Every finding on record at Tudor Oaks Health Center

Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 residents (R4).R4 made an allegation of abuse by a staff member on 9/5/25 and the facility did not put measures into place to correct the abuse and ensure R4 and other residents were kept safe and free from any additional abuse by staff.The facility's abuse policy states, in part:* The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and or misappropriation of resident property is more likely to occur.* An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1.) Identifying staff responsible for the investigation 2.) Exercising caution in handling evidence that could be used in a criminal investigation 3.) Investigation different types of alleged violations 4.) Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations 5.) Focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause; and 6.) Providing complete and thorough documentation of the investigation.*The facility will have written procedures that include: .taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. R4 was admitted to the facility on [DATE].On 9/5/25, R4 made an allegation of abuse, alleging that CNA C (Certified Nursing Assistant) was rough when rolling R4 in bed. According to documentation submitted to the State Agency by the facility, R4 alleged CNA C had ear buds in and wasn't listening to R4 as she tried to communicate what was hurting and how to perform the cares. This documentation also states that R4 was tearful after the interaction. The facility contacted the local police and interviewed residents and staff. The facility did not have documentation, nor was there any other evidence provided to Surveyors that the facility took measures to ensure the abuse did not happen again. On 10/28/25 at 12:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that the facility substantiated the abuse that R4 alleged had occurred. When asked if the facility took any measures to correct the abuse and ensure further abuse did not occur to R4 or any other residents, NHA A stated that they terminated CNA C. The facility received an allegation of abuse and substantiated the allegation but did not put measures into place to correct the abuse and help prevent similar abuse situations in the future from occurring.

Based on record review and staff interviews, the facility did not always ensure that 3 out of 5 residents reviewed (R11, R297, R298) were free from physical and verbal abuse. R11 was provided cares by an agency CNA (Certified Nursing Assistant) on 6/15/25. During this time, a facility CNA was present in the room and did not intervene when she witnessed the agency CNA being rough with R11. R297 and R298 were allegedly both physically and verbally abused by a facility Registered Nurse on 6/18/25. The facility staff did not ensure that R297 and R298 were kept safe and free from any additional abuse by immediately reporting the allegations of abuse. Findings include: The facility's policy dated as implemented on 4/24/25 and titled, Abuse, neglect and Exploitation documents: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VI. Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. 1.) On 8/4/24, Surveyor conducted a review of the facility’s self-reported incident involving R11 on 6/15/25. The facility’s report documents that R11 made a complaint that CNA (Certified Nursing Assistant)- J was rough during cares. R11 stated that “(CNA- J) pulled my legs hard apart to put brief on, and also (CNA- J) was rough wiping her with the washcloths”. The time of this occurrence was documented at 5:20 AM on 6/15/25. Surveyor conducted review of the facility’s investigation into R11’s allegations. The investigation included a written statement from CNA- F who was present in R11’s room while CNA- J was providing cares to R11. CNA- F stated that CNA-J asked her to help change R11. When CNA- J started cleaning R11 with the washcloths, she was very rough. R11 was telling CNA- J that she was hurting her. CNA- J said “sorry” but continued. When CNA- J was cleaning the backside of R11, she was rough again and R11 made another statement saying, “stop you are being so rough”. CNA-J said “sorry”. R11 then stated, “why do you keep saying sorry but still continuing to be rough with me”. When it was time to roll R11 towards CNA- J. CNA-J pulled R11 by the arm. R11 yelled out “OW”. CNA- F stated that she finished getting R11 comfortable and CNA-J walked out of the room mumbling under her breath. After the cares were completed, CNA- F did report her concerns to Nurse on the unit who then checked on R11 to make sure she felt safe. Nursing Home Administrator (NHA)- A was made aware of the situation and CNA- J was asked to leave the building and to not return until an investigation was complete. On 8/4/25 at 2:34 PM, Surveyor interviewed SSD (Social Services Director)- E who completed the investigation regarding the allegation of abuse/ rough treatment by CNA-J. SSD-E confirmed that CNA- F did write in her witness statement that she observed rough treatment to R11 by CNA- J. Surveyor asked SSD- E if the expectation would be that CNA- F should have intervened to keep R11 safe from further rough /abusive treatment. SSD- E state that yes, CNA- F should have tried to diffuse the situation right away saying something like “I can take over for you” or “can I help you with this”. CNA- F would have been expected not to leave the room until she was sure that R11 was safe. Surveyor asked SSD- E if she was aware how long the interaction between CNA -J, CNA- F and R11 lasted. SSD- E stated that they have record that R11 placed her call light on at 5:03 AM on 6/15/25. Staff stated that they immediately went in by R11 to provide cares to her and then exited the room at approximately 5:20 AM on 6/15/25. On 8/5/25 at 7:35 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A regarding the allegation that CNA- J was rough with R11 while providing cares and this was witnessed by CNA-F who did not intervene. NHA- A stated that yes, CNA-F should have immediately intervened to protect R11 from any potential harm. NHA- A stated that CNA-F had been previously trained on abuse prevention and that protecting the resident comes first. No additional information had been provided as to why CNA- F did not keep R11 safe from further potential harm when she witnessed CNA- J being rough with R11 during cares. 2.) R297's diagnoses includes dementia (loss of cognitive function that interferes with a person's daily life & activities), paraplegia (loss or impairment of motor & sensory functions in both lower legs), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and anxiety disorder. R297's quarterly MDS (minimum data set) with an assessment reference date of 6/10/25 has a BIMS (brief interview mental status) score of 2 which indicates severe cognitive impairment. R297 is assessed as being dependent for toileting hygiene, requires substantial/maximal assistance for rolling left & right, is frequently incontinent of urine and always incontinent of bowel. On 8/6/25, at 8:39 a.m., Director of Social Services (DSS)-E provided Surveyor with Facility Reported Incidents (FRI) Surveyor had requested. On 8/6/25, at 9:20 a.m. Surveyor spoke with Anonymous Staff (AS)-F on the telephone. During this conversation AS-F informed Surveyor Registered Nurse (RN)-H verbally and physically abused two residents and provided Surveyor with the names of two residents including R297. AS-F informed this abuse occurred on the same night. Certified Nursing Assistant (CNA)-I reported this abuse to Registered Nurse (RN)-C and CNA-I wrote a statement which was placed under the Director of Nursing (DON)-B's door. Surveyor reviewed the Facility Reported Incident for R297. Surveyor noted the date occurred is documented as 6/18/25 and date discovered documents 6/19/25. Under brief summary of incident documents while Administrator and Director of Social Services were meeting with [name of Certified Nursing Assistant (CNA)-G] for education regarding abuse reporting, we were made aware of another potential abuse incident from 6/18/25. [CNA-G's first name] told us that statements had been left under the Director of Nursing (DON's) office door. DON was not in the facility, so Administrator obtained the statements from her office. They describe an incident in which CNA [CNA-I's name] witnessed Registered Nurse (RN)-H, say to resident [R297's name], Oh stop, I can do whatever I want to you, all while wiping stool from [R297's initials] buttocks aggressively. When the cares for [R297's initials] were completed [CNA-I's name] reported the incident to RN [RN-C's name]. Once the Administrator and Dir. of SS (Director of Social Services) were made aware, an investigation was initiated and this initial self report was submitted. CNA-I's written statement regarding R297, which was left under the DON-B's door, dated 6/18/25 at 6:40 a.m., documents I was changing [R297's first name] when I rolled him he got poop all over the green pad. He didn't want me to change him but I told him he had poop & I should. I went to get [RN-H's first name] to help me. I was up against the wall and we rolled [R297's first name] to me. She rolled him quite aggressively. [R297's first name] was verbally upset with the roll & got worse when she started wiping him. She was very aggressive when whipping (sic) him. He was grabbing me because of this, pushing on me trying to roll back to stop her, yelling at her to stop & this is when [RN-H's first name] said Oh stop I can do whatever I want to you. Whipping (sic) very aggressive on his butt. The facility's investigation summary written by Director of Social Services (DSS)-E includes documentation of this writer called [RN-C's name] and [RN-C's first name] stated [CNA-I's first name] reported the incident to me, and I told [CNA-I's first name] to go back and check on the residents. If the residents were not okay, I told her I would go and check on the residents. I didn't want to go into Team 1 because I was afraid [RN-H's name] would get suspicious as to why I would be in Team 1. [CNA-I's first name] reported back to me that [R297's first name] and [R298's first name] were okay. [RN-C's first name] instructed [CNA-I's first name] to write out a statement of what happened, and [RN-C's first name] put their statements under the office door of the DON. On 8/6/25, at 12:50 p.m., Surveyor asked DSS-E how she became aware of the verbal & physical abuse allegation involving RN-H with R297. DSS-E explained she and Nursing Home Administrator (NHA)-A were educating [first name of CNA-G] on abuse. Surveyor asked what day was this. DSS-E informed Surveyor the 18th. Surveyor asked why was the date of discovery on the facility reported incident 6/19/25. DSS-E informed Surveyor she would have to double check the date. At 1:12 p.m. DSS-E informed Surveyor she did not speak with CNA-G until the 19th (6/19/25). DSS-E explained while they were educating CNA-G about abuse, CNA-G said what about [CNA-I's first name] and they asked CNA-G what about CNA-I. DSS-E informed Surveyor this is when they were informed CNA-I witnessed RN-H's allegation of abuse with R297. The nurse & CNA-I put statements under DON's door. The DON was not here so NHA-A went to the DON's office and they were under the door. Surveyor asked whose statement was under the DON's door. DSS-E replied at that time only [first name of CNA-I] and the nurse, the one who she reported it to, [RN-C's first name]. Surveyor asked DSS-E if they notified the police. DSS-E replied we did not. Surveyor asked DSS-E why they didn't contact the police. DSS-E replied I didn't see any harm. On 8/6/25, at 1:54 p.m. Surveyor asked NHA-A how she became aware of the allegation of verbal and physical abuse involving RN-H with R297. NHA-A informed Surveyor she and [name of DSS-E] were meeting with [name of CNA-G] on 6/19/25 about the abuse policy and [first name of CNA-G] said what about the other night with [first name of CNA-I]. [First name of CNA-I] and nurse left statements. NHA-A informed Surveyor they asked where were the statements left. CNA-G informed them under the DON's door. NHA-A informed Surveyor this is the first they were hearing about it and the DON was on vacation. Surveyor asked NHA-A if she asked RN-C why she didn't report the allegation of verbal and physical abuse immediately & why RN-C didn't go to the unit where RN-C was working. NHA-A informed Surveyor RN-C didn't know the DON was off. NHA-A informed Surveyor RN-C was being snippy to co-workers, acting passive aggressive. RN-C was hesitate. Surveyor asked NHA-A why RN-C didn't report the allegation of abuse to her. NHA-A replied I don't know and explained RN-C went to report to the DON and didn't realize she was off. Surveyor reviewed RN-H's employee time sheet and noted RN-H worked until 6:46 a.m. on 6/18/25. RN-H returned to work on 6/18/25 at 10:20 p.m. and worked until 6:48 a.m. on 6/19/25. This allegation was not reported immediately to Nursing Home Administrator (NHA)-A as CNA-I's statement was slid under the DON's door. Residents were not protected from further potential abuse. 3.) R298's diagnoses includes hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side) following cerebral infarction (type of stroke) affecting left non dominate side, heart failure (chronic condition in which the heart doesn't pump enough blood as well as it should), diabetes mellitus (high blood sugar), and dementia (loss of cognitive function that interferes with a person's daily life & activities). On 8/6/25, at 9:20 a.m. Surveyor spoke with Anonymous Staff (AS)-F on the telephone. During this conversation AS-F informed Surveyor Registered Nurse (RN)-H verbally and physically abused two residents and provided Surveyor with the names of two residents including R298. AS-F informed this abuse occurred on the same night. Certified Nursing Assistant (CNA)-I reported this abuse to Registered Nurse (RN)-C and CNA-I wrote a statement which was placed under the Director of Nursing (DON) door. Certified Nursing Assistant (CNA)-I's statement dated 6/18/25 at 6:40 a.m. for R298 documents [Name of ] Registered Nurse-H said she wanted to see [first name of R298] butt so I asked if she just wanted to come in when I changed him. She said yes. [First name] call light went off so I answered it & she wanted her remote. After I went to [R298's first name] room she was in the middle of changing him. She rolled rolled him aggressively onto his bad side & wiping him aggressively also to the point where he was showing he was in pain. On 8/6/25, at 12:50 p.m., Surveyor asked DSS-E if she is involved when there is an allegation of abuse. DSS-E replied yes. Surveyor inquired what DSS-E's role is. DSS-E informed Surveyor when an allegation is brought to her attention she will initiate an investigation, reports the allegation to the State, interviews residents and staff if needed and does the investigation summary. DSS-E informed Surveyor she and Nursing Home Administrator (NHA)-A became aware of CNA-I's statement when they were providing abuse education to CNA-G on 6/19/25. On 8/6/25, at 1:46 p.m., Surveyor telephoned RN-C. Surveyor left a messaging asking RN-C to return Surveyor's call. Surveyor did not receive a return call from RN-C. Surveyor reviewed RN-H's employee time sheet and noted RN-H worked until 6:46 a.m. on 6/18/25. RN-H returned to work on 6/18/25 at 10:20 p.m. and worked until 6:48 a.m. on 6/19/25. This allegation was not reported immediately to Nursing Home Administrator (NHA)-A as CNA-I's statement was slid under the DON's door. Residents were not protected from further potential abuse. No additional information was provided.

Based on record review and staff interviews, the facility did not ensure that allegations of potential verbal and physical abuse involving 3 out of 5 residents (R11,R297, R298) reviewed were reported to the Nursing Home Administrator (NHA) or Designee and Law Enforcement. The facility did not contact the local law enforcement after they became aware that an agency CNA was witnessed to be rough with R11 when providing cares on 6/15/25. R297 was allegedly physically and verbally abused by a facility Registered Nurse (RN-H) on 6/18/25. This allegation was not immediately reported to the NHA . This allegation was not reported to Law Enforcement as a possible crime of abuse. R298 was allegedly physically abused by a facility Registered Nurse (RN-H) on 6/18/25. This allegation was not immediately reported to the NHA. This allegation was not reported to Law Enforcement as a possible crime of abuse. Findings include: The facility's policy dated as implemented on 4/24/25 and titled Abuse, Neglect and Exploitation documents: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/ Response 1. Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies ( e.g., law enforcement when applicable) within specified timeframes: a.) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b.) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1.) On 8/4/24, Surveyor conducted a review of the facility’s self-reported incident involving R11 dated 6/15/25. The facility’s report documents that R11 made a complaint that CNA (Certified Nursing Assistant)- J was rough during cares. R11 stated that “(CNA- J) pulled my legs hard apart to put brief on, and also (CNA- J) was rough wiping her with the washcloths”. The time of this occurrence was documented at 5:20 AM on 6/15/25. Surveyor conducted review of the facility’s investigation into R11’s allegations. The investigation included a written statement from CNA- F who was present in R11’s room while CNA- J was providing cares to R11. CNA- F stated that CNA-J asked her to help change R11. When CNA- J started cleaning R11 with the washcloths, she was very rough. R11 was telling CNA- J that she was hurting her. CNA- J said “sorry” but continued. When CNA- J was cleaning the backside of R11, she was rough again and R11 made another statement saying, “stop you are being so rough”. CNA-J said “sorry”. R11 then stated, “why do you keep saying sorry but still continuing to be rough with me”. When it was time to roll R11 towards CNA- J. CNA-J pulled R11 by the arm. R11 yelled out “OW”. CNA- F stated that she finished getting R11 comfortable and CNA-J walked out of the room mumbling under her breath. After the cares were completed, CNA- F did report her concerns to the Nurse on the unit who then checked on R11 to make sure she felt safe. NHA- A was made aware of the situation and CNA- J was asked to leave the building and to not return until an investigation was complete. Surveyor conducted a review of Form F- 62447 “Misconduct Incident Report” that is required to be completed by the facility and submitted to the state survey agency within 5 working days of the date the facility knew of the incident. The form indicates that law enforcement was not involved or contacted by the facility, per policy and regulation. On 8/5/25 at 7:35 AM, Surveyor interviewed NHA-A regarding the allegation that CNA- J was rough with R11 while providing cares and this was witnessed by CNA-J . Surveyor asked NHA- A why law enforcement was not contacted. NHA- A stated that since R11 didn’t really say that she was abused by CNA-J, law enforcement was not contacted. As of the time of exit on 8/6/25, no additional information has been provided as to why the facility did not contact law enforcement when they became aware of an allegation that R11 was treated roughly/abused by CNA- J during cares on 6/15/25. 2.) R297's diagnoses includes dementia (loss of cognitive function that interferes with a person's daily life & activities), paraplegia (loss or impairment of motor & sensory functions in both lower legs), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and anxiety disorder. R297's quarterly MDS (minimum data set) with an assessment reference date of 6/10/25 has a BIMS (brief interview mental status) score of 2 which indicates severe cognitive impairment. R297 is assessed as being dependent for toileting hygiene, requires substantial/maximal assistance for rolling left & right, is frequently incontinent of urine and always incontinent of bowel. On 8/6/25, at 8:39 a.m., Director of Social Services (DSS)-E provided Surveyor with Facility Reported Incidents (FRI) Surveyor had requested. On 8/6/25, at 9:20 a.m. Surveyor spoke with Anonymous Staff (AS)-F on the telephone. During this conversation AS-F informed Surveyor Registered Nurse (RN)-H verbally and physically abused two residents and provided Surveyor with the names of two residents including R297. AS-F informed this abuse occurred on the same night. Certified Nursing Assistant (CNA)-I reported this abuse to Registered Nurse (RN)-C and CNA-I wrote a statement which was placed under the Director of Nursing (DON) door. Surveyor reviewed the Facility Reported Incident for R297. Surveyor noted the date incident occurred is documented as 6/18/25 and date discovered documents 6/19/25. Under brief summary of incident documents: While Administrator and Director of Social Services were meeting with [name of Certified Nursing Assistant (CNA)-G] for education regarding abuse reporting, we were made aware of another potential abuse incident from 6/18/25. [CNA-G's first name] told us that statements had been left under the Director of Nursing (DON's) office door. DON was not in the facility, so Administrator obtained the statements from her office. They describe an incident in which CNA [CNA-I's name] witnessed Registered Nurse (RN)-H, say to resident [R297's name], Oh stop, I can do whatever I want to you, all while wiping stool from [R297's initials] buttocks aggressively. When the cares for [R297's initials] were completed [CNA-I's name] reported the incident to RN [RN-C's name]. Once the Administrator and Dir. of SS (Director of Social Services) were made aware, an investigation was initiated and this initial self report was submitted. CNA-I's written statement dated 6/18/25 at 6:40 a.m., left under the DON office door, documents I was changing [R297's first name] when I rolled him he got poop all over the green pad. He didn't want me to change him but I told him he had poop & I should. I went to get [RN-H's first name] to help me. I was up against the wall and we rolled [R297's first name] to me. She rolled him quite aggressively. [R297's first name] was verbally upset with the roll & got worse when she started wiping him. She was very aggressive when whipping (sic) him. He was grabbing me because of this, pushing on me trying to roll back to stop her, yelling at her to stop & this is when [RN-H's first name] said Oh stop I can do whatever I want to you. Whipping (sic) very aggressive on his butt. The facility's investigation summary written by Director of Social Services (DSS)-E documents: This writer called [RN-C's name] and [RN-C's first name] stated [CNA-I's first name] reported the incident to me, and I told [CNA-I's first name] to go back and check on the residents. If the residents were not okay, I told her I would go and check on the residents. I didn't want to go into Team 1 because I was afraid [RN-H's name] would get suspicious as to why I would be in Team 1. [CNA-I's first name] reported back to me that [R297's first name] and [R298's first name] were okay. [RN-C's first name] instructed [CNA-I's first name] to write out a statement of what happened, and [RN-C's first name] put their statements under the office door of the DON. On 8/6/25, at 12:50 p.m., Surveyor asked DSS-E how she became aware of the verbal & physical abuse allegation involving RN-H with R297. DSS-E explained she and Nursing Home Administrator (NHA)-A were educating [first name of CNA-G] on abuse. Surveyor asked what day was this. DSS-E informed Surveyor the 18th. Surveyor asked why was the date of discovery on the facility reported incident 6/19/25. DSS-E informed Surveyor she would have to double check the date. At 1:12 p.m. DSS-E informed Surveyor she did not speak with CNA-G until the 19th (6/19/25). DSS-E explained while they were educating CNA-G about abuse, CNA-G said what about [CNA-I's first name] and they asked CNA-G what about CNA-I. DSS-E informed Surveyor this is when they were informed CNA-I witnessed RN-H's allegation of abuse with R297. The nurse & CNA-I put statements under DON's door. The DON was not here so NHA-A went to the DON's office and they were under the door. Surveyor asked whose statement was under the DON's door. DSS-E replied at that time only [first name of CNA-I] and the nurse, the one who she reported it to, [RN-C's first name]. Surveyor asked DSS-E if they notified the police. DSS-E replied we did not. Surveyor asked DSS-E why they didn't contact the police. DSS-E replied I didn't see any harm. On 8/6/25, at 1:54 p.m. Surveyor asked NHA-A how she became aware of the allegation of verbal and physical abuse involving RN-H with R297. NHA-A informed Surveyor she and [name of DSS-E] were meeting with [name of CNA-G] on 6/19/25 about the abuse policy and [first name of CNA-G] said what about the other night with [first name of CNA-I]. [First name of CNA-I] and nurse left statements. NHA-A informed Surveyor they asked where were the statements left. CNA-G informed them under the DON's door. NHA-A informed Surveyor this is the first they were hearing about it and the DON was on vacation. Surveyor asked NHA-A if she asked RN-C why she didn't report the allegation of verbal and physical abuse immediately & why RN-C didn't go to the unit where RN-C was working. NHA-A informed Surveyor RN-C didn't know the DON was off. NHA-A informed Surveyor RN-C was being snippy to co-workers, acting passive aggressive. RN-C was hesitate. Surveyor asked NHA-A why RN-C didn't report the allegation of abuse to her. NHA-A replied I don't know and explained RN-C went to report to the DON and didn't realize she was off. Surveyor asked NHA-A if she knew why the police weren't called. NHA-A replied I do not. Surveyor noted that the allegation of verbal and physical abuse involving R297 were not reported immediately to NHA-A and the police were not contacted. 3.) On 8/6/25, at 8:39 a.m., Director of Social Services (DSS)-E provided Surveyor with Facility Reported Incidents (FRI) Surveyor had requested. On 8/6/25, at 9:20 a.m. Surveyor spoke with Anonymous Staff (AS)-F on the telephone. During this conversation AS-F informed Surveyor Registered Nurse (RN)-H verbally and physically abused two residents and provided Surveyor with the names of two residents including R298. AS-F informed this abuse occurred on the same night. Certified Nursing Assistant (CNA)-I reported this abuse to Registered Nurse (RN)-C and CNA-I wrote a statement which was placed under the Director of Nursing (DON) door. On 8/6/25, at 10:30 a.m., Surveyor reviewed the facility's self reported incidents that DSS-E had provided to Surveyor. Surveyor noted there was not an investigation for R298. R298's diagnoses includes hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side) following cerebral infarction (type of stroke) affecting left non dominate side, heart failure (chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus (high blood sugar), and dementia (loss of cognitive function that interferes with a person's daily life & activities). Certified Nursing Assistant (CNA)-I's statement dated 6/18/25 at 6:40 a.m. for R298 documents [Name of ] Registered Nurse-H said she wanted to see [first name of R298] butt so I asked if she just wanted to come in when I changed him. She said yes. [First name] call light went off so I answered it & she wanted her remote. After I went to [R298's first name] room she was in the middle of changing him. She rolled rolled him aggressively onto his bad side & wiping him aggressively also to the point where he was showing he was in pain. On 8/6/25, at 12:50 p.m., Surveyor asked DSS-E if she is involved when there is an allegation of abuse. DSS-E replied yes. Surveyor inquired what DSS-E's role is. DSS-E informed Surveyor when an allegation is brought to her attention she will initiate an investigation, reports the allegation to the State, interviews residents and staff if needed and does the investigation summary. Surveyor inquired if this allegation of physical abuse in CNA-I's statement regarding RN-H with R298 was reported to the State. DSS-E replied no because he's his own person and said nothing happened. Surveyor informed DSS-E, CNA-I's statement dated 6/18/25 alleges physical abuse involving RN-H and should have been reported. On 8/6/25, at 1:46 p.m., Surveyor telephoned RN-C. Surveyor left a messaging asking RN-C to return Surveyor's call. Surveyor did not receive a return call from RN-C. On 8/6/25, at 1:54 a.m. Surveyor asked Nursing Home Administrator (NHA)-A if the physical abuse allegation involving R298 & RN-H was reported to the State. NHA-A replied no. NHA-A informed Surveyor she thinks CNA-I's statement was emotionally charged. Surveyor informed NHA-A this allegation should have been reported to the State and should have been reported to her immediately. Surveyor asked NHA-A if the police were contacted. NHA-A replied no. The allegation of physical abuse involving R298 was not reported to the State agency and the police were not contacted. No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R298) of 3 allegations of abuse were investigated.* The facility did not conduct an investigation for R298's allegation of physical abuse.Findings include:The facility's policy titled, Abuse, Neglect and Exploitation and dated 4/24/25, documents under the policy section: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section V. Investigation of Alleged, Abuse, Neglect and Exploitation it documents: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extend, and cause; and 6. Providing complete and thorough documentation of the investigation.On 8/6/25, at 8:39 a.m., Director of Social Services (DSS)-E provided Surveyor with Facility Reported Incidents (FRI) Surveyor had requested. On 8/6/25, at 9:20 a.m. Surveyor spoke with Anonymous Staff (AS)-F on the telephone. During this conversation AS-F informed Surveyor Registered Nurse (RN)-H verbally and physically abused two residents and provided Surveyor with the names of two residents including R298. AS-F informed this abuse occurred on the same night. Certified Nursing Assistant (CNA)-I reported this abuse to Registered Nurse (RN)-C and CNA-I wrote a statement which was placed under the Director of Nursing (DON) door. On 8/6/25, at 10:30 a.m., Surveyor reviewed the facility's self reported incident reports that DSS-E provided to Surveyor. Surveyor noted there was not an investigation for any allegation involving R298.R298's diagnoses includes hemiplegia (paralysis on one side of the body( and hemiparesis (weakness on one side) following cerebral infarction (type of stroke) affecting left non dominate side, heart failure (chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus (high blood sugar), and dementia (loss of cognitive function that interferes with a person's daily life and activities).Certified Nursing Assistant (CNA)-I's statement dated 6/18/25 at 6:40 a.m. for R298 documents: [Name of ] Registered Nurse-H said she wanted to see [first name of R298] butt so I asked if she just wanted to come in when I changed him. She said yes. [First name] call light went off so I answered it & she wanted her remote. After I went to [R298's first name] room she was in the middle of changing him. She rolled rolled him aggressively onto his bad side & wiping him aggressively also to the point where he was showing he was in pain.On 8/6/25, at 12:50 p.m., Surveyor asked DSS-E if she is involved when there is an allegation of abuse. DSS-E replied yes. Surveyor inquired what DSS-E's role is. DSS-E informed Surveyor when an allegation is brought to her attention she will initiate an investigation, report the allegation to the state agency, interview residents and staff if needed, and complete the investigation summary. Surveyor inquired if there is an investigation regarding an allegation of physical abuse in CNA-I's statement regarding RN-H with R298. DSS-E replied no because he's his own person and said nothing happened. Surveyor informed DSS-E, CNA-I's statement dated 6/18/25 alleges physical abuse involving RN-H and that this allegation should have been investigated.On 8/6/25, at 1:46 p.m., Surveyor telephoned RN-C. Surveyor left a messaging asking RN-C to return Surveyor's call. Surveyor did not receive a return call from RN-C.On 8/6/25, at 1:54 a.m. Surveyor asked Nursing Home Administrator (NHA)-A if the physical abuse allegation involving R298 & RN-H was investigated. NHA-A replied no. NHA-A informed Surveyor she thinks CNA-I's statement was emotionally charged. Surveyor informed NHA-A this allegation should have been investigated.No additional information was provided as to why the facility did not ensure that the statement involving R298 and alleged abuse was thoroughly investigated.

Based on interview and record review, the facility did not ensure 6 of 10 residents (R34, R11, R23, R2, R9, and R13) reviewed received adequate supervision and assistance devices to prevent accidents. * R34's fall on 10/29/24 was not thoroughly investigated and a root cause was not determined to help prevent additional falls. On 5/16/25, R34 fell, was transferred to the hospital, and diagnosed with a hip fracture. R34 had been observed prior to this fall coming out the bathroom by herself. The facility did not implement interventions after observing R34 coming out of the bathroom prior to R34's fall. R34 was not assessed by a Registered Nurse (RN) prior to being placed in a wheelchair after the fall even though there was an RN available. The facility's investigation did not include a root cause analysis of R34's fall to help prevent additional falls. * R11 fell from the wheelchair on 5/28/24. The facility did not conduct a thorough investigation as the facility did not investigate how R11 was seated in her wheelchair, the investigation does not include whether R11 was interviewed regarding the fall, and R11's fall care plan was not developed until 8/30/24. R11 fell on [DATE]. R11 was not transferred according to R11's plan of care when R11 fell. * R23's resident to resident altercation on 11/2/24 was not investigated and no revisions to R23's plan of care were implemented after R23's resident to resident altercation. * R2 sustained multiple falls from bed. The facility did not investigate how R2 rolled out of bed, did not determine if previous interventions were in place, did not consistently determine the root cause of R2's falls, and did not investigate how R2 fell from the bed multiple times when bilateral body pillows were in place. * R9 sustained a fall on 2/17/25. The facility did not thoroughly investigate this fall and did not determine a root cause. On 3/29/25, R9 had an unwitnessed fall. The facility did not thoroughly investigate this fall and did not investigate whether previous interventions were in place. R9's wander alert bracelet was observed on the metal bar on the back of R9's wheelchair. Per the manufacturer the wander alert bracelet should not be placed on this metal bar. * R13's intervention of fall mat was not in place and the body pillows were incorrectly placed when R13 sustained a fall on 2/4/25. On 3/29/25, R13 fell while attempting to self transfer. R13's new toileting plan was not added to the care plan until 5/19/25. On 4/1/25, R13 had a fall in another resident's bathroom. R13's care planned intervention of toileting after meals was not followed. On 5/3/25, R13 sustained a fall from bed. The facility did not thoroughly investigate this fall to determine if previous interventions were in place. During the survey, R13's body pillow was not placed correctly. R34 is being cited at severity level 3 (actual harm). R11, R23, R2, R9 and R13 are being cited at severity level 2 (potential for more than minimal harm). Findings include: The facility's policy titled, Falls Management and Prevention, and revised December 2024 under Policy documents: Residents are assessed for their risk of falling upon admission, significant change and quarterly thereafter. Resident with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the resident's condition, provides care for, safety and comfort. Under Post Fall Procedure documents 1. When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment. 2. The medical provider is notified of the fall and resident condition. Orders, if given, are implemented. 3. The resident's representative (as applicable) is notified of the fall and the resident's condition. 4. The DON (Director of Nursing) and Administrator or designees are notified of the fall. 5. The environment of the fall is evaluated for possible contributing factors and addressed. 1.) R34 was admitted to the facility on [DATE] with diagnoses that include dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), and hypertensive heart disease with heart failure (prolonged high blood pressure that leads to the heart inability to pump blood effectively). R34's fall risk assessment dated [DATE] has a score of 12 (a score of 10 or higher indicates high risk of falling.) R34's nurses note dated 9/14/24, at 14:11 (2:11 p.m.), written by Licensed Practical Nurse (LPN)-W documents: Resident on report for being new admit to unit s/p (status post) multiple falls, encephalopathy, and AMS (altered mental status). Resident adjusting to unit well. AandO (alert and orientated) to self and place. Makes needs known. No issues or complaints. Ate well at meal times. Checked frequently to maintain safety. VSS (vital signs stable) per resident baseline. R34's Fall CAA (care area assessment) dated 9/18/24 under analysis of finds for nature of problem documents: Fall CAA triggered r/t (related to) recent fall at home with UTI (urinary tract infection), AMS (alerted mental status)/hospitalization. admitted for rehab with goal to dc (discharge) home. Resident requires moderate assist with most ADL (activities of daily living). BIMS (Brief Interview for Mental Status)-8. On scheduled diuretic, anticoagulant, antihtn (antihypertensive). Occasionally incontinent of bowel and bladder. No falls during look back. Remains a fall risk d/t (due to) cognitive impairment with poor safety awareness. Under the care plan considerations it documents: Fall CAA triggered r/t recent fall at home with UTI, AMS/hospitalization. admitted for rehab with goal to dc home. Resident requires moderate assist with most ADL. BIMS-8. On scheduled diuretic, anticoagulant, antihtn. Occasionally incontinent of bowel and bladder. No falls during look back. Remains a fall risk d/t cognitive impairment with poor safety awareness. R34's falls care plan initiated and revised 9/18/24 documents the following interventions: *Fall risk evaluation on admission, quarterly, and PRN (as needed). Post fall evaluation PRN. Initiated 9/18/24. *Labs when ordered, report abnormal findings to NP/PA/MD (Nurse Practitioner/Physician Assistant/Medical Doctor). Initiated 9/18/24. *Monitor for side effects of medication: *Cardiac medication as ordered. Monitor weekly vital signs and labs as ordered. *Psychotropic medications as ordered. BIMS (brief interview mental status) evaluation, sleep log, and behavior monitoring per protocol. *Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respiration, and report to NP/PA/MD. Initiated 9/18/24. *Toileting per urinary/bowel section of this care plan. Initiated 9/18/24. *Fall risk. Initiated 9/27/24. *Bed in low position, call light within reach. Initiated 9/27/24. *Encourage [R34's first name] to be in common areas for supervision d/t (due to) frequent self transferring. She often refuses. Initiated 5/29/25. *Frequent safety checks to prevent falls. [R34's first name] self transfers and is non-compliant with call light d/t (due to) memory issues. Initiated and revised 5/29/25. R34's nurses note dated 10/29/24, at 22:20 (10:20 p.m.), written by Registered Nurse (RN)-BB documents: Writer was doing HS (hour sleep) med pass when CNA (Certified Nursing Assistant) answered a bathroom call light coming from residents' room. CNA yelled out to writer that resident was on the floor from doorway. Writer went into residents' room and found resident on the floor sitting straight up on bottom near residents' foot of bed. Writer asked resident what happened resident stated she just slid out of bed when trying to get up. Writer asked resident what she was trying to do and resident stated trying to get up to go by husband that was in the living room area of their room. Resident stated she did not have pain anywhere and did not hit head. Writer did a full Neurology assessment determined all WNL (within normal limits), Writer then took residents Vitals B/P (blood pressure): 106/69, HR (heart rate): 75, 02(oxygen): 98% RA (room air), T (temperature):97.7, R (respirations): 18. Resident was then Hoyered off the floor by writer and CNA into residents w/c (wheelchair). Neuro checks were then initiated. R34's progress note dated 10/31/24, at 10:03 a.m., written by Nursing Home Administrator (NHA)-A documents: IDT (interdisciplinary team) met to review fall from 10/29/24. Nursing, Soc. (Social) Services, therapy, and admin (Administrator) were in attendance. Documentation was reviewed. MD and patient representative were contacted. Neuro checks were initiated. Resident had moved from her private room to a shared room with her husband that date. Immediate intervention was to transfer resident to the bed on left side of room, which is similar to her previous bedroom set-up. Surveyor noted R34's fall care plan was not revised to include this intervention. Surveyor reviewed the facility's fall investigation for R34's fall on 10/29/24. The facility's fall investigation includes a fall statement from the CNA who found R34 on the floor but does not include any other staff statements or indications other staff who may have seen R34 were interviewed, how was R34 positioned in bed, and the root cause of this fall. R34's quarterly MDS (Minimum Data Set) with an assessment reference date of 4/14/25 has a BIMS (Brief Interview for Mental Status) score of 2 which indicates severe cognitive impairment. R34 is assessed as refusing care and wandering for 1 to 3 days during the assessment period. R34 is assessed as requiring set up for toileting hygiene, supervision for roll left and right, and chair/bed to chair transfer. R34 is occasionally incontinent of urine and continent of bowel. R34 is assessed as not having any falls since prior assessment period. R34's fall risk assessment dated [DATE] has a score of 19 (a score of 10 or higher indicates the resident is at high risk of falling). R34's nurses note dated 5/16/25, at 03:36 (3:36 a.m.), written by Registered Nurse (RN)-FF documents: Resident in [Room Number], [R34's name] was found on the floor in her room. Resident told nurse she was getting up to go to the bathroom and noted the floor was coming up to her. Resident hit the side of her head and has a bruised area that is 1.5cm (centimeter) x (times) 4.3cm and is raised. Resident C/O (complained of) left hip pain. Per nurse caring for resident the resident could not bear weight on her left leg. Nurse then went to see resident who was already in a w/c (wheelchair) and continued to c/o of left hip pain and resident was noted to have a low B/P (blood pressure) of 75/38 with a heart rate of 57. Resident denies being lightheaded or dizzy at this time. Message sent to Dr [Name] also at this time and will be sending resident out for evaluation. Will be sending resident out for evaluation at this time. The nurses note dated 5/16/25, at 05:54 (5:54 a.m.), written by Licensed Practical Nurse (LPN)-F documents: UWF (unwitnessed fall): CNA found res on the floor at 0250 (2:50 a.m.), sitting/lying in front of her bed with w/c (wheelchair) to her left, where it had been all NOC (night). Res (Resident) was witnessed walking in room per CNA who res was assigned and found, coming from BR (bathroom) earlier in NOC and was assisted back to bed w/(with) safety precautions in place and call light on chest. Rounds completed per CNA at 0100 (1:00 a.m.) and res toileted; per writer at 0200 (2:00 a.m.) and res asleep. Safety precautions/call light in place w/ BR light on. Injuries noted-left brow hematoma, c/o (complained of) left hip pain/disc (discomfort) noted. RN notified and escorted to room per writer and assessed. Writer initiated neuros checks per protocol. [Name] Ambulance called at 0345 (3:45 a.m.). V/S (vital signs) and res stable w/hypotension noted. BP increased as time went on per EMT (emergency medical technician) taking last BP before leaving unit at 0430 (4:30 a.m.). APAPx1 (acetaminophen times one) per pain/disc noted to left hip-7/10 and ineffective prior to leaving-6/10. RN notified MD/DON (Medical Doctor/Director of Nursing). Writer updated POA (Power of Attorney) son [Name] at 0354 (3:45 a.m.) and directed to have res transferred to [Name] hospital for eval/tx (evaluation/treatment), and POA will meet res there, appreciative for being notified per writer. Res was able to move all extremities w/ (with) noticeable, and c/o left hip pain noted. Writer will report off to AM (morning) RN to call [Hospital Name] for updated report. R34's nurses note dated 5/16/25, at 10:57 a.m., by RN-GG documents: Per SW (Social Worker) who spoke with son, resident is being admitted with hip fx (fracture). Surgery will be completed tomorrow. Son talked with resident's husband and explained what is happening. R34's progress note dated 5/16/25, at 16:21 (4:21 p.m.), written by Nursing Home Administrator (NHA)-A documents: IDT (interdisciplinary team) met to review fall from this am. Nursing, Soc. (Social) Services, and Admin (Administrator) were present. Documentation was reviewed. MD and patient representative were notified. Resident was noted to be hypotensive immediately after fall. She was transported to ER (emergency room) and admitted with hip fracture. Will assess resident for change of condition upon return, and update care plan as needed. Surveyor reviewed R34's fall investigation for R34's fall on 5/16/25. The check off sheet for falls documents: non compliant with call light; transfers. R34's fall care plan does not address R34 being non compliant with call light or transfers. The fall investigation was not thorough as this investigation does not include a root cause to help prevent further falls. R34 was readmitted to the facility on [DATE]. R34's fall care plan was not revised until 5/29/25. R34's significant change MDS with an assessment reference date of 5/24/25 has a BIMS score of 2 which indicates severe cognitive impairment. R34 is assessed as being dependent for toileting hygiene, roll left and right, chair/bed to chair transfer, and toilet transfer. R34 is assessed as always incontinent of urine and frequently incontinent of bowel. R34's fall CAA (care area assessment) dated 5/28/25 under analysis of findings for nature of problem documents: Fall CAA triggered r/t (related to) resident here for LTC (long term care). Recent fall at facility with femur fx (fracture)/hospitalization with surgical repair. readmitted for rehab with goal to stay LTC (long term care). Resident has dementia with poor safety awareness. BIMS-2. Resident is dependent on staff for most ADL (activities daily living). On scheduled antihtn (antihypertensive), diuretic, anticoagulant, antidepressant, PRN (as needed) opiate. Under care plan considerations documents Fall CAA triggered r/t resident here for LTC. Recent fall at facility with femur fx/hospitalization with surgical repair. readmitted for rehab with goal to stay LTC. Resident has dementia with poor safety awareness. BIMS-2. Resident is dependent on staff for most ADL. On scheduled antihtn, diuretic, anticoagulant, antidepressant, PRN opiate. On 6/12/25 at 7:24 a.m., Surveyor observed R34 in bed on the left side, there is a heels up pad and the call pad is within reach. Surveyor observed R34's bed is at a low position but not at the lowest position. On 6/12/25 at 10:04 a.m., Surveyor observed R34 in bed on the right side. There is a heels up pad and the call pad is within reach. Surveyor observed R34's bed is at a low position but not at the lowest position. On 6/16/25 at 8:32 a.m., Surveyor met with Registered Nurse/Unit Manager (RN/UM)-D to discuss R34. Surveyor asked RN/UM-D when R34 is in bed what position should R34's bed be in. RN/UM-D explained R34's bed should be in a low position, not the lowest position, as R34 self transfers from the bed and the bed should be locked. Surveyor inquired what frequent checks are. RN/UM-D informed Surveyor they round on residents more frequently than they normally do every two hours and if the call light is on they should get in there quick. Surveyor asked RN/UM-D who should Surveyor speak to regarding R34's fall investigations for R34's falls on 10/29/24 and 5/16/25. RN/UM-D informed Surveyor Surveyor should speak with DON-B and NHA-A as they track falls more than she does. On 6/16/25 at 8:39 a.m., Surveyor observed R34 sitting in a wheelchair in her room. On 6/16/25 at 12:05 p.m., Surveyor met with DON-B and Corporate Nurse (CN)-C to discuss R34's falls. Surveyor informed DON-B and CN-C R34's fall on 10/29/24 was not thoroughly investigated as there was only the staff statement from the CNA who found R34 but no other staff statements or indications other staff that may have seen R34 were interviewed, there is no indication as to how R34 was in bed, was she on the edge or in the middle of the bed, and root cause was not identified to help prevent further falls. R34's fall on 5/16/25, RN-FF's nurses note documents R34 was in the wheelchair. There was no RN assessment of R34 prior to R34 being transferred into the wheelchair. LPN-F's nurses note documents R34 was found coming out of the bathroom by herself earlier in the shift. There is no evidence staff increased rounds/checks on R34 after R34 was observed ambulating by herself or implemented any additional interventions to prevent R34 from getting up by self. Surveyor inquired if R34 fell at 2:50 a.m. why wasn't the ambulance called for almost an hour at 3:45 a.m. The facility's investigation does not include a root cause. DON-B did not provide Surveyor with any additional information regarding R34's falls on 10/29/24 and 5/16/25. 2.) R11 was originally admitted to the facility on [DATE]. R11's diagnoses include anxiety disorder, depressive disorder, and polyneuropathy (general term for peripheral nervous system disorders that impact nerve functions in multiple areas of the body). R11's mobility care plan initiated 8/6/24 includes an intervention of GG - Chair/Bed-to-Chair Transfer - EZ stand and 2 assist. Initiated 8/28/24 and revised on 8/30/24. R11's falls care plan initiated and revised on 8/20/24 documents the following interventions: *Call light within reach at all times. Initiated 8/30/24. *Fall risk evaluation on admission, quarterly, and PRN (as needed). Post fall evaluation PRN. Initiated 8/30/24. *Monitor for side effects of medication: *Cardiac medication as ordered. Monitor weekly vital signs and labs as ordered. *Psychotropic medications as ordered. BIMS (brief interview mental status) evaluation, sleep log, and behavior monitoring per protocol. *Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respirations, and report to NP/PA/MD (Nurse Practitioner/Physician Assistant/Medical Doctor). Initiated 8/30/24. *Resident to wear proper and non slip footwear. Initiated 8/30/24. R11's fall risk assessment dated [DATE] has a score of 5 (a score of 10 or higher is high risk). R11's Quarterly MDS with an assessment reference date of 5/24/24 documents BIMS (Brief Interview for Mental Status) score of 15, which indicates that R11 has intact cognition. R11 is assessed as not having any behaviors. R11 is assessed as requiring substantial/maximal assistance for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R11 is frequently incontinent of bowel and bladder. R11's nurses note dated 5/27/24 at 9:37 a.m., written by Licensed Practical Nurse (LPN)-DD documents: Resident had an unwitnessed fall @ (at) 0845 (8:45 a.m.) in room [Number]. Resident was placed in WC (wheelchair) by CNA (Certified Nursing Assistant) [Name] to get ready for a shower. CNA stated resident was weak so she proceeded to go get the EZ stand. CNA stated resident was safely sitting in wheel chair when she left the room and when coming back into the room resident was found on knees with lower legs behind buttock. Resident was safely lowered flat to the floor with pillow behind head so writer could take vital signs and start neuro check. Resident was able to move arms and legs and stated she did not hit her head when asked. Resident is alert and orientated and rated pain an 8 on a scale from 1-10 10 being the worst pain. Pain is located in legs and residents normal edema is present. POA (Power of Attorney), DON (Director of Nursing), Doctor, [Managed Care Name] were notified. Residents shower was completed with no noted skin issues. R11's progress note dated 5/28/24, at 10:33 a.m., written by Nursing Home Administrator (NHA)-A documents: IDT(Interdisciplinary team) met to review unwitnessed fall from 5/27/24. Nursing, SS (Social Service), admin (Administrator), and therapy present. Resident had been transferred into her wheelchair and was waiting for CNA to return for shower. When CNA returned to her room, resident was on her knees. MD and family were notified. Resident was unable to state what she was trying to do. Nursing will check orthostatic blood pressures and request lab work as resident said that she felt weak. Resident is currently receiving PT (physical therapy) intervention. Surveyor reviewed the facility's fall investigation for R11's fall on 5/27/24. The facility did not conduct a thorough investigation as the facility did not investigate how R11 was seated in her wheelchair, the investigation does not include whether R11 was interviewed regarding the fall, did not determine a root cause, and R11's fall care plan was not developed until 8/30/24. R11's quarterly MDS with an assessment reference date of 8/21/24 has a BIMS score of 14 which indicates intact cognition. R11 is assessed as not having any behaviors. R11 is assessed as requiring partial/moderate assistance for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R11 is frequently incontinent of bowel and bladder. R11's fall risk assessment dated [DATE] has a score of 7 which indicates low risk. R11's nurses note dated 10/5/24, at 22:52 (10:52 p.m.), written by Registered Nurse (RN)-BB documents: CNA assigned to resident came to writer and mentioned that resident had fallen and was on the floor during transferring. Writer took vital cart into resident room and assessed resident ROM (range of motion) which was WNL (within normal limits). Denied hitting head or any injuries. Resident states CNA was inexperienced and unable to transfer resident right and she slid to the floor. Resident was lifted off the floor via Hoyer, vitals were taken B/P (blood pressure): 123/69, HR (heart rate): 62, T (temperature): 96.8, R (respirations): 20, 02 (oxygen): 93% RA (room air). R11's progress note dated 10/7/24, at 16:47 (4:47 p.m.), written by NHA-A documents: IDT (interdisciplinary) met to review fall from 10/5/2024. Nursing, Soc. (Social) Services, Therapy and Admin were present. Documentation was reviewed. MD and patient representative were notified. Neuro checks were not necessary as fall was witnessed and resident did not hit her head. Therapy will provide resident specific transfer training with CNA that was assigned. In addition, resident specific transfer training will be arranged for all CNAs that have been hired since September 1. Surveyor reviewed the facility's investigation which included only a fall statement dated 10/5/24 from CNA-SS, the CNA who was with R11 when R11 fell. R11 was not transferred according to R11's plan of care as the mobility care plan indicates R11 is transferred with an EZ stand and 2 assist. R11's fall CAA (care area assessment) dated 12/3/24 documents under analysis of findings section: Fall CAA triggered r/t (related to) resident here for LTC (long term care). Dx (diagnoses) of COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus) (high blood sugar) with neuropathy. Resident is dependent to supervision with ADLs (activities daily living). On scheduled antihtn (antihypertensive), diuretic, diabetic meds, anticoagulant and non narcotic pain meds. Frequently incontinent of bladder and occasionally incontinent of bowel. 1 fall without injury in the last quarter. Under the care plan considerations it documents: Fall CAA triggered r/t resident here for LTC. Dx of COPD, DM with neuropathy. Resident is dependent to supervision with ADLs. On scheduled antihtn, diuretic, diabetic meds, anticoagulant and non narcotic pain meds. Frequently incontinent of bladder and occasionally incontinent of bowel. 1 fall without injury in the last quarter. On 6/11/25 at 10:40 a.m., Surveyor spoke with R11 who was sitting in a wheelchair with the call light in reach in R11's room. Surveyor asked R11 if she remembers her fall in October. R11 informed Surveyor the CNA was new and she told the CNA when she had me situated she was not right and was going down. Surveyor asked R11 what she meant by she was not right. R11 informed Surveyor she had her on the edge of the chair, went down with both legs under her. Surveyor asked R11 if the CNA was using a gait belt. R11 replied no. Surveyor asked R11 if the CNA was using a mechanical lift. R11 replied no. Surveyor asked R11 if there is anything else she remembers. R11 replied all I remember is I laid there for quite a while with my legs under me. She finally went and got help. On 6/16/25 at 12:01 p.m., Surveyor met with Director of Nursing (DON)-B and Corporate Nurse (CN)-C regarding R11's falls. Surveyor informed DON-B the facility did not conduct a thorough investigation as the investigation didn't include a root cause, how R11 was seated in the wheelchair, or whether R11 was interviewed regarding the fall. Surveyor also informed DON-B and CN-C there is not a fall care plan until 8/30/24. CN-C reviewed R11's care plans and informed Surveyor there was not a care plan prior to 8/30/24. Surveyor informed DON-B and CN-C R11 had a fall on 10/5/24 with a CNA. According to R11's care plan, R11 should have been transferred with an EZ stand and 2 assist. 3.) R23's diagnoses includes Alzheimer's Disease, dementia, depressive disorder, and anxiety disorder. Surveyor reviewed R23's care plans and noted the following: Elopement risk initiated and revised 4/25/24; PASAAR (Pre admission Screening and Resident Review) initiated 4/25/24; Psychosocial Well Being, Adjustment New Admission, Unfamiliar with staff routine, environment initiated 4/25/24; Advanced Directives initiated 4/25/24; Discharge Planning initiated 5/15/24; Nutrition Alteration initiated 4/29/24 and revised 2/13/25; Communication Problem initiated and revised 5/2/24; Falls initiated and revised 5/2/24; Pain initiated and revised 5/2/24; Oral/Dental Health Problems initiated and revised 5/2/24; Potential for Impaired Visual Function initiated and revised 5/2/24; Potential for Constipation initiate [NAME] revised 5/2/24; Potential Fluid Deficit initiated and revised 5/2/24; Impaired Cardiac Status initiated and revised 5/2/24; Hospice Care initiated 5/13/24 and revised 6/4/24; Risk for Ineffective Peripheral Tissue Perfusion initiated 6/25/24; AROM (active range of motion) Restorative Nursing Program initiated and revised 6/26/24; Transfer Restorative Nursing Program initiated and revised 6/26/24, Self Care initiated and revised 9/10/24, Bowel and Bladder initiated and revised 5/19/25, Chronic/Progressive decline in Intellectual functioning initiated and revised 4/25/24; Mobility initiated and revised 9/10/24; Potential for Impaired Skin Integrity initiated and revised 2/17/25; Feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by ineffective coping, low self esteem, tearfulness, motor agitation, withdrawal from care/activities initiated 4/25/24 and revised 5/2/24; Activities initiated 11/14/24 and revised 2/13/25; Cognition initiated and revised 5/29/25; Anti-anxiety medication initiated and revised 5/12/25; and Antidepressant medication initiated 5/12/25. R23's Annual MDS (minimum data set) with an assessment reference date of 5/13/25 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. R23 is assessed as not having any behavior other than wandering 1 to 3 days during the assessment period. R23 receives hospice services. R23's nurses note dated 11/2/24, at 12:31 p.m., documents Resident has a red mark to L (left) cheek and a bruised scratch to L neck. Skin is intact with no bleeding. Noted bruised scratch to L neck. Both areas were cleaned with an alcohol wipe. Scratches occurred from another resident. Both residents were separated. R23's nurses note dated 11/2/24, at 13:15 (1:15 p.m.), documents: POA (Power of Attorney) updated @ (at) 1316 (1:16 p.m.). R23's nurses note dated 11/2/24, at 15:09 (3:09 p.m.), documents: Writer went to check on residents L cheek and L neck scratches. No marks noted to L cheek. Noted scratch to L lower neck. Skin remains intact. R23's nurses note dated, 11/3/24 at 03:31 (3:31 a.m.), documents: Resident is on report for incident that occurred on 11/2/24 with another resident. Resident has small red scratch to left side of neck. Skin is intact. No mark noted on left cheek. Resident has been sleeping well this noc (night) and voices no C/O's (complaint of) of any pain. No Bx's (behaviors) this noc. Surveyor noted none of R23's care plans were revised and/or a resident to resident care plan was not initiated following R23's incident on 11/2/24. On 6/11/25 at 3:10 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor requested any investigation the facility did for R23's resident to resident altercation which occurred on 11/22/24. On 6/16/25 at 9:06 a.m., Surveyor received a statement that is not signed or dated which documents: Re: Incident 11/2/24 Resident #1 was showing signs of distress and was in the hallway calling out. She had already received medication for pain and anxiety. [R23's first name], being the compassionate soul that she is, went over to the resident in an attempt to console her. Resident #1, not recognizing the gesture due to her dementia and distress, reached out to grab [R23's first name] shirt. With this motion [R23's first name] received a small scratch on the left side of her neck. The residents were moved apart. At the time, [R23's first name] apologized saying that she was just trying to help out. She was not negatively affected by the interaction. This was not interpreted as a resident-to-resident altercation - it was not confrontational, intentional or willful. The behavior did not continue. It was not felt to be reportable. On 6/16/25 at 12:12 p.m., met with Director of Nursing (DON)-B and Corporate Nurse (CN)-C. Surveyor asked DON-B if DON-B knew who the other resident involved in the resident to resident altercation with R23 was. DON-B replied that was my question, believe it was [Name of R13]. Surveyor inquired if there was an investigation as Surveyor only received a statement which Surveyor read to DON-B and CN-C. DON-B informed Surveyor that was NHA-A's note. CN-C informed Surveyor Surveyor should speak with NHA-A or Director of Social Services (DSS)-K. On 6/16/25, at 12:18 p.m., Surveyor asked DSS-K if she was aware of an altercation on 11/2/24 with R23 and another Resident. DSS-K replied vaguely and explained NHA-A was more involved. Surveyor asked DSS-K if she knew who the other resident was. DSS-K informed Surveyor she thinks it was R295. Surveyor asked DSS-K if there was an investigation. DSS-K informed Surveyor when they talked about it there was a misunderstanding as R295 didn't do anything intentionally, she was anxious and R23 was trying to help. Surveyor informed DSS-K the altercation may not have had to be reported to the state agency but should have been investigated. On 6/16/25, at 2:46 p.m., Surveyor showed NHA-A the statement Surveyor was provided and asked who wrote this statement as it's not dated or signed. NHA-A informed Surveyor she did. Surveyor asked who was the other resident involved[TRUNCATED]

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 resident unit refrigerators in the facility. The facility did not ensure food was stored in a safe manner and, kitchen staff member had beard hair exposed and uncovered while preparing food, which had the potential to affect all 41 Residents currently living in the facility. *Temperature logs were not maintained for unit refrigerator/freezers. *Multiple food items were observed undated on the metal racks located in the facility's freezer. *Hand scoops were observed left in the ready to use sugar, flour, and rice flour bins. *Cook-Q was observed not wearing a beard hair guard on 6/11/25 while preparing food in the kitchen. Findings include: Temperatures Not Documented for Unit Refrigerators and Freezers The facility's undated policy General HACCP Guidelines for Food Safety documents: a.Take the internal temperatures of each unit b. Periodically, take internal temperatures of foods in the unit . On 6/12/25, at 7:30 AM, Surveyor observed Unit 1 refrigerator. Surveyor observed 4 large tubs of ice cream that are undated in the freezer, 1 yogurt not dated in the refrigerator, no thermometer in the freezer or refrigerator, dripping water from the freezer into the refrigerator and no documented temperature logs on or near the freezer and refrigerator. Surveyor also observed Unit 2 refrigerator. Surveyor observed all items dated, but no documented temperature logs on or near the freezer and refrigerator. The facility was unable to provide documentation that the facility was maintaining temperature logs for the unit refrigerators and freezers. On 6/12/25, at 9:41 AM, Surveyor informed Executive Chef (EC)-L that the facility has no documentation that the refrigerators/freezer on the units temperatures were being monitored. On 6/16/25, at 8:52 AM, Dietary Manager (DM)-R stated that the kitchen does not maintain temperatures of the unit refrigerators/freezers and does not maintain food items to be stored in a safe manner in the unit refrigerator and freezers. DM-R stated that is the responsibility of the nursing department. Food Storage The facility's undated Storage policy documents: Scoops must be provided for bulk foods(such as sugar, flour, and spices). Scoops should be kept covered in a protected area near the containers rather than in the containers. Scoops should be washed and sanitized on a regular basis. The facility's Accepting Food Deliveries undated policy documents: 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate. On 6/10/25, at 8:50 AM, during the initial tour of the kitchen with Bistro (B)-N, Surveyor observed unopened packages of Ribeye, Bags of Fries, Bags of Onion Rings, Bags of Tamale Pie Filling, Bag of [NAME] Chicken, Bags of Onion Rings, and 2 Pork Loins with no dates located on the freezer metal racks. Items were located freely on a metal rack and not on top of a box with similar items. B-N was not aware of and undated items in the freezer, removed some of the undated items, and stated the freezer would be checked for more undated items. Surveyor also observed on 6/10/25, at 8:50 AM scoops in the sugar and flour bin touching the sugar and flour. On 6/11/25, at 7:53 AM, Surveyor conducted another tour with Executive Chef (EC)-L in the freezer. Surveyor shared that there were 2 pork loins undated. Surveyor asked if EC-L observed any dates on the pork loin packaging. I don't see one, I have been doing healthcare for 1 year and I haven't known freezer items to be dated. they are frozen. Surveyor also observed on 6/11/25, at 7:53 AM, that the sugar, flour, and rice flour scoops are located in the bin. Surveyor observed the bin to be dirty on the outside with dried food items on the bins. On 6/12/25, at 7:35 AM, Surveyor conducted a 3rd tour of the kitchen coolers and freezer. In the first cooler, Surveyor observed a beef top round thawing with no date. Surveyor observed in the freezer a bag of pancakes undated, 5 bags of potatoes undated, 1 onion ring bag undated, 2 boneless pork loins undated, and 1 bag of white chicken undated. Surveyor also observed the scoop in the sugar bin and all 3 flours bins along with being dirty on the outside, sticky food droppings on the lids. On 6/12/25, at 7:50 AM, B-N stated that cooks are responsible for dating the items in the freezer and others are responsible for dating the items when stocking the orders. On 6/12/25, at 9:33 AM, Surveyor interviewed [NAME] (Cook)-M. Cook-M stated that the items are dated by supervisors when the order arrives. Cook-M stated Cook-M dates when preparing the food items and puts the items in the cooler or freezer. Usually use a range of 5 days, will write the date on masking tape. Cook-M knows everything needs to be dated. On 6/12/25, at 9:41 AM, Surveyor shared with EC-L a list of undated items in the freezer and the concern that the items were unpacked from the boxes, the box with a date is no longer present, and the bags of items are undated. EC-L did not want the list of all items located in the freezer that were undated from Surveyor. Surveyor also shared that the scoops were left in the sugar and flour bins that were also dirty on the outside with dried food on the bin. On 6/12/25, at 10:59 AM, Surveyor observed the sugar and 3 flour bins with the scoops located inside. The facility acknowledged that there is a required Cleaning and Sanitation of Dining and Food Service Areas, however, regular cleaning of the sugar and flour bins are not on the cleaning schedule. On 6/16/25, at 8:52 AM, shared the concern with Dietary Manager (DM)-R the concerns that items in the freezer were observed to be undated and the scoops were observed in the sugar and flour bins and the bins were observed to be dirty on the outside. Surveyor shared the concern that when the original packaging is not there, and no date on the food packaging, no one knows what the expiration date is. DM-R understands the concerns and provided no additional information. Hair Restraint Use The facility's undated Personal Hygiene and Health Reporting policy and procedure documents: b. Hair should be neat and clean. Hair restraints must be worn around exposed foods, in the kitchen or food service areas and dining areas. c. Beards and mustaches should be closely cropped and neatly trimmed. When around exposed foods, beards must be restrained using beard covers. On 6/11/25 at 10:59 AM, Surveyor observed [NAME] (Cook)-Q arrive into the kitchen, and wash hands. Cook-Q had a baseball hat on. Surveyor observed no beard guard on Cook-Q. Surveyor observed Cook-Q has facial hair(growth of a beard) and hair on chin, and Cook-Q also has a mustache. Surveyor observed Cook-Q put gloves on and chopped up lemons. Washed hands, put new gloves on, took out rolls from the oven. Working on chopping up other vegetables. On 6/11/25, at 11:30 AM, Surveyor shared the concern with Executive Chef (EC)-L that Cook-Q did not have a beard guard on. EC-L stated, That's a 2 day growth; Didn't think it was an issue. On 6/12/25, at 9:33 AM, Surveyor observed Cook-Q is completely shaved on this date. On 6/12/25, at 9:41 AM, Surveyor shared the concern with EC-L the observation of Cook-Q not wearing a beard guard. ECL disagrees with the beard guard issue and stated that it is only 2 days of beard growth. On 6/16/25, at 8:52 AM, Surveyor shared the concern with Dietary Manager (DM)-R the observation of Cook-Q not having a beard guard on. No additional information was provided as to why the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. * The facility was not computing baseline rates of infections for prevalent infections. * The eye wash station was not flushed weekly. * R12 has Stage 2 coccyx pressure injury. R12 was not placed on EBP (enhanced barrier precautions) staff was observed not wearing the appropriate PPE (personal protective equipment) during personal care & treatment observations and hand hygiene concerns were identified during R12's treatment observation. * Hand hygiene concerns were identified during R23's medication administration. * R24 was not placed on EBP. R24 has a heel pressure injury. * R38 was not placed on EBP. R38 has a Stage 2 coccyx pressure injury. * R3's catheter collection bag and tubing was observed during multiple observations to be laying directly on the floor. This has the potential to affect the 41 residents currently residing in the facility. Findings include: The facility's policy titled, Infection Prevention and Control Program and not dated under policy documents This facility has established and maintains 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 as per accepted national standards and guidelines. Under Policy Explanation and Compliance Guidelines documents 1. The designed Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to this program. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. The facility's policy titled, Hand Hygiene and noted dated under policy documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The facility's policy titled, Enhanced Barrier Precaution and dated March 2024 under Policy documents It is the policy of American Baptist Homes of the Midwest to reduce transmission of multidrug-resistant organisms through an infection control intervention designed that employs targeted gown and glove use during high contact resident activities known as Enhanced Barrier Precautions (EBPs). Under the procedure section it documents: 1. EBPs are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning (placing on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organisms) to staff hands and clothing. 4. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. 8. EBPs employ target gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is a also a risk of splash or spray. 9. For residents whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: a. Dressing, b. Bathing/showering, c. Transferring, d. Providing hygiene, e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator, h. Wound care: any skin opening requiring a dressing. 15. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. 1.) On 6/11/25, at 12:09 p.m., Surveyor reviewed the infection control binder provided by Infection Preventionist (IP)-Z. Surveyor noted the facility is calculating one rate of infection and not baseline rates of infection for the facility's prevalent infections. Infection rates are as follows: January 2025 the HAI (Healthcare Associated Infection) rate documents 20.21/1000 patient days. January 2025 Monthly Infection Rates Total (Community and Facility Acquired) documents 22.23/1000 patient days. February 2025 the HAI rate documents 3.77/1000 patient days. February 2025 Monthly Infection Rates total (Community and Facility Acquired) documents 4.52/1000 patient days. March 2025 HAI rate documents 4.41/1000 patient days. March 2025 Monthly Infection Rates total (Community and Facility Acquired) documents 6.62/1000 patient days. April 2025 HAI rate documents 5.85/1000 resident days. April 2025 Monthly Infection Rates (Community and Facility Acquired) documents 10.23/1000 resident days. May 2025 infections rates were not calculated. On 6/12/25, at 10:48 a.m., Surveyor met with IP-Z to discuss the facility's infection control program. During this interview Nursing Home Administrator (NHA)-A was also present. During the interview, Surveyor informed IP-Z Surveyor had reviewed her infection control binder and noted one rate of infection based on 1000 resident days. Surveyor asked IP-Z if she is calculating baseline rates of infections based on their prevalent infections. IP-Z informed Surveyor looks like its the over all rate. Surveyor informed IP-Z they should be calculating individual baseline rates of infection for their prevalent infections. On 6/16/25, at 9:55 a.m., IP-Z informed Surveyor they retroactively figured out the individual rates of infections for their prevalent infections on Friday going back to January 2025. 2.) On 6/12/25, at 12:41 p.m., during the water management interview with Environmental Services Director (ESD)-NN Surveyor inquired if there are any eye wash stations at the facility and how often the eye wash station is flushed. ESD-NN informed Surveyor he believes Environmental Supervisor (ES)-OO has the documentation. On 6/12/25, at 1:11 p.m., ES-OO provided Surveyor with the weekly eye wash inspection form which states to run water for 15 seconds to see that there is a proper flow and that running water does not appear dirty or cloudy. Water temperature is tepid. Surveyor reviewed this weekly log and note for May 2025 the week of 5/4/25 to 5/10/25 and 5/18/25 to 5/24/25 the log does not indicate the eye wash station was flushed. Surveyor informed ES-OO the log for the week of 5/4/25 to 5/10/25 does not indicate the eye wash station was flushed. ES-OO stated I was probably gone, ya I was gone. Surveyor asked when she is not working is there anyone else responsible for flushing the eye wash station. ES-OO replied no, could of assigned someone. Surveyor then asked ES-OO if she knows why the eye wash station was not flushed during the week of 5/18/25 to 5/24/25. ES-OO replied no I don't know. Surveyor noted during May 2025 the eye wash station was not flushed during 2 of the 4 weeks. 3.) R12 has a Stage 2 coccyx pressure injury. R12's quarterly MDS (minimum data set) with an assessment reference date of 5/8/25 has a BIMS (brief interview mental status) score of 11 which indicates moderate cognitive impairment. R12 is assessed as requiring supervision or touching assistance for toileting hygiene, roll left and right, chair/bed to chair transfer and toilet transfers. R12 is assessed as being occasionally incontinent of urine and always incontinent of bowel. R12 is at risk for pressure injury development and is assessed as having one Stage 2 pressure injury which was not present upon admission. On 6/10/25, at 9:21 a.m., Surveyor observed R12 sitting in a personal type recliner in R12's room wearing clothing with a bathrobe over the clothing. During the conversation with R12, Surveyor asked R12 if she has any skin concerns. R12 stated I have a hole in my butt which they are treating. On 6/10/25, at 10:37 a.m., Surveyor did not observe an EBP (enhanced barrier precaution sign) on or around R12's door frame. On 6/11/25, at 11:34 a.m., Surveyor observed Certified Nursing Assistant (CNA)-J and CNA-GG in R12's room with gloves on. Neither CNA-J or CNA-GG are wearing gowns. The sit to stand lift was placed in front of R12, the belt was connect around R12's legs and staff placed a sling around R12 and hooked the sling to the lift. R12 was raised off the bed and wheeled into the bathroom. CNA-J lowered R12's pants & product and R12 was lowered onto the toilet. Staff informed R12 they would give her a couple minutes and closed the accordion bathroom door. CNA-J & CNA-GG removed their gloves and cleansed their hands. Surveyor did not observe an EBP (enhanced barrier precaution sign) on or around R12's door frame. On 6/11/25, at 11:41 a.m., CNA-J and CNA-HH entered R12's room and placed gloves on. Neither CNA-J or CNA-HH placed a gown on. CNA-J asked R12 if she was ready and R12 was raised off the toilet. CNA-J wiped R12's perineal area with a disposable wipe, applied barrier cream and R12's incontinence product and pants were pulled up. R12 was wheeled out of the bathroom, CNA-HH informed R12 she was going down and R12 was lowered into the wheelchair. CNA-HH & CNA-J removed the sling from around R12, removed their gloves and cleansed their hands. On 6/12/25, at 7:28 a.m., Surveyor asked Certified Nursing Assistant (CNA)-PP if there are any residents on the unit who are on isolation precautions. CNA-PP replied no, there are no residents on isolation. On 6/12/25, at 8:23 a.m., Surveyor observed R12 in bed on her back stating hurry I have to go to the bathroom. Surveyor observed R12's pants were down at her knees, wearing sneakers, and there is a sit to stand lift in R12's room. On 6/12/25, at 8:26 a.m., CNA-HH entered R12's room, cleansed her hands, and placed gloves on. CNA-HH was not wearing a gown. CNA-HH assisted R12 with sitting on the edge of the bed. R12 was telling CNA-HH to hurry. CNA-HH placed the sling around R12 and connected the sling to the lift. At 8:29 a.m. CNA-HH removed her gloves and cleansed her hands. CNA-HH informed R12 I'll tell her to hurry and left R12's room. CNA-HH returned a few seconds later with CNA-GG. CNA-HH and CNA-GG cleansed their hands and placed gloves on. Neither CNA-HH or CNA-GG are wearing a gown. CNA-HH informed R12 she was going up and R12 was raised off the bed, wheeled into the bathroom and CNA-GG lowered R12's incontinence product. R12 started to urinate as she was lowered onto the toilet. CNA-HH removed R12's incontinence product. At 8:32 a.m. R12 was asked if she wanted privacy and CNA-GG & CNA-HH removed their gloves and left R12's room. At 8:33 a.m. CNA-HH entered R12's room and placed gloves on. CNA-HH was not wearing a gown. At 8:34 a.m. RN/UM-D entered R12's bathroom, dated the foam dressing and placed gloves on. RN/UM-D was not wearing a gown. RN/UM-D placed soap & water on four by four gauze, asked R12 if she was ready to stand up & asked R12 if she was able to help stand up. R12 was then raised to a standing position and wheeled out of the bathroom. RN/UM-D removed the dressing and cleansed R12's coccyx pressure injury. RN/UM-D did not remove her gloves and perform hand hygiene. RN/UM-D waved the foam dressing over the pressure injury to help dry the pressure injury and place the foam dressing over R12's coccyx pressure injury. Using a disposable wipe, RN/UM-D wiped R12's frontal perineal area. RN/UM-D and CNA-HH pulled up R12's incontinence product & pants, R12 was wheeled out of the bathroom and lowered into the wheelchair. RN/UM-D removed her gloves and cleansed her hands. CNA-HH changed R12's shirt, brushed her hair, gathered the garbage, removed her gloves and cleansed her hands. On 6/12/25, at 8:44 a.m., Surveyor asked RN/UM-D if there are any residents on isolation. RN/UM-D informed she believes [name of R6] is on enhanced barrier precautions. R6 is the only one. On 6/12/25, at 9:10 a.m., Surveyor asked CNA-HH if any resident is on isolation. CNA-HH replied just [room number] with body fluids. Surveyor noted this is not R12's room. On 6/12/25, at 10:48 a.m., during the infection control interview with Infection Preventionist (IP)-Z & NHA-A present, Surveyor asked IP-Z if they have residents on EBP. IP-Z replied yes. Surveyor asked IP-Z how they determine when a resident is placed on EBP. IP-Z informed Surveyor they follow the guidance, they have a non healing wound, artificial tube, Foley. Surveyor asked IP-Z if EBP signs are posted. IP-Z informed Surveyor for resident dignity the signs are in the room and caddy's (for PPE) are in the room. Surveyor asked if residents with pressure injuries, stage 2, 3, or 4 should they be placed on EBP. IP-Z replied yes. Surveyor asked who is responsible to place a resident on EBP if they are admitted with a pressure injury or develop a pressure injury. IP-Z informed Surveyor she would be the one reviewing the admission information. Surveyor informed IP-Z R12 has a Stage 2 coccyx pressure injury and Surveyor did not observe an EBP sign or caddy and staff were observe during personal cares and treatment observation not wearing the appropriate PPE. IP-Z informed Surveyor she will place R12 on EBP and may not have captured that one. R12's nurses note dated 6/12/25, at 12:09 p.m. written by IP-Z documents EBP initiated. Primary nursing staff updated. On 6/12/25, at 1:47 p.m., Surveyor observed an EBP sign and cart in R12's bathroom. 4.) On 6/12/25, at 8:02 a.m., Surveyor observed Registered Nurse/Unit Manager (RN/UM)-D prepare R23's medication. RN/UM-D removed R23's blister packs from the drawer and placed gloves on. Surveyor observed RN/UM-D did not perform any hand hygiene prior to placing gloves on. RN/UM-D dispensed Buspirone 5 mg (milligrams) one tablet onto her gloved hand and then placed the tablet into the medication cup. RN/UM-D repeated this process for Gabapentin 100 mg 2 capsules, Senna 8.6 mg one tablet, Memantine 10 mg one tablet, Klor Con M 10 ER 1 tablet, and Sertraline 50 mg one tablet. RN/UM-D with her gloved hands, opened a drawer in the medication cart and removed Acetaminophen 500 mg bottle. RN/UM-D poured two tablets of Acetaminophen into her gloved hands and placed the tablets into the medication cup. RN/UM-D opened the drawer of the medication cart and removed a metamucil fiber packet, opened the packet and emptied the packet into a Styrofoam cup. At 8:06 a.m., RN/UM-D removed her gloves, approached R23 stating to R23 she gave her the wrong flavor drink and left the dining room where RN/UM-D had been preparing R23's medication. At 8:08 a.m. RN/UM-D placed the vanilla ensure on the table, mixed 8 ounces of water with the fiber and then administered R23's medication one tablet at a time with the fiber drink after. At 8:16 a.m. Surveyor observed RN/UM-D cleanse her hands. On 6/12/25, at 8:52 a.m., Surveyor observed RN/UM-D place gloves on, asked R23 to remove her glasses and placed R23's glasses on top of the medication cart. RN/UM-D did not perform hand hygiene prior to placing her gloves on. RN/UM-D administered one drop of Polyvinyl alcohol 1.4% lubricating drops in R23's right eye and then one drop in R23's left eye. RN/UM-D handed R23 her eye glasses and removed her gloves. RN/UM-D then placed the eye drops in the medication cart. Surveyor did not observe RN/UM-D perform any hand hygiene during this observation. On 6/12/25, at 11:12 a.m., Surveyor asked IP-Z what is expectation for hand hygiene during medication pass. IP-Z informed Surveyor before starting medication pass, after any contamination and when exiting the room. Surveyor informed IP-Z of Surveyor's observation during medication pass with RN/UM-D. 5.) R38 was admitted to the facility on [DATE] and has diagnoses that include respiratory failure, pulmonary fibrosis, muscle weakness, and anxiety disorder. R38's Admissions Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R38 is cognitively intact. The MDS documents that R38 requires maximal assistance with 1 staff member for toileting hygiene, and moderate to minimal assistance with 1 staff member for transferring and repositioning. R38's admission Care Area Assessment (CAA) dated 4/22/2025 for pressure injuries documents: R38 triggered area for recent hospitalization with COVID/pneumonia. (R38) was admitted to the facility for rehab with a goal to discharge back to home. (R38) required maximal assistance to moderate assistance with most activities of daily living (ADLs). (R38) is frequently incontinent of bowel and bladder . (R38) was admitted with moisture associated skin damage (MASD) and excoriations on buttocks. (R38) did not have pressure injuries on admission on [DATE]. On 5/2/2025, at 6:29 AM, in the progress notes nursing documented certified nursing assistant (CNA) took R38 to the bathroom and noted an open area on R38's left buttock area. No drainage, or signs of infection noted. R38's wound data assessment dated [DATE] documents: - Coccyx, MASD - 0.2 X 0.5 X <0.1 (Length X Width X Depth), partial thickness, superficial - 100% epithelial tissue, no drainage - Macerated, MASD with open area from shearing force. There are two open areas present, same size, one directly above the other. Below level of coccyx. -Redness noted upon admission, has new open areas within the redness due to shearing force. Dressing applied and will monitor for improvement. On 6/10/2025 Surveyor reviewed the facility's list documenting the residents that have pressure injuries in the building. R38 was documenting as having a stage 2 pressure injury to the coccyx area. On 6/11/2025, at 3:42 PM Surveyor noted R38 in R38's bedroom. Surveyor noted that R38 did not have an enhanced barrier precaution (EBP) sign in room to notify staff/ visitors that personal protective equipment (PPE) is needed when providing care for R38. Surveyor also noted that PPE was not readily available to staff or visitors to put on when providing care for R38. Surveyor reviewed R38's medical record and did not note an order for R38 to be on EBP for stage 2 pressure injury to coccyx area. On 6/12/2025, at 8:06 AM, Surveyor interviewed licensed practical nurse (LPN)-W. Surveyor asked LPN-W what policy is for when someone is on EBP. LPN-W stated that if a resident has a foley catheter, any drains, and certain kinds of wounds the resident gets put on EBP. Surveyor asked what wound would require a resident to be put on EBP. LPN-W stated not specifically sure which wounds would require EBP, LPN-W stated that most definitely infected wound require EBP. Surveyor asked who determines when a resident needs to be on EBP. LPN-W stated that the infection preventionist (IP) would determine if a resident should be on EBP. Surveyor asked how staff know someone is on EBP. LPN-W stated that there would be an order included on the resident's medical record and documented on a banner, the resident will also have an EBP sign and PPE located in the resident's room. On 6/12/2025, observed staff assisting R38 with cares. Staff did not put on PPE when providing care for R38. On 6/12/2025, at 11:37 AM, A Surveyor interviewed infection preventionist (IP)-Z who stated residents that have pressure injuries should be on EBP and a EBP sign is placed in the room along with a bin of PPE. IP-Z stated that admissions are reviewed to determine if a resident would require EBP. If a resident develops a pressure injury or any situation that may require EBP it could have been missed and would need to evaluate and review. On 6/12/2025, at 3:14 PM, Surveyor shared concern with nursing home administrator (NHA)-A and director of nursing (DON)-B of Surveyors observations that R38 did not have EBP initiated when noted to have a stage 2 pressure injury to R38's coccyx area on 5/2/2025. NHA-A and DON-B agreed that R38 should be on EBP for R38's Pressure injury. 6.) R24 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's, Dementia, severe protein-calorie malnutrition, muscle weakness, cognitive communicative deficit, and weakness. R24's admission Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating that R24 has severely impaired cognition. The MDS documents that R24 has modified independence with 1 staff member for repositioning, and maximal assistance with 1 staff member for putting on and taking off footwear and lower body dressing. R24 had no pressure injuries noted on the admission skin assessment. On 5/20/2025, at 11:45 AM in the progress notes nursing documented nursing notified (R24) had bleeding to the right heel. Nursing noted a 1 cm X 1 cm blister that had opened at the bottom that had opened and was bleeding. On 5/21/2025, R24's weekly wound assessment documented: - Right heel pressure injury, Stage 2 - 1.1 cm X 1.1 cm X <0.1 cm (length X width X depth), scant serous drainage, 100% epithelial tissue. - Nursing informed that (R24) had popped blister to the right heel. No flap present appears as stage 2. Dressing order placed, heels up in device while in bed, and gripper socks until healed. On 6/10/2025, Surveyor reviewed the facility's list documenting the residents that have pressure injuries in the building. R24 was documenting as having a stage 2 pressure injury to the right heel. On 6/10/2025, at 11:26 AM, Surveyor observed R24 sitting in a wheelchair in the unit's dining/activity area. Surveyor walked past R24's bedroom and noted that there was not an enhanced barrier protection (EBP) sign indicating personal protective equipment (PPE) was required when providing cares for R24, Surveyor noted that there was not PPE readily available for staff or visitors to put on when providing cares for R24. Surveyor reviewed R24's medical record and did not note an order for R24 to be on EBP for stage 2 pressure injury to the right heel. On 6/12/2025, at 8:06 AM, Surveyor interviewed licensed practical nurse (LPN)-W. Surveyor asked LPN-W what policy is for when someone is on EBP. LPN-W stated that if a resident has a foley catheter, any drains, and certain kinds of wounds the resident gets put on EBP. Surveyor asked what wound would require a resident to be put on EBP. LPN-W stated not specifically sure which wounds would require EBP, LPN-W stated that most definitely infected wound require EBP. Surveyor asked who determines when a resident needs to be on EBP. LPN-W stated that the infection preventionist (IP) would determine if a resident should be on EBP. Surveyor asked how staff know someone is on EBP. LPN-W stated that there would be an order included on the resident's medical record and documented on a banner, the resident will also have an EBP sign and PPE located in the resident's room. On 6/12/2025, at 9:00 AM, Surveyor observed certified nursing assistance (CNA)-X assist R24 with getting washed up and dressed for the day. CNA-X did not put on appropriate PPE when providing care for R24. Surveyor asked CNA-X how staff are notified or know when someone requires EBP. CNA-X stated that the infection preventionist (IP)-Z will notify staff when a resident requires EBP and make sure the appropriate sign and PPE gets put into the resident's room. On 6/12/2025, at 11:37 AM, A Surveyor interviewed infection preventionist (IP)-Z who stated residents that have pressure injuries should be on EBP and a EBP sign is placed in the room along with a bin of PPE. IP-Z stated that admissions are reviewed to determine if a resident would require EBP. If a resident develops a pressure injury or any situation that may require EBP it could have been missed and would need to evaluate and review. On 6/12/2025, at 3:14 PM, Surveyor shared concern with nursing home administrator (NHA)-A and director of nursing (DON)-B of Surveyors observations that R24 did not have EBP initiated when noted to have a stage 2 pressure injury to R24's right heel area on 5/20/2025. NHA-A and DON-B agreed that R24 should be on EBP for R24's Pressure injury. The facility's policy titled Catheter Care Policy, with no implementation or reviewed/revision date document, documents . 1. Catheter care will be performed every shift and as needed by nursing personnel; 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use; 3. Privacy bags will be changed out when soiled, with a catheter change or as needed; 4. Leg bags may be used for ambulatory residents or per resident request; . 9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. 7.) R3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, malignant neoplasm (cancer) of bladder, and obstructive and reflux uropathy (blockage of urine flow). R3's admission MDS (Minimum Data Set) dated 4/7/25 documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R3 has intact cognition; requires partial/moderate assistance with bed mobility, substantial/maximal assistance for toileting hygiene and toilet transfers, and is unable to ambulate; has an indwelling catheter placed for urinary needs and is frequently incontinent of bowel. R3's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 4/7/25 documents under the Care Plan Considerations section, Urinary CAA triggered because resident admitted for long term care (LTC)/Hospice care. (R3) requires max to moderate assist with most activities of daily living (ADL). On scheduled diuretic, PRN (as needed) anti-anxiety. (R3) has an indwelling foley catheter in use, frequently incontinent of bowel. On 6/10/25 at 10:00 am, Surveyor observed R3 sitting in wheelchair. Surveyor observed R3's catheter bag hanging on the bottom of the wheelchair with no privacy cover and catheter tubing resting on the floor. Surveyor noted there was no barrier between the catheter tubing and catheter bag and the floor. On 6/10/25 at 11:53 am, Surveyor observed R3 sitting in wheelchair. Surveyor observed R3's catheter bag hanging on the bottom of the wheelchair with no privacy cover and catheter tubing resting on the floor. Surveyor noted there was no barrier between the catheter tubing and catheter bag and the floor. On 6/10/25 at 2:14 pm, Surveyor observed R3 sitting in wheelchair. Surveyor observed R3's catheter bag hanging on the bottom of the wheelchair with no privacy cover and catheter tubing resting on the floor. Surveyor noted there was no barrier between the catheter tubing and catheter bag and the floor. Surveyor interviewed R3 and asked if R3 was aware there was not a cover on the catheter bag. R3 did not understand what Surveyor was referencing when asked about the catheter bag being visible to others. On 6/11/25 at 7:48 am, Surveyor observed R3 laying supine (on their back) in bed. Surveyor observed R3's catheter tubing and catheter bag to be resting on the floor with no privacy cover. Surveyor noted there was no barrier between the catheter tubing and catheter bag and the floor. On 6/11/25 at 3:32 pm, Surveyor observed R3 sitting in wheelchair. Surveyor observed R3's catheter bag inside a privacy bag and catheter tubing dragging on the floor. Surveyor noted there was no barrier between the catheter tubing and the floor. On 6/12/25 at 8:23 am, Surveyor interviewed certified nursing assistant (CNA)-X regarding the care provided to residents with a catheter. CNA-X replied with catheter care, we empty it once per shift and drain it at the end of the shift and report any changes in smell or color to nurse. CNA-X stated (R3) has a privacy bag underneath her wheelchair which we put it in. On 6/12/25 during the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of Surveyor's observations of R3's catheter bag being uncovered and catheter bag and tubing resting on the floor without a barrier between the catheter bag, tubing, and floor for protection against possible infection. NHA-A and DON-B understood Surveyor's concerns. On 6/16/25, at 1:58 pm, Surveyor interviewed Infection Preventionist (IP)-Z regarding the expectations to prevent infections for residents using a catheter. IP-Z replied the resident should have indication for use, orders for routine peri-care and catheter care, orders for catheter exchange, foley bag covers. Surveyor asked what the expectation would be if catheter tubing or catheter bag is observed resting on the floor. IP-Z replied that staff should pick up catheter tubing and catheter bag off the floor and keep it contained. No additional information was provided.

Based on interview and record review, the facility did not ensure 4 (R12, R34, R39, & R41 ) of 4 residents were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed was not documented in the Transfer, Bed hold Notice and readmission Rights form. Findings include: The facility's undated policy titled, Bed Hold Notice documents: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Under Policy Explanation and Compliance Guidelines documents 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifics: a. The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: The resident requires the services which the facility provides; The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. 3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. 4. The facility will provide this written information to all facility residents, regardless of their payment source. 1.) R12's diagnoses includes dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), depressive disorder, diabetes mellitus (high blood sugar), and malignant neoplasm of colon (cancer). R12's nursing note dated 1/17/25, at 15:41 (3:41 p.m.), by Previous Director of Nursing (DON)-II documents: Residents labs came back H&H (hemoglobin and hematocrit) was down from last labs 7.0 and 21.3 MD (Medical Doctor) aware and if resident is symptomatic may send to ER (Emergency Room) may need possible transfusion. Resident feels dizzy when asked and has complaints of just being off and not feeling like herself. She was agreeable to go to the ER for possible transfusion if it would help her feel better. She was also ok with writer updating her family Son was called and left a message to call writer back. SW had also text son as he is traveling now. Awaiting return call from the family. [Name] ambulance was called, and resident and paperwork were sent to [Name] memorial hospital. Report was called to ER [Name] nurse took report. R12's social service note dated 1/20/25, at 9:23 a.m., documents: Writer obtained verbal consent to hold bed from resident's son. R12 was readmitted to the facility on [DATE]. Surveyor noted R12's transfer, bed hold notice and readmission rights form dated 1/17/25 under the document section in R12's medical record. This form documents the reason for transfer. Under Bed hold and readmission rights documents 1. If you are paying for your stay from either Private funds or Medicare with Private funds back up: *As outlined in your contact for care, while you are hospitalized or on leave from the facility your bed will bed at the daily current rate 2. If you are paying for your stay from Medicaid (T-19) funds: If you are hospitalized , your bed will be held for 15 days unless you waive this right. * If your hospital duration goes beyond 15 days, you and/or your legal Representative/Responsible Party are able to hold the bed from Private funds at 100% of your current daily rate being charged Surveyor noted for resident/resident representative signature line documents [Name] verbal consent. Date documents 1/20/25. Verbal consent was obtained three days after R12 was discharged to the hospital, written transfer notice & bed hold policy was not provided to R12 and R12's representative and the transfer, bed hold notice & readmission rights form does not have what the daily rate is to hold R12's bed. R12's nurses note dated 1/30/25, at 11:21 a.m., written by LPN-JJ documents Resident refused her AM (morning) medication, insulin, and breakfast. Blood sugar before breakfast was 215. Resident refused to get out of bed. Resident responded to writer stating that she wanted to be left alone and that she wanted to sleep. That she did not want to get up and that it was her right if she wanted to stay in bed. Writer educated resident on the importance of her eating her breakfast because of her diabetes but the resident continued to refuse. [Name] NP (Nurse Practitioner) updated. B/P (blood pressure) 140/68, T (temperature) 98.0, P (pulse) 68, R (respirations) 18 even nonlabored, POX 97% ORA. [Name] NP was in the building and she went to see resident. 1045 [Name] NP came into the nursing office and told writer to call 911, unresponsive episode. Writer called 911. Writer called POA (Power of Attorney) son [Name] updated [Name], received permission to send resident out to hospital. Order received from [Name] NP to send resident out to ER (emergency room) for unresponsive episode. 1100 EMS (emergency medical services) arrived B/P 191/73,T 98.1, P 72, R 18, Pox 95% ORA, Blood Sugar 238 Resident responsive to questioning appropriately. Stated that she wanted to be left alone. Resident went to hospital @ 1130 via ambulance. R12 was readmitted to the facility on [DATE]. Surveyor noted R12's transfer, bed hold notice and readmission rights form dated 1/30/25 under the document section in R12's medical record. This form documents the reason for transfer. Under Bed hold and readmission rights documents 1. If you are paying for your stay from either Private funds or Medicare with Private funds back up: *As outlined in your contact for care, while you are hospitalized or on leave from the facility your bed will bed at the daily current rate 2. If you are paying for your stay from Medicaid (T-19) funds: If you are hospitalized , your bed will be held for 15 days unless you waive this right. * If your hospital duration goes beyond 15 days, you and/or your legal Representative/Responsible Party are able to hold the bed from Private funds at 100% of your current daily rate being charged Surveyor noted for resident/resident representative signature line documents [Name] verbal yes from son. Date documents 1/30/25. Surveyor noted that written transfer notice & bed hold policy was not provided to R12 and R12's representative and the transfer, bed hold notice & readmission rights form does not have what the daily rate is to hold R12's bed. On 6/12/25, at 12:11 p.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D to explain the process when a resident is transferred/discharged to the hospital. RN/UM-D explained if Health Unit Coordinator (HUC)-T is she will do the paper work and if not the nurse sending the resident out will. RN/UM-D explained they send to the hospital a face sheet, order summary, power of attorney papers, and their medication administration record. The nurse should contact the POA if the resident can't speak and ask if they want a bed hold while they are out. Surveyor asked if written notice of transfer and bed hold policy is sent to the resident and resident representative. RN/UM-D informed Surveyor they get the verbal consent and was not sure if admissions sends this but it is not sent by nursing. On 6/12/25, at 12:25 p.m., Surveyor asked HUC-T if she could explain to Surveyor what she does when a resident is transferred/discharged to the hospital. HUC-T explained to Surveyor she has a blue folder with transfer sheet, face sheet, MAR (medication administration record), TAR (treatment administration record), code status, and any POA paperwork which she sends to the hospital. The nurse contacts the POA or asks the resident about the bed hold. Surveyor asked HUC-T what happens with the bed hold paperwork. HUC-T informed Surveyor the nurse fills out the bed hold paperwork. Surveyor asked HUC-T if any paperwork is sent to the POA. HUC-T replied no the nurse calls. On 6/12/25, at 2:05 p.m., Surveyor asked admission Coordinator (AC)-KK if she is involved with any paper work when a resident is transferred/discharged to the hospital. AC-KK replied no. Surveyor asked AC-KK if she is involved with the bed hold policy or notice of transfer. AC-KK replied no. On 6/12/25, at 2:11 p.m., Surveyor asked Director Social Service (DSS)-K if she is involved with any paper work when a resident is transferred/discharged to the hospital. DSS-K informed Surveyor the nurses review the notice of bed hold and transfer. Surveyor asked what happens with this paperwork. DSS-K informed Surveyor it is usually put into the medical record. 2.) R34's diagnoses include dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart rate) and hypertensive heart disease with heart failure (prolonged high blood pressure that leads to the heart's inability to pump blood effectively). R34's nurses note dated 5/16/25, at 5:54 a.m., written by LPN-F documents: CNA found res on the floor at 0250 (2:50 a.m.), sitting/lying in front of her bed with w/c to her left, where it had been all NOC (night). Res (Resident) was witnessed walking in room per CNA who res was assigned and found, coming from BR (bathroom) earlier in NOC and was assisted back to bed w/ (with) safety precautions in place and call light on chest. Rounds completed per CNA at 0100 (1:00 a.m.) and res toileted; per writer at 0200 (2:00 a.m.) and res asleep. Safety precautions/call light in place w/ BR light on. Injuries noted- left brow hematoma, c/o (complained of) left hip pain/disc (discomfort) noted. RN (Registered Nurse) notified and escorted to room per writer and assessed. Writer initiated neuro checks per protocol. [Name] Ambulance called at 0345 (3:45 a.m.). V/S (vital signs) and res stable w/hypotension noted. BP (blood pressure) increased as time went on per EMT (emergency medical technician) taking last BP before leaving unit at 0430 (4:30 a.m.). APAP (acetaminophen) x1 (times one) per pain/disc (discomfort) noted to left hip-7/10 and ineffective prior to leaving- 6/10. RN notified MD/DON (Medical Doctor/Director of Nursing). Writer updated POA (Power of Attorney) son [Name] at 0354 (3:45 a.m.) and directed to have res transferred to [Name] hospital for eval/tx (evaluation/treatment), and POA will meet res there, appreciative for being notified per writer. Res was able to move all extremities w/ (with) noticeable, and c/o left hip pain noted. Writer will report off to AM (morning) RN to call [hospital name] for updated report. R34 was readmitted to the facility on [DATE]. Surveyor noted R34's transfer, bed hold notice and readmission rights form dated 5/16/25 under the document section in R34's medical record. This form documents the reason for transfer. Under Bed hold and readmission rights documents 1. If you are paying for your stay from either Private funds or Medicare with Private funds back up: *As outlined in your contact for care, while you are hospitalized or on leave from the facility your bed will bed at the daily current rate 2. If you are paying for your stay from Medicaid (T-19) funds: If you are hospitalized , your bed will be held for 15 days unless you waive this right. * If your hospital duration goes beyond 15 days, you and/or your legal Representative/Responsible Party are able to hold the bed from Private funds at 100% of your current daily rate being charged Surveyor noted for resident/resident representative signature line documents Res's son [Name] via phone 5/16/25. Surveyor noted that written transfer notice & bed hold policy was not provided to R34 and R34's representative and the transfer, bed hold notice & readmission rights form does not have what the daily rate is to hold R34's bed. On 6/10/25, at 10:48 a.m., Surveyor spoke with R34's POA on the telephone. Surveyor asked when R34 was discharged to the hospital on 5/16/25 did the facility provide to you in writing the reason for the transfer and bed hold policy. R34's POA replied no they told me verbally why being transferred. On 6/12/25, at 12:11 p.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D to explain the process when a resident is transferred/discharged to the hospital. RN/UM-D explained if Health Unit Coordinator (HUC)-T is she will do the paper work and if not the nurse sending the resident out will. RN/UM-D explained they send to the hospital a face sheet, order summary, power of attorney papers, and their medication administration record. The nurse should contact the POA if the resident can't speak and ask if they want a bed hold while they are out. Surveyor asked if written notice of transfer and bed hold policy is sent to the resident and resident representative. RN/UM-D informed Surveyor they get the verbal consent and was not sure if admissions sends this but it is not sent by nursing. On 6/12/25, at 12:25 p.m., Surveyor asked HUC-T if she could explain to Surveyor what she does when a resident is transferred/discharged to the hospital. HUC-T explained to Surveyor she has a blue folder with transfer sheet, face sheet, MAR (medication administration record), TAR (treatment administration record), code status, and any POA paperwork which she sends to the hospital. The nurse contacts the POA or asks the resident about the bed hold. Surveyor asked HUC-T what happens with the bed hold paperwork. HUC-T informed Surveyor the nurse fills out the bed hold paperwork. Surveyor asked HUC-T if any paperwork is sent to the POA. HUC-T replied no the nurse calls. On 6/12/25, at 2:05 p.m., Surveyor asked admission Coordinator (AC)-KK if she is involved with any paper work when a resident is transferred/discharged to the hospital. AC-KK replied no. Surveyor asked AC-KK if she is involved with the bed hold policy or notice of transfer. AC-KK replied no. On 6/12/25, at 2:11 p.m., Surveyor asked Director Social Service (DSS)-K if she is involved with any paper work when a resident is transferred/discharged to the hospital. DSS-K informed Surveyor the nurses review the notice of bed hold and transfer. Surveyor asked what happens with this paperwork. DSS-K informed Surveyor it is usually put into the medical record. No additional information was provided. 3.) R39 was admitted to the facility on [DATE] and has diagnoses that include myelodysplastic syndrome (group of cancers in which the bone marrow does not produce enough healthy cells), congestive heart failure, hyponatremia (low sodium), anemia, and syndrome of inappropriate secretion of antidiuretic hormone (SIADH, produces to much antidiuretic hormone and body retains to much water). R39 is their own person. On 5/2/2025, R39 was admitted to the hospital for high potassium level and readmitted to the facility on [DATE]. On 6/12/2025, Surveyor reviewed R39's medical record and noted R39's signed transfer, bed hold notice, and readmission rights form from when R39 was transferred and admitted to the hospital on [DATE]. The bed hold and readmission rights documents: . 1. If you are paying for your stay from either private funds or Medicare with private funds back up: as outlined in your contract for care, while you are hospitalized or on leave from the facility your bed will be held at the current daily rate. Surveyor noted that the documents does not indicate what the daily rate it. On 6/16/2025, at 3:10 PM, Surveyor shared concern with nursing home administrator (NHA)-A that the bed hold document provided on 5/2/2025 to R39 when transferred and admitted to the hospital did not specify the bed hold amount R39 would have to pay. NHA-A stated that when a resident is admitted they are provided a sheet with all the prices on it and should refer to that sheet. Surveyor stated that the amount should be specified on the transfer/ bed hold document at the time of transfer in the event the prices change or the resident is not aware of the pricing at the time of transfer. 4.) R41 was admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (lung disease making it difficult to breathe), acute bronchitis (inflammation of the airways), chronic kidney disease stage 3 (impaired kidney function), type 2 diabetes mellitus (difficulty regulating blood sugar), cognitive communication deficit (difficulty remembering), anemia (lower than normal red blood cells) in chronic kidney disease, anxiety disorder, major depressive disorder, localized edema (swelling), hyperlipidemia (excess fats in the blood), unspecified urinary incontinence (impaired bladder control), and spondylosis of the lumbosacral region (arthritis of lower spine). R41 was transferred and admitted to the hospital on [DATE]. R41 was discharged from the hospital to an assisted living facility and did not readmit back to the facility. On 6/16/25 at 09:40 am, Surveyor reviewed R41's medical record and located written bed hold notice signed and dated by R41 and the facility on 3/31/25. Surveyor noted a bed hold notice specifies the reason for transfer to the hospital. Surveyor noted R41 marked an X next to the statement: I have been informed of the bed hold option and decline at this time. Surveyor noted the following verbiage on the bed hold notice: as outlined in your contract for care, while you are hospitalized or on leave from the facility your bed will be held at the current daily rate. Surveyor noted there is not a bed hold rate documented on this form. On 6/16/25 at 3:10 pm, Surveyor informed Nursing Home Administrator (NHA)-A that no bed hold rate was documented on the facility's bed hold notice. NHA-A stated residents get informed of the daily rate on admission in the admission packet, and all residents have the same daily rate amount. NHA-A stated the pay rate is specified in the admission packet, but not given on transfer again. Surveyor informed NHA-A the rate should be specified on the bed hold document at the time of transfer. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure 1 (R12) of 1 resident was clinically appropriate to self administer medications. * R12 was observed with 7 medication pills in a medication cup on the over bed table next to R12. R12's self administration assessment dated [DATE] documents that R12 not approved for the self-administration of medications. Findings include: The facility's undated policy titled, Resident Self-Administration of Medication documents under the Policy section: It is the policy of this facility to support each resident's right to self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Under Policy Explanation and Compliance Guidelines: document 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections; c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; d. The resident's capability to follow directions and tell time to know when medications need to be taken; e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff; f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs; g. The resident's ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 1.) R12's diagnosis include dementia (loss of cognitive function that interferes with a person's daily life and activities). R12's power of attorney for healthcare was activated on 1/22/25. R12's self administration of medication assessment dated [DATE] answers no, indicating that R12 is not approved for self-administration of medications. R12's quarterly MDS (minimum data set) with an assessment reference date of 5/8/25 documents a BIMS (brief interview mental status) score of 11, which indicates moderate cognitive impairment for R12. On 6/16/25, at 8:18 a.m., Surveyor observed R12 sitting in a recliner in R12's room reading the newspaper. Surveyor observed on the over bed table to the right of R12, a medication cup containing 7 pills. R12 stated to Surveyor I (R12) haven't taken my medication yet. Surveyor observed there was not a licensed nurse &/or medication tech in R12's room. On 6/16/25, at 8:23 a.m., Surveyor asked Licensed Practical Nurse (LPN)-U if she gave R12 medication. LPN-U replied yes. Surveyor asked LPN-U why she left R12's medication with R12. LPN-U replied because she told me to and that LPN-U left them (the medication pills) because R12 asked me to. R12's June 2025 MAR (medication administration record) documents that LPN-U checked & initialed (which indicates medication was administered) the following medication: Bumetanide 0.5 mg (milligrams), Carvedilol 12.5 mg, Doxycycline Hyclate 100 mg, Lisinopril 20 mg, Probiotic oral capsule, Senna 8.6 mg, and Spironolactone 12.5 mg. On 6/16/25, at 8:31 a.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D if R12 self administers her own medication. RN/UM-D replied no. Surveyor informed RN/UM-D of the observation of R12's medication in a cup on the over bed table next to R12. On 6/16/25, at 8:41 a.m., Surveyor observed RN/UM-D talking with R12 stating may I take them, referring to R12's medication, and bring them back if you aren't ready to take them. RN/UM-D indicated they have to chart the time when R12 takes the medication. At 8:42 a.m. Surveyor observed R12 start to take her medication with RN/UM-D. On 6/12/25, at 3:15 p.m., during the end of the day meeting Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Nurse-C R12 of the above findings. No additional information was provided as to why the facility did not ensure that R12 was clinically appropriate to self administer medications.

Based on interview and record review, the facility did not protect 1 (R16) of 1 Resident by not implementing their written policies and procedures to prohibit and prevent the right to be free from verbal abuse from Registered Nurse (RN)-E. * Staff did not report allegations of verbal abuse made by R16 regarding RN-E to the Nursing Home Administrator (NHA)-A immediately. This allowed for additional potential allegations of verbal abuse to occur to other residents whom RN-E provided nursing care to for the remainder of the shift. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. Establish policies and procedures to investigate any such allegations c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of Resident property, reporting procedures, and dementia management and Resident abuse prevention d. Establish coordination with the QAPI program 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigations. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation F. Providing emotional support and counseling to the Resident during and after the investigation as needed G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes a. Immediately, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrences b. Defining how care provision will be changed and/or improved to protect Resident receiving services B. The Administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1.) R16 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Anemia(lack of blood), Chronic Congestive Heart Failure(long term condition where the heart muscle is too weak or still to pump blood efficiently), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R16's Quarterly Minimum Data Set(MDS) completed 3/26/25 documents R16's Brief Interview for Mental Status(BIMS) score to be a 6, indicating R16 demonstrates severely impaired skills for daily decision making. R16's MDS documents at time of assessment that R16 did not have mood or behavior symptoms. R16 is set-up for eating. R16 requires substantial/maximum assistance for showers, mobility, transfers, toileting. R16 requires partial/moderate assistance for upper dressing and is dependent for lower dressing. R16 is frequently incontinent of urinary and occasionally incontinent of bowel. On 4/29/25, at 3:21 PM, the facility submitted a Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of verbal abuse involving RN-E and R16 occurring at 4:30 AM on 4/29/25. It is documented that Certified Nursing Assistant (CNA)-G heard RN-E tell R16 There is no reason you need to be getting up at 4:00 in the morning, there better be something in the toilet once your are done. CNA-G reported immediately to Licensed Practical Nurse (LPN)-F. The report documents that the Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Social Services (DSS)-K were immediately notified of the allegation The facility's Misconduct Incident Report submitted 5/6/25 documents that RN-E worked until the end of the shift and only then was she removed from the facility and the work schedule. Surveyor noted the shift ends at 7:00 AM. LPN-F was aware of the allegation of verbal abuse by RN-E at 4:30 AM, but did not report the allegation of verbal abuse immediately to NHA-A, DON-B, and DSS-K. RN-E remained in the facility until 7:00 AM, allowing time for RN-E to have contact with other Residents in the facility. RN-E was not immediately removed from Resident care areas. Surveyor reviewed the working punch detail for RN-E that documents RN-E arrived at the facility at 10:12 PM and left the facility at 6:48 AM. On 4/29/2025, at 5:35 AM, RN-E documented in R16's electronic health record(EMR): R16 called for staff around 430 am and hollering out to get to the toilet, CNA placed R16 on bedpan, but R16 had no results, R16 again hollering out to go to toilet, writer and CNA transferred R16 to toilet with steady lift, R16 was crying its not fair, you people just don't know and think I am crazy R16 was assured by writer that no one believes that, R16 stated I wish I was just dead, GOD please take me, again writer consoled R16. R16 had recent decrease in Lexapro and showing increased behaviors. R16 quiet at this time resting in bed. On 6/11/25, at 12:35 PM, Surveyor interviewed CNA- G via telephone in regards to the allegation of verbal abuse from RN-E directed at R16. CNA-G stated that RN-E and CNA-H were in the process of toileting R16. CNA-G confirmed that CNA-G heard RN-E tell R16 there was no reason for R16 to be up at 4:00 AM and that there better be something in the toilet. CNA-G informed LPN-F immediately of what CNA-G overheard. CNA-G stated that RN-E finished the shift and continued to pass medications. CNA-G stated , that RN-E informed CNA-G at the end of the shift that R16 had expressed R16 wanted to kill herself. CNA-G explained that R16 was screaming at the time CNA-G overheard RN-E tell R16 there was no reason to be up and there better be something in the toilet. CNA-G stated that behavior was very unusual because R16 is normally happy as can be and very thankful for us helping her. On 6/11/25, at 12:58 PM, Surveyor interviewed LPN-F vial telephone in regards to the allegation of verbal abuse from RN-E directed at R16. LPN-F confirmed that CNA-G informed LPN-G of the allegation of verbal abuse involving R16 and RN-E at approximately 4:30 AM. LPN-F stated that CNA-G was very visibly distressed by what CNA-G heard RN-E say to R16 and very upset the rest of the shift and has been still upset about the incident. LPN-F confirmed that LPN-F did not report immediately to NHA-A, DON-B, or DSS-K. LPN-F had other staff write up statements and LPN-F informed DON-B at the end of the shift when DON-B arrived to the facility. LPN-F informed Surveyor that about 5 other CNAs have informed LPN-G that RN-E can be verbally abusive to Residents. On 6/12/25, at 6:46 AM, Surveyor interviewed DON-B. DON-B confirmed that LPN-F approached DON-B in the morning after the shift and provided written statements from staff members. LPN-F explained the circumstances of the allegation of verbal abuse from RN-E towards R16. DON-B then reported the concern to NHA-A. DON-B stated, DON-B has no involvement with allegations of abuse, investigation, or contact with staff members involved in the allegations. DON-B stated that CNA-G is still very distraught about the incident. DON-B was not asked by anyone to place R16 on the 24 hour report board for follow-up. DON-B confirmed that LPN-F did not call DON-B at the actual time the allegation of verbal abuse was reported by CNA-G. On 6/12/25, at 10:55 AM, Surveyor interviewed DSS-K in regards to the allegation of verbal abuse involving R16 and RN-E. DSS-K confirmed DSS-K that DSS-K is part of the team that works on the facility facility reported incidents as well as helping to compile and investigate. NHA-A and DSS-K work together to make sure everything is completed. DSS-K stated that DSS-K was informed in the morning when DSS-K arrived to the facility. Surveyor shared with DSS-K there are 3 missing staff statements from the shift of when the allegation of verbal abuse occurred. DSS-K will look for the statements and confirm when abuse/neglect training was last completed. On 6/12/25, at 11:54 AM, DSS-K stated that DSS-K did not submit the missing staff statements to the State Survey Agency because the statements were hearsay. DSS-K stated DSS-K completes training on abuse/neglect and dementia at time of orientation which includes reviewing the facility policy and procedure to immediately report any observations of abuse. DSS-K stated the most recent all staff training on abuse/neglect and dementia was completed in May 2024. On 6/12/25, at 3:24 PM, Surveyor informed NHA-A, DON-B, and Corporate Consultant (CC)-C that LPN-F did not report immediately the allegation of verbal abuse by RN-E directed at R16. Surveyor explained it was reported by CNA-G to LPN-F at approximately 4:30 AM, but RN-E finished the shift which ended at 7:00 AM. Surveyor also shared the concern that the facility did not investigate the statements for 3 employees in order to determine if there was a pattern of RN-E verbally abusing Residents or had additional information to provide. No additional information has been provided by the facility at this time as to why the allegation of verbal abuse involving R16 and RN-E was not immediately reported which resulted in RN-E working the rest of the shift until 7:00 AM potentially placing other Residents in a vulnerable state and exposing to potential verbal abuse.

Based on record reviews and interviews, the facility did not ensure allegations of verbal abuse were immediately reported to the Administrator and/or Grievance Officer. This was observed with 1 (R16) of 1 Resident reviewed for alleged verbal abuse. * An allegation of verbal abuse by Registered Nurse (RN)-E towards R16 was reported by Certified Nursing Assistant (CNA)-G at approximately 4:30 AM to Licensed Practical Nurse (LPN)-F on 4/29/25. LPN-F informed Director of Nursing (DON)-B at approximately 7:00 AM, after RN-E's shift had ended at the facility. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: .Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. Establish policies and procedures to investigate any such allegations c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of Resident property, reporting procedures, and dementia management and Resident abuse prevention d. Establish coordination with the QAPI program 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Employee Training B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of Resident property and exploitation 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of Resident property 3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of Resident property, such as physical or psychosocial indicators 4. Reporting process for abuse, neglect, exploitation, and misappropriation of Resident property, including injuries of unknown sources 5. Understanding behavioral symptoms of Resident that may increase the risk of abuse and neglect such as: d. Outbursts or yelling our Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of Resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of Residents with needs and behaviors which might lead to conflict or neglect. H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigations. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation F. Providing emotional support and counseling to the Resident during and after the investigation as needed G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes a. Immediately, but not later than 2 hours after the allegatins is made, if the events that cause the allegation involve abuse or result in serious bodily injury 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrences b. Defining how care provision will be changed and/or improved to protect Resident receiving services B. The Administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. R16 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Anemia(lack of blood), Chronic Congestive Heart Failure(long term condition where the heart muscle is too weak or still to pump blood efficiently), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R16 currently has an activated Health Care Power of Attorney(HCPOA) to assist with decision making. R16's Quarterly Minimum Data Set(MDS) completed 3/26/25 documents R16's Brief Interview for Mental Status(BIMS) score to be a 6, indicating R16 demonstrates severely impaired skills for daily decision making. R16's MDS documents at time of assessment that R16 did not have mood or behavior symptoms. R16 is set-up for eating. R16 requires substantial/maximum assistance for showers, mobility, transfers, toileting. R16 requires partial/moderate assistance for upper dressing and is dependent for lower dressing. R16 is frequently incontinent of urinary and occasionally incontinent of bowel. On 4/29/25, at 3:21 PM, the facility submitted A nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of verbal abuse involving RN-E and R16 occurring at 4:30 AM on 4/29/25. It is documented that Certified Nursing Assistant (CNA)-G heard RN-E tell R16 There is no reason you need to be getting up at 4:00 in the morning, there better be something in the toilet once your are done. CNA-G reported immediately to Licensed Practical Nurse (LPN)-F. The report documents that the Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Social Services (DSS)-K were immediately notified of the allegation The facility's Misconduct Incident Report submitted 5/6/25 documents that RN-E worked until the end of the shift and was then taken off the schedule. Surveyor notes the shift ends at 7:00 AM. LPN-F was aware of the allegation of verbal abuse by RN-E at 4:30 AM, but did not report the allegation of verbal abuse immediately to NHA-A, DON-B, and DSS-K. RN-E remained in the facility until 7:00 AM, allowing time for RN-E to have contact with other Residents in the facility. RN-E was not immediately removed from Resident care areas. Surveyor reviewed the working punch detail for RN-E that documents RN-E arrived at the facility at 10:12 PM and left the facility at 6:48 AM. On 4/29/2025, at 5:35 AM, RN-E documented in R16's electronic health record(EMR): R16 called for staff around 430 am and hollering out to get to the toilet, CNA placed R16 on bedpan, but R16 had no results, R16 again hollering out to go to toilet, writer and CNA transferred R16 to toilet with steady lift, R16 was crying its not fair, you people just don't know and think I am crazy R16 was assured by writer that no one believes that, R16 stated I wish I was just dead, GOD please take me, again writer consoled R16. R16 had recent decrease in Lexapro and showing increased behaviors. R16 quiet at this time resting in bed. On 6/11/25, at 12:35 PM, Surveyor interviewed CNA- G via telephone in regards to the allegation of verbal abuse from RN-E directed at R16. CNA-G stated that RN-E and CNA-H were in the process of toileting R16. CNA-G confirmed that CNA-G heard RN-E tell R16 there was no reason for R16 to be up at 4:00 AM and that there better be something in the toilet. CNA-G informed LPN-F immediately of what CNA-G overheard. CNA-G stated that RN-E finished the shift and continued to pass medications. CNA-G stated , that RN-E informed CNA-G at the end of the shift that R16 had expressed R16 wanted to kill herself. CNA-G explained that R16 was screaming at the time CNA-G overheard RN-E stated that to R16. CNA-G stated that behavior was very unusual because R16 is normally happy as can be and very thankful for us helping her. On 6/11/25, at 12:58 PM, Surveyor interviewed LPN-F vial telephone in regards to the allegation of verbal abuse from RN-E directed at R16. LPN-F confirmed that CNA-G informed LPN-G of the allegation of verbal abuse involving R16 and RN-E at approximately 4:30 AM. LPN-F stated that CNA-G was very visibly distressed by what CNA-G heard RN-E say to R16 and very upset the rest of the shift and has been still upset about the incident. LPN-F confirmed that LPN-F did not report immediately to NHA-A, DON-B, or DSS-K. LPN-F had other staff write up statements and LPN-F informed DON-B at the end of the shift when DON-B arrived to the facility. LPN-F informed Surveyor that about 5 other CNAs have informed LPN-G that RN-E can be verbally abusive to Residents. On 6/12/25, at 6:46 AM, Surveyor interviewed DON-B. DON-B confirmed that LPN-F approached DON-B in the morning after the shift had been completed and provided written statements from staff members. LPN-F explained the circumstances of the allegation of verbal abuse from RN-E towards R16. DON-B then reported the concern to NHA-A. DON-B stated, DON-B has no involvement with allegations of abuse, investigation, or contact with staff members involved the allegations. DON-B confirmed that LPN-F did not call DON-B at the actual time the allegation of verbal abuse was reported by CNA-G. On 6/12/25, at 10:55 AM, Surveyor interviewed DSS-K regarding the allegation of verbal abuse involving R16 and RN-E. DSS-K confirmed DSS-K that DSS-K is part of the team that works on the facility facility reported incidents(FRI) as well as helping to compile and investigate. NHA-A and DSS-K work together to make sure everything is completed. DSS-K stated that DSS-K was informed in the morning of 4/29/25 at approximately 8:00 AM, when DSS-K arrived to the facility. On 6/12/25, at 3:24 PM, Surveyor shared the concern with NHA-A, DON-B, and Corporate Consultant (CC)-C that LPN-F did not report immediately the allegation of verbal abuse from RN-E directed at R16. Surveyor explained it was reported by CNA-G to LPN-F at approximately 4:30 AM, but RN-E finished the shift which ended at 7:00 AM. No additional information was provided by the facility as to why the allegation of verbal abuse involving R16 and RN-E was not immediately reported to the Administrator which resulted in RN-E working the rest of the shift until 7:00 AM potentially placing other Residents in a vulnerable state and exposing to potential verbal abuse.

Based on record review and staff interview, the facility did not ensure all allegations involving potential verbal abuse were thoroughly investigated for 1 (R16) of 1 reviewed facility reported incidents (FRI). *An allegation of verbal abuse on 4/29/25 by Registered Nurse (RN)-E towards R16 was not thoroughly investigated. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. Establish policies and procedures to investigate any such allegations c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of Resident property, reporting procedures, and dementia management and Resident abuse prevention d. Establish coordination with the QAPI program 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigations. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation F. Providing emotional support and counseling to the Resident during and after the investigation as needed G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation 3. Investigating different types of alleged violations 4. Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause 6. Providing complete and thorough documentation of the investigation Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes a. Immediately, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrences b. Defining how care provision will be changed and/or improved to protect Resident receiving services B. The Administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1.) R16 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Anemia(lack of blood), Chronic Congestive Heart Failure(long term condition where the heart muscle is too weak or still to pump blood efficiently), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R16's Quarterly Minimum Data Set(MDS) completed 3/26/25 documents R16's Brief Interview for Mental Status(BIMS) score to be a 6, indicating R16 demonstrates severely impaired skills for daily decision making. R16's MDS documents at time of assessment that R16 did not have mood or behavior symptoms. R16 is set-up for eating. R16 requires substantial/maximum assistance for showers, mobility, transfers, toileting. R16 requires partial/moderate assistance for upper dressing and is dependent for lower dressing. R16 is frequently incontinent of urinary and occasionally incontinent of bowel. On 4/29/25, at 3:21 PM, the facility submitted A Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of verbal abuse involving RN-E and R16 occurring at 4:30 AM on 4/29/25. It is documented that Certified Nursing Assistant (CNA)-G heard RN-E tell R16 There is no reason you need to be getting up at 4:00 in the morning, there better be something in the toilet once your are done. CNA-G reported immediately to Licensed Practical Nurse (LPN)-F. The report documents that the Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Social Services (DSS)-K were immediately notified of the allegation. The facility's Misconduct Incident Report submitted 5/6/25 documents that RN-E was at the end of the shift and taken off the schedule. Surveyor reviewed R16's comprehensive care plan. R16's care plan was not updated addressing any psychosocial issues R16 may have. Surveyor noted the shift ends at 7:00 AM. LPN-F was aware of the allegation of verbal abuse by RN-E at 4:30 AM, but did not report the allegation of verbal abuse immediately to NHA-A, DON-B, and DSS-K. RN-E remained in the facility until 7:00 AM, allowing time for RN-E to have contact with other Residents in the facility. RN-E was not immediately removed from Resident care areas. Surveyor reviewed the working punch detail for RN-E that documents RN-E arrived at the facility at 10:12 PM and left the facility at 6:48 AM. Surveyor obtained the schedule from the NOC shift for 4/29/25 and determined that 3(CNA-I, CNA-J, and LPN-F) staff statements were not readily available to Surveyor or submitted with the FRI to the State Survey Agency. On 4/29/2025, at 5:35 AM, RN-E documented in R16's electronic health record(EMR): R16 called for staff around 430 am and hollering out to get to the toilet, CNA placed R16 on bedpan, but R16 had no results, R16 again hollering out to go to toilet, writer and CNA transferred R16 to toilet with steady lift, R16 was crying its not fair, you people just don't know and think I am crazy R16 was assured by writer that no one believes that, R16 stated I wish I was just dead, GOD please take me, again writer consoled R16. R16 had recent decrease in Lexapro and showing increased behaviors. R16 quiet at this time resting in bed. On 6/11/25, at 12:35 PM, Surveyor interviewed CNA-G via telephone in regards to the allegation of verbal abuse from RN-E directed at R16. CNA-G stated that RN-E and CNA-H were in the process of toileting R16. CNA-G confirmed that CNA-G heard RN-E tell R16 there was no reason for R16 to be up at 4:00 AM and that there better be something in the toilet. CNA-G informed LPN-F immediately of what CNA-G overheard. CNA-G stated that RN-E finished the shift and continued to pass medications. CNA-G stated , that RN-E informed CNA-G at the end of the shift that R16 had expressed R16 wanted to kill herself. CNA-G explained that R16 was screaming at the time CNA-G overheard RN-E telling R16, there was no reason to be up at that time and there better be something in the toilet. CNA-G stated that behavior was very unusual because R16 is normally happy as can be and very thankful for us helping her. On 6/11/25, at 12:58 PM, Surveyor interviewed LPN-F vial telephone in regards to the allegation of verbal abuse from RN-E directed at R16. LPN-F confirmed that CNA-G informed LPN-G of the allegation of verbal abuse involving R16 and RN-E at approximately 4:30 AM. LPN-F stated that CNA-G was very visibly distressed by what CNA-G heard RN-E say to R16 and very upset the rest of the shift and has been still upset about the incident. LPN-F confirmed that LPN-F did not report immediately to NHA-A, DON-B, or DSS-K. LPN-F had other staff write up statements and LPN-F informed DON-B at the end of the shift when DON-B arrived to the facility. LPN-F informed Surveyor that about 5 other CNAs have informed LPN-G that RN-E can be verbally abusive to Residents. LPN-F stated LPN-F has not seen R16 crying any other time or distressed except during this allegation. On 6/12/25, at 6:46 AM, Surveyor interviewed DON-B. DON-B confirmed that LPN-F approached DON-B in the morning after the shift and provided written statements from staff members. LPN-F explained the circumstances of the allegation of verbal abuse from RN-E towards R16. DON-B then reported the concern to NHA-A. DON-B stated, DON-B has no involvement with allegations of abuse, investigation, or contact with staff members involved in the allegations. DON-B stated that CNA-G is still very distraught about the incident. DON-B was not asked by anyone to place R16 on the 24 hour report board for follow-up. DON-B confirmed that LPN-F did not call DON-B at the actual time the allegation of verbal abuse was reported by CNA-G. DON-B stated that RN-E has a history of be very direct with Residents. On 6/12/25, at 9:02 AM, Surveyor interviewed RN-E via telephone. RN-E stated that R16 gets very frustrated with us, says stuff like that, R16 is confused, but has never seen R16 cry. RN-E did not tell DSS-K of R16's psychosocial status. On 6/12/25, at 10:55 AM, Surveyor interviewed DSS-K in regards to the allegation of verbal abuse involving R16 and RN-E. DSS-K confirmed DSS-K that DSS-K is part of the team that works on the facility facility reported incidents as well as helping to compile and investigate. NHA-A and DSS-K work together to make sure everything is completed. DSS-K stated that DSS-K was informed in the morning when DSS-K arrived to the facility. Surveyor shared with DSS-K there are 3 missing staff statements from the shift of when the allegation of verbal abuse occurred. DSS-K will look for the statements and confirm when abuse/neglect training was last completed. DSS-K stated that DSS-K did not feel the need to update the psychologist who is currently treating R16. DSS-K stated that R16 is usually pleasant with an occasion of tearfulness. On 6/12/25, at 11:54 AM, DSS-K stated that DSS-K did not submit the missing staff statements to the State Survey Agency because the statements were hearsay. DSS-K confirmed DSS-K did not follow-up on the statements provided by CNA-I, CNA-J, and LPN-F. DSS-K stated DSS-K completes training on abuse/neglect and dementia at time of orientation which includes reviewing the facility policy and procedure to immediately report any observations of abuse. DSS-K confirmed that it is not normal for R16 to state R16 did not want to live. On 5/11/2025, at 4:14 PM, RN-QQ documented: R16 had R16's escitalopram decreased from 10 mg to 5 mg on 4/24/25. Today R16 seems more confused and is having trouble finding her room and seems very anxious. LCTA, respirations are even and unlabored, HR is irregular, BS with in normal limits, no edema noted to BLE. Vs 98.2-89-141/94-22-and 93% on RA. R16 stated that R16 can't remember anything and that R16 might as well be dead. Updated MD and added to report board for monitoring. Surveyor reviewed R16's documented psychology note by Psychology NP (Psych NP)-RR indicates that Psych NP-RR was not notified by the facility that R16 had made expressions of feeling distressed, specifically expressions of not wanting to be alive. On 6/12/25, at 3:24 PM, Surveyor shared the concern with NHA-A, DON-B, and Corporate Consultant (CC)-C that LPN-F did not report immediately the allegation of verbal abuse from RN-E directed at R16. Surveyor explained it was reported by CNA-G to LPN-F at approximately 4:30 AM, but RN-E finished the shift which ended at 7:00 AM. Surveyor also shared the concern that the facility did not investigate the statements for 3 employees in order to determine if there was a pattern of RN-E verbally abusing Residents or had additional information to provide. Further, there was no follow-up on R16's expressions of not wanting to live. No additional information was provided by the facility at this time as to why the allegation of verbal abuse was not thoroughly investigated and R16' expressions of not wanting to live with no follow-up.

2.) R12's diagnoses include dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), and syncope (fainting) and collapse. R12's nurses note dated 12/12/24, at 11:45 a.m., documents : Arrived to unit on 12/12/2014 at 1045. Came from [Name] Assisted Living - [Name] house. Resident has fall in her AL (assisted living) apartment and sustained R (right) humerus fx (fracture), no repair. Has RUE (right upper extremity) sling. A&Ox4 (alert and orientated times four). Diabetic on insulin. LCTA (lungs clear to auscultation). No pacemaker. Slight nonpitting edema to BLE (bilateral lower extremity). Continent of bowel and bladder but wears depends or pads in underwear. Has hard time falling asleep. Has reading glasses, not present at time of admission. Natural teeth. Will have occasional pain to RUE with movement. VS (vital signs) at time of admission 167/68 mmHg (millimeters of mercury), 97% room air, 98.2 f (Fahrenheit), 57 bpm (beats per minute), no pain at time of admission. R12's mobility care plan initiated & revised 12/12/24 includes an intervention dated 12/12/24 of *GG Chair/Bed-to-Chair Transfer - 2 assist sit-to-stand. R12's nurses note dated 5/20/25, at 12:26 p.m., by Registered Nurse (RN)-AA documents: Writer was called down to resident's room by HUC (health unit coordinator). CNA (Certified Nursing Assistant) was assisting resident to the bathroom and per CNA resident's legs gave out and CNA was unable to get her back into recliner. CNA had to lower resident to the floor. Resident did not hit head. Resident was incontinent at the time of the fall; CNA was trying to get her to the bathroom to be changed. Resident was assessed and denies pain. No injuries noted at the time of assessment. Writer and two CNAs assisted resident from floor back into wheelchair. Resident was able to stand in the bathroom with CNA assist to get onto toilet. VSS (vital signs stable). Resident stated that her tailbone hurt when sitting on the toilet. Resident has area already noted to left buttocks. Hospice, NP (Nurse Practitioner), POA (Power of Attorney), DON (Director of Nursing), CCM aware of witnessed fall. On 6/16/25, at 2:41 p.m., Surveyor met with Nursing Home Administrator (NHA)-A to discuss R12's falls. Surveyor informed NHA-A R12's fall on 5/20/25 documents the CNA had to lower R12 to the floor. Surveyor informed NHA-A according to R12's mobility care plan R12 was a sit to stand transfer with 2 staff. NHA-A informed Surveyor R12 was a sit to stand when she was first admitted , therapy changed her transfer status and the care plan may not have been revised to indicate this change. NHA-A informed Surveyor she will look for therapy's recommendation and provide the recommendation to Surveyor. On 6/16/25, at approximately 3:00 p.m., NHA-A provided Surveyor with therapy note dated 1/21/25 which documents: For tasks Pt (patient) to transfer with 2ww (wheeled walker) x (times) 1 assist. Surveyor noted that the facility did not revise R12's mobility care plan to reflect the change in transfer status. No additional information was provided. Based on interview and record review the facility did not ensure 2 (R24 and R12) of 12 residents care plans reviewed were revised accordingly. * R24's care plan was not revised after developing a stage 2 pressure injury to the right heel. * R12's care plan was not revised after therapy gave new recommendations for R12's transfer status. Findings include: The facility policy titled Care Plan Revisions Upon Status Change with no implementation or reviewed/revised date documented, documents: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan with be reviewed and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: . d. The care plan will be updated with new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS coordinator or other designated staff member. h. The unit manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status identified, to ensure care plans have been updated to reflect current resident needs. 1.) R24 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's, Dementia, severe protein-calorie malnutrition, muscle weakness, cognitive communicative deficit, and weakness. R24's admission Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating that R24 had severely impaired cognition. The MDS documents that the facility assessed R24 being modified independent with 1 staff member for repositioning, and maximal assistance with 1 staff member for putting on and taking off footwear and lower body dressing. R24's Pressure injury Care Area Assessment (CAA) dated 5/3/25 documents: R24's recent hospitalization after a fall at home without major injury, pneumonia with sepsis, and dementia. R24 was admitted for rehab with a goal to discharge home. R24 requires maximal to moderate assistance with most activities of daily living (ADLs) and has a BIMS score of 5. R24 receives scheduled antiplatelet, antidepressant, antihypertension, and anticonvulsant medications and is occasionally incontinent of bowel and bladder. R24 has a history of falling at home and no pressure injuries are noted on the admission skin assessment. R24's Braden Scale for Pressure Injury Development dated 4/30/24 documents a score of 16, indicating that R24 is at moderate risk for pressure injury development. R24's potential for impaired skin integrity related to immobility care plan was initiated on 5/7/2025 with the following interventions: - Apply moisture barrier as needed. - Braden skin risk evaluation completed on admission, every week for 4 weeks, quarterly, and with any significant change. - Certified nursing assistants (CNAs) to observe skin with morning (am) and bedtime (HS) cares and report any abnormalities to the nurse. - Consult dietician for nutritional assessment as needed (PRN). - Maintain good skin hygiene. Moisturize dry skin PRN. - Monitor labs and weights as ordered. - Observe for alteration in skin integrity and report to nurse practitioner (NP)/physician assistant (PA)/ medical doctor (MD). Skin inspected by licensed staff weekly per schedule. - Pressure relieving device in wheelchair- gel cushion. - Provide adequate nutrition and hydration. Nutritional supplements and vitamins as ordered. On 5/20/2025, at 11:45 AM, in the progress notes nursing documented (nursing) notified that (R24) right heel was bleeding. (R24) has a 1cm X 1cm blister that opened up at the bottom and was bleeding. New orders received from NP . (R24) to wear Prevalon boots when in bed and use gripper socks, to avoid wearing shoes for next couple of weeks. Discontinue skin prep to bilateral heels each shift. R24's potential for impaired skin integrity was revised on 6/10/2025 documenting R24 had a stage 2 pressure injury to the right heel with the following revisions: - Provide dressing changes per MD order - Heel boots while in bed. Surveyor noted that R24's care plan was not revised until 6/10/2025. R24 developed a pressure injury to the right heel on 5/20/2025. On 6/16/2025, at 11:45 AM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-D who stated that when an area of concern in noted a care plan revision is completed. Surveyor shared that R24's care plan was not revised until 6/10/2025 for R24's pressure injury that was noted on 5/20/2025. RNUM-D stated that the tasks get updated and then do the care plan later. RNUM-D stated that now staff are revising the care plan right away because staff did not realize when the tasks is updated it does not feed into the care plan. Surveyor and RNUM-D reviewed R24 tasks and could not determine when the tasks were added to R24's medical record. RNUM-D and Surveyor reviewed R24's CNA Kardex and did not locate interventions for R24's right heel pressure injury. On 6/16/2025, at 3:10 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that R24 care plan was not revised on 5/20/2025 when R24 was noted to have a stage 2 pressure injury to the right heel until 6/10/2025. NHA-A stated that the pillow boots were added to the tasks sheet. Surveyor shared that the initiation date of the pillow boots was not able to be located until 6/10/2025 on the care plan. NHA-A understood the concern and shared that R24 was getting the proper interventions right away on 5/20/2025. Surveyor shared that R24's care plan should reflect the revisions on 5/20/2025 when the concern to R24's right heel was first observed, but not documented until 6/10/2025.

2.) R12 was admitted to the facility on [DATE] with diagnoses that include dementia, depressive disorder, chronic kidney disease (progressive damage and loss of kidney function), atrial fibrillation(irregular and rapid heartbeat), malignant neoplasm of colon (cancer), and diabetes mellitus. R12's skin pressure injury care plan initiated 12/12/24 & revised 5/29/25 documents the following interventions: *Apply moisture barrier as needed. Initiated 12/12/24 & revised 12/16/24. *Braden skin risk evaluation completed on admission, Q (every) week for 4 weeks, quarterly, and with any significant change. Initiated 12/12/24. *CNA's (Certified Nursing Assistant) to observe skin with am (morning) and hs (hour sleep) cares and report any abnormalities to the nurse. Initiated 12/12/24 & revised 12/16/24. *Dressing changes per MD (Medical Doctor) order. Initiated 6/10/25. *Mild skin risk per Braden. Initiated 2/17/25. *Observe for alteration in skin integrity and report to NP/PA/MD (Nurse Practitioner/Physician Assistant/Medical Doctor). Skin inspected by licensed staff weekly per schedule. Initiated 12/12/24. *Pressure relieving device in W/C (wheelchair) and on bed. Initiated 12/12/24 & revised 2/17/25. *Encourage [R12's first name] to reposition herself often in bed. Initiated and revised 6/10/25. R12's Braden Scale assessments dated 12/12/24, 12/19/24, & 12/26/24 have a score of 18 which indicates mild risk for pressure injury development. R12's Braden Scale assessments dated 1/2/25 & 1/9/25 have a score of 14 which indicates moderate risk for pressure injury development. R12's Braden Scale assessment dated [DATE] & 2/5/25 have a score of 18 which indicates mild risk for pressure injury development. R12's significant change MDS (minimum data set) with an assessment reference date of 2/6/25 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment. R12 is assessed as not having any behavior including refusal of care. R12 is assessed as requiring supervision or touching assistance for toileting hygiene, roll left and right, chair/bed to chair transfer and toilet transfers. R12 is assessed as being occasionally incontinent of urine and always incontinent of bowel. R12 is at risk for pressure injury development and is assessed as not having any pressure injuries. R12's N Advc(Advanced) -Skin Issues -V7 dated 3/1/25 and completed by Licensed Practical Nurse (LPN)-CC documents Skin Issue: Pressure ulcer/Injury, Location: Coccyx, Length (cm) (centimeters): 0.5, Width (cm): 0.5, Depth (cm): 0, Tunneling: No, Undermining: No, Presence of wound pain: Yes. Surveyor reviewed R12's medical record and was unable to locate a comprehensive assessment of R12's coccyx. R12's nurses note dated 3/11/25, at 8:49 a.m., written by Registered Nurse/Unit Manager-D documents Resident assessed for reported redness to bilateral buttocks. Resident has blanchable redness with a scant (0.5 x 0.6) denuded area on each side. Resident is continent of bowel and bladder, is clean and dry upon inspection. Barrier cream ordered to be applied BID (twice daily) with cares. Resident understands explanation of possibility of pressure area and agrees to shift weight while in chair and try to sleep on one side or the other vs on her back. Will monitor with wound rounds to prevent open area. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's nurses note dated 3/12/25, at 9:46 a.m., written by Licensed Practical Nurse (LPN)-DD documents Resident is on the board for wounds to L (left) foot and an open area to coccyx. Resident is tolerating dressing changes well with no complaints of pain or discomfort. Resident is encouraged to reposition and drink fluids. Resident refused to eat breakfast this AM (morning) shift and insulin was held. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's nurses note dated 3/13/25, at 10:52 a.m., written by RN-AA documents Resident is being monitored for wounds. No concerns at this time. No complaints of pain noted. Taking in fluids. R12's nurses note dated 3/14/25, at 10:35 a.m., written by LPN-DD documents Resident is on the board for wounds to L foot and an open area to coccyx. Resident is tolerating dressing changes well with no complaints of pain or discomfort. Resident is encouraged to reposition and drink fluids. Resident is in a pleasant mood and ate 100% of breakfast. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's nurses note dated 3/16/25, at 21:19 (9:19 p.m.), written by LPN-CC documents Resident on report for area to L toe. Writer cleaned area with wound wash and patted dry. Betadine applied to gauze and toe dressing complete. Resident also had OA (open area) to coccyx. Denies pain to both areas. Resident has a CNS (culture and sensitivity) pending due to dysuria and frequency. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's nurses note dated 3/18/25, at 22:04 (10:04 p.m.), written by LPN-CC documents Resident on report for skin tear to L toe, OA to coccyx and positive for UTI (urinary tract infection). Resident toe dressing completed by writer. No complaints of pain. Resident states open area to coccyx does not bother her. Resident had first dose of Cipro 250 mg BID x 7 days and is tolerating well. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's weekly wound assessment dated [DATE] documents present on admission 1/21/25. Site documents 31) right buttocks. Under type for other documents abrasion. Length is 0.6, width 0.6, depth 0, and Stage n/a (not applicable). For describe in further detail wound site location documents abrasion on each side of gluteal cleft. Under comments documents abrasions present upon re-admission from hospital 1/21/25. Resident is continent of B & B (bowel and bladder). Abrasions are not over bony prominence. Barrier cream for protection, new seat cushion placed on WC (wheelchair). Resident reminded to shift weight often. R12's nurses note dated 3/23/25, at 6:19 a.m., written by LPN-EE documents Resident remains on report for ST (skin tear) to area between 4&5 toes on the left foot, area is open to air and resident denies pain. Also small open area to coccyx and calazinc cream applied every shift and PRN (as needed). Also on report for a UTI (urinary tract infection), resident denies any dysuria (painful urination). Temp (temperature) 97.7 Fluids enc (encouraged) and are provided at bedside. Remains on PO (by mouth) Cipro 250 mg (milligrams) Bid (twice daily)thru 3/25/25 No adverse reaction noted to ABT (antibiotic). Resident also being monitored for hypoglycemia. Resident is alert and verbal, speech is clear and is responding appropriately. Skin is warm and dry. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's nurses note dated 3/24/25, at 4:45 a.m., written by LPN-EE documents Resident is on report for skin tear to left foot between 4 & 5 toes. Area is open to air and resident denies any pain to areas. Also on report for open area to coccyx, barrier cream applied per order. Resident also is taking Cipro 250 mg Bid thru 3/25/25 for a UTI. No adverse reaction noted to ABT. Resident denies any dysuria. Fluids enc and are provided at bedside. Temp 97.5. Surveyor was unable to locate a comprehensive assessment of R12's coccyx. R12's skin check dated 4/23/25 written by RN-BB documents .#003: Skin issues has not been evaluated. Location: Coccyx. Laterality/Orientation: Middle. Issue type: Pressure ulcer/injury. Wound acquired in-house. Wound is new. Undermining: No. Tunneling: No. Surveyor was unable to locate a comprehensive assessment of R12's coccyx pressure injury until 5/7/25, 14 days later, treatment for R12's coccyx press injury was not initiated until 5/7/25, and R12's skin pressure injury care plan was not revised until 6/10/25. R12's Braden Scale assessment dated [DATE] has a score of 16 which indicates mild risk for pressure injury development. R12's progress note dated 5/7/25, at 4:51 a.m., written by RN-FF documents Resident had a skin assessment done at this time and was noted to have a very small-1.0 cm x (times) 0.5 cm open area on left buttock. Wound has no peri wound redness and no drainage noted. Wound cleansed with soap and water and patted dry with a foam dressing applied. Residents nurse also at bedside and aware of the wound. Resident also noted to have a few old bruises on bilateral LE's (lower extremities) and right shin has a very small scab noted with no s/s (sign/symptom) of infection noted. Resident repositioned also at this time. R12's weekly wound assessment dated [DATE] documents in house acquired on 5/7/25. Site is documented as 23) coccyx. Type is pressure. Length is 0.8, width 0.8, depth is 0.1 and Stage is II (2). Wound bed is 100% epithelial tissue. Under comments documents NP (Nurse Practitioner)/POA (Power of Attorney)/Hospice aware of wound. Dressing orders in place. R12's quarterly MDS with an assessment reference date of 5/8/25 has a BIMS score of 11 which indicates moderate cognitive impairment. R12 is assessed as not having any behavior including refusal of care. R12 is assessed as requiring supervision or touching assistance for toileting hygiene, roll left and right, chair/bed to chair transfer and toilet transfers. R12 is assessed as being occasionally incontinent of urine and always incontinent of bowel. R12 is at risk for pressure injury development and is assessed as having one Stage 2 pressure injury which was not present upon admission. R12's progress note dated 5/8/25, at 15:04 (3:04 p.m.), written by RN/UM-D documents Writer spoke with resident POA (power of attorney) this morning to update on coccyx wound. POA stated her is concerned that [R12's first name] is more tired and having urine soaked clothes in the dirty laundry. Hospice updated of concern with NNO (no new orders). R12's nurses note dated 5/12/25, at 22:51 (10:51 p.m.), written by RN-BB documents Resident is on the board for COC (change of condition) and OA (open area) to buttocks. Dressing to buttock changed this evening due to being in the wrong place and not covering wound. Resident refused to get up for dinner, resident did get up later in the evening and was given a snack to eat Surveyor noted R12's weekly wound assessment from 5/14/25 through 6/11/25. R12's comprehensive assessment dated [DATE] documents for site 23) coccyx, type is pressure, length 0.4, depth 0.2, depth <0.1 (less than 0.1) and stage is II (2). Under describe in further detail wound site location documents. Above measured wound is left of the coccyx. Resident has a small spot of denuded skin on the right buttock, intact a this time 1.0 x 1.2. Wound bed is 100% epithelial tissue. Under comments documents stable. On 6/10/25, at 9:21 a.m., Surveyor observed R12 sitting in a personal type recliner in R12's room wearing clothing with a bathrobe over the clothing. During the conversation with R12, Surveyor asked R12 if she has any skin concerns. R12 stated I have a hole in my butt which they are treating. Surveyor asked R12 how she developed the hole. R12 replied from sitting I think, I'm not used to sitting. Surveyor asked R12 if there is a cushion in her recliner. R12 replied my fanny, there is nothing extra on it, I brought in my own chair. Surveyor did not observe a cushion in R12's personal type recliner but did observe a comfort cushion in R12's wheelchair. On 6/10/25, at 10:27 a.m., Surveyor observed R12 continues to be sitting in the personal type recliner with her eyes closed. Surveyor did not observe a cushion on R12's personal type recliner. On 6/10/25, at 11:14 a.m., Surveyor observed R12 continues to be sitting in the personal type recliner. Surveyor did not observe a cushion on R12's personal type recliner. On 6/10/25, at 12:08 p.m., Surveyor observed R12 continues to be sitting in a personal type recliner eating lunch. Surveyor did not observe a cushion on R12's personal type recliner. On 6/10/25, at 1:55 p.m., Surveyor observed R12 continues to be sitting in a personal type recliner with her eyes closed and talking to herself. Surveyor did not observe a cushion on R12's personal type recliner. On 6/10/25, at 2:25 p.m., Surveyor observed R12 in bed on her back sleeping. Surveyor observed there is not a cushion in R12's personal type recliner. On 6/12/25, at 8:29 a.m., Surveyor observed Certified Nursing Assistant (CNA)-GG and CNA-HH transfer R12 from the bed into the bathroom using a sit to stand lift. CNA-GG lowered R12's product and R12 was lowered onto the toilet. At 8:32 a.m. R12 was asked if she wanted privacy and CNA-GG & CNA-HH removed their gloves and left R12's room. At 8:33 a.m. CNA-HH entered R12's room and placed gloves on. At 8:34 a.m. RN/UM-D entered R12's bathroom, dated the foam dressing and placed gloves on. RN/UM-D placed soap & water on four by four gauze, asked R12 if she was ready to stand up & asked R12 if she was able to help stand up. R12 was then raised to a standing position and wheeled out of the bathroom. RN/UM-D removed the dressing, cleansed R12's coccyx pressure injury, waved the foam dressing over the pressure injury to help dry the pressure injury and place the foam dressing over R12's coccyx pressure injury. Surveyor noted RN/UM-D completed R12's pressure injury treatment according to physician orders. On 6/16/25, at 12:24 p.m., Surveyor asked RN/UM-D if she is the facility's wound nurse. RN/UM-D replied yes. Surveyor asked RN/UM-D how she becomes aware if a resident develops a pressure injury. RN/UM-D informed Surveyor staff updates her if one is found during a shower check or a CNA sees a spot. Surveyor asked RN/UM-D once she is made aware of a resident having a pressure injury what does she do. RN/UM-D replied I go around do an assessment, get measurements and stage if need be. Surveyor asked RN/UM-D how often are pressure injury assessments are completed. RN/UM-D informed Surveyor she does wound rounds weekly on Wednesday. Surveyor asked R/UM-D who is responsible for revising the care plan. RN/UM-D replied that would be me or who ever puts an intervention should update, if its someone else other than me. Surveyor informed RN/UM-D R12's skin assessment dated [DATE] documents a coccyx pressure injury with measurements and Surveyor was unable to locate a RN assessment of R12's coccyx. Surveyor informed RN/UM-D there are multiple notes during March regarding an open area on R12's coccyx but no comprehensive assessments. On 4/23/25 RN-BB documents a new coccyx pressure injury but does not include measurements or description of wound bed. Surveyor was not able to locate a comprehensive assessment until 5/7/25 and treatment for the pressure injury was not ordered until 5/7/25. Surveyor informed RN/UM-D of the observations of R12 sitting on the personal type recliner without a pressure relief cushion. RN/UM-D informed Surveyor she doesn't know if they a cushion for the recliner care planned. Surveyor asked how they are providing pressure relief when R12 is sitting in the personal recliner. RN/UM-D informed Surveyor R12 they encourage repositioning and usually doesn't sit in the recliner. Surveyor informed RN/UM-D the first day of survey, Surveyor observed R12 sitting in the personal type recliner most of the day. Surveyor asked RN/UM-D if RN-BB made her aware of R12's coccyx pressure injury. RN/UM-D informed Surveyor she will have to see if there are any old emails and wouldn't know why she wouldn't of done an assessment. RN/UM-D informed Surveyor she will do some digging and get back to Surveyor. RN/UM-D did not provide Surveyor with any additional information. 3) R13 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure), Varicose Veins(enlarged veins in legs and feet), Hyperlipidemia(high levels of fat particles in blood), Alzheimer's(progressive disease that destroys memory and other important mental functions), Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R13 currently has an activated Health Care Power of Attorney(HCPOA) to assist with decision making. R13's Quarterly Minimum Data Set(MDS) completed 3/27/25 documents a Brief Interview for Mental Status(BIMS) score to be 2, indicating R13 demonstrates severely impaired skills for daily decision making. R13's MDS documents R13 has disorganized thinking, delusions, physical behavioral symptoms, rejection of care, and wandering daily. R13 requires set-up for meals. R13 requires partial/moderate assistance for showers and upper dressing. R13 requires substantial/maximum assistance for lower dressing, mobility, and transfers. R13 has no range of motion impairment. R13's current physician order document to check R13's wanderguard for placement every shift effective 10/17/24. Surveyor notes that R13's physician orders do not document to check for skin integrity under the wanderguard. Surveyor reviewed R13's Medication Administration Records(MARS) and Treatment Administration Record(TARS). Surveyor notes that R13's MARS and TARS indicates nursing staff are not completing daily checks for R13's skin integrity under R13's wanderguard. Surveyor reviewed R13's Elopement care plan initiated 3/7/25 which does not document any intervention to check R13's skin integrity under R13's wanderguard. Surveyor reviewed R13's risk of breakdown due to chronic incontinence and reduced mobility initiated 2/17/25 which does not document any intervention to check R13's skin integrity under R13's wanderguard. On 6/10/25, at 10:39 AM, Surveyor observed R13's wanderguard placed on R13's left ankle. R13's wanderguard is directly on R13's skin with no sock underneath. Wanderguard on left ankle. Is all over the unit. Requires a lot of redirection, wanderguard is not on a sock On 6/11/25, at 2:05 PM, Surveyor observed R13 in the lounge. R13 has R13's wanderguard on left ankle, directly on the skin with no sock underneath. On 6/12/25, at 12:08 PM, Surveyor interviewed Registered Nurse Unit Manager (RN)-D in regards to skin integrity checks related to R13's placement of R13's wanderguard. RN-D stated that the nursing staff checks for placement and function of the wanderguard but does not complete actual skin checks with placement of the wanderguard. RN-D stated, we need to work on wording. On 6/12/25, at 3:24 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Corporate Consultant (CC)-C that there is no documentation that nursing staff have been completing daily skin checks with the placement of R13's wanderguard in order to maintain skin integrity. No further information has been provided by the facility at this time in regards to why R13 has not had daily skin checks completed due to R13's placement of R13's wanderguard directly on the skin of R13's ankle. On 6/16/25, at 10:26 AM, DON-B provided documentation to Surveyor that R13's physician orders document to check R13's wanderguard placement and skin integrity every shift effective 6/13/25. No additional information was provided. Based on observation, interview, and record review, the facility did not ensure that residents received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R38, R12, and R13) of 3 residents reviewed for pressure injuries. * R38 was admitted with moisture associated skin damage (MASD) on 4/16/2025 to R38 buttocks. On 5/2/2025, R38 developed an open area on the buttocks and the facility did not reassess the area as a stage 2 pressure injury and did not revise R38's care plan until 6/10/2025. The facility did not complete a weekly skin assessment for R38 between 4/18/2025 and 5/2/2025. R38 was observed sitting in the recliner chair without pressure relief. * R12 was identified to have a pressure injury on 3/1/2025. R12 did not have comprehensive assessments completed. On 4/23/2025, R12 had another documented pressure injury and a comprehensive assessment and treatment were not implemented until 5/7/2025. There were observations on R12 sitting in the recliner chair without pressure relief. * R13 did not have daily skin checks/ assessments to monitor the skin underneath R13's wanderguard. Findings include: The facility policy titled Prevention and Treatment of Skin Breakdown/ Pressure Injury revised on 12/2024 documents: Purpose: Maintaining intact skin is integral to resident health and wellness. Care and services are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur. Policy: Resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission, weekly for 4 weeks, upon significant change and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reducing [sic] the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to improve the skin according to professional standards of care. Procedure: I.Skin Assessment . A resident centered care plan is implemented/ updated for skin risk with interventions based upon: - Areas of risk - Resident Assessment - Braden evaluation score of 15 or less - Clinicians' assessment/ evaluation - Resident Preferences . 3. Skin integrity is monitored, and abnormal findings are documented: - Skin is observed daily with cares. If any skin concerns are noted, they are reported to the licensed nurse. - Weekly skin audits are performed by a licensed nurse. II. Treatment of impaired pressure injury . If a resident is admitted with impaired skin integrity or new pressure injury . 1. Documentation of the skin impairment is completed in the medial record. Staging is completed as necessary by trained licensed nursing associates. 2. Standing orders/protocol for skin impairment are initiated. 5. Evaluate current pressure reduction interventions and revise resident centered care plan. 10. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. 1.) R38 was admitted to the facility on [DATE] and has diagnoses that include respiratory failure, pulmonary fibrosis, muscle weakness, and anxiety disorder. R38's Admissions Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R38 has intact cognition. The MDS assessed R38 as needing maximal assistance with 1 staff member for toileting hygiene, and moderate to minimal assistance with 1 staff member for transferring and repositioning. R38's Braden Scale for Predicting Pressure Injury risk dated 4/16/2025 documents a score of 18, indicating that R38 is at mild risk for pressure injury development. R38's admission Care Area Assessment (CAA) dated 4/22/2025 for pressure injuries documents: R38 triggered area for recent hospitalization with COVID/pneumonia. (R38) was admitted to the facility for rehab with a goal to discharge back to home. (R38) required maximal assistance to moderate assistance with most activities of daily living (ADLs). (R38) is frequently incontinent of bowel and bladder . (R38) was admitted with moisture associated skin damage (MASD) and excoriations on buttocks. (R38) did not have pressure injuries on admission on [DATE]. R38's potential for impaired skin integrity related to debility, altered mobility, weakness, and fragile skin care plan was initiated on 4/16/2025 with the following interventions: -Apply moisture barrier as needed. - Apply topical medications as ordered. - Braden skin risk evaluation completed on admission, every week for 4 weeks, quarterly, and with any significant change. - Certified nursing assistants (CNAs) to observe skin with Day (AM) and Evening (HS) cares and report any abnormalities to the nurse. - Consult dietician for nutritional assessment as needed. - Maintain good hygiene. Moisturize dry skin as needed. - Monitor labs and weights as ordered. - Observe for alteration in skin integrity and report to nurse practitioner (NP)/ physician assistant (PA)/ medical doctor (MD). Skin inspected by licensed staff weekly per schedule. - Pressure relieving device in wheelchair, gel cushion. - Provide adequate nutrition and hydration. Nutritional supplements and vitamins as ordered. - Toileting per elimination section of this care plan. - use lift sheet as needed to move (R38) in bed. On 5/2/2025, at 6:29 AM, in the progress notes nursing documented: Certified nursing assistant (CNA) took R38 to the bathroom and noted an open area on R38's left buttock area. No drainage, or signs of infection noted. R38's wound data assessment dated [DATE] documents: - Coccyx, MASD - 0.2 X 0.5 X <0.1 (Length X Width X Depth), partial thickness, superficial - 100% epithelial tissue, no drainage - Macerated, MASD with open area from shearing force. There are two open areas present, same size, one directly above the other. Below level of coccyx. - Redness noted upon admission, has new open areas within the redness due to shearing force. Dressing applied and will monitor for improvement. R38 continues to have weekly wound rounds completed. On 5/21/2025, 5/28/2025, and 6/4/2025 nursing documented that the area to R38's coccyx area was healed. On 6/10/2025 Surveyor reviewed the facility's list documenting the residents that have pressure injuries in the building. R38 was documenting as having a stage 2 pressure injury to the coccyx area and documented as being present on admission. Surveyor noted that R38 was documented to have MASD on the coccyx/ buttock area and on 5/2/2025 there were 2 open areas to the coccyx area. Surveyor noted that the classification of the area was still documented as MASD and not revised to state Stage 2 pressure injury. On 6/11/2025 in the progress notes nursing documented (R38's) previously resurfaced skin has re-opened to a scant slit in the skin at the tip of coccyx within the gluteal cleft. Coccyx, MASD. 0.4 cm X 0.2 cm X <0.1 cm, 100% epithelial tissue. Surveyor notes that the open area on the coccyx is being described as MASD and not a stage 2 pressure injury Surveyor reviewed R38's weekly skin assessments and noted that R38's prior skin assessment/check was documented to be completed on 4/18/2025 and nursing documented that R38 had redness to the buttock and groin area. Surveyor noted that there was not another skin assessment/check completed until 5/2/2025 when R38 was observed to have 2 open areas. On 6/12/2025 Surveyor reviewed R38's care plan and noted that there was no review or revisions made to R38's care plan after R38 was noted to have open area to the buttock/coccyx area on 5/2/2025 and 6/11/2025 to determine in the interventions in place were still appropriate or had to be revised to prevent further breakdown of skin. On 6/12/2025, at 10:16 AM, Surveyor observed R38 sitting in recliner chair on a bed pillow. Surveyor asked R38 if R38 had another cushion R38 was supposed to sit on while in the recliner. R38 stated that R38 put the pillow in because it felt better and that there was not another cushion. On 6/16/2025, at 8:15 AM, Surveyor interviewed registered nurse unit manager (RNUM)-D. Surveyor asked RNUM-D if R38 was admitted to the facility with a stage 2 pressure injury to the coccyx area. RNUM-D stated that R38 was admitted with MASD and then 2 open areas developed, closed, and there is a little area that has reopened recently. Surveyor asked what the classification of the open area would be. RNUM-D stated that it would be a stage 2. Surveyor shared concern that on R38 wound assessments the areas on R38 buttock/coccyx area were documented as MASD. RNUM-D stated that R38's MASD should have been reclassified as a stage 2 on 5/2/2025 when open areas were observed on R38's buttock/coccyx area. Surveyor shared that a weekly skin assessment could not be located between 4/18/2025 until 5/2/2025 when R38 was noted to have the open areas. RNUM-D reviewed R38's medical record and acknowledged that RNUM-D could not find a skin assessment or nursing progress note to reflect a skin assessment for R38 between 4/18/2025 and 5/2/2025. RNUM-D stated that there should have been a skin assessment, and if R38 refused there should still have been documentation. Surveyor shared Surveyors observations of R38 sitting on a bed pillow when sitting in R38's recliner chair because it felt better. RNUM-D stated that cushions are only put in wheelchairs and do not put in the recliner chairs because the recliner chairs are already padded. Surveyor shared that R38 did not think her recliner chair was comfortable and put in a bed pillow to sit on. RNUM-D stated would look into getting a cushion for R38's recliner chair. Surveyor asked when care plan revisions are completed. RNUM-D stated that the Kardex gets updated right away and then will do the care plan later. Surveyor shared that R38's care plan was never revised or reviewed on 5/2/2025 or 6/11/2025 when R38 was noted to have open areas. RNUM-D reviewed R38's care plan and shared that R38's Kardex probably was updated but the care plan should have been updated as well. Surveyor and RNUM-D reviewed R38's Kardex dated as of 6/16/2025 and noted the following interventions for skin: 1. Daily skin inspection. Report abnormalities to the nurse. 2. Monitor Skin observation. RNUN-D stated that there should be more interventions since R38 had open areas and an area has reopened. On 3/16/2025, at 3:10 PM, Surveyor informed Nursing Home Administrator (NHA)-A that R38 did not have a skin assessment/ check completed between 4/18 through 5/2/2025 and was noted to have 2 open areas to R38's coccyx area on 5/2/2025. R38's care plan or Kardex was not reviewed or revised on 5/2/2025 after R38 was noted to have developed open areas. Surveyor also shared that R38 was admitted with MASD and was not re-classified on 5/2/2025 and 6/11/2025 to indicate R38's MASD transitioned to Stage 2. Surveyor also shared that R38 was observed to be sitting in R38's recliner on a bed pillow because it felt better. NHA-A stated that R38's tasks were updated when R38's open area to the buttock was observed. Surveyor shared that no evidence of R38's care plan or Kardex and certified nursing assistant (CNA) tasks could be identified that it was revised or reviewed on 5/2/2025 or 6/11/2025 when R38 was noted to having open areas.

2.) R11's diagnoses includes diabetes mellitus (high blood sugar). R11's diabetic mellitus care plan initiated & revised on 12/15/22 documents the following interventions: *Check all of body for breaks in skin and treat promptly as ordered by doctor. Initiated 12/15/22. *Diabetes medication/insulin as ordered by doctor. Monitor/document for side effects and effectiveness. Initiated 12/15/22 & revised 3/9/23. *Fasting serum blood sugar as ordered by doctor. Initiated 12/15/22. *Monitor/document/report to MD (Medical Doctor) PRN (as needed) s/sx (signs/symptoms) of hypoglycemia: sweating, tremor, increased heart rate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Initiated 12/15/22. Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breathing (rapid, deep and consistent breathing), acetone breath (smells fruity), stupor, coma. Initiated 12/15/22. *Monitor/document/report to MD PRN for s/sx of infection to any open areas: redness, pain, heat, swelling, or pus formation. Initiated 12/15/22 Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Report any of the above to the nurse.Initiated 8/19/24 & revised 9/6/24. Surveyor reviewed R11's medical record and was unable to locate diabetic foot checks for R11. On 6/12/25, at 12:07 p.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D about diabetic foot checks. RN/UM-D informed Surveyor they do weekly shower checks and the CNA (Certified Nursing Assistant) should be documenting. Surveyor asked RN/UM-D if daily foot checks for residents with diabetes mellitus are done. RN/UM-D replied we do not. Surveyor informed RN/UM-D Surveyor was unable to locate daily diabetic foot checks for R11. On 6/12/25, at 3:15 p.m., during the end of the day meeting, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Nurse-C R11 has a diagnosis of diabetes mellitus and Surveyor was unable to locate daily diabetic foot checks for R11. \ Surveyor was not provided with any additional information as to why diabetic foot checks were not being completed for R11. 3.) R12's diagnosis includes diabetes mellitus (high blood sugar). R12's diabetic mellitus care plan initiated & revised 12/20/24 documents the following interventions: *Diabetes medication/insulin as ordered by doctor. Monitor/document for side effects and effectiveness. Initiated & revised 12/20/24. *Dietary consult for nutritional regimen and ongoing monitoring. Initiated 12/20/24. *Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Initiated 12/20/24. *Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Initiated 12/20/24. *Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Initiated 12/20/24. *Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Initiated 12/20/24. *If infection is present, consult doctor regarding any changes in diabetic medications. Initiated 12/20/24. *Monitor/document/report to MD (Medical Doctor) PRN (as needed) s/sx (signs/symptoms) of hypoglycemia: sweating, tremor, increased heart rate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Initiated 12/20/24. *Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breathing (rapid, deep and consistent breathing), acetone breath (smells fruity), stupor, coma. Initiated 12/20/24. *Monitor/document/report to MD PRN for s/sx of infection to any open areas: redness, pain, heat, swelling or pus formation. Initiated 12/20/24. Surveyor noted R12's care plan does not address diabetic foot checks. Surveyor reviewed R12's medical record and was unable to locate diabetic foot checks for R12. On 6/12/25, at 12:07 p.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D about diabetic foot checks. RN/UM-D informed Surveyor they do weekly shower checks and the CNA (Certified Nursing Assistant) should be documenting. Surveyor asked RN/UM-D if daily foot checks for residents with diabetes mellitus are done. RN/UM-D replied we do not. Surveyor informed RN/UM-D Surveyor was unable to locate daily diabetic foot checks for R12. On 6/12/25, at 3:15 p.m., during the end of the day meeting Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Nurse-C R12 has a diagnosis of diabetes mellitus and Surveyor was unable to locate daily diabetic foot checks for R12. Surveyor was not provided with any additional information as to why diabetic foot checks were not being completed for R12. Based on interview and record review, the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 3 (R9, R11, and R12) of 3 sampled residents reviewed for diabetic foot checks. *R9 has a diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease(Diabetic Nephropathy) and has no documentation of diabetic foot checks. *R11 has a diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy and has no documentation of diabetic foot checks. *R12 has a diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and has no documentation of diabetic foot checks. Findings Include: The facility's undated Skin Integrity-Foot Care policy documents: Policy: It is the policy of this facility to ensure Residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot. Policy Explanation and Compliance Guidelines: 1.The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the Resident's medical conditions. a. The facility will utilize a systematic approach for the prevention and management of foot ulcers, including efforts to identify risk; stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. 2. Assessment of Risk b. The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for impaired skin integrity of the foot. Examples include, but are not limited to: diabetes, peripheral vascular disease, peripheral arterial disease, venous insufficiency, peripheral neuropathy, and lack of sensation in feet. 3. Interventions for Prevention and to Promote Healing a. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and assessment of any foot ulcers i. As needed, licensed nurses with adequate training may perform nail care to non-diabetic Residents, or diabetic Residents who are low risk as determined by podiatrist or physician. b. Medical conditions will be managed and interventions will be implemented in accordance with professional standards of practice to prevent complications of medical conditions. 4. Monitoring b. RNs and LPNs will participate in the management of medical conditions by following physician orders, assessment of Residents, and reporting changes in condition to the Resident's physician orders, assessment of Residents, and reporting changes in condition to the Residents' physicians. Referrals to other interdisciplinary team members will be made as appropriate. 5. Modification of Interventions b. Interventions will be modified in a Resident's plan of care as needed. Considerations for needed modifications include: i. Changes in medical condition or degree of risk for developing foot ulcers ii. New onset or recurrent foot ulcer iii. Lack of progression towards healing iv. Resident non-compliance v. Changes in the Resident's goals and preferences . 1) R9 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease(Diabetic Nephropathy), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Alzheimer's(progressive disease that destroys memory and other important mental functions), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R9 currently has an activated Health Care Power of Attorney(HCPOA) to assist with decision making. R9's Annual Minimum Data Set(MDS) completed 3/25/25 documents R9's Brief Interview for Mental Status(BIMS) score to be 6, indicating R9 demonstrates severely impaired skills for daily decision making. R9's MDS documents no mood or behavior symptoms. R9 requires supervision for eating. R9 demonstrates partial/moderate assistance for showers, lower dressing, and transfers. R9 requires supervision for upper dressing and mobility. R9 has no range of motion impairment. R9's current physician orders document R9 is prescribed Metformin HCI ER Tablet Extended Release 24 Hour 1000 mg by mouth one time a day for Diabetes Mellitus effective 11/12/24. Surveyor notes there is no physician order for daily diabetic foot checks per professional standards of practice. R9's Medication Administration Records(MARS) and Treatment Administration Records(TARS) do not documents that the nursing staff are completing daily diabetic foot checks per professional standards of practice. R9's comprehensive care plan documents: R9 has Diabetes Mellitus Initiated 10/4/22 Intervention: Check all of body for breaks in skin and treat promptly as ordered by doctor Initiated 10/4/24 Surveyor noted there were no intervention for R9 to have completed diabetic foot checks. On 6/12/25, at 12:08 PM, Surveyor interviewed Registered Nurse (RN-Unit Manager)-D regarding diabetic foot checks. RN-D informed Surveyor that skin checks are completed one time a week with the resident's weekly shower checks. RN-D confirmed that weekly or daily diabetic foot checks are not completed. On 6/12/25, at 03:24 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Corporate Consultant (CC)-C that daily diabetic foot checks as recommended by professional standards of practice and that they are not being completed for R9. No additional information has been provided by the facility at this time as to why daily diabetic foot checks have not been completed for R9.

Based on interview and record review the facility did not ensure 3 (R11, R34, & R13) of 5 residents drug regimen were free of unnecessary drugs. * R11 is prescribed Eliquis (Apixaban) 2.5 mg (milligrams), an anticoagulant, for history of pulmonary embolism (condition where one or more arteries in the lungs are blocked by a blood clot). There is no monitoring for signs/symptoms of anticoagulant complications. * R34 is prescribed Rivaroxaban 15 mg, an anticoagulant, for blood clots. There is no monitoring for signs/symptoms of anticoagulant complications. * R13 is prescribed Eliquis (Apixaban) 2.5 mg, an anticoagulant, for history of pulmonary embolism. There is no monitoring for signs/symptoms of anticoagulant complications. Findings include: The facility's policy titled, High Risk Medications - Anticoagulants and not dated under policy documents This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences that other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Under Policy Explanation and Compliance Guidelines documents 4. The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusually bruising, blood in urine or stool). b. Fall in hematocrit or blood pressure. c. Thomboembolism (a blood clot that breaks loose, travels through the bloodstream, blocks a different blood vessel obstructing blood flow). 1.) R11's diagnosis includes personal history of pulmonary embolism. R11's physician orders include: Eliquis Tablet 2.5 mg (Apixaban)/ Give 1 tablet by mouth two times a day related to personal history of pulmonary embolism; order date 4/23/21. R11's anticoagulant therapy care plan initiated & revised 9/18/24 documents the following interventions: *Labs as ordered. Report abnormal labs results to the MD (medical doctor). Initiated 9/18/24. *Monitor/document/report to MD PRN (as needed) s/sx (signs/symptoms) of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs). Initiated 9/18/24. *Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk, and cheese. Initiated 9/18/24. Surveyor reviewed R11's medical record which included R11's MAR/TAR (medication administration record/treatment administration record), progress notes, and assessments. Surveyor was unable to locate evidence the facility was monitoring R11 for signs/symptoms of anticoagulant complications. On 6/12/25, at 12:09 p.m. Surveyor informed Registered Nurse/Unit Manager-D R11 is prescribed an anticoagulant and asked if R11 is monitored for complications. RN/UM-D replied oh ya, bleeding bruising, anything like that. Surveyor asked RN/UM-D where Surveyor would be able to locate monitoring in R11's medical record. RN/UM-D informed Surveyor there's not an order, doesn't think its in there, and it's a nursing judgement. Surveyor informed RN/UM-D Surveyor was unable to locate evidence the facility was monitoring R11 for complications of R11's prescribed Eliquis. On 6/16/25 Surveyor noted R11's anticoagulant therapy care plan was revised by RN/UM-D to include an intervention initiated 6/13/25 for daily skin inspection; report abnormalities to the nurse. 2.) R34's diagnoses includes atrial fibrillation (irregular and rapid heart rate) and hypertensive heart disease with heart failure (prolonged high blood pressure that leads to the heart's inability to pump blood effectively). R34's physician orders include: Rivaroxaban oral tablet 15 mg (milligrams) (Rivaroxaban). Give 1 tablet by mouth in the evening for blood clots. Give with dinner; order date 5/21/25. R34's anticoagulant therapy care plan initiated & revised 9/18/24 documents the following interventions: *Labs as ordered. Report abnormal lab results to the MD (medical doctor). Initiated 9/18/24. *Monitor/document/report to MD PRN (as needed) s/sx (signs/symptoms) of anticoagulant complications: blood tinged or frank flood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs). Initiated 9/18/24. *Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk, and cheese. Initiated 9/18/24. Surveyor reviewed R34's medical record which included R34's MAR/TAR (medication administration record/treatment administration record), progress notes, and assessments. Surveyor was unable to locate evidence the facility was monitoring R34 for signs/symptoms of anticoagulant complications. On 6/12/25, at 12:09 p.m. Surveyor informed Registered Nurse/Unit Manager-D R34 is prescribed an anticoagulant and asked if R34 is monitored for complications. RN/UM-D replied oh ya, bleeding bruising, anything like that. Surveyor asked RN/UM-D where Surveyor would be able to locate monitoring in R34's medical record. RN/UM-D informed Surveyor there's not an order, doesn't think its in there, and it's a nursing judgement. Surveyor informed RN/UM-D Surveyor was unable to locate evidence the facility was monitoring R34 for complications of R34's prescribed Rivaroxaban. 3.) R13 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure), Varicose Veins(enlarged veins in legs and feet), Hyperlipidemia(high levels of fat particles in blood), Alzheimer's(progressive disease that destroys memory and other important mental functions) Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R13's Quarterly Minimum Data Set(MDS) completed 3/27/25 documents R13's Brief Interview for Mental Status(BIMS) score to be 2, indicating R13 demonstrates severely impaired skills for daily decision making. R13's MDS documents R13 has disorganized thinking, delusions, physical behavioral symptoms, rejection of care, and wandering daily. R13 requires set-up for meals. R13 requires partial/moderate assistance for showers and upper dressing. R13 requires substantial/maximum assistance for lower dressing, mobility, and transfers. R13 has no range of motion impairment. Surveyor reviewed R13's current physician orders which document that R13 is prescribed Eliquis Tablet 2.5 mg(Apixaban) 2 times a day for history of Pulmonary Embolism; effective 5/26/21. Surveyor notes that R13's physician orders does not have an order to monitor bleeding, bruising, severe headache, blood in the urine or stools, changes in mental status, or significant vital signs. Surveyor reviewed R13's comprehensive care plan. R13's care plan does not document R13 being prescribed Eliquis, an anticoagulant, including interventions to monitor signs/symptoms of the anticoagulant. On 6/12/25, at 12:08 PM, Surveyor interviewed Registered Nurse Unit Manager (RN)-D who stated that nursing monitors for bruising, bleeding based on nursing judgment, however, there is no documentation that nursing staff are monitoring for bleeding, bruising every shift, daily. On 6/12/25, at 3:24 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Consultant (CC)-C that R13 has not been monitored for signs of bleeding and bruising for R13 being on an anticoagulant on a daily basis. Surveyor also shared that R13's care plan does not have documentation of R13's anticoagulant including interventions to monitor signs/symptoms of the anticoagulant. The facility provided no additional information as to why the facility has not been monitoring daily for signs/symptoms of R13's anticoagulant like, but not limited to, bleeding or bruising, severe headache, blood in the urine or stools, changes in mental status, or significant vital signs.

2.) R12's diagnoses includes dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), depressive disorder, diabetes mellitus (high blood sugar), and malignant neoplasm of colon (cancer). R12's significant change MDS (minimum data set) with an assessment reference date of 2/6/25 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment. Hospice care is checked for while a resident. R12's nurses note dated 2/7/25 documents Resident is being monitored for readmission. Resident is now on [Name] hospice. Resident out for breakfast today. VSS (vital signs stable). Taking in fluids. Denies pain. BGL (blood glucose level) 186 before breakfast. R12's hospice care plan initiated 2/13/25 documents the following interventions: *Establish and coordinate POC (plan of care) and services between LTC (long term care) and Hospice Team. Maintain communication to fulfill POC and inform of changes. Initiated 2/13/25. *Hospice related medications and supplies to be provided by hospice services. Initiated 2/13/25. *Medications as ordered by Hospice/MD (Medical Doctor) order. Initiated 2/13/25. *Will update and review as changes occur. Initiated 2/13/25. R12's nurses note dated 5/1/25, at 15:45 (3:45 p.m.), documents: Called [Name] hospice to update on residents COC (change of condition) by being very lethargic, refusing cares, and refusing meals. Hospice nurse is to be giving writer a call back regarding when they can come out to see resident. R12's nurses note dated 5/1/25, at 23:03 (11:03 p.m.), documents: Resident on the board for COC. Hospice nurse came out this evening to assess resident and when they arrived residents was being helped out of bed and dressed for the evening. Resident was awake and alert when hospice assessed. They expressed could be resident slowly declining but no concern at the time. Resident up for dinner, ate 75% of meal. Fell asleep at dining table and when writer asked if she wanted to go back to her room she said no she just want to be. An hour later resident was heard yelling and moaning from dining room, resident was very lethargic and writer check residents blood sugar twice from two separate glucometers getting BS (blood sugar) of 279. Resident was not responding to any questions at this time and unable to open eyes, vitals were taken and all WNL (within normal limits). Once resident woke up a little, still not responding with words was able to give bilateral hand grasp equal in strength, pick up both arms with no drift, smile was equal and able to stick out tongue. Resident was taken to the bathroom per resident's request by CNA and writer and slowly started to talk but only in one word. Resident is still responding only in one words and express feeling off and just sleepy. Writer taken residents BS (blood sugar) again at 9 PM before HS (hour sleep) insulin and BS was 465. Surveyor was unable to locate hospice communication note regarding hospice visit on 5/1/25. R12's Quarterly MDS with an assessment reference date of 5/8/25 has a BIMS (brief interview mental status) score of 11 which indicates moderate cognitive impairment. Hospice care is checked for while a resident. On 6/11/25, at 10:25 a.m., Surveyor reviewed the facility's hospice agreement with [Name] at home hospice dated July 26, 2023. Surveyor noted this agreement is not signed by the hospice representative. Nursing Home Administrator (NHA)-A received a signed agreement on 6/16/25 which was originally signed by the hospice representative on 7/27/23. On 6/11/25, at 11:08 a.m. Surveyor reviewed R12's hospice binder located on a shelf behind where Health Unit Coordinator (HUC)-T is located. Surveyor noted R12's hospice binder contains the first names of the hospice team, hospice agreement dated 2/5/25 signed by R12's POA (power of attorney) and hospice team member [Name], RN (Registered Nurse) on 2/4/25, the hospice discharge criteria, hospice benefit election, informed consent and Medicare/Medicaid benefit election signed by R12's POA on 2/4/25. An email from Nursing Home Administrator (NHA)-A dated 2/6/25 which documents to please make sure that daily skilled documentation continues to be completed on the following residents. Surveyor noted R12 is not on this list of residents. There is a calendar with scheduled visits for February 2025, March 2025, & April 2025. Surveyor noted there is not calendar indicating when R12's scheduled hospice visits are after April 2025. There are hospice notes dated 2/10/25 regarding shower/sponge bath, 4/12/25 PRN (as needed) visit due to change in condition by a hospice RN and the last notation is dated 5/30/25. There are no further hospice communication notes after 5/30/25. Surveyor reviewed R12's medical record and noted under the document section of R12's medical record there are two notes. There are hospice visit reports dated 3/1/25 and 5/25/25. Surveyor was unable to locate any additional communication notes from hospice. On 6/11/25, at 11:29 a.m., Surveyor spoke with Hospice Aide (HA)-LL who Surveyor had observed wheel R12 out of activities and into the shower room for a shower. HA-LL informed Surveyor she comes three times a week. She gives R12 a shower twice a week, does R12's nails, sits with R12 in activities and often will take R12 to her hair appointment and sit with R12. On 6/11/25, at 3:10 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B Surveyor inquired where Surveyor would locate hospice notes. DON-B informed Surveyor there is a hospice binder kept at the HUC station and hospice started emailing their notes which are being uploaded under documents. Surveyor asked DON-B if hospice communication notes are not in the binder or under the document section of the resident's medical record is there anywhere else Surveyor should look. DON-B replied no. Surveyor asked who is the facility's hospice liaison. NHA-A stated think it's always the DON. DON-B indicated she just started then stated sure, they (hospice) stop in by her. On 6/12/25 at 9:15 a.m. Surveyor interviewed HUC-T regarding hospice communication notes. HUC-T informed Surveyor [Name] hospice gives her the visit forms and she uploads them right way into the resident's medical record. Surveyor asked about [Hospice Name], which is R12's hospice,. HUC-T informed Surveyor they put their notes in the binder. Surveyor inquired if the notes get uploaded into the medical record. HUC-T replied no. Surveyor asked HUC-T if anyone is responsible to ensure hospice is providing their hospice notes. HUC-T informed Surveyor she knows hospice give a report to nursing on what cares they did but doesn't know if they specifically as for a sheet. On 6/12/25, at 12:14 p.m. Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D who is the facility's hospice liaison. RN/UM-D informed Surveyor she doesn't know if there is one designated. Surveyor asked RN/UM-D the process for communication with hospice. RN/UM-D informed Surveyor they typically tell the nurse on duty what they did, if there are any orders they write telephone orders or they will send the orders to the pharmacy. Surveyor asked RN/UM-D if hospice leaves any paperwork. RN/UM-D informed Surveyor they should be going to their binders and put their paper work in there unless it as an order. Surveyor asked if hospice attends the interdisciplinary team meetings. RN/UM-D replied they typically do may be one person. Surveyor asked if hospice social worker or chaplain comes into the facility. RN/UM-D replied yes and informed Surveyor sometimes there is music therapy or massage therapy. Surveyor was not able to locate any notes from the hospice social worker or chaplain. Surveyor asked if hospice provides a schedule when they are coming in. RN/UM-D informed Surveyor sometimes they give the CNA (Certified Nursing Assistant) a schedule but can't say it's consistent. Surveyor informed RN/UM-D the last schedule in R12's hospice binder is from April. On 6/12/25, at 9:30 a.m., Surveyor rechecked R12's hospice binder and noted the last note in the binder is still dated 5/30/25. No additional information was provided. 3.) R23's diagnoses includes Alzheimer's Disease, Anxiety Disorder and Depressive Disorder. R23's physician orders includes Hospice eval (evaluation) & tx (treat) dated 5/13/24. R23's social service note dated 5/13/24 at 13:59 (1:59 p.m.) written by Social Service (SS)-Y documents Resident signed on with [Name] Hospice Services. R23's hospice care plan initiated 5/13/24 & revised 6/4/24 documents the following interventions: *Ancillary services (PT/OT) (physical therapy/occupational therapy) for resident comfort as determined by MD/NP (medical doctor/nurse practitioner), Hospice, LTC (long term care). Initiated & revised 5/22/24. *DME (durable medical equipment) and hospice related medications and supplies to be provided by hospice service. Initiated & revised 5/22/24. *Establish and coordinate POC (plan of care) and services between LTC and hospice team. Maintain communication to fulfill POC (plan of care) and inform of changes. Initiated & revised 5/22/24. *Establish and coordinate POC and services between [Facility name] nursing staff and hospice team. Maintain communication to fulfill POC and inform of changes. Initiated 5/22/24. *Hospice related medications and supplies to be provided by hospice service. Initiated 5/22/24. *Hospice staff to document provisions of care for LTC staff. Will update and review as changes occur. Initiated & revised 5/22/24. *Hospice staff to document provisions of care for [Facility name] nursing staff. Will update and review as changes occur. Initiated 5/22/24. *Medications as ordered per hospice/MD order. Initiated 5/22/24. *Medications as ordered. Initiated & revised 5/22/24. R23's social service note dated 6/6/24, at 10:23 a.m., written by SS-Y documents: Writer met with resident's dtr/POA (daughter/power of attorney) [Name], DON (Director of Nursing), and [Name] Hospice team to discuss POC (plan of care). Hospice team will be bringing in volunteer to spend more time with res (resident) when becoming restless/agitated. No concerns were noted at this time. Hospice and IDT (interdisciplinary team) will continue to follow and assist resident and family with needs. R23's annual MDS (minimum data set) with an assessment reference date of 5/13/25 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. Hospice care is checked for while a resident. On 6/11/25, at 11:24 a.m., Surveyor reviewed R23's [Name] Hospice binder. Surveyor noted this binder contains [Hospice name] team form which has not been filled out, a note tab with interdisciplinary progress notes starting 6/13/24 to 3/13/25 and section for bowel movement tracker which has not been completed. Surveyor noted there are no hospice communication notes after 3/13/25. On 6/11/25, at 3:10 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor inquired where Surveyor would locate hospice notes. DON-B informed Surveyor there is a hospice binder kept at the HUC (health unit coordinator) station and hospice started emailing their notes which are being uploaded under documents. Surveyor asked DON-B if hospice communication notes are not in the binder or under the document section of the resident's medical record is there anywhere else Surveyor should look. DON-B replied no. Surveyor asked who is the facility's hospice liaison. NHA-A stated think it's always the DON. DON-B indicated she just started then stated sure, they (hospice) stop in by her. On 6/12/25, at 9:15 a.m., Surveyor interviewed HUC-T regarding hospice communication notes. HUC-T informed Surveyor [Name] hospice gives her the visit forms and she uploads them right way into the resident's medical record. Surveyor asked about [Hospice Name], which is R23's hospice,. HUC-T informed Surveyor they put their notes in the binder. Surveyor inquired if the notes get uploaded into the medical record. HUC-T replied no. Surveyor asked HUC-T if anyone is responsible to ensure hospice is providing their hospice notes. HUC-T informed Surveyor she knows hospice give a report to nursing on what cares they did but doesn't know if they specifically as for a sheet. On 6/12/25, at 12:14 p.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-D who is the facility's hospice liaison. RN/UM-D informed Surveyor she doesn't know if there is one designated. Surveyor asked RN/UM-D the process for communication with hospice. RN/UM-D informed Surveyor they typically tell the nurse on duty what they did, if there are any orders they write telephone orders or they will send the orders to the pharmacy. Surveyor asked RN/UM-D if hospice leaves any paperwork. RN/UM-D informed Surveyor they should be going to their binders and put their paper work in there unless it as an order. Surveyor asked if hospice attends the interdisciplinary team meetings. RN/UM-D replied they typically do may be one person. Surveyor asked if hospice social worker or chaplain comes into the facility. RN/UM-D replied yes and informed Surveyor sometimes there is music therapy or massage therapy. Surveyor was not able to locate any notes from the hospice social worker or chaplain. Surveyor asked if hospice provides a schedule when they are coming in. RN/UM-D informed Surveyor sometimes they give the CNA (Certified Nursing Assistant) a schedule but can't say it's consistent. On 6/12/25, at 10:03 a.m., Surveyor observed R23 sitting in a wheelchair in her room with Hospice Registered Nurse (RN)-MM. On 6/12/25, at 10:06 a.m., Surveyor spoke with Hospice RN-MM. Hospice RN-MM informed Surveyor this is her first visit at the facility and explained she is a visit nurse and not the case manager. Surveyor inquired if she leaves any hospice communication notes with the facility. Hospice RN-MM informed Surveyor her directions are there is apparently a white [name of hospice] binder she is to look for and write a brief summary of the visit. Hospice RN-MM informed Surveyor that there is also an email sent to DON [Name] (Previous Director of Nursing-II), Director Social Services-K, R23's daughter who is R23's POA and R23's case manager. Surveyor asked if there is a hospice care plan. Hospice RN-MM replied yes, have to look at it before she goes to the facility. Surveyor asked if the care plan is in her hospice computer. Hospice RN-MM replied yes. No additional information was provided. Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 3 (R2, R12, and R23) of 4 residents reviewed for hospice services. *R2's current hospice plan of care, visit notes, and schedule of hospice providers were not available to facility staff. The facility did not have a facility hospice care plan developed. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. *R12's current hospice plan of care, visit notes, and schedule of hospice providers were not available to facility staff. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. *R23's current hospice plan of care, visit notes, and schedule of hospice providers were not available to facility staff. The facility did not have a facility hospice care plan developed. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. Findings include: The facility's undated Coordination of Hospice policy and procedure documents: Policy: When a Resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the Resident's highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines: 1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the Resident's care. 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with Resident's needs, goals, and recognized standards of practices in consultation with the Resident's attending physician/practitioner and Resident's representative, to the extent possible. 3. The plan of care will identify the care and services that each entity will provide in order to meet the needs of the Resident and his/her expressed desire for hospice care. a. The hospice provider retains primary responsibility for the provision of hospice care and services that are necessary for the care of the Resident's terminal illness and related conditions. b. The facility retains primary responsibility for implementing those aspects of care that are not related to the duties of the hospice. 4. The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility. 5. The facility will monitor and evaluate the Resident's response to the hospice care plans. 6. The facility will maintain communication with hospice as it relates to the Resident's plan of care and services to ensure each entity is aware of their responsibilities. 7. The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary. 1) R2 was admitted to the facility on [DATE] with diagnoses of Unspecified Protein-Calorie Malnutrition (deficiency of both protein and energy), Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Unspecified Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R2's Significant Change Minimum Data Set(MDS) completed 5/20/25 documents R2's Brief Interview for Mental Status(BIMS) score to be 2, indicating R2 demonstrates severely impaired skills for daily decision making. R2 has no mood symptoms. R2 displays physical and verbal symptoms and rejection of care. R2 has no range of motion impairment. R2 requires set-up for eating. The MDS also documents that R2 requires dependent care for showers and substantial/maximum care for dressing, mobility, and transfers. R2's current physician orders document R2 is being treated by hospice effective 5/14/25. Surveyor reviewed R2's comprehensive care plan. R2's comprehensive care plan did not document that R2 is receiving hospice services. Surveyor reviewed R2's hospice agreement signed on 4/16/24. R2's hospice agreement documents: Plan of Care means a written care plan established, maintained, reviewed and modified, if necessary, at intervals identified by the Interdisciplinary Team(IDT). The plan of care must reflect hospice patient and family goals and interventions based on the problems identified in the hospice patient assessments. The plan of care will reflect the participation of the hospice, facility and the hospice patient and family to the extent possible. Specifically, the plan of care includes: -an identification of the hospice services, including interventions for pain management and symptom relief, needed to meet such hospice patient's needs and the related needs of hospice patient's family -a detailed statement of the scope and frequency of such hospice services -measurable outcomes anticipated from implementing and coordinating the plan of care -drugs and treatment necessary to meet the needs of the hospice patient -medical supplies and appliances necessary to meet the needs of the hospice patient -IDT documentation of the hospice patient's or representative's level of understanding, involvement and agreement with the plan of care. Hospice and facility will jointly develop and agree upon a coordinated plan of care which is consistent with the hospice philosophy and is responsive to the unique needs of hospice patient and his or her expressed desire for hospice care. The Plan of Care will identify which provider is responsible for performing the respective functions that have been agree upon and included in the plan of care. Coordination of Care -Facility shall participate in any meeting, when requested, for the coordination, supervision and evaluation by hospice of the provision of facility services. Hospice and facility shall communicate with one another regularly and as needed, for each particular hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of hospice patients are met 24 hours per day. Design of Plan of Care -In accordance with applicable federal and state laws and regulations, facility shall coordinate with hospice in developing a plan of care for each hospice patient. Hospice retains primary responsibility for development of the plan of care. Modifications to Plan of Care -Facility will assist with periodic review and modification of the plan of care. Facility will not make any modifications to the plan of care without first consulting hospice. Hospice retains the sole authority for determining the appropriate level of hospice care provided to each hospice patient. Coordination and Evaluation -Hospice shall retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care of hospice patients, which shall include coordination of facility services. Hospice's IDT shall communicate with facility's medical director, hospice patient's attending physician and other physicians participating in the care of a hospice patient as needed to coordinate hospice services with the medical care provided by other physicians. Designation of Hospice Representative -For each hospice patient, hospice shall designate a registered nurse who will be responsible for coordinating and supervising services provided to a hospice patient and be available for consultation with facility concerning a hospice patient's plan of care. -The hospice representative shall be responsible for communicating with facility representatives and other health care providers who participate in the care of a hospice patient's terminal illness and related conditions to ensure quality of care for hospice patients and their families. Provision of Information -Hospice shall promote open and frequent communication with facility and shall provide facility with sufficient information to ensure that the provision of facility services under this agreement is in accordance with the hospice's patient's plan of care, assessments, treatment planning and care coordination. Records -Each party shall prepare and maintain complete and detailed records concerning each hospice patient receiving facility services under this agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations. -Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each hospice patient, including evaluations, treatments, progress notes, authorizations to admission to hospice and/or facility, physician orders entered to pursuant to this agreement and discharge summaries. -Each record shall document that the specified services are furnished in accordance with this agreement and shall be readily accessible and systemically organized to facilitate retrieval by either party. Provision of Plan of Care to Facility -Upon a hospice patient's admission to facility for inpatient services, hospice shall furnish a copy of the current plan care. Copy of Plan of Care -Hospice shall document in the patient's record that the plan of care has been provided to facility and specify the inpatient services that facility will furnish. Hospice shall periodically review hospice patients' records to verify that these requirements are met. Inpatient Clinical Records -Hospice shall periodically review hospice patients' inpatient clinical records to determine that they include a record of all inpatient services furnished and events regarding care that occurred at facility. On 6/11/25, at 7:34 AM, Surveyor reviewed R2's hospice binder located at the facility's nursing station. R2's binder conatined R2's certification for hospice 5/14/25-7/12/25, consent and election of benefit statement, list of medications, hospice contacts with phone numbers, a nurse initial visit and assessment dated [DATE], and an aide care plan report. R2's binder does not contain a documented hospice plan of care or hospice visit notes. There was no schedule when hospice providers will be at the facility to provide service to R2. Surveyor notes R2's electronic medical record(EMR) did not contain a documented hospice care plan or hospice visit notes. On 6/11/25, at 2:03 PM, Surveyor interviewed Unit Secretary (US)-T. US-T is not aware of any schedule from hospice being provided to facility staff when hospice providers will be providing cares to R2. On 6/11/25, at 3:19 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B explained the hospice binders are located at the nurse's stations. NHA-A explained that hospice providers email hospice visit notes and the documentation gets 'uploaded' in the Resident's EMR. Surveyor asked who is the facility designated liaison between the facility and hospice providers. NHA-A stated it has always been the Director of Nursing. DON-B stated DON-B started employment in February but was not aware that DON-B is the designated liaison between the facility and hospice providers. DON-B stated that sometimes hospice will stop in by DON-B or the Social Worker. On 6/12/25, at 12:08 PM, Surveyor interviewed Registered Nurse Unit Secretary (RN)-D in regards to the communication between R2's hospice provider and the facility. RN-D does not know if there is a facility designated hospice liaison. RN-D stated that hospice should be placing visit notes in the hospice binder. RN-D stated that all hospice disciplines come in and provide care to R2 and sometimes hospice provides an aide schedule, but it is not consistent. On 6/12/25, at 3:24 PM, Surveyor shared the concern with NHA-A, DON-B, and Corporate Consultant (CC)-C that there is no collaboration between R2's hospice and facility. Surveyor explained R2's hospice binder and EMR does not contain documentation of hospice visit notes, or a hospice care plan. Surveyor also shared the concern that the facility has not implemented a hospice care plan and the facility has not had a designated hospice liason. The facility has not provided further information as to why there is no collaboration between R2's hospice provider and the facility and that there is no coordinated person plan of care with interventions in accordance with R2's needs, goals, and preferences.

Based on interview and record review, the facility did not ensure staff postings displayed were accurate to the actual staffing of the facility. Review of staffing schedules and required staff postings from 5/9/2025 - 6/9/2025 revealed 14 of 30 days had discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. This deficient practice has potential to affect 41 out of 41 residents. Findings include: The facility policy titled Nurse Staffing Posting Information with no initiated or reviewed/revised date documents: Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to resident, staff, and visitors at any given time. Policy Explanation and Compliance guidelines: 1. The nurse staffing sheet will be posted on a daily basis and will contain the following information: . d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses . iii. Certified Nursing Aides . 4. A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. a. The information shall reflect staff absences on that shift due to callouts and illnesses. After the start of each shift, actual hours will be updated to reflect such. Surveyor reviewed the schedules and staff postings from 5/9/2025 through 6/9/2025. Surveyor compared the actual staffing schedules with the staff positings and noted the following inaccuracies: 5/17/2025 AM SHIFT: Staff Posting: 1 registered nurse (RN), 2 licensed practical nurses (LPNs), 6 certified nursing assistants (CNAs); Staff Schedule: 0 RNs, 2 LPNs, 5 CNAs PM SHIFT: Staff posting: 6 CNAs; Staff schedule: 5 CNAs 5/18/2025: AM SHIFT: Staff Posting: 1 RN, 1 LPN, 6 CNAs; Staff Schedule: 2 LPNs, 5 CNAs PM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs 5/19/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs PM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs 5/20/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs PM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs 5/21/2025: PM SHIFT: Staff Posting: 2 RNs, 1 LPN; Staff Schedule: 1 RN, 1 LPN Night (NOC) SHIFT: Staff Posting: 5 CNAs (documents 1 CNA orientating); Staff schedule: 4 CNAs listed, none are documented as being orientated. 5/25/2025: NOC SHIFT: Staff Posting: 2 RNs, 1 LPN; Staff Schedule: 2 RNs, 0 LPNs 5/28/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs NOC SHIFT: Staff Posting: 1 RN, 1 LPN; Staff Schedule: 2 RNs, 1 LPN 5/29/2025: AM SHIFT: Staff Posting: 2 RNs; Staff Schedule: 1 RN, 1 LPN PM SHIFT: Staff posting: 2 RNs, 1 LPN; Staff Schedule: 1 RN, 1 LPN 5/30/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs NOC SHIFT: Staff Posting: 1 RN, 1 LPN; Staff Schedule: 1 RN, 2 LPNs 5/31/2025: AM SHIFT: Staff Posting: 2 LPNs, 6 CNAs; Staff Schedule: 1 LPN, 1 LPN documented as calling off at 6:30AM, 5 CNAs NOC SHIFT: Staff Posting: 1 RN, 2 LPNs; Staff Schedule: 1 RN, 1 LPN 6/5/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 4 CNAs 6/7/2025: NOC SHIFT: Staff Posting: 5 CNAs; Staff Schedule: 4 CNAs 6/8/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 5 CNAs (down to 4 CNAs after 11:00am) 6/9/2025: AM SHIFT: Staff Posting: 6 CNAs; Staff Schedule: 4 CNAs Surveyor noted that the staffing total hours for all the dates indicated above are not accurate and that there was discrepancies in the staff schedules and staff postings for 14 of 30 days reviewed between 5/9/2025 through 6/9/2025. On 6/16/2025, at 10:59 AM, Surveyor interviewed Scheduler-V who stated NOC (night) shift posts the new staff posting for the day and nursing is in charge of documenting the staffing changes throughout the day. The staff postings are given to Scheduler-V and Scheduler-V files the postings and schedules. Surveyor asked if Scheduler-V reviews the staff postings and confirms with the schedules the accuracy of both. Scheduler-V stated Scheduler-V used to but has not been recently. Surveyor shared concerns of the above days where the staff postings did not match what was shown on the schedule for actual staffing. Scheduler-V stated that Scheduler-V would have to start reviewing the staff postings with the schedules again. On 6/16/2025, at 11:24 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the above dates and the discrepancies between the staff postings and staff schedules. NHA-A stated that Scheduler-V reviews all the staff postings with the staff schedules. Surveyor informed NHA-A that Scheduler-V stated Scheduler-V has not been comparing the staff postings with the staff schedules. NHA-A stated that Scheduler-V should be comparing the staff postings with the staff schedules and will be doing some reeducation. NHA-A stated that education will be done with nursing staff as well because the staff postings should be adjusted accordingly throughout the day as changes occur. No additional informtion was provided.

Based on interview and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (R1 and R3) reviewed for falls. *R1 had four unwitnessed falls that were not thoroughly investigated to determine a root cause and develop interventions that addressed the cause to prevent future falls. R1 had a fifth unwitnessed fall that resulted in a displaced left femoral neck fracture. *R3 did not have wheelchair pedals on when moving in R3's wheelchair. R3 fell and received sutures on their forehead. Findings include: The facility's policy and procedure titled, Falls Management and Prevention last revised December 2024, documents: Purpose: Fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls . Policy: Residents are assessed for their risk of falling upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the resident's condition, provides care for, safety and comfort. Procedure . 3. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment. 4. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. 5. Residents are provided education, as appropriate, regarding her/his fall risk and interventions to reduce falls based on the fall risk assessment . Post Fall Procedure 1. When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment . 5. The environment of the fall is evaluated for possible contributing factors and addressed. 6. The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions. 7. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. 8. Documentation of the above items is completed . 1.) R1 was admitted to the facility on [DATE] on hospice services with pertinent diagnoses that include Pulmonary Heart Disease and Chronic Diastolic Heart Failure. R1's Admission Assessment Minimum Data Set (MDS) with an assessment reference date of 12/18/2024 documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. R1 was assessed as being understood by others and able to understand others with clear comprehension. R1 was assessed as having adequate vision. The MDS documents R1 was assessed to have no behaviors exhibited during the look back period and the behavior section indicates neither hallucinations or delusions were present. R1's MDS indicates there is no impairment to R1's upper or lower extremities and R1 uses a walker or wheelchair for mobility. R1 is occasionally incontinent of bowel and bladder, and per the MDS no trial of a toileting program was attempted. R1's Fall Risk Assessment completed on 12/21/24 documented R1 is at risk of falls with a score of 12. R1's care plan for Bowel and Bladder: I am incontinent of Bowel and Bladder at times. I require assistance with toileting was initiated on 12/13/2024 with the following interventions: -Bowel and bladder evaluation with screening on admission and quarterly with treatment plan annually and PRN. Created on: 12/13/2024 -Bowel medications as ordered. Record BMs every shift as they occur. Monitor bowel record daily for constipation. Notify NP/PA/MD should a pattern of constipation occur. Created on: 12/13/2024 -Provide adequate nutrition and hydration. Provide water at the bedside, encourage Resident to drink to remain hydrated. Created on: 12/13/2024 -Staff assist to transfer on/off toilet per mobility section of this Care Plan. Created on: 12/13/2024 -Staff assist with peri cares and manipulating clothing as needed. Created on: 12/13/2024 -Staff assist with toileting tasks per resident request. Created on: 12/13/2024 Surveyor noted there is no toileting plan identified in the bowel and bladder care plan. R1's care plan for Mobility: I need assist with Ambulation, transfers, and bed mobility due weakness. I am at risk for a decline in ambulation d/t (due to) respiratory failure was initiated on 12/13/2024 with the following interventions: -Provide assistance with bed mobility as necessary. Created on: 12/13/2024 -Staff assist of one to provide assist for resident to transfer using a gait belt and walker Created on: 12/13/2024 -Staff to ensure call light is in resident's reach while in room and encourage to use it to make needs known. Created on: 12/13/2024 Surveyor was unable to locate documentation of Staff assist to transfer on/off toilet per mobility section of this Care Plan information in the mobility section of R1's care plan. R1's Falls care plan: I am at risk for falls due to declining mobility, chronic respiratory failure was created on 12/13/2024 and initiated on 12/19/2024 and has the following pertinent interventions: -Fall risk evaluation on admission, quarterly, and PRN. Post fall evaluation PRN. Created on: 12/19/2024 -Monitor for side effects of medication: *Cardiac medication as ordered. Monitor weekly vital signs and labs as ordered. *Psychotropic medications as ordered. BIMS evaluation, sleep log, and behavior monitoring per protocol. *Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respirations, and report to NP/PA/MD. Created on: 12/19/2024 -PT to eval and treat per hospice orders and company. Created on: 01/20/2025 o RESOLVED: Toileting per urinary/bowel section of this care plan. Created on: 12/19/2024 R1's care plan for I require a Transfer Restorative Nursing Program due to weakness was initiated on 12/20/24 with the following interventions: -Refer to Therapy if needed. Created on: 12/20/2024 -RN to evaluate the Restorative Nursing Program periodically and make changes if indicated. Created on: 12/20/2024 -Staff report changes in resident participation to nursing staff. Created on: 12/20/2024 R1's care plan for I require an ambulation Restorative Nursing Program due to weakness was initiated on 01/17/2025 with the following interventions: -Refer to Therapy if needed. Created on: 01/17/2025 -RN to evaluate the Restorative Nursing Program periodically and make changes if indicated. Created on: 01/17/2025 -Staff report changes in resident participation to nursing staff. Created on: 01/17/2025 Surveyor noted restorative walking was the intervention that was added after R1's 1/5/25 fall but was not added to R1's care plan until 1/17/25. R1's care plan for I require an AROM Restorative Nursing Program due to weakness was initiated on 12/20/2024 with the following interventions: -Refer to Therapy if needed. Created on: 12/20/2024 -RN to evaluate the Restorative Nursing Program periodically and make changes if indicated. Created on: 12/20/2024 -Staff report changes in resident participation to nursing staff. Created on: 12/20/2024 Surveyor noted the post fall interventions for R1's toileting plan and call don't fall signs were not added to the care plan. The admission fall interventions of mat next to bed and bed in lowest position were not located in R1's care plan. Surveyor noted that the admission fall interventions of mat next to bed and bed in lowest position when resident is in it were on the Kardex which is used by Certified Nursing Assistants (CNA) to complete cares for residents. Surveyor noted that the interventions for sign posted call don't fall to remind resident to use call light for safety and toilet resident upon rising before and after meals at HS (bedtime) and prn. Toilet resident upon request were added to the Kardex only and not R1's care plan. Per an interview with the Nursing Home Administrator (NHA)-A on 4/23/25, at 12:16 PM, NHA-A had to reactivate R1's record to print the Kardex for Surveyor which changed all of the dates interventions were initiated to 4/23/25. R1's physician order dated 12/16/25 documents: Oxygen on at all times. Every shift. Surveyor noted no liter setting identified, or monitoring of resident oxygen saturation level included with order. R1's admission progress note written on 12/12/2024 documents: Resident is a new admit, from vitas hospice facility . primary diagnosis Pulmonary Heart Disease and Chronic Diastolic Heart Failure . Fall risk due to HX (history) of attempting to self transfer at night. Fall mat on floor and bed in lowest position. Resident is a 1 assist transfer with walker. Resident is on continuous O2 NC (oxygen nasal cannula) at 3L (liters), does take off at time and become Hypoxic with delusions of seeing a women named [NAME]. Resident is Regular diet, thin liquids allergy to lactose. Resident is on Vitas Hospice . resident is continent of bowel and bladder and noted as a fall risk with intervention of fall mat. Surveyor noted R1 was a known fall risk at admission with the interventions of fall mat and bed in low position in place on Kardex, but not in R1's care plan. Surveyor reviewed R1's fall packet for the fall that occurred on 12/21/24 at 3:00 AM. This was an unwitnessed fall in which R1 was noted as attempting to self toilet and was found on the floor next to the bed which was in lowest position with fall mat next to it, call light noted as in reach. Per the report R1 was last toileted at 2:30 AM. An intervention for a toileting plan upon rising, before and after meals, at bedtime, and as needed was initiated on the Kardex, but not to R1's care plan. R1's progress note written on 12/21/2024, at 04:15 AM, documents:: Patient was found in the floor. 'Patient stated was trying to get to the bathroom and fell . Patient states not hitting her head and forgot to press the call light' . Bed was at lowest position floor mat next to bed, call light within reach. R1's interdisciplinary progress note written 12/23/2024, at 10:18 AM, documents:: IDT (interdisciplinary team) team met to review the fall. Intervention put in place to set up toilet plan. Offer toileting upon arising before and after meals before bed PRN and per resident request. Surveyor noted this fall occurred in the early morning, not when the resident was rising for the day. Surveyor noted the toileting plan was added to R1's Kardex but not R1's care plan. Surveyor reviewed R1's fall packet for the fall that occurred on 1/5/25 at 5:15 PM. It was documented that R1 was last seen at 5:10 PM in bed. The CNA reported R1 stated that she got up to move a plant and tripped over her own feet. Then got up, put on call light and laid in bed. An intervention to start restorative walking was initiated. R1's progress note written on 1/5/2025 at 5:56 PM, documents: Resident in bed CNA reports she has a large egg sized swelling of a hematoma to left forehead resident states she fell and got herself back in bed after attempting to move a plant to her dresser. She did not use her walker or use her call light until after the fall. Also she has a skin tear slightly larger than a pea to her left forearm with a hematoma approx (approximately) 1.5 inch in diameter . Hospice notified and they will send out a nurse for further eval (evaluation) . Hospice documented a Focus Visit on 1/5/25 at 9:25 PM, Resident had a fall with a golf ball sized hematoma to the left forehead above the eye with bruising surrounding. Patient rated pain/discomfort at 6/10 and stated that she had 2 more hours before she could have pain medication. MD (medical doctor) was called and gave new pain medication orders. Neuro (neurological) check was negative. ROM (range of motion) per resident baseline. Patient stated that she wanted to move her plants. The hospice Interdisciplinary Plan of Care Revision/Physician Order dated 1/5/25, documents: a change in the morphine order and ice packs to hematoma TID (three times per day) x 2 days for 20 minutes. Surveyor noted the IDT team met on 1/15/25 and determined the intervention of restorative walking was to be added. Surveyor reviewed R1's fall packet for the fall that occurred 1/6/25 at 4:05 AM. It was documented that R1 had an unwitnessed fall while attempting to self toilet. R1 was found on the floor next to R1's bed and fall mat. The CNA documented that the walker was in bathroom doorway and so was O2 (oxygen) cord. It was documented that the last time R1 was toileted was 3:00 AM. The intervention added was call don't fall sign to remind resident for safety. R1's progress note written on 1/6/2025 at 05:00 AM, documents: Staff heard resident calling out 'help.' She was found on the floor in the middle of her room lying slightly on her right side. Her walker and her nasal cannula were both in the bathroom. BP (blood pressure) was 139/63 and heart rate was 123. Spoke with Hospice Nurse and she is aware of VSS (vital signs stable). She stated resident does have a history of orthostatic hypotension and also A.fib (atrial fibrillation). They will send out a Hospice nurse sometime today. Resident denies pain/discomfort. Soft touch call light within reach right by her hand. She was instructed to use it. The interdisciplinary note written on 1/8/2025, at 11:53 AM, documents: The IDT meet to review fall. intervention will post signs call don't fall to remind resident to use call light for safety. Surveyor reviewed R1's fall packet for the fall that occurred on 1/15/25 at 6:45 AM. It was documented that R1 had an unwitnessed fall while attempting to self toilet. R1 was found in the bathroom on the floor. It was documented that R1 was last toileted 2 hours before and last seen 5-10 minutes prior. An intervention to ask hospice physical therapy to work with resident was initiated. R1's progress note written on 1/15/2025 at 07:41 AM, documents: Resident was found sitting on her bathroom floor leaning up against the wall. Her oxygen was on and in place. She stated 'I had to go to the bathroom but I don't know what happened.' Denied hitting her head. Old bruising and old hematoma noted to her L (left) temple and cheek from a previous fall in the recent past. She was incontinent of urine. BP was 99/59 and resident has a hx of Orthostatic Hypotension. She was hoyered back to the bed with assist of 2 . Hospice will be coming in to assess the resident. Hospice documented a Focus Visit on 1/15/25 at 5:45 PM; the Interventions Performed section documents: Patient had a scheduled visit for a follow up fall. Patient denied any pain/discomfort. No new onset of bruising/bleeding noted, VSS and WNL (within normal limits). Patient alert and oriented. ROM (range of motion) per patient baseline. The interdisciplinary note written on 1/15/2025 at 10:58 AM documents: IDT team met to review fall resident is in hospice but still feels like she can get up and wants to maintain as much as her functional status as she can. Resident has states use it or lose it despite education provided to resident to ask for assistance. Intervention: set resident up to work with restorative CNA to help with ambulation. R1's interdisciplinary note written on 1/16/2025 at 08:10 AM, documents: IDT met to review fall. Resident very much thinks she can do more then she can. Call placed to Hospice to get order for PT (physical therapy) eval for safety. Hospice got order and will send out their PT to work with resident. R1's progress note written on 1/17/2025, at 08:37 AM, documents: Hospice called . in regard to resident falling and her last fall on 1/15/2025. The IDT team would like to know about PT eval for safety since resident continues to want to be up and active as much as possible and she has had a few falls. Awaiting a return call from hospice. Surveyor noted that discrepancy of 1/16/25 IDT note reading hospice got order and will send out their PT and the 1/17/25 progress note that facility was awaiting a return call from hospice regarding PT. R1's Hospice documentation Nursing-Updated Comprehensive Assessment, dated 1/17/25, documents: in the Prevent falls section to assess environment, provide frequent checks, anticipate patients needs. Surveyor was unable to locate documentation of hospice providing physical therapy intervention. Surveyor reviewed R1's fall packet for the fall that occurred on 1/21/25 at 7:34 AM. It was an unwitnessed fall. It was documented that R1 states was sitting on edge of bed and slid down. It was documented that R1 was wearing socks, no floor mat was down, the bed was in lowest position. For the question last time resident toilet n/a (not applicable) was the answer. R1's progress note written by LPN-G on 1/21/2025 at 08:43 AM, documents: Resident is on the board for an UWF (unwitnessed fall) this AM shift at 0730. Writer was headed to another room and noticed room [ROOM NUMBER] call light was on. Writer knocked on the door to room [ROOM NUMBER] and resident was sitting on the floor next to bed. Bed was in the lowest position. Floor mat was not in place. Resident was dressed, but no shoes on. Resident had c/o (complaints of) pain to left leg. Left leg appears to be rotated out and shorter than right leg. PRN pain medication given. Writer checked ROM and started neuro checks. Writer called for assistance and CNA helped writer mechanical lift resident back into bed. Resident stated that she slid off the side of her bed onto the floor. X-Ray ordered (#46320150) . R1 was found on the floor by an LPN. The LPN and CNA used a hoyer to get R1 back into bed. A Registered Nurse (RN) did not assess R1 until after the transfer back to bed. R1's progress note written on 1/21/2025 at 11:11 AM, documents: Called trident care for an ETA (estimated time of arrival), ETA is about 11:40 AM. Called POA . Son does not wish for resident to be sent to the ER(emergency room ). Would like to wait for in house X-Ray. Son does not want any surgical intervention just pain management at facility. Called and spoke with . Vitas hospice regarding the above . Hospice stated will be in for a visit shortly. Hospice documented a Focus Visit on 1/21/25 at 12:00 PM, The Interventions Performed section reads writer received call from DON stating patient had sustained a fall with possible hip fracture. DON stated mobile x ray was contacted and awaiting arrival. Writer called family to update and family instructed patient should not go to hospital . instead pain should be managed at facility. Doctor put in orders to increase morphine and add Ativan and senna. Writer went to facility to assess patient's pain level and discovered patient rated pain 20/10 when she is turned. Writer informed doctor and he suggested foley placement . R1's progress note written on 1/21/2025 at 1:20 PM, documents: X-Ray results are fracture of the LEFT femoral neck with displacement of the distal fragment. Femoral head appropriately positioned. Joint space narrowing. Mild soft tissue swelling. ROM intact. Conclusion is Acute, displaced left femoral neck fracture as noted. Hospice updated on X-Ray results. Surveyor noted in just over a month R1 had five falls at the facility. Three were recorded as self transfers to use the bathroom. The post fall statements do not document whether R1 was wearing oxygen at the time of falls, one documents: oxygen line was in bathroom, not on R1. At the time of the last fall, the intervention of floor mat was noted to not be in place resulting in R1 sustaining a displaced left femoral neck fracture. Hospice documented a Psychosocial/Spiritual Updated Comprehensive Assessment on 1/21/25, which reads in part she was participating in facility activities before her recent fall and going out to dining room for meals. The Response to Care section reads bedrest after a fall, sustained left hip fracture. The hospice social worker (SW) added to the comment section, patient sustained a left hip fracture after falling from the bed today. SW met with patient, her son and daughter in law (DIL). Provided emotional support. DIL advised that this was patients 4th fall at this facility. Patient used to fall at home as well despite having a caregiver. Patient was waking up at night to use bathroom without asking for help. R1's progress note written on 1/23/2025 at 09:30 AM, documents: Resident was found pulseless around 0920. Hospice called to notify. Hospice nurse in at this time. R1's interdisciplinary note written on 1/27/2025 at 8:44 PM, documents: IDT met to review fall from 1/21/25 . Documentation was reviewed . Patient was receiving hospice services and POA chose to have no surgical intervention, no hospitalization , comfort measures only. Care plan included morphine for pain management, foley catheter for bladder management, and air mattress replacement for pressure reduction. Surveyor reviewed R1's Medication Administration Record (MAR) and it was documented that the first PRN morphine was administered to resident at 8:14 AM, on 1/21/25, after the fall. None had been administered prior to the fall. On 4/23/25 at 10:56 AM, Surveyor interviewed LPN-G who responded when R1 was found on the floor after R1's fifth fall at the facility. Per LPN-G, the girls came to get LPN-G who called hospice and asked what to do as resident was in a lot of pain. LPN-G got orders from hospice for an Xray. R1's bed was made, R1 was dressed, and laying on the floor. Surveyor asked if a Registered Nurse (RN) assessed R1 and was told guessing somebody from management came in there. Surveyor asked about R1 prior to the fall and was told R1 was active, when R1 would self transfer staff would remind R1 to call for help, up until the last fall R1 could walk with a walker and assist of 1. On 4/23/25 at 10:58 AM, Surveyor interviewed CNA-I who saw R1 on the floor. CNA-I came in at 7 AM that day for work, R1's room door was slightly open, R1 was not up when CNA-I came in. CNA-I went to resident across the hall first because that call light was on. When CNA-I stepped back out in hall, while resident was in bathroom, CNA-I saw the nurse in with R1 who was on the floor. LPN-G was the only nurse to assess R1 before they got R1 off the floor and in bed using a Hoyer lift. Hospice came in and put a catheter in because using the bed pan hurt R1 so much. Staff gave R1 medication for the pain. On 4/23/25 at 11:02 AM, Surveyor interviewed CNA-H who helped Hoyer lift R1 back to bed. It was just CNA-H and LPN-G with R1 until the DON came. There was no fall mat on the floor. On 4/23/25 at 12:38, Surveyor interviewed DON-B who stated they were walking by when staff were getting resident into bed and went in. DON-B assessed resident. Not sure if fall mat was on the floor. Prior to the fall, resident was an assist of one with a walker. After the fall, resident had orders to stay in bed. On 4/23/25 at 1:53 PM, Surveyor interviewed Hospice Manager-J and confirmed R1's admission to hospice was for pulmonary heart disease. Hospice was notified of R1's previous falls and the nurse tried to do education with R1 not to self transfer. Hospice Team Manager-J shared that R1's quality of life changed after the fall. Before that, R1 was an assist of 1, then declined fast after the fall. Hospice Manager-J stated there is a correlation there that the fall expedited R1's death. On 4/23/25 at 2:52 PM, Surveyor interviewed Medical Doctor (MD)-K who stated that R1 had heart and respiratory issues. The last note MD-K had on R1 was dated 1/16/25 and at that time there had not been any changes in R1's condition. R1 had multiple issues, the fall could have accelerated R1's passing of course. Could R1 have lasted longer without the fall, it's possible, but can't say it was the cause of death. Pain control would have been MD-K's recommendation, no surgery at R1's age. On 4/24/25 at 9:32 AM, Surveyor interviewed NHA-A who is part of the interdisciplinary team and decision making for interventions after a fall. After the first fall, R1 stated that R1 still feels can get up and wants to use it so doesn't lose it. As falls progressed, facility felt R1 was so functional that they wanted restorative to help with ambulation and staff to walk with R1 to keep skills up. Surveyor asked why the signs to remind to call when R1 fell at 4 AM. Per NHA-A, R1 had toileted self and was on the way back to bed when fell . After they put R1 in bed they reminded R1 to use the call light and put it by R1's head. They then put the signs up as reminder to call for help. Per NHA-A since R1 was a hospice patient they asked hospice about therapy involvement because R1 is going to try to keep doing this. On 4/24/25 at 12:03 PM, Surveyor interviewed NHA-A regarding why some interventions were on the Kardex but not the care plan. Per NHA-A, nurses were used to putting interventions in the task list with old computer system. In Point Click Care, the new system, it's done differently. They did education with nurses back in July or August. Surveyor notes the training was months before R1 admitted to facility and nurses still weren't doing care plan correctly. On 4/24/25 at 1:20 PM, Surveyor interviewed NHA-A about R1 being monitored for delusions due to hypoxia per the admission progress note and was told that they were not monitoring R1, they had no reason to believe there was an issue. There is no documentation that supports the admission progress note statement about R1 taking off oxygen and becoming hypoxic with delusions. NHA-A was not sure where that came from. Surveyor asked after the 12/21/24 fall the intervention is a toileting plan, how was that assessed for. Per NHA-A, the IDT decided to try to keep R1's bladder empty so R1 wouldn't try to self toilet. The times were picked based on a normal person's needs. Surveyor asked why there was a delay from 1/5/25 to 1/17/25 for restorative ambulation to be added to the care plan. NHA-A cannot answer that, NHA-A was on vacation that week and the old DON must have been catching up on documentation, NHA-A is sure restorative had R1 in their program before the 17th. On 4/24/25 at 1:58 PM, during the exit meeting, Surveyor informed NHA-A, DON-B, the Regional Nurse and [NAME] President of concerns related to fall interventions not in place to prevent R1's fall that resulted in femur fracture. R1 was not assessed by an RN before being moved to the bed after the fall. The Kardex and care plan interventions do not match. Overall, root cause analysis was not used to develop pertinent interventions to prevent R1 from continued falls. No additional information was provided. 21855 2.) R3 was admitted to the facility on [DATE] with a primary diagnosis of parkinsonism. R3's Admission Minimum Data Set (MDS) assessment completed 1/2025 documents that R3 has no cognitive impairment, upper extremity impairment on one side, wheelchair for mobility, does not walk and requires staff assistance with ADLs. R3's Care Area Assessment (CAA) for Falls documents under the Analysis of Findings section: The Fall CAA triggered related to recent fall at home with hospitalization . R3 requires maximum to moderate assist with most ADLs. There were falls reported at home prior to hospitalization and no falls in look back period. On 4/23/25 at 9:30 AM, Surveyor interviewed, and observed, R3 in R3's room. R3 was sitting in their wheelchair with their feet firmly on the ground. R3 had sneakers on their feet. R3 stated they had 2 falls in the facility. The first fall was from the wheelchair. R3 stated the staff told them a driver was here to transport them to an appointment. R3 thought the appointment was a video conference. R3 stated their foot got into the wheelchair wheel and they fell forward. R3 stated they had to get stitches on their head. R3 stated the second fall was from their bed. They remember something fell and they reached for it and kept going. R3 stated they did not have any injuries from the second fall. R3 has not had any falls since then. R3 stated these falls occurred just after their admission to the facility. R3 uses a wheelchair for mobility and requires staff assist with mobility. R3 does not propel self in wheelchair. R3 had a physical therapy evaluation completed on 1/20/25. This evaluation documents: - transfer with 2 staff and Sara Steady (sit-to-stand). - maximum assist with lower and upper dressing. - moderate staff assist with bed mobility. - is a fall risk. - spastic left upper extremity limiting functional ability. R3's progress notes on 2/4/25 at 2:55 PM, by Registered Nurse (RN)-C, document: RN-C was getting shift report and a Transport Driver arrived to pick up R3 for an appointment. They had Certified Nursing Assistant (CNAs) transfer R3 into their wheelchair. One CNA was pushing R3 in their wheelchair to their doorway. The second CNA had the wheelchair pedals in their hands to place on the wheelchair. Then the Transport Driver knocked on the Nurses Station window and told RN-C R3 had fallen. R3 was not sure what happened and just stated they went forward. R3 was bleeding from their forehead. After RN-C assessment, 911 was called, R3 was sent to the hospital. R3's emergency room (ER) record on 2/4/25 documents: R3 fell forward from their wheelchair and hit their forehead on the ground. R3 did not lose consciousness. R3 is on blood thinners. R3 received 4 sutures in their forehead and was discharged back to the facility. R3's Plan of Care (POC) for Falls, created on 1/23/25, with a target date of 4/25/25. Interventions include: -2/5/25 bed in low position with mat on floor next to bed. Clip call light to resident's blanket/gown. (This was added after the fall from the bed.) - 1/23/25 Fall prevention/reduction precautions per facility protocol. - 2/5/25 Foot pedals to be applied (at time of sitting in chair) to wheelchair for out of facility appointments. (This was added from the fall from wheelchair.) -1/23/25 call light in reach. - 1/23/25 Labs when ordered, report abnormal findings to Nurse Practitioner/ Medical Doctor/Physician Assistant. - 1/23/25 Reinforce need to call for assistance. - 1/23/25 Toileting per urinary/bowel section of the care plan. R3's Plan of Care (POC) for Mobility, created on 1/23/25, with a target date of 4/25/25, Interventions include: - 1/23/25 Staff assist of two to transfer resident using the Sara Steady. - 1/20/25 unable to walk. R3 uses a wheelchair for mobility and is wheeled by staff. The wheelchair pedals were not applied with mobility. On 4/23/25 at 12:45 PM, Surveyor interviewed CNA-E. CNA-E was present when R3 fell from their wheelchair. CNA-E was getting R3's wheelchair pedals. R3 was being wheeled out of their room by CNA-D. CNA-E wanted to put the wheelchair pedals on in the hallway. CNA-E did not see what caused R3 to fall forward. The CNA-E typically applies wheelchair pedals. R3 fell before they could apply them. On 4/23/25 at 12:53 PM, Surveyor interviewed CNA-D. CNA-D stated they were wheeling R3 out of their room. They wanted to apply the wheelchair pedals in the hallway. CNA-D stated R3 just fell forward. They thought R3 passed out or something. R3 is alert and oriented, and did not say anything. CNA-D does not know how R3 fell out of the wheelchair. CNA-D stated CNA-E was behind them with the wheelchair pedals. CNA-D stated it happened fast and they could not stop R3 from

Based on observation, interview, and record review, the facility failed to ensure a licensed practical nurse (LPN) classified an incident in which a resident was found on the floor beside their bed as a fall for 1 (R1) of 4 sampled residents reviewed for accidents. As a result, the LPN did not implement all post-fall protocols in accordance with facility policies and practices, including the completion of a post-fall evaluation, a post-fall fall risk evaluation, immediate initiation of a fall investigation, communication of a fall to the oncoming shift, and listing the fall on the facility's fall tracking log. In addition, the facility failed to ensure certified nursing assistants (CNAs) transferred a resident using a Hoyer lift (a type of full-body mechanical lift) per the resident's assessment and plan of care for 1 (R2) of 4 sampled residents reviewed for accidents. Findings included: An undated facility policy titled, Falls Management and Prevention, revealed, Purpose: Fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. The section of the policy titled, Post Fall Procedure indicated, 12. The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions. 13. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. 14. Documentation of the above items is completed. The policy defined a fall as an unintentional change in position coming to rest on the ground or onto the next lower surface (e.g. [exempli gratia, for example] onto a bed, chair or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. An undated facility document titled, HELP I'VE [I have] FALLEN .NOW WHAT?? revealed, as you walk by a room, you glance and see a resident on the floor next to their bed, in the bathroom, dining room, etc. [et cetera, other similar items] What do you do now?? DON'T PANIC! Just follow these simple steps. This document indicated nurses should, -Complete a progress note, risk management assessment, fall risk assessment, and place the resident on the 24 hour report [a report used to communicate information from shift to shift]. The document indicated nurses should also, Obtain statements from all staff on duty and attach them to the fall report and place them under the DON [Director of Nursing] door. A facility policy titled, Accident / Incident Occurrence- Fall Response, dated 09/26/2018, revealed, The purpose of this procedure is to provide guidelines for assessing a resident after an accident/incident occurrence and to provide guidance in investigating the root cause(s) of the accident/incident. The policy indicated, 2. Investigate Fall Circumstances a. After evaluating and treating the resident, the licensed nurse will initiate an investigation at the time of the fall, evaluating chains of events or circumstances preceding a fall to identify possible or likely causes of the incident. 1) The licensed nurse should talk with the nursing assistant who was assigned to the resident at the time of the fall 2) The staff person that discovered or witnessed the fall should draw the fall scene using stick figures. 3)They should brainstorm together to determine likely causes 4) Re-enacting the incident may be necessary to evaluate the situation more thoroughly. It is critical that the investigation occurs immediately so that valuable clues are not missed. The policy further indicated, 3. Record Circumstances, Resident Outcomes and Staff Response a. The licensed nurse will initiate the Risk Management (SNF [skilled nursing facility]), Incidents (AL) process. b. A progress note should be written by the licensed nurse/s describing the accident/incident in its entirety. The policy specified, d. The incident/accident is added to the monthly incident log for further review by the Falls Management Program team and for QAPI (Quality Assurance and Performance Improvement) analysis/statistics. 1.) R1's Admission Record revealed the facility admitted the resident on 12/04/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified dementia, personal history of pathological fracture, orthostatic hypertension, repeated falls, dizziness and giddiness, vertigo, age-related osteoporosis, and other specified disorders of bone density and structure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. According to the MDS, the resident had no functional impairment in range of motion, used a walker and a wheelchair for mobility, and transferred from one surface to another with supervision or touch assistance. Per the MDS, the resident had sustained one fall without injury since their prior assessment. R1's Care Plan included a focus area, initiated on 12/13/2023, that indicated the resident was at risk of for falls related to dementia, orthostatic hypotension (low blood pressure upon standing), and a history of falls. An intervention dated 12/13/2023 directed staff to follow the facility's fall protocol. An undated facility document titled, Investigation Summary for [R1], signed by the Director of Social Services (DSS), revealed on 05/08/2024, R1 had complaints of pulled muscle pain in their groin area. Per the document, on 05/09/2024, the DSS began collecting statements from staff who worked with the resident, and CNA E reported they found R1 on the floor on 05/07/2024 around 7:20/7:30 PM. The document also indicated that the resident's assigned CNA on the evening of 05/07/2024 was CNA K. According to the summary, CNA K reported she had assisted the resident to bed sometime around 7:00 PM and had not witnessed a fall or assisted in getting the resident off the floor. CNA K reported she was informed of the fall by LPN D, who indicated she was completing the fall incident report. However, the document further indicated that LPN D denied knowledge of a fall in her initial statement and during subsequent follow-ups. The document indicated, It was determined that [LPN D] did not follow the standard of care management protocol when a resident has a fall. A May 2024 [NAME] Oaks Falls Tracking log did not reflect a fall involving R1 on 05/07/2024, when the resident was found on the floor by staff. R1's Progress Notes revealed a Health Status Note, documented by LPN D on 05/07/2024 at 10:16 PM, that indicated LPN D observed the resident climbing into [his/her] bed, and the resident reported they went to the bathroom and were getting back into bed but thought they may have pulled a muscle in their left inguinal region. While the note reflected the resident was assessed and the resident's bed was low to the floor, a fall mat was in place beside the bed, and the resident's call light was within reach, LPN D's documentation did not specify the resident was found on the floor or sustained an unwitnessed fall. Continued review of R1's Progress Notes revealed no evidence LPN D immediately initiated a fall investigation or began gathering statements from staff, as directed by the facility policy. There was also no indication a post-fall evaluation tool, post-fall fall risk assessment, and risk management assessment were completed related to R1 being found on the floor by staff on 05/07/2024. An email from CNA E to the DSS, sent on 05/13/2024, revealed CNA E provided a typed accounting of her knowledge regarding the incident involving R1 on 05/07/2024. Per the email, CNA E reported R1 was not technically on her assignment list for the day but she did help the resident to the bathroom a few times during the shift. CNA E indicated that later in the evening, after the resident had already been put to bed, she heard the resident screaming for help, and the resident told her they had fallen. CNA E said she saw the resident on the floor near their bed, and the resident told her they fell approaching their bed after toileting themselves independently. CNA E indicated LPN D, and other staff arrived to the room shortly after, and R1 denied pain multiple times. The email further indicated CNA E reported it seemed as though the other staff involved did not feel the need to consider the incident a fall, because the resident had been experiencing multiple falls. CNA E indicated she did not feel she was responsible for saying anything about that because LPN D was also present and as a nurse, knew more about the procedures for falls. During a telephone interview on 06/04/2024 at 10:45 AM, CNA E confirmed she found R1 on the floor sitting by their bed on 05/07/2024. CNA E indicated staff notified LPN D the resident was on the floor again. An Investigation Statement of Staff from LPN D, dated 05/08/2024, revealed LPN D reported she observed R1 climbing around in bed on 05/07/2024, and the resident said they thought they may have pulled a muscle in their left groin. Per the statement, LPN D assessed the resident with no injuries noted and notified the physician and the resident's family. During a telephone interview on 06/03/2024 at 7:12 PM, LPN D stated she remembered R1. LPN D indicated R1 had just moved to the long-term care unit from the rehabilitation unit. LPN D said R1 climbed in and out of bed and got up and down all night long, and the aides had to assist the resident numerous times because the resident was out of bed. LPN D said R1 did not have a fall on 05/07/2024, to her knowledge, but then stated the resident was on the floor on a fall mat. LPN D again stated she did not think the resident fell , but confirmed she knew the resident was on the fall mat. LPN D said no one told her the resident fell , only that the resident was on the floor. During a telephone interview on 06/03/2024 at 6:36 PM, LPN P stated she was not working on 05/07/2024 but worked on the morning of 05/08/2024. LPN P said when she came onto her shift, LPN D did not report that R1 had sustained a fall. During an interview on 06/05/2024 at 11:10 AM, the Administrator (NHA) stated if a resident had a fall, she expected staff to report the fall to her or the Director of Nursing (DON). The Administrator said when a resident was found on the ground, she expected whoever found them to notify the nurse, and the nurse then obtained statements from any staff with knowledge of the incident. The Administrator said the nurse was responsible for starting the investigation, so they could attempt to determine what caused the fall and implement interventions to prevent further incidents. The Administrator said they should also complete a post-fall evaluation, a risk management assessment, and a new fall risk evaluation. During an interview on 06/05/2024 at 11:37 AM, the DON stated she expected the nurse to immediately begin an investigation if a resident fell . The DON said the nurse should also complete the required assessments, including a post-fall evaluation, a skin check, and a fall risk assessment. The DON said if a resident was found on the floor, it was considered a fall and indicated LPN D knew the definition of a fall. 2. A facility policy titled, Lifting Machine, Using a Mechanical, revised in 07/2017, revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacture's training or instruction. General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing: or f. Repositioning. The policy indicated, Steps in the Procedure 1. Before using a lifting device, assess the resident's current condition including: a. Physical:(1) Can the resident assist with transfer? (2) Is the resident's weight and medical condition appropriate for the use of a lift? b. Cognitive/Emotional: (1) Can the resident understand and follow instructions? The policy directed staff to, Document the following in the medical record: 1. The reason for the transfer. 2. The type of lift used. 3. Equipment size and condition. 4. The names and titles of staff assisting. 5. The resident's physical and mental condition before and after the procedure. 6. How the resident tolerated the procedure. R2's Admission Record revealed the facility admitted on the resident on 04/19/2024. According to the Admission Record, the resident had a medical history that included diagnoses of a displaced fracture of the lateral malleolus of right fibula, unspecified fall, muscle weakness, difficulty in walking, unsteadiness on feet, reduced mobility, need for assistance with personal care, hemiplegia and hemiparesis, morbid obesity, and vascular dementia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2024, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderately impaired cognition. According to the MDS, the resident had a functional limitation in range of motion on both sides of their upper and lower extremities and was dependent on staff for transfers. R2's Assistive Device Evaluation, effective 04/19/2024, revealed the resident could not transfer independently. The evaluation specified the resident was to use a walker with therapy's assistance but was to be transferred using a Hoyer lift by staff on the unit and indicated if the device was not used, the resident would be at risk for falls. R2's care plan included a focus area, initiated on 04/30/2024, that indicated the resident was at risk for falls related to deconditioning and a recent fall while at home. Another focus area, initiated on 04/30/2024, indicated the resident had an activities of daily living (DL) self-care performance deficit related to hemiplegia. The goal included demonstrating appropriate use of adaptive devices to increase the resident's abilities. An intervention dated 04/30/2024 indicated the resident would be evaluated and treated by physical therapy (PT) and occupational therapy (OT) per physician's orders; however, the care plan did not specify how staff should assist the resident with transfers. A Physical Therapy Plan of Care, signed by a physical therapist on 04/21/2024, revealed R2 was unsafe with a walker and various models of sit-to stand mechanical lifts, including an EZ stand lift, and the resident required a Hoyer lift at this time. R2's PT/OT/ST [speech therapy] Recommendations to Caregivers, dated 04/21/2024, revealed PT directed staff to utilize two staff members with a Hoyer lift when transferring R2. An undated facility document titled, CNA ASSIGNMENT [sic] #5, also reflected R2 required two staff and the use of a Hoyer lift for transfers. An Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated 04/26/2024, revealed R2's assigned CNA prepared the resident for a transfer from their wheelchair back to bed using an EZ stand (a type of sit-to-stand mechanical lift). Per the report, during the transfer, the resident had difficulty holding onto the handles of the lift, slid down in the mechanical lift, and ended up sitting on the edge of their mattress. Per the report, the resident did not sustain any injuries, but a post-incident review discovered the resident was supposed to be transferred using a Hoyer lift. During a telephone interview on 06/03/2024 at 10:07 AM, CNA J stated that on 04/26/2024 she and CNA I transferred R2 with a sit-to-stand mechanical lift. CNA J said that during the transfer, the resident started sliding and let go. According to CNA J, the sit-to-stand mechanical lift was approved by therapy, but when asked what R2's care plan reflected for transfer requirements, CNA J said she thought it said Hoyer lift. CNA J said on the day of the incident, she was shown a binder that reflected each resident's transfer requirements. During an interview on 06/03/2024 at 2:14 PM, CNA I stated she remembered the incident involving R2. CNA I said CNA J asked her to assist with transferring R2, and when CNA I asked CNA J what the resident's transfer status was, CNA J said the resident used a sit-to-stand mechanical lift. CNA I indicated she did not know much about the resident, because she had not been assigned to care for them before. CNA I said they used the sit-to stand mechanical lift to transfer R2 from their wheelchair to the bed, but during the transfer, the resident started slipping, and a family member who was also present, held the resident up by their pants to keep them from falling to the floor, while the CNAs maneuvered the resident up onto the bed with the lift. During an interview on 06/03/2024 at 12:10 PM, the Director of Nursing (DON) stated R2 required a Hoyer lift for transfers and had not been assessed to use a sit-to-stand mechanical lift at the time of the incident. During a telephone interview on 06/03/2024 at 6:36 PM, LPN P stated on the day of the incident, the CNAs reported they used a sit-to-stand lift; however, LPN P said she did not think the resident was supposed to be transferred with that type of lift. LPN P said R2 required the use of a Hoyer lift instead. During a telephone interview on 06/04/2024 at 1:03 PM, LPN O stated he remembered the incident involving R2. LPN O said he believed it was a misunderstanding between the CNAs on how the resident was supposed to be transferred. LPN O said the resident was supposed to be transferred using a Hoyer lift, but the CNAs used an EZ Stand lift instead. During an interview on 06/05/2024 at 9:50 AM, the Certified Occupational Therapy Assistant/Rehab Manager (COTA/RM) stated she remembered R2. The COTA/RM said that when R2 first came to the facility, they were very weak and required a Hoyer lift for transfers. She said she was the only PT staff involved when staff transferred R2 using the wrong lift. The COTA/RM said on the day of the incident, staff got her, and when she entered the resident's room, the resident was connected to the EZ Stand lift, and appeared to be sliding down, with their buttocks half-way on the bed. The COTA/RM said that after they got the resident situated in the bed, she notified the Administrator the CNAs used the wrong lift, so that the Administrator could address it with the staff. During an interview on 06/05/2024 at 11:10 AM, the Administrator stated she expected staff to follow the care plan and expected a resident's assigned CNA to know how to care for the resident. During an interview on 06/05/2024 at 11:37 AM, the DON stated CNAs should know their residents before they transferred them. The DON further stated CNAs could always check and verify the appropriate mode of transfer if there was a question.

Based on interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R2) of 3 Residents reviewed for pressure injuries. R2 developed a coccyx pressure injury which was identified on 12/03/22. The treatment was not implemented until 12/05/22. On 12/06/22, Facility staff assessed R2's pressure injury and incorrectly staged the pressure injury as Stage 2 when there was 70% slough. R2's pressure injury continued to be incorrectly staged, the care plan was not revised after R2 developed the pressure injury, and R2's heels were observed not being offloaded according to the plan of care. Findings include: R2's diagnoses include unspecified protein calorie malnutrition, dementia, anxiety, depressive disorder, and peripheral vascular disease. R2 started receiving hospice services on 11/28/22. The risk for pressure ulcers care plan initiated 5/11/17, includes the following interventions: * Air mattress: ensure is on and functioning properly. Dated 8/19/17. * Cleanse perineal area well with each incontinence episode. Dated 5/11/17. * Consult Dietitian for nutritional assessment, and MD (medical doctor) if impaired skin integrity is noted. Dated 5/11/17. * Elevate heels off bed. Dated 1/26/21. * Monitor skin weekly on scheduled bath day to assure skin remains intact. Dated 5/11/17. * Offer afternoon nap, encourage side lying position to relieve pressure off coccyx dated 8/1/21 & revised 8/23/21. * Record percentage of meal consumed. Dated 5/11/17. * TX's (treatments) per MD order. Dated 5/11/17. The kardex as of 1/3/22 under skin section documents * Elevate heels off the bed. Not dated. * Ensure air mattress is on and working. Dated 5/1/2022. * MONITOR - Turn and Reposition Q2Hr (every two hours). Dated 10/17/19. * Monitor for changes in skin integrity. Not dated. * Offer afternoon nap. Encourage side-lying position to relieve pressure off coccyx. Dated 3/26/2021. The skin only evaluation dated 11/21/22 documents Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue: #001: Needs Review. Issue type: Redness. Location: Buttocks - generalized. Painful: No. Skin note: Bed bath given per resident request. Redness to buttocks present; cream applied. Completed Clinical Suggestions: Surveyor noted there is no documentation after completed clinical suggestions:. The Braden assessment dated [DATE] documents a score of 12 which indicates high risk. The skin only evaluation dated 11/28/22 documents Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue: #001: Needs Review. Issue type: Redness. Location: Buttocks - generalized. Painful: No. Completed Clinical Suggestions: Surveyor noted there is no documentation after completed clinical suggestions:. The significant change MDS (minimum data set) with an assessment reference date of 12/1/22, documents a BIMS (brief interview mental status) score of 2 which indicates severe impairment. R2 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet use, requires supervision with one person physical assist for eating, is always incontinent of urine & occasionally incontinent of bowel. R2 is at risk for pressure injuries and is coded as not having any pressure injuries. The nurses note dated 12/3/22, at 6:39 p.m., documents, Resident noted to have a stage 2 pressure ulcer during cares tonight above the coccyx area. Weight off loaded to her side using a pillow. [Name of] hospice nurse notified. Nurse will be out this evening to assess. There was no revision in R2's at risk for pressure ulcer care plan after R2 developed a stage 2 coccyx pressure injury. The nurses note dated 12/4/22, at 6:30 a.m., documents, Alert. Has pressure ulcer to coccyx site. Cream applied. Site is clean with no bleeding. No pain and or itching. VSS (vital signs stable). The nurses note dated 12/4/22, at 1:57 p.m., documents, Writer was told by the last shift nurse that a Hospice RN (Registered Nurse) was coming today to eval resident's coccyx wound. No one has come to the facility yet; awaiting Hospice nurse. Drsg (dressing) in place is clean, dry, and intact. The nurses note dated 12/4/22, at 4:44 p.m., documents, Hospice nurse in to assess open area on coccyx. Wound size is 2.0 cm (centimeter) x 1.0 cm. Treatment orders received and placed in orders in TAR (treatment administration record). There was no revision in R2's at risk for pressure ulcer care plan. The nurses note dated 12/4/22, at 6:35 p.m., documents, Foam dressing applied to open wound above coccyx. Area cleansed and resident off loaded coccyx to side with pillow. The physician's telephone orders dated 12/5/22, documents Hospice order: Wound care Change every 72 hr (hour) & PRN (as needed). Cleanse coccyx area with mild soap & H2O (water) F/B (followed by) N/S (normal saline) wound cleaner. Pat dry with gauze. Apply skin prep/therahoney if indicated. F/B optifoam. Surveyor noted this is two days after R2's pressure injury was identified. Review of R2's December 2022 TAR (treatment administration record) reveals the coccyx treatment started on 12/5/22. There were no other coccyx treatments documented on R2's December 2022 TAR. The nurses note dated 12/5/22, documents Resident remains on 24 hour report for O/A (open area) on coccyx. Dressing CD&I (clean dry and intact). No drainage noted. Wound care weekly and PRN (as needed). Reposition with rounds when in bed. Denies any pain or discomfort. The physician note dated 12/5/22, documents Patient with decline, weight loss. Now on hospice care. Appetite poor. Denies pain. No fevers or chills. No CP (chest pain), palpitations, or dizziness. No SOB (shortness of breath), DOE (dyspnea on exertion), or cough. No N/V (nausea/vomiting) or abdominal pain. No signs or symptoms of GI (gastrointestinal) bleed. No dysuria or hematuria. No agitation or anxiety. Surveyor noted this physician note does not include R2's pressure injury. The nurses note dated 12/6/22, documents Resident is being monitored for stage 2 PI (pressure injury) to coccyx. Wound rounds were completed today by DON (Director of Nursing) and CCMs (Clinical Care Managers). Dressing completed by them today. Resident has lower intake and is currently on hospice. Resident has air mattress on bed at this time. Cushion in w/c (wheelchair). Resident lays down after every meal per request. The wound assessment dated [DATE] for week 1 documents Stage/type as 2. Measurements for length are 2.3, width 1.7, and depth 0.1. Exudate is serosangious. For tissue type, color/percent/location is checked for granulation 30% & slough 70%. The wound margins is defined and surrounding tissue intact. The current treatment documents cleanse/SP (skin prep) or therahoney as indicated f/b (followed by) optifoam at HS (hour sleep) MWF (Monday, Wednesday, Friday). Current prevention interventions documents frequent turns while in bed (refuses frequently), nutritional or medical interventions ensure 4 oz qid (four times daily). Surveyor noted R2's pressure injury was incorrectly staged as a Stage 2 pressure injury does not have slough and 70% slough would be unstageable. There was no revision in R2's at risk for pressure ulcer care plan after this assessment. The late entry nurses note dated 12/7/22, documents Resident was seen for unit wide skin assessment on 12/6/22. Continued recent stage 2 PI to coccyx area measuring 2.3 x 1.7 x 0.1. Resident recently joined [name of] hospice and has orders as follows: HOSPICE ORDER: Cleanse coccyx area with mild soap and water/NS wound cleaner. Pat dry with gauze. Apply Skin prep/Therahoney if indicated. Apply Optifoam dressing. Change Q72 hr and prn at bedtime. Will follow with weekly wound rounds. The wound assessment dated [DATE], for week #2 documents Stage/type as 2. Measurements for length are 1.8, Width 1.6, and Depth 0.1. The tissue type, color/percent/location is checked for granulation 100%,. The wound margins are defined & surrounding tissue is intact. For current treatment & current preventative interventions Same is documented. Surveyor noted R2's pressure injury continues to be incorrectly staged as 100% granulation tissue would be a Stage 3. There was no revision in R2's at risk for pressure ulcer care plan after this assessment. The wound assessment dated [DATE], for week 3 documents Stage/type 2. Measurements for length are 1.0, width 0.7, and depth 0.1. The tissue type, color/percent/location is checked for 100% granulation. The wound margins are defined & surrounding tissue is intact. For current treatment & current preventative interventions Same is documented. Surveyor noted R2's pressure injury continues to be incorrectly staged and there was no revision in R2's at risk for pressure ulcer care plan after this assessment. The wound assessment dated [DATE], for week 4 documents stage/type 2. Measurements for length are 0.4 & width 0.2. The tissue type, Color/percentage/location checked for 50% epithelial & 50% granulation. The wound margins are defined & surrounding tissue intact. For current treatment documents cleanse/SP/Optifoam Q72 hours and PRN (as needed). The current preventative interventions document Frequent Repo. (repositioning) Nutritional and/or medical interventions ensure 4 oz QID. Surveyor noted R2's pressure injury continues to be incorrectly staged and there was no revision in R2's at risk for pressure ulcer care plan after this assessment. The wound assessment dated [DATE], for week 5 documents Stage 2. Measurements for length are 1.8 & width 0.6. For tissue type color/percentage/location checked for 100% epithelial. The periwound wound margins are closed & surrounding tissue is discoloration. For current treatment is cleanse/sp/optifoam Q72 hours & prn. The current preventative interventions documents frequent repo/cover for protection. Nutritional and/or medical interventions documents ensure qid 4 oz (ounce). Surveyor noted R2's pressure injury continues to be incorrectly staged and there was no revision in R2's at risk for pressure ulcer care plan after this assessment. On 1/3/23, at 9:27 a.m. Surveyor asked RN (Registered Nurse)-F if there are any residents on the unit with pressure injuries or any other skin concerns. RN-F informed Surveyor [name of R2] has Stage 2 pressure injury on the coccyx. Surveyor inquired if this pressure injury was facility acquired or was R2 admitted with the pressure injury. RN-F informed Surveyor facility acquired. On 1/3/23, at 9:33 a.m., Surveyor observed R2 in bed on her right side, head of the bed elevated, and on an air mattress. R2 asked Surveyor when are they going to get her up. On 1/3/23, at 9:48 a.m. Surveyor observed R2 propelling her high back wheelchair by moving her feet down the hallway. Surveyor observed there is a cushion in the wheelchair. On 1/3/23, at 10:33 a.m., Surveyor observed R2 sitting in a high back wheelchair in the hallway opposite the nurses station. On 1/3/23, at 11:16 a.m., Surveyor observed R2 continues to be sitting in a high back wheelchair in the hallway adjacent to the nurses station. On 1/3/23, at 12:23 p.m., Surveyor observed CNA (Certified Nursing Assistant)-H with gloves on place a gait belt around R2 and transfer R2 from the wheelchair into bed. CNA-H lowered R2's pants, unfastened the incontinence product, removed a disposable wipe from the container and wipe R2's frontal perineal area. R2 was positioned on her side and CNA-H wiped R2's rectal area with a wipe. Surveyor observed there was a foam dressing dated 1/3/23 on R2's coccyx area. CNA-H placed an incontinence product under R2 told R2 she could go back, fastened the incontinence product & pulled up R2's pants. CNA-H placed a pillow under R2's lower legs. Surveyor observed R2's heels are resting directly on the pillow. CNA-H covered R2 with a blanket, placed a body pillow along the right side, removed R2's glasses, lowered the bed, elevated the head of the bed and placed the call pad within reach. On 1/3/23, at 2:22 p.m., Surveyor observed R2 continues to be in bed on her back. Surveyor observed R2's heels are not being offloaded. On 1/4/23, at 7:33 a.m., Surveyor asked CNA-I if R2 usually lays down after breakfast. CNA-I informed Surveyor R2 lays down after breakfast, gets up for lunch, then lays down after lunch. Surveyor inquired if she got R2 up this morning. CNA-I replied no and explained third shift got R2 up. On 1/4/23, at 7:36 a.m., Surveyor observed CNA-I place a bath blanket on R2's bed and place gloves on. CNA-I placed a gait belt around R2 and transferred R2 onto the bed. CNA-I removed the gait belt & R2's shoes and then swung R2's legs so R2 was laying on her back. CNA-I placed a pillow under R2's calves and placed gripper socks on R2. Surveyor observed R2's heels are resting directly on the pillow and are not being offloaded. CNA-I covered R2 with a blanket, placed a body pillow along the right side, elevated the head of the bed, provided R2 with a drink of water, placed the bed in the low position and placed the call light in R2's reach. On 1/4/23, at 9:31 a.m., Surveyor observed R2 continues to be in bed on her back and R2's heels are not being offloaded. On 1/4/23, at 12:52 p.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. There is a pillow under R2's lower legs. R2's heels are resting directly on the pillow and are not being offloaded. On 1/5/23, at 8:28 a.m., Surveyor observed R2 in bed on her right side with the air mattress on. On 1/5/23, at 8:31 a.m. Surveyor asked CNA-N if CNA-N could accompany Surveyor to R2's room. Surveyor asked CNA-N to lift R2's bedding so Surveyor could observed R2's feet. Surveyor observed R2 is wearing stockings on her feet and R2's heels are resting directly on the mattress. On 1/5/23, at 11:20 a.m., Surveyor asked RN (Registered Nurse)-F if R2's heels should be offloaded. RN-F replied yes and explained they put a pillow under her knees. Surveyor informed RN-F of the observations of R2's heels not being offloaded. On 1/5/23, at 11:37 a.m., Surveyor asked CNA-G if R2 likes to lay on her side. CNA-G replied no not really and explained she likes to lay on her back with pillows on each side of her. On 1/5/23, at 12:23 p.m., Surveyor met with DON (Director of Nursing)-B to discuss R2's pressure injury. Administrator-A was also in the office during this time. Surveyor asked DON-B how R2 developed the coccyx pressure injury. DON-B informed Surveyor R2 is on hospice, spends most of the day in bed, they encourage turning and repositioning but R2 often refuses. DON-B informed Surveyor this area has opened in the past and they had a covering for protection. Surveyor informed DON-B Surveyor didn't note any order or documentation in the TAR (treatment administration record) regarding a dressing for protection. DON-B informed Surveyor they may have taken the order out when there was a change. DON-B looked at R2's electronic medical record and informed Surveyor there was an order in 5/13/18 for skin prep and an dressing but that was for an open area. Surveyor asked DON-B to look at R2's October & November 2022 TAR for the protection treatment. DON-B informed Surveyor the protection treatment was discontinued 8/22/22 and they just had on an air mattress and try to do frequent repositioning. DON-B informed Surveyor they have a body pillow on both sides, R2 won't let them turn her terribly far, she is one that eats breakfast and then goes back to bed and does the same for lunch. Surveyor asked DON-B when she did the assessment on 12/6/22 why did she stage the pressure injury as stage 2? DON-B replied because it was open with slough in there & staged as stage 2. Surveyor informed DON-B the pressure injury was incorrectly staged as 70% slough should have been staged as unstageable. DON-B informed Surveyor the next week was granulation so it was a Stage 2. Surveyor informed DON-B there is not granulation tissue in a Stage 2 and should have been a Stage 3. Surveyor informed DON-B Surveyor was unable to locate any revisions in R2's at risk for pressure ulcer care plan. Administrator-A informed Surveyor she does not see a revision. Surveyor informed DON-B and Administrator-A of the observations of R2's heels not being offloaded according to the plan of care. On 1/9/23 the Facility emailed the following: 12/5/2022 note from [Name] ON CALL VISIT R/T TO WOUND TO COCCYX - PATIENT IN BED ON ARRIVAL - PATIENT A/O X 1 TO SELF, NO S/S OF PAIN OR SOB. PATIENT ANSWERING QUESTIONS APPROPRIATELY, VSS TAKEN AND NOTED. SKIN ASSESSMENT COMPLETED, UNSTAGEABLE WOUND TO COCCYX MEASURING APPROXIMATELY 2.0CM X 1.0CM WOUND COVERED WITH YELLOW SLOUGH. WOUND CARE ORDER OBTAINED. PATIENT BECAME EXTREMELY AGITATED MIDWAY THROUGH WOUND ASSESSMENT AND REFUSED WOUND CARE TO BE COMPLETED. WRITER UPDATED FACILITY NURSE [name] OF PATIENTS REFUSAL TO WOUND CARE. PATIENT WELL PALLIATED AT END OF VISIT. WRITER UPDATED RN CM VIA TEAMS. This information does not change the deficient practice.

Based on observation, interview and record review, the facility did not ensure that 1 (R1) of 3 residents reviewed had adequate supervision and assistive devices to prevent accidents. On 5/3/18, R1 eloped from the facility in her wheelchair and rolled down the driveway of the carport near the facility's entrance, falling face first onto the pavement at the bottom of the driveway. As a result of the fall, R1 suffered a head injury, a non-displaced bone fracture and lacerations that required stitches. The facility's subsequent investigation revealed that R1 was able to elope from the facility because facility staff did not, in accordance with R1's plan of care, place a wanderguard on R1 when R1 returned from the hospital on [DATE]. In addition, LPNs (Licensed Practical Nurses) G, H, and I failed to ensure R1 had a wanderguard bracelet in place and functional on 5/2/18 and 5/3/18. LPNs G, H, and I incorrectly assumed the wheelchair with a wanderguard bracelet on it outside R1's room belonged to R1. The Facility's failure to ensure that R1 received adequate supervision and assistive devices to prevent accidents created a finding of Immediate Jeopardy beginning on 5/2/18. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy finding on 5/18/18 at 10:04 a.m. On 5/4/18, the facility had recognized the deficient practice and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the Immediate Jeopardy was removed and corrected on 5/4/18. This is being cited as past noncompliance. Findings include: The facility's policy dated as revised (MONTH) 2014 and titled Wandering, Unsafe Resident documents under the Policy Statement, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Under the Policy and Interpretation and Implementation section it documents, 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement); 3. The staff will apply a wanderguard for residents at risk for wandering, initiate a daily wanderguard check off form and place the form in the Wanderguard Binder; 6. A missing resident is considered a facility-wide emergency. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Falls Care Plan dated 9/3/17 documents, Ensure Bed and chair alarm are on and functioning every shift. Ensure wanderguard is on at all times. R1's nursing note dated 9/7/17 documents that R1 was found wandering outside in the courtyard (which was enclosed within the facility) and brought back into the facility. R1's Quarterly MDS (Minimum Data Set) dated 2/28/18 documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R1 is severely cognitively impaired. The Quarterly MDS Section G (Functional Status) documents that R1 requires supervision and a one person physical assist for her ambulation needs in her room and in corridor. Resident's Wandering assessment dated [DATE] documents a score of 9, indicating that R1 is at moderate risk for wandering. Resident's Falls Risk assessment dated [DATE] documents a score of 20, indicating that R1 is at high risk for falls. R1's (MONTH) (YEAR) TAR (Treatment Administration Record) documents the following order Check wanderguard placement/function every shift . Surveyor noted that on 5/2/18, facility staff documented R1's wanderguard as in place for the Day, Evening and Night shift. Surveyor noted that on 5/3/18, facility staff documented R1's wanderguard as in place for the Day shift. R1's nursing note dated 5/3/18 written by RN (Registered Nurse)-C and titled, Falls with Detail documents, Describe what happened: Patient (R1) wandering unit per usual, was brought back near fish tank at about 8:05 PM .By 8:15 PM R1 had left the area, CNAs (Certified Nursing Assistants) went looking for her and found her outside, about halfway down the hill to the entrance of (the) building, wheelchair behind her, patient lying face down on asphalt; medications: [REDACTED]. R1's Fall Investigation Report dated 5/3/18 documents, Incident Description: Patient found by CNA outside, halfway down hill of entrance, wheelchair had tipped forward and patient lay on asphalt face first; Notes: Patient with large hematoma to right forehead, laceration to right cheek, large skin tear to left outer elbow. Under the Notes section the Fall Investigation Report documents, IDT (Interdisciplinary Team) reviewed elopement and fall. RN-C reported resident did not have a wanderguard applied when fall occurred. DON (Director of Nursing)-B spoke with LPN (Licensed Practical Nurse)-F who was working on 5/2/18, who verbalized she (LPN-F) sent resident out to the hospital after (a) fall occurred on 5/2/18. LPN-F reported she forgot to apply the wanderguard when resident returned from the hospital. A fall statement from RN-C included as a part of R1's Fall Investigation Report dated 5/3/18 documents, Location of fall: Outside facility main doors; 2. Where was resident prior to fall? Nurse's station then (by) fish tank; 8. When & where did you last see the resident? By nurse's station (at) 8:00 PM; 10. Were there any environmental factors involved? No wanderguard in place.' A fall statement from CNA-D included as a part of R1's Fall Investigation Report dated 5/3/18 documents, Location of fall: Parking lot; 2. Where was resident prior to fall? Sitting at the nurse's station; 8. When & where did you last see the resident? 7:40 PM at the nurse station; 10. Were there any environmental factors involved? No wanderguard in place. A fall statement from CNA-E included as a part of R1's Fall Investigation Report dated 5/3/18 documents, Location of fall: Parking lot; 2. Where was resident prior to fall? Sitting at the nurse's station; 8. When & Where did you last see the resident? 10. Hallway by her room (No time is listed); Were there any environmental factors involved? No wanderguard (in place). The facility's self-report submitted to the State Agency on 5/4/18 documents, R1 eloped out of the facility. She (R1) fell out of her wheelchair and suffered a laceration to her cheek and arm. The facility's self-report submitted to the State Agency on 5/4/18 also included the above staff statements that were included in R1's Fall Investigation Report dated 5/3/18. The facility's self-report submitted to the State Agency on 5/4/18 documents, RE (regarding): R1 Elopement and Fall; Date: 5/3/18; On 5/3/18, RN-C reported to DON-B and Administrator-A that R1 did not have a wanderguard applied when elopement and fall occurred. On 5/3/18, Maintenance checked the wanderguard system after the incident occurred. The wanderguard system was functioning .On 5/4/18, DON spoke with LPN-F who was working on 5/2/17 when R1 was sent out to the hospital to rule out injury after a fall. LPN-F verbalized she sent out R1 out to the hospital after the fall occurred on 5/2/18, and reported she forgot to apply the wanderguard when R1 returned from the hospital. On 5/4/18, DON-B checked the wanderguard documentation to determine if wanderguard checks were completed. Wanderguard checks were completed by nursing staff after resident returned from the hospital on [DATE]. Writer (DON-B) spoke with LPN-G who worked on night shift 5/2/18 regarding if wanderguard was in place when she completed the check on night shift. LPN-G verbalized there was a w/c (wheelchair) in the hallway located close to R1's room. She (LPN-G) verbalized the w/c had a wanderguard on it and she (LPN-G) thought it was R1's wheelchair. She (LPN-G) verbalized she did not realize the w/c was not R1's. LPN-G continued to explain some residents wear the wanderguard on their body, but some have them on their w/c's because they try to take them off, or because they don't like wearing them. Surveyor noted that the facility's self-report identified LPN-H and LPN-I, as also incorrectly assuming the wheelchair outside of R1's room with the wanderguard placed on it was R1's as documented in R1's TAR on 5/2/18 evening shift and 5/3/18 day shift. R1's hospital Patient Discharge Summary dated 5/7/18 documents under the Discharge [DIAGNOSES REDACTED]. Under the Hospital Course section it documents, R1 is a 87 Y (year old) female with h/o (history of) right carotid stenosis, stroke and dementia who presented following a fall. Patient resides at Tudor Oaks long-term care. Reportedly rolled wheelchair outside and had fall from wheelchair. On ASA (aspirin) and [MEDICATION NAME] .CT (Computerized Axial Tomography) head showed traumatic SAH (Subarachnoid Hemorrhage)/IVH (Intraventricular Hemorrhage).Given 1 U (unit) plts (platelets). On 5/17/18 at 11:30 a.m., Surveyor interviewed RN-C regarding R1's fall on 5/3/18. Surveyor asked RN-C if R1 had prior wandering behaviors before R1 eloped from the facility on 5/3/18. RN-C informed Surveyor that RN-C had prior wandering behaviors before R1 eloped from the facility on 5/3/18 and that R1 had recent decline in her health due to R1's recent stroke and dementia disease progression. Surveyor asked RN-C if R1 was wearing a wanderguard when RN-C encountered R1 outside of the facility and on the ground on 5/3/18. RN-C informed Surveyor that when she observed R1 outside on the ground, R1 was not wearing a wanderguard and did not have a wanderguard on her wheelchair. Surveyor asked RN-C if she (RN-C) had assessed R1 on the ground prior to facility staff getting R1 off the ground. RN-C informed Surveyor that she assessed R1 on the ground prior to facility staff getting R1 off the ground. Surveyor asked RN-C how facility staff got R1 off the ground and back into the facility before R1 was sent to the hospital. RN-C informed Surveyor that due to the uneven slope of the ground and battery dying on the Hoyer lift, R1 was lifted by facility staff off the ground and into her wheelchair. RN-C informed Surveyor that once R1 was placed in her wheelchair, R1 was wheeled back into the facility and sent to the hospital via ambulance for further evaluation. Surveyor showed RN-C her statement as documented in facility's self-report dated 5/4/18 and asked RN-C if her statement as documented was accurate. RN-C informed Surveyor that her statement as documented in facility's self-report dated 5/4/18 was accurate. On 5/17/18 at 1:13 p.m., Surveyor interviewed CNA-D regarding R1's fall on 5/3/18. Surveyor asked CNA-D how R1 was found outside on 5/3/18. CNA-D informed Surveyor that R1 was assigned to her (CNA-D) on 5/3/18 and that she (CNA-D) was busy putting residents to bed on the night of 5/3/18. CNA-D informed Surveyor that R1 was next to be put to bed at approximately 8:00 PM and that when she went looking for R1 to put R1 to bed, she was unable to locate R1. CNA-D informed Surveyor that she (CNA-D) and CNA-E then went looking for R1 throughout the facility. CNA-E then observed R1 outside of the facility at the bottom of the carport entrance on the ground. CNA-D informed Surveyor that she observed R1 on the ground face down and bleeding from her face. CNA-D informed Surveyor that CNA-E stayed with R1 while she went to get RN-C whom was inside of the facility. Surveyor asked CNA-D if R1 was wearing a wanderguard when CNA-D found R1 outside and on the ground on 5/3/18. CNA-D informed Surveyor that when she found and observed R1 outside, R1 was not wearing a wanderguard and did not have a wanderguard on her wheelchair. Surveyor asked CNA-D if RN-C had assessed R1 on the ground prior to facility staff getting R1 off the ground. CNA-D informed Surveyor that RN-C assessed R1 on the ground prior to facility staff getting R1 off the ground. Surveyor showed CNA-D her statement as documented in facility's self-report dated 5/4/18 and asked CNA-D if her statement as documented was accurate. CNA-D informed Surveyor that her statement as documented in facility's self-report dated 5/4/18 was accurate. On 5/17/18 at 2:29 p.m., Surveyor interviewed CNA-E regarding R1's fall on 5/3/18. Surveyor asked CNA-E how R1 was found outside on 5/3/18. CNA-E informed Surveyor that R1 was assigned CNA-D on 5/3/18 and that she was informed by CNA-D at approximately 8:00 PM that CNA-D was unable to locate R1. She (CNA-E) and CNA-D then went looking for R1 throughout the facility. CNA-E informed Surveyor that she observed R1, through the large entrance windows, outside of the facility at the bottom of the carport ramp entrance on the ground. CNA-E informed Surveyor that she went outside with CNA-D and observed R1 on the ground face down and bleeding from her face. CNA-E informed Surveyor that she (CNA-E) stayed with R1 while CNA-D went to get RN-C whom was inside of the facility. Surveyor asked CNA-E if R1 was wearing a wanderguard when CNA-E found R1 outside and on the ground on 5/3/18. CNA-E informed Surveyor that when she found and observed R1 outside, R1 was not wearing a wanderguard on her body and did not have a wanderguard on her wheelchair. Surveyor read CNA-E her statement as documented in facility's self-report dated 5/4/18 and asked CNA-E if her statement as documented was accurate. CNA-E informed Surveyor that her statement as documented in facility's self-report dated 5/4/18 was accurate. On 5/17/18 at 2:00 p.m., Surveyor informed DON-B of the above information. Surveyor asked DON-B if through the facility investigation of R1's elopement and fall on 5/3/18, if the facility had confirmed R1 was not wearing a wanderguard at the time of R1's elopement from the facility and subsequent fall at the bottom of the facility's carport entrance. DON-B confirmed R1 was not wearing a wanderguard at the time of R1's elopement from the facility and subsequent fall the bottom of the facility's carport entrance. DON-B informed Surveyor that through staff interview, she was able to determine that facility staff were incorrectly documenting in R1's (MONTH) TAR that R1's wanderguard was in place. DON-B informed Surveyor that after R1's fall the facility implemented new procedures to prevent any further elopements from any other residents at risk for wandering/elopement. The Facility's failure to ensure that R1 received adequate supervision and assistive devices to prevent accidents created a finding of Immediate Jeopardy beginning on 5/2/18 when R1's wanderguard was not placed on R1 upon return from the hospital. Additionally, LPNs G, H, and I failed to check R1's wanderguard was in place and functional on 5/2/18 and 5/3/18. Due to the failure to ensure R1 had a wanderguard placed upon her return from the hospital on [DATE], R1 was able to elope from the facility on 5/3/18 and subsequently experienced a fall with major injury. The facility recognized the deficient practice and took the following corrective steps to remove and correct the Immediate Jeopardy on 5/4/18 when: *On 5/4/18, the facility identified the deficient practice and put in a plan of correction in place that put in place new policies and procedures regarding the identification, placement and labeling of wanderguards for residents at risk of wandering and elopement. *The policy included a labeling of all wanderguards in the facility with resident names to ensure placement and avoid confusion by facility staff conducting wanderguard checks. The Resident Wanderguard binder which contained a list, picture and the location of each resident's wanderguard placement was also implemented to help all staff easily identify and verify the placement of wanderguards for residents at risk of wandering/elopement. *On 5/4/18, the facility began mandatory in servicing for all facility staff regarding the updated Wandering-Unsafe Resident policy which included the above changes. Wanderguard audits and checks of the wanderguard system on a daily basis were also implemented. *On 5/4/18, the facility kept the wood doors leading to the front entrance closed to avoid residents wandering off unit while the facility installed handicap push buttons. Signs were placed on the wood doors stating, Please keep doors closed at all times for the safety of our residents. *During the survey, Surveyor observed handicap push buttons installed, the wood doors leading to the entrance closed and all wanderguard interventions in place for residents at risk for wandering/elopement. *Surveyor observed and reviewed daily wanderguard audit logs and a log of the wanderguard system being tested by maintenance staff on a daily basis. *Through record review, staff interview and observations, it was revealed that staff had received the mandatory training on the updated Wandering-Unsafe resident policy and that staff were knowledgeable about the steps needed to ensure all residents at risk for wandering and elopement had wanderguard interventions in place as of 5/4/18. During the survey, no additional deficient practice was identified regarding accidents, supervisions or elopements of all residents.

Based on record review and staff interviews, the facility did not ensure that 8 out of 8 residents (Resident 1, 2, 3, 4, 5, 6, 7, and 8) who were assessed to be at risk for wandering and wore a Wanderguard alert bracelet were provided with adequate supervision and assistance devices to prevent accidents. 1.) The facility relies on a Wanderguard system to alert staff if a resident exits the facility. On 11/11/14 the facility gained occupancy to a new addition of the health care center. This addition consisted of two new entries to the health care center and a new automatically opening main entrance door to the building. The facility failed to ensure that the Wanderguard system was added to the new entrance/exit doors from the units to the new addition and thus failed to provide full security of the health care center perimeter. On 12/2/14, Resident #1, who was assessed to be at moderate risk for wandering behavior and who wore a Wanderguard alert bracelet, propelled himself in his wheelchair from the living unit of the health center to the new addition and out the front entrance of the building. Resident #1 then propelled himself outside, going over the driveway entrance and down to the sidewalk. Resident #1 tipped over in his wheelchair and was found by construction staff working on a separate part of the building. Resident #1 was noted to have several abrasions, a contusion and laceration to his left forehead, as well as several abrasions near his left eye and dark purple bruising. Several abrasions were noted to his upper and lower extremities. Resident #1 was unable to explain why he wandered outside. Resident #1 was observed to have his Wanderguard bracelet on, but the Wanderguard system was not activated, as there was no Wanderguard activation device installed on the doors to the new addition. Once in the new addition, a resident could leave the facility because there was an unalarmed main entrance door. There was no other system in place to prevent outside elopement. The facility's failure to ensure that they had effective safety and supervision measures in place for the 8 residents identified to be at risk for wandering created a situation of immediate jeopardy that started on 11/19/14 when the facility took occupancy of the new addition. On 1/21/15 at approximately 2:30 p.m., Surveyor # notified Director of Nursing (DON) -B of the determination of immediate jeopardy. The facility removed the immediate jeopardy on 12/31/14. 2.) Based on record review, observation and resident and staff interviews, the facility did not always ensure that 1 of 3 residents (Resident #9) who was assessed to be at risk for falls, was provided with adequate supervision and assistance devices to prevent accidents. Resident #9 resides on Unit 1 of the facility; this building is currently under construction. As part of the construction, the facility was in the process of changing over to a newly purchased nurse call system. On 1/14/15 the existing Nursing Station was relocated to the Unit 1 Conference room and the nurse call light panel was moved to an area in the Unit 1 hallway. On 1/14/15, the contractor for the call light system informed the facility that the nurse call light panel would light up when activated, but would not sound until it was installed properly. The Administrator and the Director of Nursing were not made aware that the nurse call light panel would not sound and no plan of action was put into place to ensure call lights were working through the completion of construction. Resident #9 is at risk for falls. Resident #9's care plan indicates the resident requires assistance with toileting, should have a call light in reach to request assistance, and requires a fall pressure pad alarm on the bed. On 1/15/15, between 10:50 p.m. and 10:57 p.m., Resident #9's call light was put on for assistance with toileting. The call light lit up but the noise activation did not function. There was no staff on the unit to visually see the activated call light and to respond to the call light. Resident #9 attempted to self-transfer to use the bathroom and activated the bed alarm. There were no staff on the unit to hear the activated bed alarm and Resident #9 fell and sustained a laceration adjacent to the right eye and a subdural hematoma. The facility's failure to ensure that adequate staff supervision was provided for the 32 residents who resided on Unit 1 while the facility was in the process of changing over to a newly purchased nurse call system created a situation of immediate jeopardy that started on 1/15/15. On 2/02/15 at approximately 4:00 p.m., Surveyor # notified the Administrator and the Director of Nursing of the determination of immediate jeopardy at a scope and severity of a K (immediate jeopardy/pattern). The facility removed the immediate jeopardy on 1/16/15 when the annunciator part of the call light system was activated by the contractor on at 7:45 a.m. However, the deficient practice continues at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its correction plan related to accidents and supervision. Findings include: 1.) Surveyor # conducted a medical record review of Resident #1 as a result of a complaint stating that Resident #1 had eloped from the facility. Surveyor # did general observations of the environment of the health center and the new addition. According to Director of Environmental Services (DES) - C, the facility gained occupancy of the new addition on 11/11/14. The new addition contained a new therapy area, offices for administrative staff, and an elevator to the assisted living section. Staff began to occupy the new addition on 11/19/14. The new addition could be accessed from the living unit by two entry doors. One was a double door, which was kept open, which led to a short hallway and then turning the corner, proceeds to the hallway containing resident rooms. This double doorway was not visible to staff until you were in the short hallway. The second door was a single door, which was also not visible to staff unless you were in the short hallway and turned to use the doorway. Neither of these doors had a Wanderguard sensor alarm. The new addition had a new entrance/exit door to enter or exit from the facility. This entrance/exit door was a glass sliding door, which automatically opened by sensor, which led out to a driveway that was used for picking up or dropping off residents. This was considered the main entrance to the health center once the addition was occupied for use. This automatic door led out onto a concrete sidewalk in which you could turn and go down 2 sets of concrete stairs out to a parking area or you could proceed over the driveway, onto a walkway with railings and then down to an additional parking area. This area is used by staff and visitors to park and is also the main entry to the health center. This door was not equipped with a Wanderguard sensor. The facility has eight residents whom the facility has assessed as being at risk for elopement and who wear Wanderguard bracelets. One of these was Resident #1, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set (MDS), dated [DATE], Resident #1 has short and long-term memory problems, difficulty focusing his attention, and has moderately impaired cognitive skills. Resident #1 is also noted to need extensive assistance for locomotion on the unit and needs extensive, 2-person physical assistance for transferring. Resident #1 uses his wheelchair as his primary mode of locomotion, has had 1 fall within the month prior to admission to the facility and 1 fall at the facility without injury. On 2/16/14, the facility conducted a wandering assessment, indicating Resident #1 was at moderate risk for wandering. On 2/26/14, the facility placed a Wanderguard alert bracelet on Resident #1, to be worn at all times. The facility continued to assess Resident #1 on a quarterly basis for the potential for wandering; always noting he was at moderate risk for wandering. The most current assessment was on 11/22/14, when the staff assessed Resident #1 to be at moderate risk for wandering due to disorientation, recent death/loss of loved one, ambulating with 1-person assistance, early Dementia and a history of wandering. A review of Resident #1's plan of care showed that Resident #1 had an inability to express emotion, listen and share information due to a hearing deficit. Resident #1 needed staff assistance for all activities of daily living and was at risk for falls related to history of falls, generalized weakness and impaired balance. The plan of care stated Resident #1 recently lost a loved one and spends most of his time looking out the windows. Surveyor # conducted a review of the nursing notes in Resident #1's medical chart, which noted the following: Nursing note dated 12/2/14 at 3:30 p.m.: Resident (#1) observed by construction workers, lying on ground next to his wheelchair. Observed Resident (#1) lying on his left side, with grapefruit size contusion to his left forehead, along with laceration. Resident (#1) is alert and asking for help to get up. Assessed Range of Motion to all extremities- no complaints of pain and no limitations noted. Assisted into wheelchair then transported inside. Applied pressure dressing and ice pack to left forehead. PERL (eye reaction assessment). Hand grasps within normal limits. (Name of) ambulance called to send to emergency room . Resident (#1) is confused per baseline, cannot explain why he wandered outside. He did ask for the bathroom. Observed a bruise and abrasion on his left knee, a nickel size abrasion on his right knee, a bruise on his left 3rd finger and a small cut on his left thumb. Wheezing with minimal activity per baseline due to COPD, Resident's son notified being sent to emergency room for evaluation. Nursing note dated 12/2/14 at 4:48 p.m. states that on 12/2/14 at 3:30 p.m. outside in parking lot near new entrance back of Health Center, Resident (#1) had a fall. Alarm on wheelchair, Wanderguard in place on ankle, exit door was not alarmed-still under construction. Resident (#1) left activity on unit and wandered outside through back entrance, where construction is going on. He fell from his wheelchair and sustained a contusion and laceration to his left forehead, in the parking lot. Construction workers called for help. Resident (#1) has a history of falls, self- transfers, poor memory and safety awareness. Interventions put in place, alarm on wheelchair, Wanderguard in place, stop sign in doorway to exit until construction can hook up alarm system and 15 minute safety checks initiated. Nursing note dated 12/2/14 at 10:00 p.m. states that Resident (#1) returned to facility by Bell ambulance. Resident (#1) had a CT (computed tomography scan) of head and C-spine, which were negative for fracture, hemorrhage, or masses. [DIAGNOSES REDACTED]. Resident (#1) also received an EKG (electrocardiogram) and CXR (chest x-ray) while at the hospital, which were unremarkable. Nursing note dated 12/3/14 at 8:51 a.m. states that Resident (#1) has hematoma left forehead area with abrasion. Tissue not as raised, tender to touch. Will keep dressing on forehead area. Has many abrasions near left eye, has purple dark bruising surrounding socket. Left elbow area had irregular skin tear, covered with steri- strips and Kerlix dressing. Surveyor # noted that according to Accuweather.com, the temperature on 12/2/14 was a high of 35 degrees and a low of 24 degrees on 12/2/14; the day in which Resident #1 eloped outside the building. On 1/20/14 at 9:45 a.m., Surveyor # interviewed Director of Nursing- B in regards to the incident involving Resident #1 on 12/2/14. DON- B stated that Resident #1 had gotten out the front entrance, which is a new addition and did not have an alarm in place yet. Resident #1 had self- propelled from the unit, through the therapy area, out the double doors of the living unit (which were kept opened) and out to the new addition. Resident #1 went out the new building entry doors, which are activated to open automatically with a sensor, through the driveway and out to the sidewalk, where his wheelchair tipped. Construction workers saw Resident #1 lying on the ground and immediately called for help. Facility staff immediately responded. DON- B stated that Resident #1 had never tried to leave the building before; he only wandered about the unit in his wheelchair. DON- B stated that maybe Resident #1 was curious about the construction work that was going on outside. DON- B stated that the previous Administrator immediately called First Defense; which is the alarm installation company, to have alarms placed in the new addition. DON- B stated that she then had the doors to the living unit closed and placed a paper stop sign on the door and a sign saying please keep these doors closed. DON- B stated that she also placed a stop sign on the second door on the other side of the living unit that leads to the new addition. On 1/20/15 at 12:40 p.m., Surveyor # interviewed Administrator- A, DON- B, DES- C and Environmental Services Supervisor (ESS) - D with regard to the new addition and asked why the facility did not have the Wanderguard system in place, providing security to the entire perimeter of the health center. DES- C stated that during the weekly construction meetings they had discussed the need for the doorways to the new addition to be alarmed, but there had not been an order to move the existing Wanderguard device from the previous entrance to the new entrance and to place a new device on the second doorway. DON- B stated that staff and residents did not physically have access to the new addition until November, and once they had access, they closed off the old main entrance for construction and the new main entrance was in use. DON- B confirmed that residents have access to come over to the new area in order to visit with staff, use of the therapy area, and use of the main entrance to leave the building. Surveyor # asked what measures were put in place to provide safety and supervision to those residents who wander, once they knew on 12/2/14 that residents could get out of the building through the new entrance and the Wanderguard alarm would not sound. DON- B stated that she immediately closed the doors to the living unit (doors were not locked), placed a paper stop sign on the doors and a sign asking for the doors to remain closed at all times. DON- B stated she also sent an email to staff stating "Please keep doors closed by both new entrances to the new area (back by 133 and by 115) at all times. Also please keep an extra alert to the residents who may wander toward the new main entrance as these doors are not secure at this time." ESS- D stated that on 12/3/14, at the morning stand-up meeting, they immediately went and got Installation Manager- E and told him he needed to get the Wanderguard system up as soon as possible. It was noted that Installation Manager- E was on the premise working on additional areas of the campus. Then as the request was made to have the Wanderguard system placed, Installation Manager- E was given the order by his company to stop work immediately at the facility due to non-payment. ESS- D stated that the previous Administrator immediately went to the business office to take care of the situation. It was noted through interview that the only additional measures the facility put into place, to keep those residents identified as a risk for wandering and wore a Wanderguard bracelet, was to have a stop sign at the doors and to keep the doors closed. Residents would still be able to be out of sight of staff at either doorway and physically push open the doors themselves and then proceed to the main doorway to outside, which would open automatically. Although there are staff offices in the new addition, staff does not occupy the offices at all times of the day. It was also noted that there was not a reception desk, or staff person situated near the front building entrance door; that could stop a resident from leaving the building. Director of Environmental Services- C was able to confirm that the contractor company returned to the facility on ,[DATE]-[DATE] to move the Wanderguard alert system from the old main entrance to the double door entry between the living unit and the new addition. It was noted that at this time, the second entrance to the living unit remained un-alarmed, allowing residents to use the second doorway off the living unit, onto the new addition, and out the automatic doors of the building without activating an alarm. The 2nd doorway alarm was installed on 12/31/14, providing security to the entire perimeter of the living unit of the health center. On 1/20/15 at 1:10 p.m., Surveyor # 6584 interviewed Installation Manager- E in person at the facility. Installation Manager- E stated that the company did have a bid in place to move the existing Wanderguard alarm from the old front entrance to the new front entrance but did not have a work order to do so. Installation Manager- E stated that in December, he was given a stop work order, when his company did not do any work on the health center. Installation Manager- E stated that he came back on 12/23/14 to move the alarm device from the old entrance to the new and then back on 12/3/1/14 when they were given the order to place the alarm device near the second entrance door to the new addition. Installation Manager- E confirmed that it was not until 12/31/14, when the Wanderguard system covered all areas of the health center. On 1/20/15 at 1:25 p.m., Surveyor # conducted a tour of the entire health care facility. At this time, Director of Environmental Services- C activated all of the Wanderguard alert devices at the doorways, which all alarmed and alarmed near the nursing desks to alert staff. Additional doors of the health care facility, which led out to sidewalk areas or to courtyard areas were alarmed and activated on the tour. These were not alarmed by the Wanderguard system, but alarmed at the time anyone would open the door. It was noted that 1 door that led out to the courtyard was not alarmed at the time of the tour. This door led to an enclosed area, which had a sidewalk and grassy area. This door was not visible from the nursing desk and out of sight to most of the area. The door was currently blocked with 2 large bags of salt from the outside, preventing anybody from easily opening the doorway. Director of Environmental Services- C stated that she just spoke with a company today (1/20/15) to have a work order to put an alarm on this door. DES- C stated that because this was not an identified exit door, it was all right to have the salt bags blocking the doorway from the outside. Surveyor # confirmed through record review that the facility had identified 8 residents as being at risk for wandering and in need of wearing a Wanderguard bracelet. This bracelet would activate the Wanderguard system if the resident would approach the 3 main Wanderguard stations placed at various doors of the unit. Through interview with staff, it was confirmed that no other resident had eloped from the facility from 11/19/14 to 12/31/14 when the Wanderguard system was completely functioning. Surveyor # was provided with Wanderguard test logs that are completed both by maintenance staff and the certified nursing staff. According to DON- B, the facility has a binder at each nursing desk (2 desks) that contains information about those residents who are at risk for wandering and potential elopement. DON-B stated that these binders are updated by the Medical Records staff. Surveyor # reviewed each of the binders identified as "Wanderguard" as well as a safety postings placed on the bulletin board near the nursing desk. It was noted that both the binders and the safety posting were outdated and did not contain the information for the current 8 residents identified at risk for wandering. On 1/20/15 at 1:30 p.m., Surveyor # interviewed Medical Records Staff- F in regard to updating the safety postings. Medical Records- F stated she will usually update them monthly, or more often if staff point out they are out of date. She stated at the end of each month she will go through the binders and update them. Medical Records- F was alerted that currently the information is not correct. She immediately went to update the information. On 11/19/14, when the facility began using the new main entrance, which was located in the new addition, and when they started to use the 2 new entry doors to the health care center, they did not have an effective measure in place to keep the 8 residents identified as at risk for elopement and in need of using the Wanderguard safety system. When staff became aware that Resident #1 had eloped from the building through the new entrance, without staff knowledge, they only placed signs on the doors to the health center which stated stop and keep doors closed. This remained an ineffective measure to provide a safe environment to those 8 residents. Both doors are out of sight of the main health care center living areas, as well as still allowed residents to open the doors, go through them and out to the automatic entrance door of the building. Staff would continue to not be alerted of their potential elopement. The lack of effective measures to keep the 8 residents safe who were at risk for wandering created a situation of immediate jeopardy. The jeopardy was removed on 12/31/14, when the Wanderguard system was working through the entire health center. 2.) On 1/29/15 Surveyor # conducted a medical record review of Resident #9 as a result of a facility self-report investigation stating the Certified Nursing Assistant responded to Resident #9's call light and sounding bed alarm and found the resident on the floor bleeding. The record indicates Resident #9 has [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated 1/01/15, indicates Resident #9 is at moderate risk for falls. The annual Minimum Data Set (MDS), dated [DATE], indicates Resident #9 has a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairments), requires extensive assistance of two staff for transfers and toilet use, requires extensive assistance of 2 staff for ambulation in the room, is frequently incontinent of urine and has no falls. The Care Area Assessment (CAA) for urinary incontinence, dated 1/12/15, indicates Resident #9 is able to request assistance form staff with toileting at times, but not always aware of incontinent episodes. The CAA indicates the resident remains frequently incontinent of urine. The Care Area Assessment (CAA) for falls, dated 1/12/15, indicates Resident #9 requires assistance of one staff for all transfers with the use of the wheeled walker. The CAA indicates the Resident had no recent falls or recent attempts to self-transfer. Resident #9's plan of care for urinary incontinence, dated 1/17/13 with a goal date of 4/13/15, includes the interventions to provide necessary assistance with toileting. Resident #9's plan of care for falls, dated 1/17/13 with the goal date of 4/13/15, includes the intervention to keep call light within reach when in room, to utilize a pressure pad alarm on the bed, to reinforce the need to call for assistance and requires one person assist with transfers using a walker. The Progress Note for Falls, dated 1/15/15 at 11:17 p.m., indicates Resident #9 was found on the floor on the foot side of the bed laying on her right side around 10:55 p.m., bleeding from her head and nose. The note indicates the Resident was sent to the hospital. The Progress Note for Falls with Detail, dated 1/15/15 at 11:41 p.m., indicates Resident #9 was found on the floor in the room at 10:55 p.m. The note indicates the Resident was bleeding from a laceration on the right side of her head and from her nose. The note indicates the bed alarm was present and alarming when the resident was found. The note indicates contributing factors included the call light being on however no sound was present, and that a new call light system was installed today that is not making a sound when lit up. The note indicates interventions that were in place included the call light being in reach and the bed alarm was on. The Incident Report, dated 1/15/15, indicates Resident #9 was found on the floor in fetal position laying on her right side facing her cabinet on the foot side of the bed. The Incident Report indicates the right side of her head and her nose were bleeding. The Incident Report indicates Resident #9's roommate (Resident #11) stated the Resident had her call light on to use the bathroom and started yelling and tried to get out of bed prior to the fall. The Incident Report indicates the bed alarm was in place and working properly. The Incident Report indicates the call light system was not working properly due to current construction causing the board for the call light system to not sound. The call light on the outside of Resident #9's room was lit, but the call light system was unable to sound because the call light board was not connected. The Hospital Encounter Record, dated 1/16/15, indicates Resident #9 was admitted to the hospital related to a fall with subdural hematoma, facial contusion, facial laceration and hand contusion. The hospital Discharge Summary, dated 1/17/15, indicates Resident #9 was discharge from the hospital with a primary [DIAGNOSES REDACTED]. The Witness Statement obtained from the 3rd shift Certified Nursing Assistant-G, dated 1/15/15, indicates the CNA punched in for work at 10:57 p.m., walked down the hallway with her jacket and purse to begin the shift and saw room (#) call light on and heard a bed alarm going off. The statement indicates the CNA went to the cafeteria to take her jacket off and put her purse down and that all of the 2nd shift CNAs were standing in the cafeteria talking and charting. The statement indicates CNA-G went to room (#) and found Resident #9 in a pool of blood on the floor by the foot of the bed. The statement indicates the 3rd shift nurse was notified. The Witness Statement obtained from the 2nd shift Certified Nursing Assistant-H, dated 1/21/15, indicates the CNA was assigned to Resident #9 on the p.m. shift of 1/15/15. The statement indicates CNA -H assisted the resident to bed at 9:00 p.m., activated the bed alarm and placed the call light in the resident's hand. The statement indicates the CNA did not see the call light on did not hear the bed alarm and did not hear anyone calling for help. The Witness Statement obtained from the 2nd shift Certified Nursing Assistant-J (training on Unit 1), dated 1/21/15, indicates the CNA did not recall hearing Resident #9's bed alarm and did not hear her calling for help or see her call light going off when she was going to the dining room to review documentation and charting guidelines shortly before the end of the shift. The Witness Statement obtained from the 2nd shift Certified Nursing Assistant-K (working on Unit 1), dated 1/21/15, indicates the CNA did not see the call light, hear the bed alarm or hear Resident #9 calling for help. CNA-K indicated she was not aware that anything was going on until 3rd shift came in. The Witness Statement obtained from the 2nd shift Registered Nurse (RN)-I, dated 1/21/15, indicates that at approximately 10:50 p.m. she walked past Resident #9's room and did not notice any alarms, see a call light on or hear the Resident calling out. The Witness Statement obtained from the 3rd shift Licensed Practical Nurse (LPN)-L, dated 1/21/15, indicates she and CNA -G were walking in to begin their shift on 1/15/15, punched in at 10:57 p.m. and when they were walking down the Unit 1 hallway they heard the bed alarm and saw the call light on for room (#). The statement indicates LPN-L and CNA-G went into room (#) and found Resident #9 on the floor, bleeding from her head. The Witness Statement obtained from Resident #9's roommate (Resident #11), dated 1/21/15, indicates Resident #9 woke up and stated she had to go to the bathroom. The roommate indicated she put the call light on for Resident #9 and that she watched Resident #9 move from the head of the bed to the foot of the bed and fall onto the floor. On 1/29/15 at 2:35 p.m., Surveyor # spoke with p.m. shift Registered Nurse-I who indicated that on 1/15/15 at about 10:55 p.m., she walked passed room (#) on her way to Unit 2 to have some papers signed. RN-I indicated that she passed Resident #9's room on her way to Unit 2 and noted the resident was in the bed and the bed alarm was not sounding. RN-I indicated she was not sure if the light part of the call light system was on, but she did note that it was not making any noise. RN-I indicated the facility had been working on the call light system during the dayshift but that she was not aware that the audible part of the call light system was not functioning on the p.m. shift of 1/15/15. On 1/29/15 at 2:50 p.m., Surveyor # spoke with Certified Nursing Assistant (CNA) -H who was assigned to Resident #9 on the p.m. shift of 1/15/15. CNA- H indicated she went into the dining room at 10:50 p.m. to show a new staff member how and where the meal slips were located, and how to complete documentation of a meal. CNA - H indicated she could not visualize the nurse call system panel from where she was located in the dining room. CNA -H indicated she did not see or hear Resident #9's call light when it was activated and did not hear Resident #9's bed alarm when it was activated. CNA -H indicated she was not aware that the audible part of the call system was not working on the p.m. shift of 1/15/15. On 1/29/15 at 3:00 p.m., Surveyor # spoke with 3rd shift Certified Nursing Assistant-G who indicated that on 1/15/15 she punched in for work at 10:57 p.m., walked down the hallway to begin the shift and saw room (# ' s) call light on and heard a bed alarm going off. CNA-G indicated she went to the cafeteria to take her jacket off and put her purse down and noted the 2nd shift CNAs were standing in the cafeteria talking and charting. The statement indicates CNA-G went to room (#) and found Resident #9 in a pool of blood on the floor by the foot of the bed. CNA -G indicated the light part of the call light system was on but there was no "beeping" noise that would indicate the call light was on. On 2/02/15 at 2:45 p.m., Surveyor # spoke with p.m. shift CNA -K who indicated that on 1/15/15, at the end of the shift, she did not see or hear the activation of Resident #9's call light or hear the bed alarm sounding. On 2/03/15 at 4:40 p.m., Surveyor # spoke with 3rd shift LPN-L who indicated she and CNA -G were walking in to begin their shift on 1/15/15 at 10:57 p.m., and they heard the bed alarm sounding and saw the call light lit up for room (#). LPN-L indicated that no p.m. shift staff was responding to the bed alarm or to the lit up call light. LPN-L indicated she went to the Conference room (the temporary nurse's station) to put her stuff down and then responded to the bed alarm and the lit up call light, at which time she noted Resident #9 on the floor, bleeding from her head. LPN-L indicated the light part of the call light system was on but there was no sound that would indicate the call light was on. On 2/02/15 at 12:10 p.m., Surveyor # spoke with Resident #11 (Resident #9's roommate). Resident #11 indicated that on 1/15/15, prior to Resident #9's fall, the resident stated: "I have to go potty". Resident #11 indicated she could not recall if she put the call light on or if Resident #9 did, but staff did not come to the room before Resident #9 got up and fell to the floor. On 2/02/15 at 10:40 a.m., Surveyor # made observations and spoke with Resident #9. Resident #9 was observed to have a healing laceration adjacent to her right eye and faded yellowish colored bruising to the surrounding right eye extending down to the right cheek, jaw and neck area. Surveyor # attempted to speak with Resident #9 but she was very hard of hearing and was unable to recall the fall. On 2/02/15 at 10:00 a.m. an

Based on record review, observation and resident and staff interviews, the facility did not ensure that the nurses' station was equipped to receive resident calls through a communication system on 1 of 2 units (Unit 1) from 1/14/15 through 1/16/15 all portions of the nurse call system were not functioning. Unit 1 of the Building is currently under construction. As part of the construction, the facility is in the process of changing over from the existing Cornell nurse call system to a newly purchased nurse call system that is manufactured by Engineered Electronics, Inc. (EEI). On 1/14/15 the existing Nursing Station was relocated to the Unit 1 Conference room and the EEI nurse call light panel was moved to an area in the Unit 1 hallway. On 1/14/15, the contractor for the EEI call light system informed the facility that the nurse call light panel would light up when activated, but would not sound until it was installed properly. The Administrator and the Director of Nursing were not made aware that the nurse call light panel would not sound and no plan of action was put into place to ensure call lights were working and responded to through the completion of construction. Resident #9 resides on Unit 1 of the building and is at risk for falls. Resident #9's care plan indicates the resident requires assistance with toileting, should have a call light in reach to request assistance, and requires a fall pressure pad alarm on the bed. On 1/15/15, between 10:50 p.m. and 10:57 p.m., Resident #9's call light was put on for assistance with toileting. The call light lit up but the noise activation did not function. There was no staff on the unit to visually see the activated call light and to respond to the call light. Resident #9 attempted to self-transfer to use the bathroom and activated the bed alarm. There were no staff on the unit to hear the activated bed alarm and Resident #9 fell and sustained a laceration adjacent to her right eye and a subdural hematoma. The facility's failure to ensure that all portions of the nurse call system were functioning on Unit 1 of the building created a situation of Immediate Jeopardy that started on 1/14/15. On 2/02/15 at approximately 4:00 p.m., Surveyor # notified the Administrator and the Director of Nursing of the determination of immediate jeopardy at a scope and severity of a K (immediate jeopardy/pattern). The facility removed the immediate jeopardy on 1/16/15 when the annunciator part of the call light system was activated by at 7:45 a.m. However, the deficient practice continues at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its correction plan related to accidents and supervision. Findings include: 1. On 1/29/15 Surveyor # conducted a medical record review of Resident #9 as a result of a facility self-report investigation stating the Certified Nursing Assistant responded to Resident #9's call light and sounding bed alarm and found the resident on floor bleeding. The record indicates Resident #9 has [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated 1/01/15, indicates Resident #9 is at moderate risk for falls. The annual Minimum Data Set (MDS), dated [DATE], indicates Resident #9 has a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairments), requires extensive assistance of two staff for transfers and toilet use, requires extensive assistance of 2 staff for ambulation in the room, is frequently incontinent of urine and has no falls. The Care Area Assessment (CAA) for urinary incontinence, dated 1/12/15, indicates Resident #9 is able to request assistance form staff with toileting at times, but not always aware of incontinent episodes. The CAA indicates the resident remains frequently incontinent of urine. The Care Area Assessment (CAA) for falls, dated 1/12/15, indicates Resident #9 requires assistance of one staff for all transfers with the use of the wheeled walker. The CAA indicates the Resident had no recent falls or recent attempts to self-transfer. Resident #9's plan of care for urinary incontinence, dated 1/17/13 with a goal date of 4/13/15, includes the interventions to provide necessary assistance with toileting. Resident #9's plan of care for falls, dated 1/17/13 with the goal date of 4/13/15, includes the intervention to keep call light within reach when in room, to utilize a pressure pad alarm on the bed, to reinforce the need to call for assistance and requires one person assist with transfers using a walker. The Progress Note for Falls, dated 1/15/15 at 11:17 p.m., indicates Resident #9 was found on the floor on the foot side of the bed laying on her right side around 10:55 p.m., bleeding from her head and nose. The note indicates the Resident was sent to the hospital. The Progress Note for Falls with Detail, dated 1/15/15 at 11:41 p.m., indicates Resident #9 was found on the floor in the room at 10:55 p.m. The note indicates the Resident was bleeding from a laceration on the right side of her head and from her nose. The note indicates the bed alarm was present and alarming when the resident was found. The note indicates contributing factors included the call light being on however no sound was present, and that a new call system was installed today that is not making a sound when lit up. The note indicates interventions that were in place at the time of the fall included the call light being in reach and the bed alarm was on. The Incident Report, dated 1/15/15, indicates Resident #9 was found on the floor in fetal position laying on her right side facing her cabinet on the foot side of the bed. The Incident Report indicates the right side of her head and her nose were bleeding. The Incident Report indicates Resident #9's roommate (Resident #11) stated the Resident had her call light on to use the bathroom and started yelling and tried to get out of bed prior to the fall. The Incident Report indicates the bed alarm was in place and working properly. The Incident Report indicates the call light system was not working properly due to current construction causing the board for the call light system to not sound. The call light on the outside of Resident #9's room was lit, but the call light system was unable to sound because the call light board was not connected. The Hospital Encounter Record, dated 1/16/15, indicates Resident #9 was admitted to the hospital related to a fall with subdural hematoma, facial contusion, facial laceration and hand contusion. The hospital Discharge Summary, dated 1/17/15, indicates Resident #9 was discharge from the hospital with a primary [DIAGNOSES REDACTED]. The Witness Statement obtained from the 3rd shift Certified Nursing Assistant-G, dated 1/15/15, indicates the CNA punched in for work at 10:57 p.m., walked down the hallway with her jacket and purse to begin the shift and saw room (#)'s call light on and heard a bed alarm going off. The statement indicates the CNA went to the cafeteria to take her jacket off and put her purse down and that all of the 2nd shift CNAs were standing in the cafeteria talking and charting. The statement indicates CNA-G went to room (#) and found Resident #9 in a pool of blood on the floor by the foot of the bed. The statement indicates the 3rd shift nurse was notified. The Witness Statement obtained from the 2nd shift Certified Nursing Assistant-H, dated 1/21/15, indicates the CNA was assigned to Resident #9 on the p.m. shift of 1/15/15. The statement indicates CNA -H assisted the resident to bed at 9:00 p.m., activated the bed alarm and placed the call light in the resident's hand. The statement indicates the CNA did not see the call light on, did not hear the bed alarm and did not hear anyone calling for help. The Witness Statement obtained from the 2nd shift Certified Nursing Assistant-J (training on Unit 1), dated 1/21/15, indicates the CNA did not recall hearing Resident #9's bed alarm and did not hear her calling for help or see her call light going off when she was going to the dining room to review documentation and charting guidelines shortly before the end of the shift. The Witness Statement obtained from the 2nd shift Certified Nursing Assistant-K (working on Unit 1), dated 1/21/15, indicates the CNA did not see the call light, hear the bed alarm or hear Resident #9 calling for help. CNA-K indicated she was not aware that anything was going on until 3rd shift came in. The Witness Statement obtained from the 2nd shift Registered Nurse (RN)-I, dated 1/21/15, indicates that at approximately 10:50 p.m. she walked past Resident #9's room and did not notice any alarms, see a call light on or hear the Resident calling out. The Witness Statement obtained from the 3rd shift Licensed Practical Nurse (LPN)-L, dated 1/21/15, indicates she and CNA -G were walking in to begin their shift on 1/15/15, punched in at 10:57 p.m. and when they were walking down the Unit 1 hallway they heard the bed alarm and saw the call light on for room (#). The statement indicates LPN-L and CNA-G went into room (#) and found Resident #9 on the floor, bleeding from her head. The Witness Statement obtained from Resident #9's roommate (Resident #11), dated 1/21/15, indicates Resident #9 woke up and stated she had to go to the bathroom. The roommate indicated she put the call light on for Resident #9 and that she watched Resident #9 move from the head of the bed to the foot of the bed and fall onto the floor. On 1/29/15 at 2:35 p.m., Surveyor # spoke with p.m. shift Registered Nurse-I who indicated that on 1/15/15 at about 10:55 p.m., she walked passed room (#) on her way to Unit 2 to have some papers signed. RN-I indicated that she passed Resident #9's room on her way to Unit 2 and noted the resident was in the bed and the bed alarm was not sounding. RN-I indicated she was not sure if the light part of the call light system was on, but she did note that it was not making any noise. RN-I indicated the facility had been working on the call light system during the dayshift but that she was not aware that the audible part of the call light system was not functioning on the p.m. shift of 1/15/15. On 1/29/15 at 2:50 p.m., Surveyor # spoke with Certified Nursing Assistant (CNA) -H who was assigned to Resident #9 on the p.m. shift of 1/15/15. CNA- H indicated she went into the dining room at 10:50 p.m. to show a new staff member how and where the meal slips were located, and how to complete documentation of a meal. CNA - H indicated she could not visualize the nurse call system panel from where she was located in the dining room. CNA -H indicated she did not see or hear Resident #9's call light when it was activated and did not hear Resident #9's bed alarm when it was activated. CNA -H indicated she was not aware that the audible part of the call system was not working on the p.m. shift of 1/15/15. On 1/29/15 at 3:00 p.m., Surveyor # spoke with 3rd shift Certified Nursing Assistant-G who indicated that on 1/15/15 she punched in for work at 10:57 p.m., walked down the hallway to begin the shift and saw room (#)'s call light on and heard a bed alarm going off. CNA-G indicated she went to the cafeteria to take her jacket off and put her purse down and noted the 2nd shift CNAs were standing in the cafeteria talking and charting. The statement indicates CNA-G went to room (#) and found Resident #9 in a pool of blood on the floor by the foot of the bed. CNA -G indicated the light part of the call light system was on but there was no "beeping" noise that would indicate the call light was on. On 2/02/15 at 2:45 p.m., Surveyor # spoke with p.m. shift CNA -K who indicated that on 1/15/15, at the end of the shift, she did not see or hear the activation of Resident #9's call light or hear the bed alarm sounding. LPN-K indicated the light part of the call light system was on but there was no sound that would indicate the call light was on. On 2/03/15 at 4:40 p.m., Surveyor # spoke with 3rd shift LPN-L who indicated she and CNA -G were walking in to begin their shift on 1/15/15 at 10:57 p.m., and they heard the bed alarm sounding and saw the call light lit up for room (#). LPN-L indicated that no p.m. shift staff was responding to the bed alarm or to the lit up call light. LPN-L indicated she went to the Conference room (the temporary nurse's station) to put her stuff down and then responded to the bed alarm and the lit up call light, at which time she noted Resident #9 on the floor, bleeding from her head. On 2/02/15 at 12:10 p.m., Surveyor # spoke with Resident #11 (Resident #9's roommate). Resident #11 indicated that on 1/15/15, prior to Resident #9's fall, the resident stated: "I have to go potty". Resident #11 indicated she could not recall if she put the call light on or if Resident #9 did, but staff did not come to the room before Resident #9 got up and fell to the floor. On 2/02/15 at 10:40 a.m., Surveyor # made observations and spoke with Resident #9. Resident #9 was observed to have a healing laceration adjacent to her right eye and faded yellowish colored bruising to the surrounding right eye extending down to the right cheek, jaw and neck area. Surveyor # attempted to speak with Resident #9 but she was very hard of hearing and was unable to recall the fall. On 2/02/15 at 10:00 a.m. and 12:30 p.m., Surveyor # spoke with the Administrator and the Director of Nursing and reviewed the facility's Incident/ Action Plan, dated 1/15/15 through 1/19/15. Both the interview and the review of the action plan revealed the following: that at the time of Resident #9's fall (on 1/15/15), Unit 1 of the Building was under construction. As part of the construction, the facility was in the process of changing over from the existing Cornell nurse call system to a newly purchased nurse call system that is manufactured by Engineered Electronics, Inc. (EEI). On 1/14/15 the existing Nursing Station was relocated to the Unit 1 Conference room and the EEI nurse call light panel was moved to an area in the Unit 1 hallway. Unit 1 testing of the nurse call system was completed by the installers on 1/14/15 to verify corridor light functionality. The testing indicated the annunciator panel had not been installed on the call system yet due to construction. On 1/14/15, a facility nursing staff member was informed by the contractor that the nurse call light panel would light up but not sound until it was installed properly. However, the Administrator and the Director of Nursing were not notified that the call lights were not sounding when activated until after Resident #9 fell on [DATE], while attempted to get up after no one answered her call light. The lack of effective measures to keep the 32 residents on Unit 1 safe while the facility was under construction and in the process of changing over to a newly purchased nurse call system, created a situation of immediate jeopardy, removed on 1/16/15, when the annunciator part of the call light system was activated at 7:45 a.m.

Based on record reviews and interviews, the facility did not ensure that 3 of 9 residents (Resident's #4, #2 and #11) received adequate supervision and assistance devices to prevent accidents. Resident #4 experienced a fall after being left alone in the bathroom that resulted in a fractured hip. Resident #2 was observed seated on a towel that was placed on top the safety cushion in his wheelchair, defeating the purpose of the safety cushion, also noted the resident experienced three falls with no thorough investigations that included interviews with staff. Resident #11 sustained a fall that resulted in lacerations and no evidence of a thorough investigation that included interviews with staff. Findings include; 1.) Per clinical record, Resident #4 is noted to be alert with Dementia. The most recent MDS (minimum data set) dated 04/14/14 pertaining to Resident #4's ambulation status indicates that the resident is "not steady, only able to stabilize with staff assistance." The resident utilized the wheelchair to propel herself about and per her care plan: toileting required "one person assist." Review of the clinical record progress notes indicated that on 04/28/14 at 1:02 p.m., per LPN-I (licensed practical nurse) "resident's chair alarm sounding with wheelchair in bathroom, entered room to find resident laying on her alarmed mat near bed sounding on her back, attempted to ambulate per self from bathroom to bed without assist." "fell to knees then laid on back hit top of head lightly on bedside table, no bump or bruise to top of head, no complaints of vertigo or dizziness." At 1:12 p.m. LPN-I noted, "neuro check started within normal limits, can move all extremities, no bump or bruises or abrasions at this time." The resident's legal representative and the Physician were informed. At 7:56 p.m., it is noted by LPN-J, "resident alert....no complaints of nausea or vomiting, small purple bruise to right elbow area, no complaints of pain, neuro checks negative, range of motion within normal limits." On 04/29/14 at 1:19 a.m., per RN-K (registered nurse), "monitoring post fall, alert with cares, moves all extremities, complained of pain left hip, Tylenol given, bruise and skin tear right elbow, BP-100/48, T-95.3, P-80, R-18 and pulse oxygen 94%." On 04/29/14 at 7:45 a.m., LPN-I noted that a "Stat Xray of the left hip" was ordered. The results of the Xray showed, "left hip strong suggestion of a subcapital impaction fracture which appears recent or subacute, Osteopenia is present." The Physician was contact as well as the resident's legal representative. The legal representative was informed regarding the choice of surgical intervention or palliative care. The legal representative choose palliative care. The resident was now a hoyer lift and no weight bearing on the left leg. Per review of the facility fall investigation dated 04/28/14 with an IDT (interdisciplinary team) note of 04/29/14 "reviewed fall and it appears resident propelled wheelchair independently to bathroom and then attempted to ambulate back from the bathroom to bed." However, review of the record of employee counseling dated 05/09/14 for CNA-L (certified nurse aide) states, "employee left resident unattended in the bathroom on 04/28/14." "Resident got up from toilet and fell in her room resulting in a left hip fracture." "Investigation was completed, employee failed to follow resident's care plan of assist of one with toileting needs by leaving resident alone/unattended thus resulting in a significant injury to the resident." Per the employee counseling, the employee was questioned by the DON and RN-C as to her knowledge of leaving someone alone on the toilet. The employee stated "that it did not say on her care plan that she is not to be left alone on the toilet." CNA-L was "educated that any resident who requires assistance of one, two or an EZ stand or Hoyer lift, should never be left unattended on the toilet." A review of the facility Safe Resident/Member Transfers & Lifts Employee Commitment Statement-All Care Giver Staff Must Sign Revised 02/14 indicates, "Stay with the resident if required by the care plan or stay directly outside the bathroom door to provide for privacy while monitoring the resident in the bathroom." "If a resident is a one person or two person assist transfer and needs to use the toilet, a gait belt must be used and a CNA must stay with that resident or close by the bathroom door until the resident is finished using the toilet." "If a resident is cognitively impaired; confused, forgetful, anxious, agitated, etc., they may not use good judgment and therefore they also need supervision or assistance during ADL's." "These residents should not be left alone on the toilet." "If the care plan states supervision assist or one or two assist, they need supervision or assistance are not safe with transfers and mobility and are at risk for falls and they too need assistance toileting." Per interview with RN-C on 06/19/14 at 2:00 p.m., RN-C confirmed that CNA-L was to supervise Resident #4 while she was on the toilet. 2.) On 6/23/14 at 8:10 a.m., Surveyor # observed Resident #11 seated in a wheel chair in the dining room, being assisted with breakfast. Resident #11 had a healing laceration/scab on her forehead. On 6/23/14 Surveyor # reviewed Resident #11's medical record. Resident #11 has [DIAGNOSES REDACTED]. A Fall Risk Data Collection form dated 5/2/14 indicates Resident #11 is at moderate risk for falls due to a history of falls, receiving diuretics, memory problems, total incontinence, unable to come to standing position independently, requires use of hands-on assistance to move from place to place. Resident #11's Annual MDS (Minimum Data Set) dated 5/20/14 indicates Resident #11 has short and long term memory problems, severely impaired cognitive skills for daily decision-making, requires assist of two staff for bed mobility and transfers, is frequently incontinent of bowel and bladder and had no recent falls. Resident #11's Social Service Care Plan dated 5/12/12 and updated to include a target date of 5/31/14 states Resident #11 "has chronic and progressive decline in intellectual functioning characterized by: deficit in memory, judgement, decision-making and thought process related to short term memory loss, long term memory loss secondary to Alzheimer's disease. Resident #11's Nursing Care Plan initiated 5/10/11 and updated with a target date of 9/3/14 indicates Resident #11 is at risk for difficulties with communication related to inability to express emotion and share information related to impaired cognition secondary to dementia; has self-care deficits of feeding, bathing, hygiene, grooming, and toileting related to memory loss related to dementia; Resident #11 needs 1 person assist and use of a gait belt and walker for transfers and repositioning. Resident #11's Care Plan "Risk for Falls" was initiated 8/10/11 and updated with a target date of 9/3/14 states Resident #11 is at risk for falls characterized by history of falls/injury, multiple risk factors related to unsteady gait, poor safety awareness. Interventions include: Analyze falls to determine whether pattern/trend can be addressed; requires one person assist for all transfers with use of walker; do not leave on toilet or commode unattended; wear proper, non-slip footwear... On 6/13/14 staff added "Scoop mattress" to Resident #11's care plan for Falls. Resident #11's Nurses' Notes dated 6/12/14 at 2315 (11:15 p.m.) state "Resident found on floor next to bed by CNA (Certified Nursing Assistant). Awake, lying on left side, with lacerations to left temple/forehead and left knee. Resident complained of pain when nurses attempted to roll her onto back. Resident confused x 2 (times two) per baseline, and unable to explain etiology of fall or accurately express pain. 911 and (family) called..." Sent to ER for evaluation and treatment. Additional Nurses' Notes indicate Resident #11 returned to the facility at approximately 4:10 a.m. Resident #11 had received multiple sutures to forehead, bilateral elbows and left knee. On 6/13/14 on evening shift Resident #11 was given Tylenol for complaint of sore shoulder, dressings intact over sutures. Notes on 6/14/14 indicate Resident #11 has bilateral bruising under both eyes from the fall from bed on 6/12 and now has a scoop mattress and low bed. Notes indicate on 6/18/14 Resident #11 had a fever and elevated pulse, left knee edematous and red surrounding suture site, tender to touch. Resident #11's physician ordered Keflex (antibiotic) 500 mg. (milligrams) three times a day for 5 days along with a probiotic for 5 days for inflammation to left knee suture site. On 6/20/14 Resident #11 received a new order for two Tylenol 325 mg. three times a day for 10 days for ongoing pain to knee and forehead. Multiple notes 6/19-6/23 indicate Resident #11's left knee is warm and red. On 6/23, Resident #11's physician also ordered an antibiotic ointment. Surveyor # asked DON (Director of Nursing)-B for additional information regarding Resident #11's fall on 6/12/14. DON-B provided Surveyor # with a Fall Report dated 6/12/14 at 11;15 p.m. and revised on 6/13/14 at 10:56 a.m. The Fall Report includes the information documented in the Nurses' Notes, and indicates Resident #11's neurologic checks remain at baseline, ice applied to forehead, oriented to person only, and she was sent to the hospital. The Fall Report indicates "Predisposing Physiologic Factors" are: confused, incontinent, weakness/fainted, and impaired memory". No Predisposing Environmental Factors or Predisposing Situation Factors were checked. No witnessed were identified. The "Notes" section states "6/13/14 IDT (Interdisciplinary Team) reviewed fall and it appears Resident possibly rolled out of bed. Resident has impaired cognition and is unable to verbalize how fall occurred. Resident does not usually attempt self-transfer, and is dependent on staff for assistance with ADLs (Activities of Daily Living). Scoop mattress applied to bed to prevent Resident falling when repositioning elf in bed." The Note was electronically signed by DON-B, RN (Registered Nurse) Clinical Manager-C and Director of Social Services (DSS)-H. On 6/23/14 at 11:02 a.m. Surveyor # interviewed DON-B asking if there were any staff statements or interviews regarding Resident #11's fall- to ask staff when they last saw and/or assisted Resident #11, what staff were on the floor that night, what were they doing, was Resident #11 sleeping or restless, when was Resident #11 last assisted to the bathroom and/or changed if incontinent, what was she wearing on her feet, etc. Surveyor # noted information obtained through those interviews could provide valuable information to develop new interventions to try to prevent future falls. For example, if interviews reveal staff had not provided toileting assistance for an extended period of time, (and the Fall Report does note Resident #11 was incontinent), perhaps staff need re-education regarding toileting assistance; or perhaps staffing levels did not allow the staff to assist Resident #11 timely (were there staff call-ins, did too many staff leave the unit at the same time, was it shift change-were oncoming staff on the floor, etc.); or perhaps there was a misunderstanding regarding which staff was responsible for Resident #11- all real possibilities of what may or may not have contributed to Resident #11's fall, but without interviewing staff, the root cause(s) of the fall may not be identified. DON-B checked with RN-C and reported to Surveyor # there were no statements from staff regarding Resident #11's fall on 6/12/14. No additional information was gathered regarding Resident #11's fall. DON-B stated the nurse on duty should gather that information and incorporate that information into their Nurses' Note, but it appears they are not doing that. DON-B stated they have statements for some Resident falls, but not for Resident #11's 6/12/14 fall. No further information was provided. 3.) On 6/17/14 at 11:02 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-E assist Resident #2 to the toilet. Resident #2 was in bed. CNA-E assisted Resident #2 to sit up, then stand and turn and take a step so Resident #2 was then seated in her wheelchair. CNA-E did not use a gait belt or walker to transfer Resident #2 to the wheel chair. Surveyor # observed an alarm on Resident #2's wheel chair and an alarmed mat on the floor next to Resident #2's bed. CNA-E then pushed Resident #2 in her wheel chair to the bathroom, where Resident #2 quickly and unexpectedly stood up. CNA-E hurried around the wheel chair to hold on to Resident #2's arm and slacks to steady Resident #2 as she turned to the toilet. Again no gait belt or walker was used for the transfer. While Resident #2 was seated on the toilet voiding, CNA-E left Resident #2 in the bathroom alone to get a clean brief from the closet in Resident #2's room. CNA-E then assisted Resident #2 with peri-care and transferred Resident #2 back to her wheel chair without use of a gait belt or walker. While Resident #2 was out of the wheel chair, Surveyor # observed a white terry cloth towel over a piece of Dycem ( a product used to prevent a resident from sliding out of the wheel chair) that was on Resident #2's wheel chair seat. When Resident #2 was transferred back to her wheel chair, Resident #2 sat on the towel on top of the Dycem, reducing its effectiveness. A short while later, when CNA-E was in the dining room, Surveyor # asked her why she did not use a gait belt for Resident #2 while transferring Resident #2 to the toilet. CNA-E stated Resident #2 does not like to use a gait belt. On 6/18/14 at 7:35 a.m. and 11:05 a.m. Surveyor # observed Resident #2 sitting in the wheel chair in her room. The white towel was visible over the Dycem on the seat of the wheel chair. Surveyor # asked Resident #2 why she has the towel over the Dycem (pad in her wheel chair). Resident #2 stated sometimes when she needs to get to the bathroom, staff do not get there in time and she has an accident. The towel is in case she has an accident. On 6/19/14 at 10:38 a.m. Surveyor # and LPN (Licensed Practical Nurse)-I checked to see what mattress Resident #2 had on her bed (Surveyor # had asked if Resident #2 had a scoop mattress). Resident #2 was in bed, awake. Resident #2 did not have a scoop mattress, but Surveyor # observed the white towel over the Dycem in the wheel chair again. Surveyor # reviewed Resident #2's medical record which includes a CNA (Certified Nursing Assistant) Care Plan stating for transfers, Mobility and Repositioning, Resident #2 requires one person assist and WW (wheeled walker), wheel chair. Under "Safety Devices/Misc." it states Resident #2 is to use "Alarmed floor mat/ chair alarm, Dycem in chair..." Resident #2's Quarterly MDS (Minimum Data Set) dated 5/3/14 indicates Resident #2's BIMS (Brief Interview for Mental Status) shows moderate impairment; Resident #2 needs extensive assistance of one person for transfers and hygiene and two person assist for toileting. Resident #2 is noted to have had two or more falls with no injury since the last MDS. A Fall Data assessment dated [DATE] indicates Resident #2 is at moderate risk for falls. Resident #2's Care Plan for "At risk for falls" was initiated 8/13/12 with most recent Target Date of 3/11/14. It states Resident #2 is at "Risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired cognition, generalized weakness, and possibly adverse effects from antidepressant and diuretic daily." (Resident #2 did sustain a broken hip in August 2013, just prior to the previous recertification survey.) The "Goals" are Resident #2 will be free from falls, and free from injury if a fall does occur. Interventions include: Analyze previous falls to determine whether pattern/trend can be addressed if fall occurs; call light within reach; ensure environment is free of clutter and well lit; evaluate effectiveness and side effects of psychotropic drugs...; have commonly used articles within reach; Resident to wear proper and non-slip footwear. On 10/7/13 staff added bed alarm which was changed to a floor alarm (mat) on 1/29/14. On 5/7/14 staff added 30 minute checks on Resident #2. DON (Director of Nursing)-B provided Surveyor # with Fall Reports indicating since the last survey (September 2013), Resident #2 fell on [DATE], 3/28/14 and 5/4/14. The Fall Report for 3/27/14 at 4:30 p.m. states the nurse was notified Resident #2 was lying on the floor. When the nurse got to Resident #2's room, Resident #2 was sitting up in the doorway to the bathroom with her back to the bathroom and her wheel chair unlocked, "towel in chair halfway off the chair... Resident states "I slipped out of my chair". Immediate Action Taken: Applied Dycem to wheel chair. The Fall Report indicates Resident #2 was oriented to person, place, situation and time, and she denied pain. Predisposing Situation Factors identified are: "Ambulating without assist, and Other". The "Note" is dated 3/28/14 and states "IDT (Interdisciplinary Team) reviewed fall, and resident was attempting to self-transfer when she reports she "slipped out of the wheel chair". Resident requires one person assist with transfers using walker and overall uses call light to request assistance. Dycem applied to wheel chair to prevent Resident from slipping..." Resident (#2) had a new order for mirtazepine for depression but had not received the new medication prior to the fall. The Note was signed by DON-B and RN (Registered Nurse) Clinical Coordinator-C. Surveyor # did not observe any information indicating staff on duty were interviewed to get additional information of the facts surrounding the fall. For example, if Resident #2 was trying to get to the bathroom, when was the last time staff assisted Resident #2 to he bathroom? How many staff were on duty- where were they and what were they doing. When did staff last see Resident #2- what was she doing (sleeping, trying to get up, etc.). Dinner is at 4:00 p.m. in the facility- had Resident #2 already been to dinner? If so, did she eat in the dining room and propel herself back to her room, or did staff take her to her room or did she eat in her room- all information that could help staff identify interventions that may prevent future falls. The Fall Report for Resident #2 on 3/28/14 at 3:30 p.m. indicates the nurse was notified by a CNA that Resident (#2) was sitting on the floor next to her bed. When the nurse entered the room, Resident was located next to her bed on the floor with feet facing the head of the bed, and head near the foot of the bed...Resident had recent change in medication, resident denies dizziness or lightheadedness...When asked what happened Resident states "I slid out of bed". Immediate Action Taken includes: Resident was Hoyer-lifted off the floor and assisted to the bathroom... chair alarm and floor alarm applied, Dycem mat to wheel chair applied. Resident educated on alarms and need to ask for help when needing to transfer to and from bed, chair to bed, etc. Predisposing Physiological Factors are "Impaired memory" and Recent medication change". Predisposing Situational Factors are: Ambulating without assistance" and "During transfer". The "Note" dated 3/31/14 states "Resident had second fall within 24 hours of each other. First slipping out of wheel chair (Dycem applied) and second falling out of bed. Chair alarm and floor mat at bedside initiated. Resident re-educated on alarms and the need to call for help...Nursing staff to continue to monitor for s/s of depression/adverse effects from mirtazepine use." Again, no staff statements or interviews were noted to provide information regarding Resident #2 leading up to being found on the floor. The third Fall Report indicates Resident #2 fell on [DATE] at 10:00 p.m. Staff heard Resident #2's floor alarm sounding and found Resident #2 sitting on the floor parallel with the bed... Call light was within reach and not sounding...Resident states "I was scooting myself to the end of the bed to get to my wheel chair and slid out of bed." Resident #2 was oriented to person and place. Immediate Action Taken: Resident Hoyer-lifted to wheel chair and assisted to the bathroom per her request with assist of one without issues. Resident continues to be encouraged to use call light prior to self-transferring... Predisposing Physiological Factors are: Incontinent, Gait Imbalance, and Impaired Memory. Predisposing Situational Factors are: Ambulating without Assist. The "Note" is dated 5/7/14 and states IDT reviewed fall. Resident verbalized "I was scooting to the end of the bed to get to my wheel chair and slid out of bed. Resident attempted to self-transfer in attempt to use the bathroom. 30 minute checks initiated for staff to check on resident and offering toileting due to resident frequently requests assistance with toileting throughout the day. Resident also receives diuretics daily increasing risk for urinary frequency. Resident also has a floor mat in place and wheel chair alarm. Nursing staff to continue ensuring alarms are in place and functioning properly every shift. Surveyor # noted no staff statements or interviews were documented in this report. There is no indication of when Resident #2 was last assisted with toileting, when she was last seen or assisted by staff, what she was doing, what she had on her feet, did shift change staffing have any impact, was the unit fully staffed, etc. Surveyor # asked DON-B, who also asked RN-C, if staff were interviewed regarding when they last toileted Resident #2, or for other information about what was happening on the unit leading up to Resident #2's fall. If staff had just taken Resident #2 to the toilet and she is trying to get up again to use the toilet, that would require different interventions than if staff were too busy to toilet Resident #2 according to her toileting schedule. Without information from staff on the scene at the time, the IDT does not know if Resident #2 was wearing proper foot wear, for example, or what Resident #2 and staff were doing prior to the falls. This information is crucial to developing the right interventions to try to prevent future falls. DON-B stated they had no additional information from staff regarding Resident #2's falls. On 6/19/14 when Surveyor # shared the observations of CNA-E on 6/17/14 (transferring Resident #2 without gait belt or walker, leaving Resident #2 unattended in the bathroom), DON-B stated there is a facility policy that all CNAs sign indicating they are aware all resident transfers require use of a gait belt, and residents who require assistance should not be left alone on the toilet. On 6/23/14, Surveyor # reviewed a 'Safe Resident /Member Transfers & Lifts Employee Commitment Statement- All Caregiver Staff Must Sign" document signed by CNA-E on 5/16/14. It states "Transfers: (Resident/Member must have proper footwear for all transfers): *One-person assist transfers are to be performed with one assistant and the use of the gait belt..." The back of the form states "Stay with the Resident if required by the care plan or stay directly outside the bathroom door to provide privacy while monitoring the resident bathroom. If a resident is a one person or two person assist transfer and needs to use the toilet, a gait belt must be used and a CNA must stay with that resident or close by the bathroom door until the resident is finished using the toilet. If a resident is cognitively impaired; confused, forgetful, anxious, agitated, etc., they may not use good judgement and therefore they also need supervision or assistance during ADLs. These residents should not be left alone on the toilet. If the care plan states supervision, assist of one or two assist, they need supervision or assistance and are not to be left alone on the toilet. If they have chair alarms and bed alarms, they also are not safe with transfers and mobility and are a risk of falls, and they too need assistance toileting." (Bold and italics theirs). While toileting Resident #2, CNA-E did not use a gait belt (nor walker per plan of care), nor did she stay with Resident #2. CNA-E left the bathroom and mostly closed the bathroom door for privacy while she got a clean brief from Resident #2's closet. CNA-E had her back to the bathroom at that time, and could not see Resident #2.