Every finding on record at Town Hall Estates

Based on observation, interviews and record review, the facility failed to develop and implement written policies and procedures for ensuring the reporting of a reasonable suspicion of a crime against any individual who is a resident of the facility to law enforcement immediately but not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury and report the results of all investigations to officials in accordance with state law within 5 working days of the incident for 1 of 4 incidents reviewed for reporting. The facility failed to notify local law enforcement within 24 hours of 08/22/2026 when a confirmed resident-to-resident abuse allegation occurred.The facility failed to notify local law enforcement of the results of the investigation within 5 working days of 08/22/2026, after it was confirmed Resident #1 kicked Resident #2 in the shin. This failure could place residents and/or their guardians at risk of missing their right to press charges against a perpetrator for assault. Findings included:Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old-male who admitted to the facility on [DATE]. Resident #1 had the following diagnoses: high blood pressure, high cholesterol, stroke (when blood supply to the brain is blocked or when a blood vessel bleeds in the brain), non-Alzheimer's dementia (cognitive decline caused by conditions other than Alzheimer's disease), depression, psychotic disorder, adjustment disorder with anxiety, insomnia (habitual sleeplessness), and sleep apnea (repeated interruptions in breathing during sleep, leading to various health complications). Resident #1 had a BIMS score of 12, indicating moderately impaired cognition.Review of Resident #1's comprehensive care plan dated 6/1/2026 reflected he had potential to be verbally aggressive r/t dementia, poor impulse control. Resident #1 was physically aggressive r/t anger, dementia, history of harm to others, poor impulse control.Review of Resident #2's entry MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE].Review of Resident #2's comprehensive care plan dated 8/23/2026 reflected he had behavior problem of going into other resident's rooms, trying to take other resident's belongings, trying to take other resident's belongings, yelling/cussing at staff, resistive to care, difficult to redirect, yelling out and speaks very loudly, poor comprehension, and confusion.Review of Resident #2's progress notes reflected on 8/23/2026 Resident noted in another resident's room on the other hallway attempting to take other resident's belongings and insisting that they were actually his belongings. Nurse was attempting to redirect. Resident yelling and cussing and calling nurse an asshole very loudly. Resident was removed from other resident's room and taken back to his room. Continued yelling and calling nurse names while being assisted to room.On 8/22/2026 Resident was wandering the halls going in and out of other residents' rooms. Resident was redirected each time. Resident did go into the room where the resident that he had previously had an altercation with was moved to. Resident was removed from room and redirected to his own room. Resident became angry yelling, screaming and cussing at staff member that was redirecting him. Once staff member found his dry erase board and resident could communicate better, he calmed down and is currently in bed sleeping.Review of facility's 3613-A (self-report) dated 8/26/2026 reflected that an incident occurred on 8/22/2026 at 3:40am between Resident #1 (AP) and Resident #2. Resident #1 was indicated as being independently ambulatory, was interviewable, and did not have the capacity to make informed decisions. Resident #2 (victim) was not independently ambulatory, was not interviewable, and did not have the capacity to make informed decisions. The self-report indicated that the incident was not reported to police and there was no case number. The self-report indicated the facility's investigation findings were confirmed (meaning abuse occurred).Review of an undated RN A witness statement within the self-report reflected she heard a male voice (Resident #2) hollering for help. As she was assessing Resident #2's shin, since he was holding and rubbing it, and yelling she hit me! RN A heard Resident #1's door open, and Resident #1 appeared at Resident #2's door and began pointing at Resident #2 and said F that guy. I hope he dies before I do. RN A documented that she asked Resident #1 if he kicked Resident #2, and he stated yes. RN A documented that she separated the residents, and her assessment of Resident #2 revealed no injuries.Review of the ADM statement dated 8/22/2026 reflected that the ADM interviewed Resident #2 on 8/22/2026 and he was unable to recall the incident that occurred with Resident #1. The ADM interviewed Resident #1 as well and documented that Resident #1 told her that that clown kept me up all night with his snoring and talking. The ADM asked Resident #1 who he was referring to, and Resident #1 stated it was that clown across the hall from me. She also documented that Resident #1 stated he hoped that fucker dies before he does.In an attempted interview on 08/29/2026 at 12:40pm with Resident #1, he was observed lying in bed and he leaned up a bit when the surveyor spoke to him. When asked if he had recently had a verbal or physical altercation with another resident, he looked puzzled and said that he did not know. He stated he believed everything was going okay at the facility and that he got what he needed from staff.In an attempted interview on 08/29/2026 at 1:30pm with Resident #2 he was observed seated in the main tv area of the lobby with his headphones on. Resident #2 just smiled and shook his head up and down when asked questions. The surveyor pointed to the bandage on Resident #2's left shin and he smiled, shook his head yes, and adjusted his night pants to try and cover the bandage. Resident #2 did not vocally respond throughout the interaction.In an interview on 08/29/2026 at 4:03pm with the LEO and the DON, the LEO informed the DON that, despite Resident #2 having a guardianship it was the resident's right to pursue criminal charges should the guardian choose to make that decision. The LEO also stated that in the future if they (facility) have an assault in the facility, it was against the law, and the facility needed to report it to law enforcement.In an interview on 08/29/2026 at 12:45pm the DON had been working at the facility since 11/17/25, stated that the police were not contacted after this incident because the DON asked the ADM-who was the abuse coordinator, if they needed to report it to police and the ADM told her they did not, since after doing skin assessments there were no injuries. The DON stated that the bandage on Resident #2's left shin was to cover a skin problem that was present upon his admission to the facility.In a telephone interview on 08/29/2026 at 3:27pm with the ADM, who has been the ADM of the facility for 11 months, she stated that on the facility's abuse policy she was reading, she thought the policy said 'unless there was serious bodily injury' they would not notify police. She stated that even though the allegation was confirmed, because there was no serious bodily injury they did not notify the local law enforcement. Review of the facility's policy titled, Abuse Investigations dated October 2009 reflected, The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1's annual MDS, dated [DATE], accurately reflected her smoking status. 2. The facility failed to ensure Resident #2's admission MDS, dated [DATE], accurately reflected his smoking status. 3. The facility failed to ensure Resident #3's annual MDS, dated [DATE], accurately reflected her smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status. Findings Included: 1. Record review of Resident #1's face sheet, dated 08/21/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included dementia (memory, thinking, difficulty), major depressive disorder (mental health disorder characterized by persistent depressed mood), multiple sclerosis (disease that causes breakdown of the protective covering of the nerves) repeated falls, protein-calorie malnutrition (inadequate intake of both protein and calories), and attention deficit hyperactivity disorder (hard time staying focused, acts quickly without thought). Record review of Resident #1's annual MDS, dated [DATE], revealed Resident #1 had a BIMS of 12, which indicated moderate impairment. The MDS also revealed that current tobacco use was marked as no. Record review of Resident #1's care plan, dated 06/16/2026, reflected the following: Focus: The resident is a smoker uses vape.Goal: The resident will not suffer injury from unsafe smoking practices through the review date.Interventions: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. The resident requires a smoking apron while smoking. Record review of Resident #1's Smoking Assessment on 08/13/2026, revealed Resident #1 vaped. Resident #1 follows the facility's policy on location, and time of smoking. 2. Record review of Resident #2's face sheet, dated 08/21/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis which included chronic obstructive pulmonary disease (chronic progressive lung disease), hypokalemia (low potassium), respiratory failure, and emphysema (progressive irreversible lung disease). Record review of Resident #2's annual MDS, dated [DATE], revealed Resident #2 had a BIMS of 13, which indicated intact cognitive. The MDS also revealed that current tobacco use was marked as no. Record review of Resident #2's care plan, dated 07/02/2026, reflected the following: Focus: Tobacco Goal: Resident will Adhere to the Tobacco/Smoking Policies of the Facility.Interventions: Determine if Resident has a desire to quit. Educate Resident / Family on risks & health effects of tobacco use. If Resident would like to quit, contract provider to prescribe cessation aides. Provide education regarding the adverse effects of smoking. Provide smoking cessation information/ assistance/resources. Provide support to Resident. Provide tobacco cessation material(s).Record review of Resident #2's Smoking Assessment on 02/28/2026, revealed Resident #2 was to wear a smoking apron and needed staff to extinguish cigarettes. 3. Record review of Resident #3's face sheet, dated 08/21/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had a diagnosis which included alcohol use, cannabis use (marijuana), chest pain, reduced mobility, and Wernicke's Encephalopathy (an acute neurological emergency caused by thiamine (vitamin B1) deficiency, often associated with alcohol misuse, and can progress to irreversible brain damage if untreated). Record review of Resident #3's annual MDS, dated [DATE], revealed Resident #3 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed that current tobacco use was marked as no. Record review of Resident #3's care plan, dated 01/26/2026, reflected the following: Focus: Tobacco Use Goal: Resident will Adhere to the Tobacco/Smoking Policies of the Facility.Interventions: Determine if Resident has a desire to quit. Educate Resident / Family on risks & health effects of tobacco use. If Resident would like to quit, contact provider to prescribe cessation aides. Provide education regarding the adverse effects of smoking. Provide smoking cessation information/assistance/resources. Provide support to Resident. Provide tobacco cessation material(s). Observation of smoking on 08/22/2026 at 03:36a.m., revealed Resident #1, and Resident #2 were outside smoking with staff present. During an interview with the MDSN on 08/22/2026 at 12:54p.m., she said she was trained on MDS. She said the MDSN was responsible for completing the MDS. She said information that was on the MDS were assessments, and everything dealing with the resident. She said the MDS should be completed when there was a significant change, annually, and quarterly. She said she had fourteen days from admission to complete the MDS. She said resident's tobacco use should be on the MDS. She said if the resident's smoking status was not coded correctly it could not affect the residents. She said the new cooperate MDSN would now monitor. She said she did not know how she would monitor as the company just took over. She said Resident #1, Resident #2, and Resident #3's smoking status was not correct because smoking was still very new to the facility and it might have just been overlooked. During an interview with the ADM on 08/22/2026 at 1:18p.m., she said she had not been trained on the MDS. She said she knew very little about the MDS. She said the MDS was how the facility got paid. She said the MDSN was responsible for completing the MDS. She said the MDS was to be done annually, quarterly and if the resident had a change of condition. She said if the MDS did not have the resident's smoking status correct it would affect the resident because the staff would not know everything about the resident. She said the new company had someone who oversees the MDS. She said she did not know how the new corporate staff member monitored to ensure the MDS was correct. She said she did not know why Resident #1, Resident #2, and Resident #3's smoking status was not correct. Record review of the MDS Accuracy Policy dated 08/2026 revealed To establish the standards and controls by which [Facility Name] ensures that every Minimum Data Set assessment is accurate, supported by documentation in the clinical record, certified by qualified staff, and transmitted correctly to the Centers for Medicare & Medicaid Services and to Texas Health and Human Services through the LTC Online Portal. This policy applies to every MDS assessment and tracking record completed by the facility, every discipline that codes MDS items, and every person who submits, corrects, or certifies assessment data. It applies alongside the Resident Assessment Policy, which governs which assessments are required and when. Every MDS item is coded to accurately reflect the resident's status during the look-back period for that item, in accordance with the current MDS 3.0 RAI User's Manual.

Based on interview and record review the facility failed to provide disclosure of ownership to 4 (HS #1, HS #2 HS #3, and DA #5) of 5 contracted companies used for services in 1 of 1 facility reviewed. The facility failed to notify and get new contracts for 5 (HS #1, HS #2 HS #3, HS #4, and DA #5) of 6 contracted companies used for services of the ownership charge. This failure could result in the lack of knowledge, the contract companies possibly not getting paid and inability to connect with the appropriate leadership of the facility. Findings included: Record review revealed the facility submitted a CHOW to HHSC on 07/03/2026 reflected the effective date of the CHOW was 07/31/2026. Record review of the contracts for HS and DA revealed that 4 of 5 hospice contracts and 1 dialysis contract. HS #1 contract was dated 02/20/2025, HS #2 was dated 05/2/2024, HS #3 was dated 04/13/2023 and DA #5 was dated 05/22/2026. All the contracts were listed under the old ownerships. During an interview with the ADM on 08/22/2026 at 11:13a.m., revealed the facility did not have the new policies or contracts with the new company because she said the owners were out of state and was having to change some policies and they were still working on getting the new contracts done.

Based on interview, and record review, the facility failed to ensure that residents received care in accordance with professional standards of practice, for 1 (Resident #1) of 4 resident reviewed for resident rights. The facility failed to implement interventions, according to the comprehensive plan of care, to check on and change Resident #1 on rounds, and as needed, to keep Resident #1's and dry, and keep her free from falls. The failure placed residents at risk of falls, injuries, a decline or decrease in their quality of life and quality of care.Findings included: Record review of Resident #1's face sheet, dated 6/23/2026, revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnosis Alzheimer's Disease with Late Onset (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance (a form of cognitive decline where the exact type of dementia (e.g., Alzheimer's, vascular) and its severity are not determined), Metabolic Encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to confusion, altered consciousness, and potentially permanent brain damage if untreated). Record Review of Resident #1's quarterly MDS assessment, dated 5/06/2026, revealed BIMS score of 4, indicating severe cognitive impairment. The MDS indicated Resident #1 had 2 or more falls with no evidence of injury. This is noted on physical assessment by the nurse or primary care clinician; no complaints or pain or injury by the resident; no change in the resident's behavior is noted after the fall. Record review of Resident #1's care plan, dated 06/23/2026, revealed the Focus: [Resident #1] has had an actual fall r/t poor balance, poor communication/comprehension, unsteady gait, lack of safety awareness. Goal: [Resident #1] will have no further incidents through the review date. Interventions/Tasks: Anticipate and meet the resident's needs; be sure the call light is within reach and encourage the resident to use it for assistance as needed. The residents needs prompt to all request for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; follow facility protocol; resident has been moved in a room closest to the nurse's station for fall prevention precaution. [Staff] to encourage resident to keep door open while in room so that [staff] can frequently monitor for resident safety. Record review of Resident #1's care plan dated 06/23/2026 reflected the resident had multiple falls: 2/6/26 - Resident had an unwitnessed fall in room. Resident went to the bathroom without assistance and fell in her bedroom. C/O left hip pain. Sent to the ER via EMS and admitted into the hospital for left hip fracture. 2/10/26 - Resident had unwitnessed fall in bedroom. No injuries noted. Resident has dementia and new left hip fracture. Resident does not remember to use call light to get assistance. Staff check on resident frequently and offer frequent reminders to use call light for assistance. 5/8/26 - Resident had unwitnessed fall in bedroom with no injury. Resident reminded to use call light for assistance. 5/20/26 - Resident reported she fell in her bedroom overnight and got herself up without telling anyone. She reported that she did not hurt herself and no injuries were noted. Resident has been noted with hallucinations and delusions lately. RP stated that the resident is seeing ants, rats, birds, and cats in her room. Staff check in on resident frequently for safety and reorientation as needed. 5/25/26 - Resident had an unwitnessed fall in bedroom. Resident stated her slippers slid and she slid on the floor. Resident denied pain or injury. No injuries noted. 6/15/26 - Nurse noted bruising and swelling to resident's forehead this AM and notified RP who has a camera set up in the resident's room. RP played back footage from the night and saw that resident had a fall at 3:46 and did not report it to the staff. MD notified. Staff continued rounds for safety. During an interview with the ADM on 06/23/26 at 1:28 p.m., the ADM revealed Resident #1 had a fall and CNA A had not been in the resident room all night. She stated, however, the nurse did go into the resident's room [ROOM NUMBER] times. checked on her and administered her medication. ADM stated when she called to report the incident to the RP, the RP revealed that the resident had fallen 6 different times (the times were not provided) when she reviewed the camera. ADM stated LVN B went into the room at 4:55 a.m. to give Resident #1 her medication and found her on the floor. CNA A had no reason why he had not gone in Resident #1's room to check on her throughout his shift. ADM advised RP of the disciplinary action taken with LVN B and CNA A; RP was happy with the results. ADM stated anything could happen to a resident if they did not checked on. ADM stated an assessment was performed on Resident #,1 and she was sent out to the hospital. She stated safe surveys were completed with other residents. During an interview with the DON on 06/23/26 at 2:55 p.m., the DON revealed staff was supposed to check on residents every 2 hours and nurses every 2 hours. The DON stated she expected the staff to follow policies and procedures. Resident # 1 should be checked on especially since she was a fall risk, every hour. DON stated she was originally on the back of the hall, but they moved her specifically close to the nurse station since she is a fall risk. DON stated Resident #1's door is supposed to be left open to see her moving around, the doorway light left on, and her bed is in a low position. Resident #1 is usually in the bed or sitting in her chair. Resident #1 can ambulate by herself. Resident #1 is advised to use her walker, but she will put the walker in the corner and go back to her chair or bed. DON stated if no one is going to check on the resident regularly, a serious injury could happen or possible death. She stated CNA A allegedly checked on Resident #1 at 11:30 p.m. but once she looked at the camera from both angles, it revealed he had not gone in the room at all. She stated LVN B went in and checked on the resident 3 times that night. DON stated she was sent out to the hospital, and an x-ray was completed and the results revealed nothing was broken. She just had a laceration on her left eye. Resident #1 was sent back to the facility. During an interview with LVN B on 06/23/26 at 4:45 p.m., LVN B revealed she had checked on the residents every 2 hours. She stated her duties were to pass the meds, supervise the nurse aides, provide the residents with any treatments that they need, observe residents if they have a COC and notify the doctor. LVN B stated if the residents are checked upon regularly, they could fall, stop breathing, or they could experience any type of health crisis. LVN B stated she went into Resident #1 room [ROOM NUMBER] times that night. She stated she was not aware CNA A had not gone into the room to check on the resident. She stated he was supposed to go in and make his rounds, and he advised her he did. During an interview with Resident #1 on 06/23/26 at 5:20 p.m., Resident #1 revealed the staff treated her good. She feels safe living at the facility. Resident #1 stated she was going to get a Coke from downstairs when she fell. She hurt both butt cheeks when she fell, but nothing broke or not hurting as of 5:25 pm on 6/23/2026. Resident #1 stated she didn't press her call light, nor did she use her walker to assist her with walking. She stated the staff were making rounds and found her on the floor. She stated she was on the floor just a little bit and could not determine minutes or hours. She stated if she has any concerns, she would tell her RP. During an interview with the CNA A on 06/25/26 at 8:08 p.m., CNA A revealed he was responsible for checking on residents every 2 hours; making sure everyone is okay. He stated his shift is from 6 p.m. to 6 a.m. He stated he was getting residents ready for bed on or around 7:30/8 p.m. and remembered going to check in on Resident #1 during that time. CNA A stated around 2:30 a.m., he was documenting and getting ready to get his residents on dialysis ready for it. He stated he must have gotten busy and sidetracked with documentation as the reason why he did not check on her after that. CNA A stated if residents were not checked on regularly, they could fall, pass away; anything could possibly hurt or harm them in the brief time of not checking on them. He stated he had a brief understanding of notes documented in PCC. He stated he knew Resident #1 fell a couple of times, but he denied knowing she was a fall risk. During an interview with the RP on 06/25/26 at 8:30 p.m., RP revealed she was notified by a staff member from the facility who left a voice message that Resident #1 had a fall and was sent to the ER. The RP stated Resident #1dementia. She stated Resident #1 had been sleeping and woke up, fell a few times, and managed to get herself up. She stated during the last fall she could not get herself up, because she was sleep deprived. LVN B found her and called CNA A to assist her to put her back in the bed. Reviewing the camera revealed she had a laceration to her left eye. RP stated Resident #1's dementia is worsening. RP stated Resident #1 is [AGE] years old, and she doesn't believe she need a walker or a wheelchair because it is for older people. She stated she is trying to find a way to get Resident #1 to utilize the walker to assist with her walking to avoid the falls. Record Review of the facility Abuse, Neglect, and Exploitation Policy dated March 2018 reflected: Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect is defined as the failure of a health care provider or caregiver to perform a duty or give proper care to a patient Although neglect is considered unintentional, it ultimately causes harm to the resident by failure to provide care.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 (Resident's #17, #22) of 6 residents reviewed for baseline care plans. The facility failed to ensure Resident #17's and Resident #22's baseline care plans addressed their mobility abilities.The facility failed to complete Resident #27 and Resident #44's baseline care plans.This failure could place residents at risk of getting insufficient care, not having personal needs not met resulting in hospitalizations and injuries related to falls. An IJ was identified on 09/04/25. The IJ template was provided to the facility on [DATE] at 4:53 pm. While the IJ was removed on 09/06/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Resident #17 Record review of facility admission Record dated 08/19/25 reflected Resident #17 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, Hypoxemia (a condition characterized by a below normal level of oxygen), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and heart failure Record review of facility Progress Notes dated 08/04/25 at 4:44PM reflected Resident #17's family member states resident had a fall on 8/3/2025, resident had a bruise near right eye and a large contusion on top of his head near his forehead on the right side, bruising behind both arms, notified Dr and DON, neuro checks initiated, waiting for Dr order. Record review of admission MDS dated [DATE] for Resident #17 reflected section GG: Functional abilities chair/bed-to-chair transfer was marked 04 Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Record Review of Radiology report from The Hospital dated 08/04/25 reflected the fall resulted in minimally displaced acute fractures of the eighth and ninth ribs laterally. Nondisplaced acute intra-articular fracture medial left clavicle extending to the sternoclavicular joint (clavicle fracture). Record review of Resident #17s Medical Records for Baseline Care Plan reflected it was not completed. Resident #22 Record review of facility admission Record dated 08/21/25 reflected Resident #22 was admitted to the facility on [DATE]. Diagnoses included Malignant Neoplasm of Pancreas (cancer of the pancreas), Neoplasm related pain (pain due to cancer), protein calorie malnutrition, and elevated blood pressure. Resident #22 was admitted on Hospice Respite. Record review of Resident #22's progress notes dated 08/04/25 at 7:55PM reflected patient observed laying on the floor of her bathroom. CNA stated patient had requested to go to the restroom with assistance of 1 (one) staff. CNA gave patient some privacy and gave patient instructions to pull emergency call light when done, patient has successfully used emergency light before. Patient had a small but deep laceration above the right eyebrow. Patient was drowsy but responding to questions, could tell us her name and date of birth . 911 called or transport to emergency room. X3 assisted back into bed using (mechanical) lift. Vital signs: 83/56,100,94%. Dressing applied to head laceration. Emergency medical services in building and provided transport, patient hypotensive and believed to have had a syncopal episode (fainting). She is alert at this time, oriented x2-3. POA called and notified of fall and send out to emergency room. Primary Care Physician and hospice called and notified of fall with emergency room visit. Instructions left with this nurse to call hospice when patient is in facility so follow up visit can be completed. Signed by LVN F. Record review of Resident #22's admission MDS dated [DATE] reflected section GG: Functional abilities toilet transfer was marked 03 Partial/Moderate Assistance-Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Resident #22 was coded as using a walker and a wheelchair for mobility devices. Record review of Resident #22s Medical Records for Baseline Care Plan reflected it was not completed. Findings included: Resident #27 Record review of Resident #27's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: high blood pressure, diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired), high cholesterol, aphasia (a communication disorder that affects a person ability to speak, write, and understand both spoken and written language), stroke, hemiplegia (paralysis on one side of the body), muscle weakness, and dysarthria (a motor speech disorder that occurs when the muscles used for speech are weak or difficult to control). His BIMS score was a 12, indicating he had moderately impaired cognition. Record review of Resident #27's “Care Plan Conference” dated 11/19/2024 reflected Resident #27 was admitted on [DATE], the reason for conference was “initial”, and it included nursing, social worker, dietary, activity notes, and the members present were documented. Resident #44 Record review of Resident #44's face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: congestive heart failure (a chronic condition where the heart cannot pump blood effectively), respiratory failure (inadequate gas exchange by the respiratory system), high blood pressure, severe kidney disease (gradual loss of kidney function), type 2 diabetes mellitus (chronic condition that affects the body's way of metabolizing sugar), iron deficiency, elevated white blood cell count, atrial fibrillation, edema (swelling caused by excess fluid in the body's tissues), tachycardia (when the heart rate exceeds 100 beats per minute), and tachypnea (rapid, shallow breathing). Record review of Resident #44's undated baseline care plan reflected she was admitted on [DATE] and under part “C. Social Services” all needs/goals were left blank. In an interview on 08/21/2025 at 1:16 PM LVN D stated the Nursing assistants never told her that the care plan was never populated for Resident #17 or Resident #22. LVN D stated staff were aware the baseline care plan information was important to prevent falls and assist with rehabilitation to ensure residents needs were met. In an interview on 08/21/2025 at 2:36 PM the DON stated that she and ADON were responsible for filling out the base line care plans. The DON stated the baseline care plans should have been completed within the first 48 hours of admission. The DON stated the baseline care plan for Resident #17 and Resident #22 were overlooked and could not say why those or the others were not fully completed. The DON stated the negative effects for having an incomplete baseline care plan could be increased falls. In an interview on 09/04/25 at 1:30pm LVN E stated that she was not present when Resident #17 admitted (7/31) to the facility. When she took his blood pressure on 08/03/25 at 9:16am she saw a bruise on his head, but she thought the bruise was from when he admitted . She did not see the knot on his head until the family told her about it. She stated that she initiated a neuro check and post fall assessment at 6:13pm on him. She stated it was an agency nurse working the night shift of 08/03/25, and when she got report from that agency nurse, she was not told that Resident #17 had a fall. She stated that he had a wheelchair and very unsteady gait (ability to walk). LVN E stated Resident #22 could not get up and walk to the bathroom on her own. Resident #22 had a lot of edema (swelling) in her legs and could not toilet transfer on her own. She stated Resident #22 needed active assistance during toileting. She stated that moderate assistance means I person assisting, and I person could have assisted Resident #22 because she was so thin. She stated that Resident #22 was not to be left alone on the toilet, she could have privacy (meaning standing in the doorway with your back toward the resident). In an interview on 09/04/25 at 2:28pm The DON stated that an agency nurse was working the night of 08/03/2025 when Resident #17 fell. The DON stated the nurse failed to conduct a neuro check, post fall evaluation, and report to the ongoing nurse that Resident #17 had a fall during her shift. The DON stated that agency nurse was the one who helped Resident #17 up from the fall, even though originally the resident told the DON he did not tell anyone about the fall. The DON stated Resident #22 used a wheelchair and typically was able to be left alone on the toilet due to being cognitively intact and her ability to sit on the toilet without assistance and had previously demonstrated successful ability to use her call light and sit on the toilet without assistance. She stated that at the time of the fall The DON was told the resident was seated on the toilet, the CNA felt the resident was safe, the call light was in reach, and the CNA was no longer present in the bathroom. She stated that she or the ADON are checking fall risk assessments, check charts every 24 hours to ensure assessments are completed fully. The DON stated she opens baseline care plans upon a resident's admission, the BOM contacts families and will set up baseline care plan meeting with RP within 48 hours of admission. Review of the facility policy titled, “Care Plans- Baseline” dated December 2016 reflected, “A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. “The Interdisciplinary Team will review the healthcare practitioners' orders and implement a baseline care plan to meet the resident's immediate care needs. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders;b. Physician orders;c. Dietary orders;d. Therapy services;e. Social services; andf. PASARR recommendation, if applicable.” An Immediate Jeopardy was identified on 09/04/25 at 4:53 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time. The following Plan of Removal, submitted by the facility, was accepted on 09/05/25. Plan of Removal Immediate Threat: On 09/04/2025 an abbreviated survey was initiated at the facility. On 09/04/2025 the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification Immediate Jeopardy (IJ) states as follows: F655 –The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility failed to ensure Resident #17's and Resident #22's baseline care plans addressed their mobility abilities. Action: Director of Nursing reviewed all care plans including baseline care plans to ensure resident mobility, transfers, and supervision needs are included. Findings are recorded in an audit log and no negative findings at this time. Start Date: 09/04/2025 Completion Date: 09/05/2025 Responsible: Director of Nursing Action: Revised admission process and policy to require baseline care plan initiation within 48 hours, verified by Director of Nursing/Assistant Director of Nursing. Education will be provided to nurses, direct care staff and agencies on the revised admission process and policy to require baseline care plan initiation within 48 hours. Nurses, direct care staff and agencies staff will be required to read, acknowledge understanding and sign the in-services before the start of their shift. In addition, competency check (test) has been implemented to ensure understanding. The competency check (test) will be verified by DON for comprehension. Start Date: 09/04/2025 Completion Date: 09/05/2025 Responsible: Director of Nursing/Assistant Director of Nursing Action: Implemented admission checklist and new 'admission Quality Check' form to verify care plan and fall risk completion. Changes will be updated on the report sheet located at the nurses' desk. Education will be provided to nurses, direct care staff and agencies staff to look at the report sheet located at the nurses' desk before start of the shift and a signature is required on the report sheet acknowledging that the changes has been reviewed by the staff. Nurses, direct care staff and agencies staff will be required to read, acknowledge understanding and sign the in-services before the start of their shift. In addition, competency check (test) has been implemented to ensure understanding. The competency check (test) will be verified by DON for comprehension. Start Date: 09/05/2025 Completion Date: 09/05/2025 Responsible: Director of Nursing/Assistant Director of Nursing Action: Monitoring tools will be put in place to capture ongoing audits of all new admits' baseline care plans (daily for 30 days, weekly for 60 days, then monthly ongoing), and findings will be reported in Quality Assurance and Performance Improvement (QAPI). Start Date: 09/05/2025 Completion Date: Ongoing Responsible: Director of Nursing/Assistant Director of Nursing On 09/6/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an audit completed on 09/05/25 by The DON reflected that all care plans and baseline care plans were reviewed ensuring residents mobility, transfers and supervision needs were included. The Audit was verified by a checkoff for each resident completed signed and dated for 09/05/25 by the DON. The Surveyor audited 7 Resident medical records including new admission and readmissions within the last 30 days for verification of baseline care plan included residents' mobility and supervision needs. Record review completed on 09/05/25 of Revised reflected the admission process and policy was updated to require baseline care plan initiation within 48 hours. The policy reflected to include assistive devices needed. Record review of education provided to nurses, direct care staff and agencies on the revised admission process and policy to require baseline care plan initiation within 48 hours. Nurses, direct care staff and agencies staff were required to read, acknowledge understanding and sign the in-services before the start of their shift. A competency check (test) had been implemented to ensure understanding. The competency check (test) was completed and signed by 5 LVNs and 2 RNs from both day and night shifts. Record review completed on 09/05/25 of an Implemented admission checklist and new 'admission Quality Check' form was verified to include care plan and fall risk completion. An Inservice given to Nursing staff was completed to include an updated report sheet located at the nurses' desk directing care staff and agencies staff to look at the report sheet located at the nurses' desk before start of the shift requiring a signature acknowledging that the changes had been reviewed by the staff. Education verification and acknowledgement of understanding per the competency check was signed by 5 LVNs and 2 RNs from both day and night shifts. Record review completed on 09/05/25 of new Monitoring tools was conducted to capture ongoing audits of all new admits' baseline care plans (daily for 30 days, weekly for 60 days, then monthly ongoing). The tool included Baseline care plan initiated within 48 hours of admission. Interviews conducted on 09/06/25 between 6:00am and 8:00am with DON, ADON, LVN C, LCN D, LVN I, LVN E, RN F, from both day and night shifts reflected They had been instructed on baseline care plans ensuring residents' mobility, transfers and supervision needs were included. They stated Nurses, direct care staff and agencies staff were required to read, acknowledge understanding and sign the in-services before the start of their shift. The staff stated agencies they were to look at the report sheet located at the nurses' desk before start of the shift and sign it acknowledging that the resident changes had been reviewed by the staff. The staff verified they were given competency test on their education. On 09/06/2025 at 8:18am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #17 and Resident #22) of 8 residents reviewed for accidents and hazards. The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that The facility failed on 08/04/2025 to ensure appropriate supervision and assistive devices were in place for Resident #17 and Resident #22 to prevent falls. This failure could place residents at risk for injury and hospitalizations related to accidents. An IJ was identified on 09/04/25. The IJ template was provided to the facility on [DATE] at 4:53 pm. While the IJ was removed on 09/06/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Resident #17Record review of facility admission Record dated 08/19/25 reflected Resident #17 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, Hypoxemia (a condition characterized by a below normal level of oxygen), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and heart failure Record review of Fall Risk Assessment for Resident #17 dated 08/01/25 reflected that it was incomplete. Gait / Balance assessment was not observed and left unmarked. Medications and vision were not reviewed on the fall risk assessment. Record review of facility Progress Notes dated 08/04/25 at 4:44PM reflected Resident #17's family member states resident had a fall on 8/3/2025, resident had a bruise near right eye and a large contusion on top of his head near his forehead on the right side, bruising behind both arms, notified Dr and DON, neuro checks initiated, waiting for Dr order. Record review of admission MDS dated [DATE] for Resident #17 reflected section GG: Functional abilities chair/bed-to-chair transfer was marked 04 Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Record Review of Radiology report from The Hospital dated 08/04/25 reflected the fall resulted in minimally displaced acute fractures of the eighth and ninth ribs laterally. Nondisplaced acute intra-articular fracture medial left clavicle extending to the sternoclavicular joint (clavicle fracture). Record review of Resident #17s Medical Records for Baseline Care Plan reflected it was not completed. Resident #22 Record review of facility admission Record dated 08/21/25 reflected Resident #22 was admitted to the facility on [DATE]. Diagnoses included Malignant Neoplasm of Pancreas (cancer of the pancreas), Neoplasm related pain (pain due to cancer), protein calorie malnutrition, and elevated blood pressure. Resident #22 was admitted on Hospice Respite. Review of facility Fall Risk Assessment for Resident #22 dated 07/29/25 reflected that it was incomplete. Medications and vision were not reviewed on the fall risk assessment. Gait / Balance assessment was not observed and left unmarked. Record review of Resident #22's progress notes dated 08/04/25 at 7:55PM reflected patient observed laying on the floor of her bathroom. CNA stated patient had requested to go to the restroom with assistance of 1 (one) staff. CNA gave patient some privacy and gave patient instructions to pull emergency call light when done, patient has successfully used emergency light before. Patient had a small but deep laceration above the right eyebrow. Patient was drowsy but responding to questions, could tell us her name and date of birth . 911 called or transport to emergency room. X3 assisted back into bed using (mechanical) lift. Vital signs: 83/56,100,94%. Dressing applied to head laceration. Emergency medical services in building and provided transport, patient hypotensive and believed to have had a syncopal episode (fainting). She is alert at this time, oriented x2-3. POA called and notified of fall and send out to emergency room. Primary Care Physician and hospice called and notified of fall with emergency room visit. Instructions left with this nurse to call hospice when patient is in facility so follow up visit can be completed. Signed by LVN F. Record review of Resident #22's admission MDS dated [DATE] reflected section GG: Functional abilities toilet transfer was marked 03 Partial/Moderate Assistance-Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Resident #22 was coded as using a walker and a wheelchair for mobility devices. Record review of Resident #22s Medical Records for Baseline Care Plan reflected it was not completed. In an interview on 08/21/2025 at 1:16 PM LVN D stated Resident #17 did not use a walker or wheelchair. The family had brought in a cane from home, but he got around holding onto furniture. She stated he was very mobile. LVN D stated the CNAs always checked with the nurse to verify assistance needed for residents. LVN D stated the nursing assistants never told her that the Kardex (a section of the medical record showing how much and why type of assistance a resident needs) and care plan were never populated for Resident #17 or Resident #22. LVN D stated staff were aware the baseline care plan and Kardex information were important to prevent falls and assist with rehabilitation to ensure residents needs were met. In an interview on 08/21/2025 at 2:36 PM the DON stated the DON stated she was unsure if Resident #17 used any assistive devices other than a cane from home. She stated he was using the furniture for balance. She stated the facility did provide a walker and encouraged him to use that. The DON stated she was not sure therapy did an evaluation on Resident #17. She stated he was admitted late on a Friday and discharged quickly. In an interview on 08/21/2025 at 2:46pm the ADON stated that resident #22 entered the facility on respite care. She stated that the family decided to leave her at the facility under the care of hospice until she passed. The ADON stated that she did not feel that Resident #22 was a fall risk because there were lot of family members around and the resident was not active. The ADON stated that she did not feel that there was a need to have fall precautions in place. In an interview on 09/04/25 at 1:30pm LVN E stated that she was not present when Resident #17 admitted (7/31) to the facility. When she took his blood pressure on 08/03/25 at 9:16am she saw a bruise on his head, but she thought the bruise was from when he admitted . She did not see the knot on his head until the family told her about it. She stated that she initiated a neuro check and post fall assessment at 6:13pm on him. She stated it was an agency nurse working the night shift of 08/03/25, and when she got report from that agency nurse, she was not told that Resident #17 had a fall. She stated that he had a wheelchair and very unsteady gait (ability to walk). LVN E stated Resident #22 could not get up and walk to the bathroom on her own. Resident #22 had a lot of edema (swelling) in her legs and could not toilet transfer on her own. She stated Resident #22 needed active assistance during toileting. She stated that moderate assistance means I person assisting, and I person could have assisted Resident #22 because she was so thin. She stated that Resident #22 was not to be left alone on the toilet, she could have privacy (meaning standing in the doorway with your back toward the resident). In an interview on 09/04/25 at 2:28pm The DON stated that an agency nurse was working the night of 08/03/2025 when Resident #17 fell. The DON stated the nurse failed to conduct a neuro check, post fall evaluation, and report to the ongoing nurse that Resident #17 had a fall during her shift. The DON stated that agency nurse was the one who helped Resident #17 up from the fall, even though originally the resident told the DON he did not tell anyone about the fall. The DON stated Resident #22 used a wheelchair and typically was able to be left alone on the toilet due to being cognitively intact and her ability to sit on the toilet without assistance and had previously demonstrated successful ability to use her call light and sit on the toilet without assistance. She stated that at the time of the fall The DON was told the resident was seated on the toilet, the CNA felt the resident was safe, the call light was in reach, and the CNA was no longer present in the bathroom. She stated that she or the ADON are checking fall risk assessments, check charts every 24 hours to ensure assessments are completed fully. The DON stated she opens baseline care plans upon a resident's admission, the BOM contacts families and will set up baseline care plan meeting with RP within 48 hours of admission. Record review of the facility policy dated September 2012 titled Falls - Clinical Protocol reflected: As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. Staff will ask the resident and the caregiver or family about a history of falling. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, An Immediate Jeopardy was identified on 09/04/25 at 4:53 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time. The following Plan of Removal, submitted by the facility, was accepted on 09/05/25. Plan of Removal Immediate Threat: On 09/04/2025 an abbreviated survey was initiated at the facility. On 09 /04/2025 the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy (IJ) to resident health and safety. The notification of Immediate Jeopardy (IJ) states as follows: F689 - The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that: The facility failed to ensure new admissions received timely and completed fall risk assessments to prevent accidents. Action: All residents assessed for safety and injury. Neurological checks and follow-up assessments initiated on residents with new falls . Two residents were identified with falls requiring neurological checks. Neuro checks were initiated immediately. Licensed nursing staff will perform and document all neurological checks per policy. Nursing staff educated on performing neurological check on resident post fall. All nurses, including PRN and agency nurses will be required to read, acknowledge understanding and sign the in-services before the start of their shift. Start Date: 09/04/2025Completion Date: 09/05/2025Responsible: Director of Nursing/ Assistant Director of Nursing Action:100% audit of all residents' fall risk assessments completed to ensure they are fully documented.Start Date: 09/04/2025Completion Date: 09/05/2025Responsible: Director of Nursing/ Assistant Director of Nursing Action:Registered nurses and license nurses including PRN and agency nurses re-educated on completing fall risk assessments within 24 hours of admission and ensuring proper supervision by the Director of Nursing or designee. PRN and agency nurses will be required to read, acknowledge understanding and sign the in-services before the start of their shift. Nurse consultant or designee will re-educate the Director of Nursing and the Assistant director of Nursing on monitoring that the fall risk assessments are being completed by the charge nurses within 24 hours of admission and ensuring proper supervision by the Nurse Consultant.Start Date: 09/04/2025Completion Date: 09/05/2025Responsible: Director of Nursing/Nurse Consultant Action:Monitoring tool will be put in place to capture daily audits of new admissions for 30 days, then weekly for 60 days, then monthly ongoing, findings will be reported in Quality Assurance and Performance Improvement (QAPI).Start Date: 09/05/2025Completion Date: OngoingResponsible: Director of Nursing/ Assistant Director of Nursing On 09/6/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an audit completed on 09/05/25 by The DON reflected that an all-resident review was completed by The DON ensuring Neurological checks and follow-up assessments were initiated on residents with new falls. Neuro checks were initiated immediately for two residents identified with recent falls verified with record review. Nursing staff were educated on performing neurological check on resident post fall as evidenced by an in-service signed and dated for 09/05/25. Record review of an audit completed on 09/05/25 for all residents for admission fall risk assessment and quarterly fall risk assessments was signed completed by the ADON. Residents had current completed fall risk assessments as evidenced by a review of medical records for 7 residents within the facility. Record review completed on 09/05/25 of an Inservice verified that license nurses including PRN and agency nurses were re-educated on completing fall risk assessments within 24 hours of admission and ensuring proper supervision. The Director of Nursing and the Assistant director of Nursing on monitoring that the fall risk assessments are being completed by the charge nurses within 24 hours of admission and ensuring proper supervision by the Nurse Consultant on 09/05/25. Education was verified for 6 of 8 nursing staff Record review completed on 09/05/25 of new admission Monitoring tools was conducted. The tool included resident name, date of admission, verifying the fall risk assessment was completed along with a baseline care plan. The facility did not have any new admission as of time of exit. The [NAME] stated the tool will be reviewed daily in their morning meeting for verification of completion. Interviews conducted on 09/06/25 between 6:00am and 8:00am with DON, ADON, LVN C, LCN D, LVN I, LVN E, RN F, from both day and night shifts reflected They had been instructed on Fall Policy, Fall Risk Assessments, including assessment of neurological status. The staff stated they had been educated on need for assistive devices and fall prevention measures including keeping beds in low positions, more frequent rounding, and call light placement. The staff were able to identify the report sheet located at the nurses' station to be signed each shift verifying resident changes in condition had been reviewed from one shift to the next. On 09/06/2025 at 8:18am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 of 5 residents (Resident #25) reviewed for unnecessary medications.The facility failed to ensure Resident #25's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication.This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.Findings included:Record review of facility admission Record dated 08/19/2025 reflected Resident #25 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia (a decline in the mental ability interfering with daily life), traumatic brain injury, heart failure, and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). Record review of Resident #25's comprehensive care plan dated 06/27/2025 for Resident #25 reflected Resident #25 uses anti-anxiety medications related to anxiety disorder. Interventions included Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinationsRecord review of facility Significant change in status MDS dated [DATE] reflected Resident #25 had received an antianxiety medication within the last 7 days. Record review of Resident #25's Physician Order Report dated 8/20/25 reflected an order for Lorazepam oral tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for agitation with a start date of 08/03/2025. Record review of Medication Administration record for the month of August 2025 reflected Resident #25 had been administered Lorazepam 0.5mg 1 tablet on 08/07/2025, 08/08/2025, and 08/16/2025. In an interview on 08/21/2025 at 1:10 PM LVN C stated she was not sure why Resident #25's PRN Lorazepam did not have a stop date on it. LVN C stated she was aware PRN Lorazepam should have a stop date and the nurse putting the order into the computer was responsible for obtaining the stop date. LVN C stated the negative effects for not having a stop date on psychotropic medication would be oversedation, dehydration, and changes in mental status. In an interview on 08/21/2025 at 2:36 PM the DON stated staff were aware that there was a 14 day stop date on all PRN psychotropic medications. She stated the stop date did get overlooked at times. The DON stated there needed to be a system put in place to double check that a stop date was added for PRN psychotropic medications. The DON stated not having a stop date on medications such as lorazepam could lead to unnecessary risk of side effects , Record review of facility policy titled Medication Monitoring Medical Management dated 2007 reflected PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and record review, the facility failed to complete a Significant Change MDS assessment with 14 days after the facility determined, or should have determined, there has been a significant change in a resident's physical or mental condition for 1 of 5 residents reviewed for assessments (Resident #25).The facility failed to complete a Significant Change MDS for Resident #25 within 14 days of the resident's admission to hospice services. This failure placed residents who had a significant change in condition requiring an MDS assessment at risk of not receiving needed services. Findings included:Record review of facility admission Record dated 08/19/2025 reflected Resident #25 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia (a decline in the mental ability interfering with daily life), traumatic brain injury, heart failure, and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).Record review of Resident #25's comprehensive care plan dated 06/27/2025 for Resident #25 reflected Resident is now receiving Hospice care related to senile degeneration resulting in a declining condition. Interventions included Facility nursing staff to coordinate medical care with hospice nursing staff, Hospice to follow up in a timely manner to facility and family concerns.Record review of facility Significant change in status MDS dated [DATE] reflected Resident #25 was receiving Hospice services while a resident. In an interview on 08/21/2025 at 2:36 PM Tthe DON stated the facility has a remote MDS coordinator , and they do miss things sometimes. The DON stated the significant change MDS for Resident #25 was one that had been missed and was caught later. She stated the negative effects for missing an MDS assessment could affect the plan of care for the resident. Record review of facility policy titled Comprehensive Assessment and the Care Delivery Process dated 2001 and revised December 2016 reflected to complete the Minimum Data Set within 14 days after admission and within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually.

Based on interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 4 residents (Resident #26) who were reviewed for accuracy of assessments.The facility failed on 5/16/2025 to accurately document Resident #26's diagnosis of depression on her quarterly MDS assessment.This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included:Record review of Resident #26's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: high blood pressure, diabetes mellitus (a body's impaired ability to produce or respond to insulin), hyperlipidemia (excess of lipids or fat in the blood), non-Alzheimer's dementia (decline in cognitive function severe enough to interfere with daily life), adult failure to thrive, muscle weakness, lack of coordination, gastro-esophageal reflux disease (when stomach acid flows back into the esophagus), muscle wasting and atrophy (decrease in size of body part, cell, organ, or other tissue) and ataxia (poor muscle coordination). In Section N-Medications, Resident #26 was indicated as taking an Antidepressant. Her BIMS score was a 10, indicating she had had moderately impaired cognition.Record review of Resident #26's comprehensive care plan dated last revised 6/11/2025 reflected Resident #26 used antidepressant medications Bupropion and Mirtazapine related to depression. Record review of Resident #26's active diagnoses report as of 08/21/2025 reflected no diagnoses of depression listed. Record review of Resident #26's active orders report as of 08/21/2025 reflected an order for 300 MG Bupropion extended release to be given 1 time a day for depression.In an interview on 08/21/2025 at 12:41pm with the MD he stated that Resident #26 had a diagnosis of depression and that she had been doing well on her antidepressant medication. In an interview on 08/21/2025 at 3:21pm with the DON she stated that Resident #26 admitted on an antidepressant, and the facility failed to put depression under her active diagnoses. She stated that inaccurate assessments could lead to incomplete care plans and or need for services such as medications or therapies. Review of the Long-Term Care Facility RAI 3.0 User's Manual dated last revised October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status

Based on interview and record review the facility failed to ensure all medications that were reviewed by the licensed pharmacist were reported to the attending physician and if there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 4 residents (Resident #26) reviewed for unnecessary medications.The facility failed on 04/07/2025 to ensure the medical director documented in Resident #26's medical record the rationale for no action being taken on a GDR recommendation by the licensed pharmacist for Resident #26's Bupropion order (used to treat depression). This deficient practice could affect all residents who have pharmacy recommendations which could place the residents at risk of receiving unnecessary medications.Findings included: Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: high blood pressure, diabetes mellitus (a body's impaired ability to produce or respond to insulin), hyperlipidemia (excess of lipids or fat in the blood), non-Alzheimer's dementia (decline in cognitive function severe enough to interfere with daily life), adult failure to thrive, muscle weakness, lack of coordination, gastro-esophageal reflux disease (when stomach acid flows back into the esophagus), muscle wasting and atrophy (decrease in size of body part, cell, organ, or other tissue) and ataxia (poor muscle coordination). In Section N-Medications, Resident #26 was indicated as taking an Antidepressant. Her BIMS score was a 10, indicating she had had moderately impaired cognition. Record review of Resident #26's comprehensive care plan dated last revised 6/11/2025 reflected Resident #26 used antidepressant medications Bupropion and Mirtazapine related to depression. Record review of Resident #26's active diagnoses report as of 08/21/2025 reflected no diagnoses of depression listed. Record review of Resident #26's Orders revealed that Resident #26 received Bupropion HCl ER tablet 300 mg, given one tablet by mouth one time a day for depression. Record review of Resident #26's consultation report dated 04/07/2025 revealed the following recommendation: This 92yo resident is currently receiving an antidepressant order for buproplon-ER (Wellbutrln-XL) 300mg QD for depression. Clinical Guidelines recommend that these medications be reviewed periodically for dosage reductions in an effort to achieve the lowest effective dose. This resident's records show no behaviors are being documented. Please consider reducing this medication to 150mg QD on a trial basis if you feel this would be helpful. Record review of Resident #26's medication consultation report revealed it was sent to the physician on 04/07/2025 and the Physician's response stated, No Changes and was dated with his signature on 4/10/25. In an interview on 08/21/2025 at 12:55 PM with the MD he stated that when he got GDR recommendation from the pharmacist, he would document his review of the irregularities, the action, if any taken, and a rationale if no action was taken, on the individual printed sheets for each resident, provided by the pharmacist. He stated he would document any changes on the sheet and turned it back into the ADM. He stated that not following the recommendation by the pharmacist depended on the patient and if the recommendation was clinically necessary. He stated it would depend on if the recommendation would help or harm the resident based on their individual needs. He stated that Resident #26 was doing well on the current dose of Bupropion. He stated his rationale for not taking the recommendation by the pharmacist was that he didn't want the resident to have an increase in depressive episodes, as she had been doing well. He stated that she had a diagnosis of major depressive disorder, and it was indicated in his notes . Record review of the facility's policy titled, Medication Utilization and Prescribing, dated July 2016, revealed The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms. The physician and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks. The physician will provide and/or document a rationale when the dose, duration, or frequency of a prescribed medication is greater than commonly accepted practice or the manufacturer's recommendations or the medication is considered high-risk compared to other available, relevant alternatives. The physician will explain and/or document the rationale for not modifying a medication in a situation where an adverse drug reaction is likely. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction, dated July 2022, revealed All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions.Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effo1i to discontinue these drugs.The staff and practitioner will consider tapering under certain circumstances, including when: the resident's clinical condition has improved or stabilized; the underlying causes of the original target symptoms have resolved; non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms.The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #44) of 4 residents reviewed for unnecessary medications. The facility failed on 08/19/2025 to have an adequate indication for use of Midodrine HCl 10mg for Resident #44. This failure could place residents at risk of not receiving the needed monitoring or interventions to prevent potential harm related to adverse side effects.Findings included: Record review of Resident #44's undated face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: congestive heart failure (a chronic condition where the heart cannot pump blood effectively), respiratory failure (inadequate gas exchange by the respiratory system), high blood pressure, severe kidney disease (gradual loss of kidney function), type 2 diabetes mellitus (chronic condition that affects the body's way of metabolizing sugar), iron deficiency, elevated white blood cell count, atrial fibrillation (irregular and often very rapid heart rhythm), edema (swelling caused by excess fluid in the body's tissues), tachycardia (when the heart rate exceeds 100 beats per minute), and tachypnea (rapid, shallow breathing). Record review of Resident #44's undated baseline care plan reflected she was admitted on [DATE] and under part C. Social Services all needs/goals were left blank. Record review of Resident #44's Orders dated 8/19/2025 r evealed an order for Midodrine Oral Tablet 10 MG (used to treat low blood pressure) with a summary of Give 1 tablet by mouth three times a day for with every meal. No diagnosis was listed in the order. In an interview on 08/21/2025 at 12:55 pm, the MD stated he saw Resident #44 for the first time on 08/19/2025. He stated the order for Midodrine 10mg was necessary to combat the residents' low blood pressure. He stated Resident #44's previous order was 5mg , but he increased it due to her recent blood pressures . He stated the order should have indicated the diagnosis it was used to treat and could lead to inaccurate monitoring of side effects by facility staff. Review of the facility's policy titled, Medication Monitoring dated 2007 revealed, Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug - without adequate monitoring;- without adequate indications for its use;- in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or- any combination of these reasons.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Middle Hall-RN Cart) of 2 medication carts reviewed for drug storage. The facility failed on 08/19/2025 to ensure one medication cart (Middle Hall-RN Cart) was locked and that medications were securely stored. This failure could place residents at risk of obtaining and taking medications not prescribed for them which could result in resident's harm due to adverse medication reactions. Findings included: In a continuous observation on 08/19/2025 at 1:04 PM, the medication cart, assigned to LVN E located in front of the nurse's station on the Middle Hall, was unattended and unlocked for approximately 3 minutes, and medications were accessible to residents . No residents were observed near the medication cart at that time.In an interview on 08/19/2025 at 1:07 PM, LVN E stated she was assigned to the medication cart in question, and that she had been attending to another resident, and then she did not lock the cart back when she went to tend to another resident . She stated that a negative outcome of leaving the medication cart unlocked was that a resident could get in it and get medication. She stated she was required to ensure the cart was locked and computer was blank before leaving the cart unattended.In an interview on 8/19/2025 at 1:56 PM, the DON stated, the policy was for the medication cart to be locked and the computer screen blank when not in use in order to secure medications and resident privacy. She stated residents could take medication from the cart which could cause adverse effects with their own medications. Record review of facility policy titled, Storage of Medications, dated April 2007, reflected the following:The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observations, interviews and record review, the facility failed to store, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed on 08/19/2025 to maintain a properly cleaned ice machine used to serve ice to residents.The facility failed on 08/20/2025 to ensure staff who passed trays to residents properly sanitized their hands in between individual meal set up.This deficient practice could place residents at risk of food borne illness. Findings included: In an observation on 08/19/2025 at 9:00 AM of the facility's only kitchen revealed the only ice machine in the kitchen, had brown residue in the upper back area of the ice machine, directly above the ice. Further observation reveled that staff were serving the residents drinks with ice used from the ice machine.In an observation on 08/19/2025 at 12pm, 3 CNA's who were assisting in serving food, did not sanitize their hands in between giving residents their trays.In an observation of lunch service on 08/20/2025, at 12:00 PM, 3 CNAs were observed passing residents' trays without gloves on, nor did they sanitize in between providing residents their trays, and setup assistance. It was also observed that there was no sanitizing station located in the dining area. There was a single sink in the dining area that the CNAs used to wash their hands before they started to pass the trays to the residents.In an observation on 08/21/2025 at 2:00 PM in the facility's 1 of 1 kitchen revealed the presence of brown residue on the upper back part of the ice machine. In an interview on 08/21/2025 at 8:47 am, the DS stated her expectation was that staff who assisted with handing out trays were to sanitize their hands between each tray distribution. She stated that housekeeping refilled the sanitation stations in the dining room. The DS stated that she was unsure what the brown residue was in the ice machine. She stated that she would get a wet towel and clean it. Record review of facility invoices on 08/21/2025 revealed the facility hired a maintenance worker from a third-party vendor for routine maintenance. The invoice reflected the worker cleaned the ice machine and bin. 08/21/2025. According to the vendors notes the ice machine was operating within normal conditions upon arrival. The invoice revealed that the ice machine was inspected for any contamination or possible cause for health risks found, no issues at that time all calcium build up is due to normal operation of equipment. Ice machine was descaled and sanitized.Record review of the facility's policy titled, Nutrition Policies and Procedures Hand Hygiene/Hand Washing, dated 09/2021 reflected Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be always used that hand washing indicated. Employees shall keep their hands and exposed portions of their arms clean.

Based on interview and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 (Resident #26) of 4 residents reviewed for clinical records.The facility failed to document Resident #26's diagnosis of depression in her active diagnoses list in the EHR.This failure could place residents at risk for delays in treatment due to incomplete and inaccurate clinical records.Findings included:Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: high blood pressure, diabetes mellitus (a body's impaired ability to produce or respond to insulin), hyperlipidemia (excess of lipids or fat in the blood), non-Alzheimer's dementia (decline in cognitive function severe enough to interfere with daily life), adult failure to thrive, muscle weakness, lack of coordination, gastro-esophageal reflux disease (when stomach acid flows back into the esophagus), muscle wasting and atrophy (decrease in size of body part, cell, organ, or other tissue) and ataxia (poor muscle coordination). In Section N-Medications, Resident #26 was indicated as taking an Antidepressant. Her BIMS score was a 10, indicating she had moderately impaired cognition.Record review of Resident #26's comprehensive care plan, dated 6/11/2025, reflected Resident #26 used antidepressant medications, Bupropion and Mirtazapine, related to depression.Record review of Resident #26's active diagnoses report, dated 08/21/2025, reflected no diagnoses of depression listed.Record review of Resident #26's Orders dated 7/4/2024 revealed that Resident #26 received Bupropion HCl ER tablet 300 mg, given one tablet by mouth one time a day for depression.In an interview on 08/21/2025 at 12:55 PM, the MD stated when he got a GDR recommendation from the pharmacist, he would document his review of the irregularities, the action, if any taken, and a rationale if no action was taken, on the individual printed pharmacist consultant sheets for each resident, provided by the pharmacist. He stated he would document any changes on the pharmacist's consultant sheet and turn it back into the ADM. He stated not following the recommendation by the pharmacist depended on the patient and if the recommendation was clinically necessary. He stated it would depend on if the recommendation would help or harm the resident based on their individual needs. He stated Resident #26 was doing well on the current dose of Bupropion. He stated his rationale for not taking the recommendation by the pharmacist was that he did not want the resident to have an increase in depressive episodes. He stated she had a diagnosis of major depressive disorder, and it was indicated in his notes. In an interview on 08/21/2025 at 1:10 PM, the DON stated Resident #26 did not have a diagnosis of depression listed in her active diagnoses, and she was not sure why it was left off. She stated that the resident did have that diagnosis and was being treated with an antidepressant.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff reviewed for infection control. (CNA B)The facility failed on 8/20/2025 to practice effective infection control practices when CNA B applied a brief onto Resident #32 after it had been dropped onto the floor during incontinent care.This failure could place residents at risk of being susceptible to bacteria and cross contamination during incontinent care. Findings included:Record review of Resident #32's comprehensive MDS assessment dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: coronary artery disease (reduced blood flow to the heart muscle), high blood pressure, orthostatic hypotension (sudden drop in blood pressure when a person stands up from a sitting or lying position), gastro-esophageal reflux disease (when stomach acid flows back into the esophagus), renal insufficiency (impaired kidney function), renal failure, or end-stage renal disease, diabetes mellitus (a body's impaired ability to produce or respond to insulin), hyponatremia (low sodium levels in the blood), hyperlipidemia (excess of lipids or fat in the blood), thyroid disorder, arthritis (inflammation of the joints), non-Alzheimer's dementia (decline in cognitive function severe enough to interfere with daily life), Parkinson's disease (movement disorder of the nervous system that worsens over time), Seizure disorder, and depression (persistent feeling of sadness). In Section H-Bladder and Bowel, Resident #32 was indicated as being always incontinent. Her BIMS score was a 02, indicating she had severely impaired cognition.Record review of Resident #32's comprehensive care plan dated 08/12/2025 indicated she was treated for a UTI, beginning 6/29/2025, with antibiotics for 7 days. Her interventions included to be checked at least every 2 hours for incontinence and wash, rinse and dry soiled areas. Record review of Resident #32's active orders as of 8/21/2025 revealed she was being treated for a UTI beginning 8/18/2025 with antibiotics, with a stop date of 8/23/2025. In an observation on 8/20/2025 at 3:35 pm, CNA B was observed checking and changing Resident #32's brief. CNA B dropped the clean brief onto the floor beside the resident's bed, picked the brief up off the floor, and placed it on Resident #32.In an interview on 8/21/2025 at 10:43 AM CNA B stated she worked at the facility for 12 years. She stated she recalled dropping Resident #32's brief onto the floor when she was changing her the day before, and that after she dropped the brief, she should have gotten a new one due to cross contamination, but she was in conversation with resident's family members, and she just did not think about what had happened. She stated she had recently been in-serviced on infection control and gave examples of how to properly wash hands to prevent infections, wiping residents correctly, making sure they were consuming enough fluids, and practicing good hygiene. She stated that they were required to check and change residents every 2 hours. In an interview on 08/21/2025 at 11:36AM with the DON she stated that when CNA B dropped the brief onto the floor, she should have discarded that one and replaced it with a clean brief as the one that fell onto the floor could pick up bacteria off the floor and transfer onto the resident. She stated that Resident #32 was receiving antibiotics at the time, to combat a UTI. An Infection Control policy was verbally requested by the state surveyor on 8/21/2025 and it was not provided by the facility before exit.

Based on observations, interviews, and record review the facility failed to Identify and eliminate all known and foreseeable accident hazards in the resident's environment, to the extent possible for 1of 4 residents (Resident #1) reviewed for safety. The facility failed to ensure 1 of 4 residents (Resident #1) was free from risk of accidents and injuries when he was allowed to elope from the facility. The facility failed to properly repair a door for years. An IJ was identified on 04/16/2025. The IJ Template was provided to the facility on [DATE] at 05:09 PM. While the IJ was removed on 04/18/2025, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems. These failures could place cognitively impaired residents at risk for accidents, injuries, and possible death. Findings included: Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with Alzheimer's, stroke, dysphasia (difficulty speaking), heart failure, pacemaker, and lack of coordination. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive and communication abilities were too impaired for him to complete the assessment. Record review of Resident #1's Care Plan, reflected Focus areas were initiated for the following areas: Communication problems-Resident can make basic needs known was initiated on 7/5/23 with an intervention stating, Monitor any changes in ability to communicate. Risk for elopement was initiated on 7/22/24 with an intervention stating, Make sure that wander guard is working . ADL self-care deficit related to stroke was initiated on 7/5/23 with an intervention stating, The resident requires EXTENSIVE assistance by 1 person with personal hygiene. Incontinence focus related to Dementia was initiated on 7/5/23 with an intervention stating, Ensure the resident has unobstructed path to the bathroom. Impaired cognitive function/dementia related to Alzheimer's was initiated on 7/5/23 with an intervention stating, Administer medications as ordered. Monitor/document for side effects and effectiveness. Risk for falls related to gait/balance problems was initiated on 1/18/24 with an intervention stating, Anticipate and meet the resident's needs. Record review of Resident #1's Orders, reflected an order on 7/20/24 to monitor the wander guard to the right ankle, every shift, every day, and night shift. Observation on 4/16/25 at 11:20 AM of the facility's video surveillance revealed Resident #1 was observed on 4/9/25 going out of the door on basement egress side (Door OHD) with no alarm sounding. The video did not show any staff in the area. The Resident crossed the facility back parking lot and walked along the south side of the neighboring Urgent Care Building. The front of the Urgent Care Building was located along the feeder road of a major interstate. Observation of video surveillance revealed Resident #1 went to the front of the urgent care building corner facing the interstate feeder road; then, he turned back to the facility and crossed the back and the front parking lot. He continued going south and crossed a busy residential street then turned left on another residential street. A white car (later identified as C.N.A.-A) driving by stopped and picked him up. He was brought back to the facility at that point. The video revealed the resident was gone for 10 minutes. Observation on 4/16/25 at 12:24 PM revealed Resident #1 wearing a wander guard on his ankle (device that triggers a special alarm and locked the doors if the resident got near the door). Observation on 4/16/25 at 01:10 PM revealed multiple staff going in and out of the OHD for breaks with the alarm sounding shortly each time. Observed the alarm was loud but very short as the staff shut the door quickly to stop the noise. In an interview on 4/16/25 at 10:15 AM the DM stated a lightning strike knocked 3 doors out a couple of years ago. He stated the repair company came out on 4/11/25 to assess the doors and they were waiting on a quote from them. He stated at this point, 3 doors were not working with the wander guard alarms system, and they all had access to the outside of the building. He identified the non-working doors as WHD, WLD, and the OHD. He stated the resident went out the OHD and no alarm sounded, and the wander guard system did not lock the door. He stated the facility was aware the wander guard system was not working on those doors for years, but he was unsure why they had not been repaired. He had installed a contact alarm system on all 3 doors that would alarm only when anyone held the door open and would stop upon the door closing and making contact. The noise/contact alarm was also broken on OHD door, and it failed to work when the resident eloped. DM was the facility person responsible for checking the doors weekly. In an interview on 4/16/25 at 10:26 AM the DON stated there were 3 doors that did not work on the wander guard system and this was not a new problem. She stated 2 of the 3 doors have contact (noise) alarms but the OHD did not have a contact alarm either. She stated the OHD door was the door the resident exited from, and the facility was unaware he had left. She stated the resident was seen by CNA-A as she returned from lunch, and she stopped and brought him back. She stated he was about 1.5 blocks away and going towards a local store. She stated he crossed a residential street but was not injured. She stated he was very confused and was looking for his family. She stated his antipsychotic medication had been reduced from 50mg to 12.5 mg over a couple of months per the Gradual Dose Reduction policy. She said he had gotten near other doors a few times and his wander guard had set of the alarms, but he wasn't exit seeking until 4/9/25. She stated he could get to the freeway and get hurt. In an interview on 4/16/25 at 10:41 AM the DM stated he had replaced the contact alarm on OHD today and moved it higher to avoid it getting broken off. He stated the contact alarm would activate when the door was open now until closed but the wander guard alarm was still disabled pending repairs by the electronic company. In an interview on 4/16/25 at 11:25 AM the DM stated packages were delivered through the OHD, so they likely damaged the previous contact alarm during delivery. He stated the quote for repairs 2 years ago on the wander guard alarm system went to the previous administrator and there was no record of that quote. The wander guard alarm did sound a different alarm and it locked the doors. In an interview on 4/16/25 at 11:40 AM the ADM stated she thought all the doors were repaired and she was unaware 1 was not working. She said the OHD door did not have the contact noise alarm on it that sounds when the connection was broken (when opened). She did not know why that door was not working. She stated they were working with family to try to discharge that resident, but they were waiting on the family and they would just have to monitor him until he could be discharged . She stated the facility was unaware the resident had eloped until their staff saw him outside. She was unsure if you could walk to the interstate but stated they would be putting something up as a barrier if that was a possibility. She said they did have a couple of other doors with noise alarms that did not have wander guard alarms. The DM was checking the doors. In an interview on 4/16/25 at 03:49 PM the DON stated there was not a policy for the facility cameras to be monitored continuously. She stated the wander guard on Resident #1 was definitely working because when he returned through the other door, it set of the wander guard alarm system. In an interview on 4/16/25 at 03:50 PM the DAJ stated there is not a policy to monitor the cameras continuously. There is no paperwork from the 4/11/25 visit from the electronic company assessing the door problems. She stated she would try to get email confirmation from them to provide to me. She stated that some of the cameras are off from real time, but she provided a log to show real time and which camera (multiple cameras around the facility) the resident was showing on as he traveled around the facility on 4/9/25. In a telephone interview on 4/17/25 at 01:29 PM LVN-A stated during her lunch time she saw the resident was with the activity director on the basement level watching activities. Shortly after that, the DON told LVN-A the resident had eloped. LVN-A stated she saw CNA-A holding the resident by his hand and leading him back to the building. She assessed him and there were no injuries, gave him water, and took his vitals which were stable. The doctor had just reduced his antipsychotic medication. She stated most of the time elopement risks need to have alarms on doors like the wander guard. She stated the wander guard makes a different noise and the other type alarms do become like background noise when people open and close the doors. She stated the negative outcome to a resident wandering could be death. She stated people do not pay attention driving and they hit other cars, and they could hit people. She stated we were very close to the interstate. In a telephone interview on 4/17/25 at 01:34 PM the ENG stated he did not look at the alarm system 2 years prior, but he thinks a lightning strike caused the damage. He thinks a repair proposal was sent in December, but that staff was no longer working for his company, so he was not sure if his company followed-up on that. He stated 3 doors need new product/keypads and those doors did not work with the wander guard system now. In a telephone interview on 4/17/25 at 01:45 PM CNA-A stated as she was returning from lunch, she saw Resident #1 walking and she stopped and asked him where he was going. Resident #1 stated he was leaving but he agreed to get in her car, and he let her take him back to the facility. She stated he could have made it to the freeway. She said there was a lot of traffic and people don't pay attention and he could have been hit. She admitted that alarms were sometimes tuned-out and they may assume a staff opened the door. She stated the main door has a wander guard alarm. She stated if dementia residents elope, they could get away and harm themselves. A record review of email correspondence dated 4/16/25 (copy received) between the facility and the engineering company that maintains the alarm systems revealed: Repair person had been out 4/11/25 and confirmed the keypads for the system were not working on 3 exit doors and the damage was most likely got fried because of the lightning storm. A record review of the facility policy titled, Wandering, Unsafe Resident dated 2001 with a last revision date of August 2014 reflected the following: The facility will strive to prevent unsafe wandering . for residents who are at risk for elopement. A missing resident is considered a facility wide emergency. A record review of the facility policy titled, Hazardous Areas, Devices, and Equipment dated 2001 with a last revision date July 2017 reflected the following: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments (e.g., medications). The Safety Committee will recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility (locks, alarms, supervision, etc.) A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: Equipment or devices that are malfunctioning. Devices and equipment that are improperly maintained. Disabled locks, latches, or alarms. The POR were accepted: 4/18/2025 at 8:30 AM and included: PLAN OF REMOVAL IMMEDIATE- Jeopardy On 4/16/25 an abbreviated survey was initiated at this Facility. On 4/16/25 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety The notification of Immediate Threat states as follows: F689 The facility failed to ensure Resident #1 was free from risk of accidents and injuries. l. Immediate Action Taken A. Resident # 1 is currently in the facility. B. On 4/9/25 Resident #1 was returned to the facility via private vehicle by staff and placed on q15 minute monitoring which entails the following: staff visually confirming the resident's location, a log sheet for documenting the resident's location, including space for staff signatures, and timestamp for each observation. C. On 4/16/2025 The DON/ Designee completed a head-to-toe physical assessment on Resident #1 with no negative findings noted D. On 4/16/25 The DON/ Designee updated Resident #1 care plan for wandering/exit seeking E. On 4/16/25 The DON/ Designee completed elopement assessments on all facility residents with no changes noted. F. On 4/16/25 The maintenance director/ Designee completed environmental assessments to include checks on all door alarms. These checks identified 3 nonfunctioning door alarms (100 hall door, west hall door that faces the facility parking lot, and downstairs hallway office door). G. On 4/16/25 The administrator/Designee assigned facility staff to monitor identified nonfunctioning doors and the elevator will be locked during non-business overnight hours to allow no access without facility code to ensure that no resident exits the facility. Upstairs assigned staff will be physically present at the area that accesses the two doors waiting for repair. Department Head staff downstairs will be rotated to ensure visual observation of that door between 8a-5p. After 5p, elevators will be locked and only accessible via key access. Elevators will only be accessible via key access on the weekends. H. On 4/11/25 The Social Worker/Designee checked the wander guard appliances utilized by residents to ensure they were functioning properly with the doors that are currently functioning. No issues were identified with the appliances, and they were identified to be currently functioning properly. I. On 4/16/25 The DON/ Designee completed in-service education with facility direct care staff on the elopement policy. No employee will be allowed to work until they receive this education with drill and posttest. J. On 4/16/25 The DON/ Designee completed a Missing Resident Drill with facility direct care staff to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert via overhead paging to notify all other staff members of the missing resident and to not turn the alarm sound off until all staff are notified of the missing resident and headcount guidelines which requires visual confirmation and documentation regarding the location of each resident in the center. The designated head count coordinator will be the Administrator or DON during business hours (8a-5p) and the designated charge nurse and/or the Manager on Duty during non-business hours. (5p-8a).On 4/16/25 The facility administrator spoke with alarm company in regard to the nonfunctioning door alarm who stated they would have a tech support person to the facility on [DATE] to repair the nonfunctioning door alarms. K. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, on 4/16/25, the DON/Designee completed elopement assessments on all facility residents with no new changes noted. 3. Actions to Prevent Occurrence/Recurrence: A. On 4/16/25, the DON/Designee provided education to facility direct care staff on facility's elopement Policy including missing resident drill. B. On 4/17/25, the DON/Designee provided missing resident posttest to facility direct care staff. These in-services will be accessible via our communications platform (online information system for staff with a required 85% passing score). This will be completed at 6:00 pm on 4/17/2025 and no employee will be allowed to work until they receive this education with drill. Agency staff will be provided these trainings through access from our online communications platform as well. C. Results of facility missing resident drills will be discussed with Facility Administrator/ Designee during the facility recurring daily morning start up meetings. On 4/16/2025 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance with no new orders received. Likelihood for Serious Harm No Longer Exists: 4/17/2025. Signature of ADM on 4/17/2025 On 4/17/25 and 4/18/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: 4/17/25 Monitoring: Observation on 4/17/25 at 11:30 the ENG company at the facility working on the 3 broken doors. Office staff were turning staff away from the OHD door to prevent alarms from sounding when there was not a problem and therefore making a problem very noticeable if it occurred. Observation on 4/17/25 at 04:45 PM revealed the OHD hall staff coordinating if they leave the Office Hall to ensure staff were present to hear the alarm on OHD and to monitor the hall for residents. Observed 1 staff member assigned to the unused nurses station located between WHD and LHD with constant visual monitoring of the doors that weren't working. In an interview on 4/17/25 at 12:48 PM, the DON stated the following steps had been completed: QAPI Meeting held on 4/16/25 at 08:30 PM with the ADM, the DON, and the MD. In-services were done on 4/16/25 and 2 in-services were done on 4/17/25. Another in-service and Elopement Drill were planned for 4/17/25 on the night shift. The ENG company just left, and they confirmed doors not working and ordered the parts. They were supposed to return Monday. She further stated it was important to monitor Dementia residents because they were unaware of their own safety needs and the facility had to keep them safe. She stated the negative outcome to residents if they wander could be injury and death. She stated if alarms sound too often it becomes background noise and that was why they were now coordinating staff to not use the OHD at all so the alarm will not sound if there was not a problem. She stated they were also coordinating the office staff to make sure someone was on the hall. During the business hours the hall was accessible. Record review reflected 3 completed in-services on elopements and alarms with staff signatures attached and dated 4/1625 and 4/17/25. Record review reflected an invoice from the ENG showing doors were worked on and parts were ordered and dated 4/17/25. Record review on 4/17/25 reflected the typed minutes of the QAPI meeting held on 4/16/25 listed topics as facility elopement and the follow-up plan to sustain compliance. Attendees shown as the ADM, the DON, and the MD. 4/18/25 Monitoring: Observation on 4/18/25 at 10:50 AM revealed no residents in rooms or halls on WHD and WLD. Staff were posted specifically at these entrance points and intersections to disallow residents from accessing these doorways. Observed a staff member also posted near the nurse's station (unused station) to ensure residents did not enter that area without staff accompanying them. Observation on 4/18/25 at 11:00 AM revealed the Office Hall where the OHD was located, contained offices in which staff members were observed working with the doors open, monitoring traffic in and out. In an interview on 4/18/25 at 10:48 AM the DON stated the Elopement Drill had been completed and she would provide the documentation for that exercise. The DON stated the 3 doors that were out of service were being monitored and they were disallowing resident traffic on those halls. In an interview on 4/18/25 at 10:53 AM AL stated her role to prevent further elopements until doors were fixed was to sit at the intersection of the 2 [NAME] Halls and not allow anyone to access the malfunctioning doors. She stated this was being done for the safety and protection of the residents. In an interview on 4/18/25 at 11:00 AM the DON stated part of the plan was for staff on this hallway to monitor. She stated the staff were to communicate if they were leaving the hallway with each other to ensure someone was always downstairs. She stated the OHD would sound if opened but not for long, so staff were not to use those doors either to avoid monitoring staff from becoming accustomed to the alarm and unknowingly ignoring the alarm. Record review on 4/18/25 reflected 16 staff signatures on an Elopement Drill Sign-in form. The administrator was notified the IJ was removed on 04/18/2025 at 08:30 AM, however the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems.

Based on observation , interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three of ten (Resident #1, Resident #2 and Resident #3) residents reviewed for quality of care. 1. The facility failed to ensure skin assessment orders for Resident #1 and Resident #2 were followed. 2. The facility failed to ensure Resident #3 was not left in bedding saturated with urine. 3. The facility failed to ensure Resident #3 received incontinent care for over two hours from 3:12 PM until 5:13 PM on 03/06/25. These failures could place residents at risk of skin breakdown, infection, and injury. Findings include: 1. Record review of Resident #1's face sheet, dated 03/07/25, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included dementia , schizoaffective disorder (a mental health condition that combines schizophrenia and mood disorder, such as depression or bipolar disorder) and anxiety disorder . Record review of Resident #1's care plan, dated 10/02/21, reflected a focus of potential for pressure ulcer development related to immobility with a goal of intact skin, free of redness, blister or discoloration, dated 10/02/21, with interventions which included: 1. Follow facility policies/protocols for the prevention/treatment of skin breakdown, dated 10/02/21. 2. Inform the resident/family/caregivers of any new area of skin breakdown, dated 10/02/21. 3. Monitor/document/report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size (lengthy X width X depth) stage, dated 10/02/21. 4. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks out of blood vessels into nearby tissues). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderaterly impairted cognitive. Resident #1 was frequently incontinent. A record review of Resident #1's orders reflected an order for weekly skin assessments, dated 12/04/24 . A record review of the facility's, undated, list of residents with skin issues reflected Resident #1 had a facility acquired skin issue on 03/05/25 etiology (causation) trauma. A record review of Resident #1's skin assessments reflected the following 4 (four) skin assessments between 12/04/24 and 03/07/25: 12/25/24 skin check 01/22/25 skin check 01/29/25 skin check 02/5/25 skin check A record review of the facility's, undated, list of residents with skin issues, reflected Resident #1 had a facility acquired skin issue on 03/05/25 etiology (causation) trauma. A record review of Resident #1's Post Fall Evaluation, dated 03/05/25, reflected a small scratch to her left upper back. A record review of the Resident #1's skin assessments reflected no skin assessments after the Post Fall Evaluation, dated 03/05/25 . 2. Record review of Resident #2's face sheet, dated 03/07/25, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included blindness, one eye, intervertebral disc degeneration, lumbosacral region (a common condition characterized by age-related wear and tear of the spinal discs, potentially causing pain, stiffness, and nerve issues) and Type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). Record review of Resident #2's care plan record, dated 10/02/23, reflected a focus of potential for pressure ulcer development related to immobility with a goal, dated 08/19/24, of intact skin, free of redness, blister or discoloration with intervention, dated 08/19/24, of follow facility policies/protocols for the prevention/treatment of skin breakdown. A record review of Resident #2's MDS, dated [DATE], reflected a BIMS score of 15, which reflected no cognitive impairment. A record review of the facility's, undated, list of residents with skin issues reflected Resident #2 had a facility acquired skin issue on 03/02/25 etiology (causation) skin tear. A record review of Resident #2's orders reflected an order for weekly skin assessments, dated 02/25/25. A record review of Resident #2's Post Fall Evaluation, dated 03/02/25, reflected an open lesion (a region in an organ or tissue which has suffered damage through injury or disease, such as a wound) location buttocks, a skin tear located right lower arm, and skin tear left outer forearm. A record review of Resident #2's skin assessments reflected one skin assessment, Skin & Wound - Total Body Skin Assessment, dated 02/02/25 . 3. Record review of Resident #3's face sheet, dated 03/0/625, reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #3 had diagnoses which included metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), dementia and muscle wasting. Record review of Resident #3's care plan, dated 08/01/23, reflected a focus of occasional bladder incontinence (involuntary loss of urine) with a goal, dated 08/10/23, that resident will remain free from skin breakdown due to incontinence and brief use through the review date. Resident #3 had the care plan intervention, dated 08/10/23, of Resident #3 used disposable briefs, change Q2 hours and prn. Record review of Resident of #3's care plan focus, dated 08/10/23, reflected Activities of Daily Living self-care performance deficit related to aggressive behavior, confusion, dementia, and impaired balance with a goal, dated 08/10/23, resident was dependent for all Activities of Daily Living, staff to anticipate and meet all needs. Resident #3 had care plan intervention, dated 08/01/23, - personal hygiene: the resident required Extensive assistance by 2 staff with personal hygiene. Record review of Resident #3's care plan, dated 08/10/23, reflected a focus, dated 08/10/23, of communication problem related to dementia, Resident #3 was unable to answer questions appropriately, unable to make needs known, her speech was mostly word salad (a jumble of extremely incoherent speech) with a goal, dated 08/10/23, the resident would have basic needs met by staff on a daily basis. Resident had care plan intervention, dated 08/10/23 - anticipate and meet Resident #3's needs. Observation on 03/06/25 at 3:10 PM revealed Resident #3 in her room. While standing at the open door to the resident's room, the resident was seen laying in her bed with the right side of her bed against the wall. The State Surveyor requested Resident #3's permission to come into the room and Resident #3 turned towards the State Surveyor but did not respond. Resident #3 was fingering an adult sensory book (designed for adults who may experience sensory sensitivities or sensory processing difficulties to aid in self-regulation and comfort, featuring textured pages, varied stimuli, and calming elements) and speaking to unintelligibly to herself. The State Surveyor entered the room and stood at the side of Resident #3's bed and asked how she was doing but resident was not interviewable. The State Surveyor felt the following materials approximately 4 inches away from Resident #3's body from her waist to her thighs: 1. Resident #3's fitted sheet 2. the padding above the fitted sheet and placed under Resident #3 3. the top blanket over Resident #3 All three materials were wet and had a strong odor of urine. The State Surveyor asked Resident #3 if she was wet and needed a brief change. Resident #3 looked at the State Surveyor but did not respond and turned her attention to a dog stuffed animal to her left. Observation on 03/06/25 of Resident #3's room beginning at 3:12 PM revealed the following: Staff (name unknown) walked down hallway at 3:42 PM and did enter any resident rooms, at this time, Resident #3 was wet for approximately 25 minutes after initial observation at 3:10 pm. Observation at 4:31 PM, revealed CNA A entered Resident #3's room and no incontinent care performed. Observation at 4:58 PM CNA A entered Resident #3's room and no incontinent care performed . Observation and interview on 03/06/25 at 5:13 PM with CNA A in Resident #3's room, the State Surveyor asked CNA A to check Resident #3 and see if Resident #3 was wet. CNA A checked the front of Resident #3's brief and replied, she was, a little wet. The State Surveyor asked CNA A to feel the areas the State Surveyor felt at 3:10 PM and tell the State Surveyor if she felt fabric was wet. CNA A stated the fabric was wet. Interview on 03/06/25 at 5:17 PM with CNA A, reflected she had worked at the facility for [AGE] years. She said the requirement was for CNAs to round on the residents every 2 hours . CNA A stated rounding meant checking on resident needs and changing their briefs if the resident needed a brief change. She revealed Resident #3 had dementia and could not tell you if she needed her brief changed and she could not use the call light. When asked why she did not change Resident #3's brief when she entered Resident #3's room two times she said she did not think Resident #3 was uncomfortable. CNA A said she was not surprised Resident #3 was wet because Resident #3 was a heavy wetter (urinates frequently and/or in larger volumes). When asked if a resident was a heavy wetter, would that mean that the resident needed to be checked more often , and CNA A said, yes. She said residents who could not use the call light should be checked on more frequently. CNA A said she received incontinence care training and was trained in the importance of incontinence care. She said if you did not check on residents and they were left in briefs soaked in urine for an extended period of time residents could have skin breakdown. Interview on 03/07/25 at 2:41 PM, CNA B stated the facility expectations for residents to be checked on or rounded was every 2 hours. The CNAs were to make sure residents were clean and dry and all their needs were meet. CNA B stated Resident #3 was not able to use the call light and if she had the call light in her hand, she was playing with it. She said if a resident was left in a wet brief for an extended period of time, it could cause chaffing, urinary tract infections, skin sores and it could make residents unhappy. She said the CNAs and the charge nurses were responsible for making sure residents were rounded on and checked, every two hours. Interview on 03/07/25 at 2:21 PM with LVN C revealed she had worked at the facility for about six years and the facility requirement was for staff to round on residents every two hours. Rounding consisted of at least laying eyes on the residents. The CNAs were required to check the residents for incontinence every two hours and as needed. LVN C stated Resident #3 had severe dementia and she could not use the call light, and therefore needed to be rounded on more often. She said charge nurses were responsible for making sure the CNAs were doing rounds every two hours and changing resident briefs. She said when incontinent care was not provided residents could get a urinary tract infection and have skin breakdown. If the resident had severe dementia, and were in wet or soiled briefs, residents could have behavior issues. She said Resident #3 was a heavy wetter and she should have been changed at least once in the two-hour period of time she was observed by the State Surveyor. She said not checking on a resident every two hours was not good resident care. She said if a resident had an order for skin assessments, the order needed to be followed. She said skin assessments needed to be conducted weekly. She said if you did not conduct skin assessments, residents who might have skin breakdown might be missed and wounds could develop. She stated if wounds were bad, residents could get sepsis and could die. Interview on 03/07/25 at 1:58 PM with LVN D revealed she had worked at the facility for 2 years and 4 months. She said she was required to check in and round on residents every two hours. Rounding consisted of checking to make sure the resident had their call light and water, make sure they were responsive, confirming they had their fall interventions and check to see if they needed their brief changed. She stated if a resident was left in urine for a period of time the skin could break down and skin breakdown could happen quickly especially if residents were not independently mobile. She stated Resident #3 could not use the call light and needed more frequent checks. She said it was the responsibility of the charge nurse (LVN D said she was a charge nurse) to confirm the CNAs were doing resident rounds and resident incontinent care. She said skin care orders should be followed because the staff wanted to be sure skin was intact to prevent infections. Interview on 03/06/25 at 11:14 AM with the DON stated both Resident #1 and Resident #2 should have received skin assessments in accordance with their orders and skin assessments after their facility acquired skin issues. She said because the staff were not doing resident skin assessments, a skin assessment order was added for all residents in an effort to make sure the staff did the skin assessments. She stated skin assessments were important because if skin was assessed regularly, skin injury and issues could be prevented. She stated it was a problem that skin assessments were not being completed as ordered. She said CNAs were supposed to make rounds on residents every two hours and if a resident was left too long in a wet brief, a resident's skin could breakdown. When State Surveyor told the DON about her observations of CNA A with Resident #3, the DON said that scenario was not acceptable resident care, and the staff should have 100% checked Resident #3 and changed her brief. The DON stated if a resident was a heavy wetter they needed to be checked more frequently and needed more frequent brief changes. She said Resident #3 had severe dementia and was unable to let staff know about her needs and needed to be checked on and her brief changed more frequently. Record review of facility's Nursing Policy: Certified Nursing Assistant (CNA) Rounding Applicable to: Certified Nursing Assistance (CNAs), Licensed Nursing Staff, dated 10/21/14, reflected Purpose: To ensure timely and consistent care for residents by establishing structured rounding for CNAs. The policy aims to enhance residents' safety, comfort, and satisfaction while promoting a proactive approach to meeting resident needs. Policy Statement CNAs shall conduct regular rounds during each 12-hour shift to monitor and assist residents with their activities ADLs, ensure safety, and promptly address their needs. Rounding must be structured, documented, and performed at designated intervals to provide high-quality care. Procedure: Frequency of CNA Rounding Each 12-hour shift shall include routine CNA rounding as follows: Two-hour Rounds: Every two hours, CNAs will provide hands-on care, including by not limited to Assisting with toileting and incontinence care Checking for hygiene needs and providing perineal care as needed CNAs much document completed round in the electronic health record or designated rounding log Missed round must be documented with a reason and report to the supervising nurse Record review of the facility's Incontinent Care Policy, dated 10/21/24, reflected: POLICY: Residents are checked for incontinence every 2 hours and as needed. PURPOSE: It is our goal at [facility name] to keep residents incontinent of bowel and bladder clean and dry throughout the shift [12 hr. shifts]. PROCEDURE: CNAs are trained to check for incontinence of bowel and bladder every 2 hours and as needed. CNAs are to change the resident's adult brief and perform incontinent care when the resident is wet and/or soiled. On the occasion a resident is not wet and/or soiled, it may not be necessary to perform incontinent care. The CNA is to notify the nurse the resident did not void. However, if a resident calls the CNA for incontinent care since the last check, the CNA will perform incontinent care for the resident. CNAs are not to leave their residents wet and/or soiled before leaving their shift. Record review of the facility's Pressure Ulcer Policy, undated, reflected: Purpose: [Facility name] holds paramount the quality of care of residents. Definition: a pressure ulcer (a bed sore or pressure sore) is a dark or red area, a break or a deep, crater like wound in the skin caused by pressure. Pressure ulcers usually develop over bony parts of the body. Factors that may increase the risk of getting pressure ulcers include: Sitting or lying too long in one place Sitting in wet clothing or a wet bed Procedures: Residents' skin is checked: Within 24 hours of admission On a regular schedule At least weekly depending on the situation Whenever their condition changes Any change to the skin or unhealing skin conditions are reported through the change-of-command. Residents at-risk are closely watched by staff especially those that Can't move, don't move or are restrained Are incontinent (not able to control their bladder or bowel) Have active acute medical or psychiatric conditions Any changes to the skin or unhealing skin conditions are reported through the change-of-command .

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #4) reviewed for ADL care. The facility failed to ensure toenails for diabetic Resident #4 were smooth and trimmed. This failure could place residents at risk of skin tears and infection. Findings include: Record review of Resident #4's face sheet, dated 03/07/25, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included chronic pain, acute myocardial infarction (heart attack), cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die) and Type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). Record review of Resident #4's care plan record reflected a focus, dated 03/21/24, of Activities of Daily Living self-care performance deficit related to activity intolerance due to COPD (a group of lung diseases that cause airflow obstruction and breathing difficulties), pneumonia , and respiratory failure with a goal dated 03/21/24 to maintain current level of function in Activities of Daily Living. Resident #4 had the following intervention, dated 03/21/24: 1. The resident requires limited assistance by staff with personal hygiene. 2. The resident requires skin inspection Q Day, observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse Record review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderately impaired cognition. Observation on 03/06/25 at 3:57 PM of Resident #4's nails, revealed Resident #4 lying in his bed with his feet bare. His nails were yellowish in color, thick and overly long with uneven jagged edges. Interview on 03/06/25 at 3:57 PM with Resident #4 revealed the only thing he really needed was someone to look at his toenails because when he put socks on, his toenails made his toes sore, and it bothered and aggravated him. He couldn't cut his toenails himself because he was a diabetic and he couldn't reach his toes to cut them. He said he had not had his toes trimmed in about a year. Resident #4 gave the State Surveyor permission to take a photograph of his toenails. Interview on 03/07/25 at 1:58 PM with LVN D reflected, after showing her the photograph of Resident #4's toenails, Resident #4 needed toenail care . She said the possible negative effects of not getting toenails cared for were infection or an open skin injury. Interview on 03/07/25 at 2:21 PM with LVN C reflected, after showing her the photograph of Resident #4's toenails, Resident #4 needed toenail care. She stated the nurses were supposed to trim the nails for diabetic residents. She said if nails were not trimmed, residents could get scratches and cuts from sharp nails. The jagged edges of the toenails could get filed and he should have been referred to podiatry. She said the charge nurses were responsible for making sure nail care is taken care of . Interview on 03/06/25 at 11:14 AM with the DON reflected Resident #4 was a diabetic and a nurse would need to do his nail care but there was nothing in Resident #4's chart that reflected he was receiving nail care. The possible outcome of a resident not getting their nails clipped were wounds and Resident #4 was a diabetic and there could be wound complications . Record review of the facility's Activities of Daily Living Policy, dated 2018, reflected Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain grooming, and personal and hygiene. Policy Interpretation and Implementation: Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plain of care, including appropriate support and assistance with: a. Hygiene (grooming )

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for one (1) of one kitchen reviewed for food storage and sanitation. The facility failed to ensure food and beverages were labeled and dated in the dry storage, walk-in refrigerator, and freezer. This deficient practice could place all 57 residents at risk of food borne illnesses. The findings included: Kitchen observation on [DATE] at 12:07 pm of a dry storage cabinet, revealed an open bag of brown powder with brown powder on the shelf. The open bag was labeled cumin and there was no date on the bag. Kitchen observation on [DATE] at 12:10 pm in the walk-in fridge, revealed a container labeled applesauce [DATE]|,d+[DATE] and a container labeled prunes ,d+[DATE]. During an interview on [DATE] at 12:10 pm the DM stated the applesauce with a date of [DATE]|,d+[DATE], should have been thrown out after [DATE] and the prunes should have been discarded after [DATE]. Kitchen observation on [DATE] at 12:11 pm outside the walk-in fridge, revealed a tray of partially frozen hotdogs sitting outside the walk-in fridge. Inside the walk-in fridge, an observation of a tub of covered drink glasses with a white liquid in them. The tub was not labeled or dated. During an interview on [DATE] at 12:12 pm the DM stated the hotdogs had been taken out of the freezer in preparation for another meal the next day. The DM stated the hotdogs should not be sitting out but should have been put in the fridge. The DM identified the glasses of liquid as milk and noted they should have been labeled and dated. Kitchen observation on [DATE] at 12:12 pm in the walk-in fridge revealed a plastic container of plastic wrapped items not labeled or dated. During an interview on [DATE] at 12:12 pm the DM stated the items were sliced cheeses and lunch meat and should have been labeled and dated before being put away. Kitchen observation on [DATE] at 12:12 pm in the freezer revealed a bag of loosely wrapped frozen potatoes, a zip bag of frozen hash browns, and an opened bag of frozen okra, not labeled or dated. During an interview on [DATE] at 12:13 pm the DM identified the items as potatoes, hash browns, and fried okra and stated they should have been labeled and dated before being put away. During an interview on [DATE] at 12:15 pm [NAME] 1 stated he had been at the facility 2 years and had received training on how to properly store food. He stated it was his responsibility to label and date food items, but he got busy and forgot. He stated it was important to store food correctly because we have to make sure we don't serve spoiled food to the residents; they could get very sick. During an interview on [DATE] at 12:18 pm [NAME] 2 stated she had been at the facility [AGE] years and had received training on how to store and label food. She stated they needed to make sure we throw it out after 3 days because we can't serve resident's old food. She stated, they could get sick, get a virus, throw up or be real sick. During an interview on [DATE] at 12:34 PM the DM stated she was responsible for the kitchen and to ensure all food was appropriately stored. The DM stated they had their full book survey back in June of 2024 and the kitchen received a dietary citation for not properly storing food. The DM stated she did in-services with all dietary staff about how to properly label and date food for storage. She stated, I guess I'm going to have to in-service again. The DM stated she typically does weekly audits for food storage and if she finds things not correctly labeled, dated, or stored, she will fix it herself and then go talk to her staff. She stated she was pretty sure the applesauce and prunes were used after the dates when they should have been discarded, but no residents have gotten sick that I know of. The DM stated it was important to properly store food because the residents could get really sick, have stomach problems, have to go to the hospital, even death. During an interview on [DATE] at 12:50 am the AD stated it was the DM's responsibility to ensure food was properly stored. The AD stated she had been at the facility since January and was aware of the previous dietary citation from the [DATE] survey. She stated to her knowledge, no one from corporate had done in-services with the DM after the survey citations. She stated it was important to store food correctly to ensure residents do not get sick but no one has gotten sick from the food that I know of. During an interview on [DATE] at 12:55 pm, the DON stated that the facility currently had no residents that were provided nourishment through tube feedings. He stated all residents ate meals out of the facility kitchen. He further stated that all residents could potentially get sick or contract a food borne illness if expired food or improperly stored food was served from the kitchen. Review of the facility's, undated, policy, titled Food Date/Label Policy reflected: PURPOSE: It is the purpose of this facility to ensure time/temperature sensitive food and beverage products are dated and labeled according to the manufacture's requirements and state/federal regulations.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #2, and Resident #4) of five residents reviewed for quality of care. The facility failed to conduct a fall assessment or skin assessment after Resident #1 had a fall on 05/06/24. The facility failed to utilize a two person assist for Resident #1 while providing care, Resident #1 slipped out of bed causing an abrasion to her back and bruising on her face on 05/06/24. The facility failed to document a fall, conduct a fall assessment or a skin assessment after Resident #2 had an unwitnessed fall on 06/23/24 resulting in fractured ribs. The facility failed to document a fall and complete fall and skin assessments after Resident #4 had a fall and was sent to the hospital on 06/02/24 and was diagnosed with a scapula fracture. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/26/24 at 7:03 PM. While the IJ was removed on 08/29/24at 4:45 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Review of Resident #1's quarterly MDS assessment, dated 04/16/24, Section A (Identification Information) reflected a[AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including unspecified dementia, lack of coordination, muscle wasting and atrophy (thinning of muscle tissue due to disuse or nerve problems), and a history of falling. Section C (Cognitive Patterns) reflected no BIMS score as resident was rarely or never understood. She had both long- and short-term memory impairment. Section GG (Functional Abilities) reflected she was dependent for bed mobility and bed to chair transfers. Review of Resident #1's comprehensive care plan, revised 12/17/23, reflected in part, Resident #1 has an ADL self-care performance deficit related to aggressive behavior, confusion, dementia, and impaired balance. The resident will maintain current level of function in ADLs through the review date. Interventions included, Bed mobility: The resident requires EXTENSIVE assistance by 2 staff to turn and reposition . The resident requires EXTENSIVE assistance by 2 staff with personal hygiene . The resident requires EXTENSIVE assistance by 2 staff for toileting . The resident requires SKIN inspection every day. Observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. A second entry reflected, Resident #1 is high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs. The resident will be free of minor injury through the review date. Interventions included, Anticipate and meet needs, be sure the call light is within reach, follow facility fall protocol. Review of a progress note dated 05/06/24 reflected, Resident noted on floor when writer entered room from hearing scream. Per CNA, during incontinence care resident was turned on side while aide on opposite side providing peri-care when resident sat up and began to slide off of bed onto floor. Red abrasion to mid back noted. No further injuries note at this time. Vitals WNL. Mechanical lift 2-person assist back to bed. MD notified and POA notified. Review of Resident #1's progress notes from 05/07/24 through 05/09/24 reflected no post-fall follow up notes. Review of Resident #1's progress note dated 05/10/24 reflected, [NAME] to yellow bruising noted to left jaw line. Will monitor until resolved. Review of Resident #1's assessment log from 05/06/24 through 05/15/24 reflected no fall assessments. Review of Resident #1's skin observation tool dated 05/10/24, reflected bruising to left jaw line and previous witnessed fall 4 days past. Review of Resident #1's progress note dated 05/12/24 at 1:14 PM, reflected, Family here to visit at lunch. Daughter questioning bruising and swelling to left jaw. Daughter requesting resident go to ER for eval and treatment. Provider notified, okay to send to ER. ADM, DON, ADON notified. Review of Resident #1's radiology reports from the acute hospital, dated 05/12/24 reflected in part, Clinical indication: Injury or trauma, blunt trauma, injury date 05/06/24, injury details: Fall six days ago. The reports reflect a CT of the head, a CT of the cervical spine, and a CT of the face, all without contrast. There were no acute findings on the CT exams. The general instructions reflected the resident was treated for Multiple contusions (bruises) to the nose and left hip. Review of the facility's self-report signed by the ADM, dated 05/14/24, reflected in part, The resident had a recent fall with the result of hitting the nightstand. The Investigation Summary reflected, Resident had a fall previously and resulted in hitting head on nightstand. Review of an undated statement in the self-report folder, written by CNA D, reflected in part, LVN E checked resident and she was a little red on face and scratch on back . Review of a statement dated 05/12/24, written by CNA B, reflected in part, While assisting Resident #1 with her morning meal on 05/06/24, I noticed a slight redness to the left side of her face at the jaw line . On my next shift the following day, I noticed the redness to her jawline was more prominent . During an interview on 08/26/24 at 11:20 AM, LVN A stated she did not work the day Resident #1 fell so she was unaware of injuries. When reminded that she had given Resident #1 medication and written a progress note that day, she stated she did not recall the events of that day. LVN A stated if a resident fell , the nurse was notified and the nurse completed a head-to-toe assessment. She stated the nurse would complete an incident report and a nursing note then document every shift for 72 hours. She stated if it was an unwitnessed fall, they completed neuro checks. She stated she had not had any recent training on falls or the fall policy. During an observation and interview on 08/26/24 at 11:27 AM, CNA B stated Resident #1 fell on the night shift and she worked the day shift. She stated there was a very light bruise on the left side of Resident #1's face from the temple to the chin. She stated it got darker over the next few days. She stated she reported the bruising to LVN A. She stated the furniture in Resident #1's room was in the same position it was in on the day of the fall. Resident #1 was observed lying in bed. The bed was up against the wall on one side and the nightstand was against the wall next to the head of the bed. If resident sat on the edge of the bed, the nightstand would be on her left side. During an interview on 08/26/24 at 12:40 PM, CNA C stated she got report from CNA D the morning after Resident #1 fell . She did not know if anyone was in the room at the time other than CNA D. She stated the resident had a red mark on her back and an area on her face that was blue a couple of days after the fall. She stated she reported the injuries to LVN A. During an interview on 08/26/24 at 1:37 PM, the MDS Nurse stated she updated the care plan after a resident had a fall. She stated she got information from the nursing staff and updated the interventions. She stated she did not keep a fall log or complete a fall assessment. She stated she was not familiar with the facility policy about keeping a fall log. After reviewing Resident #1's comprehensive care plan, the MDS nurse stated no new interventions were implemented after the fall on 05/06/24. During an interview on 08/26/24 at 2:18 PM, the ADON stated it was her expectation that after a fall, the nurse would have assessed the resident, complete a head-to-toe assessment, a post fall assessment, and if the fall was unwitnessed or the resident hit their head, initiated neuro checks. She expected the nurse to write a progress note. The nurse would report to the family and the doctor and initiate an incident report. She stated there was a post-fall assessment form in the electronic medical records but she was not sure if all the staff used that form after a fall. She stated there is a change of condition assessment and some staff may complete that form instead. The ADON stated the electronic medical record system was updated 07/31/24 and since that time, some forms and documents have been renamed. She stated they did not use paper charts for documentation. The ADON stated there was not a fall log instead they used the incident reports to track falls. She stated the MDS Nurse and medical records person were responsible for auditing the incident documentation. Regarding Resident #1's fall on 05/06/24, she stated it was CNA D and LVN E in the room providing care when the resident fell . During an interview on 08/26/24 at 3:03 PM, the ADM stated she did not recall the details from 05/06/24 when Resident #1 fell . She stated she did not initially report the fall because it was witnessed. She stated she reported a few days later after the bruising appeared. She stated she believed it was CNA C who was in the room when the resident fell but she could not recall what other staff member was in the room. She stated the nurse was supposed to assess the resident and notify the doctor after a fall. She stated what they did next varied depending on if the fall was witnessed or not. During a telephone interview on 08/26/24 at 3:17 PM, LVN E stated she worked on 05/06/24 when Resident #1 fell . She stated CNA D was in the room by herself when the resident fell . She stated CNA D was the only CNA assigned to the hall that night and maybe that is why there was not a second person in the room. She stated Resident #1 required 2-person assist for care. She stated she was nearby and heard a thump. When she entered the room, the resident was on the floor. She stated she did a body assessment and saw an abrasion on the resident's back but did not see any other injuries. She stated she documented her findings in the medical record and notified the appropriate parties. She stated she reported the fall to the oncoming nurse in shift report. She stated after a fall the nurse was responsible for documenting in the electronic medical record. She stated the nurse would complete a body assessment, notify the doctor and chart in the electronic medical record. She stated neuro checks should be done if the fall was unwitnessed or if the resident hit their head. She stated not monitoring a resident after a fall could result in missing a change in the resident. During a telephone interview on 08/26/24 at 4:45 PM, the primary MD stated he usually got a text from the nurse if there is a fall with no injury or immediate concerns. She stated if there is something requiring more attention, he usually got a phone call. He stated he did not recall the details of Resident #1's fall on 05/06/24. He stated he expected the nurse to complete a thorough assessment after a fall. He stated he expected the nurse would initiate neuro checks if a resident hit their head during a fall. He stated it was very concerning that neuro checks were not completed for this fall as that was part of the standard routine when a resident hit their head. He stated depending on the level or severity of a head injury, there could be multiple negative outcomes. During an interview on 08/27/24 at 11:20 AM, the DON stated he had worked at the facility for a very short time. He stated he had started to build a timeline regarding Resident #1's fall because he believed the facility did everything they should have done for the resident. He stated the documentation was lacking, we missed the mark but that should not rise to the level of an IJ. He stated he had not looked at the documentation on the other residents. He stated they did not know if Resident #1 hit her face during the fall or if the bruise happened sometime later. He stated, But, bruises don't just show up yellow, that is some time into the healing process. He stated the policies provided yesterday were not the right policies as he talked with the corporate and each facility can revise their policies as needed. He stated he had received new policies from a sister facility that were dated. He stated he was still looking for policies in two large binders. During a telephone interview on 08/27/24 at 12:15 PM with CNA C, she stated she was alone in the room with Resident #1, getting her ready for incontinent care, when suddenly, the resident started to sit up in bed then the resident and the bedding started to slide off the bed. She stated the nurse was right there, she just stepped out to get medication when it happened. She stated she tried to hold the bedding but the resident ended up on the floor. She stated LVN E came in and assessed the resident then they used the lift to get the resident back in bed. She remembered there was a red mark on Resident #1's back but does not remember the resident hitting her head or having a red mark on her face. She stated she was aware the resident required two staff for incontinent care. She stated the next time she worked, the resident had started to bruise but she did not remember what color the bruise was. 2. Review of Resident #2's quarterly MDS assessment, dated 06/10/24, Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including unspecified injury of head, unsteadiness on feet, muscle wasting and atrophy (thinning of muscle tissue due to disuse or nerve problems), history of falling, rheumatoid arthritis (a chronic disorder that damages joints and other body systems), and cancer. Section C (Cognitive Patterns) reflected a BIMS score of 2, indicating severely impaired cognition. Section GG (Functional Abilities) reflected the resident required partial/moderate assistance with bed mobility and transfers. Review of Resident #2's comprehensive care plan revised 03/28/24, reflected in part, Focus: The resident is at risk for falls r/t confusion, deconditioning, incontinence. Goal: The resident will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach . Follow facility fall protocol . A second entry revised 06/26/24, reflected I part, Focus: 06/23/24 The resident had an actual fall without injury due to poor balance: fell coming from bathroom without walker. Remind to use walker and get assistance before ambulating. Goal: The resident will resume usual activities without further incident through the review date. Interventions: Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document/report PRN for 72 hours to MD for s/sx pain, bruises, change in mental status new onset confusion, sleepiness, inability to maintain posture, agitation. Review of Resident #2's progress notes from 06/21/24 through 06/26/24, reflected in part, a note written 06/24/25 at 2:21 PM, Day 1 post fall: patient is experiencing muscle soreness and is requiring 2 person assist with transfers/ambulating, patient is usually a 1 person assist. A note written 06/25/24 at 8:52 AM Patient this AM was requesting this nurse to send to the ER at this time, reporting, I think I have broken ribs from when I fell . A note written 06/25/24 reflected resident agreed to mobile x-ray coming to the facility. A note written on 06/25/24 at 2:00 PM reflected x-rays were ordered. There was no note describing a fall, a head-to-toe assessment, or any injuries sustained. Review of Resident #2's radiology report dated 06/25/24 at 6:40 PM, reflected in part, Age-indeterminate mildly displaced fracture at anterior ninth rib is noted. Age-indeterminate nondisplaced fracture at anterior sixth to eight ribs are noted. Remaining ribs are without acute findings . Lumbar spine fusion hardware is noted. Review of Resident #2's fall assessment log reflected no fall assessment was completed after the fall on 06/24/24. 3.Review of Resident #4's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including muscle wasting and atrophy (a chronic disorder that damages joints and other body systems), abnormalities of gait and mobility, other lack of coordination, and osteoarthritis (a joint disease that causes breakdown of cartilage and bone). Section C (Cognitive Patterns) reflected a BIMS score of 6 indicating severely impaired cognition. Section GG (Functional Abilities) reflected the resident required substantial/maximal assistance with bed mobility and transfers. Review of Resident #4's comprehensive care plan, revised 12/02/24, reflected in part, Focus: Resident is at risk for falls related to gait/balance problems . Goal: The resident will be free of falls through the review date. Interventions: Remind resident to ask for assistance when transferring. Reminders for safety precautions given not to lean, bend, stoop from wheelchair. Anticipate and meet needs. Ensure call light is in reach and remind resident to use it. Follow facility fall protocol. The resident needs a safe environment. A second entry revised 06/25/24, reflected in part, Resident had an actual fall with skin tear to right wrist and back of hand and a red hematoma to right side of head. Goal: The resident's injured area will resolve without complications by review date. Interventions: Continue interventions on the at-risk plan. Monitor injuries for healing and/or complications. Monitor/document/report PRN for 72 hours to MD for s/sx pain, bruises, change in mental status . Review of Resident #4's progress notes from 05/27/24 through 06/18/24, reflected a note dated 06/02/24 at 11:00 PM, Late Entry: F/U to fall on previous shift. This writer with aide assistance transferred resident back to facility. Family waiting in room upon arrival. Patient seen in emergency room due to fall causing injury to head and right shoulder . Shoulder immobilizer in place. Subsequent notes on 6/3/14 and 6/4/24 reflected the immobilizer in place. None of the notes addressed the head injury. Review of Resident #4's Clinical Report from the acute hospital dated 06/02/24, reflected in part, Chief complaint, fall off a chair. Lost balance. Location of injuries - head and right shoulder. CTs of the head and right shoulder were completed. Clinical impression, Closed nondisplaced acromion fracture of the right scapula. Review of Resident #4's assessment log from 08/31/20 through 08/19/24, reflected no fall assessment or skin assessment after the resident fell on [DATE]. During an observation and interview on 08/26/24 at 11:10 AM, Resident #4 was sitting up in her motorized wheelchair in her room. She held a baby doll in her lap. She denied remembering any falls or injuries recently. She stated she came to this hospital after having the baby. She pointed to the doll on her lap. During an interview on 08/27/24 at 10:45 AM, CNA B stated they learned of the resident's physical abilities from the report from the hospital when they come to the facility. From that report, they would have known if the resident required one or two people for assistance. If she did not have that report, she would have asked the aid from the previous shift how the resident transferred or moved in bed. She stated if the resident required two staff for incontinent care, it was not okay to do it alone. She stated she would grab her partner or the nurse to help. She stated if the resident required two and you did it by yourself, the resident could fall or you could hurt your back. During an interview on 08/27/24 at 11:15 AM, the ADON stated it did not meet her expectations that documentation in the records is not accurate. She stated she expected the nurses to follow the policies. She stated she still believed some of the problems were related to the electronic medical record system being changed. During an interview on 08/27/24 at 12:05 PM with CNA F, she stated there were signs in the resident rooms indicating if they required assistance of one or two staff for care and transfers. She stated it was not okay to perform care alone if the resident required 2-person assist. She stated she had to get another aid or even the nurse to help if the resident required two people. She stated doing that by herself could result in skin tears, a fall out of bed, or something else depending on the situation. She stated when a resident fell , she had to notify the nurse and not move the resident until after the nurse had completed an assessment. She stated if she saw a new wound, bruise, or skin issue, she had to notify the nurse immediately. Review of the undated facility policy Falls - Prevention and Risk Reduction reflected in part, The MDS Coordinator will: d. Update interventions on the falls care plan with any new occurrence of falls. Review of the undated facility policy Falls - Risk Assessment and Identification reflected in part, 4. Fall risk assessment must be completed: d. After any fall. Review of the undated facility policy Falls - Post-Fall Protocol reflected in part, 3. The Unit Nurse will: a. Assess the resident from head to toe, and make sure it is safe to assist the resident to a chair before moving him. c. Take a full set of vital signs. e. Interview the resident and any witnesses of the fall to determine the exact circumstances and cause of the fall. f. After the assessment and treatment is done, notify the resident's responsible family member and physician. g. Document the fall in the resident's chart and the 24-hour report. h. [NAME] the spine of the resident's chart for acute charting. i. Fill out and follow through with an Incident Report. 8. The MDS Coordinator will: a. Enter the fall in the Falls Log with its time, date, and location. b. Complete a fall risk assessment which includes a full medication review. c. Add new interventions to the resident's fall risk care plan. Review of the undated facility policy Nursing Documentation reflected in part, 5. Acute Conditions and Incidents: b. A nursing note must be completed every shift each day until the acute condition is resolved. Incidents should be charted every shift for 3 days, and if the incident was a fall, vital signs should be included. The ADM and DON were notified on 08/26/24 at 7:03 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 08/28/24 at 2:01 PM and indicated the following: The Immediate Jeopardy involves the following concerns: Assessment and documentation to follow up with any incident reports. Root cause of immediate jeopardy: Based on the evidence, documentation has not been completed during after incidents and assessments completed per policy. On 8/26/2024 an abbreviated survey was initiated. On 08/26/2024 the surveyor provided immediate jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes immediate threat to resident health and safety. The notification of immediate jeopardy states as follows: F684 The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Actions taken to remove Immediate Jeopardy: 1. update appropriate policies per facility protocol (DON/ADON) 2. in-service nursing staff on the policy for incident assessment. Anyone not available will be notified via texting system here. Agency and new hires in-servicing before shift. (DON/ADON) 3. Auditing incident reporting x 3 prior months (DON) 4. ensure care plans are accurate (audit) (MDS) These actions will take place on 08/27/2024 and complete by 8/29/2024. Training: DON/designee will update policies as needed immediately to include but not limited to incident reports, documentation and care plans. MDS coordinator will audit all care plans for accuracy. In-service direct nursing staff (full time, prn and agency) on incident reporting, documentation, following the care plan. (ADON complete) ADON will be in-serviced by DON from our sister facility. Notification of in-servicing will be notified via the group texting software at the facility. DON/designee will audit all incident reports weekly for accuracy. This is a process that will be indefinite monitoring process. Monitoring: DON/designee will ensure all incident reports are complete with all assessments completed. These will be audited weekly and discrepancies will be addressed immediately and discussed during QAPI monthly for 3 months. MDS will audit care plans weekly for a month and quarterly afterwards. Any discrepancies will be noted during QAPI. DON/designee will ensure that policies are up to date and changed as needed. In-services will be conducted until all direct care staff has been in-serviced and then upon new hire. The facility will keep a check off schedule to ensure accuracy. The Surveyor monitored the POR on 08/29/24 as followed: Review of an in-service conducted on 8/28/24 - 08/29/24 and conducted by the ADON reflected six policies and presentation titled, Untie the Knot Strategies for Unraveling the Complexity of Care Planning in Long Term Care was sent out by text to all staff. 100% of the nursing staff replied via the software program, indicating the material was received and read. Review of the policies updated and reviewed by the DON from 08/27/24 through 08/29/24 and included in the training were as follows: Resident Examination and Assessment Revised April 2007 Neurological Assessment Revised August 2002 Care Plans - Comprehensive Revised October 2009 Accidents and Incidents - Investigating and Reporting Revised July 2017 Charting and Documentation - July 2017 Charting Errors and /or Omissions - December 2006 During interviews and telephone interviews conducted on 08/29/24 from 10:53 AM - 3:50 PM, one RN, four LVNs, and six CNAs from both shifts stated they were in-serviced on falls, assessments, care plans, and 2-person assistance. All staff reported they received the training material via text on 08/28/24 and the staff in the facility reported training at the beginning of their shift. They stated if there was a fall, the nurse would be notified and the resident would be assessed for injuries prior to being moved. The nurse would conduct a head-to toe assessment and note any injuries or skin concerns. All licensed staff stated if the fall was unwitnessed, or the resident hit their head, they would initiate neuro checks. The licensed staff stated they would complete an incident report and document thoroughly in the resident's chart. They stated they would report the fall to the DON, family, and provider immediately after assessing the resident. The licensed staff all stated documentation was imperative because if you did not document, it did not happen. The staff all stated all stated it was important to follow the care plan and have two staff available to provide care when the resident required two staff. Review of an Audit of Incident Reports from 05/02/24 through 07/29/24 and conducted by the DON, reflected all incident reports were reviewed to ensure the provider and responsible party was notified, documentation was initiated, neuro checks were initiated as needed, if injuries were present, and if the resident was sent out for further evaluation. Review of an Audit of care plans completed by the MDS Nurse on 08/29/24, reflected all care plans were reviewed for accuracy and updated as needed. The ADM was notified on 08/29/24 at 4:45 PM that the IJ had been removed. While the IJ was removed on 08/29/24 at 4:45 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to ensure Resident #1 received 2-person assistance, as specified in the care plan, when CNA D provided incontinent care independently resulting in Resident #1 falling out of bed on 05/06/24, causing an abrasion on her back and bruising on her face . This failure could place residents at risk of injuries, falls, and a decline in quality of life. Findings included : Review of Resident #1's quarterly MDS assessment, dated 04/16/24, Section A (Identification Information) reflected a[AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including unspecified dementia, lack of coordination, muscle wasting and atrophy, and a history of falling. Section C (Cognitive Patterns) reflected no BIMS score as resident was rarely or never understood. She had both long- and short-term memory impairment. Section GG (Functional Abilities) reflected she was dependent for bed mobility and bed to chair transfers. Review of Resident #1's comprehensive care plan, revised 12/17/23, reflected in part, Resident #1 has an ADL self-care performance deficit related to aggressive behavior, confusion, dementia, and impaired balance. The resident will maintain current level of function in ADLs through the review date. Interventions included, Bed mobility: The resident requires EXTENSIVE assistance by 2 staff to turn and reposition . The resident requires EXTENSIVE assistance by 2 staff with personal hygiene . The resident requires EXTENSIVE assistance by 2 staff for toileting . The resident requires SKIN inspection every day. Observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. A second entry reflected, Resident #1 is high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs. The resident will be free of minor injury through the review date. Interventions included, Anticipate and meet needs, be sure the call light is within reach, follow facility fall protocol. Review of a progress note dated 05/06/24 reflected, Resident noted on floor when writer entered room from hearing scream. Per CNA, during incontinence care resident was turned on side while aide on opposite side providing peri-care when resident sat up and began to slide off of bed onto floor. Red abrasion to mid back noted. No further injuries note at this time. Vitals WNL. Mechanical lift 2-person assist back to bed. MD notified and POA notified . Review of Resident #1's progress notes from 05/07/24 through 05/09/24 reflected no post-fall follow up notes. Review of Resident #1's progress note dated 05/10/24 reflected, [NAME] to yellow bruising noted to left jaw line. Will monitor until resolved. Review of Resident #1's assessment log from 05/06/24 through 05/15/24 reflected no fall assessments. Review of Resident #1's skin observation tool dated 05/10/24, reflected bruising to left jaw line and previous witnessed fall 4 days past. Review of Resident #1's progress note dated 05/12/24 at 1:14 PM reflected, Family here to visit at lunch. Daughter questioning bruising and swelling to left jaw. Daughter requesting resident go to ER for eval and treatment. Provider notified, okay to send to ER. ADM, DON, ADON notified. Review of Resident #1's radiology reports from the acute hospital, dated 05/12/24 reflected in part, Clinical indication: Injury or trauma, blunt trauma, injury date 05/06/24, injury details: Fall six days ago. The reports reflect a CT of the head, a CT of the cervical spine, and a CT of the face, all without contrast. There were no acute findings on the CT exams. The general instructions reflected the resident was treated for Multiple contusions (bruises) to the nose and left hip. Review of the facility's self-report signed by the ADM, dated 05/14/24, reflected in part, The resident had a recent fall with the result of hitting the nightstand. The Investigation Summary reflected, Resident had a fall previously and resulted in hitting head on nightstand. Review of an undated statement in the self-report folder, written by CNA D, reflected in part, While changing Resident #1 she started sitting up in middle of brief change, she started sliding off bed . LVN E checked resident and she was a little red on face and scratch on back . We set her down sitting next to bed that is when she got scratch. Review of a statement dated 05/12/24, written by CNA B, reflected in part, While assisting Resident #1 with her morning meal on 05/06/24, I noticed a slight redness to the left side of her face at the jaw line . On my next shift the following day, I noticed the redness to her jawline was more prominent . During an interview on 08/26/24 at 11:20 AM, LVN A stated she did not work the day Resident #1 fell so she was unaware of injuries. When reminded that she had given Resident #1 medication and written a progress note that day, she stated she did not recall the events of that day. LVN A stated if a resident fell , the nurse was notified and the nurse completed a head-to-toe assessment. She stated the nurse would complete an incident report and a nursing note then document every shift for 72 hours. She stated if it was an unwitnessed fall, they completed neuro checks. She stated she had not had any recent training on falls or the fall policy. During an observation and interview on 08/26/24 at 11:27 AM, CNA B stated Resident #1 fell on the night shift and she worked the day shift. She stated there was a very light bruise on the left side of Resident #1's face from the temple to the chin. She stated it got darker over the next few days. She stated she reported the bruising to LVN A. She stated the furniture in the Resident #1's room was in the same position it was in on the day of the fall. Resident #1 was observed lying in bed. The bed was up against the wall on one side and the nightstand was against the wall next to the head of the bed. If resident sat on the edge of the bed, the nightstand would be on her left side. During an interview on 08/26/24 at 12:40 PM, CNA C stated she got report from CNA D in the morning after Resident #1 fell . She did not know if anyone was in the room at the time other than CNA D. She stated the resident had a red mark on her back and an area on her face that was blue a couple of days after the fall. She stated she reported the injuries to LVN A. During an interview on 08/26/24 at 1:37 PM, the MDS Nurse stated she updated the care plan after a resident had a fall. She stated she got information from the nursing staff and updated the interventions. She stated she did not keep a fall log or complete a fall assessment. She stated she was not familiar with the facility policy about keeping a fall log. After reviewing Resident #1's comprehensive care plan, the MDS nurse stated no new interventions were implemented after the fall on 05/06/24. During an interview on 08/26/24 at 2:18 PM, the ADON Stated it was her expectation that after a fall, the nurse would have assessed the resident, complete a head-to-toe assessment, a post fall assessment, and if the fall was unwitnessed or the resident hit their head, initiated neuro checks. She expected the nurse to write a progress note. The nurse would report to the family and the doctor and initiate an incident report. She stated there was a post-fall assessment form in the electronic medical records but she was not sure if all the staff used that form after a fall. She stated there is a change of condition assessment and some staff may complete that form instead. The ADON stated the electronic medical record system was updated 07/31/24 and since that time, some forms and documents have been renamed. She stated they did not use paper charts for documentation. The ADON stated there was not a fall log instead they used the incident reports to track falls. She stated the MDS Nurse and medical records person were responsible for auditing the incident documentation. Regarding Resident #1's fall on 05/06/24, she stated it was CNA D and LVN E in the room providing care when the resident fell . During an interview on 08/26/24 at 3:03 PM, the ADM stated she did not recall the details from 05/06/24 when Resident #1 fell . She stated she did not initially report the fall because it was witnessed. She stated she reported a few days later after the bruising appeared. She stated she believed it was CNA C who was in the room when the resident fell but she could not recall what other staff member was in the room. She stated the nurse was supposed to assess the resident and notify the doctor after a fall. She stated what they did next varied depending on if the fall was witnessed or not. During a telephone interview on 08/26/24 at 3:17 PM, LVN E stated she worked on 05/06/24 when Resident #1 fell . She stated CNA D was in the room by herself when the resident fell . She stated CNA D was the only CNA assigned to the hall that night and maybe that is why there was not a second person in the room. She stated Resident #1 required 2-person assist for care. She stated she was nearby and heard a thump. When she entered the room, the resident was on the floor. She stated she did a body assessment and saw an abrasion on the resident's back but did not see any other injuries. She stated she documented her findings in the medical record and notified the appropriate parties. She stated she reported the fall to the oncoming nurse in shift report. She stated after a fall the nurse was responsible for documenting in the electronic medical record. She stated the nurse would complete a body assessment, notify the doctor and chart in the electronic medical record. She stated neuro checks should be done if the fall was unwitnessed or if the resident hit their head. She stated not monitoring a resident after a fall could result in missing a change in the resident. During a telephone interview on 08/26/24 at 4:45 PM, the primary MD stated he usually got a text from the nurse if there is a fall with no injury or immediate concerns. She stated if there is something requiring more attention, he usually got a phone call. He stated he did not recall the details of Resident #1's fall on 05/06/24. He stated he expected the nurse to complete a thorough assessment after a fall. He stated he expected the nurse would initiate neuro checks if a resident hit their head during a fall. He stated it was very concerning that neuro checks were not completed for this fall as that was part of the standard routine when a resident hit their head. He stated depending on the level or severity of a head injury, there could be multiple negative outcomes. During an interview on 08/27/24 at 11:20 AM, the DON stated had worked at the facility for a very short time. He stated they did not know if Resident #1 hit her face during the fall or if the bruise happened sometime later. He stated, But, bruises don't just show up yellow, that is some time into the healing process. During a telephone interview on 08/27/24 at 12:15 PM, with CNA C, she stated she was alone in the room with Resident #1, getting her ready for incontinent care, when suddenly, the resident started to sit up in bed then the resident and the bedding started to slide off the bed. She stated the nurse was right there, she just stepped out to get medication when it happened. She stated she tried to hold the bedding but the resident ended up on the floor. She stated LVN E came in and assessed the resident then they used the lift to get the resident back in bed. She remembered there was a red mark on Resident #1's back but does not remember the resident hitting her head or having a red mark on her face. She stated she was aware the resident required two staff for incontinent care. She stated the next time she worked, the resident had started to bruise but she did not remember what color the bruise was. During an interview on 08/27/24 at 10:04 AM, a policy for ADLs was requested from the ADM. She stated she would look for the policy. During an interview on 08/27/24 at 10:45 AM, CNA B stated they learned of the resident's physical abilities from the report from the hospital when they come to the facility. From that report, they would have known if the resident required one or two people for assistance. If she did not have that report, she would have asked the aid from the previous shift how the resident transferred or moved in bed. She stated if the resident required two staff for incontinent care, it was not okay to do it alone. She stated she would grab her partner or the nurse to help. She stated if the resident required two and you did it by yourself, the resident could fall or you could hurt your back. During an interview on 08/27/24 at 11:20 AM, a policy for ADLs was requested from the DON. He stated he would look in the binders for the policy. During an interview on 08/27/24 at 12:05 PM with CNA F, she stated there were signs in the resident rooms indicating if they required assistance of one or two staff for care and transfers. She stated it was not okay to perform care alone if the resident required 2-person assist. She stated she had to get another aid or even the nurse to help if the resident required two people. She stated doing that by herself could result in skin tears, a fall out of bed, or something else depending on the situation. She stated when a resident fell , she had to notify the nurse and not move the resident until after the nurse had completed an assessment. She stated if she saw a new wound, bruise, or skin issue, she had to notify the nurse immediately. Review of the facility in-service records from May through July 2024, reflected a Falls and Resident Rights in-service was conducted on 05/13/24. Review of the undated facility policy Falls - Risk Assessment and Identification reflected in part, 6. c. The Nursing Assistant Care form must indicate the resident's i. Weight-bearing status ii. Balance problems iii. Method of transfer iv. Transfer aids v. How many staff members are required for transfer and ambulation. No policy on ADLs was received prior to exit.

Based on interview and record review the facility failed to consult with the resident's physician when there was a need to alter treatment significantly for one of five residents reviewed for a change of condition (Resident #1). The facility identified that Resident #1 had a bruise and small break in skin with blood draining from the wound on her left ankle (06/01/12). Twenty-two hours later the wound continued to bleed. The facility did not notify the physician until 6 hours later (28 hours after the wound was first identified) when the wound continued to bleed, the resident complained of pain, the bruise had extended to the entire foot, there were no pedal pulses, and there were crepitus sounds. Resident #1 was diagnosed on [DATE] with open, comminuted, displaced fractures to her left distal tibia and fibula requiring surgical repair. In a comminuted, displaced fracture, the bone snaps into many pieces and the pieces are not lined up straight. An open fracture is one in which the bone breaks through the skin; it may then recede back into the wound and not be visible through the skin. This failure to consult with a physician resulted in a delay of treatment and additional pain to Resident #1 and could have resulted in additional tissue trauma, infection and loss of limb. Failure to notify the physician of a change in condition could result in a delay in treatment to the additional four residents reviewed with a change of condition. The findings include: Review of Resident #1's Face Sheet dated 02/04/11 reflected she was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] documented she had moderately impaired cognitive skills for daily decision making; disorganized thinking; hallucinations; and physical, verbal and other behavior symptoms. She required extensive assistance by one person for bed mobility and total assistance on two people for transfers. She did not ambulate. Review of Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Care Plan updated on 05/10/11 documented she was at risk for bleeding secondary to anticoagulation therapy. Interventions included monitoring for bruising. The Care Plan also documented she had potential for combative behavior, was dependent on two staff members for transfers, and had a [DIAGNOSES REDACTED]. Review of Resident #1's Incident/Accident Report dated 06/02/12 reflected that on 06/01/12 at 8:45 AM a CNA noted a dark purple, 1 cm bruise to Resident #1's left outer ankle with a tear in the middle that was bleeding. The nurse cleaned it with normal saline and applied a TAO dressing and then a gauze pressure dressing. The Incident/Accident Report documented Resident #1's physician was not contacted until 06/02/12 at 1:05 PM. In a telephone interview on 06/06/12 at 2:05 PM, LVN N said she worked from 7:00 PM on Thursday, 05/31/12, to 7:00 AM on Friday, 06/01/12. Resident #1 was usually in bed before 7:00 PM and did not get up until after 7:00 AM. She did not require any transfers during the night. There was no report of anything unusual during the night. When LVN N did her walking rounds with the oncoming nurse at 7:00 AM on 06/01/12 the resident was still in bed. In a telephone interview on 06/06/12 at 7:55 PM CNA F said she worked from 7:00 PM on 05/30/12 to 7:00 AM on 05/31/12 and again from 7:00 PM on 05/31/12 to 7:00 AM on 06/01/12. On 05/31/12 Resident #1 was in an exceptionally good mood and was not combative. She was talking in a friendly manner, which was not really normal for her. CNA F saw Resident #1 at 5:00 AM on 06/01/12. She did incontinent care. She did not observe anything unusual; there was no blood on the sheets or on her ankle. She did not remember whether the resident was wearing socks. She did not get her out of bed. CNA F said the night staff never got Resident #1 up out of bed. In a telephone interview on 06/06/12 at 3:10 PM CNA E said she worked from 7:00 AM to 3:00 PM on 06/01/12. She was not Resident #1's assigned aide, but she got the resident up for breakfast for CNA B on 06/01/12. She did incontinent care but did not change the resident's clothes. The resident was already wearing her socks. She did a head to toe inspection of the resident and did not see any bleeding or anything unusual. She did not get help from any other staff member to transfer the resident from the bed into the wheelchair. There was no problem with the transfer. She did not provide care to Resident #1 for the rest of her shift. When asked why she did not get help with the transfer, CNA E said Resident #1 used to require two people for transfers, but she lost weight, and now CNA E could transfer the resident by herself. Review of CNA E ' s undated written statement reflected: " On Friday, June 1, I got (Resident #1) up about 7:00 AM to go to the feeding room for breakfast. (Resident #1) didn't complain of any pain. I didn't see any bruises or anything on her leg. I set her up in her chair one time. She wasn't my assigned resident. " In an interview on 06/06/12 at 9:50 AM and 06/06/12 at 2:30 PM CNA A said he was not assigned to be Resident #1's aide on Friday, 06/01/12. CNA E got the resident up out of bed and into the wheelchair for breakfast. After breakfast CNA A helped CNA B transfer the resident from the wheelchair back into the bed using a gait belt. He noticed blood on her sock but did not observe blood on her sheets. CNA B was the resident ' s assigned CNA and she said she would notify the resident's nurse. He helped CNA B get her up again for supper using a gait belt. CNA A did not see blood again on Resident #1's ankle on 06/01/12. Throughout the day and during the two transfers he performed with CNA B, Resident 1 showed no signs or pain; no grimacing or guarding to her left ankle. On 06/02/12 CNA A helped CNA B get Resident #1 out of bed and into the wheelchair for breakfast. He observed blood on her sock again. They told the night nurse, LVN O and she changed the dressing. Review of CNA A ' s written statement dated 06/01/12 reflected: " I helped (CNA B) put (Resident #1) to bed and saw blood on her sock. Then I left the room so I could tend to my residents. " In an interview on 06/06/12 at 10:40 AM CNA B said she was Resident #1's assigned CNA on the 7:00 AM to 7:00 PM shift on 06/01/12 and 06/02/12. Resident #1 ' s behavior symptoms included calling the staff ugly names. She was easily annoyed or agitated. Just getting her out of bed got her agitated. When she started her shift on 06/01/12 Resident #1 was already up in her wheelchair. After breakfast CNA A and CNA B transferred Resident #1 from the wheelchair to the bed using a gait belt. When they laid her down onto the bed they noticed blood on her bed linen and all over her left ankle. CNA B said the sock was covered with blood. She told the nurse, and she put a dressing on it. She watched the nurse apply the dressing and observed that the left foot was swollen. There was a dark area on the ankle with a little pin-sized hole that was bleeding. Resident #1 complained only one time on 06/01/12 that her ankle hurt. She was up for all three meals on 06/01/12 and did not complain of pain or show signs or symptoms of pain such as guarding or grimacing. She continued to bleed through the dressing and CNA B said the nurses had to change the dressing again two or three times on 06/01/12. On Saturday, 06/02/12, CNA A and CNA B got Resident #1 up for breakfast. The CNA observed dried blood in the linens " like a puddle. " She got the nurse to change the dressing. After lunch the resident was bleeding again through her dressing and her sock. She complained of pain. CNA B had to pick up her foot to put it on a pillow and it did not sound right. She got the nurse, and the resident was sent to the emergency room . Review of CNA B ' s written statement dated 06/02/12 reflected: " I (CNA B) 7:00 AM to 7:00 PM CNA went to lay (Resident #1) down with the help of another CNA (CNA A). I noticed that (Resident #1 ' s) left ankle was bleeding, so I went and got the charge nurse. She came immediately and took care of it and the nurse did notice that it was swelled (sic). This was on Friday, 06/01/12. In a telephone interview on 06/06/12 at 7:30 PM RN M said when Resident #1's wound was first reported to her on the morning on 06/01/12 her foot appeared swollen. There was a 1 centimeter (cm) bruise and a small open area of skin in the middle of the bruise. She did not check the resident ' s range of motion to that joint. She thought the wound was a pressure wound. Resident #1 had chronic bilateral [MEDICAL CONDITION] in her lower extremities; both feet were swollen. When she put pressure on it to clean it with normal saline the resident complained of pain. But, she did not complain of pain or grimace when she applied the dressing or through the rest of the day. She saw on the resident at least two more times that day after lunch and supper. There were no issues and no other report of bleeding on 06/01/12. On Saturday, 06/02/12, when RN M did walking rounds at 7:00 AM with the night nurse, the night nurse told her she had to change the dressing. RN M said she did not remember whether the night nurse meant she had to change the dressing during the night. She observed the night nurse change the dressing on the morning of 06/02/12. There was still no complaint of pain from the resident at 7:00 AM. The foot was swollen but the bruise on her ankle remained the same. Some swelling to both her feet was normal. RN M saw Resident #1 again after lunch and the ankle was bleeding. When she put pressure on it to stop the bleeding she heard a cracking sound. The whole foot had become blue. When asked why she did not call the doctor on the morning of 06/02/12 since it had been bleeding for 22 hours, the nurse said she was going to go back and look at it again on the morning of 06/02/12 but she got busy. She did not assess the range of motion to the left foot, compare the [MEDICAL CONDITION] of the left foot against the [MEDICAL CONDITION] in the right foot, or check for pedal pulses until after lunch on 06/02/12. Review of Resident #1's Nurse's Notes dated 06/02/12 reflected a late entry for 06/01/12 at 8:45 AM signed by RN M. "Called by CNA to resident's room. Noted a one centimeter in diameter bruising to outer left ankle with a tiny tear in the middle. Blood noted coming out from the wound. Swelling noted to bilateral feet. Pitting [MEDICAL CONDITION] +2 noted. Wound cleaned with normal saline. Applied TAO. Applied pressure, covered with gauze and tape. Resident has a chronic pedal swelling. When cleaned with saline resident said 'ouch' but didn't complain of pain when wound was dressed." At 10:00 AM RN M documented she asked the wound care nurse to assess Resident #1's ankle wound. "Wound Care Nurse replied we don't do bruises." At 7:00 PM RN M documented she reported the incident to the night nurse. Review of the facility ' s "Standing Orders" signed by a nurse practitioner on 12/09/11 reflected: " NS and TAO for minor wounds as needed." In an interview on 06/06/12 at 10:00 AM Medication Aide (MA) C said she worked on both Friday, 06/01/12, and Saturday, 06/02/12. She had to give Resident #1 medication three times on each of those days. On Friday, 06/01/12, she was fine. She was not in a bad mood, did not exhibit behaviors and did not show signs or symptoms of pain. On Saturday, 06/02/12, she was already up in her wheelchair when MA C gave her the morning medications. She was in a bad mood and was cussing and hollering, but that was normal for her. She did not show signs or symptoms of pain. Review of Resident #1's Nurses' Notes dated 06/02/12 at 12:50 PM and signed by RN M reflected "Went to resident's room to do wound care. Noticed blood still coming out from the wound. Applied pressure. Resident complained of pain. After five minutes of applying pressure, blood still coming out from the wound to left outer ankle. Asked the CNA to get the supervisor. Assessed left foot. Foot still swollen; bruising noted. Complained of pain when moved. At 1:05 PM supervisor called on call (doctor) and received new order to send to ER to evaluate left foot swelling, bruising, pain, and wound." At 3:00 PM on 06/02/12 RN M documented the emergency room called and informed her the resident had a fracture to her tibia and fibula; she was being admitted to the facility; and would be having surgery. "Nurse from ER also said it's an old fracture. It did not happen yesterday but days old." Continued review of Resident #1's Nurses Notes dated 06/02/12 reflected at an unspecified time the nurse was called to room to assess Resident #1's wound to her left ankle. "Noted nickel sized purple area to left outer ankle with tiny tear in the skin. Thin serosanguinous drainage present. Also noted drainage coming from wound with touching around the area. Resident complained of pain. Noted left foot with bruising, swelling. Unable to palpate pedal pulse. Cap refill two to three seconds. Attempted to perform ROM (range of motion) to left foot. Resident complained of pain. Noted the feeling of crepitus with ROM. Will notify physician of findings to left foot. Discussed with (RN M). Order received to send resident to ER for x-ray." The nurses' notes documented the call was made to the physician at 1:05 PM. Review of Resident #1 ' s emergency room report dated 06/02/12 reflected she arrived at the emergency room at 1:48 PM on 06/02/12. The hospital documented her left ankle had severe pain when palpated, had ecchymosis (bruising), soft tissue swelling, and bloody discharge. The resident was alert only to person. In an interview on 06/06/12 at 11:30 AM at the hospital where Resident #1 was admitted on [DATE] and was still a patient, emergency room , RN Z said, when Resident #1 arrived at the emergency roiagnom on [DATE] her left foot was swollen and purple. When she lifted the resident ' s left leg her foot just dropped down. It was bleeding " drip, drip, drip. " She had a two to three millimeter puncture wound on her left ankle. There was no sheering to indicate a pressure wound. There was a pool of blood under the skin of her left ankle the size of a half dollar. RN Z called the facility and talked to Resident #1 ' s nurse to see if any blood work had been done such as an INR (international normalized ratio) given that the resident was on [MEDICATION NAME]. (INR studies are used to measure the clotting tendency of blood. A high INR increases the risk for bleeding; a low INR increases the risks for blood clots.) The nurse told her they had not called the physician and had not gotten laboratory studies. The emergency room doctor said the fracture was a least a day to two days old. RN Z also said the resident had small pin-point size bruises all over her arms that did not appear to be caused by transfers but rather a possible side effect of [MEDICATION NAME]. The hospital ran lab studies and found her INR levels were within acceptable ranges. There was no skin breakdown and no sign or symptom of infection. In an interview on 06/07/12 at 9:30 AM the Administrator and DON said it was their expectation that the nurse call the physician for a wound that continued to bleed, especially since Resident #1 was receiving [MEDICATION NAME]. The DON said RN M should have at least called the physician on Saturday morning, 06/02/12. The Physician ' s Desk Reference (<http://www.pdr.net/drugpages/concisemonograph.aspx?concise=374>, accessed on 06/12/12) stated the targeted INR for a patient receiving [MEDICATION NAME] for [MEDICAL CONDITION] was 2 to 3. Resident #1 ' s laboratory study dated 05/23/12 documented her INR was 1.57. Her laboratory study dated 06/02/12 (at the hospital) was 3.06. The hospital documented a range of 2.5 to 3.5 for treatment of [REDACTED]. It did not offer a therapeutic range for the treatment of [REDACTED]. Resident #1 ' s hospital history and physical report (H&P) dated 06/02/12 documented: " Left distal tibia-fibula fracture. This appears, by history, to be an acute problem and appears to be an open compound fracture as well. . . . Discussed with Orthopedics, and overall, it is felt that this would have a moderate to high probability of developing to severe infection that can either spread systemically or require a surgery for [REDACTED]. For this reason, we will advocate to the family that she undergo surgery and cleared her medically. " Review of the facility ' s In-service Report dated 10/26/11 reflected an in-service related to documentation and notifying the physician or changes in resident status. RN M ' s name did not appear on the in-service sign-in sheet. Attached to the sign-on sheet was the policy and procedure for consulting with the physician. It documented that the physician should be notified immediately when a contusion (bruise) was accompanied by significant pain or bleeding or for any suspected fracture or discoloration. Review of Resident #1 ' s hospital clinical record reflected no evidence of infection. No culture and sensitivity studies were taken. A laboratory study dated 06/03/12 was negative [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). A complete blood count study dated 06/02/12 at the hospital documented her white blood cell count was 7.2 thousand per cubic millimeter (thou/mm3), with a reference range of 4.0 to 11 thou/mm3. Resident #1's Imaging Report dated 06/02/12 of her left ankle at the hospital documented the impression of "comminuted, displaced fractures of the distal tibia and fibula. The ankle joint remains intact." The study also documented "diffuse demineralization is noted throughout the lower leg, ankle and foot." In an interview on 06/06/12 at 1:45 PM the Administrator stated she was the facility ' s abuse and neglect coordinator. She said she did not know anything about Resident #1 ' s ankle injury until she was notified on Saturday, 06/02/12, that the resident was being transferred to the emergency room . In an interview on 06/06/12 at 8:30 AM the Administrator stated the facility census was 106.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibited nelgect to one of five residents reviewed for a change of condition (Resident #1). The facility identified that Resident #1 had a bruise and small break in skin with blood draining from the wound on her left ankle (06/01/12). Twenty-two hours later the wound continued to bleed. When the wound was first identified to the left ankle and for the following 22 hours, the facility did not assess the resident's range of motion to the injured ankle or assess the circulation to the extremity below the wound (pedal pulses). The facility did not notify the physician until 6 hours later (28 hours after the wound was first identified) when the wound continued to bleed, the resident complained of pain, the bruise had extended to the entire foot, there were no pedal pulses, and there were crepitus sounds. Resident #1 was diagnosed on [DATE] with open, comminuted, displaced fractures to her left distal tibia and fibula requiring surgical repair. In a comminuted, displaced fracture, the bone snaps into many pieces and the pieces are not lined up straight. An open fracture is one in which the bone breaks through the skin; it may then recede back into the wound and not be visible through the skin. This failure to properly assess Resident #1's injury and to consult with her physician resulted in a delay of treatment and additional pain to Resident #1 and could have resulted in additional tissue trauma, infection and loss of limb. Failure to properly assess and notify the physician of a change in condition could result in a delay in treatment to the additional four residents reviewed with a change of condition. The findings include: Review of Resident #1's Face Sheet dated 02/04/11 reflected she was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] documented she had moderately impaired cognitive skills for daily decision making; disorganized thinking; hallucinations; and physical, verbal and other behavior symptoms. She required extensive assistance by one person for bed mobility and total assistance on two people for transfers. She did not ambulate. Review of Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Care Plan updated on 05/10/11 documented she was at risk for bleeding secondary to anticoagulation therapy. Interventions included monitoring for bruising. The Care Plan also documented she had potential for combative behavior, was dependent on two staff members for transfers, and had a [DIAGNOSES REDACTED]. Review of Resident #1's Incident/Accident Report dated 06/02/12 reflected that on 06/01/12 at 8:45 AM a CNA noted a dark purple, 1 cm bruise to Resident #1's left outer ankle with a tear in the middle that was bleeding. The nurse cleaned it with normal saline and applied a TAO dressing and then a gauze pressure dressing. The Incident/Accident Report documented Resident #1's physician was not contacted until 06/02/12 at 1:05 PM. In a telephone interview on 06/06/12 at 2:05 PM, LVN N said she worked from 7:00 PM on Thursday, 05/31/12, to 7:00 AM on Friday, 06/01/12. Resident #1 was usually in bed before 7:00 PM and did not get up until after 7:00 AM. She did not require any transfers during the night. There was no report of anything unusual during the night. When LVN N did her walking rounds with the oncoming nurse at 7:00 AM on 06/01/12 the resident was still in bed. In a telephone interview on 06/06/12 at 7:55 PM CNA F said she worked from 7:00 PM on 05/30/12 to 7:00 AM on 05/31/12 and again from 7:00 PM on 05/31/12 to 7:00 AM on 06/01/12. On 05/31/12 Resident #1 was in an exceptionally good mood and was not combative. She was talking in a friendly manner, which was not really normal for her. CNA F saw Resident #1 at 5:00 AM on 06/01/12. She did incontinent care. She did not observe anything unusual; there was no blood on the sheets or on her ankle. She did not remember whether the resident was wearing socks. She did not get her out of bed. CNA F said the night staff never got Resident #1 up out of bed. In a telephone interview on 06/06/12 at 3:10 PM CNA E said she worked from 7:00 AM to 3:00 PM on 06/01/12. She was not Resident #1's assigned aide, but she got the resident up for breakfast for CNA B on 06/01/12. She did incontinent care but did not change the resident's clothes. The resident was already wearing her socks. She did a head to toe inspection of the resident and did not see any bleeding or anything unusual. She did not get help from any other staff member to transfer the resident from the bed into the wheelchair. There was no problem with the transfer. She did not provide care to Resident #1 for the rest of her shift. When asked why she did not get help with the transfer, CNA E said Resident #1 used to require two people for transfers, but she lost weight, and now CNA E could transfer the resident by herself. Review of CNA E ' s undated written statement reflected: "On Friday, June 1, I got (Resident #1) up about 7:00 AM to go to the feeding room for breakfast. (Resident #1) didn't complain of any pain. I didn't see any bruises or anything on her leg. I set her up in her chair one time. She wasn't my assigned resident. " In an interview on 06/06/12 at 9:50 AM and 06/06/12 at 2:30 PM CNA A said he was not assigned to be Resident #1's aide on Friday, 06/01/12. CNA E got the resident up out of bed and into the wheelchair for breakfast. After breakfast CNA A helped CNA B transfer the resident from the wheelchair back into the bed using a gait belt. He noticed blood on her sock but did not observe blood on her sheets. CNA B was the resident's assigned CNA and she said she would notify the resident's nurse. He helped CNA B get her up again for supper using a gait belt. CNA A did not see blood again on Resident #1's ankle on 06/01/12. Throughout the day and during the two transfers he performed with CNA B, Resident 1 showed no signs or pain; no grimacing or guarding to her left ankle. On 06/02/12 CNA A helped CNA B get Resident #1 out of bed and into the wheelchair for breakfast. He observed blood on her sock again. They told the night nurse, LVN O and she changed the dressing. Review of CNA A's written statement dated 06/01/12 reflected: "I helped (CNA B) put (Resident #1) to bed and saw blood on her sock. Then I left the room so I could tend to my residents." In an interview on 06/06/12 at 10:40 AM CNA B said she was Resident #1's assigned CNA on the 7:00 AM to 7:00 PM shift on 06/01/12 and 06/02/12. Resident #1's behavior symptoms included calling the staff ugly names. She was easily annoyed or agitated. Just getting her out of bed got her agitated. When she started her shift on 06/01/12 Resident #1 was already up in her wheelchair. After breakfast CNA A and CNA B transferred Resident #1 from the wheelchair to the bed using a gait belt. When they laid her down onto the bed they noticed blood on her bed linen and all over her left ankle. CNA B said the sock was covered with blood. She told the nurse, and she put a dressing on it. She watched the nurse apply the dressing and observed that the left foot was swollen. There was a dark area on the ankle with a little pin-sized hole that was bleeding. Resident #1 complained only one time on 06/01/12 that her ankle hurt. She was up for all three meals on 06/01/12 and did not complain of pain or show signs or symptoms of pain such as guarding or grimacing. She continued to bleed through the dressing and CNA B said the nurses had to change the dressing again two or three times on 06/01/12. On Saturday, 06/02/12, CNA A and CNA B got Resident #1 up for breakfast. The CNA observed dried blood in the linens "like a puddle." She got the nurse to change the dressing. After lunch the resident was bleeding again through her dressing and her sock. She complained of pain. CNA B had to pick up her foot to put it on a pillow and it did not sound right. She got the nurse, and the resident was sent to the emergency room . Review of CNA B's written statement dated 06/02/12 reflected: "I (CNA B) 7:00 AM to 7:00 PM CNA went to lay (Resident #1) down with the help of another CNA (CNA A). I noticed that (Resident #1 ' s) left ankle was bleeding, so I went and got the charge nurse. She came immediately and took care of it and the nurse did notice that it was swelled (sic). This was on Friday, 06/01/12." In a telephone interview on 06/06/12 at 7:30 PM RN M said when Resident #1's wound was first reported to her on the morning on 06/01/12 her foot appeared swollen. There was a 1 centimeter (cm) bruise and a small open area of skin in the middle of the bruise. She did not check the resident's range of motion to that joint. She thought the wound was a pressure wound. Resident #1 had chronic bilateral [MEDICAL CONDITION] in her lower extremities; both feet were swollen. When she put pressure on it to clean it with normal saline the resident complained of pain. But, she did not complain of pain or grimace when she applied the dressing or through the rest of the day. She saw on the resident at least two more times that day after lunch and supper. There were no issues and no other report of bleeding on 06/01/12. On Saturday, 06/02/12, when RN M did walking rounds at 7:00 AM with the night nurse, the night nurse told her she had to change the dressing. RN M said she did not remember whether the night nurse meant she had to change the dressing during the night. She observed the night nurse change the dressing on the morning of 06/02/12. There was still no complaint of pain from the resident at 7:00 AM. The foot was swollen but the bruise on her ankle remained the same. Some swelling to both her feet was normal. RN M saw Resident #1 again after lunch and the ankle was bleeding. When she put pressure on it to stop the bleeding she heard a cracking sound. The whole foot had become blue. When asked why she did not call the doctor on the morning of 06/02/12 since it had been bleeding for 22 hours, the nurse said she was going to go back and look at it again on the morning of 06/02/12 but she got busy. She did not assess the range of motion to the left foot, compare the [MEDICAL CONDITION] of the left foot against the [MEDICAL CONDITION] in the right foot, or check for pedal pulses until after lunch on 06/02/12. Review of Resident #1's Nurse's Notes dated 06/02/12 reflected a late entry for 06/01/12 at 8:45 AM signed by RN M. "Called by CNA to resident's room. Noted a one centimeter in diameter bruising to outer left ankle with a tiny tear in the middle. Blood noted coming out from the wound. Swelling noted to bilateral feet. Pitting [MEDICAL CONDITION] +2 noted. Wound cleaned with normal saline. Applied TAO. Applied pressure, covered with gauze and tape. Resident has a chronic pedal swelling. When cleaned with saline resident said 'ouch' but didn't complain of pain when wound was dressed." At 10:00 AM RN M documented she asked the wound care nurse to assess Resident #1's ankle wound. "Wound Care Nurse replied we don't do bruises." At 7:00 PM RN M documented she reported the incident to the night nurse. Review of the facility's "Standing Orders" signed by a nurse practitioner on 12/09/11 reflected: " NS and TAO for minor wounds as needed." In an interview on 06/06/12 at 10:00 AM Medication Aide (MA) C said she worked on both Friday, 06/01/12, and Saturday, 06/02/12. She had to give Resident #1 medication three times on each of those days. On Friday, 06/01/12, she was fine. She was not in a bad mood, did not exhibit behaviors and did not show signs or symptoms of pain. On Saturday, 06/02/12, she was already up in her wheelchair when MA C gave her the morning medications. She was in a bad mood and was cussing and hollering, but that was normal for her. She did not show signs or symptoms of pain. Review of Resident #1's Nurses' Notes dated 06/02/12 at 12:50 PM and signed by RN M reflected "Went to resident's room to do wound care. Noticed blood still coming out from the wound. Applied pressure. Resident complained of pain. After five minutes of applying pressure, blood still coming out from the wound to left outer ankle. Asked the CNA to get the supervisor. Assessed left foot. Foot still swollen; bruising noted. Complained of pain when moved. At 1:05 PM supervisor called on call (doctor) and received new order to send to ER to evaluate left foot swelling, bruising, pain, and wound." At 3:00 PM on 06/02/12 RN M documented the emergency room called and informed her the resident had a fracture to her tibia and fibula; she was being admitted to the facility; and would be having surgery. "Nurse from ER also said it's an old fracture. It did not happen yesterday but days old." Continued review of Resident #1's Nurses Notes dated 06/02/12 reflected at an unspecified time the nurse was called to room to assess Resident #1's wound to her left ankle. "Noted nickel sized purple area to left outer ankle with tiny tear in the skin. Thin serosanguinous drainage present. Also noted drainage coming from wound with touching around the area. Resident complained of pain. Noted left foot with bruising, swelling. Unable to palpate pedal pulse. Cap refill two to three seconds. Attempted to perform ROM (range of motion) to left foot. Resident complained of pain. Noted the feeling of crepitus with ROM. Will notify physician of findings to left foot. Discussed with (RN M). Order received to send resident to ER for x-ray." The nurses' notes documented the call was made to the physician at 1:05 PM. Review of Resident #1 ' s emergency room report dated 06/02/12 reflected she arrived at the emergency room at 1:48 PM on 06/02/12. The hospital documented her left ankle had severe pain when palpated, had ecchymosis (bruising), soft tissue swelling, and bloody discharge. The resident was alert only to person. In an interview on 06/06/12 at 11:30 AM at the hospital where Resident #1 was admitted on [DATE] and was still a patient, emergency room RN Z said, when Resident #1 arrived at the emergency roiagnom on [DATE] her left foot was swollen and purple. When she lifted the resident ' s left leg her foot just dropped down. It was bleeding " drip, drip, drip. " She had a two to three millimeter puncture wound on her left ankle. There was no sheering to indicate a pressure wound. There was a pool of blood under the skin of her left ankle the size of a half dollar. RN Z called the facility and talked to Resident #1 ' s nurse to see if any blood work had been done such as an INR (international normalized ratio) given that the resident was on [MEDICATION NAME]. (INR studies are used to measure the clotting tendency of blood. A high INR increases the risk for bleeding; a low INR increases the risks for blood clots.) The nurse told her they had not called the physician and had not gotten laboratory studies. The emergency room doctor said the fracture was a least a day to two days old. RN Z also said the resident had small pin-point size bruises all over her arms that did not appear to be caused by transfers but rather a possible side effect of [MEDICATION NAME]. The hospital ran lab studies and found her INR levels were within acceptable ranges. There was no skin breakdown and no sign or symptom of infection. In an interview on 06/07/12 at 9:30 AM the Administrator and DON said it was their expectation that the nurse call the physician for a wound that continued to bleed, especially since Resident #1 was receiving [MEDICATION NAME]. The DON said RN M should have at least called the physician on Saturday morning, 06/02/12. The Physician ' s Desk Reference (<http://www.pdr.net/drugpages/concisemonograph.aspx?concise=374>, accessed on 06/12/12) stated the targeted INR for a patient receiving [MEDICATION NAME] for [MEDICAL CONDITION] was 2 to 3. Resident #1 ' s laboratory study dated 05/23/12 documented her INR was 1.57. Her laboratory study dated 06/02/12 (at the hospital) was 3.06. The hospital documented a range of 2.5 to 3.5 for treatment of [REDACTED]. It did not offer a therapeutic range for the treatment of [REDACTED]. Resident #1 ' s hospital history and physical report (H&P) dated 06/02/12 documented: "Left distal tibia-fibula fracture. This appears, by history, to be an acute problem and appears to be an open compound fracture as well. . . . Discussed with Orthopedics, and overall, it is felt that this would have a moderate to high probability of developing to severe infection that can either spread systemically or require a surgery for [REDACTED]. For this reason, we will advocate to the family that she undergo surgery and cleared her medically. " Review of the facility's In-service Report dated 10/26/11 reflected an in-service related to documentation and notifying the physician or changes in resident status. RN M's name did not appear on the in-service sign-in sheet. Attached to the sign-on sheet was the policy and procedure for consulting with the physician. It documented that the physician should be notified immediately when a contusion (bruise) was accompanied by significant pain or bleeding or for any suspected fracture or discoloration. Review of Resident #1's hospital clinical record reflected no evidence of infection. No culture and sensitivity studies were taken. A laboratory study dated 06/03/12 was negative [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). A complete blood count study dated 06/02/12 at the hospital documented her white blood cell count was 7.2 thousand per cubic millimeter (thou/mm3), with a reference range of 4.0 to 11 thou/mm3. Resident #1's Imaging Report dated 06/02/12 of her left ankle at the hospital documented the impression of "comminuted, displaced fractures of the distal tibia and fibula. The ankle joint remains intact." The study also documented "diffuse demineralization is noted throughout the lower leg, ankle and foot." In an interview on 06/06/12 at 1:45 PM the Administrator stated she was the facility's abuse and neglect coordinator. She said she did not know anything about Resident #1's ankle injury until she was notified on Saturday, 06/02/12, that the resident was being transferred to the emergency room . In an interview on 06/06/12 at 8:30 AM the Administrator stated the facility census was 106.