WOODLAND PARK NURSING & REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 2 meals (lunch) reviewed for palatability and temperature. The facility failed to provide food that was palatable and an appetizing temperature for 1 observed on 07/22/25 (lunch) meal. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the daily menu dated on 07/22/25, indicated the lunch meal (A) items included Swiss steak with gravy, roasted potatoes, mixed veggie, and iced tea. During an observation on 07/22/25 at 11:00 a.m., the plate warmer cabinet was not plugged in to the power source. During an observation and interview on 07/22/2025 at 12:25 p.m., the test tray had Swiss steak with gravy, roasted potatoes, mixed veggie. The DM measured temperature of the roasted potatoes at 108 degrees and said not warm enough. She said the food should be at least warm. During the tasting of the test tray the potatoes were not warm enough. The DM said [NAME] PP must had forgot to plug in the plate warmer. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure). Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13, which indicated her cognition was cognitively intact. Record review of Resident #3's comprehensive care plan revised 07/22/2025 is at risk for unplanned weight loss or gain. Her intervention included determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Review of Resident #3's physician orders dated 07/01/2025 included no salt on tray, low concentrated sweets diet with a start date of 02/25/2025. During an interview on 07/23/2025 at 4:00 p.m., Resident #3 had concerns about cold food on initial tour. She said the hot food would not even be warm and she had not reported to the facility. Team also received test trays to assess temperatures. Record review of the Food Preparation and Service dated November 2022 indicated . Food and nutrition services employee prepare, distribute and serve in a manner that complies with safe food handling practices.Food Distribution and Service 1. Proper hot and cold temperatures are maintained during food distribution and service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans.<BR/>* The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. <BR/>* The facility failed to update Resident #2's care plan after she had 2 falls. <BR/>* The facility failed to develop a person-centered care plan with interventions that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall.<BR/>An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents who were assessed as high risk for falls at risk of serious harm and injury. <BR/>Findings included:<BR/>1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility.<BR/>Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls.<BR/>Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. <BR/>Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. <BR/>Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. <BR/>Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. <BR/>Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER.<BR/>Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. <BR/>Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone.<BR/>Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. <BR/>During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them.<BR/>2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. <BR/>Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. i<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. <BR/>Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had &frac14; side rails. She was not able to answer questions. <BR/>3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).<BR/>Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls.<BR/>Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. <BR/>Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx.<BR/>Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. <BR/>Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for &frac14; rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. <BR/>During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. <BR/>During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. <BR/>During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. <BR/>Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated:<BR/>Policy Statement<BR/>Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.<BR/>Policy Interpretation and Implementation<BR/> Fall Risk Factors:<BR/> 2. Resident conditions that may contribute to the risk of falls include:<BR/>a. fever; <BR/>b. infection; <BR/>c. delirium and other cognitive impairment; pain; <BR/>d. lower extremity weakness; <BR/>e. poor grip strength; <BR/>f. medication side effects; <BR/>g. orthostatic hypotension; <BR/>h. functional impairments; <BR/>i. visual deficits; and <BR/>j. incontinence.<BR/>3. Medical factors that contribute to the risk of falls include:<BR/>a. arthritis; <BR/>b. heart failure; <BR/>c. anemia; <BR/>d. neurological disorders; and balance and gait disorders; etc.<BR/>Resident-Centered Approaches to Managing Falls and Fall Risk<BR/>1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls <BR/>Monitoring Subsequent Falls and Fall Risk<BR/>1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling <BR/>The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m.<BR/>F656- <BR/>All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.<BR/>1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.<BR/>2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.<BR/>3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. <BR/>4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25.<BR/>5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025.<BR/>6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. <BR/>If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.<BR/>The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. <BR/>A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. <BR/>This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.<BR/>Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.<BR/>Monitoring: Record review and interviews of completed:<BR/>* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. <BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.<BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.<BR/>* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. <BR/>During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision and assistance devices to prevent accident for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision.<BR/>* The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. <BR/>* The facility failed to ensure Resident #2 had interventions in place after she had 2 falls. <BR/>* The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall.<BR/>An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents who were assessed as high risk for falls at risk of at risk of potential accidents, serious injuries, serious harm, or death. <BR/>Findings included:<BR/>1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility.<BR/>Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls.<BR/>Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. <BR/>Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. <BR/>Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. <BR/>Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. <BR/>Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER.<BR/>Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. <BR/>Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone.<BR/>Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. <BR/>During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them.<BR/>2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. <BR/>Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. <BR/>Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had &frac14; side rails. There were no fall mats on the floor by the bed and the bed was not in the lowest position. She was not able to answer questions. <BR/>3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).<BR/>Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls.<BR/>Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. <BR/>Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx.<BR/>Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. <BR/>Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for &frac14; rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. <BR/>During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed and the bed had &frac14; rails. There were no fall mats on the floor next to the bed and the bed was not in the lowest position. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. <BR/>During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. <BR/>During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. <BR/>Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated:<BR/>Policy Statement<BR/>Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.<BR/>Policy Interpretation and Implementation<BR/> Fall Risk Factors:<BR/> 2. Resident conditions that may contribute to the risk of falls include:<BR/>a. fever; <BR/>b. infection; <BR/>c. delirium and other cognitive impairment; pain; <BR/>d. lower extremity weakness; <BR/>e. poor grip strength; <BR/>f. medication side effects; <BR/>g. orthostatic hypotension; <BR/>h. functional impairments; <BR/>i. visual deficits; and <BR/>j. incontinence.<BR/>3. Medical factors that contribute to the risk of falls include:<BR/>a. arthritis; <BR/>b. heart failure; <BR/>c. anemia; <BR/>d. neurological disorders; and balance and gait disorders; etc.<BR/>Resident-Centered Approaches to Managing Falls and Fall Risk<BR/>1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls <BR/>Monitoring Subsequent Falls and Fall Risk<BR/>1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling <BR/>The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m.<BR/>All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.<BR/>1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.<BR/>2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.<BR/>3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. <BR/>4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25.<BR/>5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025.<BR/>6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. <BR/>If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.<BR/>The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. <BR/>A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. <BR/>This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.<BR/>Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.<BR/>Monitoring: Record review and interviews of completed:<BR/>* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. <BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.<BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.<BR/>* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. <BR/>During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 14 (Resident #14 and Resident #28) residents reviewed for dignity.*The facility failed to ensure Resident #14 was treated with dignity and respect when CNA W told her in public to go to the bathroom before lying down in bed.*The facility failed to give and maintain dignity for Resident #28 by CNA N standing up assisting Resident #28 with feeding instead of sitting down to assist with feeding. This failure could negatively affect and impact residents' quality of life as a result of not giving residents respect and dignity. Findings included:<BR/>1. Record review of Resident #14's face sheet dated 07/23/25 indicated she was admitted on [DATE] and readmitted [DATE], was a [AGE] year-old female with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and post-traumatic stress disorder (mental health condition that develops after experiencing and witnessing a traumatic event). <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #14 had a BIMS score of 13 indicating cognitively intact and other behavioral symptoms not directed towards others occurring 4 to 6 days. The assessment indicated Resident #14 had diagnoses of bipolar disorder and post-traumatic stress disorder.<BR/>Record review of the care plan with a target dated 09/07/25 indicated Resident #14 received psychotropic medication for bipolar disorder.<BR/>Record review of Resident #25's face sheet dated 07/24/25 indicated she was admitted on [DATE] and readmitted [DATE], was a [AGE] year-old female with diagnoses of dementia (progressive decline in cognitive abilities that effect daily functioning). <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #25 had a BIMS score of 9 indicating severely impaired of cognition and a diagnosis of dementia.<BR/>Record review of the care plan with a target dated 09/18/25 indicated Resident #25 had impaired cognition and a diagnosis of dementia.<BR/>During an interview on 07/21/2025 at 8:27 a.m., Resident #14 said CNA W was rude last night. She said, (CNA W) told me to go to the bathroom before I went to bed so she would not have to get me right back up. She said it loudly in the hallway as she was pushing my roommate to our room, and I was embarrassed. Resident #14 said she was not abused; it just embarrassed her. She said she told LVN H and LVN H would talk to CNA W. Resident #14 said she knew LVN H did what she said she would do and took care of it. Resident #14 said she was not afraid of CNA W, and she felt safe in the facility. Resident #14 said she still wanted CNA H to be her CNA she just needed some training. Resident #14 said, They take really good care of us at this facility.<BR/>During an interview on 7/21/25 at 9:30 a.m., Resident #25 said she said she did not hear any staff being rude or any problems last night with her Roommate, Resident #14. She said her roommate Resident #14 was not upset last night. Resident #25 said she felt safe in the facility and was comfortable telling the nurse if she had a problem or concern. She said she was not abused or neglected by the staff.<BR/>During an interview on 7/21/25 at 2:00 p.m., CNA W said she was not rude or abusive to Resident #14 last night. CNA W said she was pushing Resident #14 in a wheelchair, Resident #14's roommate back to her room. She said, (Resident #14) was going back to her room, and I was about 7 feet away and I ask her if she would use the restroom before going to bed so we would not have to get her right back up. CNA W said I know her knees hurt and was trying to save her knees. When I got to her room Resident #14 said so aides are giving orders now. I said I was not giving orders I just wanted to prevent her from having to get immediately back up after she got to bed. CNA W said I was not yelling or talking loudly, I just asked her. CNA W said she was educated on abuse/ neglect, and resident rights. She said I would report suspected abuse to the nurse and administrator immediately. <BR/>During an interview on 7/21/25 at 4:35 p.m., LVN H said she had not had any allegations of abuse reported to her this week. She said on 07/21/25 she had an incident of miscommunication with CNA W and Resident #14. She said the incident was brought to her attention, but she did not witness the interaction. She said Resident #14 said CNA W was rude when she told her to go to the bathroom before going to bed. She said then she spoke to CNA W and she was worried Resident #14 would lose the ability to get up due to pain in her knees and was encouraging her to toilet herself before lying down. LVN H said I do not think it was abusive, just a miscommunication. Looking back, I should have told the DON and Administrator. When asked the resident's risk of a resident saying she was embarrassed by an incident LVN H said she did not how to answer that question.<BR/>During an interview on 7/21/25 at 4:58 p.m., the Administrator said they had not reported the incident with Resident #14. The facility had decided it was not abuse. He talked to the Resident #14 and she said she was not abused. She was able to verbalize what abuse was. She said she was just embarrassed. Resident #14 said she still wanted CNA W to be her aide and provide care to her, she just needed more training. The Administrator said it was a dignity/ sensitivity issue. He said he in-serviced staff and would do a one-on-one in-service on sensitivity training with CNA W when she came back to work on 7/23/25 before she was allowed to work. <BR/>During an interview on 7/23/25 at 11:22 a.m., the DON said CNA W should not have spoken rudely to Resident #14. She said all the facility staff were educated on abuse neglect, resident rights and customer service. She said she was unsure what happened due to not being there during the incident. The DON said she felt it was a misunderstanding or miscommunication. She said all staff must be mindful of how they say things and the tone they use when speaking with Residents. The DON said the resident risk was a resident may be not comfortable in their home. She said her expectation was all residents be treated with respect and dignity.<BR/>During an interview on 7/24/25 at 8:40 a.m., the Administrator said he investigated the incident with Resident #14 and determined it was not abuse, it was a dignity issue. He said the staff were all educated on abuse/ neglect policy and procedures. The Administrator said CNA W was given an individual sensitivity training in-service on 7/23/25 before she returned to the facility. The Administrator said the resident risk of a resident thinking a staff member was rude was potentially a resident may not ask for assistance if needed. He said he thought the incident was a misunderstanding and miscommunication. The Administrator said his expectation was all staff treat all residents with respect and dignity and treat them as adults.<BR/> <BR/>2. Record review of Resident #28's admission record dated 07/24/25 indicated Resident #28 was admitted on [DATE], was [AGE] year-old female with diagnoses of severe intellectual disability (delayed motor, language and social accomplishments), anxiety disorder (intense excessive fear), cognitive communication deficit (difficulties in communication), and dysphagia oropharyngeal phase (difficulty swallowing that originates in the mouth). <BR/>Record review of the physicians' orders for Resident #28 dated July 2025 indicated the diet order with start date of 03/14/25 was low concentrated sweets diet mechanical soft texture, Regular consistency, ice cream with lunch and dinner, fortified food plan, divided plate and bedtime snack.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #28's cognitive skills for daily decision making were moderately impaired. Resident #28's ability to make her needs known and ability to understand others, she was rarely/never understood and understands.<BR/>Record review of the care plan dated 05/08/25 indicated Resident #28 was positive for PASRR related to intellectual disabilities. The resident requires extensive assist by 1+ staff to eat. The resident has impaired cognitive function/dementia or impaired thought processes related to severe ID.<BR/>During interview and observation on 07/21/25 at 11:15 a.m., Resident #28 was in the dining hall seated in her wheelchair at a table. Staff placed her plated lunch meal in front of her and walked away to allow Resident #28 to eat. CNA N walked over to Resident #28 and asked Resident #28 if she could assist her with feeding. Resident #28 approved, CNA N hand sanitized and picked up a fork and began cutting Resident #28 chunk ground beef and began assisting Resident #28 with feeding while standing. CNA N said I knew better than that, I should have been sitting down instead of standing up. I have been trained on sitting instead of standing while assisting with feedings. CNA N also said the risks of not sitting down while assisting with feeding was the resident thinking they are being rushed.<BR/>During interview an interview on 07/24/25 at 2:19 p.m., the DON said she expected staff to follow facility's policy and be at the same level as the resident instead of hovering over the resident while assisting with feeding. She said she has trained her staff on dignity and sitting when assisting with meals.<BR/>Record review of a revised facility policy titled Dignity indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. b. allowed to choose when to sleep, eat, and conduct activities of daily living: . 8. Staff speak respectfully to residents at all times, . When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 3 of 14 residents reviewed for physician notification. (Residents #3, #6, and #40)The facility failed to consult physician for Resident #3, #6, and #40 when their BP medications were held for patterns of vital signs being outside the prescribed parameters.These failures could place residents at increased risk for complications due to delayed physician intervention. Findings included:1. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure)Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13, which indicated her cognition was intact. Record review of Resident #3's comprehensive care plan revised 07/22/2025 revealed altered cardiovascular status related to hypertension. Interventions included to monitor/document/report to MD any signs/symptoms of altered cardiovascular status. Review of Resident #3's physician orders dated 07/01/2025 included Lopressor 50 mg twice daily, clonidine HCl 0.3 mg twice daily, and cozaar 50 mg once daily. Each of these 3 medications were prescribed for hypertension and orders on each included parameters to hold medication for BP less than 110/60 or HR less than 60. Record review of Resident #3's July 2025 MAR indicated on the following dates and times, Resident #3's medications were held when vital signs were outside the prescribed parameters of BP less than 110/60 or HR less than 60:1) Lopressor 50 mg:*07/01/2025 - PM BP was 69/41;*07/02/2025 - AM BP was 108/57, PM BP was 107/57;*07/04/2025 - PM BP was 102/63;*07/05/2025 - PM BP was 107/49;*07/06/2025 - PM BP was 95/53;*07/07/2025 - AM BP was 104/62, PM BP was 101/50;*07/08/2025 - PM BP was 100/50;*07/09/2025 - PM BP was 100/53;*07/11/2025 - AM BP was 104/63, PM BP was 108/62;*07/14/2025 - AM BP was held with no BP documented, PM BP was 107/54;*07/16/2025 - PM BP was 104/62;*07/21/2025 - AM BP was 120/53; and *07/22/2025 - PM BP was 81/41.2) Clonidine HCl 0.3 mg:*07/01/2025 - PM BP was 69/41;*07/02/2025 - AM BP was 108/57;*07/04/2025 - PM BP was 102/63;*07/05/2025 - PM BP was 107/49;*07/06/2025 - PM BP was 95/53;*07/07/2025 - AM BP was 104/62, PM BP was 101/50;*07/08/2025 - PM BP was 100/50;*07/09/2025 - PM BP was 100/53;*07/11/2025 - AM BP was 104/63*07/14/2025 - AM BP was held with no BP documented, PM BP was 107/54;*07/21/2025 - AM BP was 120/53; and *07/22/2025 - PM BP was 81/41.3) Cozaar 50 mg:*07/02/2025 - BP was 108/57;*07/07/2025 - BP was 104/62;*07/11/2025 - BP was 104/63;*07/14/2025 - BP was 110/56; and *07/21/2025 - BP was 120/53.Record review of Progress Notes dated 07/01/2025 through 07/24/2025 gave no indication Resident #3's physician was consulted regarding the resident's patterns of low BP, and these three medications being held when the BP was outside prescribed parameters. 2. Record review of Resident #6's face sheet, dated 07/24/2025, indicated Resident #6 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure).Record review of the significant change MDS assessment, dated 06/09/2025, reflected Resident #6 usually made herself understood and usually understood others. Resident #6 BIMS score was 14, which indicated her cognition was intact. Record review of Resident #6's comprehensive care plan 07/22/2025 indicated altered cardiovascular status related to hypertension. Interventions included to monitor/document/report to MD any signs/symptoms of altered cardiovascular status. Review of Resident #6's physician orders dated 07/01/2025 included spironolactone 50mg daily. The medication was indicated for hypertension and the physician order included parameters to hold medication for BP less than 110/60 or HR less than 55. Record review of the July 2025 MAR indicated on the following dates, Resident #6's spironolactone 50mg was held when vital signs were outside the prescribed parameters of BP less than 110/60 or HR less than 55:*07/01/2025 -BP was 106/62;*07/02/2025 - BP was 100/52;*07/04/2025 - BP was 106/52;*07/05/2025 - BP was 102/61;*07/06/2025 - BP was 103/54;*0707/2025 - BP was 97/49;*07/09/2025 - BP was 108/64;*07/14/2025 - BP was 92/54;*07/15/2025 - BP was 99/49; and*07/17/2025 - BP was 100/56.Record review of Progress Notes dated 07/01/2025 through 07/24/2025 gave no indication Resident #6's physician was consulted regarding the resident's patterns of low BP, and the spironolactone 50mg being held when the BP was outside prescribed parameters. 3. Record review of Resident #40's face sheet, dated 07/23/2025, indicated Resident #40 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and hypertension (high blood pressure)Record review of the Quarterly MDS assessment, dated 05/22/2025, reflected Resident #40 usually made herself understood and usually understood others. Resident #40's BIMS score was 99, which indicated Resident #40 was unable to complete the interview. Record review of Resident #40's comprehensive care plan 05/09/2025 indicated give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a form of low BP that happens when standing up from sitting or lying down) and increased heart rate. Review of Resident #40's physician orders dated 07/01/2025 included amlodipine besylate 5mg daily. The medication was indicated for hypertension and the physician order included parameters to hold medication for BP less than 110/60 or HR less than 60. Record review of the July 2025 MAR indicated on the following dates, Resident #40's amlodipine besylate 5mg was held when vital signs were outside the prescribed parameters of BP less than 110/60 or HR less than 60:*07/01/2025 -BP was 99/59, HR 52;*07/02/2025 - BP was 106/54, HR 54;*07/03/2025 - BP was 128/57, HR 53;*07/04/2025 - BP was 122/59, HR 54;*07/05/2025 - BP was 118/54, HR 55;*07/06/2025 - BP was 103/54; HR 56;*07/07/2025 - BP was 129/48; HR 54;*07/09/2025 - BP was 108/55; HR 52;*07/10/2025 - BP was 109/59, HR 57;*07/12/2025 - BP was 106/77,*07/13/2025 - BP was 115/58, HR 55;*07/14/2025 - BP was 119/52, HR 53;*07/15/2025 - BP was 103/52, HR 55; *07/16/2025 - BP was 126/56, HR 55;*07/17/2025 - BP was 123/58; HR 53;*07/18/2025 - BP was 121/54, HR 57;*07/20/2025 - BP was 104/56, HR 57;*07/21/2025 - HR 55;*07/22/2025 - BP was 104/57, HR 56;*07/23/2025 - BP was 101/55, 54; and*07/24/2025 - BP was 100/54, HR 56.Record review of Progress Notes dated 07/01/2025 through 07/24/2025 gave no indication Resident #40's physician was consulted regarding the resident's patterns of low BP and/or HR, and amlodipine besylate 5mg being held when the BP/HR was outside prescribed parameters. During an interview on 07/24/2025 at 11:30 a.m., LVN B said the MAs were to inform the nurses anytime a resident's medication was held for any reason. She said she would go and assess the resident and notify physician. LVN B said nursing staff were to document in progress notes anytime a physician was consulted. LVN B said she was unaware of the quantity of times the BP medications were held. She said the physician should have been consulted regarding Resident #40's pattern of low BP and of medication being held. LVN B said not notifying the physician could affect Resident #40's overall health.During an interview on 07/24/2025 at 11:50 a.m., MA CC said anytime medications were held for any reason, the charge nurse was to be notified. She said Resident #40's BP tended to fluctuate, and the MD should be notified. She said if a resident's heart rate or blood pressure was outside parameters, she would recheck vital signs any notify the charge nurse. MA CC said the charge nurses would then assess residents and should notify physicians, especially if a pattern of being held was noted. MA CC said she had informed her charge nurse each time of Resident #40's medication being held due to low BP. During an interview on 07/24/2025 at 1:45 p.m., the DON said her expectations were to make notifications to physician when vital signs were outside physician ordered parameters and to document notification and results in the resident's medical record. Review of a policy dated 01/2001 and titled Administering Medications indicated the following: . Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care and the facility failed to provide the resident and their representative with a summary of the baseline care plan for 1 of 14 residents (Resident #54) reviewed for new admissions The facility failed to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #54, and they failed to give a copy to him or his representative. This failure could lead to residents not receiving necessary care and decreased quality of life. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM (permanent pacemaker - a small battery-powered medical device that helps regulate the heart's rhythm by electrical impulses). Record review of the 5-day MDS showed in progress in Resident #54's clinical record due to the admission date of 07/18/2025. Record review of admission Order Summary dated 07/18/2025 indicated Resident #54 had physician orders for wound care to right ankle, barrier cream to buttocks, and open wounds on outer aspect of right ankle and outer aspect of left foot. He was to wear heel protectors bilaterally and utilize pillows to relieve pressure. Resident #54 was prescribed Eliquis (an anticoagulant blood thinner) for diagnosis of Atrial Fibrillation. Resident #54 was to receive Insulin daily as well as sliding scale insulin if needed. He was also to receive oral medication twice daily for diabetes. Resident #54 was prescribed a hypnotic medication at bedtime for diagnosis of insomnia. The baseline care plan dated 07/21/2025 for Resident #54 failed to contain the following required information:*Diabetic alert including specification of insulin, medications, and specific diet of low concentrated sweets. Resident #54 was a diabetic with prescribed daily insulin.*Anticoagulant therapy including prescribed Eliquis (blood thinner), did not address monitoring for signs of bleeding, safety measures.*Pressure sore including bilateral ankles and heel, protective boots worn in bed.*Gave no indication of Resident #54 having been on EBP due to wounds.*Failed to provide Resident #54 and his representative with a summary of the baseline care plan.Record review of a policy dated December 2016 titled Care Plans - Baseline indicated the following. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of resident admission. 2. The interdisciplinary team will review the healthcare practitioner's orders (dietary needs, medications, routine treatment, etc) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to a) immediate goals based on admission orders, b) physician orders, c) dietary orders. 4.The resident and their representative will be provided a summary of the baseline care plan that includes but not limited to: a) the initial goal of the residents, b) a summary of the resident's medications and dietary instructionsDuring an interview on 07/24/2025 at 09:00 a.m., after reviewing Resident #54's baseline care plan together, the DON said the document should have contained dietary instructions, physician treatment orders, medication regime, especially insulin, and isolation status. The DON said all fields of the baseline care plan should be completed, a copy reviewed, signed by resident and his representative, and a copy provided to them. She said she knew it was due and was left incomplete due to survey team entering facility. The DON said potential risks for the resident would be to not receive adequate care and services necessary. The DON acknowledged the baseline care plan was incomplete with accurate information regarding care for Resident #54 and a copy had not been presented to Resident #54 or his representative and should have been. The DON said she was responsible to ensure the baseline care plan was complete and completed timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for 1 of 1 resident reviewed for quality of life. (Resident #51)<BR/>The facility did not ensure Resident #51's orthopedic appointment report and orders were received and initiated causing a delay in her receiving physical therapy services as ordered by her orthopedic physician. <BR/>This failure could contribute to residents decline in physical and psychosocial well-being.<BR/>Findings included:<BR/>Record review of a face sheet dated [DATE] indicated Resident # 51 was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included fractured wrist and hand, fracture of the left socket of the hipbone, condition in which bones become weak and brittle, a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life.<BR/>Record review of a hospital Discharge Assessment/Summary Report dated [DATE] indicated Resident #51 had discharge orders of non-weight bearing to right wrist and continue splint, toe-touch weight bearing to left lower extremity, follow up with orthopedic surgery, and 4 weeks of deep vein thrombosis prophylaxis (placed on blood thinner to prevent complications). <BR/>Record review of physician orders indicated Resident #51 had an order dated [DATE] for follow up with orthopedic surgery. <BR/>Record review of the admission MDS dated [DATE] indicated Resident #51 was cognitively intact with a BIMS score of 13 out of 15, she required extensive assistance of 2 persons for transfers, she was receiving no physical therapy, and she received restorative therapy for active range of motion and dressing and/or grooming.<BR/>During interview on [DATE] at 10:30 a.m., Resident # 51 said she fell at the group home she lived in and injured her right wrist around the first of March this year. She said she later fell again and injured her hip and pelvis area. She said she just wanted to start her therapy so she can get better and go back to her group home. She stated, I don't want to stay here, my mother died in a nursing home. She said the bone doctor was not going to do any surgery for her hip and pelvis fractures just therapy to help her get stronger and back on her feet.<BR/>During an interview on [DATE] at 8:30 a.m., the TA said Resident #51 saw the orthopedic physician on [DATE] at 1:45 p.m. because she took her to the appointment. She said she stayed with the resident for the appointment and the doctor verbally told the resident he was changing her weight bearing status to 50% and ordered therapy. She said the orthopedic office was supposed to fax over new orders to the facility and the DON or ADON would initiate the orders. She said she did not remember if she notified the DON of the appointment report.<BR/>Record review of the EMR and hard chart from [DATE] through [DATE] for Resident #51 indicated:<BR/>* there was no report from the orthopedic office visit from [DATE]; <BR/>* there was no documentation in the nursing notes for changes in weight bearing status or therapy; <BR/>* there was no physician order for change in weight bearing or physical therapy. <BR/>A care plan initiated [DATE] and revised on [DATE] indicated Resident # 51 had an ADL Self Care Performance Deficit related to impaired mobility. Interventions included:<BR/>* PT/OT evaluation and treatment as per physician orders.<BR/>* Transfer-required 2-person staff participation for transfer with Hoyer lift <BR/>There was no indication of her receiving PT or weight bearing status change.<BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #51 was cognitively intact with a BIMS score of 13 out of 15, she required extensive assistance of 2 persons for transfers, she was receiving no physical therapy, and she received restorative therapy for active range of motion and dressing and/or grooming.<BR/>During an observation and interview on [DATE] at 11:00 a.m., the RA entered Resident #51's room to provide restorative care. The RA provided ROM exercises to the resident's left arm and ROM to her right lower extremity. The RA said Resident #51 only received restorative care not physical therapy at this time.<BR/>During an interview on [DATE] at 8:15 a.m., the OT said therapy performed evaluations on residents once ordered from the physician. He said no order had been received for a therapy evaluation on Resident #51. He said the resident was receiving restorative care provided by the RA.<BR/>During an interview and record review on [DATE] at 08:36 a.m., the TA entered the conference room and handed paperwork to the surveyor. She said the paperwork was from Resident #51's orthopedic appointment on [DATE]. The fax cover sheet with the paperwork was dated [DATE] at 08:35 a.m.<BR/>Record review of an orthopedics office visit note dated [DATE] for Resident #51 indicated:<BR/> 2. Fracture, Acetabulum, Closed, Left <BR/>Plan: Order CT<BR/> Protocol: Left Femur <BR/>CT without contrast <BR/>Plan: Physical therapy instructions/plan<BR/>Physical therapy plan of care: <BR/>2-3 time(s) per week for 6-8 weeks. <BR/>Weight bearing: Partial weight bearing 50% <BR/>During an interview on [DATE] at 9:30 a.m., the DON said the orders received today on Resident # 51 will be initiated today. She said the TA should notify the DON and/or the CN of any new orders or plan of care changes identified during a physician's appointment. The DON said a negative outcome for facility not receiving new orders or plan of care changes immediately following appointments could cause the resident to have a delay in care and cause a decline in their physical status and ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 14 residents reviewed for pressure sore management. (Resident #54)The nursing staff failed to document an accurate skin assessment and treat Resident #54's wounds from admission [DATE] through 07/23/2025.This failure could place residents at risk of not receiving appropriate care leading to worsening skin condition.Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM (permanent pacemaker - a small battery-powered medical device that helps regulate the heart's rhythm by electrical impulses). Record review of the 5-day MDS showed in progress in Resident #54's clinical record due to the admission date of 07/18/2025. Record review of Resident #54's baseline care plan dated 07/18/2025 indicated redness to bilateral feet[VT1] . Record review of Resident #54's Weekly Ulcer assessment dated [DATE] indicated a Stage 2 pressure wound to right ankle measuring 2.5cm x 2.5cm x 0.1cm. [VT2] During an interview on 07/21/2025 at 08:21 a.m., Resident #54 said says he is was prone for sores and thinks thought he neededs a bigger bed as his feet have been like this - hanging on edge of the bed all weekend. He said he had a sore on his right ankle - admitted to the facility with it. He said he wasn't sure if he had any other areas. Resident #54's Weekly Skin assessment dated [DATE] indicated addition of pressure wound to right heel measuring 1.5cm x 2.5cm x 0.2cm. [VT3] Record review of admission Order Summary dated 07/18/2025 indicated Resident #54 had physician orders for wound care to right ankle, barrier cream to buttocks, and open wounds on outer aspect of right ankle and outer aspect of left foot. He was to wear heel protectors bilaterally and utilize pillows to relieve pressure. Record review of Resident #54's MAR indicated admission date of 07/18/2025. Beginning 07/21/2025, an order was started to cleanse wound to lateral right ankle with wound cleanser, pat dry, apply calcium alginate with silver, cover with dry dressing daily. Beginning 07/23/2025, an order was started for right heel which indicated to clean area, apply calcium alginate and cover with dry dressing. Also, for right heel - clean area, apply skin prep, wear bilateral boots to prevent further skin issues daily for wound healing. During an observation and interview on 07/21/2025 at 08:21 a.m., Resident #54 was observed lying in bed with heel protecting boots on both feet. He was in EBP - sign on door and PPE box inside room. Resident's feet in boots with heels hanging at the edge of the bed, slightly dangling off the end. Resident #54 said he was prone for sores and thought he needed a bigger bed as his feet have been like this - hanging on edge of the bed all weekend. He said he had a sore on his right ankle - admitted to the facility with it. He said he wasn't sure if he had any other areas. During an observation and interview on 07/22/2025 at 08:30 a.m., the ADON said she has not seen Resident #54 yet as he was just admitted Friday (07/18/2025) evening. She said she did not work yesterday (Monday). The ADON donned gown and gloves and placed wound care supplies on resident's overbed table. CNA Y at bedside dressed in PPE to assist with turn and reposition Resident #54 by holding his leg to allow observation and wound care. Boots removed. Dressing noted to right outer ankle and was removed. While observing foot, an open wound was noted on the back of the resident's right heel and was not covered. The wound was open with a whitish/yellow stringy like wound bed, covering approximately 75% of the wound bed. The rest of the wound bed was pale yellow in color and surrounding skin appeared pale pink. The area was approx. the size of a nickel. Left outer foot with blanchable light pink area. The ADON applied skin prep to the area. She said this area would be closely watched but was not a pressure ulcer at this time. The ADON said she was not aware of this new area. The ADON said she was not sure if the admission nurse or weekend RN observed or assessed, and she was not sure who did his wound care yesterday (Monday 07/21). The ADON said she had not seen an order for this right heel wound or treatments on his orders. The ADON measured the area to be 1.5x 2.5 cm and said the white/yellow stringy wound bed was slough. She said he was wearing [NAME] boots -and they were not provided by the facility (he was admitted with them). The ADON removed her gloves and stepped outside of the room wearing the same gown to retrieve supplies from her cart. She reentered the room and donned gloves without hand hygiene. She cleaned the right heel with wound cleanser and applied silver alginate, covering with a dry dressing. The ADON said she would have to notify the Wound Care MD. She said he came to facility weekly and had not seen Resident #54 at this time. The ADON said Resident #54 had a physician order to consult the wound care physician. She said he was to assess Resident #54 this week when he made his weekly rounds. She said he did not have any areas on his buttocks that she knew of and nothing had been reported to her. CNA Y said she has not seen any open areas on Resident #54's buttocks. The ADON said in addition to being the ADON, she was the wound care nurse. The ADON said herself or Wound Care MD would measure resident wounds. A Charge nurse was to do wound care measurements if she was not there or if a new wound was found and she was not there. During an interview on 07/22/2025 at 10:35 a.m. LVN A said she had provided wound care to Resident #54's right outer ankle yesterday (07/21/2025) at the end of her shift (after 6 p.m.). She said she did not see any wounds on his right heel. She said there was not a dressing on his heel - just the ankle and she did not observe any other wounds when she did his right ankle. She said she followed the wound care assessment - and it only addressed the right ankle wound. She said she applied skin prep on his left outer foot - but for preventative. She said if a resident had a new wound - she would measure it and notify the wound care nurse (ADON). She said the charge nurse could do the initial assessment when it was discovered but had to notify the wound care nurse. LVN A said she would chart the new wound and notify the DON and MD. LVN A said she was not aware of any areas on his buttocks. Review of a policy dated October 2010 titled Wound Care indicated the following: . Documentation - following information should be documented in the resident's medical record: 5) any change in the resident's condition, 6) all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, 8) any problems or complaints made by the resident related to procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 14 (Resident #24) residents reviewed for pain. The facility failed to administer Resident #24's pain medication for scheduled doses on 04/27/25 at 10:00 p.m., 04/28/25 at 8:00 a.m., 2:00 p.m. and 10:00 p.m.Resident #24's pain was not assessed 41 of 90 scheduled times of pain intensity level assessments for April 2025. This failure could place residents at risk for increased pain and decreased quality of life. Findings included: Record review of the face sheet dated 07/24/2025 indicated Resident #24 was admitted on [DATE], he was [AGE] years old with diagnoses including muscular dystrophy (genetic diseases that cause progressive weakness and loss of muscle mass) and abnormalities of gait and mobility. Record review of physician's orders dated July 2024 indicated Resident #24 had orders including Acetaminophen-Codeine Tablet 300-60 MG Give 1 tablet by mouth every 4 hours as needed for pain for use when out of Norco with start date of 04/28/25. Resident #24 had an order for Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day related to pain in unspecified joints with a start date of 7/02/2024. Record review of Resident #24's Quarterly MDS assessment dated [DATE] indicated the resident had a BIMS Summary Score of a 14 (cognitively intact). Resident #24 indicated the presence of pain was frequently. The last 5 days pain was frequently and often interfered with sleep. He rated his pain as a 7 on the pain scale. During last 7 days he received opioid medication. Record review of Resident #24's MAR dated April 2025 indicated Resident #24 did not receive his Norco on 04/27/25 at 10:00 p.m., 04/28/25 at 8:00 a.m., 2:00 p.m. and 10:00 p.m. Then 04/29/25 the Acetaminophen-Codeine Tablet 300-60 MG was given twice to Resident #24. Resident #24 pain level was not assessed and charted NA on the dates as follows: April 1 -April 7 at 8:00 a.m., NAApril 1- April 6 at 2:00 p.m., NA April 9- April 15 at 8:00 a.m., NAApril 9- April 15 at 2:00 p.m., NAApril 21- April 27 at 8:00 a.m., NAApril 21- April 27 at 2:00 p.m., NAApril 30 at 8:00 a.m. and 2:00 p.m., NA Record review of the care plan dated 06/20/25 indicated Resident #24 had muscular dystrophy and his goal was he will remain free from pain or at a level of discomfort acceptable to the resident. He had interventions of anticipate and meet his needs, call light is within reach and respond promptly to all requests for assistance. Give the analgesics as ordered by the physician. Monitor and document for side effects and effectiveness for Resident #24. During an interview on 07/21/25 at 10:00 a.m., Resident #24 said while residing in the facility, there were 4 times that he went without his scheduled Norco 7.5- 325 mg tablet dose. He said the nurses and med aides told him there was an issue getting the medication from the pharmacy. He was unsure which nurses or MAs he reported to, but he did not report to the DON or the Administrator. He was unable to give dates when he missed medication. During an interview on 07/21/25 at 2:00 p.m., MA BB said she had heard Resident #24 was out of pain medication 3 or 4 months ago. She said the nurses called the physician and they have some other medication to give him if they are out of Norco. She said the nurses have that on their cart. She said the MAs only give scheduled pain medication, not as needed. During an interview on 07/23/25 at 11:27 a.m., Physician HH said he had worked with the facility on ordering control medications early and gave an order for Resident #24 to have another medication if out of the Norco. He said if he was sick or out of town, the facility has another medication for pain. He said Resident #24 had chronic pain with his muscular dystrophy. During an interview on 07/24/2025 at 3:54 p.m., MA BB said she did not document the pain level for Resident #24, Sshe thought the nurses were supposed to ask and document the residents pain levels. She said she documented NA and thought it meant (not assessable). She said she had never been trained on assessing pain and was never told to chart pain level. During an Iinterview on 07/24/2025 at 4:00 p.m., MA CC said she documented the pain level and was taught in school and the facility trained her to document in the MAR. She said she had never seen others charting NA because you only see what you chart. She said if a resident was out of pain medication, she would notify the nurse to let her give another pain medication. During an interview on 07/24/25 at 4:10 p.m., LVN B said for Resident #24 if he runs out of Norco the MAs tell the nurse on duty and the nurse will give him the Acetaminophen-Codeine Tablet 300-60 MG. She said she had never seen him in severe pain or pain not being controlled. She said they always order medications early however the Norco required a triple prescription from the physician. During an interview on 07/24/25 at 4:16 p.m., the DON said she was not really sure if she was comfortable allowing MAs to ask residents about their pain level on the pain scale while administering routine pain meds. She said she has not made it clear what the expectations were for the MAs even though it was on the resident's MAR for the MAs to ask the resident about their pain level on scale. She said some might automatically do it based on what they either learned in school or what they did at their previous job. During an interview on 07/24/25 at 4:20 p.m., the Corporate RN said she would expect the MAs to ask residents their pain level on the pain scale as to assist the nurse with monitoring the pain. She said although the MA cannot assess the pain further - they help monitor for changes in the resident's levels and to notify the nurse for increase in levels. She said this assists monitoring the effectiveness of the routine pain med - so the MA can notify the charge nurse if the resident has increased pain - monitoring the effectiveness of the pain med. Record review of the Pain - Clinical Protocol dated March 2018 indicated Assessment and Recognition I. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes. b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments.The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Monitoring I. The staff will reassess the individual's pain and related consequences at regular intervals, least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic. a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 14 residents (Resident #54) reviewed for medication administration, in that: Resident #54 missed scheduled doses of 9 different medications due to availability from the pharmacy. This failure could place the residents at risk of not receiving necessary medications and a decline in health.Record review of Resident #54's face sheet, dated 07/21/25, reflected Resident #54 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diabetes, obesity, insomnia (a sleep disorder characterized by difficulty falling asleep), and spondylolisthesis (a spinal disorder in which a vertebra slips forward onto the bone below it). Record review of the 5-day and admission MDS assessment were not available and were in progress due to new admission to facility on 07/18/2025. Record review of Resident #54's baseline care plan dated 07/18/2025 indicated diagnoses of diabetes and Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #54's Order Summary Report indicated admission date of 07/18/2025. Physician orders included the following:*amlodipine besylate 2.5mg daily for hypertension;*carvedilol 3.125 mg daily for hypertension;*Eliquis 5mg every 12 hours for A-Fib;*furosemide 40 mg daily for heart failure;*gabapentin 300mg three times daily for pain;*insulin glargine 100units/ml - give 60 units at bedtime for diabetes;*lisinopril 40 mg daily for hypertension;*metformin 1000 mg twice daily for diabetes; and*zolpidem tatrate 10 mg at bedtime for 14 days for insomnia. Record review of Resident #54'sd MAR indicated admission date of 07/18/2025. On 07/19/2025, Resident #54 did not receive the prescribed medications due to unavailable from pharmacy:*amlodipine besylate 2.5mg;*aspirin 81mg;*carvedilol 3.125 mg;*Eliquis 5mg;*furosemide 40 mg;*gabapentin 300mg;*insulin glargine 100units/ml;*lisinopril 40 mg;*metformin 1000 mg; and*zolpidem tatrate 10 mg.Record review of Resident #54's MAR indicated these medications were not given. Resident #54's progress notes contained documentation the medications had not been delivered to facility at that time.Record review of the Emergency Medication Kit contents indicated amlodipine, carvedilol, Eliquis, furosemide, gabapentin, insulin glargine, lisinopril, metformin and zolpidem were available in the facility Emergency Medication Kit and were available for Resident #54. Aspirin 81 mg was a stock medication available as over-the-counter. The Emergency Medication Kit had a detailed list of medications available for review. The facility was required to notify pharmacy of any narcotic medications removed from kit, as well as document on form indicating what medications were removed.Record review of a policy dated April 2021 and titled Emergency Medications indicated the following.4. The contents of each emergency medication kit will be clearly listed. 7. Required documentation after dispensing an emergency medication is the same as for any other medication. 9. Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order. During an interview on 07/23/2025 at 1:50 p.m., LVN L said the medications were unavailable from pharmacy for Resident #54. LVN L said she had called the pharmacy twice on 07/19/2025 to inquire of delivery times. She acknowledged Resident #54 was without his morning medications on 07/19/2025. LVN L said she had not checked the emergency kit for medication availability. LVN L said Resident #54's medications were started on 07/19/2025 late in the day and the medications were started with the evening dosages. During an interview on 07/24/2025 at 9:40 a.m., the DON said the pharmacy requisition must be sent in daily to get the medications delivered on the same day in the evening. She said Resident #54 did not arrive to facility for admission until sometime after 5:30p.m. on 07/18/2025. The DON said they use medications, if available, from the emergency kit. The DON said the ekit had a list of available medications attached to the container. The DON said she did not know if the prescribed medications for Resident #54 were available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #28) reviewed for meals. The facility failed to ensure that Resident #28 was served meat and vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss. The findings were: 1.Record review of Resident #28's admission record dated 07/24/25 indicated Resident #28 was admitted on [DATE], was [AGE] year-old female with diagnoses of severe intellectual disability (delayed motor, language and social accomplishments), anxiety disorder (intense excessive fear), cognitive communication deficit (difficulties in communication), and dysphagia oropharyngeal phase (difficulty swallowing that originates in the mouth). Record review of the physicians' orders indicated Resident #28 dated July 2025 indicated the diet order with start date of 03/14/25 was low concentrated sweets diet mechanical soft texture, Regular consistency, ice cream with lunch and dinner, fortified food plan, divided plate and bedtime snack. Record review of the MDS dated [DATE] indicated Resident #28 cognitive skills for daily decision making were moderately impair ed. Resident #28's ability to make her needs known and ability to understand others, she was rarely/never understood and understands. Record review of the care plan dated 05/08/25 indicated Resident #28 was positive for PASRR related to intellectual disabilities. The resident requires extensive assist by 1+ staff to eat. The resident has impaired cognitive function/dementia or impaired thought processes related to severe ID. During lunch meal observation and interview on 07/21/25 at 11:15 a.m., Resident #28 held a spoon in her hand but would not eat the food. CNA N walked over and started cutting residents quarter and a half size meat. Chunks of meat noted on residents' plate were not softened. The zucchini and squash were not soft nor cuttable with spoon nor fork. CNA N said she noticed the resident was having a hard time with trying to eat so she came to cut up the meat into smaller pieces so she could eat, she said her meal ticket indicated mechanical soft. Record review of Resident #28's meal ticket indicated an ordered texture of mechanical soft diet. During an interview on 07/21/25 at 11:30 a.m., the DM said the meat in the bell pepper was ground beef, she said the meat should be smaller pieces, she said she was responsible to ensure her staff follow menus . During a record review and interview 07/21/25 at 1:00 p.m., the DM was holding the menu for mechanical soft diet which indicated the ingredients inside the stuff bell pepper should have been chopped. She said the ingredients inside the stuff bell pepper should had been chopped and vegetables could had been softer. Record review of the Mechanically Altered Textures dated 2019 indicated . Mechanically altered textures are available for persons having difficulty with chewing or swallowing as prescribed by their physician, speech therapist or registered dietitian. Dysphagia diets Used for residents with swallowing difficulties due to medical conditions such as stroke, degenerative diseases. MechSoft This is a step up from the pureed diet. Some chewing ability is required. The level 2 diet is for people with mild to moderate swallowing difficulty. This diet consists of foods that are moist, soft and easily formed into a bolus (soft wad of food). Avoid foods that are difficult to chew, dry and coarse. Meats should be ground or minced and should be keep moist with sauces and gravies. Mechanical / Ground Meat Entrees should be ground or chopped into bite size pieces. Most raw fruits or vegetables unless served finely chopped. FOOD ALLOWED Moistened ground cooked meat, poultry, or fish. Moist ground or tender meat may be served with sauce; well cooked pasta, protein salads without large chunks. All soft, well-cooked vegetables, should be easily mashed with a fork FOOD NOT ALLOWED Dry or tough meats, dry casseroles, or casseroles with large chunks.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen. The facility failed to ensure items stored in the refrigerator, and in the dry storage were labeled and discarded by the expiration date. The facility failed to ensure all staff wore hair restraints which covered all hair while in the kitchen. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations on 07/21/25 at 8:00 a.m., in the refrigerator revealed: white and yellow mushy substance in a 6 oz round container covered with tin foil in the fridge not labeled. 3 green jalapenos in a round 6 oz circle container uncovered and not labeled inside the refrigerator noted. During an interview on 07/21/25 at 8:20 a.m., [NAME] OO said the white and yellow mushy substance in a 6 oz round container covered with tin foil in the fridge not labeled and 3 green jalapenos in a round 6 oz circle container uncovered and not labeled should have not been in the refrigerator and should have been labeled if it was going to be stored in the facilities refrigerator. [NAME] OO said the risk of having non-labeled exposed food can spread germs and people wouldn't know how long it's good for. During an observation on 07/21/25 at 8:30 a.m., The dry storage area contained:a bag of opened potato slices had no use by or expiration date on bag;a closed bag of corn chips- use by date 07/14/2025; and an opened bag of cocoa baking powder was opened 10/14/2024 and had a use by date of 01/14/2025. Record review indicated the bag of cocoa baking powder once opened is only good for 8 months. During an interview on 07/21/25 at 8:50 a.m., the DM said she expected staff to have all items labeled and to throw away all expired items. She said had instructed the dietary staff on labeling and food storage. During an observation on 07/22/25 at between 11:00 a.m. to 12:00 p.m., Dietary staff JJ was cutting pies, and her hair restraint was not covering the lower 3 to 4 inches of her hair. The maintenance supervisor entered the kitchen walked past the steam table and food prep area then exited. He had no beard restraint covering his beard. During an interview 07/22/25 at 12:10 p.m., DM and Dietary staff JJ said the hair restraint had moved up while she was working. The DM said they all wear hair restraints to prevent hair from falling into the food. During an interview on 07/24/25 at 8:00 a.m., the Maintenance supervisor said he just forgot. He said he had a beard net on his desk and the DM had trained him. He was busy and just forgot. Record review of the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated November 2022 indicated Policy Statement Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.Hair Nets 15. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of the undated Food Storage indicated Food storage areas shall be maintained in a clean, safe, and sanitary manner. Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 14 resident reviewed for infection control. (Resident # 3, #29, #37 and #54) The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for Resident #3 who was on EBP. The ADON failed to follow infection control procedures on 07/22/25 after Resident #3's indwelling urethra catheter tubing disconnected from the urinary catheter bag tubing during wound care. The facility failed to ensure Resident #3 was placed in contact isolation on 07/22/25 and failed to ensure staff were made aware of Resident #3 requiring contact isolation until after surveyor intervention on 07/23/25. The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for Resident #54 who was on EBP. CNA Y failed to follow infection control procedures on 07/23/25 while providing incontinent care for Resident #54 who was on EBP. MA CC and LVN D failed to follow infection control procedures on 07/23/25 while assisting Resident #54 who was on EBP. LVN A failed to follow infection control procedures on 07/22/25 when LVN A provided G-tube (a medical device that delivers liquid nutrition directly to the stomach) site care for Resident #29 who was on EBP. The ADON failed to follow infection control procedures on 07/22/25 when she assisted LVC with repositioning Resident #37 in bed who was on EBP. An Immediate Jeopardy (IJ) was identified on 07/23/2025. The IJ template was provided to the facility on [DATE] at 5:17 p.m. While the IJ was removed on 07/24/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. 1. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13, which indicated her cognition was cognitively intact. Resident #3's MDS indicated she had an indwelling urinary catheter. Record review of Resident #3's comprehensive care plan revised 04/11/2025 reflected Resident #3 had an actual impairment to skin integrity MASD/fungal to right posterior thigh/buttock. Interventions included an indwelling urinary catheter for wound healing, keep in place until the MASD is well controlled per wound care physician, and may have low air mattress. Resident #3 had an indwelling urinary catheter due to skin breakdown initiated 04/08/2025. Interventions included position catheter bag and tubing below the level of the bladder, check tubing for kinks and maintain the drainage bag off the floor, and monitor/document for pain/discomfort due to catheter. During an observation and interview on 07/21/2025 at 09:30 a.m., Resident #3 had signage at entrance to room for EBP. There was PPE in a drawer inside of her room. Resident #3 was resting in her bariatric bed with a LALM. Resident #3 was morbidly obese. The indwelling urinary catheter was positioned on the side of the bed frame and was in a privacy bag to low gravity. The catheter tubing was noted to have white sediment throughout the tubing, unable to see through the tubing. The drainage bag had turbulent, pale yellow urine with sediment in the bag. Resident #3 said she had a UTI but was not taking antibiotics at the time. She said she had a wound to her buttocks. She was receiving daily wound care to the area. She said she had the urinary catheter due to her wounds to prevent areas from getting soiled with urine. During an observation and interview on 07/22/2025 at 10:53 a.m., the ADON gathered wound care supplies at the cart outside Resident #3's room. There was an EBP sign on the outside of the resident's door. The ADON entered the room and placed the wound care supplies on resident overbed table without a barrier or cleaning the table prior. Resident #3's room had a strong ammonia smell. CNA P and MA DD were assisting with positioning of resident for the wound care. Resident #3 was on her right side with the urinary catheter tubing under her right thigh, under the Hoyer lift pad, lift sheet and chuck pad. The urinary catheter tubing was filled with white sediment and the urinary catheter urine bag was on the bed. The urine in the bag was turbulent, pale yellowish.The ADON noted it to the CNAs and started trying to pull the tubing from under the resident's leg lifting the urine collection bag and tubing, attempting to remove it from under the resident's leg. While attempting to reposition Resident #3, the urinary catheter tubing that was inserted in her urethra was pulling taut under the resident's leg. The CNAs lifted Resident #3's leg and as the ADON unwrapped the tubing from under the resident's leg, urine sprayed across the room and the urinary catheter bag tubing was disconnected from the urethra tubing. Urine was leaked onto the resident's Hoyer lift pad and the bed. The ADON grabbed the bag tubing and urethra tubing. The ADON told CNA P to open the door and call out for alcohol pads. CNA P did not remove her gloves, and while wearing the same gloves, she opened Resident #3's door. After retrieving the pads from another staff, CNA P handed the pads to the ADON.The ADON, wearing soiled gloves, wiped both tubing tips with an alcohol pad and reconnected the tip of the bag tubing into the open port of the urethra tubing. CNA P said she emptied the resident's urine bag earlier and the urine has been looking the same for awhile.The ADON and CNAs assisted the resident with turning to her right side for the ADON to provide wound care. The ADON said the open areas on the resident's buttocks was from MASD -fungal. She removed the dressing from the resident's right buttock crease (where the upper thigh and buttock meet) and cleansed the right buttock open wound with gauze and wound care cleanser. The ADON then placed the soiled gauze on the resident's bedside table. She attempted to apply the collagen to the wound bed, but it stuck to her gloves. She removed her gloves and without hand hygiene, she stepped out of the room while wearing the same gown to retrieve more wound care supplies. The ADON donned gloves and covered right buttock wound. She wiped resident's left open left buttock MASD wound with gauze and wound cleanser placing the soiled dressing on the table again. The ADON applied the barrier cream with Nystatin powder to her left buttock rubbing it in the wound with her gloved hand. Using the same gloved hand, the ADON touched Resident #3's back, bed, and legs. She removed her gloves. While wearing the same gown and not conducting hand hygiene, she retrieved a catheter tubing anchor from her cart outside of the room, then donned gloves not washing her hands. The ADON applied the catheter anchor onto the resident's upper thigh and clipped catheter bag tubing into place. She then touched the soiled lines, picked up the soiled gauze from the resident's table, and placed the soiled tray on top of the resident's PPE cart inside the room. She removed her gown and put it in the resident's overflowing trash can. There were old gloves, paper towels, and the bag with soiled linen on the ground. The ADON did not sanitize the resident's overbed table and exited the room. CNA N entered the room to assist with transferring the resident from the bed to the wheelchair. CNA N said to the other 2 CNAs you can't put that dirty bag on the floor - it is infection control issues. CNA N asked CNA P and MA DD why the trash was overflowing onto the floor, and it was dirty. Resident #3 said she smelled pee. CNA P and MA DD indicated the pad was wet from the urine, removed the soiled lift pad, and without changing gloves put the new pad under the resident, touching the resident's body to position on the pad. While wearing the same gloves, CNA P and MA DD touched the lift and assisted Resident #3 with positioning into her wheelchair. During an interview on 07/22/25 at 12:00 p.m., the ADON said she should not have reattached the urinary bag tubing with the urethra tubing after it became dislodged. She said she should have removed it and reinserted a clean, sterile urinary catheter. She said she should have removed her gown before exiting the room, washed her hands, and donned new gloves throughout the procedure. She said she knew she should have, she just didn't. She said she should not have placed the soiled gauze on the resident's overbed table and should have sanitized it after care, but she did not. She said she was trained on Infection Control procedures recently and knew what she did was not preventing the spread of infections. She said she had not had any training in Wound Care, she just went off what she knew. During an interview on 07/22/2025 at 5:15 p.m., the DON said nurses should never reconnect indwelling urinary catheters. She said the nurse should have removed indwelling urinary catheter and reinserted a new one using sterile technique. She said she does not have to train nurses on basic nursing and infection control. Record review of Resident #3's UA results dated 07/22/2025 and electronically sent to facility at 5:08 p.m. indicated positive for multiple organisms including Escherichia Coli (a group of bacteria that CNA cause infection the urinary tract), Klebsiella Pneumoniae (bacteria in urine that indicates UTI) , Prevotella Bivia (bacteria commonly found in the female genital tract), Proteus Vulgaris (bacteria that CNA cause UTI and wound infections), and Pseudomonas Aeruginosa (bacteria that can CNA cause UTI, particularly in people with urinary catheters). Record review of Resident #3's July 2025 MAR indicated Contact Isolation for UTI was initiated 07/23/2025 at 06:00 a.m. During an observation and interview on 07/23/2025 at 08:40 a.m., the outside entrance to Resident #3's room gave no indication of being under Contact Isolation. EBP signage was posted to the left upper area of the door frame. CNA Y and CNA N were outside Resident #3's room and indicated the resident was on EBP. CNA N said Resident #3 had developed a foul odor and had episode of blood-tinged urine, and she had reported to the charge nurse. CNA Y said they were to receive report at the beginning of their shift from charge nurse and off-going aides' what type of isolation a resident required. MA CC walked up and asked CNA Y and CNA N if she needed a gown to enter Resident #3's room to administer her medications. CNA Y and CNA N pointed at the EBP signage at entrance to Resident #3's room. MA CC said she was not sure if was required. After surveyor intervention, CNAs Y and N went to speak to LVN B about her current isolation status. During an interview on 07/23/2025 at 09:00 a.m., LVN B told CNA Y and CNA N that Resident #3 had an UTI and was in Contact Isolation. LVN B said she had not had time to post the Contact Isolation signage this morning. She added she had failed to pass information to the aides earlier at shift change. She agreed the lack of communication, and no signage also meant the night shift possibly had entered Resident #3's room without proper PPE. During an interview on 07/23/2025 at 10:45 a.m., LVN B said she had been asked by the DON to check and see if Contact Isolation had been ordered for Resident #3 the previous evening. She said it had not been, so she wrote the order. She said she had failed to put the signage to entrance of Resident #3's door until surveyor intervention. During an interview on 07/23/2025 at 11:00 a.m., the DON said she had requested the previous evening shift to place Resident #3 on Contact Isolation. She said when she arrived at facility this morning at 06:30 a.m., Resident #3 did not have a Contact Isolation sign posted at her door. When asked how staff were informed of change in condition, isolation status, or type of isolation, she said the information was passed between staff at shift change. The DON said her expectations were for all staff to always follow Infection Control practices. She said this failure in communication could affect residents by spread of illness or infections. 2. Record review of Resident #54's face sheet, dated 07/21/25, reflected Resident #54 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diabetes, obesity, insomnia (a sleep disorder characterized by difficulty falling asleep), and spondylolisthesis (a spinal disorder in which a vertebra slips forward onto the bone below it). Record review of the 5-day and admission MDS assessment were not available and were in progress due to new admission to facility on 07/18/2025. Record review of Resident #54's baseline care plan dated 07/18/2025 indicated redness to bilateral feet. The baseline care plan gave no indication of pressure sores or pertinent skin conditions. Record review of Resident #54's admission assessment dated [DATE] indicated he was alert, oriented to person, place, time, and situation. Answered questions appropriately. Understands verbal content and makes self-understood. Resident #54 noted to have unspecified skin problem to right foot and redness to outer left foot. Record review of Resident #54's Weekly Ulcer assessment dated [DATE] indicated a Stage 2 pressure wound to right ankle measuring 2.5cm x 2.5cm x 0.1cm. Resident #54's Weekly Skin assessment dated [DATE] indicated addition of pressure wound to right heel measuring 1.5cm x 2.5cm x 0.2cm. Record review of Resident #54's MAR indicated admission date of 07/18/2025. Beginning 07/21/2025, an order was started to cleanse wound to lateral right ankle with wound cleanser, pat dry, apply calcium alginate with silver, cover with dry dressing daily. Beginning 07/23/2025, an order was started for right heel which indicated to clean area, apply calcium alginate and cover with dry dressing. Also, for right heel - clean area, apply skin prep, wear bilateral boots to prevent further skin issues daily for wound healing. During an observation and interview on 07/21/2025 at 08:21 a.m., Resident #54 was observed lying in bed with heel protecting boots on both feet. There was an EPB sign on the outside of the resident's door. Resident #54 was lying in bed on back with HOB elevated >45 angle in a sitting up position. The bed was in a high position. Resident #54 was AAO and able to be interviewed. Resident #54's feet were in boots with heels hanging at the edge of the bed, slightly dangling off the end. Resident #54 said he was prone for pressure sores and thought he needed a bigger bed as his feet had been hanging on edge of the bed through the weekend. Resident #54 said he was admitted to the facility Friday evening/night and has been in bed all weekend. He said nobody had gotten him OOB as he was waiting on therapy to evaluate him before getting OOB. Resident #54 said he had a sore on his right ankle and had admitted to the facility with it. He said he wasn't sure if he had any other areas. He used a urinal but had leakage at times. During an observation and interview on 07/22/2025 at 08:30 a.m., the ADON said she has not seen Resident #54 yet as he was admitted Friday evening. She said she did not work yesterday (Monday). The ADON donned gown and gloves and placed wound care supplies on resident's overbed table. CNA Y was at bedside dressed in PPE to assist with turn and reposition of Resident #54. CNA Y held Resident #54's leg up to allow observation and wound care. Resident #54 was able to hold the grab bar but was unable to turn self without assist. Resident #54 needed full assistance by staff. The ADON repositioned the resident to left side. Resident #54 feet were in boots and were at the end of the bed. His boots were then removed. A dressing was noted to the right outer ankle and was removed. An open wound was noted on the back of the Resident #54's right heel. The wound was open with a whitish/yellow stringy like wound bed covering approximately 75% of the wound bed. The rest of the wound bed was pale yellow in color and surrounding skin appeared pale pink. The area was approximately the size of a nickel. Resident #54's left outer foot had a blanchable light pink area. The ADON applied skin prep and said this area was being watched but was not a pressure ulcer at this time.The ADON said she was not aware of this new area and was not sure if the admission nurse or weekend RN had observed or assessed it. She was not sure who did his wound care yesterday (Monday 07/21). The ADON said she had not seen an order for this right heel wound or treatments on his orders. The ADON measured the area to be 1.5x 2.5 cm and said the white/yellow stringy wound bed was slough[JM7] . She said he was wearing [NAME] boots, and they were not provided by the facility (he was admitted with them). The ADON removed her gloves and stepped outside of the room wearing the same gown to retrieve supplies from her cart. She reentered the room and donned gloves without hand hygiene. The ADON cleaned Resident #54's right heel with wound cleanser and applied silver alginate, covering with a dry dressing. She said she would have to notify the Wound Care MD of the new wound. The ADON said Resident #54 had not been assessed by the Wound Care MD yet. She said he did not have any areas on his buttocks that she knew of, and nothing had been reported to her. CNA Y said she has not seen any open areas on Resident #54's buttocks. She said she only knew of areas to his feet. The ADON said in addition to being the ADON, she was the wound care nurse. She said she had been working as the charge nurse at night as well. The ADON said she had worked last night, and had stayed over for Wound Care MD to come do rounds. She added either herself or Wound Care MD does wound measurements. The ADON said the charge nurses were to do wound care measurements if she was not there or if a new wound was found and she was not there. During an observation and interview on 07/23/2025 at 2:00 p.m., CNA Y walked into Resident #54's room (on EBP) and was called out of the room by the DON who was passing in the hallway. The DON reminded her to don PPE before providing care. Resident #54 was sitting up in bed at a >45-degree angle with his feet hanging on the edge of the bed with boots on. CNA Y said she walked right by the sign not thinking and had not provided care yet. CNA Y donned PPE and assisted Resident #54 by herself to roll him to his right side. Resident #54 could only grab the grab bar and struggled to turn as CNA Y struggled to get him on his side. She said she was not sure if he was a 1-person or 2-person assist but he should be 2-person. Resident #54 had BM in his rectum and CNA Y told him she needed to clean him. CNA Y's gown was not tied and was hanging halfway down her scrub top as she grabbed wipes and began wiping feces from his rectum. CNA Y continued to wipe the BM while wiping his scrotum and in his skin folds without changing gloves. Resident #54 had a pinpoint open area on his right mid-buttock area near his buttock crease. It was open with red center and redness noted around the wound. Resident #54 told CNA Y it hurt as she wiped his buttock. She changed her gloves without performing hand hygiene. CNA Y then applied barrier cream to his open area and included his buttock, anal area, scrotum, skin folds. CNA Y touched his upper back, rubbing barrier cream on his upper back. CNA Y said she had not seen the open area as this was her first time providing care for him today. She said Resident #54 would use the urinal or if he needed the bed pan. CNA Y said she would give it to him, but she had not had to provide incontinent care today. She said she was not told of his buttock having any open areas and he had not reported anything to her. She said she would need to report it to the charge nurse. During an observation and interview on 07/23/2025 at 2:45 p.m., LVN D was called to the room. MA CC walked into Resident #54's room with her BP cuff to check resident vitals. CNA Y told her to put a gown and gloves on. MA CC said she did not see the sign as she walked right by it. Both MA CC and CNA Y said they were recently in-serviced on EBP and hand hygiene. MA CC checked the resident's BP with her cuff and asked out loud what should she do about the PPE. After removing the PPE, MA CC exited the room with the PPE and placed it in the trash in the hall. MA CC did not wash her hands. She placed the BP cuff on the handrail outside the Resident #54's door without sanitizing it. MA CC then reentered the resident's room to wash her hands. MA CC then picked up the BP cuff from handrail and carried it to another hall to her medication cart where she then pulled out sanitizer wipes to clean cuff. MA CC said she forgot about sanitizing the BP cuff until she was putting on the medication cart. LVN D entered the room and donned PPE. CNA Y donned another gown, but did not secure by tying it again. CNA Y pulled Resident #54 back onto his right side. LVN D said he needed to be 2-person assist and pulled the pad with the CNA. CNA Y showed LVN D his buttock area, and LVN D said she could not see it. CNA Y pointed to the area again. LVN D said oh it is open and rubbed the open sore. She said it must have sloughed off and told CNA Y to rub barrier cream on it. CNA Y rubbed the cream on his buttock and touched the resident's scrotum area, checking under it. She did not change her gloves. CNA Y touched on Resident #54's back, bed linen, bedside table, and helped reposition him while wearing the same gloves. LVN D said it was a new open area and she would notify the ADON and call the provider. She did not measure it. She removed her PPE and walked out of the resident's room without conducting hand hygiene. LVN D then walked down the hall past the hand sanitizer on the wall and went to the nursing station. Along the way, she touched her phone in her pocket, items at the nursing station including computer and desk phone. LVN D said I should have changed my gloves prior to touching anything after touching his open wound on his buttock. LVN D said she should have washed her hands prior to walking out of his room. LVN D said she knew to do it, but she just didn't. LVN D said she was recently in serviced on Infection Control including EBP and hand hygiene. She said she would notify the ADON of the buttock area and give us copies of the orders and notes. 3. Record review of a face sheet dated 07/22/25 indicated Resident #29 was an [AGE] year-old female admitted to the facility 07/13/18. Her diagnosis included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dysphagia (difficulty swallowing foods or liquids) following cerebrovascular disease (a group of conditions that impact the brain's blood vessels and blood flow), aphasia (e disorder that affects a person's ability to communicate), and gastrostomy (the surgical opening (stoma) in the stomach, typically for a feeding tube). Record review of a care plan dated 01/30/25 indicated Resident #29 required enhanced barrier precautions related to wounds and a G-Tube. Goals included: enhanced barrier precautions would be performed daily with contact care. Interventions included: gloves and gowns would be used when performing contact activities. Record review of a significant change MDS dated [DATE] indicated a staff assessment for mental status indicated Resident #29 had severely impaired cognition, was dependent for all ADLs, and received all nutrition and water through her feeding tube while a resident at the facility. Record review of physician orders dated July 2025 indicated Resident #29 was NPO (nothing by mouth), Her G-Tube site was to be cleaned with normal saline and a clean dressing applied to G-tube site and secured with tape daily and as needed and required enhanced barrier precaution related to her wounds and G-Tube. During an observation on 07/21/25 at 8:14 a.m., Resident #29 was in bed in her room. A sign at her door indicated enhanced barrier precautions and to wear a gown and gloves for all direct contact care. Resident #29 was unable to respond to questions but did open her eyes when her name was called. She had a tube feeding of Isosource 1.5 cal running at 45ml/her per a feeding pump. During an observation of G-Tube site care on 07/22/25 at 11:14 a.m., LVN A washed her hands, gloved and sterilized the bedside table of Resident #29 and threw away her gloves. She exited the room, performed hand hygiene and applied a new pair of gloves and sterilized a small tray. She sterilized her hands, gloved, and collected her needed supplies and assembled them on the sterilized tray. She knocked and entered the room. She sterilized her hands and applied a new pair of gloves. She did not put on a gown as required by enhanced barrier precautions. During an interview on 07/22/25 at 4:10 p.m., LVN A said that she forgot to wear a gown while doing G-Tube site care for Resident #29. She said Resident #29 required EBP and a gown and gloves were required with direct contact care. She said the facility had trained her on the requirements of EBP and gloves and gown should be worn for all direct care. She said she forgot to wear the gown because she was being watched and she was in a hurry to get all her other tasks completed. She said the possible negative outcome for not wearing the gown could be cross contamination and the spread of infection to residents and staff. During an interview on 07/23/2025 12:25 p.m., the DON said a gown should have been worn to perform G-Tube care for Resident #29. She said her expectation was for all nursing staff to wear gown and gloves during close contact care including G-Tube care. She said all nursing staff are trained on EBP during orientation and annually after that. She said all nursing staff undergo skills check offs at orientation and annually and the check offs include appropriate use of PPE. She said the possible negative outcome for not wearing a gown during G-Tube care could be the spread of infection to other residents and staff. During an interview on 07/24/2025 8:57 a.m., the Administrator said the DON was the direct supervisor of all nursing staff. He said he expected all nursing staff to wear the appropriate gown and gloves when providing direct contact care to residents. He said the possible negative outcome of not wearing appropriate PPE during care could be the spread of infection. 4. Record review of Resident #37's face sheet, dated 07/23/25, indicated he was an [AGE] year-old male, admitted [DATE] and readmitted [DATE] originally admitted with diagnoses which included cerebral infarction (when a blood clot cuts off blood flow to an area of the brain leading to damage). Record review of the quarterly MDS assessment, dated 07/27/2025, indicated Resident #37 was severely impaired of cognition and total dependent for assistance with ADLs with diagnoses of cerebral infarct. Record review of Resident #37's comprehensive care plan revised 06/09/25 indicated he needed total dependency for ADLs and requires EBP to be used related to gastrostomy tube (a flexible tube surgically inserted through the abdomen and stomach wall to deliver nutrition and fluids directly to the stomach). During an observation on 07/22/2025 at 9:22 a.m., Resident #37's room had a sign indicating Enhanced Barrier Precautions beside the door with the Isolation cart filled with PPE inside the room near the door of Resident's #37's Room. LVN C was setting up her g tube medication to administer to Resident #37. She asked for a CNA to assist her pulling the resident up in bed and repositioning him. LVN C washed her hands and put on a pair of gloves. The ADON entered the room washed her hands and put on gloves and stood at the head of Resident #37's bed reached behind his back and grabbed the draw sheet as she was leaning her body against the resident's bed. LVN C grabbed the draw sheet on the left side of Resident #37's bed and the two staff members slid the resident up in bed and adjusted him in bed. The ADON started out the door and LVN C started putting on her gown and completed the medication pass without any other infection control concerns. LVN C said she was providing care for Resident #37 today and he was on EBP. LVN C said she should have put her gown on before assisting pulling the resident up in bed. She said she forgot about her gown when the ADON rushed into the room to assist her. LVN C said she was educated on EBP and should have worn her gown and gloves with direct patient care. She said the resident risk was potential infection. During an interview on 7/22/25 at 9:22 a.m., the ADON said she should have worn a gown along with her gloves when pulling Resident #37 up in bed and repositing him. She said Resident #37 was on EBP. The ADON was educated on EBP. She said the resident risk was infection. The ADON said she just did not think about it, she said she worked last night. During an interview on 7/23/25 at 11:12 a.m., the DON, said the ADON and LVN C should have worn a gown and gloves while providing high contact resident care for Resident #37 that was on EBP when pulling him up in bed and repositioning him in bed. She said all staff was educated on EBP with the most recent training on 7/11/25. The DON said the staff were not thinking and overlooked putting on their gowns. She said the resident risk of not wearing a gown for direct patient care for a resident on EBP was potential infection. The DON said the staff could pass an infection to him. She said her expectation was all staff follow EBP for all residents on EBP. During an interview on 7/23/25 at 8:45 a.m., the Administrator said the staff should not have provided direct patient care for Resident #37 without wearing a gown, he said it was an oversite. He said all staff were educated on EBP. The Administrator said the resident risk of staff members providing high contact patient care on a resident with EBP precautions without wearing proper PPE was a potential infection. The Administrator said his expectation was all staff follow policy and procedures related to EBP. Record review of a facility policy dated August 2022, titled, Enhanced Barrier Precautions indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showing; c. transferring; providing hygiene; changing linens; changing brief or assisting with toileting; g. device care or use ( . feeding tube, .) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. This was determined to be an Immediate Jeopardy (IJ) on 07/23/2025 at 5:17 p.m.]. The administrator and DON were notified. The administrator was provided with the IJ template on 07/23/2025 at 5:17 p.m.]. The following Plan of Removal submitted by the facility was accepted on 07/24/2025 at 9:13 a.m.:All items listed will be completed by 1PM on 7/24/25 with continued follow-up for scheduled staff.Resident #3 was placed in contact isolation and received catheter care and skin assessment to determine no negative outcomes.Resident #54 was assessed for skin and complications and determined no negative outcomes.Residents #29 and #37 were assessed for treatment area around g-tube and determined no negative outcome. All residents residing in the [Facility] that currently has a urinary catheter that were reviewed for complications related to urine such as urine color, smell and consistency by MDS nurse. Administrator/DON initiated an in-service regarding policy and proced

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider for 1 of 3 residents (Resident #1) reviewed for discharge communication documentation. <BR/>Resident #1 was discharged to her home on [DATE]. She did not receive home health services until 07/09/24. The facility did not ensure the HHA received the required information prior to Resident #1's discharge. <BR/>This failure placed residents at risk of not receiving necessary care and services. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet dated 07/12/24 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included sepsis (the body's extreme reaction to an infection), cerebral infarction (stroke), malignant neoplasm of overlapping sites of left breast (cancerous tumor), diabetes (high blood sugar), acute kidney failure (unable to filter waste products from the blood), and unspecified multiple injuries.<BR/>Record review of Resident #1's baseline care plan dated 06/20/24 indicated Resident #1's goals included improve ADL skills, increase continence to achieve discharge plan, and planned to discharge home.<BR/>Record review of a social service note dated 06/24/24 at 8:56 a.m., completed by ADMK B indicated Resident #1 was admitted to the facility on short-term rehabilitation. Resident #1 planned to discharge home with home health services. <BR/>Record review of Resident #1's 5-day MDS dated [DATE] indicated she was usually understood, had severe cognitive impairment (BIMS score 3), required extensive assistance of 2+ person physical assist for bed mobility and was totally dependent on 2+ person physical assist for toileting. She had one or more unhealed pressure ulcers/injuries. Her Skin and Ulcer/Injury Treatments included a pressure reducing device for her bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings, and applications of ointments/medications other than to feet. Resident #1's overall Goal was to discharge to the community. Resident #1 wanted to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. A referral to local contact agency was not made was marked as unknown.<BR/>Record review of Resident #1's physician orders dated 07/05/24 indicated discharge home 07/06/24 with home health.<BR/>Record review of Resident #1's Final Transfer/Discharge from the facility dated 07/06/24 indicated Resident #1 was discharged home. Her diagnoses included sepsis and buttock wound and all medications were sent with Resident #1 and RP. She had a Foley catheter. She was at risk for falls, limited/non-weight bearing, needed medications crushed and Flagyl (antibacterial agent) was crushed and applied to buttock wound daily. Pressure ulcers covered both buttocks with foul drainage. She had impaired cognition and sensation. She was incontinent of bladder and bowel. HHA referral was checked YES. Provision of current Reconciled medication list to subsequent provided at discharge was checked as paper based (e.g. fax, copies, printouts). <BR/>Record review of Resident #1's discharge summary fax cover sheet dated 07/03/24 indicated the summary was faxed to an HHA on 07/03/24. The fax cover sheet indicated sending is complete. The HHA's fax number noted on the fax sheet had an extra 6 in the number typed into the facility's fax machine and was not the correct HHA number.<BR/>During an interview on 07/12/24 at 8:17 a.m., a family member said the facility had not sent Resident #1's discharge information to the HHA or arranged services. She said Resident #1 was discharged home on [DATE] with no medical equipment and no nurse services. She said Resident #1 received no services for two days after she was discharged from the facility because the HHA had not received Resident #1's discharge information.<BR/>During an interview on 07/15/24 at 12:25 p.m., ADMK B she was responsible for completing the discharge process. She said she faxed Resident #1's discharge summary to the HHA on 07/03/24. She said she was not aware the HHA had not received Resident #1's discharge information until 07/09/24. She said she received a text from HHA CM C on 07/09/24 saying he had not received Resident #1's information. She said Resident #1 was discharged home on [DATE] with the HHA number and HHA CM's number to call if the HHA's staff did not arrive to provide service. She said she was not aware she had input the wrong number into the facility's fax machine. She said she thought the confirmation the fax was sent meant the receiving facility had received the information. She said it was important to ensure the HHA or other receiving provider received a resident's information to ensure continuity of care.<BR/>During an interview on 07/15/24 at 11:43 a.m., HHA MDM A said the facility faxed Resident #1's discharge summary to the HHA on 07/09/24. She said the HHA had no information from the facility prior to 07/09/24. <BR/>During an interview on 07/15/24 at 12:33 p.m., HHA CM C said he texted ADMK B on 07/09/24 when he was not able to locate Resident #1's discharge information. He said ADMK B had notified him on 07/03/24 of Resident #1's pending discharge and said she would send Resident #1's information. He said he received Resident #1's discharge information on 07/09/24 and nursing staff was sent out STAT on 07/09/24.<BR/>During an interview on 07/15/24 at 12:45 p.m., the DON said she was not aware the HHA had not received Resident #1's information. She said she was not aware the fax cover sheet that indicated information sending was completed, did not confirm the receiving facility had received the information. She said it was important to ensure the HHA or other receiving provider received a resident's information to ensure continuity of care.<BR/>Record review of the facility's Transfer or Discharge documentation policy dated 2001 (revised December 2016) indicated .2. Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: a. The basis for the transfer or discharge; (I) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met; (b) this facility's attempt to meet those needs; and (c) the receiving facility's service(s) that are available to meet those needs. b. Contact information of the practitioner responsible for the care of the resident; c. Resident representative information including contact information; d. Advance Directive information; e. All special instructions or precautions for ongoing care, as appropriate; f. Comprehensive care plan goals; and g. All other necessary information , including a copy of the residents discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision and assistance devices to prevent accident for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision.<BR/>* The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. <BR/>* The facility failed to ensure Resident #2 had interventions in place after she had 2 falls. <BR/>* The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall.<BR/>An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents who were assessed as high risk for falls at risk of at risk of potential accidents, serious injuries, serious harm, or death. <BR/>Findings included:<BR/>1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility.<BR/>Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls.<BR/>Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. <BR/>Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. <BR/>Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. <BR/>Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. <BR/>Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER.<BR/>Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. <BR/>Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone.<BR/>Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. <BR/>During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them.<BR/>2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. <BR/>Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. <BR/>Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had &frac14; side rails. There were no fall mats on the floor by the bed and the bed was not in the lowest position. She was not able to answer questions. <BR/>3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).<BR/>Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls.<BR/>Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. <BR/>Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx.<BR/>Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. <BR/>Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for &frac14; rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. <BR/>During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed and the bed had &frac14; rails. There were no fall mats on the floor next to the bed and the bed was not in the lowest position. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. <BR/>During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. <BR/>During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. <BR/>Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated:<BR/>Policy Statement<BR/>Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.<BR/>Policy Interpretation and Implementation<BR/> Fall Risk Factors:<BR/> 2. Resident conditions that may contribute to the risk of falls include:<BR/>a. fever; <BR/>b. infection; <BR/>c. delirium and other cognitive impairment; pain; <BR/>d. lower extremity weakness; <BR/>e. poor grip strength; <BR/>f. medication side effects; <BR/>g. orthostatic hypotension; <BR/>h. functional impairments; <BR/>i. visual deficits; and <BR/>j. incontinence.<BR/>3. Medical factors that contribute to the risk of falls include:<BR/>a. arthritis; <BR/>b. heart failure; <BR/>c. anemia; <BR/>d. neurological disorders; and balance and gait disorders; etc.<BR/>Resident-Centered Approaches to Managing Falls and Fall Risk<BR/>1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls <BR/>Monitoring Subsequent Falls and Fall Risk<BR/>1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling <BR/>The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m.<BR/>All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.<BR/>1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.<BR/>2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.<BR/>3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. <BR/>4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25.<BR/>5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025.<BR/>6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. <BR/>If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.<BR/>The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. <BR/>A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. <BR/>This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.<BR/>Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.<BR/>Monitoring: Record review and interviews of completed:<BR/>* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. <BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.<BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.<BR/>* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. <BR/>During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision and assistance devices to prevent accident for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision.<BR/>* The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. <BR/>* The facility failed to ensure Resident #2 had interventions in place after she had 2 falls. <BR/>* The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall.<BR/>An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents who were assessed as high risk for falls at risk of at risk of potential accidents, serious injuries, serious harm, or death. <BR/>Findings included:<BR/>1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility.<BR/>Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls.<BR/>Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. <BR/>Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. <BR/>Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. <BR/>Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. <BR/>Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER.<BR/>Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. <BR/>Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone.<BR/>Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. <BR/>During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them.<BR/>2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. <BR/>Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. <BR/>Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had &frac14; side rails. There were no fall mats on the floor by the bed and the bed was not in the lowest position. She was not able to answer questions. <BR/>3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).<BR/>Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls.<BR/>Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. <BR/>Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx.<BR/>Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. <BR/>Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for &frac14; rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. <BR/>During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed and the bed had &frac14; rails. There were no fall mats on the floor next to the bed and the bed was not in the lowest position. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. <BR/>During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. <BR/>During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. <BR/>Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated:<BR/>Policy Statement<BR/>Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.<BR/>Policy Interpretation and Implementation<BR/> Fall Risk Factors:<BR/> 2. Resident conditions that may contribute to the risk of falls include:<BR/>a. fever; <BR/>b. infection; <BR/>c. delirium and other cognitive impairment; pain; <BR/>d. lower extremity weakness; <BR/>e. poor grip strength; <BR/>f. medication side effects; <BR/>g. orthostatic hypotension; <BR/>h. functional impairments; <BR/>i. visual deficits; and <BR/>j. incontinence.<BR/>3. Medical factors that contribute to the risk of falls include:<BR/>a. arthritis; <BR/>b. heart failure; <BR/>c. anemia; <BR/>d. neurological disorders; and balance and gait disorders; etc.<BR/>Resident-Centered Approaches to Managing Falls and Fall Risk<BR/>1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls <BR/>Monitoring Subsequent Falls and Fall Risk<BR/>1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling <BR/>The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m.<BR/>All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.<BR/>1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.<BR/>2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.<BR/>3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. <BR/>4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25.<BR/>5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025.<BR/>6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. <BR/>If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.<BR/>The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. <BR/>A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. <BR/>This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.<BR/>Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.<BR/>Monitoring: Record review and interviews of completed:<BR/>* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. <BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.<BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.<BR/>* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. <BR/>During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 4 of 5 residents reviewed for advanced directives. (Residents #16, #23, #31, and #50)<BR/>* The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #16, #23, #31, and #50<BR/>This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. <BR/>Findings included:<BR/>1. Record review of a face sheet dated [DATE] indicated Resident #16 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral palsy and diabetes. He was designated as DNR (do not resuscitate). <BR/>Record review of the EMR and hard chart for Resident #16 had a scanned OOH-DNR dated [DATE] with witness signatures of the AD and Admissions/Marketer.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #16 was alert to person, place, and time with a BIMS (brief interview mental status) of 14 of 15 score which indicated he was cognitively intact. <BR/>Physician orders dated [DATE] indicated Resident #16 had a DNR order dated [DATE].<BR/>During an interview on [DATE] at 8:35 a.m., The Administrator said he wanted the resident's advance directives to be filled out correctly.<BR/>2. Record review of a face sheet dated [DATE] indicated Resident #23 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included high blood pressure, progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. She was designated as DNR.<BR/>Record review of the current MDS dated [DATE] indicated Resident #23 was alert to person, place, and time with a BIMS of 99 indicating she was unable to complete the interview. <BR/>Record review of physician orders for [DATE] indicated Resident #23 had an order dated [DATE] for DNR.<BR/>Record review of the EMR and hard chart for Resident #23 had a scanned OOH-DNR dated [DATE] with witness signatures of the AD and Admissions/Marketer. The physician signature was in the wrong section, was not dated, did not have his license number, and was on the wrong line on the bottom of the form.<BR/>During an observation and interview on [DATE] at 01:20 PM Resident #23 was up in her wheelchair propelling herself in the hallway. She said she did not want someone pounding on her chest if she died. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #31 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included high blood pressure, seizures, and loss of cognitive functioning. She was designated as DNR.<BR/>Record review of the current MDS dated [DATE] indicated Resident #31 was alert to person, place, and time with a BIMS of 14 of 15 indicating she was cognitively intact and could make her own decisions. <BR/>Record review of physician orders for [DATE] indicated Resident #31 had an order dated [DATE] for DNR.<BR/>Record review of the EMR and hard chart for Resident #31 had a scanned OOH-DNR dated [DATE]. The physician section did not have the printed name.<BR/>During an observation and interview on [DATE] at 01:20 PM Resident #31 was in her room. She said she had a DNR because she did not want anything done.<BR/>4. Record review of a face sheet dated [DATE] indicated Resident #50 was a [AGE] year-old male admitted on [DATE]. His diagnoses included high blood pressure, a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly, chronic condition in which the pancreas produces little or no insulin, condition in which bones become weak and brittle, and bleeding from the small intestine or large intestine. He was designated as DNR.<BR/>Record review of the current MDS dated [DATE] indicated Resident #50 was alert to person, place, and time with a BIMS of 08 of 15 indicating he had moderately impaired cognition and may need some help making decisions. <BR/>Record review of physician orders for [DATE] indicated Resident #50 had an order dated [DATE] for DNR.<BR/>Record review of the EMR and hard chart for Resident #50 had a scanned OOH-DNR dated [DATE] with witness signatures of the AD and Admissions/Marketer.<BR/>During an observation and interview on [DATE] at 01:20 PM Resident #50 was in the bed. He said he thought he had a DNR.<BR/>During an interview on [DATE] at 8:10 a.m., the Admissions/Marketer said she was responsible to implement advance directive on admissions and most of the time the nurses would tell her if family or resident wanted a new directive. The Admissions/Marketer said she was trained that the employees could sign as a witness and could sign if they were not performing direct care to the residents. She said if the directive was not filled out correctly, they would not be able to honor their wishes and CPR would be started.<BR/>During an interview on [DATE] at 8:35 a.m., The Administrator said he wanted the resident's advance directives to be filled out correctly.<BR/>During an interview on [DATE] at 04:22 PM the DON said she was unaware of the incomplete DNRs and could not have 2 staff signatures. She said these issues would make the DNR invalid and the residents would be a full code. She said the residents would have lifesaving procedures performed when they did not want them.<BR/>Record review of the Out-of-Hospital Do-Not-Resuscitate Order accessed on [DATE] at https://www.hhs.texas.gov/regulations/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order indicated on page 2:<BR/>Instructions for Issuing An OOH-DNR <BR/>Implementation: The OOH-DNR Order may be executed as follows:<BR/>In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals .<BR/>Definitions: <BR/>Qualified Witnesses One of the witnesses must meet the qualifications in HSC 166.003(2), which requires that at least one of the witnesses not (7) an employee of a health care facility in which the person is a patient if the employee is providing direct patient care to the patient or is an officer, director, partner, or business office employee of the health care facility or any parent organization of the health care facility.<BR/>The policy for advance directives dated [DATE] indicated advance directive will be respected in accordance with state law and facility policy.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 2 residents reviewed for PASRR assessments. (Resident #2) <BR/>The facility did not provide and arrange for a specialized customized manual wheelchair for Resident #2 as recommended and agreed upon by the IDT within the time frame set by PASRR.<BR/>This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life. <BR/>Findings included:<BR/>Record review of a face sheet dated 04/23/25 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and used a manual wheelchair. <BR/>Record review of an undated IDT and NFSS Complaint Report indicated Resident #2 had an initial IDT meeting on 10/18/24; services recommended and agreed on were OT Assessment, PT Assessment, ST Assessment, CMWC Service, and OT Service. The report also indicated an email was sent to the Administrator and MDS Nurse on 01/08/25 and a follow-up phone call was conducted on 01/27/25.<BR/>Record review of a PCSP dated 01/27/25 for Resident #2 indicated Medicaid Eligibility was marked as 1. ME Confirmed; the IDT recommended and agreed on a CMWC, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT, Habilitation Coordination, and Independent Living Skills Training. <BR/>Record review of an email dated 01/29/25 from the Administrator to the MDS Nurse regarding the NFSS PASRR Compliance Request indicated he was contacted by the PASRR Unit-Program Specialist by phone. He indicated in the email the NFSS needed to be completed in the portal as soon as possible. <BR/>Record review of a care plan last revised 01/16/2025 indicated Resident #2 was PASRR positive (screening to identify if resident has PASRR conditions serious mental illness, intellectual disability, developmental disability or related conditions) for ID/DD: schizoaffective disorder-depressive type and cerebral palsy. Goals included for Resident #4 will receive specialized services to meet her needs related to ID/DD/MI to promote her highest level of function through the review period. Interventions included complete and submit new PL1 from the MDS for any re-admission or change of condition for the PE positive status for any new services she requires; agreed to receive the following services: Habilitation PT/OT/ST, Habilitation Coordination, and Independent Living Skills Training; notify local authority of routine IDT meeting, change of condition, and any specialized services needed; notify therapy dept. of PE positive status to ensure they are screening quarterly and prn for any specialized services she may require; and schedule IDT meeting with local authority, Physician, family, and any other entities involved with her care within 14 days of an admission.<BR/>During an observation and interview on 04/21/25 at 11:30 a.m., Resident #2 was sitting in her standard wheelchair in her room. She was not able to answer surveyor's questions. <BR/>During an interview on 04/23/25 at 09:02 a.m., the MDS Nurse said a meeting was done on 10/18/24 for Resident #4. She said the IDT recommended and agreed on a CMWC, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT, Habilitation Coordination, and Independent Living Skills Training. She said Resident #4 was in and out of the hospital and returned on Medicare A several times, so they were not able to submit the NFSS because she had changed payor source to Medicare A. She said she was aware of the required time frames for submitting information since she was the corporate MDS Nurse prior to taking the position of the facility MDS Nurse. <BR/>During an interview on 04/23/25 at 09:50 a.m. the BOM said Resident #2's payor source was Medicare A for November and December 2024 because she had been in and out of the hospital frequently. She said Resident #2's payor source was Medicaid on 01/10/25 and remained until 03/13/25 when she returned to the hospital. <BR/>During an interview on 04/24/25 at 01:27 p.m., the MDS Nurse said another meeting was done on 01/27/25 for Resident #2. She said the IDT recommended and agreed on a CMWC, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT, Habilitation Coordination, and Independent Living Skills Training again. She said the physician/Medical Director did not sign the PASRR NFSS form to be submitted and went out of the country. She said they had since changed the Medical Director and were in the process of getting the NFSS signed and submitted. <BR/>During an interview on 04/23/25 at 11:30 a.m., DON H said the MDS Nurse was responsible for coordinating all things PASRR related. She said she was not employed at the facility at the time Resident #2 had the IDT meetings. She said as far as she knew the corporate MDS Nurse monitored the facility MDS Nurse. <BR/>During an interview on 04/24/25 at 3:20 p.m., the Administrator acknowledged he sent an email on 01/29/25 to the MDS Nurse indicating the PASRR Unit Program Specialist had called about the NFSS form not submitted and it needed to be submitted immediately. He said the MDS Nurse was responsible for the PASRR.<BR/>Record review of a facility policy titled Policy and Procedure for PL1/PASRR/NFSS/1012/PCSP revised 01/16/19 indicated . Rationale: The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for Long Term Care 11. Notify physicians and obtain orders for recommended items, write orders in PCC, notify Therapy of new orders, and submit NFSS forms for specific recommendations. Remember the recommendations must be completed within 25 days of the submission of the IDT form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans.<BR/>* The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. <BR/>* The facility failed to update Resident #2's care plan after she had 2 falls. <BR/>* The facility failed to develop a person-centered care plan with interventions that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall.<BR/>An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents who were assessed as high risk for falls at risk of serious harm and injury. <BR/>Findings included:<BR/>1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility.<BR/>Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls.<BR/>Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. <BR/>Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. <BR/>Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. <BR/>Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. <BR/>Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER.<BR/>Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. <BR/>Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone.<BR/>Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. <BR/>During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them.<BR/>2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. <BR/>Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. <BR/>Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. i<BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. <BR/>Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed.<BR/>During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had &frac14; side rails. She was not able to answer questions. <BR/>3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).<BR/>Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. <BR/>Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls.<BR/>Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. <BR/>Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx.<BR/>Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. <BR/>Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for &frac14; rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. <BR/>During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. <BR/>During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. <BR/>During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. <BR/>Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated:<BR/>Policy Statement<BR/>Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.<BR/>Policy Interpretation and Implementation<BR/> Fall Risk Factors:<BR/> 2. Resident conditions that may contribute to the risk of falls include:<BR/>a. fever; <BR/>b. infection; <BR/>c. delirium and other cognitive impairment; pain; <BR/>d. lower extremity weakness; <BR/>e. poor grip strength; <BR/>f. medication side effects; <BR/>g. orthostatic hypotension; <BR/>h. functional impairments; <BR/>i. visual deficits; and <BR/>j. incontinence.<BR/>3. Medical factors that contribute to the risk of falls include:<BR/>a. arthritis; <BR/>b. heart failure; <BR/>c. anemia; <BR/>d. neurological disorders; and balance and gait disorders; etc.<BR/>Resident-Centered Approaches to Managing Falls and Fall Risk<BR/>1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls <BR/>Monitoring Subsequent Falls and Fall Risk<BR/>1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling <BR/>The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m.<BR/>F656- <BR/>All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.<BR/>1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.<BR/>2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.<BR/>3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. <BR/>4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25.<BR/>5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025.<BR/>6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. <BR/>If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.<BR/>The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. <BR/>A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. <BR/>This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.<BR/>Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.<BR/>Monitoring: Record review and interviews of completed:<BR/>* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. <BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.<BR/>* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.<BR/>* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. <BR/>During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.<BR/>During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. <BR/>During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.<BR/>The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for 1 of 1 resident reviewed for quality of life. (Resident #51)<BR/>The facility did not ensure Resident #51's orthopedic appointment report and orders were received and initiated causing a delay in her receiving physical therapy services as ordered by her orthopedic physician. <BR/>This failure could contribute to residents decline in physical and psychosocial well-being.<BR/>Findings included:<BR/>Record review of a face sheet dated [DATE] indicated Resident # 51 was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included fractured wrist and hand, fracture of the left socket of the hipbone, condition in which bones become weak and brittle, a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life.<BR/>Record review of a hospital Discharge Assessment/Summary Report dated [DATE] indicated Resident #51 had discharge orders of non-weight bearing to right wrist and continue splint, toe-touch weight bearing to left lower extremity, follow up with orthopedic surgery, and 4 weeks of deep vein thrombosis prophylaxis (placed on blood thinner to prevent complications). <BR/>Record review of physician orders indicated Resident #51 had an order dated [DATE] for follow up with orthopedic surgery. <BR/>Record review of the admission MDS dated [DATE] indicated Resident #51 was cognitively intact with a BIMS score of 13 out of 15, she required extensive assistance of 2 persons for transfers, she was receiving no physical therapy, and she received restorative therapy for active range of motion and dressing and/or grooming.<BR/>During interview on [DATE] at 10:30 a.m., Resident # 51 said she fell at the group home she lived in and injured her right wrist around the first of March this year. She said she later fell again and injured her hip and pelvis area. She said she just wanted to start her therapy so she can get better and go back to her group home. She stated, I don't want to stay here, my mother died in a nursing home. She said the bone doctor was not going to do any surgery for her hip and pelvis fractures just therapy to help her get stronger and back on her feet.<BR/>During an interview on [DATE] at 8:30 a.m., the TA said Resident #51 saw the orthopedic physician on [DATE] at 1:45 p.m. because she took her to the appointment. She said she stayed with the resident for the appointment and the doctor verbally told the resident he was changing her weight bearing status to 50% and ordered therapy. She said the orthopedic office was supposed to fax over new orders to the facility and the DON or ADON would initiate the orders. She said she did not remember if she notified the DON of the appointment report.<BR/>Record review of the EMR and hard chart from [DATE] through [DATE] for Resident #51 indicated:<BR/>* there was no report from the orthopedic office visit from [DATE]; <BR/>* there was no documentation in the nursing notes for changes in weight bearing status or therapy; <BR/>* there was no physician order for change in weight bearing or physical therapy. <BR/>A care plan initiated [DATE] and revised on [DATE] indicated Resident # 51 had an ADL Self Care Performance Deficit related to impaired mobility. Interventions included:<BR/>* PT/OT evaluation and treatment as per physician orders.<BR/>* Transfer-required 2-person staff participation for transfer with Hoyer lift <BR/>There was no indication of her receiving PT or weight bearing status change.<BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #51 was cognitively intact with a BIMS score of 13 out of 15, she required extensive assistance of 2 persons for transfers, she was receiving no physical therapy, and she received restorative therapy for active range of motion and dressing and/or grooming.<BR/>During an observation and interview on [DATE] at 11:00 a.m., the RA entered Resident #51's room to provide restorative care. The RA provided ROM exercises to the resident's left arm and ROM to her right lower extremity. The RA said Resident #51 only received restorative care not physical therapy at this time.<BR/>During an interview on [DATE] at 8:15 a.m., the OT said therapy performed evaluations on residents once ordered from the physician. He said no order had been received for a therapy evaluation on Resident #51. He said the resident was receiving restorative care provided by the RA.<BR/>During an interview and record review on [DATE] at 08:36 a.m., the TA entered the conference room and handed paperwork to the surveyor. She said the paperwork was from Resident #51's orthopedic appointment on [DATE]. The fax cover sheet with the paperwork was dated [DATE] at 08:35 a.m.<BR/>Record review of an orthopedics office visit note dated [DATE] for Resident #51 indicated:<BR/> 2. Fracture, Acetabulum, Closed, Left <BR/>Plan: Order CT<BR/> Protocol: Left Femur <BR/>CT without contrast <BR/>Plan: Physical therapy instructions/plan<BR/>Physical therapy plan of care: <BR/>2-3 time(s) per week for 6-8 weeks. <BR/>Weight bearing: Partial weight bearing 50% <BR/>During an interview on [DATE] at 9:30 a.m., the DON said the orders received today on Resident # 51 will be initiated today. She said the TA should notify the DON and/or the CN of any new orders or plan of care changes identified during a physician's appointment. The DON said a negative outcome for facility not receiving new orders or plan of care changes immediately following appointments could cause the resident to have a delay in care and cause a decline in their physical status and ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 16 residents reviewed for unnecessary medication (Resident #36)<BR/>The facility did not monitor Resident #36 for side effects of the anticoagulation medication apixaban (a blood thinning medication).<BR/>This failure could place the residents at risk for adverse consequences of the anticoagulant medication.<BR/>Findings included:<BR/>Record review of a face sheet indicated Resident #36 was a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnosis including atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke).<BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #36 had a BIMS score of 6, indicating severely impaired cognition and received an anticoagulant medication 4 of 7 days.<BR/>Record review of the physician orders dated May 2023 indicated Resident #36 was prescribed apixaban (a blood thinning medication) 5 mg two times a day for atrial fibrillation with a start date of 04/24/23. The orders dddid not address monitoring the anticoagulant medication.<BR/>Record review of a care plan revised 05/03/23 did not indicate Resident #36 received anticoagulant therapy. <BR/>Record review of MAR dated 0/5/09/23 indicated Resident #36 received apixaban 5 mg two times a day. <BR/>Record review of the electronic record for Resident #36 did not indicate the nurses documented monitoring of side effects of anticoagulant daily with medication administration.<BR/>During an interview on 05/09/23 at 3:55 p.m., RN A said she was Resident #36's nurse on 5/8/23 and 5/9/23. She said Resident #36 received the anticoagulant apixaban and was not monitored but should have been when she gave it. RN A said the nurses who provided care for Resident #36 were responsible to ensure the anticoagulant was monitored. She said the monitoring was usually in the MAR when she gave the medication. She said she was educated on monitoring anticoagulants. RN A said it was just missed. She said the risk of a resident on anticoagulants not monitored was a resident bleeding, a resident could fall hit their head and have a hematoma and staff be unaware the resident was on anticoagulants.<BR/>During an interview on 05/10/23 at 2:35 p.m., the DON said Resident #36's apixaban was not monitored and should have been. She said her expectation was for all anticoagulants to be monitored as required. The DON said the nurses should have added monitoring into the computer on admission. She said the nurse who completed Resident #36's admission quit after less than a month. The DON said the ADON and herself were responsible for double check medications for monitoring. The DON said she looked over new admissions and the ADON looked over readmissions. She said Resident #36's monitoring was just overlooked. The DON said the risk of an anticoagulant medication not being monitored was staff possibly missing a resident having excessive bleeding or medication complications. <BR/>During an interview on 05/10/23 at 2:45 p.m., the ADON said the nurses were responsible for adding monitoring into the computer system for anticoagulants. She said she and the DON were responsible for double checking to ensure anticoagulants were monitored. She said the staff were in-serviced on monitoring of medication but was unsure how long ago. The ADON said Resident #36's anticoagulant was not monitored and should have been. She said it was just missed. The ADON said the risk of an anticoagulant medication not monitored was possible missed bleeding, and excessive blood in stools missed.<BR/>During an interview on 05/10/23 at 3:10 p.m., the administrator said his expectation was that all anticoagulant medications to be monitored as required accurately, completely and timely. The administrator said Resident #36's anticoagulant should have been monitored. He said it was just overlooked.<BR/>Record review of a policy titled, Anticoagulant - Clinical Protocol revised November 2018, indicated, . The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulant therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.<BR/>

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen reviewed for the environment.<BR/>The facility did not maintain an effective pest control program to ensure the kitchen was free of fruit flies.<BR/>This failure could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.<BR/>Findings included:<BR/>During an observation and interview on 05/08/23 and started at 08:30 a.m., The DM pulled out a large box that contained approximately 8 bunches of 5-6 bananas each, and there were approximately 120 fruit flies flew out of the box. Approximately 20 flew to a standing cart that had trays of cookies and 2 of 3 trays were not covered and the fruit flies landed on the exposed cookies. The DM said there should not be fruit flies in kitchen at all, and the food would be thrown away. She denied knowing there were fruit flies in the kitchen and said the dietary staff were to report any pest to her and none had been reported.<BR/>During an interview on 05/09/23 at 08:25 a.m., The Administrator said he wanted the kitchen not to have pests and provided the policy and the last reports from the pest control company.<BR/>During an observation and interview on 05/09/23 at 11:00 a.m., observed approximately 2 fruit flies in the kitchen during the food serving process. The DM said there were still 1 or 2 fruit flies She said her and the administrator had thrown out the bananas yesterday and killed the fruit flies with spray and got another pest light for the kitchen.<BR/>During a record review of the monthly pest control dated 04/20/23, 03/30/23 and 02/20/23 indicated the facility received monthly treatment for general pests.<BR/>Review of the facility's policy on pest control dated May 2008 indicated Our facility shall maintain an effective pest control program. 1. The facility maintains an on-going pest control to ensure that the building is kept free of insects.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 10 months reviewed. (August 2022 through May 2023)<BR/>* The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in August 2022, September 2022, October 2022, November 2022, December 2022, January 2023.<BR/>* The facility did not have RN coverage for 11/24/22 (Thanksgiving Day).<BR/>* The facility did not have RN coverage for 7 days in February 2023.<BR/>* The facility did not have the required eight consecutive hours of RN coverage for 4 days in March 2023.<BR/>* The facility did not have RN coverage for 8 days in April 2023.<BR/>* The facility did not have RN coverage for 2 days in May 2023.<BR/>This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.<BR/>Findings included:<BR/>Record review of the CMS Payroll Based Journal report for the 4th quarter of 2022 (July1, 2022 through September 30, 2022) indicated there were no RN hours for the following dates: 08/06/22 (SA); 08/07/22 (SU); 08/13/22 (SA); 08/14/22 (SU); 08/20/22 (SA); 08/21/22 (SU); 08/27/22 (SA); 08/28/22 (SU); 09/03/22 (SA); 09/04/22 (SU); 09/10/22 (SA); 09/11/22 (SU); 09/17/22 (SA); 09/18/22 (SU); 09/24/22 (SA); and 09/25/22 (SU).<BR/>Record review of the CMS Payroll Based Journal report for the 1st quarter of 2023 (October 1, 2022 through December 31,2022) indicated there were no RN hours for the following dates: 10/01/22 (SA); 10/02/22 (SU); 10/08/22 (SA); 10/09/22 (SU); 10/15/22 (SA); 10/16/22 (SU); 10/22/22 (SA); 10/23/22 (SU); 10/29/22 (SA); 10/30/22 (SU); 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU); 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA).<BR/>Record review of RN time sheets for November 2022 indicated there was no RN coverage for the following dates: 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU) and on 11/24/22 (Thanksgiving).<BR/>Record review of RN time sheets for December 2022 indicated there was no RN coverage for the following dates: 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA).<BR/>Record review of RN time sheets for January 2023 indicated there was no RN coverage for the following dates: 01/01/23 (SU); 01/07/23 (SA); 01/08/23 (SU); 01/14/23 (SA); 01/15/23 (SU); 01/21/23 (SA); 01/22/23 (SU); and 01/28/23 (SA). <BR/>Record review of RN time sheets for February 2023 indicated there was no RN coverage for the following dates: 02/04/23 (SA); 02/05/23 (SU); 02/11/23 (SA); 02/12/23 (SU); 02/18/23 (SA); 02/19/23 (SU); and 02/26/23 (SU).<BR/>Record review of RN time sheets for March 2023 indicated there was no RN coverage for the following dates: 03/04/23 (SA); 03/18/23 (SA); 03/25/23 (SA); and 03/26/23 (SU). <BR/>Record review of RN time sheets for March 2023 indicated there was less than 8 consecutive hours of RN coverage for the following dates: 03/04/23 (SA)-6.5 hours; 03/11/23 (SA)- 6.5 hours; 03/12/23 (SU)- 6.25 hours; and 03/19/23 (SU)-6.25 hours.<BR/>Record review of RN time sheets for April 2023 indicated there was no RN coverage for the following dates: 04/01/23 (SA); 04/07/23 (SA); 04/08/23 (SU); 04/15/23 (SA); 04/16/23 (SU); 04/21/23 (SA); 04/22/23 (SU); and 04/29/23 (SA).<BR/>Record review of RN time sheets for May 2023 indicated there was no RN coverage for the following dates: 05/06/23 (SA) and 05/07/23 (SU).<BR/>During an interview on 05/09/23 at 3:18 p.m. BOM/HR said she was not able to obtain time sheets for prior to November 2022. She said they have had no RN for the weekends for several months.<BR/>During an interview on 05/09/23 at 3:20 p.m. the ADM and Corporate Staff said they had no RN weekend coverage for over 8 months. They said they had advertised and listed on internet job sites but had no end results. They said their policy was to follow the regulations for the RN coverage. <BR/>During an interview on 05/10/23 at 12 :42 PM the DON said they did not have RN coverage. She said they had a retired RN who was working some on the weekends but then had nurses leave and now she was using her just to keep the regular nursing staffing covered.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 10 months reviewed. (August 2022 through May 2023)<BR/>* The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in August 2022, September 2022, October 2022, November 2022, December 2022, January 2023.<BR/>* The facility did not have RN coverage for 11/24/22 (Thanksgiving Day).<BR/>* The facility did not have RN coverage for 7 days in February 2023.<BR/>* The facility did not have the required eight consecutive hours of RN coverage for 4 days in March 2023.<BR/>* The facility did not have RN coverage for 8 days in April 2023.<BR/>* The facility did not have RN coverage for 2 days in May 2023.<BR/>This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.<BR/>Findings included:<BR/>Record review of the CMS Payroll Based Journal report for the 4th quarter of 2022 (July1, 2022 through September 30, 2022) indicated there were no RN hours for the following dates: 08/06/22 (SA); 08/07/22 (SU); 08/13/22 (SA); 08/14/22 (SU); 08/20/22 (SA); 08/21/22 (SU); 08/27/22 (SA); 08/28/22 (SU); 09/03/22 (SA); 09/04/22 (SU); 09/10/22 (SA); 09/11/22 (SU); 09/17/22 (SA); 09/18/22 (SU); 09/24/22 (SA); and 09/25/22 (SU).<BR/>Record review of the CMS Payroll Based Journal report for the 1st quarter of 2023 (October 1, 2022 through December 31,2022) indicated there were no RN hours for the following dates: 10/01/22 (SA); 10/02/22 (SU); 10/08/22 (SA); 10/09/22 (SU); 10/15/22 (SA); 10/16/22 (SU); 10/22/22 (SA); 10/23/22 (SU); 10/29/22 (SA); 10/30/22 (SU); 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU); 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA).<BR/>Record review of RN time sheets for November 2022 indicated there was no RN coverage for the following dates: 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU) and on 11/24/22 (Thanksgiving).<BR/>Record review of RN time sheets for December 2022 indicated there was no RN coverage for the following dates: 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA).<BR/>Record review of RN time sheets for January 2023 indicated there was no RN coverage for the following dates: 01/01/23 (SU); 01/07/23 (SA); 01/08/23 (SU); 01/14/23 (SA); 01/15/23 (SU); 01/21/23 (SA); 01/22/23 (SU); and 01/28/23 (SA). <BR/>Record review of RN time sheets for February 2023 indicated there was no RN coverage for the following dates: 02/04/23 (SA); 02/05/23 (SU); 02/11/23 (SA); 02/12/23 (SU); 02/18/23 (SA); 02/19/23 (SU); and 02/26/23 (SU).<BR/>Record review of RN time sheets for March 2023 indicated there was no RN coverage for the following dates: 03/04/23 (SA); 03/18/23 (SA); 03/25/23 (SA); and 03/26/23 (SU). <BR/>Record review of RN time sheets for March 2023 indicated there was less than 8 consecutive hours of RN coverage for the following dates: 03/04/23 (SA)-6.5 hours; 03/11/23 (SA)- 6.5 hours; 03/12/23 (SU)- 6.25 hours; and 03/19/23 (SU)-6.25 hours.<BR/>Record review of RN time sheets for April 2023 indicated there was no RN coverage for the following dates: 04/01/23 (SA); 04/07/23 (SA); 04/08/23 (SU); 04/15/23 (SA); 04/16/23 (SU); 04/21/23 (SA); 04/22/23 (SU); and 04/29/23 (SA).<BR/>Record review of RN time sheets for May 2023 indicated there was no RN coverage for the following dates: 05/06/23 (SA) and 05/07/23 (SU).<BR/>During an interview on 05/09/23 at 3:18 p.m. BOM/HR said she was not able to obtain time sheets for prior to November 2022. She said they have had no RN for the weekends for several months.<BR/>During an interview on 05/09/23 at 3:20 p.m. the ADM and Corporate Staff said they had no RN weekend coverage for over 8 months. They said they had advertised and listed on internet job sites but had no end results. They said their policy was to follow the regulations for the RN coverage. <BR/>During an interview on 05/10/23 at 12 :42 PM the DON said they did not have RN coverage. She said they had a retired RN who was working some on the weekends but then had nurses leave and now she was using her just to keep the regular nursing staffing covered.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 treatment cart reviewed for storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked and secured when left a medication cart unattended unlocked and unsecured on 07/22/25. This failure could place residents at risk of medication misuse or drug diversion. The findings included: Observation and interview on 07/22/25 at 8:09 a.m. revealed the treatment cart was left unlocked and unattended in front of the nurse's station, facing out into the main pathway where 2 residents were observed sitting in wheelchairs to the side of the treatment cart. Further observation revealed no staff at the nurse's station. The treatment cart contained antiseptic solution, which was labeled keep out of reach, 2 spray bottles of wound cleaner, bandages and dressings. The ADON walked up to the State Surveyor and said the treatment cart was left open by accident. The ADON said she was the last person using the treatment wound care cart. She said by the cart being open could result in someone coming by and getting something out of the cart. She said she had been trained on locking carts when finished using them. Record review of Storage of Medications dated November 2020 indicated The facility stores all drugs and biologicals in a safe, secure and orderly manner. 6. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 10 months reviewed. (August 2022 through May 2023)<BR/>* The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in August 2022, September 2022, October 2022, November 2022, December 2022, January 2023.<BR/>* The facility did not have RN coverage for 11/24/22 (Thanksgiving Day).<BR/>* The facility did not have RN coverage for 7 days in February 2023.<BR/>* The facility did not have the required eight consecutive hours of RN coverage for 4 days in March 2023.<BR/>* The facility did not have RN coverage for 8 days in April 2023.<BR/>* The facility did not have RN coverage for 2 days in May 2023.<BR/>This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.<BR/>Findings included:<BR/>Record review of the CMS Payroll Based Journal report for the 4th quarter of 2022 (July1, 2022 through September 30, 2022) indicated there were no RN hours for the following dates: 08/06/22 (SA); 08/07/22 (SU); 08/13/22 (SA); 08/14/22 (SU); 08/20/22 (SA); 08/21/22 (SU); 08/27/22 (SA); 08/28/22 (SU); 09/03/22 (SA); 09/04/22 (SU); 09/10/22 (SA); 09/11/22 (SU); 09/17/22 (SA); 09/18/22 (SU); 09/24/22 (SA); and 09/25/22 (SU).<BR/>Record review of the CMS Payroll Based Journal report for the 1st quarter of 2023 (October 1, 2022 through December 31,2022) indicated there were no RN hours for the following dates: 10/01/22 (SA); 10/02/22 (SU); 10/08/22 (SA); 10/09/22 (SU); 10/15/22 (SA); 10/16/22 (SU); 10/22/22 (SA); 10/23/22 (SU); 10/29/22 (SA); 10/30/22 (SU); 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU); 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA).<BR/>Record review of RN time sheets for November 2022 indicated there was no RN coverage for the following dates: 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU) and on 11/24/22 (Thanksgiving).<BR/>Record review of RN time sheets for December 2022 indicated there was no RN coverage for the following dates: 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA).<BR/>Record review of RN time sheets for January 2023 indicated there was no RN coverage for the following dates: 01/01/23 (SU); 01/07/23 (SA); 01/08/23 (SU); 01/14/23 (SA); 01/15/23 (SU); 01/21/23 (SA); 01/22/23 (SU); and 01/28/23 (SA). <BR/>Record review of RN time sheets for February 2023 indicated there was no RN coverage for the following dates: 02/04/23 (SA); 02/05/23 (SU); 02/11/23 (SA); 02/12/23 (SU); 02/18/23 (SA); 02/19/23 (SU); and 02/26/23 (SU).<BR/>Record review of RN time sheets for March 2023 indicated there was no RN coverage for the following dates: 03/04/23 (SA); 03/18/23 (SA); 03/25/23 (SA); and 03/26/23 (SU). <BR/>Record review of RN time sheets for March 2023 indicated there was less than 8 consecutive hours of RN coverage for the following dates: 03/04/23 (SA)-6.5 hours; 03/11/23 (SA)- 6.5 hours; 03/12/23 (SU)- 6.25 hours; and 03/19/23 (SU)-6.25 hours.<BR/>Record review of RN time sheets for April 2023 indicated there was no RN coverage for the following dates: 04/01/23 (SA); 04/07/23 (SA); 04/08/23 (SU); 04/15/23 (SA); 04/16/23 (SU); 04/21/23 (SA); 04/22/23 (SU); and 04/29/23 (SA).<BR/>Record review of RN time sheets for May 2023 indicated there was no RN coverage for the following dates: 05/06/23 (SA) and 05/07/23 (SU).<BR/>During an interview on 05/09/23 at 3:18 p.m. BOM/HR said she was not able to obtain time sheets for prior to November 2022. She said they have had no RN for the weekends for several months.<BR/>During an interview on 05/09/23 at 3:20 p.m. the ADM and Corporate Staff said they had no RN weekend coverage for over 8 months. They said they had advertised and listed on internet job sites but had no end results. They said their policy was to follow the regulations for the RN coverage. <BR/>During an interview on 05/10/23 at 12 :42 PM the DON said they did not have RN coverage. She said they had a retired RN who was working some on the weekends but then had nurses leave and now she was using her just to keep the regular nursing staffing covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 13 residents (Resident #10) reviewed for ADLs.<BR/>The facility failed to ensure Resident #10 received a shower on 06/01/24, 06/04/24 and on 06/06/24. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental, and psycho-social well-being. <BR/>Findings included:<BR/>Record review of Resident #10's face sheet dated 06/11/24 indicated she was [AGE] years old, admitted on [DATE] and readmitted on [DATE], with diagnoses including muscle weakness and unsteady gait.<BR/>Record review of the admission MDS assessment dated [DATE] indicated Resident #10's BIMS score was 13 indicating intact cognition. She made herself understood and understood others and required partial/moderate assistance from staff for showering. No behaviors of refusing care.<BR/>Record review of Resident #10's care plan dated 05/20/24 indicated he required assistance from staff with showering.<BR/>Record review of the undated shower list indicated Resident #10 was to be given a shower on Monday, Wednesday and Friday.<BR/>Record review of Resident #10's electronic CNA task sheet dated June 2024 indicated no bath or shower was provided for Resident #10 on 06/01/24 (Saturday), 06/04/24 (Tuesday), or 06/06/24 (Thursday). The task sheet indicated she received one shower on 06/08/24 (Saturday). <BR/>Record review of Resident #10's electronic record indicated no documentation of Resident #10 refusing care.<BR/>During observation and interview on 06/10/24 9:39 a.m., Resident #10 said she had not received her 3 showers last week and said her last shower was last Sunday (06/02/24). She said her hair needed to be cleaned. Resident #10 was sitting in her bed in her room. Her hair was unkempt and greasy, and she was scratching her head. <BR/>During an interview on 06/11/24 at 8:00 a.m., the DON said the charge nurse and the ADON were responsible for ensuring showers were given and her expectation was for the residents to be given showers on their scheduled days. <BR/>During a phone interview on 6/11/24 at 9:47 a.m., the ADON said she had noticed a problem with showers not being given last week and she had performed an in-service last week on Monday (06/03/24). She said the facility did not use shower aides so the CNAs must give the showers now. She said her expectation was for the showers to be given 3 times a week for each resident. She said if day shift was unable to get to all showers evening must finish the showers. She said there must still be an issue with Resident #10 and the DON would have staff help her with a shower today and they would investigate why she had not been given a shower 3 x a week.<BR/>Record review of the Bath, Shower/Tub dated February 2018 indicated Purpose The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 2 of 16 residents reviewed for MDS assessment accuracy. (Residents #23 and #46)<BR/>* The facility did not code Residents #23 and #46 for a daily use of a wander/elopement alarm on the MDS.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/10/23 indicated Resident #23 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. <BR/>Record review of the physician orders dated March 2023 indicated Resident #23 had an order dated 01/26/23 for a Wander Guard alarm bracelet day and change every three months.<BR/>Record review of an MDS dated [DATE] indicated Resident #23 under Section P Restraints and Alarms had wander/elopement alarm marked as not used. <BR/>2. Record review of a face sheet dated 05/10/23 indicated Resident #46 was an [AGE] year old male admitted on [DATE] with diagnoses included Alzheimer's disease and dementia.<BR/>Record review of the physician orders indicated Resident #46 had an order for a Wander Guard alarm bracelet daily and change every 3 months for wandering with a start date of 04/07/22.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used.<BR/>During an interview on 05/10/23 at 11:25 a.m., the MDS nurse said he was responsible for making sure the MDS were correct and completed. He said marking the MDS no for the elopement alarms must have been an error in transcription and the error could have affected the care planning process.<BR/>During an interview on 05/10/23 at 04:22 PM the DON said she knew the MDS nurse was working on correcting some of the MDSs for corrections. She said she expected the MDSs to be coded correctly to capture a resident's care and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 2 residents reviewed for PASRR assessments. (Resident #2) <BR/>The facility did not provide and arrange for a specialized customized manual wheelchair for Resident #2 as recommended and agreed upon by the IDT within the time frame set by PASRR.<BR/>This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life. <BR/>Findings included:<BR/>Record review of a face sheet dated 04/23/25 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). <BR/>Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and used a manual wheelchair. <BR/>Record review of an undated IDT and NFSS Complaint Report indicated Resident #2 had an initial IDT meeting on 10/18/24; services recommended and agreed on were OT Assessment, PT Assessment, ST Assessment, CMWC Service, and OT Service. The report also indicated an email was sent to the Administrator and MDS Nurse on 01/08/25 and a follow-up phone call was conducted on 01/27/25.<BR/>Record review of a PCSP dated 01/27/25 for Resident #2 indicated Medicaid Eligibility was marked as 1. ME Confirmed; the IDT recommended and agreed on a CMWC, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT, Habilitation Coordination, and Independent Living Skills Training. <BR/>Record review of an email dated 01/29/25 from the Administrator to the MDS Nurse regarding the NFSS PASRR Compliance Request indicated he was contacted by the PASRR Unit-Program Specialist by phone. He indicated in the email the NFSS needed to be completed in the portal as soon as possible. <BR/>Record review of a care plan last revised 01/16/2025 indicated Resident #2 was PASRR positive (screening to identify if resident has PASRR conditions serious mental illness, intellectual disability, developmental disability or related conditions) for ID/DD: schizoaffective disorder-depressive type and cerebral palsy. Goals included for Resident #4 will receive specialized services to meet her needs related to ID/DD/MI to promote her highest level of function through the review period. Interventions included complete and submit new PL1 from the MDS for any re-admission or change of condition for the PE positive status for any new services she requires; agreed to receive the following services: Habilitation PT/OT/ST, Habilitation Coordination, and Independent Living Skills Training; notify local authority of routine IDT meeting, change of condition, and any specialized services needed; notify therapy dept. of PE positive status to ensure they are screening quarterly and prn for any specialized services she may require; and schedule IDT meeting with local authority, Physician, family, and any other entities involved with her care within 14 days of an admission.<BR/>During an observation and interview on 04/21/25 at 11:30 a.m., Resident #2 was sitting in her standard wheelchair in her room. She was not able to answer surveyor's questions. <BR/>During an interview on 04/23/25 at 09:02 a.m., the MDS Nurse said a meeting was done on 10/18/24 for Resident #4. She said the IDT recommended and agreed on a CMWC, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT, Habilitation Coordination, and Independent Living Skills Training. She said Resident #4 was in and out of the hospital and returned on Medicare A several times, so they were not able to submit the NFSS because she had changed payor source to Medicare A. She said she was aware of the required time frames for submitting information since she was the corporate MDS Nurse prior to taking the position of the facility MDS Nurse. <BR/>During an interview on 04/23/25 at 09:50 a.m. the BOM said Resident #2's payor source was Medicare A for November and December 2024 because she had been in and out of the hospital frequently. She said Resident #2's payor source was Medicaid on 01/10/25 and remained until 03/13/25 when she returned to the hospital. <BR/>During an interview on 04/24/25 at 01:27 p.m., the MDS Nurse said another meeting was done on 01/27/25 for Resident #2. She said the IDT recommended and agreed on a CMWC, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT, Habilitation Coordination, and Independent Living Skills Training again. She said the physician/Medical Director did not sign the PASRR NFSS form to be submitted and went out of the country. She said they had since changed the Medical Director and were in the process of getting the NFSS signed and submitted. <BR/>During an interview on 04/23/25 at 11:30 a.m., DON H said the MDS Nurse was responsible for coordinating all things PASRR related. She said she was not employed at the facility at the time Resident #2 had the IDT meetings. She said as far as she knew the corporate MDS Nurse monitored the facility MDS Nurse. <BR/>During an interview on 04/24/25 at 3:20 p.m., the Administrator acknowledged he sent an email on 01/29/25 to the MDS Nurse indicating the PASRR Unit Program Specialist had called about the NFSS form not submitted and it needed to be submitted immediately. He said the MDS Nurse was responsible for the PASRR.<BR/>Record review of a facility policy titled Policy and Procedure for PL1/PASRR/NFSS/1012/PCSP revised 01/16/19 indicated . Rationale: The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for Long Term Care 11. Notify physicians and obtain orders for recommended items, write orders in PCC, notify Therapy of new orders, and submit NFSS forms for specific recommendations. Remember the recommendations must be completed within 25 days of the submission of the IDT form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 2 of 16 residents reviewed for MDS assessment accuracy. (Residents #23 and #46)<BR/>* The facility did not code Residents #23 and #46 for a daily use of a wander/elopement alarm on the MDS.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/10/23 indicated Resident #23 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. <BR/>Record review of the physician orders dated March 2023 indicated Resident #23 had an order dated 01/26/23 for a Wander Guard alarm bracelet day and change every three months.<BR/>Record review of an MDS dated [DATE] indicated Resident #23 under Section P Restraints and Alarms had wander/elopement alarm marked as not used. <BR/>2. Record review of a face sheet dated 05/10/23 indicated Resident #46 was an [AGE] year old male admitted on [DATE] with diagnoses included Alzheimer's disease and dementia.<BR/>Record review of the physician orders indicated Resident #46 had an order for a Wander Guard alarm bracelet daily and change every 3 months for wandering with a start date of 04/07/22.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used.<BR/>During an interview on 05/10/23 at 11:25 a.m., the MDS nurse said he was responsible for making sure the MDS were correct and completed. He said marking the MDS no for the elopement alarms must have been an error in transcription and the error could have affected the care planning process.<BR/>During an interview on 05/10/23 at 04:22 PM the DON said she knew the MDS nurse was working on correcting some of the MDSs for corrections. She said she expected the MDSs to be coded correctly to capture a resident's care and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 2 of 16 residents reviewed for MDS assessment accuracy. (Residents #23 and #46)<BR/>* The facility did not code Residents #23 and #46 for a daily use of a wander/elopement alarm on the MDS.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/10/23 indicated Resident #23 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. <BR/>Record review of the physician orders dated March 2023 indicated Resident #23 had an order dated 01/26/23 for a Wander Guard alarm bracelet day and change every three months.<BR/>Record review of an MDS dated [DATE] indicated Resident #23 under Section P Restraints and Alarms had wander/elopement alarm marked as not used. <BR/>2. Record review of a face sheet dated 05/10/23 indicated Resident #46 was an [AGE] year old male admitted on [DATE] with diagnoses included Alzheimer's disease and dementia.<BR/>Record review of the physician orders indicated Resident #46 had an order for a Wander Guard alarm bracelet daily and change every 3 months for wandering with a start date of 04/07/22.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used.<BR/>During an interview on 05/10/23 at 11:25 a.m., the MDS nurse said he was responsible for making sure the MDS were correct and completed. He said marking the MDS no for the elopement alarms must have been an error in transcription and the error could have affected the care planning process.<BR/>During an interview on 05/10/23 at 04:22 PM the DON said she knew the MDS nurse was working on correcting some of the MDSs for corrections. She said she expected the MDSs to be coded correctly to capture a resident's care and needs.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen reviewed for the environment.<BR/>The facility did not maintain an effective pest control program to ensure the kitchen was free of fruit flies.<BR/>This failure could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.<BR/>Findings included:<BR/>During an observation and interview on 05/08/23 and started at 08:30 a.m., The DM pulled out a large box that contained approximately 8 bunches of 5-6 bananas each, and there were approximately 120 fruit flies flew out of the box. Approximately 20 flew to a standing cart that had trays of cookies and 2 of 3 trays were not covered and the fruit flies landed on the exposed cookies. The DM said there should not be fruit flies in kitchen at all, and the food would be thrown away. She denied knowing there were fruit flies in the kitchen and said the dietary staff were to report any pest to her and none had been reported.<BR/>During an interview on 05/09/23 at 08:25 a.m., The Administrator said he wanted the kitchen not to have pests and provided the policy and the last reports from the pest control company.<BR/>During an observation and interview on 05/09/23 at 11:00 a.m., observed approximately 2 fruit flies in the kitchen during the food serving process. The DM said there were still 1 or 2 fruit flies She said her and the administrator had thrown out the bananas yesterday and killed the fruit flies with spray and got another pest light for the kitchen.<BR/>During a record review of the monthly pest control dated 04/20/23, 03/30/23 and 02/20/23 indicated the facility received monthly treatment for general pests.<BR/>Review of the facility's policy on pest control dated May 2008 indicated Our facility shall maintain an effective pest control program. 1. The facility maintains an on-going pest control to ensure that the building is kept free of insects.