Every finding on record at Venice Health and Rehabilitation Center

Based on observation, record review and staff interviews, the facility failed to have menus that were prepared in advance and reviewed by a dietitian or other clinically qualified nutrition professional for nutritional adequacy.The findings included: On 5/11/26 at 9:15 a.m., upon request, the Certified Dietary Manager provided the facility's menu for the week of May 10, 2026, through May 16, 2026. There was no documentation that the menu was reviewed by a dietitian. In an interview, the Certified Dietary Manager (CDM) said that she was only able to supply a menu for the current week and verified that the menu was not signed by a dietitian. The CDM said that the facility's contract with a food management company ended a few weeks ago and the company pulled everything from the kitchen. She said they did not currently have a menu or policies.On 5/11/26 at 10:45 a.m., in an interview, the Nursing Home Administrator (NHA) said that the former food management company had taken all the policies and menus and said that the residents' needs were being met. On 5/13/26 at 11:00 a.m., observation of tray line revealed no food items were listed on the residents' meal tickets, unless the resident requested something other than the posted menu.On 5/14/26 at 11:00 a.m., in an interview, the Nursing Home Administrator said that they were in the process of hiring a Registered Dietitian. He said they have not had a dietitian since the contract with the food management company ended on 4/30/26.

Based on observation and staff interviews, the facility failed to store food in accordance with professional standards for food service safety.The findings included:On 5/11/26 at 9:09 a.m., observation of the kitchen with the Certified Dietary Manager (CDM) revealed the following:The temperature log for the reach-in refrigerator noted April 2026 under Location name. The log did not have a temperature documented for 5/11/26 at 5:00 a.m. On 5/11/26 at 9:12 a.m., observation of the reach-in refrigerator revealed 8 unlabeled filled beverage pitchers.On 5/11/26 at 9:15 a.m., upon request of facility's policy for storing and labeling food, the CDM said that the facility did not have dietary policies and procedures. She said the facility's contract with a food management company ended a few weeks ago and the food management company pulled everything from the kitchen, including their policies and procedures.On 5/11/26 at 9:20 a.m., observation of the walk-in refrigerator revealed: 2 unlabeled containers of unidentified leftover food.3 trays of unlabeled, undated individually prepared slices of brownies.On 5/11/26 at 11:53 a.m., observation of the lunch trays revealed the unlabeled brownies were on the residents' meal trays.On 5/14/26 at 10:55 a.m., in an interview, the CDM acknowledged that the undated and unlabeled brownies observed in the walk-in refrigerator on 5/11/26 were served to the residents at lunch time on 5/11/26.

Based on observations, review of facility's policy and procedure, residents and staff interviews, the facility failed to store residents' personal care items in a sanitary manner in 7 (Rooms 501, 508, 503, 504, 506, 507, and 404) of 20 rooms observed on the 500 and 400 hallways. The facility failed to provide maintenance services to ensure the necessary repair of furniture for 2 (Residents #48 and #25) of 31 residents observed.The findings Included:Review of the facility's policy for Personal Items last reviewed 1/5/2020 revealed: The facility has designed and implemented processes which strive to ensure safekeeping of resident/patient personal items. The staff is oriented to the facility's efforts to protect the property, practice infection control, and implement safety measures upon hire; attempt to identify each personally owned item by placing the resident/patient's name on the item (if possible). This would include but not be limited to: All articles of clothing and shoes/slippers; Personal hygiene articles (toothbrush, comb, denture cup, etc.). Store personal hygiene items utilizing infection prevention practice.room [ROOM NUMBER]:On 5/11/26 at 10:08 a.m., observation of the shared bathroom revealed an unlabeled electric toothbrush with a yellow substance under the charger, and oral hygiene supplies stored in an unlabeled emesis basin. A urine collection container was observed stored on the floor next to the shared toilet. Photographic evidence obtained room [ROOM NUMBER]On 5/11/26 at 10:15 a.m. observation of the shared bathroom revealed: Oral care supplies stored in an unlabeled plastic cup on the shelf above the sink. A labeled emesis basin was stored uncovered on the sink. A pink unlabeled emesis basin was stored uncovered on the sink. A plastic bin was stored on the floor behind the shared toilet. On 5/13/26 at 9:09 a.m., a pink basin and a bedpan were observed stored behind the toilet of the shared bathroom. Photographic evidence obtained On 5/11/26 at 10:23 a.m., observation of the shared bathroom of room [ROOM NUMBER] revealed: unlabeled personal care items stored on the shelf above the sink. An unlabeled, uncovered basin was stored on the toilet lid. An unlabeled, uncovered basin was stored on the floor behind the toilet. Photographic evidence obtainedOn 5/11/26 at 10:25 a.m., observation of the shared bathroom of room [ROOM NUMBER] revealed: unlabeled personal care items (multiple safety razors and a denture holder) stored on the shelf above the sink and on the top of the sink. A pink basin was stored on the floor behind the toilet. Photographic evidence obtainedroom [ROOM NUMBER]:On 5/11/26 at 11:14 a.m., observation of the shared bathroom revealed unlabeled safety razors and a denture cup stored on the shelf above the sink and on the top of the sink. Photographic evidence obtainedroom [ROOM NUMBER]:On 5/11/2026 at 11:19 a.m., observation of the shared bathroom revealed a pink basin stored on the floor behind the toilet.On 5/12/26 at 12:03 p.m., and on 5/13/26 at 9:10 a.m., a pink basin was observed stored on the floor of the shared bathroom. Photographic evidence obtainedroom [ROOM NUMBER]:On 5/11/26 at 11:33 a.m., observation of the shared bathroom revealed a used urinary catheter drainage bag hanging from the grab bar. Photographic evidence obtainedOn 5/11/26 at 11:37 a.m., observation of Resident #48's room revealed an over the bed table partially across the resident's bed. The outer surface of the over-the-bed table was delaminated on the long edges. In an interview, Resident #48 said that the peeling edges bother him. He demonstrated how his skin and fingernails catch on the peeling edges.Resident #25:On 5/11/26 at 11:49 a.m., observation of Resident #25's over-the-bed table revealed the outer layer was peeling off, exposing the material underneath.On 5/13/26 at 9:18 a.m., in an interview, Unit Manager/Licensed Practical Nurse (LPN) Staff C said that basins, bedpans, and residents' personal care items should be labeled and stored in plastic bags. She observed the basin stored on the floor of the shared bathroom of room [ROOM NUMBER], the oral care supplies stored in an unlabeled plastic cup on the shelf above the sink, and the basin and bedpan stored behind the toilet in the shared bathroom of room [ROOM NUMBER]. Unit Manager/LPN Staff C verified that the residents' personal care items were not stored in a sanitary manner in room [ROOM NUMBER] and 507.On 5/14/26 at 10:33 a.m., in an interview, CNA Staff A said that residents' personal and grooming items should be labeled with the resident's name and stored in their bedside table, not on the shelf above the sink. When asked about storing basins on the bathroom floor, CNA Staff A said that they should not be stored on the floor and said, You see the space. Where are we supposed to put things?On 5/14/26 at 10:36 a.m., in an interview, CNA Staff F said that the nurses label the residents' personal care items with the room number and either A or B to designate door or window bed. She said that personal care and grooming items should be placed in a plastic bag and stored in the resident's drawer and not left on the shelf in the bathroom. On 5/14/26 at 10:47 a.m., in an interview CNA Staff G stated that residents' personal care items, grooming items, and basins should be stored in a plastic bag and placed in the drawer of the resident's bedside cabinet. She said that they should not be stored on the shelf above the sink in the bathroom and the basins should never be stored on the floor.

Based on record review and staff interviews, the facility failed to provide the advanced Beneficiary Notice to 1 (Resident #21) of 3 residents reviewed for potential financial liability for services that may not be covered by Medicare. The findings included: Clinical record review for Resident #21 revealed an admission date of 2/16/26. Diagnoses included Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body), and aphasia (disorder that affects how you communicate) following cerebral infarction (stroke). Resident #21 received Physical and Occupational Therapy.On 3/13/26, the facility provided Resident #21's representative the Medicare Non Coverage (NOMNC) form (Centers for Medicare and Medicaid Services (CMS) Form 10123). The form noted that Resident #21's coverage for Physical and Occupational Therapy services would end on 3/15/26. The facility determined that Medicare would probably not pay for Physical or Occupational Therapy services after 3/15/26 and Resident #21 may have to pay for Physical or Occupational Therapy services received after 3/15/26.There was no documentation in the clinical record that the facility provided Resident #1 or representative the Advanced Beneficiary Notice (ABN) Form, outlining their options and potential out-of-pocket costs related to the non-covered services. On 5/14/26 at 12:12 p.m., in an interview, the Social Services Director verified that Physical and Occupational Therapy services were discontinued before Resident #21 exhausted their 100 days Medicare Part A benefits. She said she did not have an Advanced Beneficiary Notice of Non-coverage for Resident #21.

Based on record review and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure staff consistently provide safe nursing care to prevent avoidable accidents and serious physical harm for 1 (Resident #1) of 3 dependent residents reviewed.Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility.On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed.Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and treatment.Resident #1 was diagnosed with a subarachnoid and subdural hematoma (collection of blood between the skull, brain membrane and brain surface). The facility failure to prevent the neglect resulted in serious injury to Resident #1 and created a likelihood of further incidents of neglect for all 15 residents care planned for the assistance of 2 staff for bed mobility.This failure resulted in the determination of Immediate Jeopardy.The findings included:Cross reference to F689.Review of the facility's policy titled Abuse, Neglect and Exploitation last revised 11/16/23 noted, 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 . neglect .The policy noted the facility will implement policies and procedure to prevent and prohibit all types of neglect that achieves the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to neglect.Review of the facility's incidents investigations revealed on 6/19/25 the facility initiated a neglect investigation related to Resident #1 falling out of bed while receiving care.Review of the facility provided investigation revealed:On 6/19/25 at 11:15 a.m., Resident #1 had a witnessed fall from his bed while receiving care from his assigned Certified Nursing Assistant (CNA). A bump was noted on the resident's right forehead. The physician issued an order to transfer Resident #1 to the local Emergency Department (ED) for evaluation.CNA Staff A provided a statement that on 6/19/25 she changed Resident #1's incontinent brief. The resident had a bowel movement. She turned Resident #1 to his left side to wipe him. While attempting to change the resident, she was holding him with one hand and reaching for wipes with the other. The resident slipped from her hold.Registered Nurse (RN) Staff B provided a statement that on 6/19/25 she was called into Resident #1's room and saw him on the floor. She noted the bed was in a higher position. Resident #1 was on his right side with a hematoma to his right temple. Resident #1 was assessed and 911 was called. RN Staff B stated she applied ice to the resident's head and waited with him until 911 arrived.Licensed Practical Nurse (LPN) Staff C assessed Resident #1 after the fall. A bump was noted to the resident's right forehead. The physician was notified and gave an order to transfer the resident to the ED for further evaluation.The Director of Nursing (DON) interviewed CNA Staff A about the resident's fall from the bed. CNA Staff A performed a reenactment with the DON present. CNA Staff A said that she was providing incontinent care, she reached for wipes that were placed at the resident's knees, and he rolled out of bed onto the floor.The DON asked CNA Staff A if there was anyone else in the room to help her. CNA Staff A stated, No, we usually do two people, but everyone is busy, so I did it myself.The DON asked CNA Staff A if she was aware that the resident was care planned for 2 staff assistance with toileting and bed mobility needs. CNA Staff A stated, Yes, we usually use two, but we are busy, and I needed to clean him up, so I did it myself.The DON asked CNA Staff A if she checks the Kardex (provides essential information for care) first when she comes to work and starts her assignment. CNA Staff A replied, No, I can't do that there is no time.The DON asked CNA Staff A how she knew how to take care of Resident #1. CNA Staff A responded, I know from the last time I worked.The DON asked CNA Staff A if she knew how to find the Kardex and she stated, Yes. The DON and CNA Staff A walked to the kiosk and CNA Staff A was able to locate the Kardex.The investigation noted 9 licensed nurses and 8 CNAs who were present and working on 6/19/25 at the time of the fall were interviewed. All 17 staff interviewed said that they were not asked to assist with Resident #1's care.On 6/25/25, the hospital provided the facility with a diagnosis of traumatic subarachnoid hemorrhage and subdural hematoma.On 6/25/25, the facility verified the allegation of neglect and noted CNA Staff A demonstrated her decision to act independently of the guidance provided by the facility's education and practices when she chose to not review and follow the Kardex prior to providing care to Resident #1. The resident's Kardex was available, up to date, and accurate at the time of the resident's fall.On 7/7/25, review of the clinical record revealed Resident #1 had a re-admission date of 1/26/25. Diagnoses included Cerebral Infarction with resultant hemiplegia affecting the resident's right dominant side.Review of the discharge Minimum Data Set (MDS) Assessment with a target date of 6/19/25 noted Resident #1 was dependent on staff for rolling left and right, personal hygiene, and toileting.Review of the care plan created on 5/10/25 revealed Resident #1 had Activities of Daily Living self-care performance deficit. The interventions included Dependent Assist of 2 for toileting, and Dependent Assist of 2 with bed mobility (repositioning self in bed).Review of the Kardex revealed Resident #1 required dependent assistance by 2 staff to turn and reposition in bed as necessary.Review of the progress notes revealed:On 6/19/25 at 12:41 p.m., a nursing progress note read, Resident fell off the bed while the CNA was attempting to change him at 11:20 AM. A large bump was observed on the resident's right side head . Resident was sent to emergency room for further evaluation.On 6/19/25 at 4:39 p.m., a nursing progress note documented a follow up call was placed to the local hospital. Resident #1 was being transferred to another hospital for further treatment.On 7/7/25 at 9:38 a.m., in an interview, the Administrator said Resident #1's daughter informed the facility Resident #1 passed away on June 30th. The Administrator said they investigated and confirmed neglect. She said CNA Staff a did not follow Resident #1's care plan for 2 staff assistance for bed mobility which resulted in the resident's fall and injury requiring the resident's transfer to a higher level of care.On 7/7/25 at 11:47:a.m., in an interview the Assistant Director of Nursing (ADON) said after the incident, she interviewed the nursing staff who worked on 6/19/25 and were present when Resident #1 fell out of bed. She said all staff interviewed said CNA Staff A did not ask for their assistance to provide incontinent care to the resident.On 7/7/25 at 2:18 p.m., in a telephone interview, CNA Staff A said on 6/19/25 Resident #1 had soiled himself and asked her to clean him. Staff A said she was working her hall alone. Another CNA was split with another hall. She said at the time of the incident she was alone on the hall. The nurse was busy with another patient. CNA Staff A said she raised the bed, rolled the resident on his side. She held Resident #1 with her hand and leaned to grab supplies. CNA Staff A said Resident #1 was a big man with a big belly and the bed was not big. She said Resident #1 hung over the side and rolled off the other side of the bed. She ran to get the nurse. CNA Staff A said she knew Resident #1 required 2 person assistance and they usually use 2 staff. In that situation she said she was alone and cleaned him alone. CNA Staff A said she couldn't leave someone sitting in a bowel movement.On 7/8/25 at 3:30 p.m., in an interview the Administrator said CNA Staff A had been educated multiple times before the incident on bed mobility and on the Kardex. He said CNA Staff A acted independently when she made the decision to move Resident #1 on her own. She did not seek help from anyone.On 7/9/25 at 11:00 a.m., in an interview LPN Staff H said on 6/19/25 she was at the nurses station when CNA Staff A came to tell her Resident #1 was on the floor. She went to the room. She found Resident #1 lying on his right side on the floor. He had a hematoma to the right side of his head. She called for emergency services. LPN Staff H said 2 CNAs were assigned to the hall at that time but one was split with another hall. LPN Staff H said she felt the hall required 2 CNAs dedicated just to that hallway. On 7/10/25, the survey team verified the facility's immediate actions to remove the Immediate Jeopardy effective 6/25/25. The survey team verified the facility's corrective actions to correct the noncompliance on 7/3/25, prior to the survey visit.The immediate and corrective actions implemented by the facility included:On 7/10/25 the survey team verified through review of the documentation and interview with the Administrator that on 6/19/25 CNA Staff A who failed to follow correct procedure for use of resident Kardex and care plan was immediately suspended.On 7/10/25 the survey team verified through review of audits and interview with the Administrator that the DON completed a house-wide audit of care plans/Kardex for accuracy with bed mobility tasks.On 7/10/25 the survey team verified through record review and interview with the Administrator that on 6/19/25 the facility initiated a Performance Improvement Plan (PIP) as a working document, open to edits and revisions. There was documentation the Medical Director reviewed the PIP.On 7/10/25 the survey team verified through review of the personnel file for CNA Staff A that on 4/25/25 CNA Staff A received education on proper positioning of residents in bed, customer service, Kardex and Plan of Care. On 5/6/25 CNA Staff A completed a self-study electronic education on fall prevention, CNA safely moving residents, lifting and transfers.On 7/10/25 the survey team verified through interview with the Administrator, review of sign-in sheet, and record review that on 6/20/25 an Ad Hoc (unplanned) Quality Assurance and Performance Improvement (QAPI) meeting was held with the interdisciplinary team. Participants included the Administrator, the Director of Nursing, the Staff Development Coordinator, Unit Managers, the Social Services Director, the Therapy Director and the Medical Director. The Performance Improvement Plan was reviewed and updated as appropriate.On 7/10/25 the survey team verified through record review that on 6/20/25 the facility completed a care plan review for bed mobility level of care.On 7/10/25 the survey team verified through review of sign-in sheets, content of education and interview with 3 licensed nurses and CNAs that on 6/19/25 through 6/25/25 current staff including contracted and agency staff educated in person, telephonically, or electronically prior to working their next shift: Licensed Nurses were educated on Incidents and Accidents/Supervision, Abuse, Neglect and Exploitation, and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Certified Nursing Assistants were educated on Incidents and Accidents/Supervision, Abuse, Neglect, Exploitation and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Non-clinical Staff: Non-clinical staff were educated on Abuse, Neglect, Exploitation, Incidents and Accidents/Supervision.115 of 115 current staff, 35 of 35 current contracted staff, 15 agency licensed nurses and CNAs received the education.On 7/10/25 the survey team verified through record review and interview with the Administrator that on 6/24/25 an Ad Hoc meeting was held with the interdisciplinary team (Administrator, DON, and Medical Director). The meeting included the planning of Quality Review Audits to review compliance with use of the Kardex, High Fall Risk residents, visualization of staff implementation of compliance with the Kardex and care plan interventions.On 7/10/25 the survey team verified through record review, and interview with the Administrator that on 6/27/25 the facility held a monthly Quality Assurance meeting. The Administrator, DON and Medical Director attended the meeting. The survey team verified the areas discussed included the Performance Improvement Plan in place that resulted in the Ad Hoc QAPI meeting on 6/19/25. Ongoing audits were in place. Current audits reviews were active and ongoing. The staff education was completed on 6/25/25.On 7/10/25 the survey team verified that on 7/3/25 the facility held a QAPI meeting with the Administrator, the DON, and the Medical Director to review the current status of the quality review audits completed. As of 7/3/25 audits have been completed on the following:Accidents and Incidents: Staff verbalize fall risk residents on their assignment and 1 fall intervention for fall residents. On 6/25/25 7 staff audits completed, on 6/26/25 10 staff audits completed, and on 7/3/25 10 staff audits completed.Kardex use: Staff able to verbalize how to access resident care information, provide return demonstration on accessing the Kardex, and verbalize what to do in the event they need assistance providing care to a resident as evidenced by reading the Kardex. On 6/21/25, 6/23/25, 6/24/25, and 6/30/25, 10 staff completed the audit. On 6/26/25 5 staff members One staff member was provided hand over hand direction and demonstration on using the Kardex.Accidents and Incidents: Observation of high fall risk residents for fall interventions in their room, wheelchair, or on their person. On 6/26/25 10 residents audits completed, on 6/28/25, 7 residents audits completed, on 6/30/25 59 residents audits completed, and on 7/2/25 5 residents audits completed.On 7/10/25 the survey team verified 7 of 15 residents care planned for assistance of 2 have been reviewed in the audits.On 7/10/25 during interviews, 2 residents, who require assistance of 2 staff said there are always 2 staff members to provide care.On 7/10/25 the survey team verified through record review and staff interviews that the department head team members are completing staff members audits on abuse, neglect and exploitation randomly during walking rounds as assigned. As of 7/10/25, the audits were ongoing.

Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure effective processes were in place to protect 1 (Resident #1) of 3 residents reviewed from avoidable fall and fall related major injury.Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility.On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed.Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and treatment.Resident #1 was diagnosed with a subarachnoid and subdural hematoma (collection of blood between the skull, brain membrane and brain surface). The facility failure to ensure residents safety during care resulted in serious injury to Resident #1 and created a likelihood of serious harm, serious injury or death from avoidable falls for all 15 residents care planned for the assistance of 2 staff during care and resulted in the determination of Immediate Jeopardy (IJ).The findings included:Cross reference to F600. Review of the facility's policy titled, Accidents and Supervision with a date reviewed/Revised of 10/18/2022 revealed, Each resident will receive adequate supervision and assistive devices to prevent accidents . Implementation of interventions. Using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: . Ensuring that the interventions are put into action .Resident-directed approaches may include: Implementing specific interventions as part of the plan of care. Supervising staff and residents . Monitoring and Modification . Ensuring that interventions are implemented correctly and consistently .Review of the clinical record for Resident #1 revealed a re-admission date of 1/25/25. Diagnoses included Cerebral infarction with resultant hemiplegia affecting the resident's right dominant side.Review of the discharge Minimum Data Set (MDS) Assessment with a target date of 6/19/25 noted Resident #1 was dependent on staff for rolling left and right, personal hygiene, and toileting.Review of the care plan created on 5/10/25 revealed Resident #1 had Activities of Daily Living self-care performance deficit. The interventions included Dependent Assist of 2 for toileting, and Dependent Assist of 2 with bed mobility (repositioning self in bed).Review of the Kardex revealed Resident #1 required dependent assistance by 2 staff to turn and reposition in bed as necessary.Review of the progress notes revealed:On 6/19/25 at 12:41 p.m., a nursing progress note read, Resident fell off the bed while the CNA was attempting to change him at 11:20 AM. A large bump was observed on the resident's right side head . Resident was sent to emergency room for further evaluation.Review of the facility provided fall investigation for Resident #1revealed:On 6/19/25 at 11:15 a.m., Resident #1 had a witnessed fall from his bed while receiving care from his assigned Certified Nursing Assistant (CNA) Staff A. A bump was noted on the resident's right forehead. The physician issued an order to transfer Resident #1 to the local Emergency Department (ED) for evaluation.CNA Staff A provided a statement that on 6/19/25 she changed Resident #1's incontinent brief. The resident had a bowel movement. She turned Resident #1 to his left side wipe him. While attempting to change the resident, she was holding him with one hand and reaching for wipes with the other. The resident slipped from her hold.Registered Nurse (RN) Staff B provided a statement that on 6/19/25 she was called into Resident #1's room and saw him on the floor. She noted the bed was in a higher position. Resident #1 was on his right side with a hematoma to his right temple.The Director of Nursing (DON) interviewed CNA Staff A about Resident #1's fall from the bed. CNA Staff A said that she was providing incontinent care, she reached for wipes that were placed at the resident's knees, and Resident #1 rolled out of bed onto the floor.The DON asked CNA Staff A if there was anyone else in the room to help her. CNA Staff A stated, No, we usually do two people, but everyone is busy, so I did it myself.The DON asked CNA Staff A if she was aware that the resident was care planned for 2 staff assistance with toileting and bed mobility needs. CNA Staff A stated, Yes, we usually use two, but we are busy, and I needed to clean him up, so I did it myself.The investigation noted 9 licensed nurses and 8 CNAs who were present and working on 6/19/25 at the time of the fall were interviewed. All 17 staff interviewed said that they were not asked to assist with Resident #1's care.On 6/25/25, the hospital provided the facility with a diagnosis of traumatic subarachnoid hemorrhage and subdural hematoma.On 6/25/25, the facility's investigation noted that CNA Staff A demonstrated her decision to act independently of the guidance provided by the facility's education and practices when she chose to not review and follow the Kardex prior to providing care to Resident #1. The resident's Kardex was available, up to date, and accurate at the time of the resident's fall.On 7/7/25 at 9:38 a.m., in an interview, the Administrator said CNA Staff a did not follow Resident #1's care plan for 2 staff assistance for bed mobility which resulted in the resident's fall and injury requiring the resident's transfer to a higher level of care.On 7/7/25 at 11:47:a.m., the Assistant Director of Nursing (ADON) was interviewed about facility processes to ensure that individualized interventions listed in Resident #1's care plan are consistently and correctly implemented.The ADON said after the incident, she interviewed all 17 nursing staff who worked on 6/19/25 and were present when Resident #1 fell out of bed. All 17 nursing staff said CNA Staff A did not ask for their assistance to provide incontinent care to the resident.On 7/7/25 at 12:07 p.m., in an interview the Administrator said, they always look at the breakdown of assignments. They make sure there is always someone they can ask for help. He said for example if there are 3 staff assigned, they all have a separate assignment, no floater. On weekend they have a weekend supervisor. The supervisor is not assigned to a cart and can assist as needed. During the day, they have the DON, ADON, Unit Managers and MDS nurses who can assist with care.On 7/7/25 at 2:02 p.m., in an interview CNA Staff C was asked how she knew how much assistance a resident required. She said she would find out in the Kardex. CNA Staff C said, Sometimes I work so many days, I just know and I don't need to look. But if I need the information, I can always look. When asked if there were enough staff to take care of the residents, CNA Staff A said, I cannot give that answer, I am sorry.On 7/7/25 at 2:10 p.m., in an interview CNA Staff D she worked for an agency and has worked at the facility 10 times. When asked if there was enough staff to take care of the residents, CNA Staff D said, Yes for today but no for other days. When asked how she knew how much assistance the residents needed, she said, I get a paper, I walk and look in the room. If I see a sling I know they need 2 staff. If they are heavier, or exhibit behaviors I know I will need more help. There is no paperwork that tells me. When asked if she knew about the Kardex, CNA Staff D said, Yes, I know the Kardex from prior use of [the facility's electronic documentation system]. However, when is there any time to check it? It would tell me the care plan but it is never accurate.On 7/7/25 at 2:18 p.m., in a telephone interview, CNA Staff A verified she did not follow the safety precautions listed on Resident #1's Kardex and changed the resident alone. She said on 6/19/25 Resident #1 had soiled himself and asked her to clean him. Staff A said she was working her hall alone. Another CNA was split with another hall. She said at the time of the incident she was alone on the hall. The nurse was busy with another patient. CNA Staff A said she raised the bed, rolled the resident on his side. She held Resident #1 with her hand and leaned to grab supplies. CNA Staff A said Resident #1 was a big man with a big belly and the bed was not big. She said Resident #1 hung over the side and rolled off the other side of the bed.On 7/9/25 at 10:51 a.m., the Unit Manager, Licensed Practical Nurse (LPN) Staff B was interviewed about supervising staff to ensure residents' care plan interventions are implemented correctly and consistently. Unit Manager Staff B said she made rounds every hour; she checks with staff and helps if needed. She said on 6/19/25 CNA Staff A should have checked with any other nursing staff. There was another CNA and a licensed nurse on the hall that day. She said that a lot of times the nurses are at the nurse's station doing paperwork.On 7/9/25 at 11:00 a.m., in an interview LPN Staff H said on 6/19/25 she was at the nurse's station when CNA Staff A called her and said Resident #1 was on the floor. CNA Staff A did not ask her for help. She said there were 2 CNAs assigned to that hall but one CNA was split with the other hallway. LPN Staff H said there used to be 2 CNAs dedicated to the hall were Resident #1 resided. She said the hallway needed 2 CNAs and they should not split halls.On 7/10/25, the survey team verified the immediate actions implemented by the facility to remove the Immediate Jeopardy, effective 6/25/25. The survey team verified the corrective actions implemented by the facility to correct the noncompliance, effective 7/3/25, prior to survey visit. The immediate and corrective actions implemented by the facility included:On 7/10/25, the survey team verified through review of documentation and interview with the Administrator that on 6/19/25 CNA Staff A was immediately suspended.On 7/10/25, the survey team verified through review of the audits provided that on 6/19/25 the DON completed a house-wide audit of care plans/Kardex for accuracy with bed mobility tasks.On 7/10/25 the survey team verified through record review that on 6/19/25 a Performance Improvement Plan (PIP) was initiated as a working document, open to edits and revisions. The survey team verified the Medical Director reviewed the PIP.On 7/10/25, the survey team verified through record review that on 6/20/25 CNA Staff A's personnel file was reviewed. It included education dated 4/25/25 and signed by the CNA on proper positioning of residents in bed, customer service, Kardex, and Plan of Care. On 5/6/25 CNA Staff A completed a self-study electronic education on fall preventions, CNA safely moving residents, lifting and transfers.On 7/10/25 the survey team verified through record review and interview with the Administrator that on 6/20/25 an Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held with the interdisciplinary team (IDT). The Performance Improvement Plan was reviewed and updates as appropriate. The Administrator, the DON, the Staff Development Coordinator, Unit Managers, The Social Service Director, the Therapy Director and the Medical Director attended the meeting.On 7/10/25, the survey team verified through record review that on 6/20/25 the facility completed care plan reviews of bed mobility level of care.On 7/10/25, the survey team verified through review of the education provided and the sign-in sheets that on 6/19/25 thru 6/25/25 current staff including contracted and agency staff were educated in person, telephonically, or electronically prior to working their next shift.Licensed Nurses were educated on Incidents and Accidents/Supervision, Abuse, Neglect and Exploitation, and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Certified Nursing Assistants were educated on Incidents and Accidents/Supervision, Abuse, Neglect, Exploitation and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Non-clinical staff were educated on Abuse, Neglect, Exploitation, Incidents and Accidents/Supervision.115 of 115 total Staff received the education. 35 of 35 current contracted staff received the education. 15 Agency Licensed Nurses/CNAs received the education.The survey team verified through review of documentation provided that any agency nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.On 7/10/25, the survey team verified through record review and interview with the Administrator that on 6/24/25 the facility held an Ad Hoc QAPI meeting with the IDT. The meeting included planning the planning of Quality Review Audits to review compliance with use of the Kardex, high fall risk residents, visualization of staff implementation of compliance with the Kardex and care plan interventions.On 7/10/25, the survey team verified through record review that on 6/27/25 the facility held their monthly Quality Assurance meeting. The Administrator, Director of Nursing, and Medical Director attended the meeting. The subject areas included the Performance Improvement Plan in place that resulted in the Ad Hoc QAPI on 6/19/25 was ongoing with audits in place. Current audits reviews were active and ongoing. The education was completed on 6/25/25.On 7/10/25, the survey team verified through record review and interview with the Administrator that on 7/3/25 the facility held a QAPI meeting with the Administrator, the Director of Nursing, and the Medical Director to review current status of Quality Review Audits completed by the facility.As of 7/3/25 audits have been completed on the following:Accidents and Incidents: Staff verbalize fall risk residents on assignment and 1 fall intervention for fall residents. On 6/25/25 7 staff audits were completed, on 6/26/25, and 7/3/25, 10 staff audits were completed.Compliance with Kardex and care plan interventions. This audit included visualizing during resident care the Kardex was followed. On 6/26/25 and 7/3/25, 15 staff audits were completed.Kardex use: Staff able to verbalize how to access resident care information, provide return demonstration on accessing the Kardex, and verbalize what to do in the event they need assistance providing care to a resident as evidenced by reading the Kardex. On 6/21/25, 6/23/25, 6/24/25, and 6/30/25, 10 staff audits were completed. On 6/26/25, 5 staff audits were completed.Accidents and Incidents: Observation of high fall risk residents to ensure fall interventions are in place in the residents' room, wheelchair, or on their person. 6/26/25 10 residents audits were completed. On 6/28/25, 7 residents audits were completed. On 6/30/25, 59 residents audits were completed, and on 7/2/25 5 residents audits were completed.During the above audits 7 of 15 residents care planned for assistance of 2 staff were audited.On 7/10/25 during interviews, 2 residents who were care planned for assistance of 2 staff said 2 staff members always provide care.On 7/10/25, the survey team verified through review of the documentation that the audits were being completed beyond 7/3/25.

Based on observation, facility policy and procedures review, record review and staff interviews, the facility failed to maintain urinary catheters in a safe and sanitary manner for 3(Residents #44, #51 and #65) of 5 residents reviewed with indwelling urinary catheters. The findings included: The facility policy Catheter Care implemented 11/2020 (revised 1/6/23) documented It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 1. Review of the clinical record revealed Resident #44 had an admitted [DATE] with diagnoses including cerebral palsy, obstructive and reflux uropathy, and renal calculus. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 3/13/24 documented Resident #44 was dependent on staff for toileting, personal hygiene, and bathing. The MDS noted Resident #44's cognitive skills for daily decision making were severely impaired. On 3/18/24 at 11:06 a.m., Resident #44 was in her bed and the catheter drainage bag was observed attached to the bed frame and was resting on the floor. The drainage bag was not in a protective, privacy bag. Photographic evidence obtained. Review of the care plan initiated 9/11/23 specified to keep catheter drainage bag off the floor. On 3/18/24 at 2:39 p.m., during an observation and interview, the catheter drainage bag was observed partially on the floor, hanging from the bed frame with the bed in a lower position. The drainage bag was not in a protective, privacy bag. In an interview, Resident #44 said she did not know why she had the catheter and said, it might be because of the wound on my backside. On 3/20/24 at 8:53 a.m., in an interview Certified Nursing Assistant (CNA) Staff C said she works Resident #44's assignment and is aware the drainage bags should never be on the floor. The CNA said the facility had provided education to her regarding catheter care. She said she makes sure when the residents are out of bed, she puts the drainage bag in a bag attached to the wheelchair so no one can see it and it is off the floor. 2. Review of the clinical record revealed Resident #51 had an admitted [DATE] with diagnoses including dementia, acute kidney disease, obstructive and reflux uropathy, hydronephrosis, stage 3 chronic kidney disease and suprapubic catheter. The Admission MDS with an assessment reference date of 2/23/24 documented Resident #51 required substantial to maximum assistance with toileting. The MDS noted Resident #51's cognitive skills for daily decision making were moderately impaired. On 3/18/24 at 9:29 a.m., Resident #51 was observed in bed, he had removed his hospital gown and had nothing but a brief on. He did not respond to verbal questions. The catheter drainage bag was observed on the floor and was not in a protective, privacy bag. Photographic evidence obtained. On 3/18/24 at 10:57 a.m., CNA Staff E was in the room and confirmed the drainage bag was on the floor and not in a protective, privacy bag. Staff E raised the bed to prevent the catheter tubing and drainage bag from coming into contact with the floor. CNA Staff E said the drainage bag was not supposed to be on the floor. She said, sometimes residents want you to place the catheter on one side of the bed only and don't want it behind them in the wheelchair (w/c) so we do what they ask us to do. On 3/19/24 at 8:27 a.m., Resident #51 catheter drainage bag was observed touching the floor and was not in a protective, privacy bag. Registered Nurse (RN) Staff G confirmed the observation and adjusted the drainage bag and tubing, so it was off the floor. Photographic evidence obtained. 3. Review of the clinical record revealed Resident #65 had an admitted [DATE] with a readmitted [DATE]. Diagnoses included dementia, acute kidney disease, obstructive and reflux uropathy, hydronephrosis, stage 3 chronic kidney disease and suprapubic catheter. The significant change MDS with an assessment reference date of 2/13/24 documented Resident #65 was dependent on staff assistance for toileting. The MDS noted Resident #65's cognitive skills for daily decision making were severely impaired. On 3/18/24 at 10:32 a.m., Resident #65 was observed in bed, the bed was in a low position. The Foley catheter drainage bag was on the floor resting partially on the wheel of the bed. The drainage bag was not in a protective, privacy bag. Photographic evidence obtained. On 3/18/24 at 4:15 p.m., Resident #65 was observed in the activity room, his catheter drainage bag was attached to the wheelchair but not in a privacy protected bag. The drainage bag and tubing were in contact with the wheel of the chair. Photographic evidence obtained. On 3/20/24 at 9:01 a.m., in an interview CNA staff F said she was assigned to work the 400 and 500 hallways and knew the residents who had indwelling catheters. Staff F said the drainage bag is not supposed to be on the floor. She said when in the w/c you put it behind them in a bag. When in bed you place it on the bedframe. If the resident had a low bed, sometimes it touches the floor because the bed is low. The CNA said she had in-service training on catheter care but did not remember when. Staff F said she empties the drainage bag into a container and takes it to the bathroom and pours it into the toilet. If it does not look right, I tell the nurse if I see bleeding. On 3/21/24 at 2:00 p.m., the Administrator said she initiated a Performance Improvement Plan (PIP) on 1/12/24 to address infection control. The PIP action steps included to ensure catheter drainage bags were off the floor and dignity bags were in place. The target date for the PIP was 2/10/24.

Based on record review and staff interview, the facility failed to ensure the accuracy of a Pre-Admission Screening and Resident Review by failing to make the necessary corrections for 2 (Residents #14 and Resident #41) of 5 residents with a new diagnosis of mental illness. The findings included: 1. The facility policy Resident Assessment implemented 11/2020 and revised 10/2023 stated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Review of the clinical record for Resident #14 revealed an admitted [DATE]. The documented diagnoses at the time of admission included a primary diagnosis of Encephalopathy, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hyperlipidemia, Gastro-Esophageal Reflux Disease and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS) assessment noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. The level I PASARR completed at a local hospital was dated 11/30/21, prior to admission. Section 1A and 1B where not checked for serious Mental Illness or Intellectual Disabilities. The list of medical diagnoses noted Resident #14 was diagnosed with schizoaffective disorder on 12/12/22 and generalized anxiety disorder on 5/17/23. The clinical record lacked documentation the level I PASARR was updated with the new diagnoses of mental illness. On 3/21/2024 at 1:40 p.m. the Director of Nursing, (DON), verified there was not an updated PASARR screening for Resident #14. She said Resident #14 required a level II screening because of a significant change of condition since her original admission. The DON said it was her responsibility to ensure PASARR was completed on every resident, and it should have been correctly completed and a Level II screening completed for Resident #14. 25618 2. On 3/19/24, a review of Resident #41's medical record revealed an initial admitted [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease with (acute) Exacerbation, and other diagnoses of Major Depressive disorder, Schizoaffective disorder unspecified, and Bipolar disorder unspecified. Review of Resident #41's PASARR Level 1 Screening form dated 10/6/23 completed by the Director of Nursing (DON), noted the diagnoses boxes for Schizoaffective Disorder and Bipolar Disorder in Section 1: PASARR Decision-Making were not checked. Review of the facility's Resident Assessment - Coordination with PASARR (Pre-Admission Screening and Resident Review) Program policy implemented on 11/2020 said an individual with a mental disorder, intellectual disability, or a related condition will receive care and services in the most integrated setting appropriate to the resident needs. All admissions to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. On 3/21/24 at 11:21 a.m., in an interview the DON said she was currently responsible to ensure all residents admitted to the facility had a completed and accurate PASARR Level 1 Screening form to determine if the resident would benefit from a Level II PASARR evaluation to determine if the resident could benefit from any specialized services. The DON reviewed Resident #41's medical record and confirmed Resident #4's initial admission to the facility was 11/22/22 and confirmed she had completed Resident #41's PASARR Level 1 screening form dated 10/6/23. The DON said after she reviewed Resident #41's PASARR Level 1 screening form dated 10/6/23, the PASARR was inaccurate because she did not check the diagnoses boxes for Schizoaffective Disorder and Bipolar Disorder as required per their facility policy and she would need to update Resident #41's PASARR Level 1 screening form with the appropriate diagnoses.

Based on observation, facility policy and procedures review, record review and staff interviews, the facility failed to store nebulizer inhalation equipment and bilevel positive air pressure (BiPAP) machine in a sanitary manner for 1(Resident #21) of 1 resident reviewed for respiratory care. The findings included: The facility policy CPAP/BIPAP Cleaning documented It is the policy of this facility to clean CPAP/BIPAP equipment in accordance with current Centers for Disease Control (CDC) guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. The facility policy Nebulizer Therapy implemented 11/2020 (revised 12/23/22) documented It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Care of the equipment specified to clean after each use. Rinse the nebulizer cup and mouthpiece with water. Once completely dry, store the nebulizer cup and mouthpiece in a plastic storage bag. Review of the clinical record revealed Resident #21 had an readmitted [DATE] with diagnoses including emphysema, former smoker, chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The quarterly MDS with an assessment reference date of 1/17/24 documented Resident #21's cognitive skills for daily decision making were moderately impaired. On 3/18/24 at 10:04 a.m., during an interview and observation Resident #21 had oxygen in use. She said she uses a bilevel positive air pressure (BiPAP) machine (delivers positive air pressure when you breath in and out to help with breathing) at night and receives nebulizer treatments because she gets short of breath. The BiPAP machine and mask were stored on top of a container next to the nightstand and had items stored under it and a plastic cabinet next to it. The BiPAP machine and mask were not covered. The nebulizer and mask were on top of the nightstand, uncovered. Photographic evidence obtained. Review of the care plan identified the resident was at risk of respiratory complications related to COPD, emphysema, chronic respiratory failure, and sleep apnea. The care plan instructed to administer oxygen and medications as ordered and Bi-PAP settings as ordered. Review of the physician orders specified to clean BiPAP face mask frame daily after use with soap and water on the day shift. On 3/19/24 at 8:31 a.m., in an interview Resident #21 said she used to smoke and quit [AGE] years ago. I have COPD so I am always short of breath, the oxygen helps. I sleep with the BiPAP on. The BiPAP mask and machine remained uncovered and in the same location. The nebulizer mask was uncovered and lying on the nightstand. On 3/20/24 at 9:53 a.m., in an interview and observation Licensed Practical Nurse Staff D, confirmed the BiPAP and nebulizer masks were on top of the nightstand and said they should be covered when not in use. The LPN said, I know she uses the nebulizer during the day, I don't know about the BiPAP because I am not here at night. Resident #21 said she uses the BiPAP at night. The LPN said, there are plastic bags right here and placed the masks into the plastic bags.

Based on record review, and staff interview, the facility failed to ensure ongoing communication and collaboration with the dialysis center related to assessment of the resident before, during and after each dialysis treatment for 1 (Resident #84) of 1 resident reviewed for dialysis. The findings included: The facility policy titled Hemodialysis revised on 11/28/2022 stated, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis . This will include: ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form . The facility will communicate with the dialysis facility, attending physician and /or nephrologist and significant weight changes, nutritional concerns, medication administration or withholding of certain medications prior to the dialysis treatment and document such orders. Review of the Admission Record indicated Resident #84 was admitted to the facility on [DATE]. Diagnoses included acute kidney failure and dependence on renal dialysis. Review of Resident #84's clinical record showed the facility utilized Hemodialysis communication Record forms to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The form consisted of three sections: The first section to be completed by the licensed nurse prior to the dialysis treatment, including an evaluation of the access site, blood pressure, temperature, pulse, last meal, diet, and the resident's general condition. The second section to be completed by the dialysis center following dialysis treatment included an evaluation of the access site, pre and post dialysis weight, new orders, significant change in condition during dialysis. The third section to be completed by the facility's receiving licensed nurse post-dialysis treatment included an evaluation of the access site, and any new orders from the dialysis center. The forms are kept in a dialysis book. Review of the care plan showed Resident #84 received hemodialysis at a local dialysis center on Tuesdays, Thursdays, and Saturdays. Review of Resident #84's dialysis book revealed three Hemodialysis communication Record forms. The Hemodialysis Communication Record form dated 3/16/24 had a line drawn through the date, and 3/19/24 written underneath. The section to be completed by the dialysis center was blank. The hemodialysis communication record form dated 3/19/24 was missing the post-hemodialysis information from the dialysis center, including blood pressure, pre and post weight, medications given during hemodialysis, any new orders, or significant change in condition. No hemodialysis communication form was found for 3/12/24, or 3/14/24. On 3/20/24 at 10:22 a.m., in an interview Licensed Practical Nurse (LPN) Unit Manager Staff (J), said she did not know if the nurses have been filling out the Dialysis communication Record. She noticed Resident #84's dialysis book was not leaving the resident's bag after he returned from his treatment. Staff J said she was unable to find the missing dialysis communication forms from treatment dates of 3/12/24 and 3/14/24. Unit Manager, Staff J said the nurse needs to make a phone call to the dialysis center if the post treatment section is not filled out. Unit Manager Staff J said she was the nurse who received Resident #84 after dialysis treatment on 3/19/24 and did not make a phone call to get a verbal report of post-hemodialysis care from the dialysis center. On 3/21/24 at 9:27 a.m., in an interview the Director of Nursing (DON) verified the pre and post dialysis sections of the hemodialysis communication forms were not being consistently completed. On 3/21/24 at 10:35 a.m., in an interview the DON said the purpose of monitoring the blood pressure pulse and temperature before and after dialysis was to make sure there was no infection, fever wise, hypotension (low blood pressure) or hypertension (high blood pressure). The DON stated, There is a lack of communication between the facility and the dialysis center.

Based on a review of facility policy and procedures, record review, and staff interviews, the facility failed to accurately assess and reassess risk factors and provide necessary supervision and assistance to prevent falls, for 1 (Resident #4) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including a fall with injury requiring the resident's transfer to a higher level of care. The findings included: A review of the facility policy and procedure, Falls Prevention program, stated that each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the clinical record for Resident #4 revealed a hospital physician progress note dated 6/7/22 which noted the resident was getting out of the shower and apparently fell and hit her head. The resident seemed a bit confused. The resident's friend stated the resident was unable to take care of herself alone any longer, as this was not the first fall she's had. Resident #4 was admitted to the facility on [DATE] with diagnoses including acute Right Cerebellar Infarct (Stroke), falls, hypertension (High blood pressure), Diabetes Type 2, and dementia. The Admission Minimum Data Set (MDS) (a standardized assessment tool to measure the health status of nursing home residents), effective on June 18, 2022, noted the Resident scored 3 on the Brief Interview of Mental Status, indicating severe cognitive impairment. Resident #4 was not able to report the correct year, correct month, or correct day of the week. The resident was not able to recall the words sock, blue or bed during the interview. Resident #4 required limited physical assistance of one person for transfer. The Admission MDS assessment was inaccurate and noted Resident #4 did not have a fall any time in the last month prior to admission. The fall risk evaluation tool utilized by the facility noted to assess the resident status. If the total score is 10 or greater, the resident should be considered high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The fall risk evaluation dated 6/14/22 for Resident #4 was inaccurate and noted the resident had no history of falls in the past three months. Resident #4 scored 8 on the fall risk evaluation. The care plan initiated on 6/14/22 identified Resident #4 as at risk for falls and fall-related injuries related to impaired mobility. Interventions were documented as anticipate needs, provide prompt assistance, ensure call light is within use and encourage use for assistance with standing, transferring, ambulation; follow facility fall protocol; invite, encourage, remind, escort to activity program; keep frequently used items within reach; review information on past falls and attempt to determine cause of falls; record possible root causes, alter, remove and potential causes if possible. The care plan also noted the resident was at risk for decreased ability to perform activities of daily living related to impaired mobility, recent illness, and hospitalization , including transfer, and locomotion. On 6/15/22 an activity progress note documented the Activity Director met the resident for an Admission Assessment. Resident #4 was, quite confused and unable to answer questions. A call was made to the contact person to assist with the admission assessment. On 6/26/22 a nursing progress note documented Resident #4 was oriented to self only. Review of the Physical Therapy progress report dated 6/28/2022 noted Resident #4 was able to perform functional transfers such as: coming to a standing position from a bed or wheelchair and transferring to and from a bed to a wheelchair with partial assistance. The resident was able to ambulate 15 feet with two wheel walker and contact guard assist, however required constant verbal cues for safety. The therapist documented due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the resident was at risk for falls. On 6/30/22, Licensed Practical Nurse (LPN) staff F documented Resident #4 was observed sitting in the hallway in her wheelchair and stood up and fell ; no injuries were identified. The care plan was updated on 6/30/22 to encourage the resident to not stand without assistance. On 6/7/23 at 2:15 p.m., the Director of Nursing (DON) said Resident #4 was not able to understand instructions in general. The intervention to, Encourage her to call for assistance was not something she could have done. The DON said she did the investigation. She said, I had no idea what she was wearing, what she was going to do or where she was trying to go. I was not there so I don't know if she was hungry, thirsty, or looking for something to eat. She said she did not have any documentation to reflect what interventions were in place at the time of the fall. On 7/1/22, LPN Staff C documented in a progress note Resident #4 was observed having paranoid behaviors. The progress note stated, Resident was accusing staff of stealing, calling out thief loudly, difficult to redirect away from courtyard door, attempting to bite this writer when turning the resident around. On 7/5/22, LPN Staff F documented Resident has poor safety awareness and transfers multiple times throughout the day and is unsteady. Resident #4 was unable to understand or repeat verbal education to call for assistance before transferring. On 7/9/22 at 5:00 p.m., LPN Staff F documented resident refused 5 p.m. medication and dinner and stated, It is poisonous. The Resident continually stands up from the wheelchair and is unsteady when standing. Attempts to educate on safety awareness were unsuccessful as the Resident attempted to bite and hit and stated, I don't care what you or anyone says. Resident continually went into male residents' rooms, and when asked to leave their room, she yells at them, No!, you will not steal this room from me, and you cannot make me leave. On 7/10/22 at 1:19 p.m., LPN Staff F documented resident refused both breakfast and lunch today, stating you are trying to poison me. Stop it! stop trying to make me eat poison; you are not going to kill me. Resident continued to hit, bite and punch CNAs and nurses. The clinical record lacked documentation the physician was notified of the increased in behavior. There was no documentation the resident's fall risk was reassessed for the need of increased supervision due to the increase in behavior, including continually standing up, wandering into other residents' rooms, and the resident's inability to understand safety instructions. On 7/11/22, a facility incident report noted Resident #4 was found on the floor next to the bed with a hematoma (blood collection in the tissues) to the forehead, and a laceration to the nose. The Resident was confused (as was reported at shift change) and complained of right hip discomfort. The Resident was unable to describe what happened. The Resident was transferred to the local hospital for evaluation and possible sutures. The predisposing situation factors included, Ambulating without Assist. The physician progress note from the local hospital dated 7/11/22 noted the resident was seen at 10:32 a.m. for an injury to the face. The injury occurred just prior to arrival. Staff told EMS (Emergency Medical Services) that while she was putting on her pants she missed her leg and fell forward onto her face causing a laceration to bridge of the nose and a hematoma on the central forehead. The decision was made on 7/11/22 at 2:12 p.m. to discharge the resident to the facility. On 6/7/23 review of the investigation dated 7/11/22 showed witness statements noting staff found the resident on the floor on 7/11/22 at 7:50 p.m. and the nurse assessed the resident on 7/11/22 at 8:53 p.m. On 6/7/23 the DON provided a statement from the physician which noted the Cerebellar infarct, which was new, but the timeline couldn't tell if it was pre-fall or a result of the fall. This pathology would have caused the fall and contribute to subsequent falls, as her ability to balance would have been lost . On 6/7/23 at 4:11 p.m., the DON said, We don't have any witness statements for the morning fall. The witness statements we have are null and void. She said the nurse who was on duty at the time of the fall did not write an incident report. She said there was no report of the incident from the day shift at all. The DON said, We know she was found face down on the floor, but we don't know how she got there. Last rounds are usually done at 6:00 a.m., but I am not able to access records to confirm last care.

Based on record review, and staff interview, the facility failed to promptly notify the physician of a change in condition, including increased confusion and agitation for 1 (Resident #4) of 3 sampled residents reviewed for accidents. The findings included: Clinical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses including acute Right Cerebellar Infarct (Stroke), Falls, Hypertension, Diabetes Type 2, Dementia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of June 18, 2022, noted the resident scored 3 on the Brief Interview of Mental Status, indicating severe cognitive impairment. Resident #4 had no hallucination, delusion (misconceptions or beliefs contrary to reality). Resident #14 did not display any physical or verbal behavioral symptoms (kicking, threatening, kicking) directed toward others. The nursing admission progress note dated 6/14/22 at 17:16 p.m., noted resident was alert, speech was clear and coherent, resident was able to understand verbal communication and make self-understood. Mood was pleasant, no unwanted behaviors. The care plan initiated on 6/15/22 noted the resident had potential for negative moods, behaviors related to mood disorder, encephalopathy, dementia, depression, schizoaffective disorder. Interventions included to monitor, document, and report increased anger, labile mood or agitation, feelings of being threatened by others, thoughts of harming someone, possession of items or objects that could be used as weapons. Staff was to monitor/document and report mood patterns to the physician as needed. The interdisciplinary progress notes from 6/14/22 through 6/23/22 showed Resident #4 did not display any change in mood or behavior. Review of the Treatment Administration Record (TAR) for July 2022 revealed on 7/1/22 Resident #4 had a change in condition and started to display paranoia behaviors (unjustified suspicion and mistrust of other people or their actions). The TAR noted 13 episodes of paranoia behaviors from 7/1/22 through 7/13/22. On 7/1/22 Licensed Practical Nurse (LPN) Staff C, documented Resident #4 was observed having paranoia behavior. Resident #4, was accusing staff of stealing, calling out thief loudly, difficult to redirect aware from courtyard door, attempting to bite this writer when turning the resident around. On 7/3/22 LPN Staff F, documented resident #4 refused both breakfast and lunch. Resident #4 stated, I'm not crazy, you cannot fool me, I know what this food is. On 7/5/22 LPN Staff F, documented Resident #4 was refusing meals, alternate meal choices, snacks. Resident stated, I don't know what you are saying. Resident has poor safety awareness and transfers multiple times throughout the day and is unsteady. Resident unable to understand or repeat verbal education to call for assistance before transferring. On 7/7/22 the Psychiatry evaluation noted the resident was alert and oriented x1 (person) and pleasantly confused on interview. Nursing reports her dementia persists, but no additional behaviors or concerns reported from staff. She remains compliant on her psychotropic medications without evidence of any medication side effects. On 7/8/22 at 11:20 a.m., LPN Staff F, documented Resident #4 threw an entire cup of Ensure over the nurse and yelled, Evil, Evil, Evil, you are lazy! You are a thief! Resident also grabbed a CNA (Certified Nursing Assistant) this morning and purposely scratched her causing bleeding, she scratched another CNA. Staff F documented the resident refused her medications, and food stating it was poisonous. On 7/9/22 at 5:00 p.m., LPN Staff F, documented Resident #4 refused 5:00 p.m. medications and dinner. The resident stated it is poisonous. Resident continually standing up from wheelchair and is unsteady when standing. Attempts to educate on safety awareness unsuccessful as resident attempts to bite, and hit and states, I don't care what you or anyone says. Resident continually going into male residents rooms and when asked to leave their room she yells at them, No!, you will not steal this room from me and you cannot make me leave. On 7/10/22 at 1:19 p.m., LPN Staff F documented Resident #4 refused both breakfast and lunch today. The resident stated, you are trying to poison me. Stop it!, stop trying to make me eat poison, you are not going to kill me. Resident continued to hit, bite and punch CNAs and nurses. The clinical record lacked documentation the physician was notified of the sudden increase in behaviors. There was no documentation of interventions to ensure adequate supervision to prevent unsafe transfers, ambulation, and wandering. A facility Incident report dated 7/11/22 at 8:10 p.m. noted Resident #4 was found on the floor next to bed with a hematoma (collection of blood in the tissues) to the forehead, a laceration to the nose. The resident was confused and complained of right hip discomfort. The resident was unable to give a description of what happened. The resident was transferred to the local hospital for evaluation of treatment of injuries to the head. On 6/6/23 at 4:30 p.m., the physician said she was not aware Resident #4 had been refusing medications, meals, assaulting staff and wandering in male rooms. She said the facility should have notified her. On 6/7/23 at 12:18 p.m., the Advanced Practice Registered Nurse (APRN) said most of her interactions were with Resident #4's family after the resident returned from the hospital in July. She said she did not recall receiving any notification regarding behaviors, agitation, aggression. She said she would have wanted to be notified of the behaviors. On 6/7/23 at 4:00 p.m., the Director of Nursing (DON) said the facility's policy was to report any change in condition to the physician and the family should be called. She said she could not recall if staff notified her of the resident's onset of behaviors. She verified the lack of documentation the physician was notified of the resident's behaviors, including refusal to take her medications. The DON said, As a DON, I feel like the physician should have been notified.

Based on observation, interview and record review, the facility failed to implement their Employee COVID-19 Vaccination Exemption policy to mitigate the spread of COVID-19 by not ensuring unvaccinated staff followed additional precautions while working with residents. This deficient practice had the potential to affect a limited number of residents. The staff vaccination rate for the facility was 100%. Findings included: On 5/25/22 at 10:42 AM Nursing staff A was observed on the unit passing medications. He/she was wearing a surgical mask. At that time, when asked what COVID-19 protocol he/she is supposed to follow she/he said we are supposed to wear a surgical mask at all times. At 1:33 PM Nursing staff A was observed at the nurses' station with a N 95 respirator and goggles on her/his head talking to another staff person. Review of the staff vaccination status revealed that Nursing staff A had a medical exemption and was not vaccinated. On 5/25/22 at 10:51 AM Certified Nurse's Aide (CNA) B was observed on the unit with a cloth mask. At that time, he/she stated that she/he worked for an agency and is sent to this facility often. She/he said she/he always wears a mask and has all the paperwork submitted for an exemption. At 1:36 PM, CNA B was observed working with a resident and was wearing goggles and a N 95 respirator with a cloth mask over it. Additionally, at 2:00 PM he/she was observed on the unit with a N 95 respirator but with goggles on her/his head. Review of the staff vaccination status provided revealed that CNA B was not vaccinated and had a religious exemption. Review of the Employee COVID-19 Vaccination Exemption policy dated 11/2020, reviewed and revised on 3/2022 revealed that the facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff that are not fully vaccinated . which would involve masking, social distancing, reassignment, testing, use of N 95 or higher-level respirator, etc. Interview with the Director of Nursing at 1:20 PM revealed that to mitigate the spread of COVID-19, unvaccinated staff are tested twice a week because the community transmission level is high, and they should wear eye protection and a N 95 mask. They will also use a separate break room. The facility failed to implement their additional precautions policy for unvaccinated staff that had access to residents on the unit by ensring staff correctly wore goggles and not work directly with residents.

Based on observations and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary manner to prevent possible contamination of food on the tray line from dirty air vents. The lack of sanitation in the kitchen has a potential to affect all residents who consume an oral diet. The findings included: On 4/26/22 at 11:30 a.m., the air vent located directly over the steam table containing uncovered residents' food items had a large accumulation of dust. Photographic evidence obtained On 4/27/22 at 9:00 a.m., the air vent over the steam table remained with a large accumulation of dust. On 4/28/2022 at 9:15 a.m., the Regional Food Service Director verified the air vent over the steam table was covered in dust and debris. He said he would move the steam table, cover the food with plastic bags, and clean the dirty vents himself to prevent further chance of food contamination. He said he was unsure why housekeeping had not gotten to it already. On 4/29/2022, the facility provided a cleaning schedule for the kitchen which included the air vents. The schedule was signed off as completed for March 2022 but not for April 2022.

Based on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) Assessment within 14 days of the Assessment Reference Date (ARD) as required by regulation for 5 (Residents #85, #17, #13, #12, and #30) of 20 residents reviewed for quarterly assessments. The findings included: On 4/27/22 record review revealed Resident #85 had a quarterly MDS with an ARD of 3/19/22 scheduled. As of 4/27/22, 39 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #17 had a quarterly MDS with an ARD of 2/28/22 scheduled. As of 4/27/22, 58 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #13 had a quarterly MDS with an ARD of 3/4/22 scheduled. As of 4/27/22, 54 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #12 had a quarterly MDS with an ARD of 2/22/22 scheduled. As of 4/27/22, 64 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #30 had a quarterly MDS with an ARD of 3/31/22 scheduled. As of 4/27/22, 27 days later, the required quarterly MDS assessment was not completed. On 4/27/22 at 9:00 a.m., in an interview, the RN (Registered Nurse) MDS Coordinator said the assessments are late because of the workflow and the volume of the MDS. On 4/27/22 at 2:15 p.m. the RN Regional Nurse MDS Coordinator provided a list showing the facility has 119 MDS assessment currently late as of 4/27/22. The RN Regional Nurse said, we have a problem. On 4/27/22 at 2:31 p.m., in an interview, the Director of Nursing DON said she knew we had late assessments but not that many.

Based on record review and staff interview, the facility failed to ensure completion of the admission Minimum Data Sat (MDS) assessment within 14 days from date of admission or the annual MDS assessment within 366 days of the assessment reference date (ARD) of the last annual MDS assessment as required by regulation for 5 (Resident #14, #16, #343, #345 and #346) of 20 residents sampled. This has potential to delay assessment and formulation of the plan of care. The findings included: On 4/27/22 record review of Resident #343 revealed an admitted [DATE]. As of 4/27/22, 59 days later, the admission MDS was not completed. On 4/27/22 record review of Resident #345 revealed an admitted [DATE]. As of 4/27/22, 64 days later, the admission MDS was not completed. On 4/27/22 record review of Resident #346 revealed an admitted [DATE]. As of 4/27/22, 35 days later, the admission MDS was not completed. On 4/27/22 record review of Resident #16 revealed an admission MDS assessment with an ARD date of 3/8/21. The resident remained at the facility. As of 4/27/22 an annual MDS was not completed within 366 days from the admission MDS assessment ARD date of 3/8/21. On 4/27/22 record review of Resident #14 revealed the [NAME] annual MDS had an assessment reference (ARD) date of 3/2/21. The resident remained at the facility. As of 4/27/22, an annual MDS was not completed within 366 days from the prior annual MDS assessment ARD date. On 4/27/22 at 9:00 a.m., in an interview, the RN (Registered Nurse) MDS Coordinator said the assessments are late because of the workflow and the volume of the MDS. On 4/27/22 at 2:15 p.m. the RN Regional Nurse MDS Coordinator provided a list showing the facility has 119 MDS assessment currently late as of 4/27/22. The RN Regional Nurse said, we have a problem. On 4/27/22 at 2:31 p.m., in an interview, the Director of Nursing DON said she knew we had late assessments but not that many

Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) tracking records were submitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion of the event for 6 residents (Resident #347, #72, #350, #351, #20 and #349) of 10 reviewed for timely submission. The findings included: On 4/26/22 at 8:05 a.m., record review for the following residents revealed: Resident #20 had an entry with event date (admitted ) of 2/26/22. The record should have been transmitted by 3/12/22. Facility transmitted on 3/14/22 (2 days late). Resident #347 had an entry with event date of 3/24/22. The record should have been transmitted by 4/7/22. Facility transmitted on 4/19/22 (12 days late). Resident #349 had an entry with event date 3/31/22. The record should have been transmitted by 4/14/2. Facility transmitted entry tracking on 4/25/22 (11 days late). Resident #350 had an entry with event date of 3/29/22. The record should have been transmitted by 4/12/22. Facility transmitted on 4/27/22 (15 days late). Resident #351 had death tracking form with event date of 3/22/22. The record should have been transmitted by 3/26/22. Facility transmitted on 4/22/22 (27 days late). Resident #72 had an entry with event date of 4/1/22. The record should have been transmitted by 4/15/22. Facility transmitted entry tracking on 4/22/22 (7 days late). On 4/27/22 at 9:09 a.m., record review of validation reports for Resident #347, #72, #350, #20 and #349 noted Warning: Record submitted late. The submission date is more than 14 days after A1600 and for Resident #351, Warning. Record submitted late. The submission date is more than 14 days after A2000. On 4/27/22 at 09:50 a.m., in an interview, Registered Nurse MDS Coordinator confirmed the entry tracking records for Residents #347, #72, #350, #20 and #349 and the death tracking form for Resident #351 were submitted late. She said entry and death tracking records should be submitted no later than 14 days after the event date.

Based on observation, record review, Resident and staff interview, the facility failed to identify, assess, address, and monitor individual underlying causes and contributing factors for decline in 4 areas in functional mobility for 1 Resident (Resident #17) who had a significant change in condition of 2 Resident reviewed. On 4/25/22 at 12:15 p.m. Resident # 17 was observed in bed with staff assisting with feeding. On 4/25/22 at 1:36 p.m., Certified Nursing Assistant (CNA), Staff G, said Resident # 17 was now dependent on staff for eating. Resident #17 used to be able to feed herself. Staff G said Resident #17 used to be able to transfer with minimal assistance but now required a mechanical lift for transfers. On 4/26/22 at 8:09 a.m., Licensed Practical Nurse (LPN) Staff H said Resident # 17 was requiring more assistance with activities of daily living (ADL) from staff. LPN Staff H stated, it is a change for her. On 4/26/22 at 2/03 p.m. Review of Resident # 17's Annual Minimum data set (MDS) with an assessment reference date (ARD) of 12/8/21 indicated Resident was independent with eating and dressing and extensive assistance with bed mobility. Review of the activities of daily living log for the months of February, March and April 2022 showed Resident # 17 had declined in four areas, eating, personal hygiene, bed mobility and dressing. On 4/27/22 at 12:04 p.m., RN (Registered Nurse) MDS Coordinator confirmed Resident #17 had declined in bed mobility, dressing, eating and personal hygiene. RN Coordinator said in the areas of bed mobility, Resident # 17 went from extensive to total, dressing was supervision and now is total, eating was supervision and now is extensive, and personal hygiene is now total. RN MDS Coordinator said Resident #17 would have benefited from a significant change and the interdisciplinary team should have evaluate, assess, and find the root cause of the change. RN MDS said team should have attempted to address and update Resident # 17's plan of care. On 4/28/22 at 2:19 p.m., the Director of Nursing (DON) acknowledged a significant change in condition MDS should have been completed for Resident #17.

Based on observation, review of facility's policy, and staff interview, the facility failed to maintained medications in locked compartment when not under direct observation for 1 (400 hall) of 6 medication carts observed. The findings included: The facility policy for medication storage implemented on 4/20/20 and reviewed on 1/2/22 indicated, All drugs and biologicals will be stored in locked compartments i.e., medication carts. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 4/26/22 at 7:53 a.m., the medication cart in the 400 hall was unlocked. Licensed Practical Nurse (LPN) Staff H was behind closed door in a resident's room. The unlocked cart was not within her direct observation. LPN Staff H returned to the medication cart at 8:01 a.m. Surveyor introduced self and said she was going to observe medication pass for some residents. LPN Staff H stated, I have to go wash my hands. She left the medication cart unlocked and unattended and returned at 8:04 a.m. for an additional 2 minutes. LPN Staff H verified the medication cart was left unlocked and not under direct supervision. She said oh I should have locked it. On 4/26/22 2:55 at p.m., the Director of Nursing (DON) said she would make sure it does not happen again. On 4/26/22 at 4:12 p.m., the medication cart on the 400 hall was observed unlocked and unattended. On 4/26/22 at 4:16 p.m., LPN Staff J returned to the unlocked medication cart and said, I am sorry, my cart should be locked . On 4/26/22 at 5:03 p.m., the observation was shared with the DON. she said, In-services are needed.

Based on observation, review of facility policies and procedures, review of clinical records and resident and staff interviews, the facility failed to provide appropriate services and interventions for the management of contractures for 1(Resident #63) of 2 residents reviewed with limited range of motion. The findings included: The facility policy Functional Maintenance Program, (revised 1/5/21) specified the program is designed to assist patients in maintaining functional status achieved in skilled therapy. The program goal is to maintain the resident's functional capacity, improve quality of life, improve, or maintain resident safety and to decrease risk for physical or medical complications. The therapist will develop a patient specific, written functional maintenance plan for nursing/caregiver staff to carry out. On 4/25/22 at 2:51 p.m., during an observation and interview, Resident #63 had limited range of motion (ROM) of both hands and did not have splints in place. Resident #63 was not able to fully open his right hand. Resident #63 said he had splints at one time, but no one had put them on for him. On 4/26/22 at 1:44 p.m., Resident #63 was in his wheelchair and did not have a splint on the right hand. A review of the clinical record revealed Resident #63 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with a target date of 2/4/22, documented Resident #63 had functional limitation in Range of Motion (ROM) on both sides of upper and lower extremities. The care plan initiated on 5/1/20 and revised on 11/2/21 identified the resident was at risk for decreased ability to perform ADLs (activities of daily living). The interventions included to monitor for ADL decline and refer to therapy, monitor complications of immobility including contractures. On 4/26/22 at 4:28 p.m., the Therapy Director said Resident #63 was not currently on therapy case load for management of contractures. He said the process is when a resident is discharged from therapy with a splinting device, they train the certified nursing assistant (CNA) and nurse who work with the resident and then they in turn pass it along to the staff on the other shifts. He said the facility did not have a restorative program and no one to ensure the splints and braces were applied once a resident was discharged from therapy. The OT said I wish the facility had someone to monitor the application of the splints and braces, but they don't have that here. The OT said Resident #63 had received occupational therapy beginning in February 2021 through March 2021 and had been discharged with a right-hand splint to be applied and removed every 2 hours. The OT said, every resident was screened annually to assess the need for therapy. He said the nurse would send a therapy referral for any resident who had a change in condition and therapy would complete a screen to determine if the resident would benefit from therapy. Review of the occupational therapy discharge summary for Resident #63, dated 3/1/21 documented Functional Maintenance Program established/trained- splint and brace program. Splint for 2 hours a day. Resident does not want to wear more than that and does not want to wear at night. On 4/27/22 at 9:30 a.m., Certified Nursing Assistant (CNA) Staff E said Resident #63 did not have any splints for his hands. She said if a resident had a splint or brace therapy would show the staff how to put it on and take it off. CNA Staff E said she gets report from the previous shift and the nurse would tell her if anything had changed with a resident. On 4/27/22 at 9:31 a.m., Certified Occupational Therapy Assistant (COTA) Staff K said Resident #63 was discharged from services in March 2021 with a resting right-hand splint. The COTA said once a resident was discharged from therapy, they provide the CNA and nurse with education on the use and application of the device, and the resident is considered to be on a Functional Maintenance Program. The COTA confirmed there was no one to oversee the Functional Maintenance Program, she said she suppose it would be the nurse. On 4/27/22 at 9:44 a.m., the Director of Nursing (DON) said once a resident was discharged from therapy with a splint or device, therapy places them on a functional maintenance program and the CNA and nurse would be responsible to ensure the device was applied. The DON confirmed no staff member assigned to ensure the Functional Maintenance Program was followed and the positioning devices were applied. On 4/28/22 at 1:05 p.m., Licensed Practical Nurse (LPN) Staff H said she did not know what the Functional Maintenance Program was or who was responsible to apply splints or braces for residents. On 4/28/22 at 1:06 p.m., LPN Staff I said there was no one to oversee the Functional Maintenance Program or keep track of the residents who had a splint or brace. LPN Staff I said therapy discharges the resident with a splint and educates the staff who care for the resident but there was no record or individual responsible to ensure the splints or braces were applied. On 4/28/22 at 2:03 p.m., the Therapy Director said he had evaluated Resident #63 today and was not able to locate the resident's right hand splint. The Therapy Director said he planned to place him on case load and order a new resting hand splint for the resident's right hand.