Every finding on record at The Health Center at Standifer Place

Based on observation and interview, the facility failed to ensure 2 of 2 Physical Therapy Gym's mat platform tables were maintained in good repair. The findings include:During an observation on 7/23/2025 at 11:20 AM, in the facility's Physical Therapy Gym, revealed 2 mat platform tables had multiple large rips and tears which exposed the foam padding.During an interview on 7/23/2025 at 11:25 AM, the facility's Director of Therapy, confirmed, .the rips and tears have been there a while and I see what you are saying, they could be a problem, and we do need them covered or replaced .

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure biohazard waste was contained properly for 1 resident (Resident #3) of 6 residents observed on transmission based precautions, failed to ensure a sanitary environment for 1 resident (Resident #95) of 4 residents observed, and failed to offer hand hygiene assistance prior to meals to 5 residents (Residents #244, #199, #268, #359, and #350) on 1 of 4 hallways observed for meal tray distribution.The findings include:Review of the facility's policy titled, Handwashing and Hand Hygiene, dated 10/2024 revealed .staff will encourage residents to complete hand hygiene .before eating .Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Tracheostomy (surgical opening the trachea that provides airway for breathing) and Multi-Drug-Resistant Organisms (MDRO) and was in Contact Precautions and Droplet Precautions.During an observation on 7/21/2025 at 3:08 PM, in Resident # 3's room, revealed the biohazard trash container contents was overflowing with the used Personal Protective Equipment (PPE) onto the floor. Continued observation revealed the cubical curtains were being held in place with the biohazard trash container. Medical record review revealed Resident #95 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Lower Lobe, Right Bronchus of Lung, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, and Hypertension.During an observation on 7/21/2025 at 3:00 PM, revealed Resident #95's urinal was observed with urine, sitting on his overbed table adjacent to his water pitcher.During an interview on 7/21/2025 at 3:30 PM, the Unit Manager stated she was unaware the biohazard trash container was overflowing and stated she did not realize the biohazard trash container was touching the cubicle curtains and held them back in place. The Unit Manager further confirmed the urinal stored on Resident #95's overbed table did not follow safe infection control practices.During an observation on 7/22/2025 at 8:40 AM and 12:04 PM, revealed Resident #95's urinal was observed with urine, sitting on his overbed table adjacent to his water pitcher.During an observation on 7/23/2025 at 7:30 AM, revealed Resident #95's urinal was observed with urine, sitting on his overbed table adjacent to his water pitcher.Review of the medical record revealed Resident #244 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance, Moderate Protein-Calorie Malnutrition, and Cognitive Communication Deficit.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #244 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #244 required setup or clean-up assistance with eating and required supervision or touching assistance with personal hygiene.Review of Resident #244's comprehensive care plan dated 6/17/2025, revealed .ADLs [Activities of Daily Living] Functional .requires assistance with her ADLs d/t [due to] impaired mobility and generalized weakness r/t [related to] Dementia with Psychosis .lack of coordination .muscle weakness .During an observation on 7/22/2025 at 8:39 AM, of the breakfast meal tray pass, revealed Certified Nursing Assistant (CNA) A brought Resident #244's meal tray into the resident's room and placed the meal tray in front of the resident. CNA A set up the resident's meal tray and failed to offer hand hygiene assistance prior to the meal. Review of the medical record revealed Resident #199 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Muscle Weakness, and Lack of Coordination.Review of Resident #199's comprehensive care plan dated 4/29/2025, revealed .ADLs Functional .requires assistance with her ADLs d/t impaired mobility, generalized weakness .moderately advanced Vascular Dementia .able to feed herself after meal tray is setup .Review of a quarterly MDS assessment dated [DATE], revealed Resident #199 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #199 required setup or clean-up assistance with eating and required substantial/maximal assistance with personal hygiene.During an observation on 7/22/2025 at 8:42 AM, of the breakfast meal tray pass, revealed CNA A brought Resident #199's meal tray into the resident's room and placed the meal tray in front of the resident. CNA A set up the resident's meal tray and failed to offer hand hygiene assistance prior to the meal. Review of the medical record revealed Resident #268 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (complete paralysis) and Hemiparesis (loss of strength) following Cerebral Infarction (Stroke) affecting Left Non-Dominant Side and Lack of Coordination.Review of an annual MDS assessment dated [DATE], revealed Resident #268 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #268 was independent with eating.Review of Resident #268's comprehensive care plan dated 5/19/2025, revealed .ADLs Functional .requires assistance w/ [with] ADL's d/t dx [diagnoses] of left sided hemiparesis mild from CVA [Cerebrovascular Accident] .lack of coordination .During an observation on 7/22/2025 at 8:42 AM, of the breakfast meal tray pass, revealed CNA A brought Resident #268's meal tray into the resident's room and placed the meal tray in front of the resident. CNA A set up the resident's meal tray and failed to offer hand hygiene assistance prior to the meal. During an interview on 7/22/2025 at 8:54 AM, Resident #268 confirmed CNA A had not offered the resident hand hygiene assistance prior to the breakfast meal.Review of the medical record revealed Resident #359 was admitted to the facility on [DATE] with diagnoses including Dementia with Other Behavioral Disturbance and Muscle Weakness.Review of an annual MDS assessment dated [DATE], revealed Resident #359 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #359 was independent with eating. Review of Resident #359's comprehensive care plan dated 5/22/2025, revealed .ADLs Functional .requires assistance with ADLs d/t decreased mobility and weakness r/t .muscle weakness .During an observation on 7/22/2025 at 8:45 AM, of the breakfast meal tray pass, revealed CNA A brought Resident #359's meal tray into the resident's room and placed the meal tray in front of the resident. CNA A set up the resident's meal tray and did not offer hand hygiene assistance prior to the meal. During an interview on 7/22/2025 at 8:51 AM, Resident #359 confirmed CNA A had not offered the resident hand hygiene prior to the breakfast meal.Review of the medical record revealed Resident #350 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis and Hemiplegia affecting Left Nondominant Side.Review of a significant change in status MDS assessment dated [DATE], revealed Resident #350 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #350 required setup or clean up assistance with meals and required partial/moderate assistance with personal hygiene.Review of Resident #350's comprehensive care plan dated 5/27/2025, revealed .ADLs Functional .requires assistance with ADL's d/t .generalized muscle weakness with diagnosis of Multiple Sclerosis, intellectual disabilities .hx [history] of CVA .L [left] hemiparesis .During an observation on 7/22/2025 at 8:47 AM, of the breakfast meal tray pass, revealed CNA A brought Resident #350's meal tray into the resident's room and placed the meal tray in front of the resident. CNA A set up the resident's meal tray and did not offer hand hygiene assistance prior to the meal. During an interview on 7/22/2025 at 8:50 AM, CNA A confirmed she failed to offer hand hygiene assistance to Residents #199, #244, #268, #359, and #350 prior to the residents eating the breakfast meal.During an interview on 7/22/2025 at 1:09 PM, the 2 East/West Unit Manager confirmed the expectation was for staff to offer hand hygiene assistance to residents prior to meals.During an interview on 7/22/2025 at 3:50 PM, the Director of Nursing stated staff were expected to ensure cleanliness of resident's hands prior to meals.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 of 3 dumpsters (dumpster B) and failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition. The findings include:Review of the facility's policy titled, Garbage/Refuse Disposal, dated 5/2023, revealed .All garbage, refuse .shall be disposed of in a sanitary manner .The area around dumpsters shall be free of waste products, including paper trash .but not limited to .gloves .to prevent harborage and feeding of pests .During an observation of the outside dumpster area on 7/22/2025 at 10:43 AM, with the Dietary Manager, revealed 3 dumpsters for waste disposal. Observation of the ground surrounding the dumpster area revealed cardboard, multiple gloves, and multiple plastic eating utensils. Further observation revealed 1 dumpster (dumpster B) had no drain plug intact resulting in the dumpster contents being left open to the elements and potential to attract pests.During an interview on 7/22/2025 at 10:45 AM, the Dietary Manager confirmed the dumpster area was not maintained properly, the drain plug for (dumpster B) was not intact and the dumpster contents were not contained properly.

Based on facility Respiratory Therapy Manual review, medical record review, observation, and interview, the facility failed to properly date and store a nasal cannula for 1 resident (Resident #220) of 7 residents reviewed for oxygen therapy and failed to properly date an inline suction catheter (closed suction system designed to remove secretions in patients with artificial airways) for 1 resident (Resident #147) of 11 residents sampled with inline suction catheters.The findings include: Review of the facility's undated Respiratory Therapy Manual revealed .Change Out of Respiratory Disposables.applies to OXYGEN .VENTILATORS.SUCTION.Nasal Cannulas.Inline suction catheters.are to be changed weekly. Medical record review revealed Resident #147 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Tracheostomy Status (surgically created opening into the windpipe to provide an alternative airway for breathing), and Ventilator Status (machine used to mechanically support or replace the breathing of a person who is ill, injured or anesthetized). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #147 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Comprehensive Care plan dated 4/30/2025, revealed Resident #147 had a Respiratory care plan indicating . Vent [Ventilator] chronic .compromised airway secondary to trach [tracheostomy] .decreased secretion clearance .Suction as needed . Review of the Physician Order Report for Resident #147, dated 4/30/2025, revealed .VENT/Trach SUCTION PRN [as needed] . During an observation in Resident #147's room on 7/22/2025 at 9:30 AM, Resident #147's inline suction catheter was observed undated. During an observation and interview in Resident #147's room on 7/22/2025 at 10:00 AM, Resident #147's inline suction catheter was observed undated. Respiratory Therapist (RT) B confirmed Resident #147's inline suction catheter was not dated and was unsure when it had been changed. RT B stated it was the facility's policy all inline suction catheters were to be dated. During an interview on 7/23/2025 at 4:00 PM, the Director of Respiratory Care stated it was her expectation and facility policy that all respiratory disposables, to include inline suction catheters were to be dated. The Director of Respiratory care confirmed if Resident #147's inline suction catheter was not dated when observed on 7/22/2025, staff did not follow facility policy. Review of the medical record revealed Resident #220 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Atrial Fibrillation. Review of a quarterly MDS assessment dated [DATE], revealed Resident #220 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Care Plan for Resident #220 initiated 1/26/2025 and revised 7/15/2025, revealed .at risk for respiratory complications. She has a dx COPD, Acute Respiratory Failure with Hypoxia.Change tubing per policy. Review of the Physician Order Report for Resident #220, revealed an order dated 6/1/2025 for .Oxygen at 2-5 L [liters]/min [minute] via [by way of] nasal cannula.PRN . During an observation in Resident #220's room on 7/21/2025 at 2:09 PM, an unused nasal cannula was observed connected to the concentrator undated, uncovered and open to air. During an observation and interview in Resident #220's room on 7/22/2025 at 8:38 AM, the 2 West/2 East Assistant Unit Manager confirmed the nasal cannula was observed connected to the concentrator, not dated, and not stored in a bag. The 2 West/2 East Assistant Unit Manager stated the nasal cannula should have been dated and stored in a plastic bag when not in use. During an interview on 7/23/2025 at 1:22 PM, the Director of Respiratory Care confirmed respiratory disposables, such as nasal cannulas should be dated and stored in plastic equipment bags when not in use.

Based on facility policy review, medical record review, observation, and interview, the facility failed to revise the care plan for 1 resident (Resident #142) of 42 residents reviewed for care plans. The findings include:Review of the facility's policy titled, Care Plan Policy, dated 12/2023, revealed .comprehensive care plan .includes .services that are to be furnished .maintain the resident's highest practicable .well-being .individualized interventions .care plans are updated as needed .Review of the facility's policy titled, Side Rail Assessment, dated 11/2018, revealed .side rail(s) are used to assist with resident safety, positioning .update care plan as needed .Review of the medical record revealed Resident #142 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Hypertension, and Moderate Protein-Calorie Malnutrition.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #142 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.Review of the comprehensive care plan for Resident #142 dated 7/9/2025, revealed .risk for falls d/t [due to] decreased mobility, unsteady gait, poor safety awareness, and/or medication usage .has a complicating dx [diagnosis] of muscle weakness, lack of coordination, and abnormal posture d/t hereditary ataxias .will be maintained in a safe environment .bilateral 1/4 upper side rails up while resident in bed r/t [related to] resident representative request. Resident representative denied use of any other interventions and requested to keep side rails up for safety/mobility and transfers .R/L [Right/Left] upper side rails raised to assist with bed mobility .During an observation on 7/22/2025 at 7:15 AM, Resident #142 was lying in bed with 2 upper and 2 lower 1/4 side rails in the up position. During an interview on 7/22/2025 at 7:30 AM, Certified Nursing Assistant (CNA) C confirmed Resident #142 had both 1/4 upper and lower side rails in the up position. CNA C stated staff must have put the 4 side rails up when they assisted Resident #142 to bed last night.During an observation on 7/23/2025 at 7:17 AM, Resident #142 was lying in bed with 2 upper and 2 lower 1/4 side rails in the up position. During an interview and observation in Resident #142's room on 7/23/2025 at 7:26 AM, Licensed Practical Nurse (LPN) D confirmed Resident #142 was lying in bed with 2 upper and 2 lower 1/4 side rails in the up position. During an interview on 7/23/2025 at 7:57 AM, the Director of Nursing (DON) and LPN E confirmed Resident #142's care plan was not revised to include the resident's preference for the use of 4 1/4 side rails in the up position.During an interview on 7/23/2025 at 10:19 AM, Resident #142 confirmed he preferred the use of 4 1/4 side rails in the up position to aid in his mobility.

Based on medical record review, review of the facility grievance logs, observations and interviews, the facility failed to maintain clean, comfortable, sanitary and homelike conditions, for 2 residents (Residents #17 and #18) of 18 sampled residents, in 1 of 2 buildings, on 2 of 12 nursing units observed for environment. The facility failure resulted in unsanitary conditions in resident rooms and bathrooms for the impacted residents. Medical record review showed Resident #17 was admitted to the facility on [DATE] with diagnoses including Aphasia Following Cerebral Vascular Accident, Hemiplegia, Type 2 Diabetes, Hypertension, Depression and Barrett's Esophagus. Resident #17 discharged from the facility on 1/16/2023 at request of the family. Review of facility grievance logs showed Resident #17's family filed grievances related to care concerns prior to the resident's discharge on 1/16/2023. Interview with the Housekeeping Services Director (HSD) on 3/27/2023 at 5:52 PM in the conference room, revealed he had received complaints from the Administrator and Director of Nursing (DON) related to conditions inside Resident #17's room on 1/13/2023, shortly after the resident arrived for admission. The HSD reported he did go the room and inspect concerns voiced by the resident and his family, after they arrived for admission, viewed the bathroom, and determined it had not been adequately cleaned to the facility standards. The HSD reported he then exited the bathroom and immediately apologized to the family, then ordered staff to deep clean the entire room.The HSD reported the room flooring and bathroom flooring had water stains on it, debris near the junction of the wall and floor tiles, and it did not appear clean. The HSD reported the toilet and floor of the bathroom were also unkempt and appeared to not have been cleaned to facility expectations in advance of the new admission, per facility standards. Interview with the Administrator and observations of the [NAME] building on 3/27/2023 at 7:20 PM, revealed the Administrator reported on 1/16/2023, he was called to the [NAME] building to speak with the resident's daughter regarding complaints about room conditions which began on admission. The Administrator reported he viewed the bathroom in Resident #17's room, determined it was not sufficiently cleaned to the facility standards, apologized to the family for the oversight, contacted the housekeeping supervisor, then ordered the situation rectified at once. The Administrator confirmed the facility failed to provide clean, comfortable and sanitary conditions for Resident #17. Medical record review showed Resident #18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Type 2 Diabetes, Major Depression, Generalized Anxiety, Atherosclerotic Heart Disease, Congestive Heart Failure, Bipolar Disorder, and Peripheral Vascular Disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #18 was severely cognitively impaired, had behaviors directed at self or others, impaired thought processes and was dependent upon one or two persons for all activities of daily living (ADLs). Observations of Resident #18's room on 3/27/2023 at 4:50 PM, showed the floor was stained with water marks and dark debris near the edges of the tiles nearest the walls, and the floor was sticky when walked on. Continued observations of the bathroom showed the bathroom was also dirty, with sticky floors, stained tile, fecal material was in the toilet, and observations of the commode showed a dark brown to black ring around the entire circumference of the base of the commode, where it was affixed to the floor. Observations of Resident #18's room, conducted with the facility Administrator on 3/27/2023 at 7:15 PM, showed conditions were unchanged from the prior observations. The Administrator confirmed the room was not cleaned to facility expectations and confirmed the facility failed to maintain clean, comfortable and homelike conditions in Resident #18's room.

Based on the medical record review and interviews the facility failed to provide restorative nursing care for 1 resident (Resident #91) of 10 residents reviewed. The findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #91 had moderate cognitive impairment. He required extensive assistance of 2 staff persons with bed mobility, extensive assistance of 1 staff person with dressing, toileting, and personal hygiene. The resident required set up assistance with meals and could eat independently. Resident #91 received 170 minutes of occupational therapy services and 134 minutes of physical therapy services. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .B LE as tolerated . Review of the care plan dated 4/11/2022 showed .Restorative ROM [Range of Motion] .B LE [Bilateral Lower Extremity] as tolerated .[NAME] tech [Restorative technician] will provide AAROM [Active Assisted Range of Motion] B LE .x 10 reps [repetitions] x 2 sets or as tolerated . During an interview on 6/8/2022 at 3:55 PM, the Physical Therapy Assistant Director stated there is an active order, but restorative had not seen Resident #91 since 4/19/2022. During an interview on 6/9/2022 at 7:48 AM, Licensed Practical Nurse (LPN) #1 stated she had not observed therapy/restorative working with Resident #91 recently. During an interview on 6/9/2022 at 8:23 AM, the Director of Therapy and Restorative Services confirmed Resident #91 had not received restorative services since 4/19/2022.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure infection control practices were followed for 1 resident (Resident #540) of 4 residents reviewed for transmission-based precautions which had the potential to result in transmission of COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus). The findings include: Review of the facility's undated policy titled, INFECTION PREVENTION AND CONTROL PROGRAM/PLAN, showed .will maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Transmission-based Precautions are used additionally with Standard Precautions when caring for those residents who are known or suspected to be infected or colonized with pathogens that can be transmitted by contact or by droplets .A medical staff order is needed for the application and removal of transmission-based precautions .Patients with medical staff orders for transmission-based precautions are identified with the presence of an isolation kit located outside of the patient's care area with the appropriate donning apparel. The type of transmission-based precaution is identified on the isolation kit with instructions for facility staff . Resident #540 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Transmission Based Precautions - Covid Isolation (Contact & [and] Droplet) .Start Date .06/02/2022 .End Date .06/16/2022 . During an observation on 6/6/2022 at 12:30 PM, there was a sign on Resident #540's door that read, OBSERVATION ROOM .MASK, GOWN & EYE PROTECTION REQUIRED TRANSMISION PRECAUTIONS IN PLACE . Further observation showed Certified Nursing Assistant (CNA) #1 entered Resident #540's room wearing a mask and eye protection. The CNA did not don a gown or gloves for the resident care interaction. During an interview on 6/6/2022 at 12:31 PM, CNA #1 stated .I don't know .I think the signage is old . when asked if Resident #540 was in isolation. During an interview on 6/6/2022 at 12:32 PM, with Unit Manager #1 and CNA #1, Unit Manager #1 confirmed Resident #540 was in Transmission Based Precautions due to a recent return from the hospital on 6/2/2022. CNA #1 confirmed a gown and gloves were not donned for the interaction with Resident #540. During an interview on 6/8/2022 at 4:51 PM, Unit Manager #1 and Unit Manager #2 confirmed it was their expectation for staff to don appropriate Personal Protective Equipment (PPE) for residents in Transmission Based Precautions. Further interview confirmed CNA #1 should have donned a gown, gloves, mask, and eye protection prior to entering Resident #540's room. During an interview on 6/9/2022 at 9:23 AM, the Director of Nursing confirmed it was her expectation for staff to observe and wear appropriate PPE when entering isolation rooms.

Based on medical record review and interviews, the facility failed to address the Pharmacist's recommendations for 1 resident (Resident #114) of 5 residents reviewed for unnecessary medications. The findings include: Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including [CONDITION(S)], Anxiety Disorder, Major Depressive Disorder, Encounter for Palliative Care (Hospice), and Unspecified Dementia without Behavioral Disturbance. Review of the Clinical Pharmacist Review dated 3/10/2022 showed .[MEDICATION(S)] [a medication to treat mental disorders] .[MEDICATION(S)] [a medication to treat mental disorders] XR [extended release] 50 mg [milligrams] .[MEDICATION(S)] [an anxiety medication] 5 mg .Please review for possible trial gradual dose reduction if patient is ineligible, document reason . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #114 had moderate impaired cognition. Review of the 7 day look back showed the resident received antipsychotic and antidepressants medications for 7 days. During an interview on 6/9/2022 at 9:15 AM, the Director of Nursing stated her office was responsible for sending the pharmacy recommendations to the provider. The DON further stated she had contacted the Nurse Practitioner by telephone, and he was unable to recall if he received the recommendations dated 3/10/2022. The DON confirmed the pharmacy recommendation dated 3/10/2022 for Resident #114 was not addressed to the provider.

Based on facility policy review, medical record review, and interview, the facility failed to submit a PASRR (Preadmission Screening and Resident Review) Level II evaluation for 1 resident (Resident #193) of 6 residents reviewed for PASRR Level II evaluation. The findings include: Review of the facility policy PASRR Policy, undated, showed .Individuals who have or are suspected to have MI [Mental Illness] or ID/DD [Intellectual Disability/Mental [CONDITION(S)]] or related conditions have a level II PASRR review .when individuals with MI or ID/DD have a significant change in physical or mental condition, a new level II PASRR completed .all new orders .are reviewed no less frequently than weekly .an updated PASRR will be completed and submitted .to determine if the resident requires specialized services . Resident #193 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #193's PASRR dated 7/6/2017 showed resident .has mild Depression and Anxiety Disorder suspected his symptoms are well controlled and managed with medications as listed. Level I Outcome No Level II Condition-Level I Negative . Review of Resident #193's medical record showed a PASRR Level II was not submitted after Resident #193 received the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/08/2022 at 2:23 PM, the MDS Coordinator confirmed a PASSR Level II was not submitted when new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of facility policy, review of the Centers for Medicare and Medicaid Services (CMS) press release, review of an Internal Revenue Service (IRS) press release, medical record review, review of resident billing statements, and interview, the facility misappropriated money distributed under the CARES (Coronavirus Aid Relief and Economic Security) Act from resident funds accounts to outstanding account balances without the resident's consent for 7 of 35 residents (Residents #3, #4, #28, #29, #30, #31, and #32) reviewed with resident funds accounts. The findings included: Review of the facility policy titled Bookkeeping Manual, Patient Trust, revised 12/2009 showed .this account will protect funds such as Social Security Checks, Pension Checks, and/or gifts of cash .upon written request of the patient, the center must hold, safeguard, manage and account for the patient's personal funds through the Patient Trust Fund .is subject to any and all regulation and audit procedures required by Federal and State Agencies . Review of the facility policy titled Resident Rights, undated, showed .free from misappropriation of resident property .the patient (resident) has a right to manage his or her financial affairs .this includes the right to know, in advance, what charges a facility may impose against a patient's personal funds . Review of the CMS Press Release dated 6/11/2020 showed .CMS is aware of allegations that some nursing homes are seizing residents economic impact payments (or 'stimulus checks') .This practice is prohibited .Seizing .stimulus checks could be a violation of Federal Regulations .this could be considered misappropriation . Review of an IRS press release dated 6/16/2020 showed .IRS alert: Economic Impact Payments belong to recipient, not nursing homes or care facilities .the Economic Impact Payments do not count as resources that have to be turned over by benefit recipients of nursing homes whose care is provided by Medicaid . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #3 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of Resident #3's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 4/29/2020. Further review showed on 5/26/2020 the facility applied the entire amount of the stimulus check to bad debt recovery. During an interview on 7/20/2020 at 4:22 PM, Resident #3 stated he was compelled by the Administrator to surrender his stimulus check to pay debts owed to the facility and as of 7/20/2020 his money had not been refunded by the facility. Medical record review showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #4 scored a 15 on the BIMS. Review of Resident #4's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 5/28/2020. Further review showed on 5/29/2020 the facility applied the entire amount of the stimulus check to bad debt recovery. During an interview on 7/20/2020 at 4:05 PM, Resident #4 stated he had spoken with Administration at the facility in late May or early June 2020 regarding the facility using his economic stimulus payment to pay debts owed to the facility without his authorization. Resident #4 stated the Administrator informed him because he had signed a Resident Trust Fund Agreement, the facility was entitled to apply the $1200.00 stimulus payment to bad debt owed to the facility and no refund of his stimulus payment was possible. Resident #4 stated he investigated the matter online and upon reading public postings by multiple federal agencies he filed a formal complaint with the State Ombudsman office sometime around 7/11/2020. Resident #4 reported after the Ombudsman investigated the matter the facility issued him a refund of his economic stimulus payment on 7/14/2020 (33 days after the CMS press release). Resident #4 stated .If I wouldn't have called the state they would have kept my money. But because I did they gave it back . Medical record review showed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #28 scored a 15 on the BIMS. Review of Resident #28's billing statement from the facility showed the resident received a stimulus check on 4/29/2020 in the amount of $1200.00. Further review showed the facility withdrew the entire amount of the stimulus check on 5/8/2020 and applied it toward a Care Cost Payment (monthly bill for services rendered to the resident). There was no evidence in the medical records or billing records the facility had contacted the Power of Attorney (POA) for Resident #28 and gained authorization for the stimulus check to be applied to the resident's monthly bill. Medical record review revealed Resident #29 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #29 scored a 10 on the BIMS (moderate cognitive impairment). Review of Resident #29's billing statement from the facility showed the resident received a stimulus check on 5/28/2020 in the amount of $1200.00. Continued review showed on 6/1/2020 the facility applied the entire amount of the stimulus check toward the resident's outstanding account balance. There was no evidence in the medical record or billing records that Resident #29 or her responsible party had consented for the stimulus check to be applied to the resident's outstanding account balance. Medical record review showed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #30 scored a 1 (severe cognitive impairment) on the BIMS. Review of Resident #30's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 4/29/2020. Further review showed the facility applied the entire amount of the stimulus check toward the resident's account balance on 4/30/2020. There was no evidence in the medical record or billing record the resident's responsible party had consented to the stimulus check being applied to the resident's account balance. Medical record review showed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #31 scored a 15 on the BIMS. Review of Resident #31's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 5/28/2020. Further review showed the facility applied the entire amount of the stimulus check toward the resident's account balance on 6/1/2020. There was no evidence in the medical record or billing record the resident or the resident's responsible party had consented to the stimulus check being applied to the resident's account balance. Medical record review showed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] showed Resident #32 was unable to complete the BIMS due to his persistent vegetative state. Review of Resident #32's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 5/28/2020. Further review showed the facility applied $475.00 of the stimulus check to the resident's outstanding account balance on 6/1/2020. There was no evidence in the medical record or the billing records that Resident #32's POA had consented to $475.00 of the stimulus check being applied to the resident's outstanding account balance. During an interview on 7/20/2020 at 4:45 PM, the Director of Accounts Receivable (AR) stated between the period of late March 2020 and early April 2020 she and her assistant reviewed all resident accounts for outstanding balances owed to the facility after they became aware the residents would be receiving stimulus checks. The Director of AR stated she formulated a plan to apply the stimulus checks toward outstanding debts owed to the facility by the residents and she discussed the matter with the facility Administrator who directed the billing department to apply the stimulus checks to the resident's outstanding balances. The Director of AR reported at the time, the facility was unaware the stimulus checks were not considered income or assets and not subject to forfeiture. The Director of AR stated the stimulus checks were applied toward the resident's account balances automatically and without the prior written or oral consent of the recipients or their responsible parties. The Director stated some residents had been refunded their money, but the facility had not taken steps to address the situation facility wide until sometime around 6/30/2020 after several residents had complained. During an interview on 7/22/2020 at 11:55 AM, the Administrator and Assistant Administrator stated the facility had applied the residents' stimulus checks to debts owed to the facility without prior authorization from the residents or their responsible parties for Resident #3, Resident #4, Resident #28, Resident #29, Resident #30, Resident #31, and Resident #32.

Based on review of facility policies, review of Social Security Administration (SSA) guidance for CARES (Coronavirus Aid Relief and Economic Security) Economic Impact Payments, review of the Centers for Medicare and Medicaid Services (CMS) press release and guidance related to the disposition of Economic Stimulus Payments, an Internal Revenue Service (IRS) press release, review of a Trust Fund Permission form, medical record review, and interviews, the facility failed to ensure economic impact payments (stimulus funds) were readily available when requested by 2 residents (Residents #4 and #3) of 35 residents reviewed with resident funds accounts. The findings included: Review of the facility policy titled Bookkeeping Manual, Patient Trust, revised 12/2009 showed .this account will protect funds such as Social Security Checks, Pension Checks, and/or gifts of cash .upon written request of the patient, the center must hold, safeguard, manage and account for the patient's personal funds through the Patient Trust Fund .subject to any and all regulation and audit procedures required by Federal and State Agencies . Review of the facility policy titled Resident Rights, undated, showed .the patient (resident) has a right to manage his or her financial affairs .this includes the right to know, in advance, what charges a facility may impose against a patient's personal funds . Review of the Social Security Administration (SSA) guidance dated 5/1/2020 showed .Economic Impact Payments (EIP) .The EIP belongs to the .beneficiary .A representative payee should discuss the EIP with the beneficiary .if the beneficiary wants to use the EIP independently, the representative payee should provide the EIP to the beneficiary . Review of a CMS press release dated 6/11/2020 showed .CMS is aware of allegations that some nursing homes are seizing residents economic impact payments (or 'stimulus checks') .This practice is prohibited .Further, nursing homes requiring residents to deposit their stimulus check with the nursing home may be in violation of CFR (Code of Federal Regulations) 483.10 which gives residents the right to manage his or her financial affairs . Review of an IRS press release dated 6/16/2020 showed .IRS alert: Economic Impact Payments belong to recipient, not nursing homes or care facilities .the Economic Impact Payments do not count as resources that have to be turned over by benefit recipients of nursing homes whose care is provided by Medicaid . Review of a Patient (resident) Trust Fund Permission Form, undated, showed the form was used for those residents who wished to establish a resident funds account. The form stated .my patient trust fund belong to me and are managed by the Center as part of its services to me .this account is subject to any and all regulation .required by federal and state agencies . Further review revealed the form was to be signed by the resident or the resident's representative and was to be dated and witnessed. Medical record review showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] showed Resident #4 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of Resident #4's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 5/28/2020. Further review showed on 5/29/2020 the facility applied the entire amount of the stimulus check to bad debt recovery. During an interview on 7/20/2020 at 4:05 PM, Resident #4 stated he had spoken with Administration at the facility in late May or early June 2020 regarding the facility using his economic stimulus payment to pay debts owed to the facility without his authorization. Resident #4 stated the Administrator informed him because he had signed a Resident Trust Fund Agreement, the facility was entitled to apply the $1200.00 stimulus payment to bad debt owed to the facility and no refund of his stimulus payment was possible. Resident #4 stated he took issue with that and he investigated the matter online. Upon reading public postings by multiple federal agencies, including the Internal Revenue Service and CMS, he filed a formal complaint with the State Ombudsman office sometime around 7/11/2020. Resident #4 reported after the Ombudsman investigated the matter, sometime between 7/12/2020 to 7/14/2020, the facility issued him a refund of his economic stimulus payment on 7/14/2020. Resident #4 stated .If I wouldn't have called the state they would have kept my money. But because I did, they gave it back . During an interview on 7/21/2020 at 5:05 PM, the Administrator confirmed he was aware on 6/11/2020 that CMS had issued public guidance stating stimulus payments were not considered income or assets under current SSA and IRS guidelines. The Administrator confirmed the facility did not issue a refund of the economic stimulus payment to Resident #4 until after the State Ombudsman investigated complaints related to the matter on 7/14/2020. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #3 scored a 15 on the BIMS. Review of Resident #3's billing statement from the facility showed the resident received a stimulus check in the amount of $1200.00 on 4/29/2020. Further review showed on 5/26/2020 the facility applied the entire amount of the stimulus check to bad debt recovery. During review of Resident #3's trust fund permission form and interview on 7/20/2020 at 4:22 PM, Resident #3 stated he was compelled by the Administrator to surrender his stimulus check to pay debts owed to the facility. He stated his stimulus payment was applied to debts without his consent sometime in May 2020. Resident #3 stated he informed the Social Services Director (SSD) of the issue. The SSD investigated the matter and informed the resident the monies had been applied to debts owed to the facility by the billing office. Resident #3 stated he spoke with the Administrator and informed him he did not wish to apply the stimulus check to debts owed to the facility and he asked for a refund, which was denied. Resident #3 reported the Administrator informed him his signature on the Patient Trust Fund Permission Form legally entitled the facility to seize the funds for debt repayment. Resident #3 reported the Administrator presented him with a copy of the document which was undated, unwitnessed, and had an illegible signature on it. The resident denied the signature was his. Resident #3 stated he attempted to negotiate with the Administrator and asked for half the funds to be returned to him and half be applied to debt, which the Administrator declined again, referring to the Trust Fund Permission Form before ending the conversation. Resident #3 then provided the surveyor a copy of his Trust Fund Permission form given to him by the Administrator. Review of the form showed the signature was illegible, the witness signature line was blank, and the document was undated. Resident #3 stated sometime around 6/24/2020 he informed both the SSD and the Administrator he did not consent to application of the stimulus funds to bad debt and he had not signed the Resident Trust form as the facility alleged. Resident #3 stated as of 7/20/2020 his stimulus payment had not been refunded to him. During an interview on 7/21/2020 at 5:05 PM, the Administrator confirmed the facility applied Resident #3's stimulus check to his outstanding debt without Resident #3's prior authorization to do so. The Administrator confirmed he was aware on 6/11/2020 that CMS had issued public guidance stating stimulus payments were not considered income or assets under current SSA and IRS guidelines. The Administrator confirmed Resident #3 had requested a refund of his stimulus funds and the facility had denied the request as of 7/21/2020.

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to notify the responsible party of a fall for 1 resident (#2) of 3 residents reviewed for change in condition. The findings included: Review of the facility policy, Resident Condition Change Notification, last revised 11/2016, revealed .The medical staff .and .patient (resident) representative are to be notified when there is a patient status change . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a facility fall investigation dated 11/21/19 revealed Resident #2 fell on [DATE] at approximately 4:00 AM. Review of a facility document dated 11/23/19 revealed the responsible party for Resident #2 was not notified of the fall until 11/23/19 at approximately 6:30 PM (2days after the fall). Interview with the Director of Nursing on 12/16/19 at 7:15 PM, in the conference room, confirmed the facility failed to notify the responsible party for Resident #2 of the resident's fall on 11/21/19. Further interview confirmed the responsible party was not notified until 11/23/19 (2 days later) and the facility failed to follow facility policy.

Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (#266) was free from significant medication errors of 7 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed .Medications are administered safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in the medical management of [DIAGNOSES REDACTED].at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .[DIAGNOSES REDACTED].[MEDICAL CONDITION] (stroke) .GOAL .will remain free of .episodes of her diasease (disease) process .Administer medications as ordered . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .[MEDICATION NAME] (medication used for irregular heartbeats) . twice a day; 09:00 AM, 05:00 PM .Levetiracetam (medication used for [MEDICAL CONDITION]) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for sleep) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for high blood pressure) .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often given late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock meds (medications) until 11:30 at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain .if I don't ask for them at 8:30 (PM) or 9:00 (PM) then I may have to wait and then I'm in pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain. .of course it would .I think I would be complaining too if I was the patient . Further interview revealed the [MEDICATION NAME] and [MEDICATION NAME] administered late would place the resident at .potential risk for arrhythmia (irregular heartbeat) .for anything related to blood pressure .she has already had a stroke . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's medications timely.

Based on medical record review, review of the facility's Assignment Sheets, review of the facility's Midnight Census Reports, resident interviews, and staff interviews, the facility failed to maintain adequate staffing levels to ensure timely administration of medications for 1 resident (#266) residing on 1 unit (2 East) of 10 units observed. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .[DIAGNOSES REDACTED].[MEDICAL CONDITION] (stroke) .GOAL .will remain free of .episodes of her diasease (disease) process .Administer medications as ordered . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .[MEDICATION NAME] (medication used for irregular heartbeats) . twice a day; 09:00 AM, 05:00 PM .Levetiracetam (medication used for [MEDICAL CONDITION]) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for sleep) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for high blood pressure) .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Review of the Facility's Midnight Census Reports dated 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/16/19, 7/18/19 revealed a resident census of 53 for the 2 East Unit. Review of the Facility's assignment sheets dated 7/1/9, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/18/19 revealed one LPN on duty on the 2 East Unit for the 7:00 PM to 7:00 AM shift. Further review of the Facility's assignment sheet dated 7/16/19 revealed one LPN on duty on the 2 East Unit for 7:00 AM to 7:00 PM shift until 9:00 AM when another nurse came on duty. Continued review of the facility assignment sheet dated 7/23/19 revealed one LPN on duty on the 2 East Unit from 3:00 PM to 5:30 PM. Further review of the facility assignment sheet dated 7/24/19 revealed on LPN on duty on the 2 East Unit for the 7:00 AM to 7:00 PM shift. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with Licensed Practical Nurse (LPN) #7 on 7/28/19 at 3:50 PM, at the 2 East nurse's station, revealed she had been .pulled to another floor . on 7/23/19 and 7/24/19 leaving one nurse on the 2 East Unit. Interview with LPN #3 on 7/28/19 at 3:56 PM, at the 2 East nurse's station, revealed she works the 7:00 AM to 7:00 PM shift. Further interview revealed nurses are frequently .pulled to another floor .leaving one nurse to care for 53 residents . Continued interview revealed the last time this occurred was on 7/23/19 and 7/24/19. Interview and observation of the assignment sheets dated 7/23/19 and 7/24/19 with the Director of Nursing (DON) on 7/29/19 at 2:16 PM, in conference room A, revealed the facility's goal for staffing for the 2 East Unit was to have two LPNs on staff for the 7:00 AM to 7:00 PM shift. Further interview confirmed on 7/23/19 one LPN had been on duty from 3:00 PM until 7:00 PM due to the other LPN had been pulled to cover the 3 East Unit leaving one nurse to provide care for 53 residents. Continued interview confirmed one LPN had been on duty on the 2 East Unit on 7/24/19 for the entire shift of 7:00 AM to 7:00 PM to provide care for 53 residents. Interview with the 2 East Unit Manager on 7/29/19 at 3:39 PM, in the Unit Manager's office, revealed medications are frequently administered late when there is one nurse on duty. Further interview revealed the Unit Manager would do all of the charting, take phones calls, and take physician orders [REDACTED]. Continued interview revealed the Unit Manager works 5 days a week and the LPN on duty would have to administer medications, chart, take phone calls, and take physician orders [REDACTED]. Interview with the DON on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with LPN #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM to 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with LPN #4 on 7/30/19 at 7:23 AM, on the 2 East hallway, revealed the medications are sometimes administered late .that happens .sometimes I'm just busy with other things Continued interview revealed it was difficult to get the medications administered on time when there is one nurse on duty. Interview with LPN #5 on 7/30/19 at 7:27 AM, on the 2 East hallway, revealed medications are to be administered .1 hour before or 1 hour after the scheduled time. Further interview revealed it was difficult to administer meds on time when there was one LPN on duty .we have 52 to 53 patients . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with LPN #5 on 7/30/19 at 9:21 AM, on the 2 East hallway, revealed Resident #266's 5:00 PM medications had been administered at 7:41 PM on 7/16/19 .that's the day my partner (LPN #4) called in . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain. .of course it would .I think I would be complaining too if I was the patient . Further interview revealed the [MEDICATION NAME] and [MEDICATION NAME] administered late would place the resident at .potential risk for arrhythmia (irregular heartbeat) .for anything related to blood pressure .she has already had a stroke . Interview and observation of the 2 East Unit with Certified Nursing Assistant (CNA) #2 on 7/30/19 at 10:05 PM, on the 2 East hallway, revealed no nurse was on the unit. Continued interview with CNA #2 revealed the night shift nurse had called in and the Shift Supervisor had been covering the unit but was not currently on the floor. Interview with LPN #6 on 7/30/19 at 10:10 PM, at the 2 East nurse's station, revealed she had just arrived to the unit. Further interview revealed she had been called to come in to work at 11:00 PM due to the nurse who had been scheduled for the 7:00 PM to 7:00 AM shift had called in. Interview with the Shift Supervisor on 7/30/19 at 10:12 PM, at the 2 East nurse's station, revealed she had been on another unit assisting with a pharmacy delivery but was the nurse responsible for the 2 East Unit until another nurse arrived. Continued interview revealed the night shift nurse had called in. Further interview revealed the day shift nurses had stayed over to administer the 9:00 PM medications. Continued interview revealed the Shift Supervisor had been covering the 2 East Unit with a census of 53 residents from 9:30 PM until another nurse arrived at 10:00 PM but had also been assisting with the other units in that building and had not been on the 2 East Unit the entire time. Interview and observation of the Assignment sheets, Midnight Census Reports, and Administration Log Reports with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed Resident #266's 9:00 PM medications had not been administered timely on 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, and 7/18/19. Continued interview confirmed there had been 1 LPN on duty for the 7:00 PM to 7:00 AM shift with a resident census of 53 for these dates. Further interview confirmed Resident #266's 5:00 PM medications had not been administered timely on 7/16/19. Continued interview confirmed 2 LPN's had been scheduled to work the 7:00 AM to 7:00 PM shift on 7/16/19 but one of the LPN's had called in with a resident census of 53. Further interview confirmed the facility failed to provide adequate staffing to provide timely administration of Resident #266's medications.

Based on facility policy review, medical record review and interview, the facility failed to ensure pain medication was administered timely resulting in an increase in pain for 1 resident (#266) of 3 residents reviewed for pain of 37 sampled residents. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed, .Medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in the medical management of [DIAGNOSES REDACTED].at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed, . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .monitor for break-through pain .monitor and document response to pain meds .administer prescribed pain medication as needed/ordered to maintain patient comfort level .perform ongoing pain assessments to determine if the pain management regimen is meeting the patient's pain relief goal . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible). Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of [MEDICATION NAME] had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed, .my normal pain level is about 7 or 8 . Further interview revealed when the 9:00 PM meds are late .oh it may be a 10 by then .it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, confirmed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain. .of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's pain medications in a timely manner resulting in an increase in pain for Resident #266.

Based on medical record review and interview, the facility failed to implement a comprehensive care plan for pain management for 1 resident (#266) of 3 residents reviewed for pain of 37 residents sampled. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of [MEDICATION NAME] had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain. .of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the comprehensive care plan had not been implemented to provide pain medications as ordered for Resident #266.

Based on medical record review, and interview, the facility failed to refer 1 resident (#90) identified with a possible serious mental disorder to the state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) of 6 residents reviewed for PASARR of 37 sampled residents. The findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Medical record review of a PASARR Level I assessment dated [DATE] revealed the resident had no [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Evaluation dated 3/11/19 revealed .Worsening depression .she reports the increase of [MEDICATION NAME] (medication to treat depression) did not help .she does admit to a history of mood swings and thinks she may have [MEDICAL CONDITION] (a psychiatric disorder) .Diagnosis .[MEDICAL CONDITION] 1 Disorder . Interview with the Minimum Data Set (MDS) Coordinator on 7/30/19 at 1:39 PM, in the conference room, confirmed the facility failed to refer Resident #90 to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services after her [DIAGNOSES REDACTED].

Based on review of the facility policy, medical record review, review of the facility's documentation of the Notification Summary Report (resident trust funds/Resident Statement), and interview, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for 2 discharged residents (#402 and #403) of 313 Patient Trust Funds reviewed. The findings include: Review of the facility policy, Patient Trust, Subject: Refunds, revised date ,[DATE], revealed .Timing (Schedule) the funds should be refunded within 30 days of death or discharge . Medical record review revealed Resident #402 was admitted to the facility on [DATE]. Continued review revealed the Resident was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #402 had a balance of $1719.70. Medical record review revealed Resident #403 was admitted to the facility on [DATE]. Continued review revealed Resident #403 was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #403 had a balance of $1686.57. Interview with the Trust Bookkeeper on [DATE] at 8:40 AM, in the business office, confirmed the facility had not refunded the Resident's Trust Fund accounts for Residents #402 and #403. Continued interview confirmed the facility had not refunded the accounts within the required time frame.

Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to report an allegation of abuse within 2 hours to the State Survey Agency for 1 resident (#4) of 3 residents sampled for abuse, of five sampled residents. The findings included: Review of facility policy, Abuse, (undated) revealed .if you have reasonable suspicion that a crime has occurred against a resident .Federal Law Requires that you report your suspicion directly to .the State Survey Agency . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of a Nursing Note dated 3/26/19 at 10:00 PM revealed .Pt (patient) A&O (alert and oriented) .some confusions (at) times . Medical record review of a Nursing Note dated 4/11/19 at 4:00 AM revealed .went to check on pt .not responding in usual manner .very lethargy .speech sluggish . Continued review revealed the resident was transferred to a local hospital with altered mental status and a urinary tract infection [MEDICAL CONDITION]. Review of the facility investigation dated 4/24/19 revealed a caseworker with Adult Protective Services (APS) contacted the facility on 4/24/19 and advised them while Resident #4 was in the hospital the resident alleged she was sexually abused by an unidentified male staff member at the facility sometime prior to her hospitalization on [DATE]. Further review revealed the facility did not report the allegation to the State Survey Agency. Interview with the Director of Nursing and the Risk Manger on 4/30/19 at 6:00 PM, in the conference room, confirmed the facility failed to report an allegation of abuse to the State Agency within 2 hours of notification of the allegation. In summary, the facility was aware of an allegation of abuse on 4/24/19 and as of 4/30/19, the facility had not reported the allegation of abuse to the State Survey Agency (7 days).

Based on medical record review and interview, the facility failed to revise a care plan to include effective fall prevention measures for one resident (#2) of six sampled residents, resulting in a fall and fractured pelvis (Harm) for Resident #2. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Interim Care Plan dated May 29, 2014, revealed, "...at risk for falls d/t (due to) decreased mobility and [DIAGNOSES REDACTED].(discontinued)...Assist with all transfers and ambulation...Monitor for steadiness, balance, and coordination..." Medical record review of a Physical Therapy (PT) Plan of Care dated May 30, 2014, revealed, "[MEDICAL CONDITION] residual L (left) sided weakness...alert and oriented to person and place...Safety Awareness: Fair (to) Poor..." Medical record review of a nurse's note dated June 2, 2014, at 10:30 a.m., revealed, "...up to therapy this (morning)...conf (confused) and tries to get out of bed. Total care by staff for ADLs (Activities of Daily Living), transfers..." Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, sometimes able to understand others, and sometimes able to express needs and wants. Continued review revealed the resident required extensive assistance of two persons for bed mobility, transfers and toileting; and extensive assistance of one person for ambulation in the resident's room. Continued review revealed the resident had impaired balance during transitions and walking and a history of falls. Medical record review of a nurse's note dated June 9, 2014, at 3:00 p.m., revealed, "pt (patient) attempting transfers without assistance, unsteady...will monitor for safety." Medical record review of a nurse's note dated June 14, 2014, at 11:00 a.m., revealed, "...O (oriented) to self...attempts to ambulate without assistance d/t dementia...confusion..." Medical record review of the care plan dated June 18, 2014, revealed, "...at risk for falls due to decreased mobility, unsteady gait, and weakness...at risk for injury if a fall does occur due to a [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated June 19, 2014, at 11:00 a.m., revealed, "...cont (continue) to monitor for safety d/t pt ambulating without assistance..." Medical record review of a nurse's note dated June 22, 2014, at 4:50 a.m., revealed, "...found in BR (bathroom) by CNA (Certified Nursing Assistant) pt up OOB (out of bed) without asst (assistance). Alarm sounding...Confused diff (difficult) to re-direct. c/o (complained of) pain with Lt. LE (Left Lower Extremity) and back...sent to (Hospital) per family request..." Medical record review of a physician's orders [REDACTED]." Medical record review of an emergency room record dated June 22, 2014, revealed, "...fall, unknown etiology, occurred last night. C/O generalized pain, localized to right knee. Unable to provide further (history secondary to) dementia....lower extremity exam (examination)...abnormal, ecchymosis (bruising) to R (right) knee...chronic bilateral foot contractures...L (left) sup/inf (superior/inferior) rami (pelvis) fx (fracture)...pt w (with) significant pain..." Continued review of the emergency room record revealed, "...[DIAGNOSES REDACTED]. Medical record review of a nurse's note dated June 22, 2014, at 11:30 a.m., revealed the resident returned to the facility. Interview with Registered Nurse (RN) #1 on July 21, 2014, at 11:45 a.m., in a conference room, revealed "...judgment was impaired right from the start...moments of clarity..." Interview with Physical Therapist Assistant (PTA) #1 on July 21, 2014, at 1:40 p.m., in a conference room, revealed PTA #1 treated the resident in therapy; the resident was unable to retain reminders and was impulsive. Continued interview revealed there was difficulty improving the resident's safety awareness; PTA #1 had observed the resident get out of the wheelchair numerous times in therapy and PTA #1 reported the unsafe behavior to nursing staff. Telephone interview with Certified Nursing Assistant (CNA) #1 on August 11, 2014, at 12:10 p.m., revealed the resident was confused and the resident quickly walked and/or ran after getting up unassisted. CNA #1 stated, "...(resident) got so (resident would) try to get up on (resident's) own without using (a) call light. We'd try to catch (resident) to prevent (resident) falling...(Resident would) try to get out of bed and wheelchair...We constantly explained to (resident) to ask for assistance and to use the call light...had to be right on (resident) due to (resident's) quickness. We had to hurry...wouldn't always use the light and couldn't remember...accurate to say use of a call light was unreliable." Telephone interview with RN #1 on August 11, 2014, at 12:20 p.m., revealed the resident was increasingly confused following admission to the facility, and the resident would not use the call light for assistance. Continued interview revealed the resident ambulated and/or ran unassisted at times, the resident's gait was not always steady, and RN #1 stated, "...We couldn't anticipate when/if (resident would) use call light...observed (resident) running we'd have to run right after (resident)..." Telephone interview with Care Plan Coordinator #1 on August 11, 2014, at 2:10 p.m., revealed the care plan dated June 18, 2014, did not reflect the resident's inability to retain reminders for safety or inconsistent use of a call light. Continued interview revealed the use of reminders and a call light were ineffective interventions and confirmed the facility failed to revise the care plan to address the needs of Resident #2 prior to the fall on June 22, 2014. C/O: #

Based on medical record review, review of facility investigation, and interview, the facility failed to provide effective supervision of a resident with Dementia/fall risk for one resident (#2) of four residents reviewed, resulting in a fall and fractured pelvis with pain and functional decline (Harm) for Resident #2. The findings included: Resident (#2) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE]. Medical record review of the resident's fall risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of a physician's orders [REDACTED]. Medical record review of an Interim Care Plan dated [DATE], revealed, "...at risk for falls d/t (due to) decreased mobility and [DIAGNOSES REDACTED].(discontinued)...Assist with all transfers and ambulation...Monitor for steadiness, balance, and coordination..." Medical record review of a Physical Therapy (PT) Plan of Care dated [DATE], revealed, "...Safety Awareness: Fair (to) Poor...Coordination: Impaired L (left) side worse than R (right)...Current Level of Function...demonstrates...total balance and gait score of ,[DATE], which relates to the high...fall risk category...demonstrates balance instabilities during gait, evidenced by intermittently veering off path...impaired bed mobility...functional deficit with rolling side to side, transferring...and ambulating..." Medical record review of a nurse's note dated [DATE], at 10:30 a.m., revealed, "...up to therapy this (morning)...conf (confused) and tries to get out of bed. Total care by staff for ADLs (Activities of Daily Living), transfers..." Medical record review of an untimed nurse's note dated [DATE], revealed, "PA (Physician's Assistant) in and reviewed pt (patient) meds (medications) d/t (due to) fall risk, impulsiveness in getting out of chair and decreased B/P (blood pressure) and pulse." Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, sometimes able to understand others, and sometimes able to express needs and wants. Continued review revealed the resident required extensive assistance of two persons for bed mobility, transfers and toileting; and extensive assistance of one person for ambulation in the resident's room. Continued review revealed the resident had impaired balance during transitions and walking and had a history of [REDACTED]. Medical record review of a nurse's note dated [DATE], at 10:45 a.m., revealed, "Pt...continuously trying to ambulate without assist. Extensive assist with ADLs (activities of daily living), transfers, and bed mobility..." Medical record review of a nurse's note dated [DATE], at 3:00 p.m., revealed, "pt attempting transfers without assistance, unsteady...will monitor for safety." Medical record review of a nurse's note dated [DATE], at 11:00 a.m., revealed, "...O (oriented) to self...attempts to ambulate without assistance d/t dementia...confusion..." Medical record review of a nurse's note dated [DATE], at 2:00 p.m., revealed, "Pt continues to attempt ambulation without assistance...Pt placed at NS (nurse's station) in WC (wheelchair) when OOB (out of bed) for observation. This is to be done at all times that pt is OOB..." Medical record review of resident #2's care plan dated [DATE], revealed, "...at risk for falls due to decreased mobility, unsteady gait, and weakness...at risk for injury if a fall does occur due to a [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated [DATE], at 11:00 a.m., revealed, "...cont (continue) to monitor for safety d/t pt ambulating without assistance..." Medical record review of a nurse's note dated [DATE], at 4:50 a.m., revealed, "...found in BR (bathroom) by CNA (Certified Nursing Assistant) pt up OOB (out of bed) without asst (assistance). Alarm sounding...Confused diff (difficult) to re-direct. c/o (complained of) pain with Lt. LE (Left Lower Extremity) and back...sent to (Hospital) per family request..." Medical record review of a Post Fall Nursing assessment dated [DATE], revealed, "...time of incident...5:25 a.m...Describe the actual known facts...(Resident) got OOB to BR (bathroom) and locked BR door. Bed sensor pad in place and alarming. When CNA entered room, the BR door was locked and CNA had to go to other resident's room to enter BR...was found in the BR floor, crying...stated...left hip and back was hurting as (resident) is unable to clearly answer at times...placed on blanket...carried to bed...pain med was given per nurse...Call light in room was within reach...did not call for assist...Bathroom call light was within reach...did not call for assist...Describe task patient attempting at time of fall: Exiting commode while unattended...Safety devices in use: ALARM..." Continued review revealed, "What was patient's statement regarding the fall...is confused, but did state...left hip was hurting and back...(resident) was unable to tell me if (resident) hit (resident's) head..." Medical record review of a physician's orders [REDACTED]." Medical record review of an emergency room record dated [DATE], revealed, "...fall, unknown etiology, occurred last night. C/O (complains of) generalized pain, localized to right knee. Unable to provide further (history secondary to) dementia...lower extremity exam (examination)...abnormal, ecchymosis (bruising) to R (right) knee...chronic bilateral foot contractures...L (left) sup/inf (superior/inferior) rami (pelvis) fx (fracture)...pt w (with) significant pain..." Continued review of the emergency room record revealed, "...[DIAGNOSES REDACTED]. Medical record review of a nurse's note dated [DATE], at 11:30 a.m., revealed the resident returned to the facility. Review of a facility investigation dated [DATE], (regarding the resident's fall on [DATE]) revealed, "...experienced a fall while ambulating unattended in (resident's) room...Got OOB without assistance - Why? Got OOB without req (requesting) assistance and took...self to BR...unable to complete BIMS (Brief Interview for Mental Status) test for cognition d/t level of confusion...Should we try or add a different approach...NA (Not Applicable)...Staff were unable to redirect resident and (resident) fell off balance...was unavoidable because the patient was ambulating in the room and fell . Staff responded to...sounding alarm...did not request assistance, did not use call light...has osteoporosis..." Medical record review of a Physical Therapy progress note dated [DATE], revealed, "...The patient unable to ambulate following fall on [DATE] secondary to pelvic fracture ..." Interview with Registered Nurse (RN) #1 on [DATE], at 11:45 a.m., in a conference room, revealed the resident was oriented to self, ambulated with assistance, and RN #1 stated, "...judgment was impaired right from the start...moments of clarity..." Interview with Physical Therapist Assistant (PTA) #1 on [DATE], at 1:40 p.m., in a conference room, revealed PTA #1 treated the resident in therapy; the resident was unable to retain reminders and was impulsive. Continued interview revealed there had been difficulty improving the resident's safety awareness; PTA #1 had observed the resident get out of the wheelchair numerous times in therapy, and PTA #1 reported the unsafe behavior to nursing staff. Telephone interview with Certified Nursing Assistant (CNA) #1 on [DATE], at 12:10 p.m., revealed the resident was confused and the resident quickly walked and/or ran after getting up unassisted. CNA #1 stated, "...(resident) got so (resident would) try to get up on (resident's) own without using (a) call light. We'd try to catch (resident) to prevent (resident) falling...(Resident would) try to get out of bed and wheelchair...We constantly explained to (resident) to ask for assistance and to use the call light...had to be right on (resident) due to (resident's) quickness. We had to hurry...wouldn't always use the light and couldn't remember...accurate to say use of a call light was unreliable." Telephone interview with RN #1 (Head Nurse) on [DATE], at 12:20 p.m., revealed the resident became increasingly confused following admission to the facility, and as confusion increased, the resident less frequently used the call light for assistance. Continued interview revealed the resident ambulated and/or ran unassisted at times, the resident's gait was not always steady, and RN #1 stated, "...We couldn't anticipate when/if (resident would) use call light...observed (resident) running we'd have to run right after (resident)..." Telephone interview with Physician Assistant (PA) #1 on [DATE], at 12:37 p.m., revealed the resident required subcutaneous administration of pain medication for pain management following the fall and pelvic fracture on [DATE]. Continued interview confirmed it was reasonable to conclude the resident's increased pain resulted from the pelvis fracture on [DATE]. Telephone interview with the Assistant Director of Nursing (ADON) on [DATE], at 2:30 p.m., revealed the fall prevention measures implemented by the facility were ineffective interventions for Resident #2. Continued interview revealed the facility had not increased the frequency of rounds for the resident with recurrent unsafe behaviors and confirmed the facility failed to provide adequate supervision to prevent a fall with pelvic fracture for Resident #2. The ADON stated, "...with (resident's) physical capabilities we did the best we could. With this particular patient...was extra challenging with (resident's) dementia...no way to prevent (resident) from falling..." Telephone interview with the Director of Nursing on [DATE], at 2:32 p.m., revealed the facility utilized alarms as a constant monitor to prevent the resident from falling, and stated, "There is nothing I would have done differently for (resident)." In summary, the facility failed to identify an intervention of a call light with reminders to call for assistance before transferring or ambulating was inappropriate for the cognitively impaired resident. Additionally, the facility failed to increase supervision for a resident who was known to be impulsive, relying on alarms instead of increased supervision, resulting in a fractured pelvis (Harm) for resident #6. C/O: #