the mattress was sinking and showed with her hands to indicate concave or boat-shape, it was difficult to get up from the bed and Resident 53 stated I have to scoot myself to get to the edge of the bed. During a concurrent observation and interview on 7/15/2026 at 9:05 a.m. with the QAN, inside Resident 53's room, observed Resident 53's LALM was currently inflated (filled with air) and had soft (deflated, not filled with air) sections and firm (inflated) sections. A sticker on the LALM pump indicated 162. The setting of the LALM pump was set at 260 lbs. per indicator light on the panel. The QAN stated the setting of the pump was wrong and more on the firm side and the LALM pump should be set up for 170 lbs. The QAN stated the mattress setting should be set according to the resident's weight. The QAN stated the risks of not following the weight settings were pain and pressure injury to resident's skin. During a review of the facility provided LALM manufacturer's Operating, Maintenance and Trouble Shooting Guide (LALM Guide), undated, the LALM Guide indicated a comfort control per patient weight grid for indicator panel and Select patient comfort setting: Based on average patient weight. During a review of facility's P&P titled, Pressure Injury Prevention and Management, last reviewed and approved on 1/12/2026, the P& P indicated, Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions may include, but are not limited to provide appropriate, pressure-redistributing, support surfaces. During a review of facility's P&P titled, Support Surface Guidelines, last reviewed and approved on 1/12/2026, the P&P indicated, Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed.

Based on observation, interview, and record review, the facility failed to ensure residents' bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) prior to installation were assessed for its use for four of four sampled residents (Residents 54, 25, 26, and 42) reviewed for accidents by failing to ensure: 1. Resident 54's Bed Safety Assessment (BSA), dated 7/4/2026, was followed by not applying the bed rails on the resident as recommended. 2. Resident 25's BSA, date 7/2/2026, was completed. 3. Resident 26's BSA, dated 7/4/2026, was followed by not applying the bed rails on the resident as recommended. 4. Resident 42's BSA, dated 6/22/2026, was assessed for the right bed rails applied to the resident. The physician's order was to apply bilateral grab bars (short metal or plastic handles attached to the side of a bed to help residents safely pull themselves up, sit, or get out of bed), the facility assessed for the use of half (1/2) bed rail (is typically 28 to 36 inches long, placed near the head of the bed, and used to help people sit up, turn over, or get in and out safely rather than locking them in). These failures placed the residents at risk for potential accident such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails. Cross-reference F726. Findings: 1. During a review of Resident 54's admission Record (AR), the AR indicated the facility admitted the resident on 7/28/2021, and readmitted the resident on 7/4/2026, with diagnoses including muscle weakness, dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)/hemiparesis (paralysis or weakness of one side of body). During a review of Resident 54's History and Physical (H&P), dated 7/6/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 7/10/2026, the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a large loss of mental function that stops a person from living on their own). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 54's Order Summary Report (OSR), dated 7/6/2026, the OSR indicated an order for May have Bilateral Grab bar(s) up as an aid to bed mobility, turning and repositioning, and to assist with transfers. Every shift. During a review of Resident 54's Bed Safety Assessment (BSA), dated 7/4/2026, the BSA indicated based on interdisciplinary team (IDT - is a group of different healthcare workers-such as nurses, physical therapists, social workers, and dietitians-who team up with the resident and their family to build and manage a single, shared plan for the resident's care and recovery) and Physician consultation the bed rails were not recommended. During a review of Resident 54's Fall Risk Evaluation (FRE), dated 7/4/2026, the FRE indicated the resident was at risk for falls. During a review of Resident 54's Care Plan (CP) Report titled, Use of side rail as an enabling device that does not limit freedom of movement, initiated on 7/6/2026, the CP indicated a goal of the resident will be able to use side rail to aid in turning and repositioning within the bed through next review. During a concurrent observation and interview on 7/14/2026 at 10:13 a.m., with Certified Nursing Assistant (CNA) 2, inside Resident 54's room, observed Resident 54 had bilateral grab bars on. CNA 2 stated the resident had bilateral grab bars for mobility. During an interview and record review on 7/16/2026 at 8:40 a.m. with the Quality Assurance Nurse (QAN), Resident 54's Medical Diagnoses, OSR, BSA, FRE, CP, and the facility's policy and procedure (P&P) were reviewed. The QAN stated grab bars are bed rails. The QAN stated in their facility, before they apply a bed rail or grab bars for residents, they need a physician's order, informed consent, bed rail assessment for entrapment (when a person gets stuck, caught, or tangled in the gaps around a bed-most often between the mattress, the bed frame, and side rails), and a care plan on its use. The QAN stated the resident was at risk for falls and the BSA, dated 7/4/2026, indicated the IDT and the Physician was not recommending the use of the bed rail/grab bars. The QAN stated the staff still applied the grab bars. The QAN stated the failure of the staff to follow the BSA can potentially cause entrapment and isolation to Resident 54. The QAN stated the facility did not follow their P&P titled, Bed Rails- Safe Use Policy, and Bed Safety. During an interview on 7/17/2026 at 8:49 a.m. with the Director of Nursing (DON), in the presence of the QAN, the DON stated grab bars are an example of a bed rail. The DON stated the bed rails should have a proper assessment, and they should follow the process of applying a bed rail.2. During a review of Resident 25's AR, the AR indicated the facility admitted the resident on 7/1/2026, with diagnoses including hemiplegia and hemiparesis, and muscle weakness. During a review of Resident 25's H&P, dated 7/3/2026, the H&P indicated that the resident can make needs known but cannot make medical decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had moderate cognitive impairment (a clear decline in thinking and memory that noticeably affects daily life, meaning a person needs help with complex tasks like managing money, taking medicines, or keeping track of time). The MDS indicated the resident was dependent to needing substantial assistance on mobility and ADLs. During a review of Resident 25's OSR, dated 7/2/2026, the OSR indicated an order for May have Bilateral Grab bar(s) up as an aid to bed mobility, turning and repositioning, and to assist with transfers. Every shift. During a review of Resident 25's BSA, dated 7/2/2026, the BSA had an incomplete assessment and had no recommendation for bed rail use. During a review of Resident 25's CP Report titled, Use of bilateral grab bars as an enabling device that does not limit freedom of movement, last revised on 7/2/2026, the CP indicated intervention of serious injuries from fall when resident climb over bars. During a review of Resident 25's FRE, dated 7/2/2026, the FRE did not indicate the resident was at risk falls. The FRE was not completed, the Gait/Balance, Medications, and Clinical Suggestions was not filled out. During a concurrent observation and interview on 7/14/2026, at 11 a.m., with Registered Nurse (RN) 2, inside Resident 25's room, observed Resident 25's bed had bilateral upper grab bars on. RN 1 stated the grab bars were for safety and mobility. During a concurrent interview and record review on 7/16/2026 at 10:14 a.m. with the QAN, Resident 25's Medical Diagnoses, OSR, BSA, FRE, CP, and the facility's P&P were reviewed. The QAN stated the grab bars are bed rails. The QAN stated in their facility, before they apply a bed rail or grab bars to residents, they need a physician's order, informed consent, bed rail assessment for entrapment, and a care plan on its use. The QAN stated the resident had moderate risk for falls however, the FRE was not completed on 7/2/2026. The QAN stated the failure of the staff to complete the BSA can potentially cause entrapment and isolation to Resident 25. The QAN stated the facility did not follow their P&P titled, Bed Rails- Safe Use Policy, and Bed Safety. During an interview on 7/17/2026, at 8:49 a.m. with the DON, in the presence of the QAN, the DON stated grab bars are an example of a bed rail. The DON stated the bed rails should have a complete assessment and they should follow the process of applying a bed rail. 3. During a review of Resident 26's AR, the AR indicated the facility admitted the resident on 6/19/2026, with diagnoses including reduced mobility, muscle weakness, and altered mental status. During a review of Resident 26's H&P, dated 6/22/2026, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 26's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was needing substantial to set up assistance on mobility and ADLs. During a review of Resident 26's OSR, dated 6/26/2026, the OSR indicated an order for May have bilateral grab bars up as an aid to bed mobility, turning and repositioning, and to assist with transfers. Every shift. During a review of Resident 26's BSA, dated 6/19/2026, the BSA indicated the grab bars were not recommended by the IDT and Physician. During a review of Resident 26's FRE, dated 6/19/2026, the FRE indicated the resident was at risk for falls. During a concurrent observation and interview on 7/13/2026 at 9:52 a.m with RN 2, inside Resident 26 room, observed the resident was sleeping in bed with bilateral grab bars on. RN 2 stated the grab bars were for mobility. During a concurrent observation and interview on 7/14/2026 at 10:14 a.m. with RN 3, inside Resident 26's room, observed Resident 26's bed with bilateral upper grab bars on. RN 3 stated the grab bars were for mobility. During a concurrent interview and record review on 7/16/2026 at 10:41 a.m. with the QAN, Resident 26's Medical Diagnoses, OSR, BSA, FRE, and the facility's P&P were reviewed. The QAN stated the grab bars are bed rails. The QAN stated in their facility before they apply a bed rail or grab bars to residents they need a physician's order, informed consent, bed rail assessment for entrapment, and a care plan on its use. The QAN stated the resident was at risk for falls and the BSA, dated 6/19/2026, indicated the IDT and the Physician was not recommending the use of the bed rail/grab bars. The QAN stated the staff still applied the grab bars. The QAN stated the failure of the staff to follow the BSA can potentially cause entrapment and isolation to Resident 26. The QAN stated the facility did not follow their P&P titled, Bed Rails- Safe Use Policy, and Bed Safety. During an interview on 7/17/2026 at 8:49 a.m. with the DON, in the presence of the QAN, the DON stated grab bars are an example of a bed rail. The DON stated the bed rails should have proper assessment and they should follow the process of applying a bed rail. 4. During a review of Resident 42's AR, the AR indicated the facility admitted the resident on 6/22/2026, with diagnoses including muscle weakness, history of falling, and hemiplegia/hemiparesis. During a review of Resident 42's H&P, dated 6/24/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. The MDS indicated the resident was dependent to needing supervision on mobility and ADLs. The MDS indicated the resident had fallen in the past month. During a review of Resident 42's OSR, dated 6/23/2026, the OSR indicated an order for May have Bilateral Grab bar(s) up as an aid to bed mobility, turning and repositioning, and to assist with transfers. Every shift. During a review of Resident 42's BSA, dated 6/22/2026, the BSA indicated an assessment for 1/2 rails (approximately 30 1/2 inches long). During a review of Resident 42's FRE, dated 6/22/2026, the FRE indicated the resident was at risk for falls. During a review of Resident 42's CP Report titled, Use of Bilateral grab bars as an enabling device that does not limit freedom of movement, last revised on 6/24/2026, the CP indicated an intervention serious injury from fall when resident climb over bars. During an observation on 7/13/2026 at 9:13 a.m., observed Resident 42 in bed with bilateral grab bars on. During a concurrent interview and record review on 7/16/2026 at 11:59 a.m. with the QAN, Resident 42's Medical Diagnoses, OSR, BSA, FRE, CP, and the facility's P&P were reviewed. The QAN stated the grab bars are bed rails. The QAN stated the BSA was for a 1/2 bed rail and the physician's order was for grab bars. The QAN stated the staff did assess for the incorrect bedrail which was for 1/2 bedrail. The QAN stated the failure of the licensed staff to perform the correct assessment for the bed rail applied had the potential for injury and entrapment on Resident 42. The QAN stated the facility did not follow the P&P titled, Bed Rails- Safe Use Policy, and Bed Safety. During an interview on 7/17/2026 at 8:49 a.m. with the DON, in the presence of the QAN, the DON stated grab bars are an example of a bed rail. The DON stated the licensed staff should have assessed for grab bars as it was the physician's order not the 1/2 bed rails. The DON stated the bed rails applied should have proper assessment and they should follow the process of applying a bed rail. During a review of the facility's recent P&P titled, Bed Rails- Safe Use Policy, last reviewed on 1/12/2026, the P&P indicated to facilitate safe and appropriate bed rail use, in compliance with regulatory requirements, while prioritizing the rights, dignity, safety, and individualized care needs of the resident, P&P not followed. General Guidelines 2. When bed rail use is desired/considered, Resident's sleeping environment shall be assessed by the Interdisciplinary team, considering safety needs, entrapment risks, medical conditions/symptoms, cognitive/behavioral status, functional needs, comfort, freedom of movement, and input from the resident and family regarding previous sleeping habits and bed environment. 5. When bed rails are indicated for use, physician will be consulted to establish concurrence/orders. 6. Informed consent for using bed rails shall be obtained from the resident or legal representative. 8. Facility shall assess spaces for unsafe gaps between mattress and bed rails and bed system components to reduce entrapment risk in consideration of resident's size, weight, and behavioral patterns. 10. Bed rail use and safety supervisions shall be included in resident's care plan. 11. Use shall be reassessed periodically for ongoing indications and safety. During a review of the facility's recent P&P titled, Bed Safety, last reviewed on 1/12/2026, the P&P indicated our facility shall strive to provide a safe environment for the resident. Policy Interpretation and Implementation 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position.); e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 7. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. During a review of the facility-provided User Service Manual Grab Bar (GB) 1, undated, the User Service Manual indicated a Warning: Risk of serious injury or death. Do not use this assist device until you have verified that it is locked in place. Injury to resident or caregiver may result if this procedure is not followed. Warning: An optimal bed system assessment should be conducted on each resident by a qualified technician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, an in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration.

Based on interview and record review, the facility failed to ensure the facility had sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure: 1. The facility provided documented evidence of the Director of Nursing's (DON's) annual skills competency checklist (yearly evaluation used to verify that employees maintain the specific technical, clinical, or professional proficiencies required for their roles). An unsigned document regarding the DON's annual skills checklist was provided to the State Survey Agency on 7/17/2026 at 5:37 p.m. after the State Survey Agency completed the facility's annual recertification survey and had exited the facility. 2. The facility was able to provide documented evidence on the skills competencies of Registered Nurse (RN) 2 and Licensed Vocational Nurse (LVN) 1 when the DON was only able to provide their (RN 2 and LVN 1) Annual Skills Assessments addressing medication administration and not addressing other competencies. 3. The DON was able to demonstrate appropriate competencies and skill sets by failing to recognize potential negative effects of licensed staff failing to provide evidenced-based nursing process/procedures (making patient care decisions using the best scientific research, a nurse's real-world experience, and the patient's personal needs and choices) on residents in the facility. These failures had the potential for provision of substandard nursing care leading to harm on residents. Cross-reference F550, F604, F605, F656, F686, F689, F700, and F760. Findings: 1. During an interview on 7/17/2026, at 3:07 p.m., with the DON, during Sufficient and Competent Nurse Staffing Facility Task, the DON stated the facility's Registered Nurse Clinical Consultant (R.N. CC - a healthcare professional who provides expert advice) was responsible for verifying his (DON) annual skill competency check. The DON stated the documented evidence of his (DON) annual skills competency check was with the R.N. CC, who had left the facility for personal reasons. The DON stated he (DON) did not know where the R.N. CC kept his (DON) annual skills competency check. During an interview on 7/17/2026 at 5:01 p.m. with the DON, the DON stated he (DON) could not provide documented evidence of his annual skills competency check. The DON stated that him (DON) or DON's designee (a person authorized to perform specific duties, make decisions, or act on behalf of another individual) were responsible for the verification and assessment of the annual skills competency checks for the facility's licensed staff. The DON stated failure to have his (DON) competencies assessed could potentially lead to failure of identifying problems in the competencies of the facility's licensed staff, which could negatively affect residents' care. During a review of the unsigned document regarding the DON's Annual Skills Checklist (provided on 7/17/2026 at 5:37 p.m., after the State Survey Agency had completed the facility's annual recertification survey and had exited the facility), dated 3/19/2026, the first page of the Annual Skills Checklist indicated the facility's name, the date of the evaluation, and the name and title of the employee (DON). The Annual Skills Checklist contained a table with four columns indicating the topic assessed, the employee's initials, the evaluator's initials, and the date of the assessment. Only the first column of the table on each page of the Annual Skills Checklist indicated the initials of the employee, the evaluator, and the date of the assessment with the rest of the rows marked with lines (did not indicate what the lines meant). The end of each page of the Annual Skills Checklist indicated, upon completion, to place the form in the employee's personal file. The Annual Skills Checklist indicated that the evaluator of the assessment was the R.N. CC. The section of the Annual Skills Checklist for the evaluator's signature contained evaluator's printed name but was not signed by the evaluator. 2. During a concurrent interview and employee file review on 7/17/2026 at 1:57p.m. with the DON, RN 2's and LVN 1's employee files were reviewed. The DON stated the only Annual Skills Assessment he (DON) could provide for RN 2 and LVN 1 was addressing medication administration. The DON stated he (DON) would check the Director of Staff Development's (DSD's) office for annual skills checklist addressing other competencies but was not able to provide documented evidence on RN 2 and LVN 1's skills checklist on other competencies other than medication administration. During an interview on 7/17/2026 at 2:26 p.m. with the DON, the DON stated that the DON or the assigned designee, were responsible for monitoring for the compliance of the annual skills check completion of the facility staff. The DON stated he (DON) could not find the annual skills assessment of RN 2 and LVN 1 in the skills checklist binder. The DON stated he would need to check several binders in the DSD's office and in other parts of the facility to attempt to find the requested annual skills assessments for RN 2 and LVN 1. 3. During an interview on 7/17/2026 at 8:49 a.m. with the DON in the presence of the Quality Assurance Nurse (QAN), while presenting initial findings for the Recertification Survey (an unannounced, periodic health and safety inspection), the DON stated the low air loss mattress (LALM, a medical bed system that uses a continuous, gentle flow of air escaping through tiny microscopic holes to keep skin cool, dry, and free of pressure sores [are areas of damaged skin caused by staying in one position for too long]) was not set according to the manufacturer's specification to set the LALM according to the resident's weight had no effect on the resident's skin integrity. The DON was insisting the LALM was tampered per his interview with the family members (cross-reference F686). The DON stated he does not want to answer the potential effects of not setting the LALM according to the resident's weight as it is a hypothetical question. The DON was presented with certain residents with psychotropic medication (any prescription drug that changes how a person thinks, feels, acts, or perceives the world) with informed consents that were signed as verified by licensed nurses with no reason for use, the DON stated it was a physician issue. The DON stated there was no potential issue with the signed consent not having a reason for psychotropic medication use (cross-reference F605). The DON also refused to answer the issue regarding insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites not being rotated (a method to ensure repeated injections are not administered in the same area) per physician's order, manufacturer's specification and professional practice if it was considered a medication error (cross-reference F760). The DON also cannot foresee the potential harm of placing a side table on top of the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) when they are trying to prevent an injury to a resident who was high risk for falls (cross-reference F689). The DON also cannot understand why placing a resident on a LALM with bolster (a padded roll, cushion, or specialized raised-edge mattress placed alongside a resident that traps them or blocks their movement, preventing them from getting out of bed or a chair on their own), together with the tab/pad alarm (a safety device featuring pressure pads, pull cords, or motion sensors designed to alert caregivers when a person attempts to get out of bed unassisted) in bed, and a bedrail (a metal or plastic bar attached to the side of a bed that helps residents move around, supports getting in and out of bed, and acts as a barrier to stop falls) constitutes as a restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body) to prevent the resident from getting out of bed to prevent further falls in the facility, the DON insisted the LALM with bolster does not need a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment (a careful check by a care team to see if a resident needs a device that limits movement, like a lap belt or bed rail, and whether it is legally allowed and safe), and a care plan (an individualized, written document created by healthcare professionals and the resident) (cross-reference F604). The DON also initially stated that grab bars (are sturdy, securely anchored safety handles designed to support a person's full body weight, prevent slips and falls, and help residents stand up or sit down safely) were not bed rails (cross-reference F700). During an interview on 7/17/2026 at 9:08 a.m. with the DON, in the presence of the Administrator, the DON stated that the staff sits down while assisting the resident with meals. When asked what the reason for staff to sit down while assisting the resident with meals, the DON stated, there is no federal regulation that the staff needs to sit down while assisting with feeding. When asked what the reason for staff to be at eye level while assisting with resident with meals, the DON stated, there is no federal regulation that the staff needs to sit down while assisting with feeding. When asked what potentially could happen to the residents when staff are standing over while assisting them with their meals, the DON stated there is no potential because nothing happened to the resident. The DON stated he does not answer hypothetically questions. When asked if he sees an issue when staff are standing over the residents while assisting with feeding, the DON stated that he does not see an issue (cross-reference F550). During a concurrent interview and record review on 7/17/2026 at 4:40 p.m. with the DON, in the presence of the QAN, the facility's policy and procedure (P&P) titled Continuous Glucose Monitoring (CGM, a wearable medical device that measures blood sugar levels in real-time via subcutaneous sensor) sensor (needle probe inserted into the skin and transmits signal to a reader machine), dated May 2026, was reviewed. The DON stated we are not responsible for changing of the needle, it is family's responsibility, we do not use it in the facility for any glucose reading, and we do not replace the implantable sensor needle. Our staff can monitor skin changes. The DON could not answer the question whether a care plan for the sensor needle change should be developed and implemented. The DON did not know if the CGM sensor needle was a self-administered device and the DON stated he had to check on that. The P&P indicated, Replace sensors in accordance with manufacturer's recommendations or per physician's order; incorporate CGM use, monitoring parameters, and response protocols in the plan of care. The DON stated the risk of having the implantable device in the skin was infection (cross-reference F656). During a review of Director of Nursing Services Job Description, copyright 2003, the job description indicated the primary purpose of your job description is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Personnel Functions -Assist the HR Director in developing performance evaluation schedules, criteria, and annual reviews for the nursing service department (e.g., RNs, LPNs, CNAs, medication aides, etc.) Staff Development -Assist the In-service Director/Educator in developing annual facility in-service training programs (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.) Specific Requirements -Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. -Must be knowledgeable of nursing and medical practices and procedures as well as laws, regulations, and guidelines that pertain to nursing care facilities. -Must not pose a direct threat to the health and safety of other individuals in the workplace. During a review of the facility's recent P&P titled, Competency of Nursing Staff, last reviewed on 1/12/2026, the P&P indicated, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. Policy Interpretation and Implementation 5. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of five sampled resident (Residents 2 and 30) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. These failures had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F726. Findings: 1. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted the resident on 4/21/2026, and readmitted the resident on 6/3/2026, with a diagnosis of type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's History and Physical (H&P), dated 6/5/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/6/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a distinct middle ground where a person has noticeable trouble with thinking and memory that begins to disrupt independent daily life, requiring regular help with complex tasks). The MDS indicated that the resident was on a high-risk drug class hypoglycemic medication (a prescription drug used to lower high blood sugar levels, commonly prescribed for people with Type 2 diabetes). During a review of Resident 2's Order Summary Report (OSR), dated 6/4/2026, the OSR indicated an order for Humalog KwikPen Subcutaneous Solution Pen injector 100 units per milliliter (unit/ml, how strong the insulin is) (Insulin Lispro) Inject as per sliding scale (a personalized chart used to decide how much fast-acting insulin to inject based on your current blood sugar level right before a meal or at bedtime): if 71 - 150 = 0; 151 - 200 = 1; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 6; 401-999 = 8, subcutaneously every 6 hours for DM2 call MD if Blood sugar is less than (<) 70 or greater than (>) 400. Rotate sites. During a review of Resident 2's Location of Administration Report (LAR) for 5/2026 to present, the LAR indicated insulin was subcutaneously administered on: Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml 5/18/2026 at 12:45 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 5/19/2026 at 12:35 p.m. on the Abdomen - LLQ 6/21/2026 at 1:26 p.m. on the Abdomen - LLQ 6/22/2026 at 12:13 p.m. on the Abdomen - LLQ 6/27/2026 at 5:48 a.m. on the Arm - Upper arm (rear) (left) 6/28/2026 at 6:36 a.m. on the Arm - Upper arm (rear) (left) During a review of Resident 2's Care Plan (CP) Report titled, At risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes, last revised on 6/10/2026, the CP indicated an intervention to administer prescribed insulin as ordered. During a concurrent interview and record review on 7/16/2026 at 9:18 a.m. with the Quality Assurance Nurse (QAN), Resident 2's Medical Diagnosis, OSR, LAR, CP, and the facility's policy and procedure (P&P) were reviewed. The QAN stated there was an order to rotate sites of administration on the insulin order of the resident. The QAN stated to rotate means not repeating the same site it was given, example if at 6 a.m. the licensed nurse gave the insulin at the Right Upper Quadrant (RUQ) of the abdomen, at 12 noon they will give the insulin on a different site like Right Lower Quadrant (RLQ), right arm (RA), left arm (LA), Left Upper Quadrant of the abdomen (LUQ) etc. The QAN stated the facility was rotating sites of insulin administration to prevent lipodystrophy on residents. The QAN stated the staff did not follow the physician's order to rotate sites of administration, the facility's P&P, and the Manufacturer's Specification on the use of Humalog. The QAN added as a professional nurse they should be rotating insulin administration sites. The QAN stated not rotating insulin administration sites was considered a medication error. During an interview on 7/17/2026 at 12:11 p.m. with the Director of Nursing (DON) in the presence of the QAN, the DON stated the licensed staff should follow the physician's order to rotate the sites of insulin administration on Resident 2. The DON stated they did not follow the physician's order to rotate sites of administration. The DON stated the failure of the licensed staff had the potential to cause lipodystrophy on Resident 2. 2. During a review of Resident 30's AR, the AR indicated the facility admitted the resident on 5/4/2026, with a diagnosis of type 2 diabetes mellitus. During a review of Resident 30's H&P, dated 5/6/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a major loss of brain function that completely strips a person's ability to live, think, or care for themselves independently). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 30's OSR, dated 5/5/2026, the OSR indicated an order for Humalog KwikPen Subcutaneous Solution Pen injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 6 units, subcutaneously every 6 hours for DM call MD if BS < 70 or > 400. Rotate sites. During a review of Resident 30's Location of Administration Report (LAR) for 5/2026 to present, the LAR indicated insulin was subcutaneously administered on: Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml 5/6/2026 at 6:18 a.m. on the Arm - right 5/6/2026 at 12:45 p.m. on the Arm - right 5/14/2026 at 5:47 a.m. on the Arm - left 5/14/2026 at 11:57 a.m. on the Arm - left 5/28/2026 at 6:27 a.m. on the Abdomen - Left Upper Quadrant (LUQ) 5/29/2026 at 6:11 a.m. on the Abdomen - LUQ 6/29/2026 at 5:41 a.m. on the Arm - left 6/30/2026 at 7:20 p.m. on the Arm - left During a review of Resident 30's Care Plan (CP) Report titled, At risk for hypoglycemia and hyperglycemia related to diabetes, last revised on 5/5/2026, the CP indicated an intervention to administer prescribed insulin as ordered. During a concurrent interview and record review on 7/16/2026, at 10:56 a.m., with the QAN, reviewed Resident 30's Medical Diagnosis, OSR, LAR, CP, and P&P. The QAN stated there was an order to rotate sites of administration on the insulin order of the resident. The QAN stated to rotate means not repeating the same site it was given, example if at 6 a.m. the licensed nurse gave the insulin at the RUQ of the abdomen, at 12 noon they will give the insulin on a different site like RLQ, RA, LA, LUQ, etc. The QAN stated the facility was rotating sites of insulin administration to prevent lipodystrophy on residents. The QAN stated the staff did not follow the physician's order to rotate sites of administration, the facility's P&P, and the Manufacturer's Specification on the use of Humalog. The QAN added as a professional nurse they should be rotating insulin administration sites. The QAN stated not rotating insulin administration sites was considered a medication error. During an interview on 7/17/2026 at 12:11 p.m. with the DON in the presence of the QAN, the DON stated the licensed staff should follow the physician's order to rotate the sites of insulin administration on Resident 30. The DON stated they did not follow the physician's order to rotate sites of administration. The DON stated the failure of the licensed staff had the potential to cause lipodystrophy on Resident 30. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 1/12/2026, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection site. b. Injection sites should be rotated, preferably within the same area general area (abdomen, thigh, upper arm). During a review of the facility's recent P&P titled, Adverse Consequences and Medication Errors, last reviewed on 1/12/2026, the P&P indicated the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Policy Interpretation and Implementation 3. An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug and is different from the therapeutic and helpful effects of the drug. An ADR is any noxious and unintended response to a drug and occurs in doses for prophylaxis, diagnosis or therapy. 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specification, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility-provided KwikPen U-100 Instructions for Use Humalog KwikPen (insulin lispro) injection, for subcutaneous use, 3 ml single patient use pen (100 units per mL), copyright 2007, the Instructions indicated on Giving your injection, indicated to change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

Based on observation, interview, and record review, the facility failed to: 1. Follow the recipe for serving egg rolls by not serving the egg rolls at or above 140 degrees Fahrenheit (F, a unit of measure for temperature) for 21 out of 35 residents listed in the diet list. 2. Provide a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, or increase specific nutrients in the diet, or to provide food the resident is able to eat) menu and food for a liberal renal diet (a diet designed to reduce the buildup of waste products in blood to protect kidneys) during lunch for one of one sampled resident (Resident 14). These failures had the potential for residents to not meet their nutritional needs, to complain about the food temperature and palatability affecting the residents' appetite to eat the food served in the facility. Findings: 1. During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted the resident on 7/2/2026, with diagnoses including pressure-induced deep tissue damage/injury (DTI, a serious type of pressure sore that starts as: a purple or dark red area on the skin, a blood-filled blister, or damage happening deep inside the muscle near a bone) of the sacral region (the lower part of the back located just above the buttocks and right between the hip bones, featuring a large, triangular bone that connects the spine to the pelvis) and gastro-esophageal reflux disease (GERD, a chronic digestive condition where stomach acid frequently flows backward into the esophagus (the tube connecting your mouth and stomach). During a review of Resident 55's History and Physical (H&P), dated 7/3/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool), dated 7/5/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a clear and noticeable decline in thinking skills, memory, and judgment that begins to disrupt daily independence). The MDS indicated the resident was on a therapeutic diet (a special meal plan prescribed by a doctor or planned by an expert to help treat, manage, or prevent a medical condition). During a review of Resident 55's Order Summary Report (OSR), dated 7/4/2026, the OSR indicated a diet order of NAS (No Added Salt) diet Regular texture, Thin Liquids consistency. During a review of Resident 55's Care Plan (CP) Report regarding the resident being at risk for impaired nutritional status and hydration status., last revised on 7/3/2026, the CP indicated an intervention to determine food likes and dislikes. During a review of the facility's Select Menu- Spring/Summer 2026, Regular/No Added Salt, indicated for Monday July-13 Lunch, the residents will receive soup of the day, seared tuna salad, alt. Carolina BBQ Pulled pork on a pita, mini egg roll, Alt. white bean, artichoke & caper salad, wheat dinner roll, margarine, butterscotch pudding, and 2% milk. During a review of the facility's Quantified Recipe (QR), dated 4/29/2026, the QR for egg roll mini 0034233 to hold and serve hot food at or above 140 degrees F. During an interview on 7/13/2026 at 9:16 a.m. with Resident 55, Resident 55 stated her only complaint about the facility is the food. Resident 55 stated her breakfast today came with her blintzes cold and was served acidic foods. During a concurrent observation and interview on 7/14/2026 at 11:37 a.m. with Dietary Aide (DA) 1, inside the Tray Line Room, observed DA 1 measuring hot food temperatures being served for lunch that day. DA 1 stated hot food should be served 141 degrees F and above. DA 1 measured the following hot foods: rice - 165 degrees F; puree vegetables - 150 degrees F, puree soup - 150 degrees F; regular soup 165 degrees F, sandwich alternative- nobody ordered, so it was not reheated, and eggrolls - room temperature. DA 1 stated she will verify with cook what temperature should the eggrolls be served. DA 1 stated [NAME] 1 told her to serve the eggrolls on room temperature. During a concurrent interview and record review on 7/14/2026 at 12:09 p.m. with the Certified Dietary Manager (CDM), the facility's QR for egg rolls mini was reviewed. The CDM stated the QR for egg rolls mini indicated to serve the food at or above 140 degrees F. During a concurrent interview and record review on 7/16/2026 at 8:02 a.m. with the CDM, the facility's QR and policy and procedure (P&P) were reviewed. The CDM stated DA 1 should have served the egg rolls at 140 degrees F per the QR. The CDM stated the purpose of the QR is to ensure residents receives proper nutrition and to make sure the food is meeting the temperature and safe for consumption. The CDM stated the importance of serving the food according to the temperature indicated in the QR is to meet the resident's liking for palatability. The CDM stated they did not follow the recipe/QR because they did not serve the egg rolls at or above 140 degrees. The CDM stated they did not follow the P&P titled, Standardized Recipes. During a review of the facility's recent P&P titled, Standardized Recipes, last reviewed on 1/12/2026, the P&P indicated standardized recipes shall be developed and used in the preparation of foods. 2. During a review of Resident 14's admission Record, the admission record indicated the facility admitted Resident 14 on 5/19/2026 for aftercare following cerebral infarction due to thrombosis (condition of brain tissue damage due to blood vessels blocked by a blood clot), type two (2) diabetes mellitus with chronic kidney disease (DM 2, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure, requiring artificial filtration of blood), dependence on renal dialysis (also known as hemodialysis [HD], a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), presence of other vascular implants and grafts (a surgically placed flexible tube into a large vein used for hemodialysis), cognitive communication deficit (an impaired ability to speak, listen, read, or write caused by disrupted thinking skills such as attention, memory, and executive function). During a review of the MDS, dated [DATE], the MDS indicated Resident 14's cognitive function (brain's complex mental processes involved in gaining knowledge and comprehension) had moderate cognitive impairment (moderate problems with thinking and memory). The MDS indicated Resident 14 is dependent on staff or requires maximal assistance (helper does more than half of the effort) with bed mobility, dressing, and dependent on standing, toileting, showering, transferring to wheelchair. During a concurrent observation and interview on 7/13/2026 at 10:45 a.m., in Resident 14's room, with Resident 14, Resident 14 was awake, sitting at the edge of the bed. Resident 14 stated food at the facility was awful, they give turkey and tuna sandwiches for each meal, often soggy, that's my lunch, sometimes no mayonnaise on bread, just tuna. During a concurrent observation and interview on 7/14/2026 at 12:16 p.m., in dining room, with Resident 14, Resident 14 stated she was served a hot dog type of sandwich with peppers and onion, the other residents were served chicken with pasta. Resident 14 asked the staff, Why can't I have chicken? Observed a nurse explain to Resident 14 that the pasta with chicken had cheese, and, because of Resident 14's diet, the kitchen served the sandwich to Resident 14. Certified Dietary Manager (CDM) came and offered to change Resident 14's food to pasta with chicken. Resident 14 agreed. Resident 14 further stated, I filled out their menu five times and told them what I like and not like, and they kept telling me what foods I cannot have, but that does not help me, I need to have options of what I can have. Observed current food on Resident 14's tray: hoagie with sausage, onion and red bell peppers, chicken noodle soup, salad, cranberry juice, apple sauce and piece of cake. Resident 14's tray ticket for 7/14/2026 lunch indicated diet order: Regular (RG 7 texture), Consistent Carbohydrate (CCHO, diet for persons with diabetes), Liberal Renal, Thin Liquids, fluid restriction 12 fluid ounces (oz, unit of measurement of liquid volume), (1500 milliliters [mL, metric unit measurements of liquid volume] per day), standing orders: applesauce 4 oz, sugar-free (SF) beverage, 4 oz, 8 oz water. No dislikes indicated. During a concurrent interview and record review on 7/14/2026 at 12:25 p.m. with Certified Dietary Manager (CDM), regular diet menu dated 7/14/2026 was reviewed. CDM stated Resident 14 was on renal diet and could not have cheese. CDM stated CDM offered Resident 14 an alternative with grilled chicken and pasta. CDM was not aware whether Resident 14 received the list of food items Resident 14 can eat at the facility. CDM stated regular diet menu for lunch indicated; Creamy Chicken Alfredo, (Alternative - Italian Sausage on a hoagie roll), Soup of the day, Arugula salad (alternative - artichoke and tomato salad), Garlic Bread, Lemon Cake with Lemon Icing, and 2% milk. During a concurrent observation and interview on 7/14/2026 at 1 p.m., in dining room, with Resident 14, Resident 14 sat at the table, eating lunch. Resident 14 stated she was served cooked pasta without sauce or cheese, and deep-fried chicken, with dipping sauce on the side. During a concurrent interview and record review on 7/16/2026 at 8:16 a.m. with the Registered Dietician (RD), Resident 14's Nutritional Risk Assessment, dated 5/25/2026, was reviewed. The nutritional risk assessment indicated Current diet order - Liberal Renal CCHO diet Soft and Bite-sized texture, Thin Liquids consistency. Describe food preferences (religious/cultural/ethnic foods), include family/ RD impact - noted by dietary. Poor dentition and chewing problems noted. Husband also requested glanced menu and list of food allowed for residents. Dietary made aware and will provide list. Husband grateful for the information provided and care given to resident. The RD stated residents had regular diet menus to look at, but Resident 14 would get therapeutic diet food replacing certain food items according to the therapeutic diet spreadsheet (a table with all menu items available at the facility's kitchen). The residents are not provided with a separate therapeutic diet menu listing the foods the residents can choose from. The kitchen should provide alternative menu, for example, if she dislikes chicken and rice, then she can have a sandwich. During a concurrent interview and record review on 7/16/2026 at 9:05 a.m. with DA 2, the Diet Spread Sheet, dated 7/14/2026, was reviewed. DA 2 stated she served lunch on 7/14/2026 to Resident 14. DA 2 stated she served initially Italian Sausage hoagie with peppers and onions, which was the alternative menu item to creamy chicken vegetable alfredo pasta on the regular diet menu. DA 2 stated DA 2 should have served pork loin sandwich, an alternative according to the liberal renal diet, and Resident 14 was not offered the alternative. DA 2 stated if residents don't like the food they are served, dietary aides change the food items for something residents prefer. During a concurrent interview and record review on 7/16/2026 at 9:42 a.m. with the CDM, the Regular diet menu and Diet Spreadsheet, both dated 7/14/2026, were reviewed. The CDM stated, the CDM assessed Resident 14 upon admission, assessed food choices and allergies, informed Resident 14 about prescribed diet, and any food dislikes. The CDM stated food alternatives on 7/14/2026 lunch menu for liberal renal diet were chicken with noodles, or pork loin sandwich. The CDM stated Resident 14 received Italian Sausage hoagie with peppers and onions, which was an alternative to creamy chicken alfredo on the regular diet menu. The CDM stated residents choose and decide what foods to be served to them. The CDM stated a regular diet menu was given to the residents each week and residents can circle the food items they would like to get and give back to the kitchen. The CDM stated that Resident 14 was never provided the menu with circled food items to the kitchen staff. The CDM stated residents do not receive therapeutic diet menu to choose from. The CDM stated the importance of following the preferences in diet is for residents to get enough nutrients, to get good oral intake, get better and it is their right. The CDM stated no more dietary assessments notes were done afterwards admission because no changes in Resident 14's oral intake, weight or complaints were reported to the CDM. During a concurrent interview and record review on 7/17/2026 at 10:33 a.m. with Resident 14, a hard copy of regular diet menu (menu), dated 6/28/2026, present in Resident 14's room, the menu indicated handwritten comments about food preferences. Resident 14 stated her husband filled it out on week of June 28 with preferences' comments and gave it to the kitchen staff, Resident 14 stated and emphasized she had filled out the menu and provided it to the kitchen staff five times. Resident 14 stated the other week resident 14 filled out the menu and gave it to the activity personnel, who took it to the kitchen. Resident 14 stated she didn't receive the liberal renal diet menu to choose foods from. During an interview on 7/17/2026 at 4:56 p.m. with the Director of Nursing (DON), the DON stated nurses and dietary staff need to make sure the staff serves residents appropriate foods per diet order. During a review of facility's P&P titled, Food Preferences – Honoring, dated 6/2026, the P&P indicated, Diet modifications and therapeutic diets will be implemented with resident's/representative's informed consent, as appropriate. Residents have the right to make informed choices regarding food and nutrition, including the right to decline recommended dietary restrictions or therapeutic diets after receiving education regarding potential risks and benefits.

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, on 7/13/2026 during kitchen tour found/observed the following: SEASONINGS -1 container of Granulated Garlic with open date of 7/1/2021, no received date, and no use by date. -1 big container of garlic powder with received date of 4/6, with use by date of 10/17/26, with no open date. -1 container of steak seasoning with use by date of 10/17/2026, no open date, and received date. -1 container of parsley flakes, no received date, no open date, and no use by date. -1 container of ground cummin seed with use by date of 10/17/26, no open date, and no received date. -1 container Ginger ground with received date of 11/25, with use by date of 5/21/26, no open date. -1 container of Jamaican jerk seasoning, with open date of 6/26, no use by date, and no received date. -1 container of Curry powder, with use by date of 10/17/26, no open date, and no received date. -1 container of Whole rosemary leaves with date received 5/26 no open date, and use by date. -1 container of Gumbo File with open date of 1/12/26, no use by date, and no received date. -1 container of Ground Bay leaves with open date 4/1/25, use by date of 4/2026, and no received date. -1 container of Ground nutmeg with use by date of 5/6/26, no open date, no received date. -1 container of Lemon pepper seasoning with date received 6/9, no open date, no use by date. -1 container of ground cummin seeds with received date of 4/6, no open date, no use by date. -1 container Spanish paprika, no open date, no received date, no use by date. -1 container of Ground cinnamon, received date of 4/6, with unreadable scribbling on the label. -1 container of Ground cinnamon with open date of 7/9/26, received date of 7/7, no use by date. -1 container of Dill weed, received date of 4/6, no open date, no use by date. DELI -2 packs of Deli hot dog buns with use by date of 7/9, no open date, no received date. - 1 pack of Sliced bread with date received 12/3, no open date, no use by date. -1 pack of Bagels no date open, no received date, and no use by date. -1 pack of English Muffin with use by date of 7/10, no received date, no open date. -1 pack of Sliced bread with use by date of 7/9, no received date, no open date. -1 pack of Sliced bread with received date of 12/3, with no open date and use by date. - 1 pack of opened English Muffin, without open date, with use by date of 7/10, no received date. -1 pack of Swirl bread with use by date of 7/9, no received date, no open date. -1 pack of open sliced bread with received date of 12/3, no open date, no use by date. Walk in Refrigerator -a tub of chopped garlic in oil, no open date, use by date, and no received date. - one 100% key lime juice, no expiration date, no open date, and no received date. -1 bottle of Kewpie mayonnaise with use by date of 6/27/26, no open date, and no received date. - 1 chef's celery with use by date of 7/11, no received date, no open date. - chopped salad in a pan with use by date of 7/11/2026. -lettuce heads in a plastic bag with use by date of 7/12/26, no received date. -a pan of chopped tomato with use by date of 7/12/26. -1 bag of parsley dated 6/29/26 with yellowing leaves. -1 bag of arugula no received date. -another bag of arugula no received date. -green onions with no received date. - green bell peppers with a cucumber with mold. - 1 bag of carrots no received date. - heads of lettuce without received date. -cantaloupes and honey dew without received dates. Dry Pantry -1 bag of Buttermilk Pancake with use by date of 7/10, no open date, no received date. -1 bag of opened powdered mash potato with received date of 6/18, no open date and use by date. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals). Findings: During a observation on 7/13/2026, at 7:50 a.m., with [NAME] 1 and the Certified Dietary Manager (CDM) observed the food items in the kitchen: SEASONINGS -1 container of Granulated Garlic with open date of 7/1/2021, no received date, and no use by date. -1 big container of garlic powder with received date of 4/6, with use by date of 10/17/26, with no open date. -1 container of steak seasoning with use by date of 10/17/2026, no open date, and received date. -1 container of parsley flakes, no received date, no open date, and no use by date. -1 container of ground cummin seed with use by date of 10/17/26, no open date, and no received date. -1 container Ginger ground with received date of 11/25, with use by date of 5/21/26, no open date. -1 container of Jamaican jerk seasoning, with open date of 6/26, no use by date, and no received date. -1 container of Curry powder, with use by date of 10/17/26, no open date, and no received date. -1 container of Whole rosemary leaves with date received 5/26 no open date, and use by date. -1 container of Gumbo File with open date of 1/12/26, no use by date, and no received date. -1 container of Ground Bay leaves with open date 4/1/25, use by date of 4/2026, and no received date. -1 container of Ground nutmeg with use by date of 5/6/26, no open date, no received date. -1 container of Lemon pepper seasoning with date received 6/9, no open date, no use by date. -1 container of ground cummin seeds with received date of 4/6, no open date, no use by date. -1 container Spanish paprika, no open date, no received date, no use by date. -1 container of Ground cinnamon, received date of 4/6, with unreadable scribbling on the label. -1 container of Ground cinnamon with open date of 7/9/26, received date of 7/7, no use by date. -1 container of Dill weed, received date of 4/6, no open date, no use by date. DELI -2 packs of Deli hot dog buns with use by date of 7/9, no open date, no received date. - 1 pack of Sliced bread with date received 12/3, no open date, no use by date. -1 pack of Bagels no date open, no received date, and no use by date. -1 pack of English Muffin with use by date of 7/10, no received date, no open date. -1 pack of Sliced bread with use by date of 7/9, no received date, no open date. -1 pack of Sliced bread with received date of 12/3, with no open date and use by date. - 1 pack of opened English Muffin, without open date, with use by date of 7/10, no received date. -1 pack of Swirl bread with use by date of 7/9, no received date, no open date. -1 pack of open sliced bread with received date of 12/3, no open date, no use by date. Walk in Refrigerator -a tub of chopped garlic in oil, no open date, use by date, and no received date. - one 100% key lime juice, no expiration date, no open date, and no received date. -1 bottle of Kewpie mayonnaise with use by date of 6/27/26, no open date, and no received date. - 1 chef's celery with use by date of 7/11, no received date, no open date. - chopped salad in a pan with use by date of 7/11/2026. -lettuce heads in a plastic bag with use by date of 7/12/26, no received date. -a pan of chopped tomato with use by date of 7/12/26. -1 bag of parsley dated 6/29/26 with yellowing leaves. -1 bag of arugula no received date. -another bag of arugula no received date. -green onions with no received date. - green bell peppers with a cucumber with mold. - 1 bag of carrots no received date. - heads of lettuce without received date. -cantaloupes and honey dew without received dates. Dry Pantry -1 bag of Buttermilk Pancake with use by date of 7/10, no open date, no received date. -1 bag of opened powdered mash potato with received date of 6/18, no open date and use by date. During a concurrent interview and record review on 7/16/2026, at 7:43 a.m., with the CMD, reviewed the list of items found in the kitchen with missing labels (received date, open date, use by date) and the facility policy and procedure (P&P). The CMD stated for all food products in the kitchen they have to put received date, open date, and use by date. To ensure the food cannot be used after the use by date because it is unsafe. The CMD stated the failure of the staff to label the food items in the facility with the received date, open date, and use by date had the potential for residents to experience food poisoning. The CMD stated the P&P titled, Labeling and Dating of Foods, was not followed. The CMS stated everybody is responsible for ensuring all food items in the facility were labeled appropriately. The CMD stated they were checking the food items in the facility for labeling of the items. During a review of the facility's recent P&P titled, Labeling and Dating of Foods, last reviewed on 1/12/2026, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Procedure: -Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product. -Newly opened food items will need to be closed and labeled with an open date and use by the date that follows the various storage guidelines within this section- specifically the Dry Goods Storage Guidelines (page 6.9), Refrigerated Storage Guidelines (page 6.16), Produce Storage Guidelines (page 6.18), and Freezer Storage Guidelines (page 6.10). -Produce is to be dated with received date.

Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of three sampled residents (Residents 2 and 26) reviewed for antibiotic use by failing to ensure: 1. Resident 2's Amoxicillin-Pot Clavulanate Tablet 875-125 milligrams (mg, a unit of weight) had monitoring for its adverse effects (an unwanted, harmful, or unpleasant physical or mental reaction caused by a medical treatment, such as a medication or surgery). 2. Resident 26's Cephalexin Oral Capsule 500 mg (Cephalexin) had monitoring for its adverse effects. These failures had placed the residents at risk for adverse effects and multidrug resistant organisms (MDRO, are types of bacteria or germs that have developed the ability to withstand multiple, common antibiotics that used to kill them) resistance to antibiotics. 3. Resident 3's prescribed order for Terbinafine tablets (antifungal medication, [a class of anti-infectives], drug used to treat fungal infection [a disease caused by microscopic fungi, such as molds or yeasts]) had a stop date for one of one resident (Resident 3). This failure had potential to cause unnecessarily prolonged use of antifungal medication, decrease its effectiveness and potential to develop antibiotic drug resistance and cause adverse effects to Resident 3's health. Findings: 1. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted the resident on 4/21/2026, and readmitted the resident on 6/3/2026, with diagnoses including fracture (break in bone) of neck of femur (thigh bone) and urinary tract infection (UTI, an infection in the bladder/urinary tract). During a review of Resident 2's History and Physical (H&P), dated 6/5/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/6/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a clear decline in thinking and memory that noticeably disrupts daily life, making tasks like managing money or medications harder). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 2's Order Summary Report (OSR), the OSR indicated an order for: 5/29/2026 Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give 1 tablet by mouth two times a day for UTI. for 10 Days start from the emergency kit (EKIT, a secured container holding backup medications and vital medical supplies). During a concurrent interview and record review on 7/16/2026, at 9:45 a.m., with the Quality Assurance Nurse (QAN), reviewed Resident 2's Medical Diagnoses, OSR, Progress Notes, and policy and procedure (P&P). The QAN stated the Amoxicillin-Pot Clavulanate Tablet 875-125 mg (Augmentin) was ordered for 10 days for UTI, and there were missing monitoring for adverse effects on its use in the progress notes on 6/4/2026, 7 a.m. to 3 p.m. shift, 6/7/2026. 7 a.m. to 3 p.m. shift, 6/9/2026, 7 a.m. to 3 p.m. shift, 6/10/2026, 7 a.m. to 3 p.m. shift, and 6/12/2026, 7 a.m. to 3 p.m. shift. The QAN stated the licensed staff should have monitored for its adverse effect every shift to ensure the antibiotic was appropriate and to prevent antibiotic resistance. The QAN stated the facility failed to follow the P&P titled, Antibiotic Stewardship Program and Antibiotic Stewardship- Orders for Antibiotic, by missing shift assessments. During an interview on 7/17/2026, at 8:49 a.m., with the Director of Nursing (DON), the DON stated Resident 2's use of antibiotic Amoxicillin-Pot Clavulanate Tablet 875-125 mg should have been monitored of its adverse effects and documented every shift. The DON stated it is an industry standard and there should be no missed documentations to prevent the adverse effects of the medication. 2. During a review of Resident 26's AR, the AR indicated the facility admitted the resident on 6/19/2026, with diagnoses including urinary tract infection and sepsis (a life-threatening blood infection). During a review of Resident 26's H&P, dated 6/22/2026, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 26's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment (person has lost a large amount of their mental ability, such as memory, thinking, and reasoning, to the point where they cannot live alone or care for themselves safely). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 26's OSR, dated 6/19/2026, the OSR indicated an order for Cephalexin Oral Capsule 500 mg (Cephalexin). Give 1 capsule by mouth two times a day for UTI for 10 Days. During a concurrent interview and record review on 7/16/2026, at 10:50 a.m., with the QAN, reviewed Resident 26's Medical Diagnoses, OSR, Progress Notes, and P&P. The QAN stated the Cephalexin Oral Capsule 500 mg (Cephalexin). Give 1 capsule by mouth two times a day for UTI for 10 Days, and there was no monitoring for adverse effects on its use in the progress notes. The QAN stated the licensed staff should have monitored for its adverse effect every shift to ensure the antibiotic was appropriate and to prevent antibiotic resistance. The QAN stated the facility failed to follow the P&P titled, Antibiotic Stewardship Program and Antibiotic Stewardship- Orders for Antibiotic, by missing shift assessments. During an interview on 7/17/2026, at 8:49 a.m., with the DON, the DON stated Resident 26's use of antibiotic Cephalexin Oral Capsule 500 mg (Cephalexin). Give 1 capsule by mouth two times a day for UTI for 10 Days should have been monitored of its adverse effects and documented every shift. The DON stated it is an industry standard and there should be no missed documentations to prevent the adverse effects of the medication. During a review of the facility's recent P&P titled, Antibiotic Stewardship Program, last reviewed on 1/12/2026, the P&P indicated to establish and implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use. This policy is aimed in limiting antibiotic resistance in the post-acute care setting, improving treatment efficacy and resident safety, and reducing treatment-related costs. During a review of the facility's recent P&P titled, Antibiotic Stewardship- Orders for Antibiotics, last reviewed on 1/12/2026, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. Policy Interpretation and Implementation 9. When a resident is discharged home, the nurse will review complete antibiotic orders with the resident, including: c. Possible side effects. 3. During a review of Resident 3's admission Record, dated 7/16/2026, the admission record indicated the facility initially admitted Resident 3 on 4/11/2026 and readmitted on [DATE] with diagnoses of aspiration pneumonia (infection of the lungs following inhalation of food or a liquid), Parkinson's disease (a slow brain disorder marked by tremors, muscle stiffness, and a hard time moving), type 2 diabetes mellitus (DM 2, a disorder, characterized by difficulty in blood sugar control), acute respiratory failure with hypoxia (sudden severe difficulty breathing and low oxygen level in blood), dysphagia (difficulty of swallowing), depression (mood disorder, marked with persistent sadness, hopelessness, lack of interest in activities), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) dementia (a progressive state of decline in mental abilities), malignant neoplasm of breast (breast cancer), paraplegia (loss of movement and/or sensation, to some degree, of the legs), tinea unguium (a fungal infection of the fingernails or toenails). During a review of the MDS, dated [DATE], the MDS indicated Resident 3's cognitive function (brain's complex mental processes involved in gaining knowledge and comprehension) had severe cognitive impairment (severe problems with thinking and memory). MDS indicated Functional Abilities (ability to move body and perform activities of daily living like dressing, bathing, transfer, and walking) of Resident 3 are dependent on maximal assistance (helper does more than half of the effort) with bed mobility, dressing, standing, toileting, showering, transferring to wheelchair. During a concurrent interview and record review on 7/16/2026 at 1:18 p.m. with Quality Assurance Nurse (QAN) Resident 3's Order Summary Report dated 7/16/2026, and Hospitalist Discharge Summary report, dated 6/5/2026 were reviewed. QAN stated Resident 3 had a prescription for Terbinafine HCl oral tablet 250 milligrams (mg, unit of weight measurement), to give one tablet by mouth one time a day for toe fungus, start date on 7/9/2026 without stop date. QAN stated terbinafine is an antifungal medication and should have a stop date, and a nurse should have let the medical doctor (MD) know about the stop date. QAN stated that, according to hospitalist discharge summary report, dated 6/5/2026, Resident 3 had been taking Terbinafine 250 mg one tablet daily for one month now and per podiatrist (a specialist doctor that treats foot problems), Resident 3 needed to take Terbinafine continuously for three months. QAN stated that the stop date should be 8/5/2026 and QAN would notify the MD. QAN stated that it was important for antifungal medications administration to have a stop date. QAN stated if there was no stop date for medication, then there would be risks such as medications would not be effective anymore and side effects might develop. During an interview on 7/17/2026 at 4:45 p.m. with the Director of Nursing (DON), the DON stated that medication reconciliation (a formal healthcare process that compares a patient's current medication list including prescriptions, over-the-counter drugs, and supplements, against their newly prescribed or administered medications aimed to prevent adverse events like omissions, duplications, dosing errors, and drug interactions during care transitions) was completed by a desk nurse. The DON stated that Infection Preventionist Nurse (IP nurse) should have checked on antifungal medication to ensure the nurses follow the order. The DON stated that the DON or the DON designee was responsible for checking as well. The DON stated there should be a stop date for the antifungal medication. The DON stated if there was no stop date for the antifungal medication, there were risks associated with the drug administration for example, unnecessary medication or harm to the resident. During a review of the facility's policy and procedure (P & P) titled, Antibiotic Stewardship - Orders for Antibiotics, dated 1/12/2026, the P & P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: drug name, dose, frequency of administration, duration of treatment, start and stop date, or number of days of therapy, route of administration, and indications for use. The P & P further indicated, If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic or anti-infective orders.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of five sampled residents (Resident 4) during dining observation task by failing to ensure Certified Nursing Assistant (CNA) 3 was not standing over Resident 4 while assisting them during a meal. This deficient practice had violated the residents' right to be treated with dignity and respect. Findings: During a review of Resident 4's admission Record (AR), the AR indicated that the facility admitted the resident on 6/30/2026 with diagnoses including lumbar region (lower back) spinal stenosis (narrowing of the spinal canal compressing nerves) with neurogenic claudication (a syndrome characterized by leg pain, numbness, tingling, or heaviness brought on by standing upright or walking), dorsalgia (a broad medical term for back pain), and generalized muscle weakness. During a review of Resident 4's History and Physical (H&P), dated 7/1/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 7/2/2026, the MDS indicated that the resident has clear speech and adequate hearing and had the ability to understand others and makes self-understood. The MDS indicated that the resident has lower extremity impairment on both sides. The MDS indicated the resident needed supervision or touching assistance with eating where the helper provides verbal cues and/or touching/steadying and/or contact guard assistant as resident completes activity where assistance may be provided throughout the activity or intermittently. The MDS indicated that the resident received mechanically altered diet (require change in texture of food or liquids) and therapeutic diet (specialized eating plans designed to manage or treat various health conditions). During a review of Resident 4's physician order, dated 7/1/2026, the physician order indicated consistent carbohydrate (CCHO - a diet containing the same amount of carbohydrates per meal for blood sugar management) with no added salt (NAS), soft & bite-sized texture (foods that are soft, tender, moist, but with no thin liquid leaking/dripping from the food), thin liquids consistency. During a review of Resident 4's Care Plan (CP) titled, Self Care and Mobility Deficit as evidenced by: requiring assistant in eating (supervision)., dated 7/1/2026, the CP indicated the resident with goals of maximizing activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily) function within the limitation of the disease process which included interventions of providing verbal, visual, and physical cues as indicated and providing diet as ordered. During a concurrent observation and interview on 7/13/2026 at 12:36 p.m., inside Resident 4's room, Resident 4 stated he has carrots and rice, and he needs help to eat. Resident 4 stated he has hand tremors ever since he got out of the hospital. CNA 3 was inside the room assisting Resident 4's roommate. CNA 3 stated she will assist Resident 4 with his lunch. During an observation on 7/13/2026 at 12:39 p.m., inside Resident 4's room, CNA 3 assisted Resident 4 with his lunch while standing over the resident. During an interview on 7/13/2026 at 12:45 p.m. with CNA 3, CNA 3 stated she could not find a chair, but she is not supposed to be standing over the resident when assisting with feeding. CNA 3 stated Resident 4 requested for assistance to eat. Resident 4 stated CNA 3 should sit, and he needs help to eat. During an interview on 7/13/2026 at 2:18 p.m. with CNA 3, CNA 3 stated they (CNAs) are supposed to sit down while assisting with feeding for the resident's comfort. CNA 3 stated that when she continues to feed the resident standing over the resident, the resident would not be comfortable. During an interview on 7/17/2026 at 7:51 a.m. with the Quality Assurance Nurse (QAN), the QAN stated that standing over residents while assisting them to eat is a dignity issue and a safety issue. The QAN stated that the staff need to sit down. The QAN stated it does not meet the requirement for residents' rights. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed and approved on 1/12/2026, the P&P indicated that employees shall treat residents with kindness, respect, and dignity. The P&P indicated that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity. During a review of the facility's P&P titled, Assisting the Resident with In-Room Meals, last reviewed and approved on 1/12/2026, the P&P indicated that the purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in their rooms. Steps in the Procedure 1. Place the tray on the overbed table or serving area. Be sure it is adjusted to a comfortable position and height for the resident. 4. Assist the resident as necessary. However, encourage the resident to feed himself or herself as much as possible.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who were wearing a wander guard bracelet (monitoring device that triggers an alarm when the resident gets close to or goes through a door equipped with the alarm; this device is applied to residents at risk for elopement [a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave]), out of a total six sampled resident, did not leave the facility unnoticed by staff. On 1/13/2024 around 3:15 p.m., Resident 1 was noticed missing from the facility. Resident 1 was wearing the wander guard bracelet but there was no alarm going off when Resident 1 went through a door (it was unknown what door Resident 1 use to leave). As a result, Resident 1 walked to a nearby bus stop and fell . Paramedics (persons specially trained to provide emergency medical services, as in or from an ambulance) picked up Resident 1 and transferred to General Acute Care Hospital 1 (GACH 1) where he was diagnosed (to identify a disease or a condition in a patient) with a right rib fracture (broken bone). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses that included muscle weakness, anxiety disorder (a persistent and excessive worry that interferes with daily activities), dementia (the loss of cognitive [conscious mental activities including thinking, reasoning, understanding, learning, and remembering] functioning to such extent that it interfered with a person ' s daily life and activities), and history of falling. A review of Resident 1 ' s Internal Medicine Initial Evaluation, dated 11/27/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Elopement Screening, dated 12/1/2023, indicated the resident had a history of elopement and had exit-seeking behavior or expression of wanting to go home. A review of Resident 1 ' s Morse Fall Risk Screen, dated 12/1/2023, indicated the resident ' s score was 60 (tool did not indicate highest possible score). A total score of 45 or more indicated high fall risk. The Gait (the manner of moving on foot) section of the Morse Fall Risk Screen indicated Resident 1 ' s gait was impaired and Resident 1 ' s steps were short, may shuffle, and the resident was unable to walk without assistance. A review of Resident 1 ' s Physical Therapy (PT) Evaluation and Plan of Treatment, dated 12/2/2023, indicated the treatment diagnoses of muscle weakness. The Functional Assessment, Gait section indicated Resident 1 required total dependence on level surfaces. A review of Resident 1 ' s Care Plan on depressive symptoms, initiated on 12/3/2023, indicated interventions that included to always maintain a safe and secured environment. A review of Resident 1 ' s Physician Orders, dated 12/5/2023, indicated the physician ordered the following: 1. Wander guard (a term the facility used to refer to a monitoring device for residents at risk for elopement; the facility is using the brand Door Guardian) placement. Monitor for placement every shift. The physician order did not indicate Resident 1 ' s specific behavior for the need of a monitoring device. 2. Wander guard battery replacement one time a day every seven days. The facility was not able to provide documentation that the battery of the monitoring device was changed every seven days. 3. Wander guard placement secured every shift. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/7/2023, indicated the resident ' s cognitive skills for daily decision making was severely impaired. Resident 1 was dependent on staff in performing activities such as sit to stand, chair to chair transfer, toilet transfer, and picking up (the ability to bend or stoop from standing position) objects. Resident 1 used a walker and a wheelchair as mobility devices. The MDS indicated Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity and assistance may be provided throughout the activity or intermittently) for walking 10 feet, walking 50 feet with two turns, and walking 150 feet. A review of Resident 1 ' s Care Plan on falls, initiated on 12/11/2023, indicated the resident was high risk for falls and injury. The care plan interventions indicated that Resident 1 wore a wander guard. A review of Resident 1 ' s Care Plan on anxiety, initiated on 12/11/2023, indicated the resident was taking anti-anxiety medications that could increase the resident ' s risk of confusion, amnesia (the loss of memories, including facts, information, and experiences), loss of balance, and increased risk of falls. The care plan interventions indicated to monitor Resident 1 for safety. A review of Resident 1 ' s care plans indicated that the facility did not create a plan of care for the resident to address Resident 1 ' s elopement risk behavior. A review of Resident 1 ' s Progress Notes, dated 1/13/2024, indicated that the resident was wearing a wander guard on the ankle. The progress notes indicated that Resident 1 continuously requested to go home and constant reassurance from the staff was provided. The progress notes indicated that between 2 p.m. to 3p.m., Resident 1 was propelling self in the hallways. The progress notes indicated that around 3:15 p.m., Resident 1 could not be found in the facility and the wander guard did not alarm. Resident 1 ' s family was notified, and the paramedics were called for assistance. At 5 p.m., the Police Department informed the facility that Resident 1 was found and was sent to the hospital. A review of Resident 1 ' s GACH 1 Progress Notes, indicated the resident was admitted on [DATE] and discharged on [DATE]. The progress notes indicated the diagnoses during GACH 1 visit that included ground-level fall and right rib fracture. A review of Resident 1 ' s GACH 1 General Radiology report, dated 1/13/2024, indicated the resident ' s chest x-ray (a procedure that creates pictures of the inside of the body in different shades of black and white) indicated acute (sudden) appearing mildly displaced fracture of the right ninth rib. On 1/16/2024 at 3:15 p.m., during a concurrent observation and interview, the Maintenance Supervisor (MS) stated that the wander guards were checked every week on every door in the facility. The MS stated that he checked all the wander guards and door alarms after Resident 1 eloped and all were in working condition. The MS stated that he checked Resident 1 ' s wander guard after the resident returned from GACH 1 and it was in working condition. Observed that the facility patio had two gates with exit to the facility ' s front and side parking lot. The MS stated that the two gates from the patio can only be opened from inside. Observed exit door alarm pad labeled #14 located inside the staff lounge did not alarm but the red emergency alarm box was activated. The MS stated that the red emergency alarm box needed a key to stop the alarm. The MS stated that he did not know there was a wander guard alarm in the staff lounge. Observed exit door alarm labeled #11 located inside the PT room that had a low volume alarm and the red emergency alarm box did not alarm. The MS stated that the emergency alarm box was turned off. The MS stated that he does not check the exit door alarms in the PT room because the residents do not have access to the room at night. On 1/16/2024 at 3:35 p.m., during a concurrent observation and interview, observed the exit door inside the dining room did not alarm and did not have the red emergency alarm box. Observed the MS open the dining room door, went outside to the patio, went back inside, and closed the door then the alarm was activated with a loud sound. The MS stated that the wander guard may or may not have worked during the day the resident left the facility. The MS stated that it should alarm to prevent residents from going out unsupervised. On 1/16/2024 at 4:42 p.m., during an observation, observed the facility ' s back parking lot had access to the main street. There were few cars passing by on that street. On 1/16/2024 at 5:05 p.m., during an interview, the Administrator (ADM) stated that the monitoring alarm system was shared with the adjacent building. The ADM stated that facility staff should respond to the door that alarmed. The ADM stated that the wander guard alarm could only be turned off at the alarm pad located at the door using a number code. On 1/16/2024 at 7:30 p.m., during an interview, the Director of Nursing (DON) stated that Resident 1 was assessed for elopement behavior and a wander guard was attached to the resident. The DON stated that the facility failed to provide more monitoring for Resident 1 to prevent Resident 1 from leaving the facility. The DON stated that Resident 1 had the potential for accidents on the street, a serious injury, or even death because the resident was not cognitively intact and did not have a stable gait. A review of the current facility-provided policy and procedure titled, Wandering and Elopements, dated 1/26/2023, indicated the facility will identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy indicated that a resident identified as at risk for wandering, elopement, or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety. A review of the current facility-provided policy and procedure titled, Elopement, dated 1/26/2023, indicated the purpose to enhance the safety of residents in the facility, to help identify residents who were at risk for elopement, and to minimize possible injury as a result from elopement. The prevention section of the policy indicated the facility shall safeguard exit doors with devices such as audible alarms, if possible, to alarm staff whenever a resident attempt to leave the premises unsupervised.

Based on interview and record review, the facility failed to provide the needed supervision and assistance to prevent falls and injuries for one of two sampled residents (Resident 1). For Resident 1, who had history of falls before admission and was confused, the facility failed to ensure: 1. Resident 1 ' s fall risk care plan interventions were evaluated (reviewed and revised) for effectiveness and develop new interventions based on the individual needs of the resident. 2. The Interdisciplinary Team (IDT, group of professionals from different health care disciplines who participate in the care of the resident) including the attending physician, met to identify causative factors for Resident 1 ' s repeated incidents of falls while attempting to use the bathroom. As a result, Resident 1 fell a total of five times from admission on 12/27/2022 to discharge date d 3/17/2023 while attempting to go to the restroom, after the 4th fall on 3/2/2023, X-ray of the right hip taken the same day, 3/2/2023, with the result dated 3/5/2023, suggested right hip fracture. On 3/5/2023, the physician ordered computerized tomography (CT) scan (combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images [slices] of the bones, blood vessels and soft tissues inside the body; CT scan images provide more-detailed information than plain X-rays) which was done 3/16/2023 and the result received on 3/20/2023 confirmed the right hip fracture. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident, an [AGE] year-old female, on 12/27/2022, from an acute hospital after falling at the assisted living facility (ALF) where the resident resided. Resident 1 ' s diagnoses included parkinsonism (a disorder of the central nervous system that affects movement, often including tremors [shaking movements in one or more parts of the body, most often in the hands]) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 1 ' s History and Physical (H&P) exam by the attending physician, dated 12/28/2022, indicated the resident had a history of frequent falls at the ALF. A review of the Physician ' s Orders for Resident 1, dated 12/27/2022, indicated to Physical Therapy (PT) evaluation and treatment as indicated; another order was for landing mat (floor mat, cushioned mat placed at the bedside to reduce the impact and injury risk). A review of Resident 1 ' s PT Evaluation and Plan of Treatment dated 12/29/2022 indicated Resident 1 was referred to PT due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely walk, reduced balance, reduced functional activity tolerance, decreased coordination, decreased judgment, cognitive deficits (problems with a person's ability to think, learn, remember, use judgement, and make decisions), increased need for assistance from others, and reduced participation in activities of daily living (ADLs, refers to resident's daily self-care activities) and skilled PT services were warranted. A review of Resident 1 ' s Morse Fall Risk (a rapid and simple method of assessing a patient's likelihood of falling) Screen, dated 12/27/2022, indicated the resident as high risk for falling (a score of 45 or higher). Resident 1 ' s Morse Fall Risk score was 65. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/31/2022, indicated the resident had severe cognitive impairment (unable to understand, remember and make decisions), was able to communicate but confused. Resident 1 needed one-person physical assist with bed mobility, transfer, walk in room and in corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated the resident was not steady and only able to stabilize with staff assistance for moving from seated to standing position, walking, moving on and off toilet, moving on and off toilet, and for surface-to-surface transfer (transfer between bed and chair or wheelchair). Resident 1 used wheelchair to move around. A review of Resident 1 ' s Care Plan developed on 1/10/2023 for the resident ' s fall risk related to diagnoses, had a goal for Resident 1 to be free of falls through the next review on 3/27/2023. The interventions included anticipating and meeting the resident ' s needs, making sure the call light was within reach and encouraging its use for assistance, encouraging the resident to participate in activities, responding promptly to all Resident 1 ' s requests for assistance, and provide a safe environment. A review of Resident 1 ' s Care Plan developed on 1/24/2023, for the resident ' s high fall and injury risk, indicated as one of the goals to prevent falls and injury until next review 3/27/2023. Another goal was to manage Resident 1 ' s risk factors to minimize falls and injuries. The care plan interventions included using landing mats to both sides of the bed, keeping the bed in a low position, assisting with activities of daily living (ADLs, walking, personal hygiene, toilet use, transfer, and bathing), and check surfaces for sharp edges. A review of Resident 1' s SBAR (Situation, Background, Assessment, and Recommendation, a tool to aid in facilitating and strengthening communication between health care staff) Communication Form dated 2/1/2023, indicated that at 7:55 a.m. CNA 1 reported finding Resident 1 lying on the floor in front of the restroom when CNA 1 entered the room to serve breakfast to the resident. A review of Resident 1 ' s Post Fall Assessment, dated 2/1/2022, indicated that around 7:55 a.m., resident had redness and a bump on the back of the head and ice pack was applied. Resident 1 ' s attending physician when notified order to send the resident to a hospital for further evaluation. A review of Resident 1 ' s Care Plan for fall risk, dated 1/24/2023, indicated an added intervention, to keep bed in low position. A review of Resident 1 ' s Admission Record indicated the facility readmitted the resident on 2/7/2022, with no other injuries from the fall. A review of Resident 1 ' s x-ray of the right hip, dated 2/16/2023, indicated normal hip with no evidence of fracture. A review of Resident 1 ' s SBAR Communication Form, on 2/20/2023, timed at 2:41 p.m., indicated the resident was found on the restroom floor at 2:40 p.m. accompanied by Family Member 1 (FM 1, her husband and roommate) and sustained a laceration(wound that is produced by the tearing of soft body tissue) on the back of the left arm and on the left elbow. The SBAR indicated FM 1 brought Resident 1 to the restroom without informing staff. Resident 1 was transferred to a hospital via emergency medical services (EMS or paramedics). Resident 1 returned the same day with no new injuries identified. A review of Resident 1 ' s Post Fall Assessment/IDT, dated 2/20/2023, indicated FM 1 brought Resident 1 to the restroom without informing staff. A review of Resident 1 ' s Care Plan for Actual Falls on 2/1/2023 and 2/20/2023, included as new intervention to conduct a review of the resident ' s medication regimen. A review of Resident 1 ' s SBAR Communication Form, dated 3/2/2023, indicated the resident was found lying on the floor on her back at 7:30 p.m. Resident 1 did not complain of pain and was able to move joints. Resident 1 could not recall what happened. The physician when notified ordered x-rays of spine (neck and chest areas), skull, both wrists, and both hips. A review of Resident 1 ' s Post Fall assessment dated [DATE], indicated that at 7:30 p.m., the resident was found in her room on the floor. Resident 1 stated she was trying to walk. A review of Resident 1 ' s X-rays results taken on 3/2/2023 with the results dated 3/5/2023, indicated the left hip had hardware (history of left hip fracture surgery) intact with no acute fracture. The right hip impression suggested a right acetabular fracture (a break in the socket portion of the ball-and-socket hip joint). This result was correlated to the X-ray dated 2/16/2023. The physician was notified of the X-ray results on 3/5/2023. A review of the Physician ' s Order for Resident 1, dated 3/5/2023, indicated to do a CT scan of the hips. A review of Resident 1 ' s Care Plan developed on 1/24/2023 and revised on 3/7/2023, had the same goals and additional interventions were developed: the use of a bedside commode portable (toilet that look like a chair and have a bucket-like receptacle beneath it which can be removed for cleaning) and the use of sensor pad alarms (the alarm go off when the pressure is released as a result of the resident standing up or getting off the bed) while in bed and wheelchair to remind the resident not to stand up initiated on 3/7/2023. A review of Resident 1 ' s SBAR Communication Form, dated 3/8/2023, timed at 8:00 a.m., indicated the resident had been getting out of bed and assigned CNA 3 to monitor the resident all through the night. The SBAR indicated around 5:00 a.m. when CNA 2 was called to help another resident in another room, the chair alarm sounded and when CNA 2 ran back to the resident ' s room, Resident 1 was on the floor. RN 1assessed Resident 1 and found no obvious injury. A review of Resident 1 ' s Post Fall Assessment/IDT, dated 3/8/2023, indicated the resident was seen sitting on the wheelchair, the alarm was heard, and Resident 1 was found sitting on the floor. A review of Resident 1 ' s SBAR Communication Form, on 3/16/2023, timed at 4:45 a.m., indicated FM 1 went to the Nursing Station requesting help with Resident 1. Licensed Vocational Nurse 1 (LVN 1) found the resident lying on the safety pad (also known as a landing mattress, a cushioned device placed by the bedside to protect from injury if the resident falls out of bed). LVN 2 and the RN supervisor assessed Resident 1 and a skin tear was identified on the right lateral arm. A review of Resident 1 ' s Post Fall Assessment/IDT, dated 3/16/2023, indicated the alarm was heard, the resident was on the landing pad, lying on her left side with right lateral arm side skin tear. Resident stated she was trying to use the bathroom/commode. A review of Resident 1 ' s Fall Care Plan interventions, dated 3/16/2023, indicated to anticipate the resident ' s needs and offer fluids. A review of Resident 1 ' s PT Discharge Summary dated 3/16/2023 for PT sessions from 2/8/2023 to 3/16/2023 indicated the resident was returning to the ALF and PT recommended home health PT. A review of Resident 1 ' s nursing Progress Notes, dated 3/17/2023, indicated the resident was transferred to the ALF and the result of the CT scan of hips was not received. Resident 1 ' s attending physician was informed and okayed the discharge. On 4/5/2023 at 1:35 p.m., during an interview, the Assistant Director of Nursing (DON) stated Resident 1 ' s non-compliant with calling for assistance before trying to walk alone. The ADON stated the facility could not provide Resident 1 with a 1:1 caregiver (a staff to be always with the resident) and it was discussed with FM 2, but FM 2 declined because it had to be paid out of pocket. On 4/5/2023 at 1:59 p.m., during an interview, the ADON stated he could not provide documentation the IDT met to conduct a root cause analysis for Resident 1 ' s repeated falls. The ADON stated Post Fall Assessments were conducted by the interdisciplinary team attended by him, the Director of Nursing, and the Rehab Director. The attending physician did not participate in the IDT teams. There was no documentation to indicate a scheduled toileting program was attempted. A review of the facility ' s policy and procedures titled, Fall Risk Assessment, reviewed on 9/29/2022, indicated that upon admission, the nursing staff and the physician will review a resident ' s record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. A review of the facility ' s policy and procedures titled, Fall Management, reviewed on 9/29/2022, indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help the staff reconsider possible causes that may not previously been identified. Staff would identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility ' s policy and procedures titled, Care Planning dated 9/12/2019 indicated the comprehensive care plan must describe services that are furnished to maintain the resident ' s highest practicable physical, mental, and psychological well-being. The resident ' s goals for admission and desired outcomes. The planning process must facilitate the inclusion of the resident and/or resident representative. Include an assessment of the resident ' s strengths and needs.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had poor safety awareness, had history of falls, and was admitted to the facility for rehabilitation after a fall at home resulting in a left [CONDITION(S)] (break of a bone), was provided a safe environment and supervision as indicated in the facility ' s policies, by not: 1. Reviewing and revising the plan of care after Resident 1 fell on [DATE] and on 6/9/2022. 2. Not developing new interventions to prevent further falls after each unwitnessed fall on 5/23/2022 and on 6/9/2022. As a result, on 6/14/2022, less than a month after admission, Resident 1 sustained a third unwitnessed fall requiring transfer to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a right [CONDITION(S)]. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 5/19/2022, with diagnoses including left femur (hip) fracture, presence of left artificial hip (the hip joint is replaced by artificial implants made of ceramic or metal [NAME]) joint, history of falling, [CONDITION(S)] (a drop in blood pressure that occurs when moving from a laying down position to a sitting or standing position), and [CONDITION(S)] (bone disease that that causes bones to gradually thin and weaken, leaving them at greater risk of fractures). A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 5/19/2022, with diagnoses including left femur (hip) fracture, presence of left artificial hip (the hip joint is replaced by artificial implants made of ceramic or metal [NAME]) joint, history of falling, [CONDITION(S)] (a drop in blood pressure that occurs when moving from a laying down position to a sitting or standing position), and [CONDITION(S)] (bone disease that causes bones to gradually thin and weaken, leaving them at greater risk of fractures). A review of the Physician ' s Orders for Resident 1, dated 5/23/2022, indicated physical therapy evaluation and treatment, once a day five days a week for forty-five days for gait (manner of walking) training and group therapy. A review of Resident 1 ' s Physical Therapy Evaluation and Plan of Treatment, dated 5/20/2022-7/3/2022, indicated the need for skilled services due to balance deficits, strength impairments, unilateral weakness, gross motor coordination deficits, joint mobility/integrity deficits, decreased safety awareness and judgment. A review of Resident 1 ' s Care Plan developed on 5/21/2022 for the resident ' s fall risk had a goal for the resident not to sustain serious injury. The intervention included making sure the resident ' s call light was within reach and encouraging the resident to use it for assistance as needed and responding promptly to all requests for assistance. A review of Resident 1 ' s SBAR (Situation, Background, Assessment, and Recommendation - a tool to aid in facilitating and strengthening communication between health care staff) Communication form, dated 5/23/2022, timed at 9:30 p.m., indicated Resident 1 had an unwitnessed fall. The Charge Nurse heard the resident yelling for help inside her room. The resident was found lying on the floor mat next to her bed (a cushioned mat to prevent injuries if falling out). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/24/2022, indicated the resident sometimes made herself-understood and sometimes understood others. Resident 1 had severe cognitive impairment (very hard time remembering things, making decisions, concentrating, or learning), needed extensive assistance with transfers from or to bed and wheelchair, walking with one or two-person assist, and was able to balance and stabilize during transitions and walking with staff assistance. Resident 1 used a walker and wheelchair to move around. A review of Resident 1 ' s Notification of Room Change, dated 6/2/2022, timed at 11 a.m., indicated Resident 1 was moved to a room near the Nurses ' Station due to high fall risk for the nurses to hear Resident 1 moving or calling for assistance. A review of Resident 1 ' s Care Plan Conference Summary, dated 6/3/2022, indicated the resident was alert (awake), occasionally incontinent (unable to control) of bowel and function, had history of falls, and a was a high fall risk. The physical therapist focused on her mobility. The resident was walking 20-30 feet with front wheel walker (FWW) with 25-50% assist focusing on her safety. The resident required 50-75% assist with toileting. A review of Resident 1 ' s SBAR Communication form, dated 6/9/2022, timed at 10 a.m., indicated Resident 1 was in her room sitting in a wheelchair and had an unwitnessed fall. The housekeeper saw the resident lying on the floor on the right side of her wheelchair. The resident told the nurses she was trying to use the bathroom. A review of Resident 1 ' s SBAR Communication form, dated 6/14/2022, timed at 6 p.m., indicated the resident was found on the floor inside her room next to her wheelchair. Resident 1 could not remember what she wanted to do. Four staff assisted Resident 1 back to the wheelchair, Resident 1 complained of severe pain on the right hip. The licensed nurse called 911 (emergency telephone number) for emergency medical services (EMS, paramedics) who took Resident 1 to an emergency room (ER). A review of the facility ' s Incident Investigation Report, dated 6/14/2022, indicated Resident 1 had history of restlessness (inability to remain still or at rest) and anxiety (intense, excessive, and persistent worry and fear about everyday situations), was at risk for falls, did not have safety awareness, required maximum assistance with transfer and walking, was confused, forgetful, and disoriented, and attempted to get up unassisted. The investigation conclusion indicated Resident 1 ' s fracture to the right hip was a result of the fall from the wheelchair. On 6/21/2022, at 10:26 a.m., during an interview, Registered Nurse Supervisor (RNS) stated Resident 1 had a fall at home and was admitted at the facility on 5/19/2022 for left femur fracture. Resident 1 had the first fall at the facility on 5/23/2022, in her room when she tried to walk without assistance and did not call for assistance or used the call light. They moved Resident 1 to a room near the Nurses ' Station for frequent observation. On 6/9/2022, Resident 1 sustained a second fall in her room after attempting to walk without assistance and did not call for assistance or used the call light. On 6/14/2022, at around 6 p.m., Resident 1 had her third fall after attempting to walk without assistance and without calling for assistance or using the call light and was transferred to GACH 1. The following day the facility got a call from GACH 1 that Resident 1 sustained a right [CONDITION(S)]. On 6/21/2022, at 11:00 a.m., during an interview, the Physical Therapist (PT) stated Resident 1 required extensive assistance in walking, needed help with transferring, was forgetful, but followed simple commands. On 6/21/2022, at 11:12 a.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 1 was very restless, confused, and no safety awareness. The resident does not call when getting out of bed or wheelchair. ADON stated that they did not think of using a chair alarm or 1:1 supervision during those incidents because they thought placing the resident near the nurses ' station and scheduled rounding was enough to keep resident from getting out of her bed or wheelchair. ADON stated a chair alarm or a 1:1 (one staff with the resident at all times) care companion could have made a difference. ADON stated they forgot to update the care plan on 5/23/2022 fall and 6/9/2022 fall incident of the resident to address the falls and to include new interventions to prevent further falls. During an interview on 6/21/2022, at 3 p.m., the ADON and MDS Coordinator, both stated that Resident 1 ' s Care Plan should be reviewed and updated on 5/23/2022 and 6/9/2022 incident of fall to include new interventions. A review of the facility's policy and procedure titled, Safety and Supervision of Residents, revised 7/2017, indicated that monitoring the effectiveness of interventions shall include the following: (a) ensuring that interventions are implemented correctly and consistently; (b) evaluating the effectiveness of interventions; (c) modifying or replacing interventions as needed; and (d) evaluating the effectiveness of new or revised interventions. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. A review of the facility's policy and procedure titled, Safety for Residents, dated 7/2015, indicated that residents should be visualized for safety during rounds and per care plan for individual residents. A Review of the facility ' s policy and procedure titled, Falls Management Policy, last revised date of 2/2022, indicated when a fall occurs, care plan is reviewed and updated as necessary. A review of the facility ' s policy and procedure titled, Comprehensive Care Plan Policy, dated 11/2017, indicated care plans will be revised as information about the resident and the resident ' s condition changes.

Based on observation, interview and record review the facility failed to properly assess and provide a timely treatment for one of 2 sample residents (Resident 1) who complained of left leg pain, was unable to move the left leg and was observed limping by multiple facility staff. This deficient practice resulted in delayed interventions and treatment for Resident 1 who complained of left hip pain and was observed to be limping on February 27, 2017, (on the 11p.m. - 7 a.m. shift) which required surgical intervention to repair a fractured left hip. Findings: On March 2, 2017, the department received an entity - reported incident involving a resident who complained of pain while being assisted to the bathroom by the Certified Nursing Assistant (CNA) on February 28, 2017. Resident 1 was unable to stand up due to the pain and when an X-ray was completed the results showed she sustained a [MEDICAL CONDITION] femoral neck (a bone in the human leg extending from the hip to the knee) with displacement (the moving of something from its orginal position). On March 10, 2017, at 9:00 a.m., an unannounced visit was conducted at the facility to investigate an entity - reported incident. A review of Resident 1's Admission Record indicated that Resident 1 was initially admitted to the skilled nursing facility (SNF) on December 24, 2014, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized comprehensive assessment and care-plan screening tool) dated February 28, 2017, indicated Resident 1 was able to make self understood and understand others. Resident 1's cognitive skills (related to thinking, reasoning, decision making and problem solving) were significantly impaired. Resident 1 required extensive assistance from one person to perform activities of daily living such as bed mobility, transferring from bed to wheelchair, walking in room, dressing and toileting. A review of Resident 1's document titled BD (Brookdale) Nursing Admission, Data Collection, dated February 24, 2017, indicated that Resident 1 was at risk for falls related to having a history of falls and limited mobility. This document also indicated Resident 1 ambulates with problems and uses assistive devices, was not steady and is only able to stabilize with physical assistance. A review of Resident 1's care plan focused on Risk for Falls initiated on February 25, 2017, indicated the resident was at risk for falls related to having a history of falls and limited mobility. A review of Resident 1's Medication Administration Record [REDACTED]. A review of the facilities investigation report and interview form of the Registered Nurse (RN 1) indicated on February 28, 2017, at 7:15 a.m., RN 1 found Resident 1 sitting at the edge of bed and was trying to get out. According to the report, RN 1 assisted the resident back into bed and noted Resident 1 was complaining of leg pain. RN 1 reported this to the charge nurse (LVN 1). A review of Resident 1's document titled BD Change of Condition dated February 28, 2017, at 11:20 a.m., indicated Resident 1 had new or unrelieved pain and that the medical doctor (MD) was notified. A review of Resident 1's document titled BD Situation, Background, Assessment and Recommendation Communication and Progress Note (SBAR-change of condition communication document for healthcare providers) dated February 28, 2017, at 4:36 p.m., indicated Resident 1 had increased pain. The SBAR document also indicated at 11:20 a.m., LVN 1 was informed by CNA 1 that the resident complained of left hip pain and appeared weak in the left hip. An assessment by LVN 1 also indicated, the resident was unable to perform self-range of motion (ROM-full joint movement) and had complained of pain being 8 out of 10 on the pain scale (numeric scale that measures the intensity of pain) with movement of the left leg. The note further indicated the resident had previously received pain medication on February 28, 2017 at 5:56 a.m. The note further read that MD 1 was called and had given an order for [REDACTED].>A review of Resident 1's X-ray results dated February 28, 2017, at 2:25 p.m., indicated the resident had a fracture involving the neck of the left femur (a bone in the human leg extending from the hip to the knee) with displacement (the moving of something from its original position). A review of the facility's investigation report dated March 1, 2017, indicated on February 28, 2017, the results of the X-ray were relayed to MD 1 who ordered to transfer Resident 1 to a General Acute Care Hospital (GACH) for possible surgical intervention. A review of Resident 1's (GACH) History and Physical record dated March 1, 2017, indicated Resident 1 was admitted on [DATE], due to an X-ray showing a left [MEDICAL CONDITION] with a complaint of left hip pain. A review of Resident 1's GACH document titled Operative Record dated March 3, 2017, indicated Resident 1 underwent a left hemiarthroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact) and an Open Reduction and Internal Fixation (ORIF -a type of surgery used to stabilize and heal a broken bone with the use of an internal device such as a steel rod or screws) of the left hip .The operative report also indicated the resident lost 200 milliliters of blood during surgery, which resulted in an extended hospitalization to treat [MEDICAL CONDITION] (low red blood cells). A review of Resident 1's admitting record dated February 28, 2017, indicated the resident's blood hemoglobin level (red blood cells responsible to transport oxygen to the body), was 11.5 grams/deciliter (gm/dL-measurement of mass of certain substances such as red blood cells). Resident 1's hemoglobin level after surgical intervention measured 9.9 gm/dL. A normal hemoglobin level for a female is 12-15.5 gm/dL. On March 10, 2017 at 11:00 a.m., during an interview LVN 1 stated, CNA 1 informed her Resident 1's leg was weak when standing up. LVN 1 and LVN 2 placed Resident 1 back into bed from the wheelchair. LVN 1 performed an assessment on Resident 1. LVN 1 stated, Resident 1 pointed to the left groin when she was asked to describe pain. Resident 1 was unable to move the left leg on her own. LVN 1 stated, she called the medical doctor (MD 1) and received an order for [REDACTED].>On March 10, 2017 at 11:30 a.m., during an interview CNA 1 stated, Resident 1 refused to get out of bed because of the pain. CNA 1 explained that when she assisted Resident 1 to the bathroom using the wheelchair CNA 1 noted weakness of Resident 1's left leg. Resident 1 was slow during the transfer to the wheelchair and complained of pain. After assisting Resident 1 back to the wheelchair from the restroom, CNA 1 left Resident 1 with a family member and went to inform LVN 1 of the pain and weakness of the left leg. CNA 1 said, that the night shift CNA 2 did not report that Resident 1 had gotten out of bed during the 11:00 p.m. to 7:00 a.m., shift. On March 13, 2017 at 11:45 a.m., during an interview, CNA 2, who was assigned to Resident 1 on the 11:00 p.m. to 7:00 a.m., shift, on February 27, 2017, stated, Resident 1 was limping when CNA 2 and LVN 3 assisted Resident 1 to the bathroom at approximately 11:00 p.m. CNA 2 said, Resident 1 told her it hurt. CNA 2 said, that LVN 3 noticed Resident 1 limping while they assisted her back to bed. CNA 2 also said, she did not inform LVN 3 that the resident had complained of pain. On March 13, 2017 at 12:00 p.m., during an interview, RN 1 stated, on February 28, 2017 at 7:15 a.m., she went into Resident 1's room to check on her peripheral intravenous catheter (IV-a small, flexible tube placed into a peripheral vein in order to administer medication or fluids) and found Resident 1 sitting at the edge of the bed. RN 1 stated, Resident 1 complained of pain to the left leg. According to RN 1 she had to assist the resident to place her leg back into bed and then instructed her to stay in bed. RN 1 also stated,between 7:15 a.m. to 7:30 a.m., she had informed LVN 1 that the resident was complaining of pain on the left leg. RN 1 further stated, she did not inform LVN 1 that the resident could not move her legs back into bed. On March 13, 2017 at 12:25 p.m. during an interview, LVN 3 (February 27, 2017 during the 11 p.m. to 7 a.m. shift) stated, Resident 1 was observed limping and could not stand upright while being assisted to the bathroom at approximately 11:00 p.m. LVN 3 said, he did not report the limping to LVN 4. A review of the investigation report of LVN 4's interview dated February 28, 2017, did not indicate that he was aware of Resident 1's complaint of pain and limping. There was no documented evidence that MD 1 was notified of Resident 1's limping and pain being reported to CNA 2 on February 27, 2017, at approximately 11:00 p.m. There was no documented evidence that RN 1 notified MD 1 or LVN 1 that the resident was not able to move her left leg on February 28, 2017, at 7:15 a.m. On March 13, 2017, at 8:55 a.m., during an interview, the Director of Nursing (DON) stated that Resident 1 did not have a bed alarm in place. The DON further stated, the SNF was no longer using bed alarms per corporate policy and procedure. The DON was not able to provide a policy and procedure regarding the use of bed alarms. On March 13, 2017, at 9:25 a.m., the Assistant Director of Nursing (ADON) stated, no bed alarms are used and interventions for fall risk are initiated such as; low bed, placing the residents close to the nursing station, and landing pads if the resident or family agrees to their use. On March 13, 2017, at 11:00 a.m., during an interview at the GACH, Resident 1 was observed to be awake, alert, and oriented to self and place only, and on fall precautions. Resident 1 stated, she does not remember falling or what happened. Resident 1 stated, her leg hurt and she had told the staff member helping her (CNA 2) it hurts. Resident 1 was not able to recall the day of the incident. When Resident 1 was asked to describe what the facility staff did after she complained about pain she said, a whole lot of nothing. A review of the facility's policy and procedure revised in October 2014, July 2015, and April 2017, titled Change of Condition for Skilled Nursing Communities indicated when a resident is evaluated or assessed as having a change in condition, the charge nurse will follow through in documenting notification to family legal representative, the health care provider and other licensed nurses in order to facilitate the appropriate plan of care. The policy indicated a Stop and Watch form will be completed to notify the charge nurse of a resident's status. The policy indicated a change of condition includes but is not limited to falls, decline in functional limitation / range of motion (ROM), and complaint of new or unrelieved pain. There was no documented evidence that a Stop and Watch form was completed when Resident 1 complained of pain or was noted to be limping on February 27, 2017, at 11:30 p.m. There was no documented evidence that LVN 3 had notified LVN 4 when he saw Resident 1 limping on February 27, 2017 at 11:30 p.m. A review of the facility's policy and procedure on the Falling Star Program revised in July 2015, indicated residents will be reviewed for fall risk by the nursing department and referred to the rehabilitation department as indicated, discussed in interdisciplinary team meetings (IDT) and placed on the Falling Star Program (program designed to decrease the number of falls and identify residents who are at risk for falls). A review of Resident 1's Nursing Admission Data Collection Notes revealed a fall risk assessment dated [DATE], which indicated she had a history of [REDACTED]. According to this record Resident 1 was at risk for falls and was placed on the Falling Star Program. The notes also indicated the resident had denied pain. On June 28, 2017 at 11:20 a.m., the Physical Therapist (PT 1) stated, Resident 1 did not complain of any pain during the session on the morning of February 28, 2017. PT 1 stated, the resident was able to ambulate with moderate assistance and showed no signs of grimacing, moaning or limping.

Based on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 7), who had a history of [REDACTED]. 1. Failure to follow physician's orders [REDACTED]. 2. Failure to follow the facility's policy on Food and Mealtime Preferences - Meal service/Food Preferences, by not offering Resident 7 fluid of preference. 3. Failure to follow the facility's policy on Resident Hydration and Prevention of Dehydration, by not documenting Resident 7's fluid intake to ensure the resident consumed sufficient fluid as indicated in the facility's policy. 4. Failure to follow the recommendation from the Registered Dietitian (RD) to provide Resident 7 with the minimum fluid needed. 5. Failure to develop a comprehensive care plan addressing Resident 7's hydration and fluids needs. As a result, on August 24, 2017, Resident 7 was transferred to a General Acute Care Hospital (GACH), where she received intravenous (IV) hydration and antibiotic therapy to treat a urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra) and manage her [MEDICAL CONDITION] (elevated sodium in the blood) and acute kidney injury (an abrupt decrease in kidney function). Findings: According to the Admission Record, Resident 7 was admitted to the facility from a GACH on April 28, 2017, with [DIAGNOSES REDACTED]. A review of Resident 7's History and Physical (H&P) examination report completed at the GACH on April 21, 2017, indicated the clinical impressions included dehydration, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A review of a GACH Consultation Report dated April 21, 2017, indicated Resident 7 was admitted with severe dehydration. The physician's impression included acute [MEDICAL CONDITION] due to volume depletion (reduction), not drinking enough fluids and [MEDICAL CONDITION] due to volume depletion. A review of Resident 7's H&P examination report from the facility, dated April 29, 2017, indicated the resident was confused, was not responding to verbal stimulus, and the [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. 1. Pureed diet, nectar liquids consistency. 2. Monitor fluid intake, 640 milliliters (ml) for breakfast, lunch, and dinner for dehydration prevention. 3. Health Shake with lunch and dinner. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated May 5, 2017, indicated Resident 7 usually understood others and made her-self understood, required extensive one-person physical assistance with transfer, eating, and toilet use, was receiving a mechanically altered diet (required change in texture of food or liquids). A review of the care plans indicated no documentation of a care plan developed addressing Resident 7's fluid order to provide the resident with 640 ml each meal. This was confirmed on August 23, 2017 at 9:20 a.m. by the Director of Nursing (DON). A review of the Nutritional Risk assessment dated [DATE], completed by the RD, indicated Resident 7 had an estimated daily fluid needs of 2,318 ml in 24 hours. A review of Resident 7's laboratory results dated [DATE], indicated the following: 1. BUN (blood urea nitrogen - a test that measures the amount of nitrogen waste in the blood) 14 milligram per deciliter (mg/dl) within the reference range 7-25 mg/dl. 2. Creatinine (Cr) 0.75 mg/dl, within the reference range 0.60-1.20 mg/dl. 3. Sodium (NA-salt) of 144 milliequivalent per liter (mEq/L), within the reference range 136-145 mEq/L. 4. Potassium (K) of 4.0 mEq/L, within the reference range 3.5-5.1 mEq/L. 5. BUN/Cr ratio of 18.7 within the reference range 10.0-20.0. 6. Estimated glomerular filtration rate (eGFR) of 73 mL/min/1.73m2, reference range equal or greater than 60. An eGFR is a test to measure the level of kidney function and determine the stage of kidney disease. On August 22, 2017, at 12 p.m., an observation of Resident 7's meal card indicated the following meal preferences: health shake with meal (4 ounces-oz. or 120 ml.), 8 oz. of milk nectar thick (240 ml), and four oz. of orange juice nectar thick (120 ml), for a total of 480 ml. The meal card did not include the ordered 640 ml per meal. On August 22, 2017 from 12:05 p.m. to 12:40 p.m., during a dining observation in the presence of the Dietary Services Supervisor (DDS), Resident 7 was sitting in her wheelchair at a dining table and was sleeping at times. The meal tray contained 120 ml of apple juice (not the preferred orange juice written in the meal card). Resident 7 did not receive the 640 ml ordered. The health shake (120 ml) and the thickened milk (240 ml) were not served during lunch. The resident was not served 640 ml fluid intake during lunch as the physician's orders [REDACTED]. On August 22, 2017 at 12:40 p.m., during an interview, the DSS stated fluid preferences should be provided with meals. The DSS also stated the nectar thick milk, the orange juice and the health shake should have been provided to Resident 7, as indicated on the tray card. A review of the meal intake report for August 22, 2017, indicated Resident 7 consumed 51 percent (%) to 75 % of her lunch meal, but Resident 7 was observed not to eat her lunch. There was no documentation of the amount of fluid the resident consumed. On August 23, 2017 at 10:05 a.m., during an interview, the DSS stated the facility was using the point system to determine the amount of food consumed. The DSS stated she observed Resident 7 ate about 25 percent or less of her lunch meal on August 22, 2017. A review of the Medication Administration Record (MAR) for August 2017, indicated by a checkmark, Resident 7 was monitored for 640 ml of fluid intake for breakfast, lunch, and dinner. The licensed nurses checked the MAR for the 640 ml each meal without specifying the actual amount of fluid the resident consumed to ensure her fluid/hydration needs were met. On August 23, 2017 at 9:20 a.m., during an interview and concurrent record review, the DON stated the physician's orders [REDACTED]. on the meal tray. The DON reviewed Resident 7's MAR and nursing notes and stated she could not determine how much fluid Resident 7 consumed during breakfast, lunch, and dinner. The DON stated a care plan addressing hydration/dehydration was not developed because the nursing staff did not accurately process the physician's orders [REDACTED]. On August 23, 2017 at 10:25 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 7 had variable fluid intake. LVN 1 reviewed Resident 7's MAR for the month of August 2017 and was unable to determine how much fluid Resident 7 consumed during breakfast, lunch, and/or dinner. LVN 1 stated she monitored Resident 7's fluid intake by adding the resident's fluid intake from breakfast, snacks, medications, and fluids offered during shift. LVN 1 was unable to provide documented evidence of monitoring the resident's fluid intake to ensure the specific amount of fluid ordered by the physician, was consumed, during her shift. A review of the documentation by the Certified Nursing Assistants (CNAs) for the month of August 2017 indicated the amount of fluid Resident 7 consumed was not included. A review of Resident 7's meal intake report, indicated the resident refused dinner five evenings from August 15, 2017 to August 22, 2017. On August 23, 2017 at 11:05 a.m., during an interview, Medical Record staff 1 (MR 1) stated she reviewed Resident 7's CNAs documentation and could not find a specific amount of fluid entered in the record by the CNAs. On August 23, 2017 from 12:10 p.m. to 12:34 p.m., during dining observation, Resident 7 did not consume the milk nectar (240 ml) or orange juice (120 ml). Resident 7 consumed less than 25 percent of the health shake (120 ml). On August 23, 2017 at 1 p.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated Resident 7 refused to eat breakfast and lunch on the same day and she notified LVN 1. On August 24, 2017 at 7:30 a.m., during an interview, the DON stated Resident 7 was transferred to the GACH on August 24, 2017 at 1:26 a.m. for further evaluation due to abnormal laboratory results. A review of Resident 7's laboratory results dated [DATE] and timed 12:58 a.m., indicated the following: 1. BUN of 44 mg/dl (above the reference range 7-25 mg/dl). 2. Creatinine of 1.59 mg/dl (above the reference range 0.60-1.20 mg/dl). 3. Sodium of 156 mEq/L (above the reference range 136-145 mEq/L). 4. Potassium of 5.3 mEq/L (above the reference range 3.5-5.1 mEq/L). 5. BUN/Cr ratio of 27.7 (above the reference range of 10.0-20.0). A BUN/CR ratio greater than 20 is an indicator for impending dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, and Page 47). 6. eGFR of 31 (below the reference of equal or greater than 60, a range of 30 to 59 indicates moderately reduced kidney function). There are laboratory values that may indicate signs of dehydration: Elevated BUN, (reference range 5-20 mg/dL) when the body is dehydrated the kidneys will reabsorb water to compensate the loss; with water, BUN is also reabsorbed passively in the kidney tubules thus increasing the BUN level. When fluid volume is diminished - as it is during dehydration - the renal tubules increase their re-absorption of waste, which in turn increases the re-absorption of urea (a substance normally cleared from the blood by the kidney into the urine). The result is an increased BUN. Elevated sodium may support dehydration, as sodium is retained to conserve water. (AJN May 1999- Vol. 99-Issue 5 PP 66-69). Water depletion (reduced quantity) in the elderly is characterized by [MEDICAL CONDITION]. (Journal of National Medical Association, 1987- Vol. 79-Issue 10 PP 1033-1038). Dehydration is a condition in which the total body's fluids (intra and extra vascular) volume is reduced or depleted due to several causes including insufficient fluid consumption. The clinical signs of dehydration included fever and altered level of consciousness. Delayed treatment or delayed hydration may lead to acute [MEDICAL CONDITION], which is a sudden decrease in renal function which, if uncorrected, can lead, to irreversible tubular necrosis (AJN May 1999, Vol. 99, Issue 5, Pp. 66 - 69). On August 24, 2017 at 8:45 a.m., during an interview, Resident 7's family member (FM 1) stated Resident 7 had been slowly declining for a week and a half. FM 1 stated Resident 7 had become less talkative and had a decreased appetite. On August 24, 2017 at 11:05 a.m., during an interview, the RD stated if the fluids (health shake, milk nectar, and orange juice) were not on the resident's meal tray and the meal intake documentation was inaccurate, it was possible Resident 7 was not meeting her estimated fluid intake needs. A review of the GACH emergency room report dated August 24, 2017, indicated Resident 7 was in serious condition and was to be admitted to the telemetry unit (a hospital unit with patients under continuous electronic monitoring). The [DIAGNOSES REDACTED]. A review of the MAR from the GACH, indicated Resident 7 received 2500 ml bolus (rapid infusion) of normal saline on August 24, 2017 from 2:30 a.m. to 5:35 a.m. in the Emergency Department and 9000 ml of fluids (0.45 percent normal saline with 20 mEq/L potassium chloride at 75 ml per hour) from August 26, 2017 to August 31, 2017. A review of the facility's revised policy and procedure dated December 2011, titled Resident Hydration and Prevention of Dehydration indicated the facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standard of practice. The dietitian will include resident preference in distribution of allowed fluid. Nursing will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. A review of the facility's revised policy and procedure dated February 2017, titled Food and Mealtime Preferences-Meal service/ Food Preferences indicated that food and meal preference information is gathered from the residents for use in meeting their personal tastes and nutritional needs.

Based on observation, interview, and record review the facility failed to ensure Resident 8, who had a history of [REDACTED].: 1. Develop a plan of care with interventions clinically proven, useful and effective in the prevention of recurrent falls that resulted in a fracture of the right femur from a third fall. 2. Closely monitor the resident at set intervals to anticipate her need to use the bathroom, and provide assistance and/or ask whether she needed assistance with toileting. 3. Provide supervision and/or frequent scheduled nursing rounds to ensure a resident receiving two psychoactive medications that increased the risk for falls would not get out of bed unnoticed and go to the bathroom unassisted. 4. Apply a monitoring device such as a bed-alarm (a devise used to alert care givers with an audio alarm when a resident attempts to get out of a chair or bed unassisted) in order to prevent the resident from getting out of bed unnoticed and go to the bathroom unsupervised. Findings: On August 8, 2011, during the group interview/meeting with alert and oriented members of the Resident Council, it was brought to the attention of the survey team that there was a problem related to call lights not being answered timely. It was also stated that a fell ow resident, Resident 8, was transferred to the acute care hospital after she fell from bed and sustained an injury. Investigation of the incident revealed Resident 8 had three falls since admittance to the facility. The resident sustained [REDACTED]. The resident was transferred to the acute care hospital and had a surgery under a general anesthesia to repair the fractured femur and readmitted back to the facility on [DATE]. A review of the admission record revealed Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact, required extensive assistance from staff members for transfer, locomotion on the unit, dressing, and toilet use, with activity of daily living (ADL) support provided by staff members with one person physical assist. The resident had functional limitations in range of motion of the upper extremities. The resident was always continent of bowel and bladder. The resident had occasional moderate pain and insomnia. On August 5, 2011, at 6:15 p.m., during the initial tour of the facility, the resident was observed lying in bed, and was alert and oriented. According to Registered Nurse 4 (RN 4) who was present during the tour, the resident was very forgetful, and was able to walk to the bathroom, although a commode (portable toilet) was present at her bedside. The physician's orders [REDACTED]. 1. Restoril 15 milligrams (mg) at bed time as needed for insomnia ordered on June 11, 2011. According to the Medication administration Record (MAR), the resident had received fifteen doses of Restoril 15 mg, during the month of June, 2011, and ten doses in July, 2011, at bed time as needed. 2. Xanax 0.5 mg by mouth twice a day at 9 a.m. and 5 p.m. for anxiety manifested by restlessness ordered on June 11, 2011. According to the MAR, the resident received this medication until June 22, 2011. On June 22, 2011, the dosage was changed to 0.25 mg at 9 a.m. and 0.5 mg at 5 p.m. daily. According to the MAR, the resident had received the medication as ordered until July 23, 2011. On July 23, 2011, the dosage was changed to 0.5 mg at bedtime only. According to the MAR, the resident had received the medication as ordered until August 5, 2011. On August 5, 2011, the dosage was again changed 0.25 mg by mouth at 9 a.m. daily and 0.5 mg at bedtime. According to the MAR, the resident had received the medication as ordered. The half-life of Xanax is 19.5 hours and its elimination from the body in prolonged in the elderly. However, the resident received high doses of up to 0.5 mg daily including on August 5, 2011, at 9 p.m. approximately five and one-half hours before the fall. Restoril is a drug known to have adverse drug reactions that include drowsiness, dizziness, confusion, sedation, ataxia (a lack of muscle coordination during voluntary movements, such as walking or picking up objects), and impaired coordination. Restoril has a half-life (period of time that takes for a substance/drug to lose half of its pharmacologic effects) of up to 18.4 hours. Xanax is a sedative hypnotic drug that causes drowsiness, dizziness, confusion and sedation and it has half-life of 19.5 hours and its elimination from the body in prolonged in the elderly. Both Restoril and Xanax increase the risk for falls. (Geriatric Drug Therapy Handbook, Pages 40-41 and 868). According to the plan of care initiated on June 11, 2011, fall was identified as a problem and a goal was set that stated ... "Resident will be free from injuries daily." The plan of care had interventions that included assisting the resident with ADLs (activities of daily living), providing supervision, visually check frequently (not specified how frequently), provide a low bed, and encourage to call for help. The care plan lacked specificity and did not include interventions useful and effective in minimizing falls and preventing an injury from falls. For example, one of the interventions was to provide supervision. The care plan, however, did not indicate the frequency, designated responsibility, when and how supervision was to be provided. Another plan of care dated June 11, 2011, on continence indicated interventions that included assisting the resident to the toilet at least before and after meals. However, this plan of care did not include interventions to address the resident's toileting needs during the night. A review of the resident's clinical record from June 18, 2011, to July 20, 2011, revealed the resident had the following falls: First Fall According to the licensed nurse's notes dated June 18, 2011, at 10 a.m., seven days after admission, Certified Nursing Assistant 3 (CNA 3) found the resident sitting on the floor. The resident told CNA 3 she lost her balance and fell as she was trying to grab the edge of the bathroom door. During assessment, it was discovered that the resident had sustained a skin tear to the right elbow that measured two centimeters (cm.) by 0.3 cm. The wound was cleansed and triple antibiotic and steristrip was applied. The resident was able to move all four extremities and denied pain at that time. According to the MAR, on June 17, 2011, the day and the night before the fall, the resident had received Xanax 0.5 mg at 9 a.m. and 5 p.m. and Restoril 15 mg at bedtime. On June 18, 2011, the plan of care was updated to include intervention for " Bladder/Bowel Management." This intervention lacked specificity in that it did not state the process involved, and the time and the designated person(s) in bladder/bowel management was not identified. The plan of care was not updated to include clinically proven and evidence-based useful and effective interventions to prevent a major injury from a fall. For example, the resident's behavior of using the bathroom was not assessed in order to include specific interventions that would not allow the resident to get out of bed unnoticed, and use the bathroom unattended and unsupervised. A review of the literature indicates that falls frequently occur when residents get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent "structured" nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the resident needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in patients'/residents' use of call lights and the incidence of falls, and with an increase in resident satisfaction (Stefancyk, Amanda, "Safe and Reliable Care," American Journal of Nursing, July 2009, Volume 109 No. 7, Pages 70-71). Second Fall A review of the licensed nurses' note dated July 20, 2011, at 7:45 a.m., revealed the resident had the second fall in the facility. The note indicated she was found sitting on the floor beside her bed in front of her walker. The resident stated she was going to the bathroom and some how she lost her balance and fell . The nursing assessment indicated the resident had a "skin tear" on the right elbow that measured approximately one cm by one cm and there was no bleeding noted, but the elbow seemed bumpy when touched. The resident complained of pain to the right elbow, right shoulder, right hip, lower back, and to her head. The resident was able to move the upper and lower extremities. An x-ray was ordered and the result was negative for fractures. A review of the Plan of Treatment for Outpatient Rehabilitation form dated July 22, 2011, indicated following this fall, the resident had a significant decline in mobility and gait with strength and balance deficit, decrease in safety awareness, and required extensive assist in mobility and gait. According to the MAR for July 19, 2011, the day and evening prior to the resident's fall, the resident had received the following medications that may have contributed to her fall due to the potential side effects mentioned above: 1. Xanax 0.25 mg at 9 a.m. and 0.5 mg at 5 p.m. 2. Restoril 15 mg at 10 p.m. (approximately 10 hours prior to the second fall). The resident had the second fall because the interventions were not useful to alert the facility staff when the resident attempted to get out of bed, stood up unnoticed and attempted to go the bathroom unsupervised or unassisted, until she was found on the floor. In addition, considering the resident's history of falls prior to admission, and two subsequent falls in the facility, the effects of the medications the resident received and their potential to increase the risk for falls, was not assessed in order to include the appropriate interventions to supervise the resident's behavior of getting up unassisted. On July 20, 2011, the plan of care was updated to include an intervention that stated "Bedside commode." However, the resident's ability to independently use the bedside commode, especially while she received sleeping medication as needed, was not assessed to ensure the updated plan of care included interventions to achieve the goal stated. The interventions did not include specific nursing actions to prevent injuries from falls. For example, the updated plan of care did not include nursing actions to anticipate the resident's toileting needs or to apply a device such as a bed-alarm to alert the staff and provide timely assistance before the resident got out of her bed unnoticed, and attempted to go to the bathroom unattended or unsupervised. A review of the literature indicates high-risk patients (residents) require close observation and surveillance. Move the person at risk for falls closer to the nurses' station, and use bed alarms. Meade and colleagues found that hourly rounds that are focused on anticipating and meeting residents' needs helps prevent injuries from falls, and nursing assistants are especially critical to its success (AJN, American Journal of Nursing: March 2008 - Volume 108 - Issue 3 - p 40-49). Third Fall According to the licensed nurse note dated August 6, 2011, at 2:30 a.m., a facility staff member heard a noise. CNA 3 went to the resident's room and found the resident on the floor next to the bathroom door. According to the note the resident told CNA 3 that she lost her balance and fell while trying to use the bathroom. A walking cane (assistive device) was next to her bed but the resident did not use it to ambulate. The resident's call light was still clipped to her blanket. The bedside commode was next to her bed. The resident had a swollen right thigh and complained of pain rated at 10 on a pain rating scale of 1 to 10 (10 being the worst pain). On August 6, 2011, at 5:55 p.m., during an interview with the director of staff development (DSD), she stated the fall incident happened between 2:30 a.m. to 3 a.m. on August 6, 2011. According to her, she did not hear the call light but she learned of the resident's fall from Registered Nurse 1 (RN 1). The DSD and RN 1 went to the resident's room and observed the resident sitting on the floor with her back leaning on the right side of the wall in her room near her bed with the right leg internally rotated and the resident was screaming that she was in extreme pain. The resident's affected leg was immobilized and she was transferred to the acute care hospital in an ambulance. During an interview with the director of nursing (DON) on August 6, 2011, at 8 p.m., she stated they (facility staff) were not able to place a bed alarm since the interdisciplinary team did not identify the use of a bed alarm as a useful intervention. According to the DON, the resident was non-compliant in using the call light. However, the issue of the resident's non-compliance with the use of the call light was not addressed, with appropriate interventions to ensure the resident did not get out of bed unnoticed or without supervision, and go to the bathroom unattended and without assistance. A review of the acute hospital emergency room (ER) medical record indicated the resident was received at the ER with a swollen and deformed right thigh and a head injury that resulted in loss of consciousness. The x-ray report revealed oblique, overriding, and angled fracture of the proximal shaft of the right femur. The ER report also indicated the right thigh was growing in size and the blood pressure dropped to 97/56. A blood transfusion was started, and Resident 8 was admitted to the acute care hospital. Surgery was performed (known as open reduction internal fixation with intramedullary rod placement and nailing) under a general anesthesia, to repair the fractured femur. Literature indicates the risk and complications associated with a surgery under a general anesthesia included bleeding, infection, heart attack, pneumonia, and kidney failure during or after an operation, deep venous thrombosis ((DVT) occurs when blood clots develop in the large veins of the leg. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) (Savel, Richard H., "Postoperative Care." Hospital Medicine. 2nd. Ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261-269). A review of the discharge summary revealed the resident was hospitalized from August 6, 2011, until discharged to the skilled nursing facility on August 10, 2011. According to the discharge summary, the resident required extensive physical therapy. A review of the literature indicates that in the older adult, traumatic injuries are typically more severe than a younger resident's and prospects for survival less certain. Recovery takes longer and the threat of complications looms larger (Stamatos, Christine A. RN, MS, CCRN and Co. American Journal of Nursing: May 1996- Volume 96-Issue 5-Pages 40-47). Cross Refer to F329 - 483.25(l) Drug Regimen is Free from Unnecessary Drugs.