Every finding on record at The Valley Health and Rehab

Based on observations, interviews, and record review, the facility failed to ensure a resident received care for the prevention and treatment of pressure ulcers; failed to complete and document the pressure ulcer/skin assessments, treatments, and services to promote healing, and prevent infection, for 1 (#7) of 3 sampled residents for pressure ulcers/skin care. This deficient practice resulted in skin breakdown and resident #7 developing a large Stage IV pressure ulcer, which became infected, requiring hospitalization and treatment, and the staff reported the resident's behaviors, anxiety, and pain made care difficult. Findings include: Review of [Hospital Name] History and Physical, dated 3/4/26, showed resident #7 admitted to the hospital with increased weakness, numbness of extremities, and inability to walk or complete ADLs. Resident #7 was discharged on 3/10/26 to the skilled nursing facility for a surgical neck wound and rehabilitation. Review of the facility Admit/Readmit Screener, dated 3/10/26, showed resident #7 admitted to the facility with red skin on his right elbow, left neck surgical laminectomy site, and a left shin abrasion. Resident #7 was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #7 had a Foley catheter.Review of the weekly wound Observation Tool, dated 3/16/26, showed resident #7 had developed right and left buttock moisture-associated skin damage (MASD), and the area was measured and found to be 9.0 cm x 6.5 cm in size on the right buttock and 12.0 cm x 6.0 cm in size on the left buttock. Review of a [Hospital Name] admission note, dated 3/19/26, showed resident #7 was at a post-surgical clinic appointment and noted to be confused and sent to the emergency room. Resident #7 was found to be hyponatremic, and had a sodium level of 113, and had been drinking 10-12 glasses of water a day, per the report. The resident received several doses of Narcan at the hospital. In addition, resident #7 was hypoxic, requiring high-flow oxygen. Review of the [Hospital name] wound care assessment, dated 3/20/26, showed resident #7 admitted to the hospital (3/19/26) with skin breakdown to his sacrum and buttocks. Resident #7 had a non-blanching deep tissue pressure injury, centrally located on the sacrum, with scattered spots of non-blanching purple/maroon, denuded skin, likely a combination of pressure and moisture. The pressure injury was 3.5 cm x 2.5 cm x 0.1 cm in size. Review of a [Hospital name] Progress Note, dated 3/23/26, showed resident #7's labs reflected he had severe protein-calorie malnutrition related to social/environmental circumstances.Review of a [Hospital Name] Wound Care Assessment, dated 3/24/26, showed resident #7's sacral wound had evolved with moist yellow slough, was pink, and a Stage III pressure injury with yeast. Review of facility Admit/Readmit Screener, dated 3/27/26, showed resident #7 returned to the facility with moisture-associated skin damage to his left and right buttocks. No pressure injury was noted on the sacral area. A yeast rash was noted on the buttocks and groin. Review of the facility Weekly Wound Observation Tool, dated 3/30/26, showed resident #7 had scattered ulcerations with moisture-associated skin damage to the left and right buttocks. The measurements were noted as 5.1 cm x 4.3 cm x 0.2 cm. Resident #7 also had a Stage III pressure ulcer to his right medial lower buttock measuring 1.9 cm x 1.5 cm x 0.2 cm. Orders for the skin/pressure ulcer were requested from the physician.Review of the facility Weekly Wound Observation Tool, dated 4/6/26, showed resident #7's Stage III bilateral buttock wounds were now Unstageable and had merged into one large pressure ulcer wound. Resident #7's wound had an odor and moderate purulent drainage (signs of potential infection). The wound measurements were 5.6 cm x 8.0 cm x 0.3 cm. Resident #7 was transferred to the emergency room for a possible infection in the sacral wound.Review of the [Hospital Name] ED to Hosp-admission record, dated 4/6/26, showed resident #7 presented to the emergency room with a fever of 102.6 Fahrenheit, and a blood pressure of 136/102. Resident #7 reported he had a fever for five days while at the facility. Resident #7 had a Large sacral decubitus wound with purulent tissue . with surrounding cellulitis and redness. The radiology results noted a severe sacral decubitus ulcer with erosion nearly to the coccyx with a rim-enhancing gas and fluid collection measuring 4.0 cm. The hospital diagnoses included: abscess, ulcer, osteomyelitis, cellulitis, sepsis, and a necrotizing soft tissue infection. The physician noted the sacral ulcer was nearly to the bone. General surgery was consulted, and operative debridement was completed. Post-operatively resident #7's wound showed progressive improvement with regular wound assessments and a wound vac. Resident #7's discharge summary noted resident #7 presented to the emergency room with an altered mental status related to metabolic encephalopathy in the context of severe infection and pain from the sacral wound. Resident #7 declined to return to the facility and was sent to an alternate facility for ongoing care and rehabilitation. During an interview on 4/21/26 at 3:08 p.m., NF1 stated that after the resident's first hospitalization with hyponatremia, a pressure ulcer, and malnutrition, he stayed in close contact with the facility management. NF1 stated the staff was frequently frustrated by resident #7's constant need for attention and anxiety. NF1 explained to management that resident #7 had very high anxiety and needed to feel he had some control over things. NF1 also felt that some of the residents' behaviors were related to the low sodium levels, and he improved when he was in the hospital. NF1 stated he repeatedly educated management staff about resident #7's hyperfocus and high anxiety, and he did not understand how the facility staff was supposedly spending so much time with him but did not know he was so sick with the infection and became septic. During an interview on 4/22/26 at 11:50 a.m., staff member B stated the facility was not equipped to manage resident #7's behaviors. Staff member B stated the sacral wound was facility-acquired, and the resident did become obtunded (confused) related to the opioids, and the medication doses were reduced. Staff member B stated she did not know why the facility staff did not note the resident was obtunded before sending him out for an appointment. Staff member B stated she was not aware that resident #7 was drinking 10-12 glasses of water a day until he returned from the hospital. During an interview on 4/22/26 at 4:50 p.m., staff member B stated she did not know where the skin/wound assessments were or why the assessments were not done for resident #7 during the week of 3/31/26 through 4/6/26, which was when resident #7 presented to the hospital with a Stage IV pressure sacral wound and sepsis. Staff member B stated she could not explain why no one reported that the resident's wound was worsening.During an interview on 4/23/26 at 10:31 a.m., staff member I stated she went into the facility to complete the readmission history and physical visit for resident #7. She found he had a fever, and physical therapy had been unable to get him up and moving due to pain. Staff member I stated resident #7's pain medication regimen was intense, and stated, He was gorked out on medications (heavily sedated), and the medication regimen started long before he came to the facility. Staff member I stated there were a lot of opportunities for improvement in the nursing assessments. Staff member I stated she had never taken care of a resident with that level of psych and pain issues before. Staff member I stated the facility could not handle the complex psych needs of resident #7. Review of resident #7's Skin Integrity Care Plan, with a last revision date of 3/27/26, showed:-Potential for Impaired Skin Integrity as evidenced by MASD to sacrum/coccyx with a date initiated of 3/11/26. Interventions included educating resident #7 on skin protection, proper use of pressure-relieving devices, and keeping skin clean and moisturized. Additional interventions included skin evaluations, monitoring the nutritional status, performing skin assessments, and providing skin care according to facility guidelines. The frequency of the tasks was not included on the care plan. The care plan showed:-[Resident #7] has alternation in skin integrity as evidenced by MASD to his R & L buttock, with a date initiated of 3/16/26. Interventions included informing the physician of healed tissue, signs or symptoms of infection, and skin care twice a day, and as needed. -Risk for impaired skin integrity r/t (immobility, incontinence, decreased sensory perception) (surgical and left toe as well as buttocks and coccyx stg III) [sic] with a date initiated of 3/17/26. Interventions included applying barrier cream to the perineal area, assisting with routine turning and repositioning to promote circulation, CNA skin inspections with routine care and report to the nurse, educating the resident on the importance of repositioning, mobility, and nutrition, keeping the skin clean and dry, and for the nurse to perform weekly skin evaluations.

Based on observations, interviews, and record review, the facility failed to ensure that food items stored in the walk-in cooler were dated and labeled appropriately. This deficient practice placed all residents at risk for foodborne illnesses. Findings include: During an observation on 4/23/26 at 8:06 a.m., the following items were observed in the walk-in cooler:- Two zip-lock bags of slimy, sliced tomatoes, which were not dated. - One gallon zip-lock bag of ground meat, not labeled with the food type or date. - One gallon zip-lock bag of sliced ham, not dated.- One gallon zip-lock bag of sliced roast beef, not dated.- One gallon zip-lock bag of sliced cheese, not dated; and,- A cup of sliced strawberries with no date.During an interview on 4/23/26 at 8:24 a.m., staff member H stated the kitchen staff did see mold on strawberries when the food came in off the truck and would usually try to pick the molded strawberries out. During an interview on 4/23/26 at 8:24 a.m., staff member G stated he was aware of the dating issues and was trying to get staff to date food with and add the use-by dates. Staff member G stated he was re-educating staff and was checking the dates weekly.During an interview on 4/23/26 at 8:36 a.m., staff member B stated that the facility had moldy dinner rolls one day, and she had the staff go around and collect the dinner rolls left from residents who had been served the moldy rolls. Review of the facility's policy, Food Safety Requirements, dated 4/11/25, reflected, .3. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded .

Based on observations, interviews, and record review, the facility failed to provide meaningful activities to meet the needs of dementia residents for 6 (#s 1, 4, 5, 9, 12, and 14) of 11 sampled residents with dementia. This deficient practice resulted in residents in the memory unit wandering without activities, remaining in rooms throughout the day, and sitting and staring at blank televisions. Findings include: During an observation on 7/22/26 at 7:55 a.m., residents were sitting in the dining area and the common room. No activities were being provided. Resident #1 sat in a recliner in the common room, scratching her arms repeatedly and staring at the television, which was off. Residents #12 and 14 were sitting in the dining room at tables. Resident #9 was walking around the unit, running into walls and being redirected to walk a different direction. During an observation in the memory unit on 4/22/26 at 10:03 a.m., staff member E stated the activities were canceled due to weather, and the residents would be doing nails and bingo as alternate activities in the afternoon. Staff member E was working on care plans on her computer while sitting at a table with residents. Residents had a newsletter in front of them. Several residents were sitting, staring at the floor or sleeping in their chairs. Residents #4 and 14 were participating in the activity. Residents #5 and #12 were not participating. Resident #1 was in the common room staring at a blank television while sitting in a recliner. Resident #9 was wandering in the hall. Residents in the dining area were then given a word search to complete for points toward prizes. Residents #4 and 14 were actively working on the word search. The other residents continued to sit and not participate. The facility sitters (non-CNAs who watch residents to redirect them to prevent resident-to-resident incidents) sat at the tables but did not attempt to assist residents with the activity. Resident #12 did not speak English and was staring off down the hall. Resident #5 repeatedly stated she would have to get her glasses to see the paper. No one went and got her glasses for her. Resident #1 was wandering the hallways. Staff member E stated she had other duties to attend to in another unit and left.During an interview on 4/22/26 at 10:35 a.m., staff member E stated she was limited on the activities for memory care residents because the staff would get angry and tell her no physical activities or music should be done, because it would get the residents ramped up (excited/agitated) and they would have behaviors. Staff member E stated she had reported this to management, and management agreed that she should not have activities involving music or physical activities. Staff member E stated she was told to limit activities to calming things only. Staff member E stated she felt the residents were left in bed and not taken to activities because it was easier for the staff to manage. Staff member E stated she had many duties outside of the memory care unit activities and had very limited time to spend with residents in the memory care unit. Staff member E stated that the floor staff was supposed to provide activities when she was not present, but the floor staff would not do activities with the residents. Staff member E stated that the floor staff just wanted the residents to sit and be calm and quiet. Staff member E stated she felt the residents' lack of exercise and boredom, for those in the memory care unit, led to more behaviors. Staff member E showed the surveyor the memory care activity calendar and stated the residents did not have activities at all on weekends because there was no activities person working on the weekend, so the calendar showed, Resident Choice Day!!!!During an interview on 4/22/26 at 11:24 a.m., staff member B stated activities should be patient-centered, calming, and engaging. Staff member B stated that staff member E is still learning what activities she can do in memory care. During an observation on 4/22/26 at 9:53 p.m., resident #1 was sleeping in a recliner in the common area. Resident #19 was sitting in the common room staring at a wall. The television was on and cartoons were playing.During an interview on 4/23/26 at 9:39 a.m., staff member O stated that activities do not usually happen in the memory care unit. Staff member O stated that the activities happening yesterday (4/22/26) and that day were a show just for surveyors.During an interview on 4/23/26 at 11:09 a.m., staff member F stated that staff member E did not stick to doing the activity calendar in the memory care unit most of the time. Staff member F stated she heard complaints from staff regularly, and she heard complaints from residents who would come out of the memory care unit to participate in skilled activities, stating staff member E did not do the activities scheduled. During an interview on 4/23/26 at 11:24 a.m., staff member P stated that staff member E spent most of her time in the memory unit on her computer, not doing any activities. Review of the facility's Activities Calendar Memory Care, dated April 2026, showed:- Resident Choice Day on all Saturdays and Sundays,- Trivia was scheduled for Wednesdays,- Exercise/stretching was scheduled for 19 of 22 weekdays, and - Book club was scheduled for Thursdays. Review of resident #1's MDS, dated [DATE], for the Cognitive Section, reflected that resident #1 had a BIMS of 0 (severely impaired memory).Review of resident #5's MDS Cognitive Section, dated 2/17/26, reflected that resident #5 had a BIMS of 9 (moderately impaired memory).Review of resident #12's MDS Cognitive Section, dated 3/24/26, reflected that resident #12 had a BIMS of 3 (severely impaired memory).Review of resident #14's MDS Cognitive Section, dated 4/1/26, reflected that resident #14 had a BIMS of 5 (severely impaired memory).Review of the facility policy, Activities, dated 1/7/26, showed:- . 2. Activities will be designed with the intent to:a. Enhance the resident's sense of well-being, belonging, and usefulness, . c. Promote or enhance physical activity, .d. Promote or enhance cognition, .g. Reflect residents' interests and age .9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.

Based on interviews and record reviews, the facility failed to closely monitor and address a resident's lack of bowel movements and provide as-needed medications to treat and prevent constipation, for a resident who had a history of opioid induced constipation and had used constipation medications before admission, for 1 (#7) of 20 sampled residents. This deficient practice resulted in resident #7 having an extensive stool burden. Findings include:Review of [Hospital Name] History and Physical, dated 3/4/26, showed resident #7 admitted to the hospital with a 9.6 cm stool ball noted on the imaging (fecal impaction). Resident #7 was discharged on 3/10/26 to the skilled nursing facility for care of a surgical neck wound and rehabilitation. A review of resident #7's [Hospital Name] physician notes, dated 3/6/26, showed he reported he would not have a bowel movement for up to 5 days, which was possibly due to opioid use.A review of resident #7's [Hospital Name] physician notes, dated 3/9/26, showed under the Subjective section that the physician was . working on balancing between opioid-induced constipation and to many constipation meds. [sic]Review of the facility Admit/Readmit Screener, dated 3/10/26, showed resident #7 admitted to the facility and was totally dependent for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #7 had a Foley catheter. The document showed resident #7 had normal formed stool, rarely/never depends on laxative.Review of a [Hospital Name] admission note, dated 3/19/26, showed resident #7 was at a post-surgical clinic appointment and was sent to the emergency room due to medical concerns. Resident #7 was found to be hyponatremic and received treatment. During an interview on 4/22/26 at 11:50 a.m., staff member B stated she did not know why the facility staff did not note the resident was confused before sending him out for an appointment. Staff member B stated she was not aware resident #7 was drinking 10-12 glasses of water a day until he returned from the hospital, and he was placed on fluid restrictions. A review of resident #7's nursing progress notes, dated 4/6/26, showed the resident was assessed and found to have a flat abdomen, which was not tender, no indigestion, no vomiting, no bowel sounds present, no nausea, no diarrhea, and no constipation. A review of resident #7's [Hospital Name] notes, dated 4/6/26, which was after the resident was readmitted back to the hospital, showed an Extensive stool burden within the rectum distending the rectum to 8.8 cm with mild rectal wall thickening and perirectal fat stranding concerning for stercoral colitis1.During an interview on 4/22/26 at 4:50 p.m., staff member B stated she could not explain why no one reported that resident #7 had not had a bowel movement in six days, and stated the resident had gone without any as-needed bowel medications.Review of resident #7's Medication Administration Record, dated March - April 2026, showed resident #7 had not received any scheduled or as-needed medications for constipation. Review of resident #7's Bowel documentation, dated 3/11/26 - 4/5/26, showed that resident #7 did not have a bowel movement from 3/29/26 to 4/3/26, and then had diarrhea on 4/4/26, followed by a putty-like stool on 4/5/26. During an interview on 4/23/26 at 11:30 a.m., staff member B stated the facility did not have a policy specific to bowel and bladder management.1Stercoral colitis is inflammation inside your colon caused by fecal impaction (hard impacted stool). Stercoral means feces-related. Colitis means inflammation in your colon (irritation, pain, and swelling). It's a rare but serious complication of severe constipation.Stercoral Colitis: What It Is, Symptoms & Treatment

Based on observations, interviews, and record review, facility staff failed to ensure hand hygiene was completed while providing care for a resident's infected wounds/skin for 1 (#16) of 3 sampled residents for wound care. This deficient practice placed all residents receiving care from these staff members at risk of exposure to infectious agents and resident #16 at risk of a spread of skin cellulitis to his right leg. Findings include:During an observation and interview on 4/23/26 at 9:20 a.m. staff members C and J entered the room of resident #16 to assess his reported weeping (edema fluid) and hot (temperature) lower legs. Staff member J removed resident #16's ted hose on the left leg and noted the leg was hot to the touch, and the skin was weeping fluid. Staff member J then moved from the left leg to the right leg, removed the ted hose, and touched and assessed the resident's right leg, noting the skin was dry but intact. Staff member J did not change gloves after touching the resident's bodily fluids on the left leg. Staff member J then had staff member C go to the supply room for new ted hose while she completed hand hygiene and then added lotion to resident #16's legs. Staff member C returned with ted hose and new socks. Staff member C donned gloves and began assisting with placing the new ted hose. Staff member C applied the ted hose to the left leg and noted there was weeping fluid from the skin on the leg. Staff member J applied the ted hose to the right leg. Afterwards, staff member J went to wash her hands and staff member C began to clean up the room, touching the resident's food on his bedside table, grabbing his pillow off his bed, and placing it in the chair where resident #16 was sitting, and putting her gloved hand in her clothing pocket to turn off her ringing cell phone. Staff member C did not perform hand hygiene or change gloves after touching bodily fluids and continued to touch other items in the room. After leaving the room, staff member C stated she did not think of performing hand hygiene when she finished putting the ted hose on the resident. Staff member J stated she thought she had hit all the hand hygiene opportunities, but realized, when this surveyor asked, that she had moved from one leg to the other without hand hygiene. Staff member J stated resident #16 was started on Cipro, an antibiotic, for cellulitis (bacterial skin infection) this morning. Review of the facility's policy, Hand Hygiene Table, dated 4/11/25, reflected that hand hygiene with either soap and water or alcohol-based hand rub should occur during the following opportunities:- . After handling contaminated objects; - . When, during resident care, moving from a contaminated site to a clean body site;- . After handling items potentially contaminated with blood, bodily fluids, secretions, or excretions .

Based on interview and record review, the facility failed to complete comprehensive resident assessments in accordance with the required timeframe of 14 days after admission for 4 (#s 2, 3, 25 and 41) of 10 sampled residents. The failure had the potential to prevent the residents from achieving their highest practicable level of function. Findings include:During an interview on 1/26/26 at 1:05 p.m., staff member A stated the MDS Coordinator worked remotely. Staff member A stated the MDS Coordinator was shared with another facility. Staff member A did not know why MDS's had been completed late.During an interview on 1/28/26 at 9:58 a.m., staff member D stated that comprehensive assessments had 14 days from admission to be closed. Staff member D stated he was aware MDSs had been closed late. Staff member D stated the facility had MDSs that were late when he started completing the MDS assessments for the facility on 12/22/25. Staff member D stated he was still working to get caught up and that it was a learning process covering two facilities.A review of resident #41's medical record showed an admission date of 10/21/25. The comprehensive assessment, with an ARD of 10/27/25, was due to be completed on 11/3/25. The comprehensive assessment was completed late on 11/4/25.A review of resident #3's medical record showed an admission date of 11/5/25. The comprehensive assessment, with an ARD of 11/11/25, was due to be completed 11/18/25. The comprehensive assessment was completed late on 11/19/25.A review of resident #2's medical record showed an admission date of 11/19/25. The comprehensive assessment, with an ARD of 11/22/25, was due to be completed 12/2/25. The comprehensive assessment was completed late on 12/6/25.A review of resident #25's medical record showed an admission date of 1/9/26. The comprehensive assessment, with an ARD of 1/15/26, was due to be completed 1/22/26. The comprehensive assessment was completed late on 1/23/26.A review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, effective 10/1/25, showed: . Chapter 2: Assessments for the Resident Assessment Instrument (RAI). 2.6 Required OBRA Assessments for the MDS. [table] RAI OBRA-required Assessment Summary. Assessment Type/Item Set. admission (Comprehensive). MDS Completion Date. No Later Than. 14th calendar day of the resident's admission (admission date +13 calendar days) .

Based on observation, interviews, and record review, the facility failed to ensure staff followed appropriate hand hygiene when passing meal trays, increasing the risk of bacterial transmission to all residents who received meals in their rooms. Findings include:During an observation on 1/26/26 at 7:49 a.m., staff member K was passing room trays to residents in their rooms. Staff member K entered a room, delivered a meal, removed the plate cover, and set it on the cart. Staff member K grabbed another tray from the warmer and took it to another resident's room. Staff member K came out, put the plate cover on the cart in the hallway, then grabbed another tray and took it into a resident's room. Staff member K failed to sanitize in between room trays. During an interview on 1/26/26 at 8:08 a.m., staff member K stated hand sanitizer should be used before passing trays to residents and in between each tray. Staff member K said, I do not carry hand sanitizer on me; I use the one on the wall. I did not use it while doing those last few trays. During an observation on 1/26/26 at 12:52 p.m., staff member L was observed entering a resident's room with a meal tray, exiting the room, grabbing another tray, and delivering it to a resident without sanitizing their hands in between. During an interview on 1/26/26 at 4:29 p.m., staff member F stated, I would expect staff to be sanitizing between each tray while delivering them to the residents. During an observation on 1/27/26 at 12:56 p.m., staff member Q was assisting with passing room trays. Staff member Q passed multiple trays without sanitizing their hands between rooms. During an interview on 1/27/26 at 2:53 p.m., staff member Q stated, We (staff) should be sanitizing our hands after each tray while passing them to residents. I don't help pass them very often. I didn't know that was the process until yesterday. During an observation and interview on 1/28/26 at 7:50 a.m., staff member M was observed passing meal trays and not sanitizing their hands between resident rooms. Staff member M stated, You should sanitize every time you leave a resident's room. I did not sanitize when I came out of that room and grabbed another room tray. During an interview on 1/28/26 at 9:27 a.m., staff member H stated when staff were serving residents during meals they should have been performing hand hygiene between trays. Review of a facility document titled Hand Hygiene with an initiation date of 4/11/25 showed: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Hand Hygiene Table: Between resident contacts. Review of a facility document titled Food Safety Requirements with an implementation date of 4/11/25 showed: Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. 5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include, but are not limited to: .c. Washing hands properly before distributing trays.d. Washing hands between contact with residents and after collecting soiled plates and food waste.

Based on interview and record review, the facility failed to maintain a completed POLST (Provider Orders for Life-Sustaining Treatment), including the resident or resident representative signature showing the residents preferences for Provider Orders for Life-Sustaining Treatment in the medical record, for 1 (#33) of 22 sampled residents. This deficient practice had the potential for the resident to receive life sustaining care against her wishes. Findings include:A review of resident #33's POLST form, in her electronic health record, showed in section A, NO CPR: Do Not Attempt Resuscitation (DNAR)/Allow Natural Death (AND), was checked. The patient/legal decision maker signature/mandatory box was marked with an X, showing where the person was supposed to sign, but there was no signature of the resident or responsible party. During an interview on [DATE] at 11:23 a.m., staff member E stated she would explain the POLST to the resident or the resident's POA, during the admission process, she would then sign the person preparing the form box and instruct the resident or the resident's POA to sign the patient/ legal decision maker box.A review of a facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, with an implemented date of [DATE], showed, Policy:It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives.Policy Explanation and Compliance Guidelines:On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions.

Based on interviews and record review, the facility failed to provide a resident or resident representative with a notice of transfer/discharge, or a bed hold notice, when the resident was transferred to the hospital for 1 (#53) of 22 sampled residents. This deficient practice increased the risk that the resident would not be fully prepared for transfer. Findings include: Review of resident #53's electronic medical record showed resident #53 was transferred emergently to the hospital on [DATE], for a decline in health and abnormal behaviors. During an interview on 1/28/26 at 8:41 a.m., staff member B stated resident #53 was transferred to the hospital for further evaluation, and they (the facility) utilized the ambulance services due to his bed-bound status. Staff member B stated they would expect transfer and bed-hold notices to be completed for any resident being sent out of the facility. Review of resident #53's electronic medical record failed to show the facility provided resident #53 or their representative with a notice of transfer/discharge or notification of bed hold.During an interview on 1/28/26 at 11:56 a.m., staff member H stated they did not have the transfer/discharge and bed hold notices for resident #53, and they must not have been completed when the resident was transferred to the hospital on [DATE].

Based on interview and record review, the facility failed to complete a comprehensive resident assessment within 14 days after the facility determined there had been a significant change in the resident's physical and or mental condition for 1 (#4) of 10 sampled residents and their MDS assessments. The failure had the potential to prevent the residents from achieving their highest practicable level of function. Findings include:During an interview on 1/26/26 at 1:05 p.m., staff member A stated he did not know why MDSs had been completed late.During an interview on 1/28/26 at 9:58 a.m., staff member D stated a comprehensive Significant Change assessment had 14 days to be completed. Staff member D stated he started doing MDSs for the facility on 12/22/25. Staff member D stated the facility had multiple late MDSs when he started, and he was still catching up. A review of resident #4's medical record showed a comprehensive Significant Change MDS was scheduled, with an ARD of 11/16/25. The MDS was due for completion on 11/29/25. The MDS was completed late on 12/6/25.A review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, effective 10/1/25, showed: . Chapter 2: Assessments For the Resident Assessment Instrument (RAI). Significant Change in Status (SCSA) (Comprehensive). MDS Completion Date. No Later Than. 14th calendar day after determination that significant change in resident's status occurred (determination date +14 calendar days) .

Based on interview and record review, the facility failed to complete a Quarterly resident assessment in accordance with the required timeframe of 14 days after the ARD for 2 (#s 16 and 23) of 10 sampled resident assessments. The failure had the potential to prevent the resident from achieving their highest practicable level of function. Findings include:During an interview on 1/28/26 at 9:58 a.m., staff member D stated a Quarterly assessment had 14 days from the ARD to be closed. Staff member D stated he was aware of MDSs for facility residents that had been completed late, and since he started on 12/22/25, was still working to catch up on them. A review of resident #16's medical record showed a Quarterly assessment was scheduled with an ARD of 11/20/25. The Quarterly assessment was due to be completed 12/4/25. The MDS was completed late on 12/7/25.A review of resident #23's medical record showed a Quarterly assessment was scheduled with an ARD of 12/29/25. The Quarterly assessment was due to be completed 1/12/26. The MDS was completed late on 1/18/26.A review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, effective 10/1/25, showed: . Chapter 2: Assessments For the Resident Assessment Instrument (RAI). Quarterly (Non-Comprehensive) . MDS Completion Date. No Later Than. ARD +14 calendar days.

Based on observation, interview, and record review, the facility failed to provide restorative services to a resident in an attempt to prevent the resident from a deterioration in her range of motion, when she was not able to extend her arms or complete some of her own ADL care, and the facility did not follow their policies and procedures for restorative care for 1 (#5) of 22 sampled residents. Findings include:During an observation and interview on 1/25/26 at 12:31 p.m., resident #5 was in her room. Resident #5 stated she had difficulty lifting her arms. Resident #5 lifted her arms as far as she could, and her arms were only about halfway extended. During an observation and interview on 1/26/26 at 7:55 a.m., resident #5 stated, I was in PT and OT, but due to insurance, I haven't had any therapies. I try to do my own exercises. The staff don't assist with any of the exercises. I wish I had more assistance with my range of motion. I'm getting stiff in my arms. Resident #5 raised her arms to show how far she could reach, and it was only about halfway to full extension. Resident #5 stated, The staff even have to brush my hair because I can't with my arms the way they are.During an interview on 1/26/26 at 11:53 a.m., staff member N stated we (the facility) really don't have a restorative program. I think they (management) are working on one. Staff member N stated, I encourage residents with decreased range of motion to do as much for themselves as possible.During an interview on 1/26/26 at 4:06 p.m., staff member O stated she did not think the facility had a restorative program but thought they were working on one. During an interview on 1/26/26 at 4:07 p.m., staff member J stated, Yes, there is a restorative program, and it is really good. They also just hired a new full-time therapist. Staff member J stated residents with decreased range of motion would be referred to PT and OT for an evaluation. During an interview on 1/27/26 at 3:21 p.m., staff member B stated, I'm not sure if we have a restorative program. Staff member B stated, If a resident has a decreased range of motion, staff will notify the physician and obtain an order for PT and OT to evaluate the resident. During an interview on 1/27/26 at 3:22 p.m., staff member H stated, We don't have a restorative program. During an interview on 1/28/26 at 11:32 a.m., staff member P stated resident #5 was discharged from therapy 5-6 weeks ago. Staff member P said she was not sure if the aides worked with resident #5 on the range of motion. Review of resident #5's care plan, with a revision date of 10/26/25, showed: Focus: ADL, [Resident #5] has a risk for decline in ADL function related to disease processes, mobility, and mental health status.Goal: [Resident #5] will improve or maintain the current level of function through the next review date.Interventions: .Encourage to participate to the fullest extend possible.,PT/OT evaluation and treatment as per MD orders. [sic]Review of a facility document titled Prevention of Decline in Range of Motion, with an initiation date of 4/11/25, showed: Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable.Policy Explanation and Compliance Guidelines: 1. The facility, in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapist, shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care.2. Assessment for Range of Motion.b. Resident who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion.3. Appropriate Care Planninga. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion.4. Preventative Care. b. Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to:. v. Assisting resident with range of motion exercises, performing passive range of motion for resident unable to actively participate. [sic]

Based on observations, interviews, and record review, the facility failed to assess a resident for injury after a fall, increasing the risk of delayed treatment for 1 (#46) of 22 sampled residents. Findings include: During an observation and interview on 1/25/26 at 12:46 p.m., resident #46 was lying in bed with a neck brace on. Resident #46 talked about his recent surgery and about a fall he had after arriving at the facility. During an interview on 1/27/26 at 2:38 p.m., staff member J stated, When a resident falls, we (staff) complete neuro checks if the fall is unwitnessed. The nurse will assess the resident for injury, and then the staff will transfer the resident to a safe area. Vital signs are taken, and an assessment is completed. A risk assessment is completed post-fall.During an interview on 1/27/26 at 3:21 p.m., staff member B stated, The facility's process for a resident fall would be to leave the resident on the floor and assess them. If they are ok, assist them to a safe location. Then notify the appropriate individuals, conduct a risk management assessment and neuro checks, and send them to the hospital if needed.During an interview on 1/28/26 at 9:31 a.m., resident #46 stated, I have fallen three times since I got here. During my first fall, I pulled the (call) light and waited for 10-15 minutes for help. I tried to get into my chair and slipped. During an interview on 1/28/26 at 9:41 a.m., staff member L stated, she was not on shift when resident #46 fell the first time, and she assumed it was unwitnessed. Staff member L said, He (resident #46) was pretty unstable when he first got here. During an interview on 1/28/26 at 10:45 a.m., staff member B stated she spoke with the nurse who was on duty when resident #46 fell, and the nurse said she had completed the required neuro checks and risk assessment but could not find them. Review of resident #46's electronic medical record showed a health status note, with a date of 1/9/26, which showed: Resident was found on floor after pressing call light. CNA and RN helped resident up with Hoyer (mechanical lift) and then to the restroom. Resident then did Stand pivot transfer to bed form the wheelchair with CNA and RN assistance. No injury noted, Neuro, pain and physical assessments preformed and at normal baseline. [sic]Review of resident #46's list of assessments in the electronic medical record failed to show that a fall assessment was completed for the fall on 1/9/26. A request for resident #46's neuro checks and risk assessment for the fall on 1/9/26, was made on 1/27/26, and was not received by the end of the survey period. Review of a facility document titled Fall Prevention Program with an implementation date of 4/11/25, showed: Policy: Each resident will be assessed for all risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines:1. The facility utilizes a standardized risk assessment for determining a resident's fall risk.2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 9. When any resident experiences a fall, the facility will: a. Assess the resident.b. Complete a post-fall assessment.c. Complete an incident report.f. Document all assessments and actions.

Based on observations, interviews, and record review, the facility failed to provide meals at regularly scheduled times, causing a resident to become frustrated for 1 (#31) of 22 sampled residents. Findings include:During an observation and interview on 1/25/26 at 12:56 p.m., resident #31's meal tray was delivered to his room on the Birch Hall. NF1, who was in the resident's room, said lunch meals are often served late. NF1 stated, You get used to it over time. During an observation on 1/26/26 at 12:35 p.m., NF1 came down the hall and asked staff member A where the lunch meal was. NF1 stated, Resident #31 is really wanting to lie down, and he was told he can't lie down until after lunch. He is not happy lunch is so late. During an observation on 1/26/26 at 1:07 p.m., resident #31's lunch tray was delivered to his room on Birch Hall. Resident #31 stated he was not happy with the meal, and NF1 returned it to the cart and ordered an alternative.During an observation on 1/26/26 at 1:14 p.m., staff were delivering the last lunch tray to the Birch Hall. During an interview on 1/26/26 at 4:29 p.m., staff member F stated, The lunch meal was served late. I was training a new cook. Meals are sometimes late, depending on how quickly the staff get them dished up and passed. I am down a couple of staff members who are on leave. During an interview on 1/27/26 at 2:37 p.m., staff member K stated, I can't for sure say how often meals are late, but I can say the residents sit down in the dining room for quite a while most days.During an interview on 1/27/26 at 2:38 p.m., staff member J stated meals have been served late more often lately. Staff member J said, I heard they are down two staff members in the kitchen; the meals could be late due to being short-staffed.Review of a facility document titled Meal Times, undated, showed: .Lunch: -11:30 AM: Pearl Dining Room and Pearl Room Trays,-12:20 PM: Birch and Aspen Room Trays,-12:30 PM: Big Sky Dining Room. [sic]Observations showed meals were served late which frustrated some residents. -1/25/26 at 12:56 p.m. lunch trays were being passed, 36 minutes late,-1/26/26 at 1:07 p.m. lunch trays were being passed, 47 minutes late.Review of a facility document titled Frequency of Meals with an implementation date of 4/11/25, showed: Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner, increasing the risk of foodborne illness for all residents receiving food from the dietary department. Findings include:During an observation on 1/25/26 at 12:11 p.m., the following items were observed in the walk-in coolers with no label or date:Freezer:-an open bag of French friesRefrigerator:-2 halves of a tomato, each wrapped in a cellophane wrap,-half of an onion wrapped in a cellophane wrap,-large pan of red Jello half empty.During an interview on 1/26/26 at 7:27 a.m., staff member F stated she directed her staff to check the received date and the expiration date when they open an item. Staff member F stated that staff should put a label and a date on any open items and on anything that was cut and wrapped in cellophane. Staff member F stated she continues to remind her staff to label open items. Staff member F pointed to a document (Use by Date Guide) on the outside of the refrigerator door and stated, I put those there as a reminder to my staff on the rules for dating open items.Review of a facility document titled Food Safety Requirements with an implementation date of 4/11/25, showed: Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.3. c. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers.

Based on interview and record review, the facility failed to designate an individual who worked at least part time at the facility as the dedicated Infection Preventionist. The deficient practice had the potential for an ineffective infection prevention program and placed all residents in the facility at risk of infection and exposure to pathogens. Findings include:During an interview with staff member B and staff member H on 1/28/26 at 9:11 a.m., staff member B stated in addition to her Director of Nursing Role she was also the Infection Preventionist. Staff member B stated she devoted approximately five hours per week to the Infection Preventionist role. Staff member H stated staff member B started performing the Infection Preventionist role a couple of weeks ago, and every couple of weeks staff member B received regional support with those duties. Staff member B stated it (Infection Preventionist role), had been a learning process, and once she had a routine, she felt there would be adequate time for the Infection Preventionist duties. Staff member B stated, We're pushing to get there in regard to meeting the regulation for an Infection Preventionist. Staff member H stated she was aware the infection preventionist was required to be a dedicated staff member who worked at least part-time in the facility.A review of a facility-provided document, not titled, with a date range 10/16/25 to 1/27/26, showed a breakdown of staff member B's time worked. The document did not show any time designated for Infection Prevention.A review of a facility policy titled, Infection Preventionist last reviewed 8/7/25, showed: . Policy Explanation and Compliance Guidelines:1. The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program.2. The facility will ensure the Infection Preventionist is adequately qualified and meets eligibility requirements: . e. Works at least part-time at the facility. [sic]

Based on observations, interviews, and record reviews, the facility failed to provide sufficient staff for the Memory Care Unit residents, to ensure monitoring and assistance with safety, provision of ADL care, meal assistance, and abuse prevention for 6 (#s 1, 2, 5, 8, 9, and 10); and failed to ensure staff were available to assist with resident bathing/showering, as needed, for 10 (#s 6, 7, 11, 12, 13, 14, 15, 16, 17, and 18) of 18 sampled residents. The failure to provide ADL bathing/shower assistance made some residents feel dirty, and they appeared unkempt or neglected. Findings include: During an interview on 9/23/25 at 8:50 a.m., staff member F stated there was not enough supervision on the memory care unit when resident #1 was going at it because she was a one-to-one. Staff member F stated that resident #1 was very disruptive and loud. Staff member F further stated that resident #1 was difficult to redirect; she banged on things, wandered, and targeted other residents. Staff member F stated the facility was having staffing issues. When asked about the frequency of support from the activity staff, staff member F said activities on the memory care unit just started this week.During an observation on the memory care unit, on 9/23/25 at 8:55 a.m., resident #2 was observed in blue pajamas with pink hearts. Resident #9 was observed in sweatpants and a button-up shirt that was misbuttoned over her night gown.During an interview on 9/23/25 at 11:10 a.m., staff member E stated, It is sometimes hard to complete all my tasks. I usually stay late to chart and skip doing baths just to get through the demands of the shift.A review of bathing records for 30 days for resident #s 6, 7, 11, 12, 13, 14, 15, 16, 17, and 18 showed baths or showers were not provided as scheduled or needed for the residents reviewed. Observations, interviews, and record reviews supported the lack of bathing services. Refer to F677 ADL Care, for individualized information related to the provision of ADL assistance with bathing/showers. During an observation on 9/23/25 at 5:45 p.m. to 6:10 p.m., the following was observed on the memory care unit:Resident #2 was seated at a dining table observed in the same set of blue pajamas with pink hearts as earlier in the day. Resident #2 got up from her seat, left her walker at the dining table and walked unassisted down the hall. Resident #5 followed resident #2 with her walker. There was no staff member in the area to assist.Resident #1 was seated in a recliner in the common area and was yelling, help! and she stated she was scared. Resident #8 then asked resident #1 to be quiet and told her to shut up. Staff member F had stated that prior resident #1 was a one-to-one supervision, but there was no staff member in the area to intervene.During an interview on 9/23/25 at 6:25 p.m., staff member F stated, I don't think there is enough staff in the memory care unit. Staff member F stated there were residents with lots of behaviors, and only one nurse and one aide. There was never time to do the baths, and staff member F stated, I would say bathing is the number one task that gets missed when short-staffed. We just don't have time to do them.During an interview on 9/24/25 at 9:32 a.m., staff member K stated, I do think there is an issue with being understaffed. I know it affects bathing. The staff don't have enough time to do baths, along with the rest of their tasks. The facility used to employ a bath aide, and that helped a lot.During an interview on 9/24/25 at 9:41 a.m., staff member H stated it was difficult to get to the Memory Care Unit since she took over the department in June. Staff member H stated she has not been able to do it (work on the memory care unit) at all. Staff member H stated that transport comes first before activities. Staff member H stated she had asked time and again to get help, and it hasn't happened. Staff member H stated she does not feel like there is enough staff on the Memory Care Unit to ensure the protection of the residents.During an observation on 9/24/25 at 11:38 a.m., resident #9 was observed wearing sweatpants and a button-up shirt that was misbuttoned over her nightgown, which was the same clothing she wore the day prior. Resident #2 was observed in blue pajamas with pink hearts, the same clothing she wore the day before. During an interview on 9/24/25 at 11:54 a.m., staff member H stated she was the only certified staff member on the memory care unit, providing ADL care, and it was rare that another person (certified) was scheduled to work the unit also. During an observation on 9/24/25 at 12:06 p.m., resident #10 was eating her lunch with her fingers and was not assisted by staff. Resident #10 poured her water onto her lunch plate. Staff present in the dining room did not intervene or assist resident #10 with her meal.During an interview on 9/24/25 at 12:22 p.m., staff member C said she thought the facility was going in the right direction for staffing (improving), and they have identified staffing as an issue.During an interview on 9/24/25 at 12:35 p.m., staff member A stated they have identified staffing as an issue as it pertains to bathing and are working to hire more employees. Staff member A didn't think there were systemic issues that had been identified due to a lack of staffing.Review of a facility document titled QAPI PIP - Action Plan with an initiated date of 8/18/25 showed: .Root Cause Identified: In review with staff, the following was identified: staffing issues.Review of the facility's Daily Staffing Sheets, compared to the facility assessment for the identified staffing needs, showed of the 14 days, 7 days were staffed lower than the facility assessment identified necessary. Dates with low staffing included: 911/25, 9/12/25, 9/15/25, 9/16/25, 9/17/25, 9/19/25, 9/22/25.

Based on interview and record reviews, a staff member displayed verbally abusive behavior to residents residing in the secure unit. The facility identified the verbal abuse, reported it, investigated the event, and implemented corrections. This event was identified to be past non-compliance. Findings include:Review of a facility reported incident, submitted to the State Survey Agency, dated 8/29/25, showed, an unidentified staff member reported to staff member I, they overheard staff member J yelling at residents on the memory care unit. All residents residing in the memory care unit were identified to be vulnerable. During an interview on 9/25/25 at 10:49 a.m., staff member I stated that she is the one who completes abuse investigations. Staff member I said she was told about the incident with staff member J yelling at the residents, and she immediately reported it to the administrator, and an investigation was started. Review of the findings and documentation included in the investigation for staff member J yelling, which was submitted to the State Survey Agency on 9/8/25, and the information showed: - At approximately 2:26 p.m., a facility CNA reported, via text message to staff member I, that an employee (J) allegedly yelled at residents in the Memory Care Unit during the night shift. The allegation involved potential verbal abuse directed toward vulnerable residents. The initial report did not identify specific residents or the exact language used by staff member J. - The allegation was immediately reported to the administration. - All residents on the Memory Care Unit were assessed for signs of distress or changes in behavior. No acute distress was noted.- Observations of the residents residing in the Memory Care Unit were conducted to ensure their safety and well-being.- Staff member J was suspended following initial staff interviews to ensure resident protection.- A thorough investigation was conducted, which included staff interviews and observations. Interviews confirmed that staff member J had demonstrated negative verbal interactions with residents on prior occasions. The facility substantiated the allegation of verbal abuse. A review of the facility's investigation documents showed staff member J was suspended immediately while the abuse investigation was conducted, and residents were assessed for negative outcomes. The results of the investigation showed staff member J was subsequently released from the position at the facility. All staff were educated on resident rights, the facility's policy on zero tolerance for abuse and neglect, and mandatory requirements for reporting abuse and neglect. Ongoing monitoring of the Memory Care Unit was conducted through leadership rounds to identify concerns related to abuse or neglect. Additional in-service training sessions on abuse prevention and communication standards were completed with staff. The results of the investigation were reviewed in QAPI to ensure corrective measures were taken and corrections were sustained. Review of a facility document titled Abuse, Neglect and Exploitation, with an implementation date of 4/11/25, showed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;b. Establish policies and procedures to investigate any such allegations; andc. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; andd. Establish coordination with the QAPI program. [sic]It was determined that the deficient practices related to the events in the secure unit with the vulnerable residents were corrected, therefore, the failure was cited as past noncompliance. The facility corrected the deficient practice(s) on 9/19/25.

Based on observation, interview, and record review, the facility failed to provide regular showers for 10 (#s 6, 7, 11, 12, 13, 14, 15, 16, 17, and 18) of 18 sampled residents, and some of the residents felt dirty and or were upset by the failure. Findings include:1. During an observation and interview on 9/23/25 at 9:35 a.m., resident #12 was in her room; her hair appeared oily, and she looked unkempt. Resident #12 stated, A staff member refused to help me with my baths. I missed a few baths, and it made me feel dirty and stinky. I wish I could take a bath every day.Review of resident #12's last 30 days of the shower log showed the resident had a bath/shower given on 9/9/25, and then again on 9/17/25, with seven days between the bath/shower. The next bath/shower was performed on 9/22/25, four days later. Review of resident #12's care plan, with a revision date of 6/1/25, showed: Focus: Self care deficit: Requires assist with ADL's due to: decreased mobility secondary to disease process, required assistance with ADLs as noted on nursing admission evaluation.Interventions: .Bathing/Shower assistance requires supervision/cueing only. [sic]2. During an observation on 9/23/25 at 8:52 a.m., resident #14 was sitting in a wheelchair in her room. Her hair looked matted and messy. She looked unkempt.Review of resident #14's 30-day lookback shower log showed two baths were given in the 30-day lookback period of 8/25/25 to 9/22/25. There were only two baths/showers given, which were on 8/31/25 and 9/8/25. There were 14 days after the last bath/shower. Review of resident #14's care plan, with a revision date of 6/1/25, showed: Focus: Self care deficit: Requires assist with ADL's d/t memory deficits related to her diagnosis of Parkinson's.Interventions: [resident's name] requires extensive assist with showering. If she declines a shower offer a bed bath. Notify nurse if resident declines bed bath as well. [sic]3. Review of a questionnaire filled out by resident #17, on 8/31/25, showed a response to the question, Do you feel safe living here at the facility? The following was marked, No - I have felt neglected and ignored. I had two showers in a month.Review of resident #17's shower logs showed two baths were completed in the 30-day lookback period, which were on 8/26/25 and on 9/2/25.Review of resident #17's care plan, with a revision date of 9/6/25, showed: Focus: [resident name] has self care deficit: requires assist with ADL's due to left knee instability, weakness, dyspnea.Interventions: Bathing/Shower assistance requires physical help in part of bathing activity. [sic]4. During an observation on 9/23/25 at 8:54 a.m., resident #11 was sleeping in her wheelchair, bent forward. Her hair was matted and uncombed.During an observation and interview on 9/23/25 at 11:22 a.m., resident #11 was sitting in a wheelchair in her room; her hair was matted and messy. Resident #11 was having difficulty answering questions, but did say no when asked if she was receiving baths regularly.Review of resident #11's shower logs showed only two baths were conducted in a 30-day lookback period. Baths were done on 9/3/25 and 9/19/25. There were 16 days in between the two baths. Review of resident #11's care plan with a revision date of 9/28/22 showed: .Focus: ADLs: [Resident Name] requires fluctuating assistance with ADLs due to decreased mobility, weakness, unsteady gait/balance, and history of falls.Interventions: Bathing: [resident name] needs extensive staff assist with bathing. Allow [resident name] to assist in the bathing process as much as she is able. If she declines to bathe please re approach her at a later time. [sic]5. Review of a facility reported incident, dated 9/3/25, showed that resident #18's family had contacted the facility and expressed a concern about her mother's hair being matted and uncombed. She further expressed concern with the number of baths her mother was receiving.Review of resident #18's shower logs showed two baths were provided in a 30-day lookback period. Baths were done on 8/31/25 and 9/10/25. Review of resident #18's care plan with a revision date of 6/1/25 showed: .Focus: ADLs/Communication: [Resident name] needs assistance with her ADL's related to history of left sided ischemic stroke with right side hemiparesis. She has expressive and receptive aphasia, and history of convulsions. She is not able to use her right arm.Interventions: [resident name] needs extensive assistance of one person for bathing. She chooses to shower once a week. She prefers showers when she bathes. [sic]6. During an observation and interview on 9/23/25 at 9:47 a.m., resident #16 was in his room, sitting in his recliner. His hair appeared oily, his whiskers were long, and he had drool and dried food on his shirt. When asked if he received regular showers, he stated, I had one last week, but not yet this week.Review of resident #16's shower logs showed five baths were provided in a 30-day look back, which were on 8/25/25, 8/31/25, 9/10/25, 9/14/25, and 9/17/25. There was a period of nine days between the 8/31/25 and 9/10/25 bathing sessions. Review of resident #16's care plan with a revision date of 6/1/25 showed: .Focus: ADLs/Communication: [resident name] requires assistance with ADLs due to decreased mobility and weakness related to a diagnosis of Parkinson's disease.Interventions: Bathing: [resident name] needs extensive staff assist with bathing. If he declines a shower, offer to assist with a bed bath or clean up at the sink. [sic]7. During an observation and interview on 9/23/25 at 9:15 a.m., resident #7 was sitting in her recliner. Her hair looked uncombed and oily. Resident #7 stated, I haven't gotten a shower in a while. It might be my fault because I get cold easily.Review of resident #7's shower logs showed two baths were completed in a 30-day lookback, which started on 8/26/25. There was no bath provided to the resident until 9/16/25 which a 15-day period without a bath. Review of resident #7's care plan with a revision date of 8/11/25 showed: .Focus: ADL: resident has a risk for decline in ADL function related to decreased mobility secondary to recent fall with fracture.Interventions: BATHING/SHOWERING: The resident requires moderate by (1) staff with showering 2x wk and as necessary. [sic]8. During an observation and interview on 9/23/25 at 9:44 a.m., resident #13 was lying in her bed in her nightgown. Her hair looked uncombed. Resident #13 stated, I haven't received a bath since I returned from the hospital.Review of resident #13's shower logs showed no baths were completed in the last 30 days, with a look-back period beginning on 8/25/25 and ending on 9/22/25.Review of resident #13's care plan with a revision date of 6/1/25 showed: .Focus: Self care deficit: [resident name] requires assist with ADL's due to wedge compression fracture, assistance with late loss ADLs noted on initial nursing evaluation.Interventions: Bathing/Shower assistance requires extensive assistance of 2 people with the sit-to-stand (mechanical lift). [sic]9. During an interview on 9/23/25 at 9:47 a.m., resident #6 stated he had concern about the lack of showers he received when he was admitted to the facility. Resident #6 stated he did not receive a shower for two weeks. Review of resident #6's bathing logs showed there were four baths provided in a 30-day lookback period, which were on: 8/26/25, 8/31/25, 9/17/25 (16 days between the two baths), and 9/19/25. Review of resident #6s care plan with a revision date of 7/17/25 showed: .Focus: Potential for altered skin integrity related to: .Interventions: Staff will help promote clean skin by encouraging/assisting resident to bathe regularly. [sic]10. Review of resident #15's shower logs showed facility staff provided three baths during the 30-day lookback period, which included: 8/31/25, 9/8/25 (7 days between the two baths), and 9/15/25. Review of resident #15s care plan with a revision date of 7/16/25 showed: .Focus: [resident name] is at risk for ADL Performance/Self-care deficit r/t chronic and acute pain in the setting of DM2 respiratory failure, fluid overload with localized edema, chronic pulmonary embolism.Interventions: BATHING/SHOWERING: [resident name] requires Partial to moderate assistance by 1 staff with bathing/showering. [sic]Review of the facilities QAPI PIP - Action Plan for the showering and bathing concerns, with an initiation date of 8/18/25, showed: QAPI PIP: Completion of Shower/Bath. Identified Concern: It was identified that residents are not being offered baths/showers on routine intervals to maintain adequate hygiene. Root Cause Identified: In review with staff the following was identified: staffing issues, lack of understanding of following schedule, documentation expectations. [sic]The facility identified the issue with bathing, but did not follow through with corrective actions, as shown in the review of resident bathing logs and care plans.Review of a facility document titled Activities of Daily Living (ADLs) with an implementation date of 4/11/25 showed: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care.

Based on interview and record review, the facility failed to complete a thorough investigation on a staff to resident verbal abuse and neglect allegation, by failing to complete resident monitoring, failed to carry out interventions identified and documented on the report, and failed to complete other resident interviews to rule out other concerns of abuse by the staff member, for 2 (#s 17 and 18) of 18 sampled residents. Findings include:Review of all facility reported incidents and facility investigations since August 27, 2025, showed there was insufficient documentation to show the facility completed thorough investigations on events reported to the State Survey Agency. The concerns included: -Incident #2609523 - There was no summary provided on the incident; there were no other residents and or staff interviews, and no corrective actions or interventions taken by the facility.-Incident #2609623 - The documents failed to include evidence on how the facility provided education to staff, and there were no bathing logs or audits conducted by the facility for monitoring and sustaining any corrections attempted. -Incident #2609701 - The documentation failed to show that the facility interviewed other residents and staff to identify others who may have been affected by the deficient practice.During an interview on 9/23/25 at 6:30 p.m., staff member C stated she had not reviewed the incident investigation folders yet and would look through them. During an interview on 9/24/25 at 7:20 a.m., staff member C stated she reviewed the incident and investigation folders, and staff member C identified that the investigations were not complete. Staff member C stated the facility was still working on them, as the events were part of the plan of correction from a prior complaint survey. Review of a facility document titled Abuse, Neglect and Exploitation with an implementation date of 4/11/25 showed: Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VII. Reporting/Response A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence.b. Defining how care provision will be changed.c. Training of staff on changes made and demonstration of staff competency.d. Identification of staff responsible for implementation of corrective actions.e. The expected date for implementation.f. Identification of staff responsible for monitoring the implementation of the plan. [sic]

Based on observation, interview, and record review, the facility failed to follow the required discharge process to include obtaining physician orders to discharge the resident from the facility; failed to obtain physician orders to setup up home health post discharge as care planned; and failed to document discharge planning communication, and the day of discharge process, including when, where to, what the discharge orders for care were for 1 (#1) of 6 sampled residents. This failure led to the resident not having proper support in place at the discharge location, and subsequently, the resident returned to the hospital for continued care. Findings include: During an interview on 8/26/25 at 11:20 a.m., NF1 stated, she was just made aware of a resident being in the hospital that had discharged from the facility in the beginning of August. NF1 stated the facility never notified her of the discharge and in talking with representatives of [resident #1], he had ended up having to go to the ER and then transferred hospitals for surgery for an infection. NF1 stated she was told he now had been placed on hospice at the hospital. NF1 stated there were other issues mentioned by the representatives. During an interview on 8/26/25 at 4:48 p.m., NF2 stated she was working with the family of resident #1 for support in the community for housing. NF2 stated the only notice they were given for resident #1 discharging was when the notice of non-coverage from his insurance was issued on 8/6/25. NF2 stated the facility did not communicate with her or the family on the discharge at all during his stay at the facility or his condition level and they were not able to ensure the home was safely set up for his return. NF2 stated it took three people to get resident #1 into the home the day of discharge because he could not ambulate. NF2 stated they were under the impression resident #1 was to have home health ordered to continue care and therapy when he was discharged ; however, it was not set up by the facility. NF2 stated resident #1 was not able to be safe at home and subsequently had ER visits with an admission to a local hospital. NF2 stated the hospital placed resident #1 in the intensive care unit after surgery for an infection. NF2 stated the family of resident #1 elected to place him on hospice. During an interview on 8/27/25 at 12:23 p.m., staff member C stated she was the nurse working when resident #1 discharged from the facility. Staff member C stated she did not document a progress note or discharge note in resident #1's medical record. The only documentation was the discharge form the resident signed when leaving, acknowledging the nurse reviewed medications and treatments, and any follow-up care after discharge. Staff member C stated she was unaware of any discharge planning communication or meeting with resident #1, and his family before discharge. Staff member C stated she just discharged him because it was on her assignment for the shift. Staff member C stated resident #1 went home in the mid-morning with a family friend on 8/8/25, and it took two facility CNAs assisting the resident's friend to transfer resident #1 into the vehicle. Staff member C stated she did not believe the facility had social services or a DON at the time who would have done the discharge summary documentation.During an interview and observation on 8/27/25 at 2:18 p.m., staff member D stated she would not normally document in her notes the family was visiting or discussions about insurance not covering the resident's stay if the resident did not participate in therapy. Staff member D showed her records of missed therapy visits and pulled up multiple missed ones for resident #1 being unavailable or his refusals due to visitors being present, him not wanting to get up, or pain (which was being managed and adjusted). Staff member D stated resident #1 was not participating in therapy and had declined prior to the discharge from the facility from his prior functioning level on admission. Staff member D stated resident #1's family support was limited as the spouse had her own health concerns. Staff member D stated she did not know of any documentation, communication, or care planning with resident #1 prior to his discharge.During an interview on 8/27/25 at 3:45 p.m., NF5 stated resident #1 was a very sick person and had multiple rehospitalizations prior to his stay at the facility. NF5 stated resident #1 had home health support services to help with wound care and comorbidity management before he stayed at the facility and would expect the facility to order this again on the resident's discharge. NF5 stated he could not find a discharge order for resident #1, but the practice was to get the physician's order near the day of, or on the day of, discharge, and this would include any other orders for home health. NF5 stated there was a chance another provider wrote the physician order, but he could not find it at the time. NF5 stated resident #1 would have preferred being home and was not the best at managing his health conditions. NF5 stated he was recently notified resident #1 was admitted to a local hospital and had written a physician's order to place resident #1 on hospice due to his decline and osteomyelitis.During an interview on 8/26/25 at 4:32 p.m., staff member A stated the facility did not have any discharge orders or other discharge documentation other than the NOMNC notice.During an interview on 8/27/25 at 4:48 p.m., staff member B provided a progress note and then stated the physician was notified on 8/27/25 of resident #1's discharge.Review of the facility admissions and discharge report from June 2025 to August 2025 listed resident #1 admitted on [DATE] from a local hospital and discharged home with home health services on 8/8/25.Review of resident #1's MDS dated [DATE], showed he had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment.Review of resident #1's EHR did not include a form signed by the resident with the nurse who reviewed discharge instructions. Only a NOMNC notice was given on 8/6/25, to the discharge on [DATE], which resident #1 signed.Review of resident #1's progress notes, from 7/15/25 to 8/28/25, did not show any discharge planning prior to or on the day of discharge. The only progress note linked from the MAR showed discharged as the reason ordered medications were not given after the discharge. A request was made on 8/27/25 for all discharge communication and documentation from resident #1's stay from 7/15/25 to 8/8/25. No other information was provided by the end of the survey.Review of the facility policy, Transfer and Discharge (including AMA), dated 4/11/25, showed: 12. Anticipated Discharge to the Communitya. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care.b. A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but is not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post discharge medications. iv. A post discharge plan of care that is developed with the participation of the resident, and the resident representative(s).c. Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility.may be provided by multiple members of the interdisciplinary team.f. Supporting documentation shall include evidence of.a discharge plan, and documented discussions with the resident and/or resident representative.

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for nutritional deficits was monitored to prevent the resident from having severe weight loss, for 1 (#30) of 19 sampled residents. Findings include: During an interview on 12/4/24 at 4:15 p.m., staff member E stated the CNAs would check the EHR to see what residents needed to be weighed that day. Staff member E stated the residents had different frequencies to be weighed. Some were monthly, weekly, or daily. Staff member E stated the nurse would check the weight entered by the CNA and let them know if they needed a reweight for a drastic change. During an observation and interview, on 12/4/24 at 4:18 p.m., resident #30 was in his wheelchair. He was thin and was missing front teeth on the top and bottom of his mouth. Resident #30 stated he had lost a lot of weight while at the facility, and his weight went down to 160 pounds, and he was currently under what he weighed in high school at 172 pounds. Resident #30 stated he also took a medication that caused him to urinate a lot and was just now getting daily weights completed in the last two weeks to see if he needed to remain on the medication. Resident #30 stated he was now eating more meals as he was getting the requested fresh fruit and vegetables for lunch. During an interview on 12/5/24 at 10:21 a.m., staff member D stated she reviewed resident #30 on admission, and he was at risk for weight loss due to a recent large weight loss, inadequate intakes of food, and current comorbidities including wounds. Staff member D stated she had added supplements for him to try and was likely the one asking for more frequent weights in the beginning. The weight frequency could have been ordered by the doctor through nursing and should be taken by facility policy. Staff member D stated she would run the weight report weekly and address any resident noted with a change. Staff member D stated she checked in on resident #30 in November to see how the food changes he requested were working out and update his nutrition assessment. She realized he had not had a recent weight. Staff member D requested to get accurate weights on resident #30 and the regular weights had continued now. Staff member D stated resident #30 did lose a lot of weight but never looked underweight and his wounds had not worsened during that time. Review of resident #30's weights showed on 9/9/24 he weighed 190.0 pounds, slowly lost weight to 185.0 on 9/23/24. No weights were done for resident #30 from 9/24/24 to 11/5/24. The weight on 11/6/24 was 159.5 pounds, a 25.5 pound severe weight loss from his last September weight. Review of the facility policy, Weight Monitoring, last reviewed 10/14/24, showed: Based on the comprehensive assessment, the facility will ensure the resident maintains acceptable parameters of nutritional status, such as body weight . resident weights should be taken: a. Newly admitted residents - weekly for 4 weeks b. Residents with weight loss - weekly c. If clinically indicated - daily d. All others - monthly

Based on observation, interview, and record review, the facility failed to prevent the development, recurrence, and worsening of two pressures ulcers on the foot and coccyx for 1 (#7) of 18 sampled residents. Findings include: During an observation on 7/10/18 at 10:35 a.m., resident #7 had a very small pinpoint hole on her sacrum. Staff member A stated the pressure ulcer looked much better. During an observation on 7/11/18 at 10:50 a.m., resident #7 had a quarter size pressure wound on her left medial foot. The wound was red and contained slough. Staff member H stated the tendon was no longer visible. Review of resident #7's Skin Note, dated 6/20/18, showed, There is tendon visible today and no eschar on the wound. Patient is currently wearing a Prevalon boot. Patient is contracted most of the time while in bed, which is allowing pressure to be constantly applied. It was staged as a Stage III pressure wound. During an interview on 7/11/18 at 2:30 p.m., staff member H stated the resident's boots probably were homemade, and did not provide adequate pressure relief. They were made of cloth and contained no pressure relieving material. He also stated the resident was to receive comfort care, and no aggressive wound treatments. Review of resident #7's Treatment Administration Record from 4/22/18 forward, showed Heel protectors on when in bed. Make sure she is turned off of right side frequently, every shift for [MEDICAL CONDITION]/Blister to right outer lateral foot. The Treatment Administration Record did not address pressure relief for the left foot, or a treatment. During an interview and observation on 7/12/18 at 12:50 p.m., staff member C stated the resident was on an air overlay mattress. The observation showed resident #7 was on a regular mattress. Staff member C stated she would order air boots for resident #7, as the cloth boots probably were not adequate for pressure relief. She did not know why the air mattress was not on the bed. Review of resident #7's Wound Care Flow Sheet, dated 9/21/17 and 9/28/17, showed the resident had a pressure area on the same area on her left foot. The area was not staged. No other documentation was provided for the pressure area during (MONTH) (YEAR). Review of resident #7's Progress Note, dated 12/14/17, showed the Pressure ulcer to left foot bunion area has resolved. Review of resident #7's MAR for (MONTH) (YEAR) showed Heel protectors on when in bed. Make sure she is turned off of right side frequently for right outer foot blister. No treatment was prescribed. The pressure ulcer was not on her heel. Review of resident #7's undated Care Plan, showed I am at risk for skin breakdown. I have an area on my coccyx that comes and goes. Left foot bunion with pressure area that comes and goes. The goal was to have no breakdown. Interventions included: · Gel cushion in the wheelchair. · Skin check with care and report any breakdown. · Place splint in my hands to prevent further contractures. · About every 2 hour turning and repositioning. I need to be turned and repositioned about every 2 hours and as needed, with one to two staff members. Please be sure my soft booties are on when I rest in bed. During observations on 7/10/18 and 7/11/18 at 10:20 a.m., resident #7 was unable to participate in bed positioning. During an interview on 7/11/18 at 10:41 a.m., staff member H stated he thought the foot ulcer had worsened to a Stage IV, because the dressing was changed too often, and would remove the good healing skin from the wound.

Based on observation, interview, and record review, the facility failed to ensure prescribed medications were available for 1 (#24) of 18 sampled residents, which caused significant mouth pain¹, and reduced the ability for the resident to enjoy the foods normally eaten by the resident. Findings include: During an interview on 7/10/18 at 11:20 a.m., resident #24 stated the facility had run out of medication used to treat his oral thrush, and he had been experiencing a lot of mouth pain. Resident #24 stated he was not able to eat anything hotter than black pepper, and that he normally ate and enjoyed habanero sauce and kimchee. Review of resident #24's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Staff were to continue the use of [MEDICATION NAME] until 24 hours past resolved symptoms. - On 7/6/18, three doses were not available to the resident. - On 7/9/18, four doses were not available to the resident. - On 7/10/18, one dose was not available to the resident, and staff discontinued the use of [MEDICATION NAME] on 7/10/18 at 11:02 a.m. During an observation and interview on 7/12/18 at 8:40 a.m., resident #24 stated he would have really liked to continue with the use of [MEDICATION NAME] suspension because of mouth pain. Resident #24 stated he was unhappy that he was not able to eat and enjoy spicy foods because of continued mouth pain related to thrush. The resident opened his mouth, and the oral mucosa was red. No visible white plaque was seen, but the resident complained of significant pain.¹ He stated he had spicy sauces, including kimchee, in his room, and would really like to enjoy his food. The resident stated eating anything hotter than black pepper would cause him significant amounts of pain. During an interview on 7/12/18 at 9:00 a.m., staff member C stated she had spoken with staff member B regarding medications not being available for resident #24. Staff member C stated staff member B had done an assessment on resident #24, and staff member B did not see active thrush plaque, therefore [MEDICATION NAME] suspension had not been reordered, and discontinued on 7/9/18. Review of a Pharmacy Packing Slip, dated 7/3/18, showed the facility received 240 milliliters of [MEDICATION NAME] suspension for resident #24. A review of a Pharmacy order, dated 7/5/18, showed staff had ordered more [MEDICATION NAME] suspension for resident #24. A Pharmacy Packing Slip, showing receipt of the medication was requested, but not provided prior to the end of the survey. A review of a facsimile for resident #24, submitted to the resident's physician, dated 7/9/18, read, oral thrush has resolved, discontinued the swish and swallow per orders. A review of resident #24's dietitian notes, dated 7/9/18 at 5:47 p.m., read, Resident's intake has been reduced impacted by recent oral thrush 'even salt and pepper burned and I usually like spicy foods.' Review of nurse's notes, dated 7/12/18 at 9:20 a.m., read, Called and spoke with (name, physician assistant (PA)) about res (sic) mouth pain and need for swish and swallow. Notified (him) that there were no white patches to tongue or cheeks as previously noted but mouth showed some redness and res (sic) says that spicy foods make his mouth burn. PA gave orders to restart [MEDICATION NAME] swish and swallow 30 cc po QID x 10 days, then re-evaluate. Orders posted, pharmacy notified. Res aware. During an interview on 7/12/18 at 9:40 a.m., staff member B stated, When the [MEDICATION NAME] was out, she informed staff member G, so a resident assessment, or the medication could be reordered. Staff members B and G stated each one thought the other had informed, reordered, documented the medication and informed the primary care physician of the need for more [MEDICATION NAME]. References: ¹https://www.medicalnewstoday.com/articles/ 4.php Occasionally, the affected area simply becomes red and sore, with no detectable white spots.

Based on record review, interview and observation, the facility failed to prevent serious injury from falls, identify and evaluate fall hazards, implement interventions in the care plan, monitor interventions for efficacy, and accurately assess the resident's environment to determine whether supervision to avoid an accident was needed for 9 (#s 1, 3, 4, 5, 6, 8, 9, 10, and 11) of 14 sampled residents. Specifically, resident #5 had an unwitnessed fall that resulted in a pelvic fracture. The resident did not receive medical treatment for 2 calendar days. Resident #5 also had increased pain and decline in her ambulation as a result of her fall. Resident #4 had a fall resulting in a 1 laceration on the right forehead. The laceration required emergent medical attention. Resident #9's falls resulted in hematomas to the head, elbow and knee. She had skin abrasions on both her elbow and her knee. Resident #1 acquired a hip fracture and is no longer mobile following her fall. Resident #11 went to the ER with a non-reactive pupil and a head injury following her fall. Findings include: IMMEDIATE JEOPARDY The facility failed to respond to repeated falls for 9 identified residents who had falls with and without injury. The facility failed to implement interventions for fall prevention and resident safety; failed to update the residents' plan of care for identified measurable interventions; and failed to monitor the implemented interventions for efficacy and modify the interventions when needed. On 2/25/16 at 1:35 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 9 of the 14 sampled residents. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an abatement plan for the immediate jeopardy on 2/26/16. The deficient practice remained at the scope and severity of H once the immediate jeopardy was abated. A summary of the facility's abatement plan to remove the immediate jeopardy is as follows: All identified residents will be checked every 30 minutes to observe for potential safety concerns and will be documented on the Falls Q 30 Minute Checklist. All identified residents were assessed using the facility's falls assessment. Results of the resident's assessments were used to create specific, individualized interventions that were added to the resident's care plan. All nursing, contract, and activities staff were in-serviced, prior to the start of their next shift, on each resident's fall history and the specific care plan interventions. All staff on leave will be in-serviced prior to the start of their next shift by 3/1/16. The facility's Falls Policy was revised to ensure thorough documentation and care planning changes will be implemented for each resident. A Care Plan Changes Report Sheet was created to ensure communication on falls and care plan changes would be reviewed. A Post Falls Follow-Up Policy was created to ensure documentation was reviewed and to trend related falls to look at in their quality assurance process. 1. Resident #5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], section C0500, showed the resident had a BIMS score of 8, indicating that she was moderately impaired. Review of the MDS dated [DATE], reflected resident #5 did not have a history of falls with injury. The MDS showed in section J1700A, the resident had one fall in the past month. In section 1700B, the resident had one fall in the past 2-6 months, and in section 1700C, the resident had 0 falls with fracture in the past 6 months. Review of the facility's Fall Assessment showed the resident scored a 24.0 showing she was a high risk for falls. The facility failed to provide a copy of the fall assessment. The information was requested on 2/25/16 at 11:40 a.m. but was not provided prior to exiting the facility on 2/26/16 at 5:30 p.m. Review of the Physician Fax Sheet dated 10/7/15, showed resident #5 had an unwitnessed fall on 10/7/15. The record showed she was trying to take herself to the bathroom, went to sit on the toilet, missed and sat on the floor. Information on the fax sheet reflected, No injury noted, will observe x 5 day. The facility failed to provide a copy of the facility's Neurological Assessment for the fall on 10/7/15. Review of SNF Progress Notes, dated 10/7/15, showed the facility failed to address the fall on 10/7/15. The facility failed to record vital signs in the note dated 10/7/15. Review of the Unusual Occurrence Report-Falls worksheet dated 10/7/15, showed the resident had a fall in the bathroom while trying to sit on the toilet. The Immediate Falls Investigation section of the worksheet reflected the resident had inappropriate footwear, was trying to transfer independently, and walked without assistance. The worksheet showed that the resident did not use her call light. The Actions To Prevent Recurrence section of the worksheet showed the actions to be implemented were for the resident to use the call light and use non-slip footwear. Review of resident #5's SNF Progress Notes, dated 10/8/15, showed that non-staff member AA sent a fax to the facility regarding fall of 10/7/15 without injury. The note also showed, No new orders or changes in the plan of care. The facility failed to record vital signs in the note dated 10/8/15. Review of resident #5's SNF Progress Notes, dated 10/9/15 at 4:43 a.m., showed that the resident was requesting to go to the bathroom but that it took two CNAs to transfer her and she still tried to sit on the floor because she was too weak to stand. She had to use a wheel chair to be mobile, no complaints of pain or discomfort. Another note entered on 10/9/15 at 1:02 p.m., showed the resident was unable to ambulate. Resident required a wheel chair with one person to push her. Resident #5 was able to perform most ADLs with minimal assistance but she needed assistance with toileting. The facility failed to record any vital signs in the notes on 10/9/15. Review of Progress Note dated 10/9/15 at 4:29 p.m., written by staff member I, showed that the resident was complaining of left leg/hip pain with attempt to walk or bear weight. The note showed the resident's left foot appeared to be rotated slightly outward and the resident was unable to lift her leg without the presence of pain. Staff member I recorded the facility attempted to notify the doctor but because the doctor was out of the office, the facility decided to send the resident to the emergency room for an evaluation and treatment. The noted ended by showing there were no complaints of pain or injury at that time. The facility failed to record the vital signs in the progress note at 4:29 p.m. Review of the Physician Fax Sheet dated 10/10/15, showed the facility notified non-staff member AA of the emergency room visit. The fax stated the resident was taken into the emergency room for complaints of left hip pain. The fax explained the details of the hip/pelvic fracture and the medications prescribed by the emergency room staff. Review of resident #5's SNF Progress Notes, dated 10/10/15 at 9:55 a.m., showed a note reflecting the facility took the resident to the emergency roiagnom on [DATE] for complaint of left hip pain. The note showed the resident had a left superior pubis ramous fracture extending to the anterior wall of the left acetabulum, comminuted, minimally displaced. Mild displaced fracture of the mid portion left inferior pubic ramus. Findings suspicious for an acute-subacute L5 compression fracture. Norco 5/325 mg one tab every 4 hours PRN pain. A nursing note on 10/10/15 at 9:31 p.m., showed resident #5 refused to stand and walk, was in a lot of pain so was given a PRN for the pain. There were no vital signs noted in the notes on 10/10/15. Review of resident #5's SNF Progress Notes, dated 10/12/15, showed that the facility had received a fax from Physician AA, stating that he noted the information from the emergency room visit. The SNF Note showed that there were no new orders or change in the plan of care. Review of resident #5's SNF Progress Notes, dated 10/17/15, showed the resident was given medication for pain and that she was refusing to stand. Review of resident #5's SNF Progress Notes, dated 10/22/15, showed the resident was too weak to complete her ADLs and she was requiring extensive assistance with all her ADLs. The note also showed resident #5 was refusing to participate with therapy, grabbing onto staff and the side of the furniture. She required two staff assist with gait belt. Review of resident #5's SNF Progress Notes, dated 10/23/15, showed the resident was refusing to bear weight on the right leg and complained of hip and side pain on the right side. She was given Norco 5/325 mg, 1 tablet oral every 4 hours for pain. Her note, dated 10/24/15, reflected the resident continued to refuse to bear weight on her right leg and complained of hip and side pain on her right side. She was given pain medication. Review of resident #5's SNF Progress Notes, dated 11/4/15, showed that the facility contacted the resident's power of attorney and discussed the need for the resident to have non-skid foot wear for her physical therapy and transfers. Review of resident #5's SNF Progress Notes, dated 11/5/15, showed she complained of right hip pain that required pain medication. The nursing notes, dated 11/6/15, showed the resident was hollering out for help and refused to stand on the floor for fear of falling. She complained of her coccyx area being in pain. She was given pain medication. The resident continued to complain of hip area pain on the following dates: 11/14/15 (2:45 a.m. and 9:43 p.m.), 11/15/15, 11/19/15, 11/20/15, and 11/26/15. Review of resident #5's SNF Progress Notes, dated 11/8/15, showed the resident was a toe-touch transfer and had to be toileted by the restorative aide. The note on 11/9/15 showed that the resident was a toe-touch to transfer and not able to assist with ambulation. The note reflected the resident had a fear of falling. Nursing notes dated 11/29/15, showed that the resident continued to be toe-touch weight bearing. Review of resident #5's SNF Progress Notes, dated 12/13/15, showed the resident continued to be an assist for transfers and was in a wheel chair to be weighed. The note reflected the resident walked with therapy. The note dated 12/15/15, showed that she continued to be unsteady in standing or attempts to pivot. Review of resident #5's Initial Care Plan, dated 10/02/15, showed the facility implemented a goal that stated, I will not have any falls that will require Hospital/ED or Doctor Intervention during my stay. The focus of the goal was safety and showed, I am weak and unable to stand or transfer without assistance. I am often forgetful, have poor safety awareness and will try to self-transfer. The interventions for the goal included an FYI statement that read, I may use my call light continuously, thinking it is my remote or phone. Please re-educate me as needed and place my remote within reach. This was initiated 10/20/15. Other interventions included on the Care Plan: 1. Ability to transfer with assistance and ensure resident had non-skid footwear. 2. Resident may wander and look for an exit to return home so staff need to check on resident frequently. 3. Resident needs to be reminded to use her call light for assistance. Please offer to toilet her every two hours, and resident needs assistance with all toileting. This intervention was implemented on 10/2/15. 4. Please check on resident frequently to ensure all needs are met and to ensure call light is within reach. The facility failed to provide documentation of how the interventions were being implemented and/or monitored. During an interview on 02/22/16 at 2:20 p.m., resident #5 stated the facility struggled to answer the call lights promptly. She stated it feels sometimes like she has to urinate x 4 prior to the staff attending to her needs or answering her call light. During an interview on 2/25/16 at 2:45 p.m., staff member B stated the interventions implemented for residents would be located on the back of the Unusual Occurrence Report-Falls worksheet. Staff member B also stated that after a fall, she was not aware of any change in the care plan if the plan to prevent section of the Unusual Occurrence Report-Falls worksheet was filled out. During the interview, staff member B stated the interventions to the plan to prevent should be updated in the care plan but she was unsure how the interventions were being monitored by the CNAs. Staff member B stated the official way to monitor if the interventions were working or not was to keep a count of the falls by their residents. She stated that the facility tracked this with their Falls Worksheet. She expressed that the residents were assessed quarterly only but stated that the residents' needs were assessed daily. Staff member B stated she was unable to provide documentation of the individual needs being discussed by the staff. 2. Record review showed resident # 4 had falls on 3/18/15, 6/19/15, 6/21/15, 8/2/15, and 8/5/15. Review of the Unusual Occurrence Report- Falls, dated 3/18/15, showed the resident had an unwitnessed fall and was found on the floor, leaning up against her recliner. The resident stated she did not hit her head. Review of the Physician Fax Sheet dated 3/18/15, showed the resident was heading to the bathroom when she fell . She doesn't remember what happened. The fax sheet showed that the wheel chair or walker was not near the resident when she was found. It also showed that no injuries were noted. Review of the SNF Progress Notes, dated 3/18/15, stated that the resident was found on the floor, did not remember how she fell , and that no apparent injuries were noted. The facility failed to provide the resident's neurological assessments post fall on 3/18/15. Review of the resident's care plan showed that an intervention was added on 4/29/15 for resident #4 to have non-skid shoes for transfer. Review of the Unusual Occurrence Report - Falls, dated 6/19/15, showed the resident had another fall and was found sitting on the floor in front of her bed. The report showed the resident was attempting to self transfer and thought her wheel chair was locked, but wasn't and rolled out from under her, resulting in her fall. The investigation portion of the form showed the power was out and the resident was in poor lighting. The Actions To Prevent Recurrence section of the form states anti-roll back brakes for the wheel chair should be installed. Review of the Physician Fax Sheet dated 6/19/15, showed the resident had an unwitnessed fall and the resident was found sitting on the floor at 0025. The fax showed that resident was attempting to independently transfer to her wheelchair. The fax reflected the resident's range of motion was assessed and she was transported to bed with a mechanical lift. Review of the SNF Progress Notes, dated 6/19/15, showed that the resident was found at 0025 sitting on the floor in her room in front of her bed. The resident reported she was trying to self transfer, the wheel chair brakes were not locked, causing her to fall onto her buttocks. The resident denied hitting her head. An additional note entered on 6/19/15, showed the physician received notification by fax and that no new orders or changes in the plan of care were ordered. The facility failed to provide neurological assessments or provide the interventions implemented on the resident's Care Plan to prevent future falls. Review of the Unusual Occurrence Report - Falls, dated 6/21/15, showed the resident had an unwitnessed fall at 0000. The report showed that the resident had a hematoma over left eyebrow, and chafing of posterior of left upper thigh. She was found sitting and slightly lying on her left side in the bathroom doorway; she stated her wheelchair brakes were not locked and she fell , hitting her recliner. The Immediate Falls Investigation section of the report reflected the resident had clutter in her room, no alarms were in place to notify staff a fall had occurred, and that the resident was able to demonstrate safety awareness. Review of the SNF Progress Notes, dated 6/21/15, showed CNA staff found resident #4 sitting on her buttock partially in the bathroom. The resident hit the side of her recliner causing abrasion and bruising on left side of resident #4's forehead and she had abrasion to the left posterior thigh. Resident had complaints of generalized discomfort, but was stable and alert. The facility failed to document resident #4's vital signs post fall in their nursing notes. Review of the SNF Progress Notes, dated 6/23/15, showed that the facility received a fax from physician about the fall and no new orders or changes in plan of care were ordered. Review of the Physician Fax Sheet, dated 6/23/15, showed the resident had a fall while attempting to self transfer. The fax showed the resident was flustered by her roommate. The fall had head involvement, range of motion was intact but there was chafing of the left posterior upper thigh. The facility failed to provide documentation that the physician was notified on the day of the fall. The facility failed to update interventions to the resident's care plan to prevent falls. Review of the facility's Neurological Assessment showed the facility started neuro checks on 6/21/15 and discontinued them on 6/23/15. Review of the resident's care plan showed the facility had updated the care plan on 7/21/15 by implementing an intervention to lock the resident's brakes on her wheel chair prior to transferring. Review of the Unusual Occurrence Report - Falls, dated 8/2/15, showed the resident had an unwitnessed fall and was found around 0430 sitting on the floor. The resident reported that she got up to use the restroom and fell backward. The report showed that no injuries were noticed but the resident did hit her head on the right side behind her ear. The report also showed resident #4 was lifted back into bed with the hoyer lift. On the report, the Actions To Prevent Recurrence section suggested facility staff should increase observation, and a motion alarm was placed on the resident. Review of the SNF Progress Notes dated 8/2/15 showed resident #4 had a small purplish discoloration noted behind her right ear that was tender to touch, but no other details were documented. Review of Physician's Fax Sheet dated 8/2/15, showed the resident was found on the floor of her room at 0430. The fax showed the resident got up to use the bathroom and fell backwards, hitting her head on her dresser. It stated resident #4 denied any pain or discomfort at the time of Neurological Assessment. Review of the Neurological Assessment, dated 8/2/15, showed the resident was checked on 8/2/15 and 8/3/15. Review of the Unusual Occurrence Report - Falls, dated 8/5/15, showed the resident had an unwitnessed fall at 0215. The report reflected resident #4 was found on the floor by the bedside sitting on her knees. A small pool of blood was found on the floor by her. The resident had a 1 laceration to her right forehead, and had a large lump on the top of her head. The resident also had complaints of pain of her left arm. The Unusual Occurrence Report, dated 8/5/15, also showed that an alarm was going to be placed on the resident and the facility was going to be increasing observations of the resident. The facility failed to show documentation of placing the alarm on the resident and also failed to show how they increased the observations of the resident. During observations 2/22/16-2/26/16, resident #4 was not wearing a fall alarm. During an interview on 2/25/16, staff member D stated that she had been working in her department for about 1 year and that she did not recall resident #4 ever having a fall alarm placed on her. Review of Physician's Fax Sheet, dated 8/5/15, showed resident #4 had leaned forward to get something off the table in front of her. She fell and scratched her head on the table and hit the top front of her head on the table. She was returned to bed with a Hoyer lift after her neurological assessment and range of motion was assessed. She was transported to the emergency room via ambulance. Review of a Fax Sheet, dated 8/5/15, showed the fax was sent to physician to get an order for [REDACTED]. Review of SNF Progress Notes, dated 8/5/15, stated resident #4 had a fall at 0215. The note described the resident sitting on the edge of her bed; she went to reach for something on the table and lost her balance and fell . The resident scraped her forehead on the table and hit the top of her head on the floor which caused a large lump to form. Resident #4 also hit the right side of her forehead on a table leg which caused a gash on her forehead. The gash was measured at 1 long and fairly deep. The resident was transported to the emergency room via ambulance. The Care Plan did not include how the facility implemented increased observation or any other suggested interventions on the Unusual Occurrence Report for resident #4. During an interview on 2/25/16 at 2:45 p.m., staff member B stated all interventions for fall prevention should be on the care plan. The facility monitored those interventions as effective if there were no further falls. 3. Resident #9 was admitted to the facility with Parkinson's disease and various cardiac diagnoses. Record review showed Resident #9 had falls on 6/2/15 and 2/5/16. Review of the Unusual Occurrence Report- Falls, dated 6/2/15 showed the resident was found on the floor in the activity room. Resident #9 was folding towels and leaned forward to place the towel in a container, lost her balance, and fell out of her wheel chair. The injuries listed on the form included a 2 cm round skin tear on the left upper forearm, 3 small bruises inside the left forearm, and a bruise on the upper inside of the left upper arm. On the same report, the facility stated they were going to increase observation of resident #9. The facility failed to provide evidence or documentation that increased observation was implemented after the fall on 6/2/15. Review of the Physician Fax Sheet dated 6/2/15, stated the resident fell out of her wheel chair. No changes were indicated on the fax sheet. Review of the Unusual Occurrence Report- Falls, dated 2/5/16, showed resident #9 had an unwitnessed fall at 1735. The resident was attempting to self transfer and fell forward hitting her head on her roommate's bed, resulting in a large hematoma. The resident was hoyer lifted off the floor and her wounds were dressed. The resident had a right knee hematoma and an abrasion. She had a right elbow hematoma and skin tear. The staff failed to identify any further actions to prevent recurrence of falls on the report dated 2/5/16. Review of the Physician Fax Sheet, dated 2/5/16, showed resident #9 had a fall while attempting to transfer from her wheel chair to her bed. She hit her head on her roommate's bed rail which caused a large hematoma. The resident had some injuries on her elbow and her knee. Review of the Nursing Progress Notes, dated 2/5/16, showed ice was applied to resident #9's right forehead and right elbow after her fall, to reduce swelling. The resident had a hematoma on her right forehead, right elbow, and right knee. The note described the resident falling and hitting her head on roommate's bed rail. Review of the Nursing Progress Notes, dated 2/6/16, stated the skin tears to resident #9's elbow and right knee had a moderate amount of blood seeping through. The wounds were cleaned and dressed. The note revealed the resident was encouraged to use her call light for assistance. Review of Nursing Progress Note dated 2/7/16 stated that there was no post fall complications observed, but reported resident #9 did say, my heads a little fuzzy but I am OK. The resident also reported knee pain and the hematoma to the right side of her head was tender. Review of the Nursing Progress Note dated 2/10/16 showed that the resident was encouraged to use the call light for assistance. During an interview, on 2/25/16 at 10:00 a.m., resident #9 stated she did not have a fall alarm and has never had a fall alarm placed on her to notify staff if she fell . Resident #9 stated her fall on the 2/5/16 happened when she attempted to stand upright and turned her body's direction, lost her positioning, and fell . She stated it usually takes the staff 15-20 minutes to respond to the call lights. The resident stated the facility did not discuss prevention of falls with her and she was not aware of any interventions added to her care plan to prevent falls. She stated she was examined by the physician at the facility but she was never taken to the hospital. During an observation of the resident during the interview, the resident had a very large hematoma on her face and she reported it was from her fall on 2/5/16. The resident also showed her unhealed injuries on her knee and elbow. During an interview on 2/25/16 at 10:30 a.m., staff member A stated there was not a change in action to prevent further recurrence in falls for resident #9. 4. Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Record review revealed the resident had a fall on 5/30, 5/31, and 6/1/15. Review of the physician orders [REDACTED]. Review of the Unusual Occurrence Report- Falls, dated 6/6/15, showed the resident had another fall after being left unattended on the toilet. She sustained a skin tear to the elbow. The action to prevent reoccurrence was, instructed CNA to stay with resident when on the toilet. Review of the Unusual Occurrence Report - Falls, dated 6/16/15, showed the resident had another fall after being left unattended on the toilet. The action to Prevent Recurrence was Do not leave her side at all when toileting. Review of the Unusual Occurrence Report - Falls, dated 9/7/15, showed the resident lunged forward out of her wheelchair and slid to the floor. Review of the medical record lacked information regarding the use or discontinued use of the lap buddy. Review of the quarterly MDS, with the ARD of 8/28/15, did not reflect the use of a physical restraint. Review of the Unusual Occurrence Report - Falls, dated 9/18/15, showed the resident was found on the floor of her room after her alarm went off. (Resident) had made multiple attempts (sic) to self transfer during the evening, was restless and agitated. The resident complained of right hip pain and was unable to bear weight. Review of the Discharge MDS, dated [DATE], showed the resident was discharged to the hospital, and returned with a pinned hip fracture. Review of the Unusual Occurrence Report, dated 10/4/15, showed the resident was found on her bedside mat. Bruising was noted, as well as a cluttered room, with bedside table too close to bed. Review of the Unusual Occurrence Report, dated 2/14/16, showed the resident was found sitting on the floor next to a lounge chair outside of the dining room. Review of the Unusual Occurrence Report, dated 2/19/16, showed the resident was in the hall in her wheelchair and tried to stand up with the hand rail and fell . The chair alarm was not connected at time of fall. Review of all of the above Unusual Occurrence Reports - falls reflected the Action to Prevent Recurrence {of falls} was increase observation. Review of resident #1's care plan, dated 9/22/15, showed SAFETY: I am at risk for falls related to history of falls, generalized weakness, loss of balance and poor safety awareness with self transferring. The interventions included: 1.I have a bed and chair alarm as I forget to ask for assistance and will get up out of bed during the night when I need to toilet. I attempt self transfer placing me at risk of fall/injury. Please check on me frequently and anticipate my needs. 2.I have a wheelchair seat alarm to remind me not to stand. The care plan did not include how the facility implemented increased observationor any other suggested interventions on the Unusual Occurrence Report. During an interview on 2/25/16 at 2:00 p.m., staff member I stated the increased observation was to put the resident by the fish tank located in front of an enclosed nursing station that had windows. During an interview on 2/25/16 at 2:45 p.m., staff member B stated all interventions for fall prevention should be on the care plan. The facility monitored those interventions as effective if there were no further falls. Review of the Falls and Unusual Occurrence Report showed resident #1 fell 6 times prior to the hip fracture, and three times after the hip fracture, without any new interventions. 5. Review of the Unusual Occurrence Report - Falls, showed resident #11 fell on [DATE], and was found on the floor with approx. 1 inch laceration to left eyebrow. Bleeding significantly. Large hematoma to left cheek bone and left hand. Bruising on left hip. ROM WNL. Right pupil reacts to light but left one didn't. The report lacked a falls investigation and a follow up on injuries. Review of the discharge MDS, with the ARD of 10/27/15, showed the resident was sent to the hospital due to her injuries. Review of the unusual Occurrence Report - Falls, dated 12/2/15, showed resident #11 was found on the floor in her room with a hematoma to her left forehead, a laceration to the bridge of her nose, and a bruise on her left elbow and wrist. The Actions To Prevent Recurrence included increased observation and a mat next to her bed. During an observation on 2/26/16 at 2:15 p.m., a mat was not found in resident #11's room. Resident #11 moved about the room without a walker. She held onto an unlocked wheel chair as she moved from the bed to the dresser. During an interview on 2/26/16 at 2:20 p.m., resident #11 stated the mat did not work for her and the facility staff took it out. During an interview on 2/26/16 at 2:25 p.m., a family member stated resident #11 tripped over her oxygen tubing. Review of the Unusual Occurrence Report - Falls, dated 6/11/15 and 2/20/16, showed the resident slid out of her recliner onto the floor. Review of resident #11's care plan, dated 10/28/15, showed she was at high risk for injury and falls related to psychotropic drug use, unsteady gait and transfers and altered awareness. Interventions to prevent falls included: 1. I have a tendency to wander in and out of other resident's rooms during the night, if observed, direct me back to my room. 2. I may barricade myself in my room that prevents staff from coming into my room to avoid noise and people. Please use gentle reassurance for me to open the door again. 3. I sometimes have altered awareness and may not know where I am and I forget to use my assistive devices such as my 4 wheeled walker when I ambulate. Please remind me that I need to use my 4 wheeled walker if I am to ambulate. 4. Please keep my room clutter free and items I use close by, so I can use them. I do not use the call light, so check on me frequently and see if I need any assistance. 5. Please monitor me for any side effects from psychotropic medications such as lethargy, sedation, unsteady gait, constipation, dry mouth, urinary retention. During an interview on 2/26/16 at 2:00 p.m., staff member I stated the facility observed resident #11 in the hallway, as she sat by the aviary. The falls occurred inside her room. 6. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility's Unusual Occurrence Report - Falls showed resident #6 had falls on 1/28/16, 1/16/16, 12/2/15, 11/28/15, 8/10/15, 7/8/15, 6/16/1

Based on observation, interview and record review, the facility failed to ensure an effective quality assurance process was in place to identify fall hazards, evaluate and analyze fall hazards, and monitor for effectiveness and modify interventions in the plan of care to prevent falls with major injury for 3 (#s 4, 5, and 9) of 14 sampled residents. Specifically resident #5 had an unwitnessed fall that resulted in a pelvic fracture and did not receive medical treatment for 2 calendar days. Resident #5 also had increased pain and decline in her ambulation as a result of her fall injury. Resident #4 had a fall resulting in a 1 laceration on the right forehead. The laceration required emergent medical attention. Resident #9's falls resulted in hematomas to the head, elbow and knee. She had skin abrasions on both her elbow and her knee. Resident #1 acquired a [MEDICAL CONDITION] and is no longer mobile following her fall. Resident #11 went to the ER with a non-reactive pupil and a head injury following her fall. In addition, the facility failed to identify quality deficient practices which were identified as Immediate Jeopardy deficiencies for Accidents, Hazards, and Supervision which affected 9 (#s 1, 3, 4, 5, 6, 8, 9, 10, and 11) of 14 sampled residents. Findings include: 1. Quality of Care a. F323-Accidents/Supervision. The facility failed to prevent serious injury from falls, identify and evaluate fall hazards, implement interventions in the care plan, monitor interventions for efficacy, and accurately assess the resident's environment to determine whether supervision to avoid an accident was needed. (Refer to F323 for detailed information.) Falls: -Identification of falls -Ensuring interventions were implemented and effective -Updating the current care plan to include new interventions for fall prevention -Monitoring falls by the interdisciplinary care team b. F309-Highest well-being. The facility failed to adequately assess and manage pain which inhibited the highest practical physical and mental well-being for the resident. (Refer to F309 for detailed information.) 2. Resident Behavior and Facility Practices a. F221-Physical Restraints. The facility failed to keep residents free from physical restraints that prevented the residents from rising from a chair. (Refer to F221 for detailed information.) 3. Resident Assessment a. F274-Significant changes to MDS. The facility failed to determine that there had been a significant change in the resident's physical or mental condition. (Refer to F274 for detailed information.) b. F278-Accuracy of MDS. The facility failed to accurately reflect the physical and mental status of the resident in the MDS. (Refer to F278 for detailed information.) c. F279-Comprehensive care plan. The facility failed to develop a potential or actual skin care plan to maintain the resident's highest practicable physical and mental well-being that were identified in the comprehensive assessment. (Refer to F279 for detailed information.) d. F280-Care plan time frames and participation. The facility failed to revise the care plan with a change in the resident's status after a fall. (Refer to F280 for detailed information.) e. F281-Professional standards. The facility failed to follow the physician's orders [REDACTED]. (Refer to F281 for detailed information.) 4. Administration a. F490-Administration. The facility failed to ensure there was efficient and effective administration that directed the facility policy procedures; assist department managers in following policy and procedures in accordance with federal and state laws; ensure continued compliance with current regulations; ensure residents received care in a manner to enhance their quality of life without a negative effect on their rights, privacy/dignity and psychosocial health. (Refer to F490 for detailed information.) b. F520-Quality assurance. The facility failed to identify issues related to the quality of care for the residents and to develop and implement appropriate plans of action to correct identified problems. During an interview on 2/26/16 at 3:30 p.m., staff member A stated that they look at falls during their quality assurance meetings and discuss solutions. They were looking at root cause analysis for some residents with frequent falls for a while and their frequency on falls went down in that last quarter. They stopped looking at root cause analysis for falls at that time.

Based on observation, record review and interview, the facility failed to adequately assess and manage pain for a resident with dementia, which resulted in harm and inhibited the highest practical physical and mental well-being for 1 (#1) of 14 sampled residents. Findings include: Review of resident #1's SNF Progress notes dated 9/22/15 showed the resident returned from the hospital with a new pinned [MEDICAL CONDITION]. Review of the MAR for the month of 9/2015 showed a [MEDICATION NAME] Tablet was ordered, as needed every 4 hours, for pain related to the [MEDICAL CONDITION], for 3 days. The MAR indicated [REDACTED]. Review of the Physician orders [REDACTED]. Review of the September MAR, after the readmit showed a continued routine order for [MEDICATION NAME], 400 mg two times a day. Resident #1 did not receive any additional pain medication from 9/25/15 through 10/6/15. Review of the October MAR indicated [REDACTED]. She received one dose of [MEDICATION NAME]-[MEDICATION NAME] tablet 5-325 mg each of these days. Review of the admission MDS, with the ARD of 9/29/15, showed the resident was interviewed for pain. Have you had pain or hurting in the last 5 days? She answered no. Her BIMS was 6, indicating severe cognitive impairment. No further hands on assessment was completed. Review of the Social Services Notes, dated 6/10/15, reflected the resident was oriented only to person, and had difficulty comprehending all but simple messages. During an interview on 2/25/16 at 2:50 p.m., resident #1 was unable to state the day of the week or where she was. During an interview on 2/25/16 at 1:15 p.m., staff member M stated the resident was absolutely in pain after the [MEDICAL CONDITION], but she was unable to say I hurt because of her impaired cognition. During an interview on 2/25/16 at 1:30, staff member N stated resident #1's pain was probably at an 8 during therapy, based on her face. Review of the Weekly Occupational Therapy Notes showed: at times, severe pain in RLE continues to be limited due to pain in RLE times 3 weeks. Review of the Weekly Physical therapy notes showed yes to pain, without a severity level described each week, until therapy was discontinued on 11/13/15. Review of the SNF Progress Note dated 10/2/15, reflected was medicated for pain prior to attempting to bath (sic) her at 1100. Res became combative, hitting and refusing to be bathed. Review of the 10/2/15 MAR indicated [REDACTED]. [MEDICATION NAME] was not provided during the month of October. Review of the SNF Progress Notes dated 10/3/15 reflected her discomforts are managed with [MEDICATION NAME] and scheduled [MEDICATION NAME]. Review of the October MAR indicated [REDACTED]. Review of the SNF Progress Note, dated 10/22/15, reflected often is resistive to cueing and hits at staff. Continues to have hip pain with activity. Pain medication offered prior to Therapy. Review of the MAR indicated [REDACTED]. Review of the SNF Progress notes, dated 10/27/15, reflected one CNA reported {the resident} now refuses to roll in bed and that it appears to be d/t pain. She does not initiate requests for help for pain but will answer yes if asked and is in pain. Perhaps would benefit from PRN before HS care and see if she is less combative. Review of the Physician order [REDACTED]. Review of the SNF Progress Note, dated 11/6/15, showed CNAs reported that {the resident} was yelling and trying to hit them. The note lacked evidence of a pain assessment. Review of the SNF Progress Note, dated 11/8/15, reflected pain to lower back/hip area and was med x 1 with good relief, CNAs were able to do HS cares. Review of the 11/8/15 MAR indicated [REDACTED]. Review of the Restorative/Therapy note, dated 11/9/15, reflected (the resident) does not enjoy doing bed mobility and often will strike out at staff or yell. She still complains of right hip pain when turning in bed and nursing has been notified when she has episodes of pain. Review of the October MAR indicated [REDACTED]. It was not provided the rest of the month. Review of the SNF Progress Notes dated 12/3/15 showed a discussion with the resident's son, Son thinks the Oxycod/APAP 5/325 is too much. Would like it changed to 1/2 tab. Review of the November and December MAR indicated [REDACTED]. Review of the physician facsimile response dated 12/3/15 showed OK to change [MEDICATION NAME] to 1/2 -1 tab. PO q 4 hours PRN if feels better taking, can try scheduled 1/2 TID. Review of the December MAR indicated [REDACTED]. Review of an undated SNF Progress Note in January showed res tried to bite them and bit her own right wrist causing a 0.5 skin tear. The note lacked evidence of a pain assessment. Review of a SNF Progress Note dated 12/24/15 showed When care were being done on resident got 2 skin tears 1 on each arm where she was hitting and scratching on the CNA she hit her arm on the watch face of CNAs watch, could not measure because resident was still fighting. Pain was not assessed during this incident. Review of the January MAR indicated [REDACTED]. Review of a SNF Progress note, dated 2/6/16, from the social worker showed Pain medication may alleviate some of {the resident's) resistive cares. Review of a SNF Progress Note, dated 2/16/16, showed Resident is extremely agitated, trying to strike aids and climb out of her chair. This nurse asked if she was in pain and resident denies any pain. Review of a SNF Progress Note, dated 2/19/16, reflected the MD was notified that giving PRN [MEDICATION NAME] at night had decreased the resident's combative behaviors with cares. MD orders for [MEDICATION NAME] 5 mg po Q HS. Review of a SNF Progress Note, dated 2/23/16, showed the resident punched the nurse in the throat and CNA in the forehead during care. She complained about bad pain during care and stated she did want pain med. When nurse returned to room she stated she did not want to take it. Review of the Quarterly Pain assessments, dated 11/27/15 and 2/15/16, showed the resident denied pain and no further assessment for pain was completed. During an interview on 2/24/16 at 9:55 a.m., staff member B stated that nursing homes are not very good with PRN medications, so the facility would typically try a scheduled pain medication for 5 days. She did not know why this did not happen for resident #1. During an interview on 2/25/16 at 7:45 a.m., staff member A stated the facility did not recall any pain concerns for resident #1 in the medicare meeting.