Every finding on record at The Redwoods, A Community of Seniors

Based on observation, interview, and record review, the facility's dietary staff failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 42 when:1. A manual can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation; and,2. A resident was served a beverage in a glass tumbler with jagged, sharp edges during the lunch meal service.This failure decreased the facility's potential to prevent the spread of foodborne illnesses, physical injuries such as cuts, increased blood exposure risk, and unsanitary meal conditions for a vulnerable resident population.1. During the initial kitchen tour on 5/19/26 at 8:33 a.m., the can opener blade was observed with significant dark discoloration along the cutting edges, consistent with buildup or corrosion. The tip of the blade was noted to have missing metal.During an interview on 5/20/26 at 3:01 p.m., with the Registered Dietitian (RD), the RD confirmed the manual can opener had visible discoloration and stated that such deterioration can cause metal fragments or debris to enter resident food.A review of the Food and Drug Administration's (FDA) Food Code (2022) section 4-501.11 indicated, can-opener blades must be sharp to prevent metal fragments from breaking off into food.A review of the FDA Food Code (2022) section 4-202.15 indicated, can openers that become pitted or unable to be cleaned must be replaced because they can no longer be properly sanitized.2. During an observation on 5/20/26 at 12:24 p.m., Resident 42 was observed holding a clear glass tumbler and placing it on the table after drinking from it. The glass tumbler was observed to have a large, severe fracture with exposed jagged and sharp edges.During an interview on 5/20/26 at 3:01 p.m., the RD stated staff were expected to remove damaged items when identified and notify management so replacements can be arranged. The RD stated a cracked glass poses a risk of resident injury or infection.During an interview on 5/22/26 at 10:13 a.m., the Administrator (ADM) stated items must be discarded if chipped, cracked, or defective prior to washing, re-inspected after dishwashing, and visually checked by servers during meal service setup. The ADM stated defective dishware presents a potential hazard for resident injury or accidental ingestion of broken fragments.A review of the facility's policy and procedure (P&P) titled, Damaged China and Glassware Surveillance, revised January 2024, indicated, Cups, saucers, plates, dishes, glasses, and trays are under surveillance constantly and damaged items are immediately taken out of service.

Based on observation, interview and record review, the nursing staff failed to ensure infection prevention and control practices were implemented for a census of 42 residents when:Hand hygiene was not performed during resident dining;Hand hygiene was not performed during medication administration;Shared resident equipment was not cleaned between uses; and,Appropriate Personal Protective Equipment (PPE-specialized clothing and gear which acts as a physical barrier to the wearer to minimize spread of infectious diseases) was not worn by nursing staff during a transfer of Resident 6 who had Enhanced Barrier Precautions (EBP-infection control measures used to prevent spread of multi-drug resistant organisms by using PPE during high contact resident care) in place .These failures decreased the facility's potential to prevent the spread of infection amongst the residents. Findings: 1. During an observation conducted on 5/19/26 at 12:10 p.m. in the facility dining area, Certified Nursing Assistants (CNAs) were observed obtaining individual plated meals from a hot buffet service line and delivering each plate directly to residents. At 12:19 p.m., CNA 1 was observed retrieving meals from the service line, dispensing drink thickener from a pump bottle, and delivering meals to residents without performing hand hygiene between these tasks. At 12:21 p.m., CNA 2 was also observed collecting plated meals from the hot buffet line and delivering them to multiple residents without conducting hand hygiene between successive trips from the service line to resident tables. At 12:35 p.m., both CNA 1 and CNA 2 observed to end meal delivery and sit down to feed residents without performing hand hygiene. During an interview on 5/19/26 at 12:38 p.m. in the facility hallway, the Infection Preventionist (IP) stated that all clinical staff received instruction on the requirement to perform hand hygiene between resident contacts, including during communal dining activities. The IP further indicated this education was reviewed annually with all staff. The IP stated the rationale for enforcing hand hygiene during communal dining was staff could pick up bacteria from shared objects or from unknown infected residents and spread it to other residents. During an interview on 5/19/26, at 2:03 p.m. in the facility hallway, CNA 1 acknowledged she forgot to perform hand hygiene in between resident meal deliveries, and further stated dining service was very busy which made it easy to forget. CNA 1 stated hand hygiene was important to prevent residents getting sick with germs another resident has. During an interview conducted on 5/19/26 at 2:22 p.m. in the facility hallway, CNA 2 apologized for failing to perform hand hygiene. CNA 2 stated an understanding of the importance of hand hygiene and indicated adhering to proper hand hygiene practices helped to protect both residents and staff. A review of the facility's policy and procedure (P&P) titled Hand Hygiene/Handwashing, dated March 2024, indicated the infection prevention and control program was designed to provide a safe, sanitary.environment and to help prevent the development and transmission of communicable diseases and infections.[the facility] considers hand washing/hand hygiene the primary means to prevent the spread of infections. 2. During medication administration observation on 5/20/26 at 7:57 a.m. with Licensed Nurse 1 (LN 1), LN 1 missed three hand hygiene opportunities: twice when LN 1 failed to use hand sanitizer before entering Resident 48's room and when LN 1 failed to use hand sanitizer before collecting medications from the medication cards. During medication administration observation on 5/20/26 at 8:07 a.m., LN 1 missed one hand hygiene opportunities when LN 1 failed to use hand sanitizer before entering Resident 18's. During medication administration observation on 5/21/26 at 11:05 a.m., LN 2 missed one hand hygiene opportunity when not using hand sanitizer before she began to collect medications for Resident 3. A review of facility's P&P titled Hand Hygiene/Handwashing, dated March 2024, indicated staff are to wash hands [or use alcohol-based hand sanitizer] . before and after contact with a resident.before preparing or handling medications. 3. During medication administration observation on 5/20/26 at 8:10 a.m. with Resident 18, LN 1 cleaned a blood pressure cuff by wiping it with a wipe that its manufacturer recommended a 2-minute dwell time. LN 1 cleaned the cuff, rolled it up and put it away without allowing the cuff to air dry. When asked if the blood pressure cuff was clean, LN 1 stated, It still has alcohol all over it. A review of the facility's P&P titled Disinfecting Multiple Use Medical Equipment after Each Resident Use, revised August 2023, indicated, It is the policy of [the facility] to disinfect multiple use medical equipment using [Brand Name] Disposable Germicidal Wipes .allow to remain wet for 2 minutes, let air dry. 4. During an observation on 5/19/26 at 9:07 a.m. outside of Resident 6's room, EBP signage was observed posted by the door which indicated Resident 6 was on EBP. An over the door isolation PPE organizer containing PPE was also observed hanging on the exterior of the door. During an observation on 5/19/26 at 11:33 a.m. inside Resident 6's room, CNA 3 was observed not wearing the required PPE while assisting with transferring Resident 6 from the bed to the wheelchair. During an interview on 5/19/26 at 11:41 a.m., CNA 3 acknowledged noticing the sign indicating that Resident 6 was on EBP and stated she should have worn a gown for the transfer. During an interview on 5/22/26 at 9:41 a.m., LN 3 stated all staff are expected to follow posted PPE signage and to wear gowns and gloves when performing high contact care activities, including transferring a resident. During an interview on 5/22/26 at 10:13 a.m., the ADM reported that clinical staff were trained in EBP procedures and all staff providing care were expected to wear the required PPE. The ADM also identified potential risks of non compliance, including exposure to infectious agents and transmission between residents, caregivers, and other individuals. During a review of the facility's P&P titled Enhanced Barrier Precautions, revised May 2023, indicated, staff are required to don both a gown and gloves when performing any high contact resident care activity, including transferring a resident. The P&P indicated these precautions are required in addition to Standard Precautions to prevent the transmission of multidrug resistant organisms (MDROs—organisms resistant to multiple drugs, making infections difficult to treat) to staff hands and clothing during care. Facility signage posted outside resident rooms directs staff to the required PPE, and staff are expected to adhere to these directives at all times.

Based on observations, interviews, and record review the facility failed to implement an effective pest control program for a census of 42 when a fly was observed in the kitchen's food prep area.This failure had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.During the initial kitchen tour on 5/19/26 at 8:29 a.m., a large, clear plastic storage container labeled Jam, Opened: Apricot was observed sitting completely uncovered on the stainless-steel prep table. A live fly was perched directly on the top rim of this uncovered container, in immediate proximity to the exposed food product.During an interview on 5/19/26 at 8:41 a.m. with the Registered Dietitian (RD), the RD confirmed a fly was in the kitchen, noting it posed a food safety and sanitation risk for resident meals.During an interview on 5/22/26 at 10:13 a.m. with the Administrator (ADM), the ADM stated the facility was expected to remain free of hazards, including pests to prevent potential contamination of surfaces.A review of the facility's policy and procedure (P&P) titled, Pest Control, revised January 2025, indicated, The Food and Nutrition Services Department shall be free of all rodents and insects.

Based on observation, interview, and record review, the licensed nurses failed to remove the following expired items from Medication Cart One of two medication carts:One expired bottle of NSAIDs,One expired bottle of aspirin,One expired bottle of vitamin B-12, andOne expired Covid-19 test. In addition, the medication disposal container contained only pills, with no drug blocker or moisture activated agent to breakdown the medications. These failures decreased the facility's ability to safely administer medications and increased the risk of drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use).Findings:In a concurrent observation and interview with Licensed Nurse 2 (LN 2) on 5/20/26 at 2:36 p.m. during a medication cart inspection, LN 2 confirmed:One bottle of naproxen sodium, expired February 2026, was in use;One bottle of aspirin, expired September 2025, was in use;One bottle of Vitamin B-12, expired May, 2026, was in use; and,One Covid-19 test, expired on 4/3/24, was in the cart. LN 2 stated the expired medications should have been removed from the cart. LN 2 further stated that expired medications may have a reduced therapeutic effect or could negatively impact a resident if administered.In a concurrent observation and interview of the medication disposal container with the Director of Nursing (DON) on 5/20/26 at 3:31 p.m., the DON acknowledged there were several intact loose pills at the bottom of the medication disposal bin. The DON stated, Pharmacy comes in every Monday to restock our shelves and check our stock. They forgot to put the drug buster in the disposal container. A review of the facility's policy and procedure titled, Discarding and Destroying Medications, dated June 2025, indicated, Non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications .For unused, non-hazardous controlled substances not disposed of by an authorized collector, the EPA [Environmental Protection Agency, a federal agency tasked with protecting human health and the environment] recommends destruction and disposal of the substance with other solid waste following the steps below .Take the medication out of the original containers. Mix medications, either liquid or solid, with an undesirable substance. Undesirable substances include, sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can or other container to prevent leakage.

Based on interview and record review, the Interdisciplinary Team (IDT-a coordinated group of healthcare professionals who collaborate and plan resident care) failed to review psychotropic medications (medications that affect brain activity associated with mental processes and behavior) for one resident (Resident 8) out of a sample of 14 residents when a gradual dose reduction (GDR) was recommended but not completed.This failure resulted in the continued use of psychotropic medications without reassessment and placed the resident at risk for unnecessary drug exposure and associated adverse outcomes.A review of Resident 8's facesheet indicated admission to the facility on [DATE] with diagnoses of Alzheimer's Disease (a progressive, irreversible brain disorder that gradually destroys memory, thinking skills and the ability to carry out daily tasks), Dementia (generalized term for decline in mental ability which is severe enough to interfere with daily life) without behavioral disturbance, psychotic disturbance, mood disturbance, and Bipolar Disorder (mental health condition causing emotional highs and lows).A review of Resident 8's physician's orders, dated 11/20/25, indicated Resident 8 was prescribed Trazodone HCI [medication used to treat depression) 100 mg [milligram-a unit of measure]. Give one tablet by mouth a day at 8 PM for depressions m/b [manifested by] insomnia. The physician's order also indicated an order dated 12/2/25 which indicated Olanzapine [used to treat bipolar disorder] oral tablet 2.5 mg. Give 1 tablet by mouth one time a day for hallucination and behaviors, psychosos [sic] and 2 tablets at HS [at bedtime].A review of the Gradual Dose Reduction Tracking Report, dated 1/15/26, indicated Resident 8 had a GDR letter pending physician review for olanzapine 7.5 mg daily and trazadone 50 mg HS.A review of Resident 8's behavior monitoring documents dated February through May 2026 indicated Resident 8 had not demonstrated behaviors of agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression or refusal of care. A review of the pharmacist's monthly consultation report dated February 2026 indicated, [Resident 8] recently reviewed during the facility's behavior management committee meeting. Olanzapine 2.5 mg and 5 mg HS.trazadone 50 mg HS. Falls noted and discussed-letters of GDR forwarded to MD [physician] for review and response. GDR letter pending MD review. Recommendation: [Director of Nursing (DON)] to follow up with [MD] re [regarding] GDR of Olanzapine 2.5 BID [twice per day].A follow-up review of the Gradual Dose Reduction Tracking Report, dated 4/28/26, indicated the GDR letters for olanzapine and trazadone were still pending MD review.During an interview on 5/21/26 at 11:30 a.m., the DON acknowledged it had been three months since the recommendation for Resident 8's GDR was received and needed to be approved by the physician. The DON stated prolonged use of psychotropic medications could lead to serious side effects and expressed an understanding for the importance of a regular GDR review.A review of facility's policy titled Psychotropic Medication Use, revised on February 2025, indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.residents on psychotropic medication receive gradual dose reductions.to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication.

Based on interview and record review, the nursing staff failed to revise fall care plans for one resident (Resident 27) out 14 sampled residents when Resident 8's fall care plans were not updated after repeated falls.This failure decreased the facility's potential to prevent additional falls for both residents when Resident 27 to sustained additional falls with a minor injury.Findings:A review of Resident 27's facesheet indicated admission to the facility on 7/31/24 with diagnoses of collapsed vertebrae (the bony block of the spine breaks and collapses), age-related osteoporosis (bone disease characterized by decreased bone mass and density, making the bones weak and fragile) and repeated falls.A review of Resident 27's fall risk evaluations were reviewed. Each evaluation determined the probability of a resident falling based on their individual history, ambulation, vision, gait, blood pressure and medications. The following are the scores and fall risk category Resident 27 was placed into:4/3/26 - score 7 (not at risk)4/18/26 - score 9 (not at risk)A review of Resident 27's progress notes indicated Resident 27 sustained a fall on the following days:On 4/3/26, at 11:58 p.m. indicated, Resident was by the nursing station in her wheelchair and noted sliding down.On 4/18/26, at 2:01 p.m. indicated [Resident 27] was found in a seated position on the floor in front of the bathroom doorway following an unwitnessed fall.[Resident 27] reports hitting her head during the fall and rates pain 5/10 [5 out of 10 pain scale] localized to left eyebrow area.noted ecchymosis [bruising] to left eyebrow with swelling and yellow discoloration.A review of Resident 27's care plans indicated a care plan dated 3/24/26 in which Resident 27 had an unwitnessed fall with a minor injury. This care plan was revised on 4/18/26 with a goal set for Resident 27 show no complications through the review date. To assist with this goal a physical therapy consult was ordered, nursing staff would provide activities building strength and continue with the at-risk plan interventions. There was no update of Resident 27's fall risk or actual fall care plans between 3/24/26 and 4/18/26.During an interview on 5/21/26 at 11:30 a.m., Licensed Nurse 1 (LN 1) stated care plans were used to guide care the residents received. LN 1 stated fall care plans should have different interventions if a fall occurs to prevent it from happening again.During an interview on 5/21/26 at 1:32 p.m., the Director of Nursing (DON) stated after a fall, the care plan needed to be updated. The DON further stated, This is important because it mitigates a recurrent fall. The DON acknowledged the care plans for Resident 27 were not updated after the falls. In addition, the DON acknowledged many of the interventions listed were medical in nature and not fall prevention related.A review of facility's policy titled Accident Prevention/Mitigation and Response , updated November 2025 indicated, It is the policy of [this facility] .ensure that the environment remains free of accident hazards, make proactive efforts to eliminate or reduce the risk of accidents occurring in the facility.the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.when a resident is experiencing repeated falls in relatively close proximity to one another, the IDT [interdisciplinary Team-coordinated group of healthcare professionals who collaborate and plan resident care] will review the frequency of visual/safety checks being completed and will increase the frequency of those checks accordingly. This shall be documented in the resident's care plan.

Based on observation, interview and record review, the nursing staff failed to ensure necessary nail care services were provided to maintain good grooming and hygiene for one (Resident 6) of five sampled residents, when Resident 6 had long, untrimmed, and visibly dirty fingernails.This failure had the potential to expose Resident 6 to avoidable infection risks, skin breakdown, and injury from jagged or dirty nails.A review of Resident 6's admission record indicated he was last admitted in February 2023 with the diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/18/25, indicated Resident 6 required extensive assistance of two for personal hygiene.During an observation on 5/19/26 at 9:41 a.m., Resident 6 was observed with poor nail hygiene. Resident 6's left hand displayed long, untrimmed fingernails with an accumulation of dark yellow brown debris underneath the free edges. The middle fingernail was jagged and broken along the lateral edge, with visible debris underneath.During an interview on 5/21/26 at 3:51 p.m. with Certified Nurse Assistant 4 (CNA 4), CNA 4 confirmed Resident 6's nails were long, dirty, and required trimming.During an interview on 5/22/26 at 10:13 a.m. with the Administrator (ADM), the ADM stated staff are expected to ensure residents' fingernails remain clean and properly maintained. The ADM identified potential risks associated with inadequate nail care, including scratching, broken nails, compromised skin integrity, and poor hygiene.A review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, dated 2001 indicated, nail care included daily cleaning and regular trimming and was performed to clean the nail bed, keep nails trimmed, and prevent infections. The policy also indicated proper nail care helps prevent skin problems around the nail bed and that trimmed, smooth nails help avoid accidental scratching or injury.

Based on interview and record review, the nursing staff failed to ensure one resident (Resident 4) out of 14 sampled residents received appropriate care for a documented wound when the hospice (a specialized, compassionate model of end-of-life care focused on comfort, dignity, and quality of life rather than finding a cure) provider did not initiate treatment orders for Resident 4's excoriated (scraped or worn away), blistering (raw, sore skin) sacrum (an area located at the base of the spine and above the tailbone). This failure decreased the facility's potential to prevent infection and hinder continuous pain Resident 4 experienced as a result of the wound.Findings:A review of Resident 4's facesheet indicated Resident 4 was admitted to the facility on [DATE] with Senile Degeneration of the Brain (the progressive loss of brain cells and cognitive function associated with advanced aging).A review of Resident 4's hospice progress notes, dated 5/1/26, indicated Resident 4 was admitted to hospice care for senile degeneration of the brain with protein-calorie malnutrition (a condition caused by inadequate intake of protein, calories or both).A review of Resident 4's nursing progress notes dated 5/13/26 at 7:08 a.m., indicated Resident 4 was noted to have a blister and multiple excoriations. [Hospice Agency] called and informed regarding the skin issues. [Hospice Agency] will come and will order treatment for resident.During a concurrent interview and record review with the Director of Nursing (DON) on 5/21/26 at 8:14 a.m. at the nursing station, the DON acknowledged that no documented evidence could be found in Resident 4's electronic record or the hospice binder to indicate treatment orders had been obtained from the hospice physician to care for Resident 4's sacral wound. The DON acknowledged the absence of treatment orders and stated, This isn't good practice.During an interview on 5/21/26 at 11 a.m. at the nursing station, Licensed Nurse 2 (LN 2) stated she did not know how to treat Resident 4's sacral wound after finding no written orders in the electronic record or in the hospice binder.During a concurrent interview and record review on 5/21/26 at 11:33 a.m. in the conference room, the hospice Clinical Resource Specialist (CRS) acknowledged the orders, care plan and hospice binder should have been updated earlier to reflect appropriate wound care treatment. The CRS stated that without the update, Staff wouldn't know how to appropriately care for the resident.A review of the facility's Hospice-Skilled Nursing Facility Agreement, dated 3/29/21, indicated, [Hospice Agency] had a professional responsibility for oversight of all services provided to their patients .The Hospice Interdisciplinary Group.shall prepare and individualized written Hospice Plan of Care.necessary to meet the needs of the Hospice Patient.A review of the hospice agency's information, located in the hospice binder titled Record Keeping indicated, .hospice staff will file these documents.for each patient: the most recent plan of care.hospice physician and attending physician orders.

Based on interview and record review, the Social Services Director (SSD) failed to ensure one resident (Resident 13) of eight sampled residents received trauma-informed care when the SSD did not update Resident 13's Trauma Informed Care Assessment at least quarterly. This failure decreased the facility's potential to ensure Resident 13's nursing care needs were met.Findings:A review of Resident 13's admission record indicated admission in May 2022 with the diagnoses including Chronic Obstructive Pulmonary Disease (COPD a chronic lung disease causing difficulty in breathing), Dementia (a progressive state of decline in mental abilities) with psychotic disturbance, anxiety disorder, and bipolar disorder. A review of Resident 13's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/13/26, indicated she had mild memory impairment.A review of Resident 13's Trauma Informed Care Assessment, dated 3/7/24, identified no trauma related concerns. A review of Resident 13's care plan, initiated and last revised on 4/10/26, indicated Resident 13 was experiencing hallucinations involving people falling and dying, crushing a bird, and someone attempting to harm her. A review of Resident 13's chart on 5/20/26 indicated no updated Trauma Informed Care Assessment after 3/7/24. In an interview on 5/21/26 at 10:12 a.m. the SSD stated she checked Resident 13's electronic chart to ensure all trauma screenings were up to date. The SSD confirmed Resident 13 has not had a trauma assessment since 3/7/24. During an interview on 5/21/26 at 10:31 a.m. with the Director of Nursing (DON), the DON stated trauma screenings were expected to be conducted upon admission and quarterly thereafter. The DON stated, If we don't do it, a resident could potentially have negative outcomes. Various triggers or environment sounds could cause an event, potentially disrupting emotional vulnerability. The DON added stated, She [Resident 13] has bizarre hallucinations that cannot be substantiated. I've talked to the Medical Director about it. A trauma assessment is a good though. A missed opportunity. The DON confirmed no trauma assessment had been completed since 3/7/24. A review of the facility's policy, titled, Trauma Informed Care, dated January 2023, indicated all residents will be screened for past trauma upon admission and as indicated by the resident's behavior.

Based on observation, interview and record review, the licensed nurse failed to ensure the medication error rate remained below 5 percent when four errors were observed during 29 medication administrations, which resulted in a 13.79% medication error rate. This failure decreased the facility's potential ensure the health and safety of residents by administering the correct dosage and effective therapeutic effect.Findings:During an observation of a medication administration on 5/20/26 at 7:57 a.m., Licensed Nurse 1 (LN 1) administered medications to Resident 48. The following errors were identified: Resident #48 received a complete pill and a half of a pill of carbidopa-levodopa from two medication cards (a container used to securely hold medications with a push-through aluminum foil back (a blister) that allows the distribution of medication one dose at a time) with another resident's name. Two errors were observed.In an interview on 5/20/26 at 8:21 a.m., LN 1 stated, They moved the cards, they weren't in the same place as they were before. I will double check next time the name and the time. It could have impacted the Resident's health. If you are late, or give incorrect dosages, the resident can get dyskinesia [uncontrolled, involuntary muscle movements]. During an observation of medication administration on 5/21/26 at 7:37 a.m., LN 2 administered medications to Resident 26. The following error was identified: Resident 26's Medication Administration Record (MAR) indicated an order for one 20 mg tablet of escitalopram. LN 2 chose the medication card which contained 20mg pills in half tablet form, resulting in 10 mg per dose. LN 2 prepped one half tablet for administration which was half the prescribed dose. In an interview on 5/21/26 at 7:45 a.m. with LN 2, LN 2 stated, Oh, my mistake. This card [the 1/2 tablet card] needs to go. I will get rid of this.A record review of Resident 26's physician orders at 5/21/26 at approximately 8:30 a.m. confirmed the order for escitalopram was for 20 mg daily at 9 a.m. One error was observed.In an observation of a medication administration on 5/21/26 at 11:05 a.m., LN 2 administered medications to Resident 3. The following errors were identified: Resident 3's MAR indicated an order for one 5 mg tablet of midodrine. The medication card LN 2 chose indicated 1.5 tablets. LN 2 popped one blister which had one tablet in it for administration. In an interview with LN 2 on 5/21/26 at 11:08 a.m., LN 2 stated, I know he only gets one pill . we looked on the MAR and it was only one pill, a 5mg order, but the card said 1.5, pills. LN 2 put a sticker on the card not to use it. LN 2 added, That's a big booboo. I will talk to the DON [Director of Nursing] about this.A record review of Resident 3's physician's orders on 5/21/26 at approximately 12 p.m. confirmed the physician order for midodrine, 5 mgs, 1 tablet, three times a day at 8 a.m., noon, and 5 p.m. A total of 4 errors were observed out of 29 opportunities.In an interview with Resident 18 on 5/19/26 at 3:48 p.m., Resident 18 stated. I am concerned about medication errors. Happens more with agency nurses. I'm a healthcare worker. When it happens, I can catch it, but I worry about those residents who cannot. It's nothing personal and I know mistakes are made but it is concerning. In an interview on 5/21/26 at 10:37 a.m., the DON stated she expected medications to be given as ordered. If they were not, it could be harmful to the resident. The facility policy and procedure titled, Administering Medications dated April 2019 indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident 28) of eight sampled residents remained free of significant medication errors when licensed nurses administered prescribed Parkinson's medications up to two hours late.This failure decreased the facility's potential to ensure medication was administered as ordered by the physician. Findings:A review of Resident 48's admission record indicated admission on 5/15 26 with a primary diagnosis of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movements) or without mention of fluctuations. A review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/19/26, indicated he had no memory impairment.In an interview on 5/19/26 at 9:58 a.m. with Resident 48, Resident 48 stated, My [Parkinson's] medications are late. Over an hour the other day. A record review of Resident 48's Medication Administration Record (MAR) dated May 2026 indicated the following:On 5/16/26: Resident 48's carbidopa-levodopa 8 a.m. dose was given at 9:51 a.m.; and, Resident 48's memantine 9 a.m. dose was given at 11:03 a.m.On 5/17/26: Resident 48's carbidopa-levodopa 8 p.m. dose was given at 9:02 p.m.On 5/19/26: Resident 48's carbidopa-levodopa 8 a.m. dose was given at 10:01 a.m.; Resident 48's carbidopa-levodopa 12p.m. dose was given at 1:15 p.m.; and, Resident 48's memantine 9 a.m. dose was given at 10:03 a.m.In an interview on 5/21/26 at 10:37 a.m. with the Director of Nursing (DON), the DON stated, Parkinson's medications are a critical medication to have and should be given within an hour window rather than a 2-hour interval. The expectation is that medications are given as ordered. If not, it can harm the resident. Delayed doses can cause dyskinesia, and it could take a couple of days to get back in to balance. It's a hard and challenging thing to get into that sweet spot of medication control with Parkinson's medications. A review of the carbidopa -levodopa medication package leaflet indicated, Always take this medicine exactly as your doctor or pharmacist has told you. Take them at regular time intervals according to your doctor's instructions. Do not change the times at which you take your tablets or take any other medicines for Parkinson's disease without first consulting your doctor. A National Institute of Health (NIH) National Library of Medicine article titled, Delayed Administration and Contraindicated Drugs Place hospitalized Parkinson's Disease Patients at Risk, dated January 2018, states, Patients with Parkinson's disease require strict adherence to an individualized, timed medication regimen of antiparkinsonian agents. When medications are not administered on time and according to the patient's unique schedule, patients may experience an immediate increase in symptoms.2 Delaying medications by more than one hour, for example, can cause patients with Parkinson's disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating.A review of an NIH National Library of Medicine article, A Systematic Review of the Parkinson's Foundation Hospital Care Recommendations, dated 7/30/25, states: the review included 33 studies. Multiple studies showed that medication errors were associated with longer hospital stays, motor deterioration, and increased mortality in people with Parkinson's. Interventions such as electronic medical record alerts, staff education, and specialized PD units reduced medication errors. Limited evidence was found on the impact of immobility and dysphagia during hospitalization.A review of the facility's policy titled, Administering Medications, revision date April 2019, indicated, medications are administered in accordance with prescriber orders.

Based on interview, and record review, the facility failed to ensure professional standards of practice were met for one of three sampled residents (Resident 1) when neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments and vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation [a measurement of how much oxygen is being carried by red blood cells]) were not conducted, monitored, or documented after a witnessed fall, in Resident 1's medical record per facility policy and protocol.These failures decreased the facility's potential to recognize a change in condition for Resident 1, which could have led to a delay in treatment with other negative outcomes.A review of Resident 1's admission record indicated she was initially admitted to the facility in July 2024 with medical diagnosis which included collapsed vertebra (when the bones in the spine collapse or break due to injury or weakening) and repeated falls. A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/8/25 (dated prior to her witnessed fall) indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 9 , which indicated her cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). In addition, this document indicated Resident 1 required supervision or touching assistance (helper provides verbal cues or touching/steadying as resident completes activity) with sit to stand and walking at least 150 feet. Resident 1's MDS also indicated Resident 1 depended on others for ambulation.A review of Resident 1's progress notes, titled, Alert Note, dated 8/04/25 at 7:20 a.m., indicated, Resident [Resident 1] with witnessed fall.sustained laceration (an open wound caused by injury) to forehead; with large amount of blood noted.sent patient [Resident 1] to ER (hospital emergency department) for further evaluation.A review of Resident 1's ED (Emergency department) Provider Notes, dated 8/04/25 at 11:43 a.m., indicated, Clinical Impressions.Traumatic closed fracture (a bone break where the skin remains intact [undamaged]) of patella (knee cap) with minimal displacement, left, initial encounter.A review of Resident 1's progress notes, type Skin only, dated 8/04/25 at 2:17 p.m., indicated, Skin issue: Laceration. Skin issue location: forehead length: 2 cm (centimeter, a unit of measure), width: 0.2 cm.Skin note: Resident [Resident 1] with laceration to middle of forehead due to fall; with sutures (sterile threads used to close open wounds) in place, with swelling noted.A review of Resident 1's undated document titled, Weights and Vitals Summary, indicated vital signs were taken on 8/04/25 at 4:15 p.m., 8/04/25 at 8:21 p.m., 8/05/25 at 2:30 a.m., 8/05/25 at 9:47 p.m., 8/07/25 at 3:42 p.m., 8/08/25 at 2:02p.m., and 8/08/25 at 11:03 p.m. No vital signs were documented at the time of the fall, 8/04/25 at 7:20 a.m. A review of the facility's document titled, Neurological Assessment Flowsheet, for Resident 1 dated 8/04-8/08/25, indicated, Instructions: Document the date and time of each assessment. This document indicated completed neurological assessments were conducted twice on Resident 1 on 8/04/25 for evening shift, but the timing of the assessments was not recorded. Similarly, on 8/05/25, 8/06/25, 8/07/25 & 8/08/25 completed neurological assessments were documented for Resident 1 for morning, evening, and night shift, but the timing of the assessments was not documented.During an interview and concurrent record review on 8/18/25 at 3:26 p.m., the Director of Staff Development (DSD) stated after an initial fall, neuro checks were to be completed and documented Q [every] 15 mins. (minutes) x4 (4 times), Q30 mins. x2, Q2 hrs. (hours) x2, Q4 hrs. x2 and, Q shift for 24 hrs. on the resident's neurological assessment flowsheet. The DSD reviewed Resident 1's document, Neurological Assessment Flowsheet, dated 8/04-8/08/25, and confirmed the neuro sheet reflected Resident 1's recent fall on 8/04/25. The DSD stated she would expect Resident 1's vital signs and assessment to start at 7:20 a.m., when Resident 1's fall occurred, and then per protocol. The DSD further stated, I should have seen more Q15 checks prior to her [Resident 1] going out. There was a note that she [Resident 1] transferred at 8:05 a.m. [on 8/04/25]. It should have been documented that she [Resident 1] transferred at that time on the neuro check sheet, and after that- I would expect that the documentation would start from the beginning of the neuro check protocol when she returned. The DSD verified no specific times were documented for each neurological assessment on the neuro assessment sheet and instead, the timing of the assessments was documented as AM (morning), PM (evening) and NOC (night shift). The DSD stated, My expectation is that the times are documented, not the shift. The DSD confirmed the neurological assessments for Resident 1 were not up to her expectation. The DSD stated all resident vital signs were expected to be completed in the morning and evening, and documented at the time they were taken in the resident's electronic medical record.During an interview and concurrent record review on 8/19/25 at 1:28 p.m., the DSD reviewed Resident 1's document, Weights and Vitals Summary, and verified, based on the documentation, on 8/04/25, no vital signs were taken the morning of Resident 1's fall. The DSD confirmed vital signs documented on 8/05/25 at 2:30 a.m. was not during normal morning hours. The DSD confirmed vital signs documented on 8/05/25 was not documented again until the evening. The DSD confirmed there were no vitals signs documented on 8/06/25, and no morning vital signs documented on 8/07/25 and 8/08/25. The DSD stated, I would expect to see documentation of vital signs for the morning and evening every day, for all residents. The DSD stated she did not audit vital sign documentation, and further stated, It's something we are working on. I expect more. It's important to have more oversight so that a change of condition can be noted, or if a resident may need a higher level of medical attention- then we know what is going on. It's very important to stay on top of it. Say for example, with a head trauma- it's important to follow up. Visually, we don't actually see everything that is going on following a head trauma. If there are unseen issues related to a fall, especially one with head trauma, it could be detrimental to the resident.A review of the facility's undated document, Neuro Check Frequency for Falls, indicated, When neuro sheet started at the time of the fall: The nurse initiating the sheet will fill in all dates/times to ensure all nurses know when to do the neuro checks. [Assessments/Documentation] Q15x4, Q30x2, Q1 hour x2, Q2 hours x 2, Q4 hours x2, and Q Shift for 24 hrs.A review of the facility's policy and procedure (P&P) titled, Medical Record Documentation, dated 2024, indicated, .to ensure that pertinent information regarding each resident's course of care in the community is documented in the individual's medical record in an accurate, timely, and professional manner.Medical record documentation is currently a combination of an electronic record, as well as, manual (i.e. on paper).In general, all documentation should be completed as soon as possible after the respective event.A review of the facility's P&P titled, Accident Prevention/Mitigation and Response, dated 2025, indicated, As part of the post fall response.Conducting neuro-checks on the resident for a period of five (5) days.A review of the facility's document titled, RN/LVN CHARGE NURSE dated 2023, indicated, Charting and Documentation.Enter the (EMR [electronic medical record]) data for residents.assessments.and all other assessments as they are due.Complete the entry of Incident reports and associated paper work. Follow established procedures. A review of the facility's undated document titled, Certified Nursing Assistant, indicated, Performs the following tasks.vital signs.

Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with the facility's Infection Control policy for influenza (flu- an illness caused by a virus [a germ] that is spread from person to person) when: Licensed Nurses (LNs) did not notify Resident 1's doctor (MD) that Resident 1 had symptoms of the flu and a report of Resident 1had been exposed to a family member who tested positive for flu; LNs did not notify the MD the facility ran out of flu tests; LNs did not place Resident 1 on droplet precautions (measures implemented to prevent the spread of infection when a person who is infected with a pathogen [germs that cause disease] coughs, sneezes, or talks);These failures resulted in Resident 1's hospitalization from 4/27/25 up to 5/6/25 where she was diagnosed with Influenza A and Acute Hypoxemic Respiratory Failure (AHRF, a serious condition where the respiratory system can't maintain adequate oxygen levels in the blood, potentially leading to organ dysfunction), received a new order for supplemental oxygen (additional oxygen to a person who is not receiving enough oxygen from the air they breathe), and decreased the facility's potential to prevent the spread of flu among other residents, visitors, and staff.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] at the age of [AGE] years old.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/27/25, indicated the primary reason for Resident 1's admission was due to a medically complex condition (a broad category of illnesses, diseases, or impairments that require extensive and ongoing medical care, often involving multiple body systems and comorbidities [simultaneous presence of two or more medical conditions in a patient]) including a diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing),.A review of Resident 1's admission Summary progress note, dated 4/24/25, indicated Resident 1 presented to the facility with stable (within normal limits [WNL] or acceptable ranges) vital signs (measurements of the body's most basic functions) including pulse (number of times the heart beats within a minute) at 94 beats per minute (bpm), and oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at 94% without the use of supplemental oxygen.A review of Resident 1's nurse health status note, dated 4/24/25 at 4:06 p.m., indicated Resident 1's daughter notified Licensed Nurse (LN) A that Resident 1 had been exposed to a family member who tested positive for flu. The note also indicated Resident 1 had complained of sore throat and earache earlier that day.A review of Resident 1's nurse health status notes, for dates 4/24/25 and 4/25/25 did not indicate Resident 1's physician was notified that Resident 1 had been exposed to flu, had a reported symptom consistent with flu, and had not been tested for flu due to the facility not having flu testing supplies.A review of Resident 1's health status note, dated 4/26/25 at 9:56 p.m., indicated, [Resident 1's] daughter expressed concern regarding her mother's respiratory status. She requested that MD be notified regarding her concern that [Resident 1] may have flu.[with] [temperature] 98.7 [Fahrenheit, a unit of measure] ([Resident 1's] daughter notes that this is a high temp [temperature] for her mother.A review of Resident 1's health status note, dated 4/27/25 at 2:59 p.m., indicated, .[Resident 1] with elevated temp noted 99.1 [Fahrenheit].with episode of cough noted.family requesting to see MD; MD will be in on 4-28.A review of Resident 1's incident note, dated 4/27/25 at 11:30 p.m. indicated, .[Resident 1's] daughter called [facility] at approximately [4:30 p.m.] to report her concern that [Resident 1] had loose stools x2 [two times]. next call from [Resident 1's daughter] came after approximately one hour.that [Resident 1] had another loose stool.that [Resident 1] needed to be transferred to ‘the hospital' because ‘you are not doing anything for her'. [Resident 1] left [facility] with EMS [emergency medical services] staff at approximately [7 p.m.].[Resident 1] had resisted having vitals taken.A review of Resident 1's incident note, dated 5/11/25, indicated, late entry /addendum for 4/27/25: assessment of time.Timing of [Resident 1's] discharge from [facility] with EMS Paramedic staff is now estimated to be between [9:15 p.m.] and [9:30 p.m.] .A review of the emergency department (ED, provides unscheduled outpatient services to patients whose condition requires immediate care) provider note, signed 4/28/25, indicated on 4/27/25 Resident 1 was, .[brought in by ambulance] from [skilled nursing facility] for concerns of flu.HR [heart rate, the number of times the heart beats per minute] 140s, [O2 sat] 92% . placed on [supplemental oxygen].Triage vital signs Temp 99 [Fahrenheit], Heart rate 153, [Respiratory Rate] 35, [O2 sat] 97% [on supplemental oxygen].presenting with shortness of breath. wheezing [a high-pitched sound made when breathing is restricted/obstructed in the lungs] and rhonchi [low-pitched, continuous, snoring or gurgling sounds heard in the lungs, resulting from mucus or other secretions obstructing the larger airways] present. Sepsis [a life-threatening response to infection] was present on arrival, specifically at [9:45 p.m.].ED diagnosis:1. Acute hypoxemic respiratory failure. 2. Influenza A. A review of Resident 1's Hospital Discharge summary, dated [DATE], indicated, . Date of admission: [DATE] Date of discharge: [DATE].Hospital summary.[Resident 1] with complain [sic] of shortness breath, sore throat, cough.Acute respiratory failure with hypoxia [condition with low oxygen] and hypercapnia [condition with high levels of carbon dioxide].Influenza A.COPD with exacerbation [worsening of a disease or its signs and symptoms]. Per [oxygen] eval, [Resident 1] will benefit from PRN [as needed] [supplemental oxygen] to keep [O2 sat] above 92% .[supplemental oxygen] has been ordered and will be delivered to [home health agency]. [Resident 1] influenza positive.COPD made worse by influenza a. discharge disposition: home with home health.During an interview on 7/29/25 at 10:20 a.m., LN A stated when a facility received a report that a resident was exposed to flu, [AD1] the facility would test the resident for flu as a precautionary measure. LN A acknowledged Resident 1 had not been tested for the flu at the facility because there were no flu test kits available. LN A stated that since there was no confirmation Resident 1 was positive for flu, Resident 1 could only be suspected of having the flu virus. LN A stated testing for flu was important to protect the residents and provide Resident 1 with the appropriate treatment. LN 1 clarified, when a resident tested positive for flu, the resident should be put on transmission-based precaution (TBP, an infection control measures used in healthcare settings to prevent the spread of pathogens that can be transmitted through contact with an infected patient, their body fluids, or contaminated surfaces or objects). LN A added placing a resident who tested positive for flu on TBP was for everyone's safety and to prevent outbreaks (a sudden increase in the number of cases of a disease in a specific area or population over a short period). During a concurrent interview and record review on 7/29/25 at 10:26 a.m. with the facility's Infection Preventionist (IP, a healthcare professional who specializes in preventing and controlling infections in healthcare settings), Resident 1's nurse health status notes, dated 4/24/25 through 4/25/25, were reviewed. The IP verified Resident 1's daughter had reported that Resident 1 was exposed to flu. The IP stated that since the family member told the facility staff Resident 1 was exposed to flu, the facility staff should have tested Resident 1 for flu. The IP stated the flu test was not done on Resident 1 because the facility ran out of flu tests. The IP stated it was important to do the flu test to determine Resident 1 flu status and to provide appropriate treatment. The IP verified the nurse health status notes dated 4/24/25 through 4/25/25 did not indicate the MD was notified Resident 1 was exposed to flu, suspected of having flu since she reported a symptom consistent with flu, or that the facility was unable to test Resident 1 for flu virus due to facility's lack of flu test. The IP verified, Resident 1's electronic health record did not indicate Resident 1 was placed on any TBP.During a concurrent interview and record review on 7/29/25 at 11:21 a.m., with the IP, the facility's policy and procedure (P&P) titled Infection Control Plan- Influenza, dated 02/2024 was reviewed. The IP verified that based on their flu plan, which the facility follows, Resident 1 was considered a suspect for flu and should have been tested for flu, placed on droplet precautions and immediately started on antiviral medication. The IP confirmed that none of those actions were done for Resident 1. The IP stated it was important to test Resident 1 for flu to know her flu status and to be able to treat her right away. The IP stated placing Resident 1 on droplet precaution ensures the safety of everyone and could help prevent outbreaks.During a concurrent interview and record review on 7/29/25 at 11:50 a.m. with the Director of Nursing (DON), Resident 1's nurse health status notes from 4/24/25 through 4/27/25 and Resident 1's electronic medication administration record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) for April 2025 was reviewed. The DON verified Resident 1 should have been tested for flu upon report she had been exposed to flu and was symptomatic but was not tested due to lack of a flu test kit. The DON verified that when Resident 1 was admitted on [DATE] and up to the time Resident 1 was sent out to the hospital on 4/27/25, Resident 1 was not tested for flu, did not receive any antiviral medications nor was placed on droplet TBP. The DON confirmed Resident 1 was sent to the ED due to concern from Resident 1's daughter that Resident 1's condition was worsening and the belief that the facility was not taking care of Resident 1. The DON verified the facility's flu policy and procedure (P&P) was not followed, since Resident 1 was suspected of flu, Resident 1 should had been tested for flu, should have been placed on droplet TBP and should have been started on antiviral medication.A review of the facility's P&P titled Infection Control Plan-Influenza (Residents/Patients), last reviewed on 2/2024, the P&P indicated, .Healthcare clinic infection control lead and clinical staff will evaluate, observed or report residents with symptoms and implement daily surveillance and/or testing and symptoms screening.LTC [long term care] residents who have confirmed or suspected influenza should receive antiviral treatment immediately as antiviral treatment works best when started within the first 2 days of symptoms.communications/notifications to residents physicians.A review of the Center for Disease Control and Prevention (the national public health agency for the United States) document titled, Treating Flu with Antiviral Drugs, dated 9/11/24, indicated, .Treatment of flu with flu antiviral medications works best when started within 1-2 days after flu symptoms begin. Flu antiviral drugs can lessen symptoms and shorten the time you are sick. It's very important that flu antiviral drugs are started as soon as possible to treat patients who are. at increased risk of serious flu complications based on their age or underling health conditions, if they develop flu symptoms. For example, people with asthma and chronic lung disease.

Based on interviews and record reviews, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was accurate for one resident (Resident 1), when Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a set of medical orders, based on a patient's preferences, that guide medical care for individuals with serious illnesses) form information was different from the information documented on Resident 1's MDS assessment.This failure could result in inappropriate care and treatment.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of April2025 and she was her own responsible party (RP, a person who is designated in making decisions about health care and financial matters).A review of Resident 1s MDS assessment, dated [DATE], indicated Resident 1 was admitted to the facility with a medically complex condition (a broad category of illnesses, diseases, or impairments that require extensive and ongoing medical care, often involving multiple body systems and comorbidities). Section S California POLST indicated Resident 1 had chosen for staff to attempt resuscitation/ cardiopulmonary resuscitation (CPR, an emergency treatment that's done when someone's breathing or heartbeat has stopped), full treatment (indicating the patient wishes to receive all medically appropriate and available treatments to prolong life, including interventions like mechanical ventilation, intensive care, and other life-sustaining measures), and opted for a trial period of artificial nutrition which can include the use of a feeding tube (FT, a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation).A review of Resident 1's signed POLST form, dated [DATE], indicated Resident 1 chose Do not Resuscitate (DNR, a medical order instructing healthcare provider not to perform CPR if a patient's breathing or heartbeat stops), selective treatment (indicating the patient wants medical conditions treated while avoiding burdensome measures. This option prioritizes treating the immediate medical issue but avoids measures like prolonged life support, intensive care, or invasive procedures such as intubation or mechanical ventilation), and no artificial means of nutrition including feeding tubes.During a concurrent interview and record review on [DATE] at 11:04 a.m. with the Minimum Data Set coordinator (MDSC), Resident 1's MDS assessment section S, dated [DATE], was reviewed. The MDSC verified Resident 1's MDS section S indicated Resident 1 had chosen attempt resuscitation/ cardiopulmonary resuscitation, full treatment, and trial period of artificial nutrition including feeding tubes. The MDSC stated MDS assessments should be accurate and the POLST accuracy in MDS section S was important because it provided direction of care in case of a medical emergency. During an interview on [DATE] at 11:50 a.m., the Director of Nursing (DON) stated the MDS section S information should be filled in from the POLST form signed by Resident 1 and the physician. The DON stated if the information did not match, it meant the MDS assessment was inaccurate. The DON stated inaccurate MDS could result in ineffective care and treatment. During a telephone interview on [DATE] at 2:58 p.m. the DON verified the information on Resident 1s POLS, dated [DATE], and the MDS assessment section S, dated [DATE], did not match. The DON confirmed Resident 1's MDS assessment section S dated [DATE] was inaccurate. The DON stated the facility did not have a policy and procedure on MDS assessment. A review of the American Association of Post Acute Care Nursing article titled understand the MDS trickle-down effect dated [DATE], it indicated, . well maintained and accurate source of documentation . are essential for MDS accuracy.

Based on observation, interviews and record reviews, the facility failed to provide written notice of transfer to the Long-Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for two out of two sampled residents (Resident 1 and Resident 2), when they were transferred to the hospital in March of 2025 without the Ombudsman being notified. These failures could result in loss of residents ' advocacy and protection and prevent innapropriate transfers and discharges. Findings: During an interview on 4/23/25 at 3:14 p.m., the Director of Staff Development (DSD) stated she was not sure if the nurses were completing a written notice of transfer when residents were discharged or transferred to the hospital. The DSD also stated she was not sure whether the Ombudsman needed to be notified when residents were transferred to the hospital. During an interview on 4/23/25 at 3:30 p.m., the Administrator (Admin) stated she was not sure if the facility had to complete a written notice of transfer and notify the Ombudsman when residents were transferred to the hospital. The Admin stated as far as she knew, the Ombudsman did not need to be notified when residents get transferred or sent to the hospital. During an interview on 4/23/25 at 3:33 p.m., Licensed Nurse (LN) C stated she had discharged and transferred residents to the hospital but had never completed a notice of transfer nor had she notified the Ombudsman when residents were transferred to the hospital. LN C stated she was not aware they have to notify the Ombudsman if a resident was being transferred or discharged to the hospital. LN C stated the Ombudsman should be notified to protect residents ' rights. During an interview on 4/23/25 at 3:36 p.m., LN D stated she had discharged and transferred residents to the hospital but had never completed a notice of transfer. LN D stated she also had never notified the Ombudsman of any residents ' transfers to the hospital. LN D stated she was not aware the Ombudsman should be notified when residents ' gets transferred or discharged to the hospital. LN D stated the Ombudsman should probably need to be notified of residents ' discharges or transfers to the hospital to protect residents ' rights and assist residents with their needs. During an interview on 4/23/25 at 3:37 p.m., the Social Services Director (SSD) stated she oversaw notifying the Ombudsman of residents ' discharges however the SSD added, she had never notified the Ombudsman of any residents' transfers to the hospital. SSD stated she was not aware the facility had to notify the Ombudsman of residents ' transfers to the hospital. The SSD stated the Ombudsman should be notified of transfers and discharges to protect residents ' rights and to help prevent inappropriate discharges. During a telephone interview on 4/24/25 at 3:23 p.m., the Director of Nursing (DON) verified there was no notice of transfer completed nor had the Ombudsman been notified when Resident 1 was transferred to the hospital on 3/31/25 and when Resident 2 was transferred to the hospital on 3/30/25. A review of the facility ' s policy and procedure (P&P) titled Transfer and Discharge, last reviewed 7/2024, the P&P indicated, .Notice Before Transfer or discharge: In all cases of transfer or discharge, the resident/patient, their representative/responsible party (if applicable) .the State Long-Term Care (LTC) Ombudsman shall also be notified in accordance with applicable regulatory requirements . A review of the All Facilities Letter (AFL 17-27), dated 12/26/2017, indicate, . The facility must send notice to the local LTC Ombudsman for any transfer or discharge that is initiated by the facility .

Based on observation, interview and record review, the facility failed to ensure two of fourteen sampled residents (Resident 34 and Resident 190) at risk for falls, were provided with supervision (visual checks) by direct care staff and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 190 suffered two falls with major injuries, consisting of hip fractures, at the facility, and one fall with no injuries. This caused severe pain to Resident 190 and may have contributed to her death, just 7 days after her last fall with major injury. Resident 34 fell 7 times in 4 months due to lack of supervision, revision, and implementation of care plans to prevent falls. This had the potential to result in falls with major injuries for Resident 34. Findings: Resident 190 Record review of the facility Face Sheet (Facility Demographic) indicated Resident 190 was admitted to the facility on [DATE] with medical diagnoses including History of Falling (History of having suffered falls, which may indicate increased risk for future falls), Alzheimer's Disease (A progressive brain disorder that slowly destroys memory and thinking skills), Restlessness and Agitation. Record review of Resident 190's MDS (Minimum Data Set-An assessment tool) dated 1/14/24 indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 3, which indicated her cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). This document also indicated under section GG (Section of the MDS that evaluates the amount of assistance a patient needs) dated 1/14/24, that Resident 190 required partial to moderate assistance with toileting and personal hygiene. Record review of an undated facility document titled, POST FALL INVESTIGATION, provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., in response to a request for a policy on neurological checks (A healthcare provider's evaluation of a person's nervous system after a fall to help determine the extent of damage from head trauma), indicated that after a resident fall, the following tasks were required to be completed, Complete Post Fall investigation Report .Complete Risk Management in [Electronic documentation system] .Update care plan on falls .Initiate Q30 (Every thirty minutes) checks for the next 72 hours .Complete neuro (neurological)-check (paper form). Neurological checks, as indicated in this form titled, POST FALL INVESTIGATION, were required to be performed every thirty minutes for 72 hours after the fall. Record review of a facility document titled, Falls Risk Assessment, dated 10/16/23, indicated Resident 190 was at medium (Moderate) risk for falls. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., Resident 190's care plans for falls were reviewed. There were no care plans created prior to the first fall on 1/01/24. The DON stated she would look to see if she could find one but did not provide this care plan. 1st Fall Record review of a progress note dated 1/01/24 at 2:45 p.m., indicated, Resident [Resident 190] called help, help from her room. Entered room with CNA (Certified Nursing Assistant). Resident is on the floor on her L (Left) side next to her bood (Sic, possibly meant bed). Resident unable to explain what happened .L hip is tender to touch. Pain intensifies with movement and attempt to reposition .911 called for transport to [General Acute Care Hospital (GACH)] .Resident left for hospital 15.20 (3:20 p.m.). Record review of a progress note dated 1/01/24 at 10:47 p.m., indicated, Received a phone call .on resident [Resident 190] status, resident has a left hip fracture with possible surgery. Record review of a facility physician progress note dated 1/13/24 at 7:35 a.m., indicated, [Resident 190] is a [AGE] year old female who was living in the healthcare center of [Name of facility] and sustained a fall resulting in left hip fracture. Patient was subsequently transferred to [name of GACH]. Patient underwent successful left hip hemiarthroplasty (A surgery to repair half of a hip joint after a traumatic injury in which the femoral head (Upper joint of the thigh bone) is fractured. Record review of a facility document titled, Fall Risk Assessment, dated 1/02/24 at 11:35 a.m., indicated Resident 190 was at low risk for falls, although she had just fallen the day before, on 1/01/24 and suffered a hip fracture. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., the document, Falls Risk Assessment, dated 1/02/24 at 11:35 a.m., was reviewed. The DON stated this document was completed inaccurately, since it indicated Resident 190 had no history of falls within the last three months, was ambulatory and continent, and was taking only two medications increasing her risk of falls, when she was taking eight medications. The DON stated Resident 190 did have a history of falls within the last three months, since she had fallen on 1/01/24, required supervision with ambulation, and was incontinent (Inability to control the bowels and bladder) at times. The DON confirmed this assessment indicated Resident 190 was at low risk for falls due to the inaccurate responses submitted. Record review of a care plan for falls initiated on 1/08/24 (no time documented) for Resident 190, listed the following interventions to prevent further falls, Keep call light in reach at all times .Keep personal items and frequently used items within reach .Anticipate needs and meet on timely basis. There were no interventions in the care plan aimed at increasing supervision for Resident 190. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., the care plan for falls initiated on 1/08/24 (no time documented), was reviewed. The DON confirmed there were no interventions to increase supervision for Resident 190 in the care plan, but supervision was increased through rounds completed every two hours by staff, which were initiated on 1/17/24 (17 days after the first fall with major injury) and provided the documents titled, RESIDENTS ON TOILETING SCHEDULE, dated 1/17/24 through 2/27/24. Record review of the documentation for staff rounding titled, RESIDENTS ON TOILETING SCHEDULE, from 1/17/24 to 2/27/24 indicated there were several shifts and hours of the day, when Resident 190 was not checked, as the boxes were left empty. For example, on 2/25/24, Resident 190 was required to be checked at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m., but the documentation indicated she was not checked at all throughout morning shift. This was repeated on multiple occasions, such as on 2/15/24 for morning shift, 2/17/24 for night shift, 2/26/24 for evening shift, 2/27/24 for night and evening shifts, etc. Record review of interdisciplinary team (IDT) meetings titled, [Name of Facility], a Community of Seniors Clinical Sign in Sheet, dated 1/10/24 at 10:25 a.m.,1/16/24 at 10:35 a.m., 1/17/24 at 10:25 a.m., and 1/19/24 at 10:30 a.m., indicated Resident 190 returned from the GACH to the facility on [DATE], and was admitted to hospice (Palliative services aimed at keeping resident comfortable at the end of life) on 1/19/24. There was no documentation in these IDT meeting reports that Resident 190 suffered a fall with major injury at the facility. This was confirmed by the DON during an interview on 7/11/24 at 9:38 a.m. 2nd Fall Record review of a progress note dated 1/30/24 at 9:25 a.m., indicated, Resident [Resident 190] is OOB (Our of bed) for meals eating breakfast in the dining area. @0925 (At 9:25 a.m.) resident fall (Sic) in the wheelchair at dining area .no skin tear, denies hitting head and no discoloration. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., the care plan for falls revised on 2/02/24 (3 days after the fall) for Resident 190 was reviewed. This care plan for falls included only two new written interventions. One of the newly written interventions indicated, Toiletted (Sic. Assisted to use the restroom) QAC (Before meals), PC (After meals), HS (Before bedtime) and PRN (As needed). The DON confirmed this new intervention was already in place before the fall on 1/30/24, although it had not been formally written before in the care plan. The second intervention indicated, Close monitoring for safety. The DON confirmed the resident continued the same rounding schedule by staff every two hours (Since 1/17/24), therefore, there was no increased supervision for Resident 190. The DON stated they did increase visual checks for Resident 190 but did not have any documentation of it. Record review of the documentation for staff rounding titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 1/17/24 indicated Resident 190 continued to be checked every two hours, despite the fall on 1/30/24. 3rd Fall Record review of a progress note dated 2/20/24 at 8:36 a.m., indicated, Rd [Resident 190] was found on the floor .She was on the floor on her right side at the base of the floor mat next to her bed .she was not complaining of pain at the time .She was lifted back to her bed and she started to complain of right inner thigh pain. Record review of a progress note dated 2/21/24 at 11:40 a.m., indicated, Resident is on S/p (Status post) unwitnessed fall Day 2 .Right hip fracture .Administrator, DON .was notified with the result of the Right Hip X-ray. Record review of a facility document titled, NEUROLOGICAL ASSESSMENT FLOW SHEET, indicated staff documented neurological checks only from 2/20/24 at 12:15 a.m., to 2/20/24 for, NOC (Night shift, no specific hours documented). This was less than the 72 hours required in the document titled, POST FALL INVESTIGATION (Above). This was confirmed by the DON during an interview on 7/11/24 at 9:38 a.m. Record review of a, Falls Risk Assessment, for Resident 190 dated 2/20/24 at 6:37 p.m., indicated Resident 190 was at high risk for falls. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., Resident 190's care plan for falls, updated on 2/20/24 (No time documented) was reviewed. The care plan only had one intervention aimed at preventing further falls. This intervention indicated, Remind resident not to get up by herself. Frequent checks. The DON confirmed this was the only intervention to prevent further falls, as other interventions had the intention of keeping the resident comfortable. The DON confirmed reminding the resident not to get up by herself was not appropriate as the resident's cognition was severely impaired. The DON stated she had no documented evidence supervision was increased after this fall, as they continued with the same rounding by staff every two hours. Record review of the documentation for staff rounding titled, RESIDENTS ON TOILETING SCHEDULE, from 1/17/24 through 2/27/24 indicated staff continued to check on Resident 190 every two hours, despite the fall on 2/20/24 which resulted in a fracture. During an interview on 7/11/24 at 9:38 a.m., the DON was asked to provide care plans for the two hip fractures caused by Resident 190's falls at the facility. During an interview on 7/11/24 at 1:44 p.m., the DON confirmed there were no care plans found specifically for the care of Resident 190's hip fractures. Record review of nursing progress notes (see below for dates and times) indicated Resident 190 experienced moderate to severe pain levels during her last days at the facility related to her right hip fracture, before passing away on 2/27/24 at 4:10 p.m., as follows: a) Progress note dated 2/21/21 at 11:40 a.m., indicated, Resident c/o (Complained of) 7/10 (Pain scale where 0 indicates no pain, and 10 is the worst pain experienced in a person's lifetime. A pain level of 0-2 = mild, 3-5 = moderate, and 6-10 = severe) r/t (Related to) Right hip fracture. b) Progress note dated 2/22/24 at 8:21 a.m., indicated, resident able to verbalize pain to rt (Right) hip . c) Progress note dated 2/22/24 at 11:40 a.m., indicated, Resident c/o pain 8/10 during turning and repositioning r/t right hip fracture. d) Progress note dated 2/22/24 at 3:51 p.m., indicated, Resident c/o pain when she moved . e) Progress note dated 2/23/24 at 9:34 a.m., indicated, received resident in bed .able to vocalize pain to right upper leg . f) Progress note dated 2/23/24 at 6:21 p.m., indicated, resident verbalized pain with mobility. Record review of a progress note dated 2/27/24 at 5:49 p.m., indicated, resident's dtr (Daughter) present at bedside, notified passed away around 410 pm (4:10 p.m.). During an interview with the DON on 7/11/24 at 9:38 a.m., she stated the facility needed improvement in several areas of managing falls, such as completing the fall risk assessments accurately, care planning after every fall, and documentation of the visual checks. Resident 34 Record review of the facility Face Sheet indicated Resident 34 was admitted to the facility on [DATE] with medical diagnoses including Hemiplegia (Complete or severe loss of strength on one side of the body), & Hemiparesis (One-sided muscle weakness), Aphasia (Inability to speak or understand, or both), and Anxiety Disorder (Intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident 34's MDS dated [DATE] indicated she was completely dependent on staff for toileting, personal hygiene and bed-to-chair transfer. Record review of a facility document titled, Falls Risk Assessment, dated 1/26/24 at 6:33 p.m., indicated Resident 34 was at high risk for falls. Record review of a care plan for prevention of falls for Resident 34 initiated on 1/23/24, indicated, [Resident 34] is at High risk for falling R/T (Related to) recent hospitalization .Keep call light in reach at all times .Keep personal items and frequently used items within reach .anticipate needs. During an interview with the Director of Staff Development (DSD) on 7/11/24 at 3:30 p.m., the DSD was asked in writing and verbally to provide the following documents: a) All documentation of Resident 34's falls since 1/01/24 to the present. b) All care plans updated or revised after every fall since 1/01/24 to the present. c) All neurological checks performed after every fall since 1/01/24 to the present. d) All fall risk assessments performed after every fall since 1/01/24 to the present. During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but stated she could not find them all. The DSD stated she was providing what she was able to find regarding the above request. The documents not provided by the DSD are written below. 1st Fall Record review of a progress note dated 2/07/24 at 7:55 a.m. indicated, Incident Date: 02/07/2024, Incident Time: 05:00 .resident found with bedding on the floor on right side of bed lying on her weak/right side at 5am (5:00 a.m.) when this nurse went to check on her. Record review of a Falls Risk Assessment, dated 2/08/24 at 6:57 p.m., indicated Resident 34 was at high risk for falls. During concurrent record review and interview with the DSD on 7/12/24 at 7:50 a.m., the care plan for falls initiated on 2/07/24 was reviewed. This care plan indicated, frequent checks per facility protocol (The care plan did not indicate how often, or how this was going to be monitored) .request cradle mattress from hospice. This was confirmed by the DSD. During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but the neurological checks after the fall on 2/07/24, was not included. The DSD stated she was providing what she could find. 2nd Fall Record review of a progress note dated 2/18/24 at 3:52 p.m., indicated, Resident had an unwitnessed fall at around 0900 (9:00 a.m.) in the morning (The morning of 2/18/24). Resident was seen sitting on the right side of her bed in a sitting position with her back leaning on her bed. During a concurrent interview and record review with the DSD on 7/12/24 at 7:50 a.m., the care plan for falls initiated on 2/18/24 was reviewed. The care plan did not contain any new interventions to prevent falls, or increased supervision. The interventions included, Neurochecks (Neurological assessments) as per facility protocol .VS (Vital Signs-Clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) .Monitor for pain. This was confirmed by the DSD. During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but the neurological checks and fall risk assessment after the fall on 2/18/24, were not included. The DSD stated she was providing what she could find. 3rd Fall Record review of a care plan for falls initiated on 3/13/24 indicated, Fall-3/5/24-no injury (No time of the fall documented). During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but specific documentation on the fall that occurred on 3/05/24, was not included. The DSD stated she was providing what she could find. Record review of a facility document titled, MORSE FALL-Senior Living (Fall risk assessment), dated 3/05/24 at 6:41 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 (8 days after the fall on 3/05/24) indicated, Activity staff will provide 1:1 (One staff to one resident) visit for socialization .Call light is present and within reach .Staff to anticipate needs .The resident is mostly bedbound r/t personal preference, physical impairment. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34 was placed on a schedule for staff checks every two hours. This document indicated there were several shifts and hours of the day, when Resident 34 was not checked, as the boxes were left empty. On 3/05/24, Resident 34 was required to be checked for evening shift at 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m., according to the form. This document indicated Resident 34 was not checked at all throughout evening shift on 3/05/24. Record review of neurological checks initiated on 3/05/24 at 8:30 a.m., indicated they were not conducted every 30 minutes as required (The POST FALL INVESTIGATION, provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., above, indicated neurological checks were to be conducted every 30 minutes for 72 hours after a resident fall). On 3/05/24, the documentation indicated neurological checks were completed at 4:15 p.m., and again at 8:15 p.m. (4 hours later), and again at 12:15 a.m., (4 hours later). The next time neurological checks were documented for Resident 34 was on 3/06/24 for AM (Morning shift, which started at 7:00 a.m.). 4th Fall Record review of a care plan for falls initiated on 3/13/24 indicated, Fall-3/15/24-no injury (No time of the fall documented). Record review of the care plan for falls initiated on 3/13/24 indicated the care plan was not revised or updated after the fall on 3/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, Fall Risk Evaluation, dated 3/05/24 at 4:03 p.m., indicated Resident 34 was at risk for falls. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff despite the fall on 3/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. 5th Fall Record review of a progress note dated 4/13/24 at 9:10 p.m., indicated, PT (Patient [Resident 34]) found on the floor during routine check around 445pm (4:45 p.m. on 4/13/24). Staff assisted back to bed, no visible injuries. Record review of a facility document titled, MORSE FALL-Senior Living (Fall risk assessment), dated 4/13/24 at 10:43 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 indicated the care plan was not revised or updated after the fall on 3/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff, despite the fall on 4/13/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. 6th Fall Record review of a progress note dated 4/15/24 at 9:55 p.m., indicated, During morning rounds right after am report at 7:30 am (On 4/15/24), resident found on the floor mat next to bed. Record review of a facility document titled, MORSE FALL-Senior Living, dated 4/15/24 at 10:44 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 indicated only two new interventions were added to the care plan after the fall on 4/15/24. These two new interventions were added on 4/19/24, four days after the fall, and indicated, Continue with the plan of care to frequently check the resident .Request [Hospice] scheduled visit to offset private caregiver time when possible. The care plan did not specify what frequently check the resident, meant, or how it was monitored. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff, despite the fall on 4/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 p.m. Record review of neurological checks initiated on 4/15/24 at 7:30 a.m., indicated they were only conducted from 4/15/24 at 7:30 a.m. to 4/16/24 for PM, which was approximately 40 hours, and not the 72 hours required in this form (The form, POST FALL INVESTIGATION (above), provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., indicated neurological checks were to be conducted every thirty minutes for 72 hours after a resident fall). 7th Fall Record review of a progress note dated 4/24/24 at 6:13 p.m., indicated, Resident noted to be on floor laying on R (Right) side. Assessed-No apparent injuries. Record review of a facility document titled, MORSE FALL-Senior Living, dated 4/24/24 at 10:44 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 indicated it was revised after the fall on 4/24/24, but only one new intervention was added. The new intervention was added on 7/11/24 (more than 2 months after the fall on 4/24/24) and indicated, Follow facility fall protocol. The care plan did not indicate to increase supervision. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through the 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff, despite the fall on 4/24/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of neurological checks initiated on 4/24/24 at 4:45 p.m., indicated they were not conducted every 30 minutes as required (The form, POST FALL INVESTIGATION (above), provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., indicated neurological checks were to be conducted every thirty minutes for 72 hours after a resident fall). On 4/25/24, the documentation indicated neurological checks were completed at 12:30 a.m., and again at 4:30 a.m. (4 hours later), and again at 8:30 a.m., (4 hours later). The next time neurological checks were documented for Resident 34 was on 4/25/24 for PM (Evening shift, which started at 2:30 p.m.). During a concurrent observation and interview with Unlicensed Staff S, assigned to Resident 34, on 7/08/24 at 3:14 p.m., he was asked if Resident 34 was able to speak. Unlicensed Staff S stated he did not know, as he was unfamiliar with Resident 34. Resident 34 was observed awake in bed, with the bed in the lowest position, right next to another bed, and a mat on the floor. Unlicensed Staff S stated he was from a registry company. Unlicensed Staff S was asked the reason Resident 34 had a mat right next to her bed, and another empty bed to the right of her bed. Unlicensed Staff S stated not knowing the reason. Unlicensed Staff S was asked if Resident 34 was at risk for falls. Again, Unlicensed Staff S stated not knowing the answer to the question. During an interview on 7/09/24 at 11:45 a.m., Unlicensed Staff E stated she was a private caregiver for Resident 34, hired by Resident 34's family. Unlicensed Staff E stated she worked with Resident 34 from Monday through Friday from 9:00 a.m., to 2:00 p.m. Unlicensed Staff E stated that if she did not notify facility staff Resident 34 needed to have her brief changed, they did not come to check on her every two hours, and even when notified, they had still left her up to thirty minutes with a soiled brief. Unlicensed Staff E also stated that most of the time, when she came to the facility at 9:00 a.m., Resident 34's breakfast tray was observed sitting on her bedside table, untouched and cold, waiting for her to assist Resident 34 with the meal. Unlicensed Staff E also stated the facility often assigned unfamiliar staff to Resident 34, including registry staff. During a concurrent interview and record review with the DSD on 7/12/24 at 7:50 a.m., after reviewing the care plans for falls, supervision documentation, fall risk assessments and other documents related to falls (Dates and specific titles of each document mentioned above, in falls 1 through 7), the DSD stated Resident 34's fall management process needed improvement. During a phone interview on 7/12/24 at 8:31 a.m., Anonymous Witness G stated being very dissatisfied with Resident 34's care at the facility. Anonymous Witness G stated she had hired a private caregiver to care for Resident 34 from 9:00 a.m. to 2:00 p.m., because she felt Resident 34 was not receiving the care she needed. Anonymous Witness G stated she made arrangements to transfer Resident 34 out of the facility on 7/11/24. Anonymous Witness G stated she had brought up resident care issues with the DON, but the DON never followed up on them. Anonymous Witness G stated being aware Resident 34 had fallen multiple times at the facility. During an interview with Licensed Staff D on 7/12/24 at 12:00 p.m., she was asked how often Resident 34 was required to be checked by staff when she was still residing at the facility. Licensed Staff D stated Resident 34 was required to be checked every two hours, which corroborated that supervision requirements were never changed for Resident 34 despite multiple falls at the facility. Record review of the facility policy titled, Accident Prevention/Mitigation and Response, last reviewed in November of 2023, indicated, Avoidable Accident: means than an accident occurred because the facility failed to: Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk .Monitor the effectiveness of the interventions and modify the care plan as necessary .Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on interview and record review, the facility did not have a system to track staff compliance in required trainings, when: 1. Two of four sampled employees had mandatory trainings that were overdue (Licensed Staff K and Unlicensed Staff L). This finding had the potential to result in inadequate staff competency to care for the residents within professional standards or practice, poor quality of care, and harm to the residents of the facility. 2. The facility failed to provide a competent DSD to enforce training and verify competencies for Nursing staff when Unlicensed Staff F's (BLS) Basic Life Support Certification (CPR Cardiopulmonary Resuscitation the act of performing chest compressions and artificial respirations) was expired for 4.5 months while working in the facility. This failure had the potential to result in 30 out of 36 sampled residents needing CPR but not having access to a Certified CPR staff member to perform CPR. Findings: 1. During an interview on [DATE] at 11:00 a.m., with the Director of Staff Development (DSD), she was asked to provide the list of annual mandatory trainings for Licensed Nurses and Certified Nursing Assistants (CNAs) and another list of all direct care personnel working at the facility. The DSD provided these lists on [DATE] at 2:10 p.m. From the list of employees, the Surveyor chose two Licensed Nurses and two CNAs and asked the DSD to provide evidence by [DATE] at 10:00 a.m., that these employees had completed their mandatory trainings. The DSD explained the mandatory trainings were taken using an online training platform. During a concurrent interview and record review with the DSD on [DATE] at 10:00 a.m., the transcripts of the annual mandatory trainings were reviewed for both Licensed Nurses and CNAs. Of these four sampled employees, one Licensed Nurse (Licensed Staff K) and one CNA (Unlicensed Staff L) had annual mandatory trainings that were overdue. For example, for the Licensed Staff K, the mandatory annual training on infection control and prevention was last taken on [DATE], according to the transcript. The rest of the annual mandatory trainings were also taken in May of 2023. For Unlicensed Staff L, the mandatory annual trainings were over a year overdue. For example, the training on abuse and neglect in the elder care setting was last taken on [DATE] according to the provided transcript. This was confirmed by the DSD. The DSD was asked if she tracked mandatory trainings to ensure staff were taking them annually as required. The DSD stated she did not have a tracking system to ensure these trainings were taking annually. Record review of the facility document titled, Employee Benefits, dated 2023, indicated, Attendance at new hire, annual training an in-service training is mandatory and attendance time is paid .Training for the job requirements and for compliance is mandatory and must be completed on time every year or as necessary. Record review of the undated job description for Director of Staff Development, indicated, Oversees the [Computerized training] training for all HCC (Healthcare Center) .Tracks participation and follows up to ensure all team members are compliant with the policies of [Name of Facility]. 40402 2. During an observation on [DATE] at 9:00 a.m., outside of room [ROOM NUMBER], observed an Enhanced Barrier Isolation Cart (a cart that contains gloves, alcohol, masks, and gowns for staff to wear while providing high contact (Hygiene and bathing) activities for residents. Unlicensed Staff F was also observed in room [ROOM NUMBER] without a gown on providing hygiene for Resident 31 when he was incontinent of stool. Observed Unlicensed Staff F exiting Resident 31's room without washing his hands or using hand sanitizer after caring for Resident 31. During an interview on [DATE] at 9:20 a.m., in the hallway outside room [ROOM NUMBER], Unlicensed Staff F queried as to what care he was providing in room [ROOM NUMBER]. Unlicensed Staff F stated, he had to change and wash Resident 31 due to Resident 31 being incontinent of Stool. Unlicensed Staff F queried why he did not wear a gown while providing high activities care with Resident 31. Unlicensed Staff F stated, he forgot. Unlicensed Staff F queried why he did not wash his hands or use hand sanitizer after he finished with high activities with Resident 31. Unlicensed Staff F stated, he forgot. Requested Human Resource File from NHA on Unlicensed Staff F. Observed in file, Registry Staff Orientation Form dated [DATE], signed by DSD. The area on the form for CPR card verification with expiration date was left blank. Observed CPR BLS Certification Card in file to be expired [DATE]. During an interview with the DSD on [DATE] at 8:20 a.m., DSD queried if she was aware that Unlicensed Staff F's CPR card was expired. DSD stated, she was not aware that Unlicensed Staff F's BLS card was expired. DSD queried as to who is responsible to verify the current competencies and current certifications of the nursing staff. DSD stated, the ADP which is our Payroll Department. Queried DSD as to why a Payroll Department would be checking for current competencies and certifications. DSD stated, well, it's actually, my job as Director of Staff Development to keep track of the current competencies and current certifications. DSD queried if Unlicensed Staff F had a current BLS certification card. DSD stated, after she notified Unlicensed Staff F, he produced a BLS card with today's date [DATE]. DSD queried if she verified the company named on Unlicensed Staff F's BLS Certification Card to be sure it is accredited by the (AHA) American Heart Association. DSD stated, she did not verify that the company was approved by AHA. DSD queried what the risks are to resident safety if the facility does not have CPR certified staff. DSD stated, she thinks the residents would not receive the correct CPR. During a review of DSD's job description, signed by DSD, dated [DATE], Job Description indicated, DSD is responsible for Staff Development. DSD Prepares required paperwork for CNA (certified nursing assistants) re-certifications. Submits all required training plans to CDPH. Assists in survey preparation, maintains all training and in-service records. During a review of the facility's policy and procedure titled, Sufficient and Competent Staffing, Revised ,d+[DATE], indicated, Applicable Redwoods personnel will develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. We determine the amount and types of training necessary based on their facility assessment. The Facility will hire only qualified licensed or registered personnel and/ or consultants and outside contract services, as specified within the laws, rules and regulations by which the facility shall abide, including Evaluation where applicable shall have their license and required reviews conducted annually or as required thereafter, including where applicable their competency training requirements as well as required training for the position. Certified Nursing Assistants (CNA) shall be hired as qualified CNA and meets all the facility, state, federal personnel licensing and certification requirements and facility personnel requirements. During a review of the facility's Facility Assessment, dated [DATE], signed by NHA, DON, Licensed Staff B, and the Governing Body representative, indicated, on page 21 Contracted Providers, The Facility does maintain relationship with contracted providers to perform certain services on behalf of the Facility. Each Provider is expected to meet certain requirements depending on the nature of services that they are providing. In general, each contracted provider is expected to: Ensure that its staff members performing the services in the facility are appropriately trained/certified/licensed to perform the service. Comply with all applicable rules, regulations, standard of practice, facility policies and procedures. Adhere to standards of professional conduct. Promptly respond to any reported/identified concerns. Abide by any clauses/rules/expectations set forth in the applicable contract.

Based on observation, interview and record review, the facility failed to ensure the daily nursing staffing information was posted in a conspicuous place, during one of five days (7/08/24). This finding had the potential to result in inability for residents, visitors, and staff to review the staffing information, advocate for the residents' care, and identify issues with staffing numbers, which could have contributed to decreased quality of care. Findings: During a concurrent observation and interview with the Director of Staff Development (DSD) on 7/08/24 at 9:20 a.m., the posting that included the nursing staffing information, posted on the wall across the nursing station of the facility, had staffing posting information from the previous Friday, 7/05/24. At the time of the observation, there was a lot of activity going on at the facility. More than 10 residents were observed in the dining area involved in recreational activities, and staff were busy with their morning work routines. The DSD confirmed the finding and stated the unit clerk was responsible for posting the nursing staffing information, and this was usually done daily at around 10:00 a.m. During an interview on 7/08/24 at 11:01 a.m., the Staffing Coordinator stated she was the staff member responsible for creating and posting the daily nursing staffing information. The Staffing Coordinator stated she usually posted this document at around 8:30 a.m., Monday through Friday, as she did not work on the weekends. The Staffing Coordinator stated that on the weekends, this assignment was delegated to one of the charge nurses, but if the charge nurses were busy, they did not post the nursing staffing information. The Staffing Coordinator confirmed the posting in place the morning of 7/08/24 was from 7/05/24, which indicated the daily staffing information was not posted on 7/06/24 or 7/07/24 (Saturday and Sunday). Record review of the facility policy titled, Sufficient and Competent Nurse Staffing, dated July of 2024, indicated, Within three (3) hours of the beginning of each shift, the number of Licensed Nurses .and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. This policy contradicted Federal regulation S483.35(g)(2) which indicated, The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.

Based on interview and record review, the facility failed to ensure the Pharmacist's Drug Regimen Review (DRR/Medication Regimen Reviews- a monthly summary report of each resident's medication irregularities) report was acted upon with timely responses from Physicians and Medical Director. This failed practice had the potential to affect all residents currently receiving medications (36 of 36 residents) and placed them at risk for negative clinical outcomes due to a potential urgent action not being communicated in a timely fashion. Findings: During a review of the monthly Drug Regimen Review binder on 7/11/24, it was observed that monthly medication reviews conducted by the Consulting Pharmacist for the months of May and June showed no follow-up responses to recommendations made by the Consulting Pharmacist, and no documentation was present in the binder. Previous months (February, March, and April) Pharmacist recommendations for several residents was incomplete and did not show Physician responses or that follow-through was conducted. During an interview on 7/12/24 at 9:30 a.m., the Consulting Pharmacist (CP) was asked how often she conducts medication reviews at the facility. The CP stated she comes to the facility monthly reviews all resident charts and makes her recommendations. When asked who was present at the monthly meetings she stated the DON, DSD, and sometimes the Medical Director. When asked if the recommendations are followed through with timely responses from the physicians' she stated No, I had to hunt down physicians to receive responses, it has improved since we have a new Medical Director, he is more responsive and involved with the other physicians to ensure more timely responses to medication recommendations. When asked what her expectation was for a response to her recommendations, she stated a reasonable response time would be 30-days. During an interview with the Director of Nursing (DON) on 7/12/24 at 11:30 a.m., the DON could not show any paper or electronic documentation indicating the prescribing physicians had addressed the pharmacist's requests or that Nursing had contacted the physicians and Medical Director for responses to the pharmacist's recommendations. The DON was asked who had oversight to ensure the pharmacist's medication recommendations were followed-up and responses from physicians were documented. The DON stated she had oversight and acknowledged that she had not followed through with recommendations from the pharmacist. Further discussion with the DON, regarding lack of follow-through and documentation of recommendations did not ensure residents were medicated appropriately and safely. The DON stated she understood and would follow-up with the medical director and the pharmacist's recommendations. A request of the facility's Policy and Procedures for Medication Regimen Review was requested but not provided. Review of the Pharmacy policy and procedure titled, Medication Regimen Review and Reporting, dated 9/2018, indicated, Procedures - 6. Resident-specific MRR recommendations and findings are documented and acted up by the nursing care center and/or physician. 8. The nursing care center follows-up on the recommendations to verify that appropriate actions have been taken. Recommendations shall be acted upon within 30 calendar days.

Based on observation, interview and record review, the facility failed to ensure one of fourteen sampled residents (Resident 16) was free of psychotropic drugs (Medications used to treat mental health disorders. These medications have many side and adverse effects) she did not need. This failure had the potential to result in adverse consequences such as medication interactions, depression, confusion, immobility, falls with fractures, and death. Findings: Record review indicated Resident 16 was admitted to the facility on [DATE] with medical diagnoses including Dementia (A condition that affects memory) without Behavioral Disturbance (When a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), and Repeated Falls (History of having suffered falls, which may indicate increased risk for future falls), according to the facility Face Sheet (Facility demographic). Record review of Resident 16's MDS (Minimum Data Sheet-An assessment tool) dated 6/04/24 indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 6, which indicated her cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of Resident 6's physician orders for July, 2024, indicated she was initiated on Seroquel (Brand name for the medication Quetiapine Fumarate, an antipsychotic medication that treats several kinds of mental health conditions) 12.5 mg tab daily beginning on 5/16/24. The order indicated, at bedtime for Aggression. These physician orders for July 2024 did not indicate Resident 16 was to be monitored for aggression, to track the effectiveness or need for the medication. This was confirmed by the Director of Staff Development (DSD) during an interview on 7/11/24 at 3:53 p.m. Record review of an article titled, Quetiapine Oral Route, last revised on 7/01/24 by the Mayo Clinic (A non-profit academic medical center that provides integrated health care, education, and research), indicated, Quetiapine is used alone or together with other medicines to treat bipolar disorder (A mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and schizophrenia (A serious mental health condition that affects how people think, feel and behave) .This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer disease (A progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out simple tasks). Record review of Resident 16's Medication Administration Record (MAR) for July 2024, indicated Resident 16 was being administered Seroquel 12.5 mg tab daily at 9:00 p.m., as prescribed. Record review of all active care plans for Resident 16 did not indicate she had aggression issues or was being monitored for aggression. Record review of Resident 16's Face Sheet did not indicate she had medical diagnoses related to or causing aggression. This was confirmed by the DSD during an interview on 7/11/24 at 3:53 a.m. The DSD was also asked to provide evidence the facility had attempted other interventions to control aggression prior to the administration of Seroquel. The DSD stated she was unable to find this evidence. During a dining observation on 7/08/24 at 12:30 p.m., Resident 16 was observed having lunch in the dining room of the facility. Resident 16 was noted to be a pleasant, polite and charming individual. No aggression was observed at all during interactions with other residents or staff. During an interview with the DSD on 7/11/24 at 2:25 p.m., the Surveyor asked the DSD to contact Physician R (The Physician that prescribed Seroquel for Resident 16) for an interview. The DSD contacted Physician R through text. Physician R texted the DSD back indicating, I am about to board my flight. She [Resident 16] has behavioral issues of aggressive behavior when she came. We can try to reduce dose and tapering it off if able. Please reach out to hospice [Agency that provides end of life services] staff and MD (Medical Director) they can help address too. You can address how the facility is monitoring. The Surveyor was unable to conduct an interview with Physician R to inquire about the Seroquel prescription. During a phone interview with Pharmacist J on 7/12/24 at 9:43 a.m., she stated Resident 16 was originally prescribed Seroquel on 12/05/23 at the facility. The Pharmacist stated she wrote a recommendation on 5/05/24 to the prescribing Physician to stop Seroquel, on the facility Medication Regimen Review (A thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication). Pharmacist J stated the pharmacy psychiatric team had met and noted that Resident 16 did not have issues with aggression, therefore, she felt this medication was not necessary. Pharmacist J stated she never received a response back from Physician R regarding this recommendation. Pharmacist J stated physicians were expected to respond to their recommendations within 30 days. Record review of the facility policy titled, Psychotropic Medications, last reviewed on 7/2024, indicated, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective .The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications .The Physician shall respond appropriately to feedback from the staff by changing or stopping problematic doses or medications, or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 40402

Based on interviews and record reviews, the facility failed to 1. provide supervision and assistance for a toileting needs for one out of two sampled residents (Resident 4). 2. ensure the pharmacist conduct a medication regimen review (MRR, a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions) for fall to prevent avoidable accidents or falls. These failures led to Resident 4 ' s unwitnessed fall that resulted to hospitalization due to left leg severe pain. While at the hospital, Resident 4 was diagnosed with closed fracture (a break in the bone) of neck of left femur (thigh) and subsequently had to undergo left hip fracture hemiarthroplasty (a type of partial hip replacement procedure that involves replacing half of the hip joint). Findings: During a review of Resident 4 ' s face sheet (demographics), it indicated she had a diagnoses of Essential Hypertension (high blood pressure that is not due to another medical condition), Hyperlipidemia (an elevated level of lipids - like cholesterol, a waxy, fat-like substance that your body needs for good health, but in the right amounts and triglycerides, a major form of fat stored by the body, in your blood) and Acute Respiratory Failure (occurs when your lungs cannot release enough oxygen into your blood). Her Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/9/2023, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 7 indicating severely impaired cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 1 needed limited assistance (the resident is highly involved in performing a given activity, and yet still receives physical help in performing the activity) to extensive assistance (resident performed part of activity while staff provided 50 percent (% , a number that tells us how much out of 100) or more assistance and includes weight-bearing (the amount of weight a resident puts on a body part) support by staff of 1 staff when performing her Activities of Daily Living (ADLs, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 4 needed a limited assistance of 1 staff during toileting. During an interview on 9/20/23 at 11:31 a.m., Licensed Staff E stated it was the facility ' s policy to ensure the residents' were safe all the time. Licensed Staff E stated, if staff were not monitoring residents who were fall risk, every 2 hours or more often as needed and not assisting residents to the toilet every 2 hours and as needed, it could put residents' safety at risk. Licensed Staff E stated these could result to injury, fracture, and hospitalization . During an interview on 9/20/23 at 11:36 a.m. with Unlicensed Staff B and C, Unlicensed Staff B stated the facility ' s policy for falls includes toileting residents every 2 hours and checking on residents every 2 hours. Unlicensed Staff B stated the facility need to make sure residents were always safe. Unlicensed Staff C stated if residents who were at risk for falls were not monitored closely, it could lead to injury and fracture. During an interview on 9/20/23 at 11:43 a.m., Licensed Staff C stated to decrease likelihood of fall, staff needs to monitor, check on residents every 2 hours and provide toileting every 2 hours. Licensed Staff C stated it was the facility ' s responsibility to ensure resident ' s safety. During an interview on 9/20/23 at 12:04 p.m., the Rehabilitation Director stated she was aware Resident 4 was a high fall risk. The Rehabilitation Director stated she was not aware of the details of Resident 4 ' s fall incident. During an interview on 9/20/23 at 12:09 p.m., Resident 4 stated she do not recall all the incidents regarding her fall. Resident 4 stated she does remember needing to use the bathroom prior to her fall. Resident 4 stated staff usually assists her when going to the bathroom. Resident 4 stated she did not recall if staff assisted her to the bathroom prior to her fall. During an interview on 9/20/23 at 12:52 p.m., the Director of Nursing (DON) and the Director of Staff Development (DSD) stated it was the facility ' s policy to ensure fall risk residents were on frequent rounding and toileting. The DSD stated this meant monitoring, rounding or toileting the residents every 2 hours and as needed. The DON and the DSD stated Resident 4 was a high fall risk. During a nursing note dated 9/9/23 1:06 a.m. record review, the nursing note indicated Resident 4, while going to the bathroom, slipped and fell on the floor on 9/9/23 at 12:20 a.m. The nursing note indicated Resident 4 was experiencing severe pain and was unable to be assisted back to bed so 911 ( the telephone number used to reach emergency medical, fire, and police services) was called. The nursing note also indicated Resident 4 was transferred to the emergency department on 9/9/23 at 12:50 a.m. During a review of the anaesthesia (a medication used to stop you from feeling pain during surgical or diagnostic procedures) preprocedure evaluation note from the hospital dated 9/9/23 12:40 p.m., it indicated Resident 4 was diagnosed with closed fracture of neck of left femur. It indicated Resident 4 would have left hip fracture hemiarthroplasty surgery. During a telephone interview on 9/21/23 at 4:06 p.m., the DON stated there was no MRR for fall done by the pharmacist before and after Resident 4 ' s fall incident. A review of the nursing note dated 9/9/23 1:06 a.m. indicated Resident 4 fell on [DATE] at 12:20 a.m. while going to the bathroom. A review of the daily charting note by a CNA dated 9/8/23 indicated Resident 4 was last toileted at 8:36 p.m. meaning she was last toileted almost 4 hours before her fall. During a review of the facility ' s policy and procedure (P&P) titled Accident Prevention/Mitigation and Response dated 4/2023, the P&P indicated it was the facility's policy , to the extent possible/feasible/practicable make proactive efforts to eliminate or reduce the risk of accidents occurring in the facility .provide each residents with adequate supervision .the nursing staff, attending physician and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risks

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff with appropriate competencies and skills to supervise and adequately care for one of 3 sampled resident ' s (Resident 1), when Resident 1, who had Dementia (memory loss) was reminded by staff to call for assistance with transfers resulting in falls and a fractured right femur (thigh bone). Findings: During a review of Resident 1 ' s Profile Face Sheet, on 3/30/23, Resident 1 ' s Face Sheet, indicated, diagnosis of Dementia. During an interview on 3/30/23 at 2:20 p.m., with DON, she stated, she was aware Resident 1 had fallen and this was Resident 1 ' s second fall within one month. Both falls occurred in the bathroom where Resident 1 was found on the floor calling for help. DON stated she read the hospital report and in both falls Resident 1 sustained a right femur fracture. DON stated, she received a text at the time of the fall on 3/24/23 around 8:00 a.m. from Licensed Staff C alerting her Resident 1 had fallen. DON stated, she checked the chart and Resident 1 had a BIMS (score assigned for memory, orientation, and judgement ability) of 9 (out of 15 possible) and a diagnosis of dementia. During an interview on 3/30/23 at 3:10 p.m., Unlicensed Staff A stated, she heard a crash while she was in room [ROOM NUMBER] next to room [ROOM NUMBER] where she heard the crash coming from. Unlicensed Staff A stated, she then heard a man yell help. Unlicensed Staff A, stated, she walked to room [ROOM NUMBER] where Resident 1 resided, and she found Resident 1 laying on the floor on his right side. Unlicensed Staff A yelled for a nurse at which time Licensed Staff C came to the room to assess Resident 1. Unlicensed Staff A stated she never heard the nurses call light sounding or saw the nurses light on when she entered room [ROOM NUMBER]. Unlicensed Staff A stated after Licensed Staff C came into room [ROOM NUMBER], Licensed Staff C then called for Licensed Staff B to assist with Resident 1. During an interview on 3/30/23 at 2:45 p.m. with Licensed Staff C, stated she went to room [ROOM NUMBER] on 3/24/23 around 8:30 a.m. after hearing Unlicensed Staff A call for help. Licensed Staff C said, she saw Resident 1 lying on the floor in the bathroom in room [ROOM NUMBER]. Licensed Staff C stated, she did not see or hear the nurses light when she entered Resident 1 ' s room. Licensed Staff C stated, she asked Resident 1 if he hit his head and Resident 1 responded, no. Licensed Staff C called Resident 1 ' s primary nurse, Licensed Staff B to room [ROOM NUMBER]. Licensed Staff B performed Neurological examination (nervous system evaluation) on Resident 1. Licensed Staff C stated, Resident 1 ' s neurological evaluation was within normal limits. Licensed Staff C stated, she assisted 3 staff members who assisted Resident 1 back to his wheelchair. Licensed Staff C stated she called the MD1 and contacted the Resident ' s Representative after the fall. Licensed Staff C stated MD1 ordered an X-ray (picture) of Resident 1 ' s right femur but Resident 1 ' s pain was escalating so MD1 requested Resident 1 be transferred to the hospital immediately instead of waiting for Xray. During an interview on 3/30/23 at 3:40 p.m., with Licensed Staff B, she stated, she was the primary nurse for Resident 1 on 3/24/23 at 8 a.m. Licensed Staff B stated on 3/24/23 around 8:00 a.m. she was busy passing medications to other residents when she heard Licensed Staff C call for help in room [ROOM NUMBER]. Licensed Staff B stated, when she entered the room, the nurses light was not on, and she saw Resident 1 lying on the floor in the bathroom. Licensed Staff B stated, she performed a neurological evaluation, and she asked Resident 1 if he hit his head and Resident 1 responded, no. Licensed Staff B stated Resident 1 ' s neurological exam was normal, so they moved Resident 1 back to his wheelchair. Licensed Staff B stated Resident 1 has a diagnosis of dementia and when staff instruct him to put on his call light on if he needs to get out of bed or another task Resident 1 forgets what you have instructed him to do. Licensed Staff B stated Resident 1 has a Wander guard but that doesn ' t help if he is getting out of bed when he doesn ' t put his nurses light on. During a review of Resident 1 ' s medical records, Post Fall Investigation dated, 3/24/23, authored by Licensed Staff B, indicated, resident lost his balance, found on floor alone and unattended, confused and disoriented at the time, and no meds given in last 8 hours. During an interview with Resident 1 ' s Family Representative on 3/30/23 at 4 p.m., Family representative expressed concerns that Resident 1 did not have his walker in his room for a few days before the fall that occurred on 3/24/23. Family Representative stated, she noticed that the staff at this facility are spread thin. When family representative queried if Resident 1 was using the walker to ambulate, she said no, he uses the wheelchair but sometimes transfers and pivots with the walker. During an interview with Resident 1 on 3/30/23 at 4:10 p.m., Resident 1 was queried by this surveyor if he knew where he was? Resident 1 said no. Resident 1 queried by this surveyor if he remembered falling recently. Resident 1 responded; no. Resident 1 queried by this surveyor if he knew who the Family Representative was standing next to his bed, Resident 1 smiled and said, yes. This surveyor noticed a yellow sign at the left side of Resident 1 ' s bed. The sign was observed to have written on it, Dad, don ' t get up, you have a broken leg. Family Representative stated, he forgets his leg is broken and tries to get up. During an interview with Unlicensed Staff E at 4/3/23 at 11 a.m., Unlicensed Staff E stated, he is employed directly by a health care agency and was filling in that day when Resident 1 fell . Unlicensed Staff E was queried by this surveyor about Resident 1 ' s fall and he stated, I had 8 residents at the time of breakfast and had to make sure they got their meals on time. Unlicensed Staff E stated, he had 2 residents who required me to feed them. Unlicensed Staff E stated, I was in the dining room with my back to Resident 1 while I was feeding Resident 3. Unlicensed Staff E stated, Resident 1 apparently left the dining room while my back was turned toward Resident 1 when I was busy feeding Resident 3. Unlicensed Staff E stated, he did not see Resident 1 leave the dining room. Unlicensed Staff E queried if there were any other staff assisting him in the dining room? Unlicensed Staff E responded yes, there was another CNA (Certified Nursing assistant) from the agency in the dining room off and on because he was also handing out breakfast trays. Unlicensed Staff E stated, Unlicensed Staff D was busy feeding Resident 2. Unlicensed Staff E stated Resident 1 has Dementia and is very forgetful and left the dining room when he was instructed to wait until someone could take him back to his room. Unlicensed Staff E queried by this surveyor if he had any Dementia training with his current employer within the last year and he responded, no. During an interview with Unlicensed Staff D on 4/4/23 at 1:10 p.m., Unlicensed Staff D stated, he works directly for an agency and comes to work at the facility sometimes. Unlicensed Staff D stated, there was only Unlicensed Staff E and me in the dining room and we both had residents to feed and other residents to pass breakfast trays to on the unit. When Unlicensed Staff D was queried as to Resident 1 whereabouts after Resident 1 left the dining room, Unlicensed Staff D stated, I saw him in the hallway [NAME] himself back to his room. Unlicensed Staff D stated, he asked him what do you want to do? Unlicensed Staff D stated, Resident 1 responded, he wanted to go to bed and take a nap, so I helped him back to bed. Unlicensed Staff D stated, he had to feed Resident 2, so he told Resident 1 to put his light on if he needed to get up. Unlicensed Staff D stated he had heard about Resident 1 ' s fall later on in his shift but was not involved with Resident 1 when it occurred. Unlicensed Staff D queried by this surveyor if he had any training in Dementia? Unlicensed Staff D stated, no, I just know residents with Dementia forget a lot. During a review of Resident 1 ' s records, an email dated 4/3/23, authored by Unlicensed Staff I, indicated the facility has, no Dining Observation Policy but it is a standard practice to have staff (Licensed Nurse and Certified Nursing Assistant) present in the dining room during meals. During a review of Resident 1 ' s Neurological Assessment Flow Sheet, dated 3/24/23, authored by Licensed Staff B, Flow Sheet indicated Resident 1 ' s Neurological Assessment immediately following his fall were within normal limits. During a review of Resident 1 ' s MDS, Section C, dated 3/3/23, authored by Licensed Staff H, BIMS 9, Recall 1, Resident is a 2 person assist for transfers, Toilet use Resident is a 2 person assist. During a review of Resident 1 ' s Care Plan dated, 2/27/23, no Dementia interventions were noted for monitoring of safety precautions for Resident 1 ' s decrease memory recall of staff instructions as it pertains to ambulation and transfers. During a review of Resident 1 ' s Physical Therapy Note, dated 3/23/24, authored by Licensed Staff G, indicated Resident 1, was weight bearing as tolerated but Resident 1 demonstrates ability to weight bear only partially on right lower extremity due to right hip pain. Precautions: Fall risk and Dementia. During a review of Resident 1 ' s Interdisciplinary Note, dated 3/24/23, authored by DON, This morning Resident 1 attempted to self-transfer from wheelchair to the bathroom and fell , and landed on the same surgical side. A staff from nearby location heard the noise and ran to check and found the resident was already on the floor lying on this right side. At first the doctor ' s advice to get an Xray and applied Lidocaine patch to area. Nursing applied Lidocaine patch and ice immediately to area of pain. The resident also received Tylenol 100 mg and Oxycodone 5 mg. Then the doctor decided to send the resident to the ED instead, for further evaluation. Family was also notified. Nursing staff called ED (emergency department) instead, for further evaluation. Nursing staff called ED and found that the resident had re-injured previously repaired right hip fracture. Per resident ' s son, a surgical procedure is scheduled on the next day. During a review of Resident 1 ' s nurses note, dated 3/29/23, authored by Licensed Staff F, indicated, admitted from hospital via Gurney after stay in the hospital due to right hip fracture post fall 3/24/23. Current Conditions indicate, Cognitive status: Alert with confusion and forgetfulness During a review of the facility ' s policy and procedure titled, Sufficient and Competent Staffing, dated 2/2023, indicated, it is the policy of The Redwoods, A community of Senior to provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. Applicable Redwoods personnel will develop, implement, and maintain an effective training program for all new existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. We determine the amount and types of training necessary based on their facility assessment. Definitions: Staff: Includes employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care. Personnel hired for positions in this facility shall meet the qualification of the job or be trained to perform those duties. Training Program: Competency Based Education and Training is defined as a measurable pattern of knowledge, skills, abilities, behaviors, communication abilities to perform specific tasks and assignments with success. A continuing competency-based education program is conducted for all staff at the facility, to promote and measure specific competencies and skill sets necessary to provide related services to meet resident needs, safety of the resident while considering the resident ' s choices, rights, physical, mental, and psychosocial well-being based on the facility assessment. Orientation and ongoing training and competency will include, but not be limited to (as applicable to job duties) Resident rights and facility responsibilities, person-centered care, behavioral health, care of the cognitively impaired and dementia management. Pertinent information pertaining to staffing in the facility (e.g., turnover trends, staffing levels, CMS data NNPPD data, etc.) shall be routinely reviewed at the QAA Committee meetings. On an as-needed basis, the committee may initiate performance improvement projects in response to negative trends/patterns. During a review of facility ' s policy and procedure titled, Accident Prevention / Mitigation and Response, dated, 1/2023, indicated, It is the policy of The Redwoods to the extent possible/feasible/practicable ensure that the environment remains free of accident hazards, make proactive efforts to eliminate or reduce the risk of accidents occurring in the facility, provide each resident with adequate supervision and assistance devices so as to prevent accidents, as well as to comprehensively respond when an accident occurs. Avoidable Accidents: means that an accident occurred because the facility failed identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or Evaluate analyze the hazards and risks and eliminate them, if possible, or , if not possible, identify and implement measures to reduce the hazards/risks as much as possible, and / or Implement interventions, including adequate supervision and assistive devices, consistent with a resident ' s needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and or monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standard of practice. Personnel shall conduct/complete routine and as-needed safety walks/inspections/audits of the facility. In general, all staff are responsible for identifying, reporting, and/or resolving any hazards/unsafe conditions within the facility. Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try to minimize complication from falling. The nursing staff, in conjunction with the attending physician, consultant, pharmacist therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan abased on relevant passement information. The staff, with the support of the attending physician, will evaluate functional psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living capabilities, activity tolerance, continence, and cognition. The staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview and record review, the facility failed to assess, prevent, and treat a wound for one of thirteen residents (Resident 14) when the facility admitted Resident 14 with right shoulder Anti-subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule), and no weekly skin assessment was done. This failure resulted in Resident 14 developing a wound inside her right armpit with infection, and there was no current wound assessment and wound care order from the Physician. Findings: During a review of Resident 14's medical record, the facility admitted Resident 14 on 12/30/21. The Skin Evaluation Form dated 12/30/22, indicated Resident 14's skin had no existing issues. The Baseline care plan dated 1/3/22, indicated Resident 14 was at risk for skin breakdown and skin would be checked weekly and new skin concerns would be reported to the doctor for treatment and follow up. The Nursing Notes dated 2/11/21, indicated there was an open wound with pus on Resident 14's right armpit and her Physician was notified. Resident 14 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/14/22, at 2:52 p.m., Staff M stated Resident 14 had a wound on her right armpit, and it was caused by the brace digging into her skin. During an interview on 2/15/22, at 10:06 a.m., Staff H stated Resident 14 has an unhealed wound on her right armpit, and it was caused by the brace digging to her skin. Staff H stated that Resident 14 did not have treatment orders for her wound. Staff H stated staff would sometimes use saline on the wound and then covere it with a dressing. Staff H stated treatments were completed by the afternoon staff. When asked how staff knew if a wound is getting better or worse, Staff H did not verbalize a response. During an interview on 2/16/22, at 2:40 p.m., with the Director of Rehab (DOR), she stated Resident 14 was admitted to the facility with the right anti-subluxation brace. The DOR stated her department did not provide training to direct staff on the use of the brace. The DOR stated the brace might have contributed to Resident 14's right armpit wound development. During an interview on 02/16/22, at 3:47 p.m. the DON stated the right armpit wound was possibly due to the sling digging through her skin, and it was possible staff did not know how to use it appropriately. The DON also stated there was no need to investigate the cause of the wound because we already knew it was from the sling. During interview and concurrent Resident 14's record review, on 2/16/22, at 3:58 p.m., the DON verified Resident had one Skin Evaluation Form dated 12/30/21. The DON verified there was no documentation to show weekly skin assessments were completed. The DON verified there was no Care plan for the right armpit wound and the Anti-Subluxation brace/sling. The DON verified there was no documentation for wound care treatment. · During an observation and concurrent interview on 2/17/21 at 4:30 p.m. with the DON and Staff C, Staff C looked at Resident 14's right armpit. DON and Staff C verbalized that the wound presented with slough (yellow/white material in the wound bed). The DON directed Staff C to call the doctor for wound treatment order. The DON did not provide policies and procedures for Brace/Sling use and Pressure Ulcer Prevention when requested.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent falls for 5 out of 13 sampled residents (Resident 130, Resident 133, Resident 26, Resident 13, and Resident 20) when the facility did not accurately assess residents for their risk of falls, did not timely implement, or attempt to implement, appropriate fall prevention interventions, and did not revise or update fall prevention care plans with additional or different interventions after a fall. These failures resulted in significant injury when Resident 130 sustained a broken right hip after a fall and placed at risk residents at a greater risk for falls, harm, and possibly cause a decline in Residents' health condition. Findings: Resident 130 During a review of the clinical record for Resident 130, the Minimum Data Set ([MDS] a comprehensive, standardized assessment of each resident's functional capabilities and health needs), dated 2/9/22, indicated Resident 130 was admitted to the facility on [DATE]. The Care Area Assessment ([CAA] reflects conditions, symptoms, and other areas of concern identified or suggested by MDS findings) section indicated Resident 130's assessment triggered 8 care areas. The assessment identified dementia, falls, and rehabilitation potential as areas Resident 130 needed further assistance with. The assessment indicated the facility marked all 8 triggered areas as Addressed in Care Plan. During a review of the facility policy and procedure titled, Fall Risk Assessment, updated 3/2018, indicated the facility would document risk factors for falls and establish a resident-centered falls prevention plan. The policy indicated staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During an observation, on 2/14/22, at 11 a.m., Resident 130 was lying in bed with his eyes closed. The bed was flat and approximately 3 feet off the ground, not in its lowest position. No observation of any indication Resident 130 had been identified as a resident at risk for falls. The bed in the lowest position, padded mats placed on either side of the bed and alarms with sensors that alert if a resident attempted to change positions were seen in use throughout the building. None of those interventions were seen in Resident 130's room. During a concurrent observation and interview on 2/15/22, at 3 p.m., with Staff L, in the hallway in front of Resident 130's room, Staff L looked into the room at the empty bed and stated Resident 130 was sent out to the hospital because he fell . During a concurrent interview and record review on 2/15/22 at 5:18 p.m., with Staff B and Staff Q, Resident 130's Electronic Medical Record (EMR) was reviewed. Staff Q reviewed the Interdisciplinary Notes and confirmed the notes indicated Resident 130 had fallen on 2/5/22, 2/12/22, and 2/14/22. Staff Q reviewed Resident 130's Care Plan and stated there was no nursing care plan to address Resident 130's risk for falls. Staff B and Staff Q reviewed Resident 130's care plan and stated there was no nursing care plan created to address Resident 130's actual falls until 2/14/22. Staff B stated there should have been a nursing care plan since his admission on 2/2/2022 to address Resident 130's risk for falls. Staff B stated the documentation reviewed did not meet the facilities expectations for processing new admissions or for resident falls. Staff Q stated doctors orders, the care plan and its interventions were used as indicators to add specific tasks to the Point of Care section of the EMR. Staff Q stated the Point of Care section listed all the tasks and vital information Certified Nurses Assistants (CNA) used for them to provide adequate assistance and supervision during tasks of daily living. Staff B was unable to provide documentation to show Resident 130's functional abilities and limitations were input into Resident 130's EMR Point of Care section for direct care staff to review. The point of Care section of Resident 130's EMR was blank. When asked how a CNA would know what assistance or safety precautions Resident 130 needed, Staff B stated the staff all talk to each other, they knew from verbal report. Staff B stated the lack of documentation could have contributed to Resident 130's 3 falls in 13 days. During a review of the Electronic Medical Record (EMR) for Resident 130, the Profile Face Sheet indicated his admitted was 2/2/22. The record indicated Resident 130 was admitted with a diagnosis of [CONDITION(S)] (cancer that develops in the thin, flat cells that make up the outermost layer of your skin). During a review of the Electronic Medical Record (EMR) for Resident 130, the Admission History and Physical, dated 2/2/22, indicated on 1/25/22 Resident 130 was seen at an acute hospital after he fell at home. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/3/22, indicated Resident 130 was confused and attempted to get out of bed many times. There was no documentation of the fall on 2/5/22, Staff B was unable to show a post fall assessment, or a care plan, or a new change of condition incident note. Staff B stated all 3 of those documents were expected for every fall. Staff B Staffed in addition to the original assessments, nurses should chart a note related to the fall every shift for 72 hours. Staff Q reviewed the ID notes and found one that indicated charting for multiple reasons including a fall on the previous shift. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/13/22, indicated Resident 130 was found on the floor next to his bed on 2/12/22 at 6 p.m. The note indicated a significant amount of blood was observed on the floor near Resident 130's head. The note indicated Resident 130 stated he got out of bed to go to the hospital because they have good coffee there. A review of the care plan indicated Resident 130's risk for falls was not identified or care planned at the time of admission or after the first fall on 2/3/22. The facility did not put any interventions in place to reduce the risk of falls. The EMR indicated the post fall assessment and charting was not done. No interventions were put into place to prevent Resident 130 from additional falls. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/14/22, indicated at 10 a.m. Resident 130 was found on the floor close to his bed on his back with his legs bent. The note indicated Resident 130 stated he was going to the roof. The note indicated Resident 130 complained of right hip and knee pain after the fall. The note indicated Resident 130's pain had gotten worse over time; x-rays were ordered. During a review of the physical medical chart for Resident 130, the Physicians Orders page, dated 2/14/21 indicated portable x-rays of the right hip and right knee after the fall were ordered. The page indicated at 4:30 p.m. the doctor ordered the x-rays to be upgraded to STAT (a common medical abbreviation for urgent or rush) status. The page indicated at 7 p.m. the doctor ordered [MEDICATION(S)] (a narcotic medication used to treat moderate to severe pain) Five milligrams (mg a unit of weight measurement) to be given by mouth every four hours as needed for moderate pain. The page further indicated the doctor ordered [MEDICATION(S)] ten mg to be given by mouth every four hours as needed for severe pain. The page indicated on 2/15/22 the doctor ordered the facility to transfer Resident 130 to the acute hospital for evaluation. During a review of the Electronic Medical Record (EMR) for Resident 130, the Discharge Summary, dated 2/15/22, indicated Resident 130 fell out of bed on 2/14/22 and sustained an intertrochanteric right femoral neck fracture (the right hip bone fractured in the area between the ball joint and the leg bone). Resident 133 During a concurrent interview and record review on 2/15/22 at 5:08 p.m., with Staff B and Staff Q, Resident 133's EMR was reviewed. Staff Q reviewed the ID notes and confirmed the notes indicated Resident 133 had fallen on 2/12/22 while attempting to walk by herself to the bathroom. Staff Q reviewed the record and stated the facility had identified Resident 133 as being at risk for falls. Staff Q was unable to find documentation to show the facility had interventions in place to prevent falls. Staff B stated she was not aware Resident 133 had sustained a fall since admission on 2/6/2022. Staff B stated the fall was not reported to management and therefore not discussed at the daily Stand up meeting. Staff Q reviewed the EMR and was unable to find a Change of Condition assessment, or an incident tracking note, or a post fall assessment. Staff B confirmed those reports should have been completed by the licensed nurse on the shift the fall occurred. Staff B confirmed this did not meet facility expectations for nursing responsibilities after a fall. Staff Q reviewed the care plan and stated Resident 133 did not have a nursing care plan the EMR. Staff B reviewed the blank page and stated there should be a nursing care plan for every identified care area. A review of Resident 26's face-sheet indicated, Resident 26 was admitted with a diagnosis that included [CONDITION(S)] (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), history of Falling, and unsteadiness on feet. During an interview on 2/16/2022 at 1:35 p.m., Resident 26's daughter stated she is worried about her father's increased number of falls. The daughter stated her father just returned two days (2/12/22) ago from (name) (acute care) hospital because of a fall. The staff told her, the CNA (Certified Nursing Assistant) could not watch her father all the time and suggested that she might consider getting a 1:1 (one-on one) sitter (one person who will only monitor one resident), but we would have to pay out of pocket for that care. During an interview on 2/17/2022 at 4:17 p.m., Staff Q was asked what they do to monitor Resident 26 for falls. Staff Q stated when a resident fell , she completed an assessment of the Resident and made sure they were not injured. She stated they called the physician, DON (Director Of Nursing), and responsible party and placed the resident on neuro checks (assessment of mental status and motor responses, including reflexes, to determine whether the nervous system is impaired including vital signes) following the facility process. Staff Q showed the documented records for the fall, and the neuro checks she completed for the 2/11/22 fall. When asked to see the other documentation for previous falls that occurred for Resident 26, Staff Q stated she did not find them in the medical record. Review of Resident 26's care plan and interventions for falls revealed dates of falls that had occurred. Review of the clinical records did not show any documentation for the interventions or monitoring that were performed for each of the falls listed in the Care Plan. There were no IDT notes or Physician notes to show a cause analysis was conducted for the increased falls. Review of the facility Policy and Procedure titled, Fall Monitoring dated January 14, 2014, indicated, vital signs including neuro check will be monitored for 72 hours post fall. Procedure: 1. Vital signs, including neuro checks, will be obtained and documented . 2. Charting will be performed every shift for 3-days post fall. During an interview on 2/15/22 at 10:34 a.m., Family Member 1 stated Resident 13's multiple falls in the past year was a factor in hiring a part-time private caregiver for him. Family Member 1 stated, We understand the staff could get busy, and thought the private caregiver could help keep Resident 13 company. A review of Resident 13's face sheet indicated he was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)] (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems, but does not include disruptive mood and behavior such agitation, aggression, disinhibition, and sleep disturbances). During an interview on 2/16/22 at 2:13 p.m., Staff J stated Resident 13's last fall was a long time ago. Staff J stated she would try and sit close to him [Resident 13], or always check on his room when the private caregiver leaves. Staff J confirmed it was not always possible to stay at Resident 13's bedside if other residents were calling for help. A review of Resident 13's Care Plans and interventions revealed: a. Falls Care Plan, dated 05/27/21, indicated, unwitnessed fall with no apparent injuries . Check on resident frequently when care partner if not present . b. Falls Care Plan, dated 06/02/21, indicated, Unwitnessed Fall - no injuries . Do not leave resident [sic] in room by himself when awake if companion [sic] is not present . c. Falls Care Plan, dated, 06/10/21, indicated, unwitnessed fall in the bathroom with no injury . Monitor resident in the bathroom at all times . Continue to monitor resident . Monitor resident while using the toilet . Check resident. d. Falls Care Plan, dated 08/28/21, indicated, unwitnessed [sic] fall with no apparent injuries . Keep bed in lowest position and call light within reach. Ensure resident is toileted accordingly . e. Falls Care Plan, dated 01/5/22, indicated, unwitnessed fall in his room with no injury . ensure resident is dry and clean, toileted and is comfortable. Lower bed in lower position. Monitor resident Q-shift (every shift) and PRN (as needed) . During a concurrent interview and record review of Resident 13's care plans on 2/18/22 at 10:30 a.m., Staff B confirmed Resident 13 had repeated falls and stated she expected the staff to frequently round and check on him [Resident 13] after his private caregiver leaves. When asked if the facility has identified such efforts as effective and adequate for Resident 13's pattern of unwitnessed falls, Staff B did not respond. During an interview on 2/15/22 at 11: 17 a.m., Resident 20 stated he had a fall about two months ago. Record review revealed Resident 20 was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)] (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and generalized weakness. During an interview on 2/16/22 at 2:25 p.m., Staff O stated Resident 20 was at risk for falls. When asked how the staff knows which interventions were needed to prevent Resident 20 from further falls, Staff O stated, It's general -- lowering the bed, keeping the call lights close, removing clutter in the room, and ensuring the residents get adequate sleep. Staff O stated, I don't think there's any specific interventions for [Resident 20]. A review of Resident 20's chart revealed IDT (Interdisciplinary Team) Notes indicating Resident 20 sustained falls without injuries on 12/21/21, 12/19/21 and 12/7/21. Further record review revealed there were no care plans developed or revised to address Resident 13's multiple falls during December 2021. During an interview and concurrent record review on 2/16/22 at 10:35 a.m., Staff B confirmed Resident 20 did not have any fall care plans initiated. When asked if there should have been one, Staff B stated, Yes. During an interview on 2/18/22 at 2:59 p.m., Staff A confirmed resident falls continue to be a concern in the facility. Staff A stated they had new bed- and chair-pad alarms, but were currently not being used, as they have been broken since last fall [season]. A review of the facility policy titled, Falls and Fall Risk, Managing, dated March 2018, indicated, The staff, with the input of the attending physician, will implement a resident-centered fall prevention pan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . Staff will try various interventions, based on assessment of the nature or category or falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . The staff will monitor and document each resident's response to interventions intended to reduce calling or the risks of falling .

Based on interview and record review, the facility failed to provide the necessary treatments and services, consistent with professional standards of practice, to one of 12 sampled residents (Resident 5) to prevent pressure ulcers when: 1) The facility failed to complete quarterly skin/risk for pressure ulcer assessments for Resident 5, per its policies and procedures; 2) The facility completed skin/risk for pressure ulcer assessments for Resident 5 inconsistent with data in the clinical record, which led to an underestimation of Resident 5's risk for pressure ulcers; 3) The facility failed to quarterly revise and update Resident 5's pressure ulcer care plan, per its policies and procedures; and 4) The facility failed to care plan and implement the pressure ulcer prevention intervention of floating (elevating) Resident 5's heels while in bed. These failures resulted in Resident 5 developing a pressure ulcer (unstageable) on her right heel. Findings: 1) A review of Resident 5's face sheet indicated she was admitted to the facility on [DATE]. Resident 5's face sheet indicated [DIAGNOSES REDACTED]. A review of Resident 5's Progress Notes indicated Resident 5 developed a pressure ulcer on 7/16/18. Progress note dated 7/16/18, at 4:05 p.m., indicated, Called to bathroom by CNA who noted dark area to R heel. On inspection an area of UTD (unstageable) stage of pressure injury 2 x 1.5 cm noted on R(right) heel. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is, localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer . the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or staged according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as, unstageable, which occurs when the wound is covered by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. (http:/www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/2012/02/Shear_slides.pdf). During an interview on 12/14/18, at 4:05 p.m., the Director of Nursing (DON) provided Resident 5's skin/risk for pressure ulcer assessments for (YEAR). The DON provided a copy of four skin/risk for pressure ulcer assessments, dated: 4/5/18, 5/21/18, 9/4/18 and 9/25/18. The DON stated skin/risk for pressure ulcer assessments were done quarterly, per facility policy, or when there was a change in condition. During the review of Resident 5's skin/risk for pressure ulcer assessments, the DON provided no explanation why no skin/risk for pressure ulcer assessments were done for Resident 5 during the first quarter of (YEAR), between 1/1/18 and 4/4/18. Facility policy titled, Skin Integrity/Wound Care, revised 12/26/17, indicated: Each resident will be assesses (sic) for risk of skin breakdown using the Braden Scale upon admission, readmission, when a change in condition occurs, and at least quarterly thereafter. 2) A review of Resident 5's skin/risk for pressure ulcer assessments indicated the facility used the Braden Scale for Predicting Pressure Sore Risk. This tool assigns numerical values to pressure ulcer risk factors and the total indicates if the resident is at risk of developing pressure sores. Scores range from 0 to 23. The lower the score, the higher the risk of pressure ulcers, and vice-versa. The first two skin/risk for pressure ulcer assessments completed for Resident 5 in (YEAR), dated 4/5/18 and 5/21/18 (prior to Resident 5 developing a pressure ulcer on 7/16/18) indicated scores of 15 and 14 respectively. Per facility policy titled, Skin Integrity/Wound Care, revised 12/26/17, Braden Scale scores are interpreted as follows: 9 or less = severe risk 10-12 = high risk 13-14 = moderate risk 15-18 = mild risk 23 = not at risk The 4/5/18 and 5/21/18, skin/risk for pressure ulcer assessments, however, did not reflect Resident 5's clinical condition, as documented in the Minimum Data Set (MDS - an assessment tool) assessments completed on 2/20/18 and 5/22/18, and other clinical records for Resident 5, as follows: - The skin/risk for pressure ulcer assessments dated 4/5/18 and 5/21/18, indicated Resident 5, Moves freely or requires minimum assistance, whereas the MDS assessments dated 2/20/18 and 5/22/18, indicated Resident 5 required, Extensive Assistance, with regards to bed mobility and transfers. - The skin/risk for pressure ulcer assessments dated 4/5/18 and 5/21/18, indicated Resident 5's skin was, Rarely Moist and, Occasionally Moist respectively, whereas the MDS assessments dated 2/20/18 and 5/22/18, indicated Resident 5 was, Always and, Frequently incontinent of bowel (feces - moist's the skin). - The skin/risk for pressure ulcer assessment dated [DATE], indicated Resident 5's sensory perception (ability to respond meaningfully to discomfort) was, Slightly limited, whereas the MDS assessments dated 2/20/18 and 5/22/18, indicated Resident 5 had a BIMs (Brief Interview for Mental Status - a cognitive test) score of 3 (0-15 range), indicating severe cognitive impairment. - The skin/risk for pressure ulcer assessment dated [DATE], indicated Resident 5 had, no comorbidities contributing to circulatory or sensory deficits, which the Braden Scale listed as: Diabetes, [MEDICAL CONDITION], immune deficiency, malignancies, [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], recent fracture, severe [MEDICAL CONDITION] or skin breakdown. Resident 5's clinical record, however, indicated Resident 5 had depression. A Physician order [REDACTED]. The 4/5/18 and 5/21/18, skin/risk for pressure ulcer assessments, if completed using the clinical data from Resident 5's MDS Assessments dated 2/20/18 and 5/22/18, would have resulted in a Braden Scale score of 12, placing Resident 5 at a, high risk of developing a pressure ulcer, per the facility's Skin Integrity/Wound Care policy. 3) During an interview on 12/14/18, at 4:05 p.m., the DON provided Resident 5's care plans (documents instructing staff how to care for residents). A review of Resident 5's care plans indicated two care plans for the prevention of pressure ulcers: Care plan titled, Pressure Ulcers, started on 11/21/17, and care plan titled, Pressure Ulcers, started on 9/6/18. The 11/21/17, Pressure Ulcer care plan indicated, (Resident 5) has potential for skin breakdown or pressure ulcer and listed the following pressure ulcer prevention interventions: - assess skin when turning or performing personal care for skin breakdown; - preventative mattress to bed; - assess for incontinent episodes and change brief, linen, clothing to prevent breakdown; - encourage resident to consume at least 75% of food; - assist resident in repositioning; and - monitor Braden scale. Additional pressure ulcer prevention interventions were documented in the MDS assessments dated 2/22/18 and 5/22/18, as follows: Pressure reducing device for chair and turning and frequent turning and repositioning Resident 5. A review of the 11/21/17, Pressure Ulcers care plan indicated it was not revised or updated during the first two quarters of (YEAR) (January to June). The 11/21/17, Pressure Ulcer care plan was first updated on 7/16/18, after Resident 5 developed an unstageable pressure ulcer to her right heel. On 7/16/18, it was updated to include the following additional interventions: - notify MD and RP (responsible party); - monitor for changes every shift; - avoid footwear that will cause pressure to heels; - reposition every 2 hours; and - float (elevate heels) while in bed. Facility policy titled, Care Plans, revised 1/24/14, indicated, The care plan will be reviewed and revised as necessary to reflect the changes in the resident's status . These reviews are held within seven days of completion of the MDS and Rap Summary and at least quarterly. 4) A review of Resident 5's 11/21/17, Pressure Ulcer care plan indicated it was updated on 7/16/18, after the facility detected an unstageable pressure ulcer on Resident 5's right heel, to include the intervention of floating (elevating) Resident 5's heels while in bed. A review of Resident 5's Progress Notes indicated this intervention was implemented immediately after the detection of Resident 5's unstageable pressure ulcer on the right heel on 7/16/18. A Progress Note dated 7/16/18, at 4:05 p.m., indicated: .pressure injury 2x1.5 cm noted on R(right) heel .Will float heels in bed to avoid pressure. The following Progress Notes, dated 7/16/18, at 11:12 p.m., 7/17/18, at 4:10 a.m., 2:18 p.m., 10:22 p.m., 7/18/18, 2:55 p.m. and others following, all documented Resident 5's heels were being floated while in bed. A review of Progress Notes dated 45 days prior to 7/16/18, revealed no references to Resident 5's heels being floated while in bed. A review of Resident 5's Physician order [REDACTED]. A review of Resident 5 Treatment Administration Record (TAR), from (MONTH) to (MONTH) (YEAR), revealed this order was implemented continuously throughout Resident 5's stay at the facility starting at 7/17/18, even after the Resident 5's pressure ulcer healed on 10/11/18. A fax transmission dated 10/11/18, sent to Resident 5's physician by Licensed Nurse L, indicated Resident 5's pressure ulcer had healed but the facility would continue to float Resident 5 heels while in bed for protection. A review of Resident 5's TAR and Physician order [REDACTED]. During an interview on 12/14/18, at 4:05 p.m., the DON was asked if floating heels while in bed was an appropriate pressure ulcer intervention for residents like Resident 5. The DON responded, Yes, but stated the facility investigated Resident 5's right heel pressure ulcer and determined it was caused by an ill-fitting shoe. The DON did not explain or provide records of this investigation showing how the facility reached this conclusion. The National Pressure Ulcer Advisory Panel (NPUAP), in its 2014 International Pressure Ulcer Prevention and Treatment Guidelines (The NPUAP Guidelines - http:/www.npuap.org/wp-content/uploads/2015/02/4.-Preventing-Treating-Heel-Ulcers-D-Langemo.pdf) indicated patients with the following risk factors, among others, are at risk for developing heel pressure ulcers: Age, immobility, Braden Scale scores of 16 or less. Resident 5's clinical record indicated she had all those risk factors. Resident 5's face sheet indicated she was [AGE] years-old. Resident 5's MDS assessments, dated 2/20/18 and 5/22/18, indicated Resident 5 required, Extensive Assistance, with regards to bed mobility and transfers. Resident 5's Braden Scale skin assessments, dated 4/5/18 and 5/21/18, indicated scores of 15 and 14, respectively. For patients at risk of developing heel pressure ulcers, the NPUAP Guidelines recommended as follows: Ensure that heels are free of the surface of bed .Use heel suspension devices that elevate and offload the heel completely . Facility policy titled, Skin Integrity/Wound Care, revised 12/26/17, indicated: Guidelines that are copyrighted to the National Pressure Ulcer Advisory Panel (NPUAP) have been adopted by the facility.

Based on interview and record review, the facility failed to ensure one of three closed sampled residents (Resident 20) and two of 12 sampled residents (Residents 27 and 5) received adequate supervision and assistance to prevent accidental falls when: 1) Resident 20 had an accidental fall when the facility did not use the minimum required number of staff (two) to safely assist Resident 20 during a transfer from the bathroom to the bed. As a result of this failure, Resident 20 had an accidental fall which resulted in an open fracture injury to her left leg that required hospitalization and surgical repair; 2) Resident 27 had an accidental fall when the facility did not use the minimum required number of staff (two) to safely assist Resident 27 while using the bathroom and did not use a gait bell (a safety device for transfers). As a result of these failures, Resident 27 had an accidental fall and experienced pain; and 3) The facility failed to complete quarterly fall risk assessments for Resident 5 and failed to revise Resident 5's fall care plan quarterly, per its policies and procedures. These failures placed Resident 5 at risk for accidental falls, resulting in Resident 5 experiencing an accidental fall. Findings: 1) A review of Resident 20's face sheet indicated she was admitted to the facility on [DATE]. A review of Resident 20's Physician History and Physical, dated 9/15/18, indicated Resident 20 had a history of [REDACTED]. A review of Resident 20's Minimum Data Set (MDS - an assessment tool), dated 11/2/18, indicated Resident 20 required the assistance of two or more persons for transfers to and from the bathroom. A review of Resident 20's care plan (documents instructing staff how to care for residents), dated 9/24/18, indicated: Resident will be free from injury related to falls thru the review date of 12/23/18. The care plan interventions to prevent falls included, Consult with therapy regarding current functional status and follow recommendations. During an interview on 12/18/18, at 2:10 p.m., Physical Therapist M stated she worked with Resident 20 while she was a resident at the facility and stated Resident 20, required two person max assist for all transfers, use of gait belt and verbal cues for all movement and placement of hands. Nursing Interdisciplinary Note dated 11/25/18, at 12:55 p.m., indicated, .Resident use wheelchair to transfer and requires two person assist with ADL's (Activities of Daily Living) and transfers. During an interview on 12/14/18, at 11 a.m., Residents 20's family member indicated he visited Resident 20 often at the facility and on several occasions observed Resident 20 being transferred by one staff member only. A review of Resident 20's Interdisciplinary Note dated 11/30/18, at 8:34 p.m., by Licensed Nurse O, indicated Resident 20 had a fall on 11/30/18, at 6:55 p.m., while being transferred from the bathroom to her bed by a single CNA. Licensed Nurse O's note dated 11/30/18, at 8:34 p.m., indicated: (Resident 20) obtained an assisted fall to the floor today at approximately 1855 (6:55 p.m.), per Galdwell CNA she and patient were returning from the bathroom back to bed, when she assisted patient to standing from wheelchair with front wheel walker used to stand, the CNA then noticed the left leg began to shake, so she then assisted patient to sitting position on the floor . Visual observation of Left lower leg prior further assessment noted gray boot is on foot but velcro straps are undone. At this time attempted to adjust patients leg to attach straps and noticed active bleeding on floor, approximately ½ ounce of bright red blood below left leg . because of (leg) asymmetry, I decided to send patient to (Acute Care Hospital) ED. A review of the Acute Care Hospital Emergency Department note dated 11/30/18, at 8:52 p.m., indicated Resident 20 was evaluated by a orthopedic surgeon, who, recommended admission for operative reduction (manipulation of bone) and casting. A review of the orthopedic surgeon's report, dated 11/30/18, indicated Resident 20 was, diagnosed with [REDACTED]. Facility Policy titled, Fall Prevention Program, revised 2/20/17, indicated: Falling Stars is a program used for residents identified at high risk for falls and/or with a history of falls (past or current). It reminds staff to monitor these patients for fall prevention. It alerts staff to patients at risk for falls and who have approaches or interventions in their care plans to reduce and/or prevent repeat falls. 2) A review of Resident 27's face sheet indicated she was admitted to the facility on [DATE]. A review of Resident 27's admission Progress Note dated 9/7/18, 3:12 p.m., indicated she was admitted for physical rehabilitation after a [MEDICAL CONDITION] resulting from a fall. A review of Resident 27's hospital records, physician progress notes [REDACTED]. Resident 27's, Patient Discharge Instructions, dated 9/7/18, indicated she was transferred to the facility for rehabilitation on 9/7/18. Resident 27's Fall Risk Assessment, dated 9/9/18, indicated Resident 27 was at a high risk for falls. A Progress Note dated 9/8/18, at 2:31 p.m., indicated Resident 27 required two people to assist her with transfers and activities of daily living. Resident 27's Fall Care Plan (care plans are documents orienting staff on how to care for residents), dated 9/9/18, indicated Resident 27 was at risk for falls and required the use of a gait belt (a belt placed around the resident's wait to assist with transfers) for all transfers. Resident 27's Minimum Data Set (MDS - an assessment tool), dated 9/14/18, indicated Resident 27 required extensive assistance with toilet/bathroom use and required two or more persons to assist her with toilet/bathroom use. A Progress Note dated 9/23/18, at 3:38 p.m., indicated Resident 27 fell while using the toilet. The Progress Note indicated Resident 27 was being assisted by one person who was not using a gait bell when she fell . The Progress Note indicated: (Resident 27) was asked to hold on to the bar next to the toilet while CNA (Certified Nursing Assistant) pull her pants up. Resident felt weak and lost her balance while holding on to the bar. CNA assisted the resident to the floor by holding under her arms. The note indicated Resident 27 then complained of pain in her right hip (the site of her [MEDICAL CONDITION]). During an interview on 12/18/18, at 12:20 p.m., the Director of Nursing (DON) reviewed the Progress Note dated 9/23/18, at 3:38 p.m., and confirmed Resident 27 had a fall on 9/23/18. The DON stated it appeared only one person was helping Resident 27 use the toilet when she fell , and Resident 27 was not wearing a gait belt at the time. Facility Policy titled, Fall Prevention Program, revised 2/20/17, indicated: Falling Stars is a program used for residents identified at high risk for falls and/or with a history of falls (past or current). It reminds staff to monitor these patients for fall prevention. It alerts staff to patients at risk for falls and who have approaches or interventions in their care plans to reduce and/or prevent repeat falls. 3) A review of Resident 5's face sheet indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Progress Note dated 7/23/18, at 10:21 p.m., indicated Resident 5 had an unwitnessed fall on 7/23/18. The Progress Note indicated Resident 5 was found lying on the floor in front in her room and had redness on her right side. During an interview on 12/14/1/8, at 4:05 p.m., the Director of Nursing (DON) provided Resident 5's fall assessments for (YEAR). The DON provided five fall assessments, dated 2/28/18, 7/24/18, 9/4/18, 9/6/18 and 11/6/18. During a review of the fall assessments, the DON stated residents were assessed for falls on admission, every three months and/or after a fall. No explanation was provided why Resident 5 was not assessed for falls between 2/28/18 and the 7/24/18, a period of five months. Facility policy titled Fall Prevention Program, revised 2/20/17, indicated: Assess patient quarterly, annually and significant change to identify patients' change in risk status. During an interview on 12/14/1/8, at 4:05 p.m., the DON provided Resident 5's care plans (documents instructing staff on how to care for residents). A review of Resident 5's care plans with the DON indicated a care plan titled, Falls (Fall Care Plan), dated 11/21/17, indicating, (Resident 5) has risk factors that require monitoring and intervention to reduce potential for self injury. The Fall Care Plan was not revised or updated until 8/21/18, when a new intervention was added for staff to use the mechanical lift when transferring Resident 5. During review of the Fall Care Plan with the DON, no explanation was provided why the Fall Care plan was not updated quarterly, from 11/21/17 to 8/21/18, or after Resident 5 had a fall on 7/23/18, as required by facility policy. Facility policy titled, Care Plans, revised 1/24/14, indicated: The care plan will be reviewed and revised as necessary to reflect the changes in the resident's status. These reviews are completed within seven days of the completion of the MDS . and at least quarterly.

Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 6), who had a history of [REDACTED]. Resident 6 propelled her wheelchair away from the nurses station, unnoticed by staff, and fell in the doorway of her room. Resident 6 sustained an extension of the right hip fracture that was surgically repaired approximately two months prior. A second hip surgery was required at the acute care hospital. Findings: Review of Resident 6's face sheet (admission record), undated, documented Resident 6 was admitted to the facility on [DATE]. The face sheet noted Resident 6 had multiple active [DIAGNOSES REDACTED]. (an abnormal, irregular heart rhythm). Resident 6's Minimum Data Set (MDS - an assessment tool), dated 2/29/16, indicated a Brief Interview for Mental Status (BIMS) score of 3 (scores of 0 to 7 denoted severe cognitive impairment.) Functional Status, indicated Resident 6 was not yet ambulating (walking) and required extensive assistance, with two staff members, for transfers (bed to wheelchair, wheelchair to toilet.) A subsequent MDS assessment, dated 3/21/16, documented Resident 6's BIMS score remained at 3. Resident 6's transfer ability, indicated she had improved to the point of requiring limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) for transfers with one staff member present. The MDS cognitive assessment, dated 10/18/16, indicated Resident 6's BIMS score remained at 3. Review of the facility's Fall Risk Assessment, for Resident 6, dated 2/22/16, indicated Resident 6 had a total score of 15. A score of 10 or more indicated high risk for falls. The assessment further indicated: Resident 6 had intermittent confusion, history of 1-2 falls in the prior three months, balance problems while standing and walking, and did not consistently use assistive devices (walker, wheelchair, cane). The fall assessment documented Resident 6 had taken or currently took the following medications within the previous seven days: antihypertensives (lowers blood pressure), anesthetics (pain relievers), benzodiazepines (sedatives generally used for anxiety and/or sleep problems), and antidepressants (drugs used to treat depression). A subsequent Fall Risk Assessment, dated 4/4/16, at 8:14 p.m., had a score of 13. Review of the facility's Charge Nurse Rounds Report, with the residents' fall risk scores, indicated, on 5/2/16, Resident 6 had an increased score of 17. On 7/18/16, the fall risk score rose to 21. The Care Plan for the prevention of falls, dated 2/22/16, indicated Resident 6 had risk factors that required monitoring and intervention to reduce potential for falls. Risk factors included, Altered mental status as evidenced by confusion. The goal of the Care Plan was Resident 6 would have no injuries due to falls with supervision and verbal reminders for better control of risk factors . The facility's approach (interventions) to reduce the potential for falls was to, attempt to anticipate needs - toileting, hydration .before Resident attempts to fulfill on own; bring (Resident 6) to the nurse's station when out of bed for observation; require 1-2 persons to assist with all transfers; and encourage Resident to sit in areas well supervised by staff. Updated approaches, dated 3/29/16, after a fall to the floor next to her bed on 3/28/16, included, visual checks of resident every two hours; position (Resident 6) near the nurse's station for increase (sic) visibility. After another fall on 6/28/16, interventions were to place Resident 6 at the nurse's station or in the activity room for increased visibility and monitor resident's whereabouts. After another fall on 7/12/16, interventions dated 7/28/16, were to monitor Resident 6's activity with frequent checks for safety, bring to common areas to avoid being left alone, and provide 1:1 sitter as appropriate. Review of the Interdisciplinary Notes, dated 2/23/16 at 5:31 p.m., indicated Resident 6 .needs constant supervision .is very impulsive and is a high risk for fall. Resident 6's Care Plan, dated 2/22/16 and 3/29/16 did not indicate a plan to provide constant supervision. During an interview on 4/21/16 at 11:30 a.m., Licensed Staff D stated Resident 6 was confused when admitted to the facility in February 2016. Resident 6's family provided a daytime sitter to accompany the resident. At night, the facility provided a sitter from a homecare agency. Interdisciplinary Notes dated 2/23/16, at 5:31 p.m., indicated Resident 6 was provided a one on one sitter for being very impulsive and a high risk for falls. Resident 6's Care Plan did not document the addition of a sitter. Review of attendance records from a private homecare company, indicated Resident 6 had a sitter for 12-hour shifts, generally from 6 p.m. to 6 a.m. or 8 p.m. to 8 a.m., starting on 2/22/16. There was no attendance record of a sitter after 3/21/16. During a concurrent interview, on 4/21/16, at 2 p.m., Licensed Staff D stated, approximately one week before 3/28/16, there was no longer a sitter, Because she had cleared, (confusion had diminished.) There was no documentation of a nursing assessment that indicated Resident 6's decrease in confusion or evaluation of need for a sitter. A licensed nurse's note dated 3/21/16, at 10:33 p.m., indicated Resident 6 was alert with confusion. Licensed nurses notes, dated 3/27/16 at 7:37 a.m., indicated Resident 6 was confused and tried to get out of bed and dislodged her urinary catheter (a thin sterile tube inserted into the bladder to drain urine.) A nurses note, dated 3/27/16, at 10:39 p.m., indicated Resident 6 had increased agitation and kept wanting to get out of bed. Confusion was noted and Resident 6 was placed in her wheelchair during the shift. A clip alarm (an alarm unit placed on a resident's wheelchair and clipped to the resident's clothing which activates an alarm if the resident attempts to get up from the wheelchair unassisted) was in place. Licensed nurses notes, dated 3/28/16 at 7:31 a.m., indicated Resident 6 had an unwitnessed fall at 6:30 a.m. Resident 6 was found sitting on the floor next to her bed, confused and highly impulsive and had mild pain to her right hip. The licensed nurse noted there was no apparent injury or bruising and the resident was able to move her extremities (arms/legs) without difficulty. Licensed nurses notes, dated 4/4/16, contained the following documentation: On 4/4/16 at 4 a.m., Resident 6, .continues to be confused .Fall precautions maintained. Bed low. Alarms in place. The nursing note at 2:43 p.m. documented , .resident had been agitated during the day. On 4/4/16 at 10:25 p.m., Licensed Staff H documented Resident 6 had an unwitnessed fall at 7:45 p.m. No injury or bruising was identified, however, Resident 6 complained of moderate to severe right hip pain, unrelieved by Tylenol (pain reliever) .alternating with Tramadol (a narcotic pain medication used to treat moderate to severe pain.) Additionally, the nurse's note indicated Resident 6 remained agitated and continued to ask to be toileted. Resident 6's doctor and family were informed of the fall, and Resident 6 was monitored every 30 minutes during the shift. Review of the acute care hospital's discharge summary, dated 4/12/16, indicated Resident 6 was at (the facility) when she tried to get up on her own and had a ground level fall. Resident 6 sustained a right periprosthetic (around the components and/or implants of her hip surgery in February 2016) hip fracture. Resident 6 was admitted to the hospital on [DATE]. On 4/8/16, Resident 6 underwent another right hip surgery to repair the new fracture. During the interview on 4/21/16 at 11:30 a.m., Licensed Staff D stated Resident 6 had an unwitnessed fall the evening of 4/4/16. Resident 6's physician ordered an X-ray of her right hip which appeared normal. Licensed Staff D stated Resident 6 continued to have right hip pain after the fall, unrelieved by pain medication. A follow-up office visit to Resident 6's surgeon, on 4/7/16, (to examine the resident after the original hip surgery in February) revealed an extension of the repaired right hip fracture. During an interview on 4/21/16 at 3:10 p.m., Unlicensed Staff K stated she was assigned to care for Resident 6 on the P.M. shift (3-11 p.m.) on 4/4/16. Unlicensed Staff K described Resident 6 as being agitated since admission and was a fall risk. Unlicensed Staff K stated, on 4/4/16 between 5 and 6 p.m., she took Resident 6 to the dining room for dinner and Resident 6 was shouting telling people to take her home and saying, Who's coming for me?' Unlicensed Staff K stated, between 6 and 7 p.m., Resident 6 wanted to go to the bathroom three times, although she had a urinary catheter. Unlicensed Staff K stated, I took her to the bathroom though. Unlicensed Staff K stated, on 4/4/16 at 7:15 p.m., she placed Resident 6, in her wheelchair, at the nurse's station, informed Licensed Staff D and continued caring for other residents. At 7:45 p.m., Unlicensed Staff K stated housekeeping staff found Resident 6 on the floor at the threshold of her room. Unlicensed Staff K stated no one saw her (Resident 6) leave the nurse's station. Unlicensed Staff K stated Resident 6 was found on her back and the clip alarm was on (sounding off). Unlicensed Staff K stated five staff members responded to Resident 6's fall. When asked if Resident 6 had pain, Unlicensed Staff K stated, No, she told the nurse she was ok. For the remainder of the P.M. shift, Unlicensed Staff K stated she sat with Resident 6 and she (Resident 6) was still yelling out and saying, 'There's a man here,' like she was hallucinating. When asked to describe some of the safety measures the facility implemented for resident's at risk for falls, Unlicensed Staff K stated, room changes, floor mat, call cord (call bell) within reach, bed alarm, clip (alarm). During a telephone interview on 4/25/16 at 2:38 p.m., Family Member Q stated Resident 6 had a history of [REDACTED]. Family Member Q stated, on 4/4/16 Resident 6 probably felt like she needed to use the bathroom, took herself there and tried to stand on her own. During a telephone interview on 4/26/16 at 2:17 p.m., when asked who monitored residents when they were placed at the nurse's station, Licensed Staff D stated the licensed nurse (on duty) would be there, especially when preparing for med pass (administering medications) but not at all times. Licensed Staff D stated the CNA (Certified Nursing Assistant) would alert the licensed nurse that a resident is being placed there while the CNA tends to his/her other residents. During an interview on 5/2/16 at 12:20 p.m., when asked who monitored Resident 6's whereabouts on the evening of 4/4/16, Licensed Staff D stated, Staff involved in her care .would have to coordinate, to keep an eye on her. During a telephone interview on 5/2/16 at 2:20 p.m., Licensed Staff G stated, she responded to Resident 6's fall on 4/4/16 and, She was on the floor by the time I got there. When asked how residents were monitored at the nurse's station, Licensed Staff G stated, We're all watching them, and a CNA would tell the nurse if he/she placed a resident at the nurse's station. Licensed Staff G stated Resident 6 did not have a sitter when she fell on [DATE]. During a telephone interview on 5/2/16 at 3:53 p.m., Licensed Staff H stated she was assigned to care for Resident 6 on 4/4/16. Licensed Staff H described Resident 6 as being Very, very agitated, she didn't want to be there, (at the facility). When asked to describe agitated, Licensed Staff H stated Resident 6 was very forgetful and repeated over and over can you help me, I want to go home. Licensed Staff H stated Resident 6 could not recall having just spoken to a family member on the telephone. Licensed Staff H stated Resident 6 was at the nurse's station after dinner and, I continued my med pass. Licensed Staff H stated the CNA usually tells me she's (Resident 6) there (at the nurse's station) or I see her there. When asked who supervised Resident 6 at the nurse's station, Licensed Staff H stated, I go back and forth and I park (place) my cart (medication cart) at the nurse's station and the CNA's walk by her. When asked how long Resident 6 was at the nurse's station, Licensed Staff H stated she did not know and added, I didn't see her leave the nurse's station .next thing she's on the floor in her room. When asked how she supervised or monitored an agitated and confused resident as Resident 6 was described, Licensed Staff H stated I assign one CNA to stay with her if there's no sitter available and kept the bed very low and a padded floor mat next to the bed. Licensed Staff H confirmed Resident 6 did not have a 1:1 sitter on the evening of 4/4/16. During an interview on 10/11/16 at 2:04 p.m., Administrative Staff B stated Resident 6 was on the facility's Falling Star Program. Concurrent review of the facility's Falling Star policy indicated the Falling Star Program was used to remind staff to monitor high risk residents for fall prevention and that these resident's have interventions in their care plans to reduce and/or prevent repeat falls. During an interview on 12/13/16 at 12:50 p.m., when asked if Resident 6 had a current 1:1 sitter, Licensed Staff D stated she had a family companion during the day, however, No sitter, not on a regular basis. When asked how staff monitored Resident 6 to prevent falls, Licensed Staff D stated licensed staff and CNA's (certified nurse assistants) made visual checks, placed resident near common areas if restless, and used a sensor monitor (an alarm that sounds if a resident attempts to get up from bed or wheelchair). During an observation, on 12/15/16 at 11:55 a.m., in the dining room, Resident 6 sat in a wheelchair alone at the table. During a telephone interview on 12/19/16 at 9:55 a.m., Licensed Staff D stated Resident 6 had two additional falls on 6/28/16 and 7/12/16. Review of the facility's policy and procedure titled, Resident Accident and Incident, dated 6/7/13, indicated the purpose of the policy was to ensure each resident .received adequate supervision and assistance to prevent accidents and/or injury . When a resident was identified as at risk for falls or accidents, the policy indicated the facility would implement procedures to prevent accidents and injury related to accidents. Review of the facility's policy and procedure titled, Fall Prevention Program, dated 8/31/15, indicated a resident with a high risk for falls or potential for repeated falls would be monitored daily for falls and/or lack of falls to determine effectiveness of .interventions .