**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and interviews for 8 out of 11 sampled residents, (Residents #5, # 8, #13, # 25, # 29, #31, #35, and # 38) observed eating lunch in the [NAME] dinning/activity room, the facility failed to ensure the residents experienced a dignity dining by not serving food on a dietary tray. The findings include: Observation of the noon meal service on 3/13/24 at 12:15 PM identified 8 residents (Residents #5, # 8, #13, # 25, # 29, #31, #35, and # 38) were served their meal on a dietary tray. The residents' food and drink items remained on the dietary tray and not on the dining table. Interview on 3/19/24 at 9:35 AM with Nurse Aide (NA#1) identified food remain on the tray because residents spill their food and drink therefore causing a mess. The dietary tray helps to contain the mess. Interview on 3/19/24 at 9:50 with Assistant Director of Nursing Services (ADNS) identified drink and food items should be removed from the dietary tray and set in front of the resident. The ADNS also indicated she was unsure why the facility policy was not being followed and she was going to investigate it. Review of the Dietary Services Policy dated 7/28/21 directed, in part, the philosophy of the dietary department is to provide meals emphasizing resident rights, choice, and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and staff interviews for 1of 1 resident (Resident # 57) reviewed for Advanced Directive, the facility failed to ensure that an updated code status form was signed by the resident and physician to reflect Resident #57 wishes and physician's orders. The findings include: Resident #57 was admitted to the facility on [DATE] with diagnoses that included venous insufficiency, urinary tract infection, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 cognitively intact, requires supervision assistance for bed mobility, and personal hygiene, independent for toileting, transfer, and eating. Review of the clinical record identified Resident #57 had a signed Advanced Directive form on 4/17/23 from her/himself along with the physician which identified Resident #57 was a full code. Further review identified a physician's order dated 5/1/23 directed Do Not Resuscitate (DNR). However, the clinical record failed to provide evidence that reflected Resident #57 consented to the DNR. Interview on 3/14/24 at 12:07PM with Registered Nurse (RN#1) and Licensed Practical Nurse (LPN #1) identified that an updated code status form was not signed by the resident or the physician to reflect the change in the code status from a full code status to a DNR. RN #1 was unsure of the policy for the Do Not Resuscitate Order. The facility policy for Do Not Resuscitate order notes after consultation with the resident of health care agent the physician will write a Do Not Resuscitate Order on the physician's order form or complete the Advance Directive form, when a resident can express his/her own judgment, the Do Not Resuscitate decision should be reached consensually by the resident and the attending physician. An Advance Directive, previously made by the resident, must be used in making the decision. The nurse managers are responsible for assuring the accuracy of these forms. After surveyor's inquiry, the facility provided an updated Code status form signed and dated by the resident and physician on 3/14/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 residents, (Resident #52) reviewed for medication administration, the facility failed to ensure the physician was notified of a medication refusal. The findings include: Resident #52's diagnoses included type II diabetes mellitus and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 as cognitively intact, independent with bed mobility, supervision with transfer, toileting, and ambulation. The Resident Care Plan Dated 2/29/24 identified Resident #52 as type II diabetes mellitus. Interventions directed to monitor diet, laboratory values, glucose monitoring and the physician/Nurse Practitioner would review Resident #52's diabetic medications, sliding scale orders, Accu-Check (blood glucose monitoring) schedule, diet, and individualized orders for glycemic management accordingly. The physician's orders dated 3/1/24 directed Humalog insulin (fast acting hormone used in the treatment of diabetes mellitus) to be administered based on a sliding scale (parameters that determine dosage based on blood sugar reading) four times a day. The sliding scale directed the following dosage based on blood sugar reading at 7:30 AM, 11:30 AM, 4 :30 PM and 8:00 PM: If Blood Sugar is less than 60, call MD. If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is 401 to 450, give 12 Units. If Blood Sugar is greater than 450, give 14 Units. If Blood Sugar is greater than 450, call the physician. The Medication Administration History dated 3/11/24 identified the prescribed (6 units) of insulin was not administered with a notation that read, 'Resident insisted on 4 units only, not 6 per sliding scale. A nurse's note completed by Licensed Practical Nurse, LPN #4 dated 3/12/24 at 7:43 AM identified at 8:00 PM (on 3/11/24), Resident #52's blood sugar was 300 milligrams per deciliter, mg/dl (normal 80-100), requiring 6 units of insulin. Resident #52 refused and requested 4 units of Humalog insulin, stating s/he did not want the blood sugar level to be low during night. Patient teaching provided; 6 units were encouraged. Blood sugar at 12:00 AM (on 3/12/24) was 212. The blood sugar early morning 397. Resident #52 was asymptomatic. The supervisor was notified. A re-check of the blood sugar at 5:45 AM was 432 and 12 units of Humalog (insulin) were given per Advanced Practice Registered Nurse (APRN) order. Resident #52's next recorded blood sugar at 7:30 AM was 283 with 6 units of insulin administered with no other documented intervention. An interview with LPN #4 on 3/18/24 at 9:42 AM identified she was the assigned charge nurse working 7:00 PM - 7:00 AM from 3/11/24 to 3/12/24. LPN #4 reported she checked Resident #52's blood sugar at 8:00 PM and determined s/he would require 6 units of insulin. Resident #52 refused the 6 units but agreed to receive 4 units which she administered. LPN # 4 reported she did not notify the evening/night shift supervisor, or the physician, further stating she should have notified them. LPN #4 did report to the day shift nurse manager, Registered Nurse #1 prior to leaving on the morning of 3/12/24. An interview with the Director of Nursing, DNS on 3/18/24 at 10:01 AM identified she was unaware the medication error had occurred. The DNS indicated nurses should not change medications dosages without first notifying the physician. An interview with APRN #1 identified that she provided routine medical services to Resident #52. APRN #1 indicated she was not notified at any time Resident #52 refused the prescribed dose of insulin and was instead administered a reduced dose. APRN #1 indicated she would expect to be notified if a resident refused a prescribed medication. An interview with RN #1 on 3/18/24 10:14 AM identified LPN #4 reported to her Resident #52 did not receive a full dose of insulin and that she could not recall notifying APRN #1 of the medication error but would have documented the event in the clinical record. An interview with APRN #2 on 3/21/24 at 12:36 PM identified she was the afterhours provider on call on 3/12/24 who did not provide routine services to Resident #52 and could not recall being contacted by the facility the night of the incident. APRN #2 identified nursing staff should be contacting a provider for orders if the resident was preferring a reduced dose. A review of the facility policy for Notification of Change in Resident Condition dated 12/16/22 directed changes in a resident's condition, medications, treatments, and plan of care are reported timely to the resident's physician/ nurse practitioner and resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documents, review of policy and staff interviews for 1 of 5 residents reviewed for accidents (Resident # 40), the facility failed to assess the use of full siderails at night to ensure the resident was free from a physical restraint and failed to obtain a consent for the utilization of the siderails. The findings include: Resident #40 was readmitted to the facility on [DATE] after hospitalization for surgical repair of a hip fracture sustained after having a fall. Resident # 40's diagnosis included aftercare following a joint replace with presence of an artificial hip joint after fracture of part of the neck of the femur, cognitive communication deficit and Alzheimer's disease. A Side Rail Assessment and consent dated 2/22/2024 with no time, indicated Resident # 40 returned from the hospital after having hip surgery had poor safety awareness and family member requested to have 2 full siderails in place. The reason for use indicated for safety with risks and benefits explained to the family member. The Side Rail Assessment and consent did not contain an assessment as to identify that the side rails were not considered a physical restraint. A physician's order dated 2/22/2024 at 6:25 PM directed to have 2 full side rails up while in bed at night for safety per family request. The Significant Change Minimum Data Set (MDS) dated [DATE] indicated Resident #40 was cognitively impaired, required partial assistance for going from lying to sitting at the edge of the bed and substantial assistance from sitting at edge of bed to standing. The assessment noted the utilization of a walker and wheelchair and indicated the resident was able to walk 10 feet with supervision or touching assistance. The MDS further indicated side rails were used daily as a restraint. The Care Plan dated 3/5/2024 indicated physical restraints, 2 side rails up at night for safety when in bed at night related to recent fall with hip fracture as requested by a family member. Interventions included checking on resident every 2 hours while in bed, keeping bedroom door open when resident in bed, inform resident family of risk and benefits of use and to obtain a signed consent before applying a restraint. On 3/20/2024 at 12:35 PM interview and record review with RN #1(unit manager), indicated Resident #40 was unable to remove the siderails or put them up or down independently making them a restraint. RN#1 was unable to provide evidence of an evaluation of the siderails to determine whether they were a restraint or any plans to monitor and evaluate in the future. Review of the care plan indicated 2 full siderails were in place but did not indicate they were a restraint. Interview and review of the facility's Side Rail Policy with the DNS on 3/20/24 at 12:42 PM indicated a form labeled Consent to use Restraints should be used. The DNS indicated the side rail form was always used and s/he was unable to provide a copy of the consent for use of a restraint form as indicated in the facility policy. Although a copy of the side rail policy was requested one was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview for 1 of 3 resident (Resident # 47) with a change in condition, the facility failed to ensure a comprehensive resident assessment was completed timely after a significant change in condition was identified and for 1 of 2 residents at risk for weight loss for ( Resident 38), the facility failed to complete a significant change of condition for the resident's weight loss. The findings included: 1. Resident #47's diagnosis included fracture of the right femur, pressure ulcer of the sacrum, deep tissue damage of the left hip and right heel. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 had no pressure ulcers. The care plan dated 3/8/2024 indicated Resident #47 was at risk for unavoidable pressure or currently has an unavoidable pressure injury(ulcer) related to poor nutrition, immobility, and incontinence. Interventions included to provide stage appropriate wound care and controlled risk factors for prevention of additional ulcers, pain management and pressure reduction such as specialty mattress, chair cushions, heel protectors, incontinence products/supplies and nutritional supplements. A physician's progress note dated 3/15/2024 at 6:42 PM indicated in part on 3/1 2024 identified the resident had a right heel deep tissue injury with declining nutrition and mobility. On 3/8/2024 a new left hip deep tissue injury and coccyx pressure ulcer stage 1. The progress notes on 3/15/2024 indicated the coccyx wound progressed to a stage 2 pressure ulcer. On 3/19/2024 at 10:50 AM an interview and record review with the MDS Coordinator (LPN #7) indicated the admission MDS assessment was completed on 2/27/2024 indicated Resident #47 had no pressure ulcers. The pressure ulcer was noted on 3/1/2024 (18 days ago) Resident #47 was found to have a pressure ulcer. However, LPN#7 was unable to provide indication the MDS department was monitoring Resident #47's condition for up to 14 days to determine if Resident #47 had a significant change in condition (even though on 3/8/24 the development of two new pressure ulcers occurred and on 3/15/24 the coccyx wound declined to a stage 2 pressure ulcer). LPN #7 further indicated Resident #47 developed 3 pressure ulcers, most likely had weight loss. LPN # 7 also indicated according to the Resident Assessment Instrument guidelines the completion of a significant change MDS assessment should have been done and he/she would schedule a significant change MDS for completion. 2. Resident #38's diagnoses included dysphagia, dementia, and nutritional deficiency. The care plan dated 1/25/24 identified Resident #38 as at risk for nutritional decline related to an advancing dementia diagnosis. Interventions included meals to be served with supervision, to encourage completion of at least 75% of each meal, utilization of adaptive devices, and to monitor weights. A physician's order dated 1/25/24 directed to weigh daily for 3 days. A physician's order dated 2/7/24 directed to administer Boost or Ensure twice daily. The admission Minimum Data Set assessment dated [DATE] identified Resident #38 was moderately cognitively impaired and required set up assistance for eating, substantial assistance for hygiene and showering/bathing. A dietician note dated 2/7/24 at 2:25 PM identified Resident #38 had a weight loss of 19 lbs. in one week. An Occupational Therapy note dated 2/26/24 at 12:09 PM identified an OT assessment was completed due to maximum assistance needed for eating. Further, the note states that resident has had mental status changes and falls in February. A Vital Sign Report for the period of 1/24/24 through 3/19/24 identified a weight loss trend: 2/12/24 weight was 179.8 lbs., 2/20/24 weight was 173.4 lbs., 2/28/24 weight was 177.4 lbs., 3/6/24 weight was 169 lbs., 3/12/24 weight was 168.4 lbs., and 3/19/24 weight was 163.6 lbs. A dietician note dated 3/19/24 at 4:12 PM identified Resident #38 had a 5.6% weight loss in one month. Review of the MDS assessments identified that a significant change in condition assessment was not completed. In an interview and clinical record review with LPN #7, MDS Coordinator on 3/19/24 at 11:50 AM identified an MDS Assessment for a significant change should have been completed for the significant weight loss. Review of the Notification of Change in Resident Condition policy dated 12/16/22 directed, in part, that a change in resident condition is defined as, Resident change from baseline including physical, cognitive behavior, and ADL status. Review of Long Term-Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2023 identified in part, a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. A Significant Change in Status Assessment is appropriate when: 1. There is a determination that a significant change in a resident's condition from their baseline has occurred as indicated by comparison of the resident's status to the most recent comprehensive assessment and any subsequent quarterly assessments; and 2. The resident's condition is not expected to return to baseline within two weeks.

Based on clinical record reviews, facility policy review, and interview for 4 of 4 residents (Residents #12, #32, #53, #56) reviewed for Resident Assessment, the facility failed to ensure the residents quarterly assessments were completed timely. The findings included: Clinical record review of the following completion of the Minimum Data Set (MDS) assessments identified: 1. Resident #12's quarterly MDS assessment with Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (33 days late) 2. Resident #32's quarterly MDS assessment with ARD of 1/8/24 was due on 1/22/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (57 days late) 3. Resident #53's quarterly MDS assessment with ARD of 2/6/24 was due on 2/20/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (28 days late) 4. Resident #56's annual MDS assessment with ARD of 2/1/24 was due on 2/15/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (33 days late). Interview with LPN #7 (MDS Coordinator) on 3/19/24 at 12:30 PM identified s/he was responsible for completing and submitting the MDS assessment. LPN # 7 also identified that s/he needs to complete the MDS assessment 14 days after it set ARD. S/he acknowledged s/he was late completing Resident # 12, # 32, # 53 and #56 quarterly assessments because s/he was the only staff in the MDS office and could not catch up. The facility policy title Resident Assessment identified a quarterly assessment will be completed every 92 days from admission to provide for revision of the care plan as necessary.

Based on clinical record review and interviews for 4 of 4 residents (Residents #12, #32, #53, #56) reviewed for Resident's Assessment, the facility failed to ensure the residents assessment were submitted timely. The findings included: Clinical record review of the following completion of the Minimum Data Set (MDS) assessments identified: 1. Resident #12's quarterly MDS with Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24 and required submission on 2/29/24; however, Resident #12's assessment was not submitted as of 3/19/24. (19 days late) 2. Resident #32's quarterly MDS with ARD of 1/8/24 was due on 1/22/24 and required submission on 2/5/24; however, Resident #32's assessment was not submitted as of 3/19/24 (43 days late) 3. Resident #53's quarterly MDS with ARD of 2/6/24 was due on 2/20/24 and required submission on 3/5/24; however, Resident #53's assessment was not submitted as of 3/19/24. (14 days late) 4. Resident #56's annual MDS with ARD of 2/1/24 was due on 2/15/24 and required submission on 2/29/24; however, Resident #56's assessment was not submitted as of 3/19/24 (19 days late). Interview with LPN #7 (MDS Coordinator) on 3/19/24 at 12:30 PM identified she was responsible for completing and submitting the MDS assessment. She also identified she need to complete the MDS assessment within 14 days after it set ARD and submit within 14 days after completion. LPN # 7 acknowledged that she was late with completing the MDS assessment and not able to transmit the MDS in timely manner because she was the only one in the MDS office and was not able to catch up with the timeframe of completing the MDS assessment. The Resident Assessment Instrument 3.0 user manual 10/2023 identified that to be considered timely the ARD of the quarterly assessment must be completed within 14 days and submitted within 14 days after its completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record, facility policy and staff interview for 1 of 3 sampled residents (Resident #52) reviewed for accidents, the facility failed to ensure the care plan was comprehensive and individualized for a resident who did not require a safety device. The findings include: Resident #52's diagnoses included type II diabetes mellitus and heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 as cognitively intact, required partial assistance of one with transfers and ambulation and did not require any electronic devices that monitor movement. The Resident Care Plan dated 8/25/23 identified Resident #52 as at risk for falls and took chances transferring him/herself. Interventions directed use of alarms to notify staff that the resident had needs and required assistance, do not leave the resident alone on the toilet during the time the safety device was in use and re-evaluate the need for bed/chair alarms. An observation on 3/18/24 at 7:34 AM identified that there was no visible use of safety devices in Resident #52's room. An interview with Licensed Practical Nurse, LPN #7 on 3/19/24 at 9:14 AM identified nursing staff was responsible for the completion of initial care planning while she was responsible for overseeing the care plan cumulatively. LPN #7 identified Resident #52 never had any alarms and that nursing staff may have likely inadvertently indicated the resident had. LPN #7 further identified she should have removed the information when reviewing the care plan and did not. An interview with Registered Nurse, RN #1 on 3/19/24 at 10:12 AM identified she placed interventions regarding the use of alarms in the event their use would ever be required. RN #1 further identified Resident #52 never had any motion detection alarms and would require an order and consent to implement their use. An interview with the Director of Nursing, DNS on 3/19/24 at 12:03 PM identified the Resident Care Plan should accurately reflect individualized resident need. A review of the facility policy for Resident care Plan directed the Resident Care Plan developed by the resident, family and staff shall ensure the maintenance of high quality, individualized care. The Interdisciplinary Plan of Care is developed and implemented within 21 days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility documentation, facility policy and interviews for 2 of 3 residents reviewed for accidents for (Residents # 11 and # 38), the facility failed to revise the care plan after after the resident experienced falls and for 1 of 5 sampled resident, (Resident# 57) reviewed for care planning, the facility failed to ensure the care plan was revised to reflect a resident who frequently refused a daily treatment and for 1 of 3 residents reviewed for accidents, the facility failed to revise the care plan after several falls. The findings included: 1. Resident #11 was admitted to the facility on [DATE]. The resident's diagnoses included heart failure, generalized muscle weakness, and repeated falls. The care plan dated 6/28/23 identified Resident #11 as at risk for falls related to a history of multiple falls. Interventions included arranging the resident's room so that necessary items are kept accessible, remind the resident to use the call bell, ensuring adequate lighting, performing safety checks per policy, reviewing medications if needed, and re-evaluating the need for bed/chair alarms. A quarterly fall risk assessment dated [DATE] identified Resident #11 as not at risk for falling, with a fall risk score of 7 on a scale where a score of 10 or higher represents a high risk for falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was cognitively intact and independent in toileting, dressing, and ambulating. The MDS also identified Resident #11 had no falls since admission. A facility Incident Report and investigation dated 8/13/23 indicated on 8/13/23 at 1:30 PM, Resident #11 was found lying on the floor in front of a chair. Resident #11 reported to facility staff that he/she had missed the chair when attempting to sit. The Incident Report further indicated the resident was alert, oriented, and independent with care at the time and was assisted back to the room. A post-fall observation assessment dated [DATE] indicated the resident did not require any post-fall interventions therefore no changes to the resident care plan were made. A review of RCP did not identify any new interventions or care plan edits secondary to the 8/13/23 fall. Additionally, the care plan was last reviewed on 6/28/23 before the fall. The last time an intervention was added to the fall care plan before the fall 8/13/23 was 1/12/23. A quarterly fall risk assessment dated [DATE] identified Resident #11 was not at risk for falling with a fall risk score of 9 on a scale where a score of 10 or higher represents a high risk for falls. a. A facility Incident Report and investigation dated 9/24/23 identified on 9/24/23 at 6:45 PM, Resident #11 was found lying on the floor. Resident #11 reported to facility staff that s/he had lost his/her balance when reaching to wash his/her hands. The incident report further indicated that the resident was alert, oriented, and independent with care at the time. A post-fall observation assessment in the medical record dated 9/24/23 indicated a potential factor that could have contributed to the fall was poor placement on the walker in front of the sink. The post-fall observation does not identify any measures taken to prevent further falls. A review of the resident care plan did not identify any new interventions or care plan revisions related to the 9/24/23 fall. b. A facility Incident Report and investigation dated 9/26/23 identified on 9/26/23 at 6:00 AM, Resident #11 was found lying on the floor next to the bed. Resident #11 reported to facility staff that he/she was getting up to go to the bathroom, slipped, and fell. The Incident Report further indicated the resident was educated on the importance of using the nursing call light for assistance. A review of the resident care plan identified the resident was care planned to be reminded to use the call bell from 1/12/23 (prior to the resident's admission date). A revision to the care plan indicated that the most recent fall was dated 9/26/23; however, no new interventions were noted related to the 9/26/23 fall. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident was cognitively intact and independent in toileting, dressing, and ambulating. The MDS dated [DATE] also identified Resident #11 had experienced one fall with injury and two falls with no injury since the prior MDS assessment. c. A facility Incident Report and investigation dated 10/1/23 identified on 10/1/23 at 7:00 PM, Resident #11 was found sitting on the floor leaning against their recliner. The resident reported to staff that he/she had missed the chair when attempting to sit and slid to the floor. A post-fall observation assessment dated [DATE] indicated Resident #11 was educated to feel the edge of any seat with the back of his/her legs before sitting down. A review of the resident's care plan identified a revision on 10/1/23 to indicate that the resident had fallen. However, no new interventions were noted in the care plan to address the fall on 10/1/23, and there was no revision to the care plan indicating that the resident should be reminded to feel the edge of any seat before sitting down. d. A facility Incident Report and investigation dated 10/16/23 identified on 10/16/23 at 6:30 PM, Resident #11 was found sitting on the floor in his/her room. The resident reported to staff that he/she was getting up to get his/her cell phone when he/she lost his/her balance and fell in front of the recliner. A post-fall observation assessment dated [DATE] indicated Resident #11 was educated on proper stance and securing balance with the walker. A review of the resident care plan identified that the care plan had been revised on 10/16/23 to indicate that the resident had fallen; however, no new interventions were noted in the care plan because of the 10/16/23 fall. Additionally, the care plan indicated that it had been reviewed/revised on 10/17/23. e. A facility Incident Report and investigation dated 11/1/23 identified on 11/1/23 at 12:00 PM, Resident #11 fell on his/her right side while independently walking to the dining room. A post-fall observation assessment dated [DATE] indicated that a gait belt would be utilized by staff during ambulation if the resident feels weak. A review of the resident care identified that the resident care was planned for gait belt use on 1/12/23. The care plan was revised on 11/1/23 to indicate the resident had fallen; however, no new interventions were noted in the care plan due to the 11/1/23 falls until after the 11/26/24 when the care plan was revised to reflect to encourage the resident to wear adequate footwear. f. A facility Incident Report and investigation dated 12/8/23 identified on 12/8/23 at 3:07 PM, Resident #11 was found sitting on the floor. The resident reported to staff that he/she fell when trying to reach for an envelope from the nightstand. A post-fall observation assessment dated [DATE] indicated Resident #11 was educated on using the walker for support. A review of the resident's care plan identified the care plan was revised on 12/8/23 to indicate the resident had fallen; however, no new interventions were noted in the care plan because of the 12/8/23 fall. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitively intact and independent in toileting, dressing, and ambulating. A quarterly fall risk assessment dated [DATE] identified Resident #11 was at a high risk for falling. g. A facility report and investigation dated 1/12/24 identified on 1/12/24 at 10:15 AM, Resident #11 was found sitting on the floor in the resident's bathroom. Resident #11 reported to staff that he/she missed the toilet, slipped, and fell. The report further identified Resident #11 was not wearing shoes or socks. A post-fall observation assessment in the medical record dated 1/12/24 indicated that Resident #11 was educated on wearing proper footwear. A review of the resident care plan identified the resident care was planned to encourage the resident to wear adequate footwear on 11/26/23. No new interventions were identified related to the 1/12/24 (before the resident's admission). h. A facility Incident Report and investigation dated 1/18/24 identified on 1/18/24 at 9:45 AM, Resident #11 was found sitting on the floor next to the bed. The resident reported to staff that he/she was trying to pull the recliner away from the wall and fell backward. A post-fall observation assessment in the medical record dated 1/18/24 indicated Resident #11 was educated on using the nursing call bell. A review of the resident care plan identified no new interventions related to the 1/18/24 fall, and no care plan was noted to address the resident not moving furniture. i. A facility Incident Report and investigation dated 2/1/24 identified that on 2/1/24 at 1:45 PM, Resident #11 was found sitting on the floor with his/her back against the bed. Resident #11 reported to staff that he/she was trying to move his/her recliner and fell backward. The report further indicated Resident #11 suffered a left arm skin tear that measured 3 centimeters (cm) by 0.1 cm and required treatment with a dressing. A post-fall observation assessment dated [DATE] indicated Resident #11 was reminded not to move furniture. A review of the RCP identified no new interventions related to the 2/1/24 fall. Additionally, no interventions in the care plan addressed that the 2/1/24 fall which was the second time Resident # 11 had fall related to attempting to move furniture. j. A facility Incident Report and investigation dated 2/26/24 identified on 2/26/24 at 7:45 PM, Resident #11 was found on his/her knees by the bed without shoes or socks. The resident reported to staff that he/she lost his/her balance taking off his/her jacket. The report further indicated that the resident suffered a right second toe abrasion that measured 1.5 cm by 1.5 cm. A post-fall observation assessment dated [DATE] indicated Resident #11 was not wearing footwear at the time of the fall. The assessment further indicated that measures to prevent further falls were to continue safety checks and anticipate resident needs. A review of the resident care plan identified the resident care was planned to encourage the resident to wear adequate footwear on 11/26/23. No new interventions were identified related to the 2/26/24 fall. k. A facility Incident and Report and investigation dated 3/5/24 identified on 3/5/24 at 3:05 PM, Resident #11 was found sitting on the floor in the resident's bathroom. The resident reported to staff he/she misjudged the distance when transferring from the toilet to the rollator. A post-fall observation assessment dated [DATE] did not identify any potential factors that may have contributed to the failure to identify any measures taken to prevent future falls. A review of the RCP failed to identify any new interventions or care plan revision related to the 3/5/24 fall. l. A facility Incident Report and investigation dated 3/13/24 identified on 3/13/24 at 8:50 PM, Resident #11 was found sitting on the floor in the resident's bathroom. The resident reported to staff that he/she reached over his/her walker to reach his/her pajamas, lost his/her balance, and fell backward, hitting his/her head. A post-fall observation assessment dated [DATE] identified the resident did not have shoes or socks on at the time of the fall. The assessment further indicated that physical therapy was ordered, and that the resident would likely need increased supervision in performing activities of daily living. A review of the resident care plan did not identify any of the new interventions related to the 3/13/24 fall in the RCP. An interview with the DNS on 3/20/24 at 11:00 AM indicated that a new intervention for falls would be added if therapy was not already working on the issues that caused the resident's fall or if there was not done, such as not having the resident's call bell in reach. The DNS also indicated that educating and reminding the resident on how to properly feel a chair behind him/her before sitting down was not added to the care plan because the supervisor may have thought educating the resident immediately post-fall was enough. Additionally, the DNS could not identify why no education or care planning was done regarding moving furniture when the resident fell moving his/her recliner on 1/18/24. The DNS further identified the MDS Coordinator, nursing supervisors, and nurse managers can update the care plan and the MDS Coordinator and nurse managers oversee the care plans. An interview with the MDS Coordinator on 3/20/24 at 2:20 PM identified she was unsure why Resident #11's care plan was initiated in January 2023 when the resident's admission was in March 2023 and indicated it could be because the resident's care plan was not discontinued when the resident was discharged from a previous admission to the facility. The MDS Coordinator also identified the care plan from the previous admission should have been discontinued and a new care plan initiated for the March 2023 admission. The MDS Coordinator further indicated the admitting nurse initiates the care plan on admission and nurses, managers, and the MDS Coordinator can put in new interventions. The MDS Coordinator indicated the care plan should be updated with each fall and be personalized to the resident. Additionally, the MDS Coordinator could not identify why Resident #11 was not care planned for non-compliance with certain fall-prevention interventions. 2.Resident #38's diagnoses included muscle weakness, dementia, and abnormalities of gait and mobility. A physician's order dated 1/26/24 directed to place motion sensor for patient safety in the room. The admission Minimum Data Set assessment dated [DATE] identified Resident #38 was moderately cognitively impaired and required set up assistance for eating, substantial assistance for hygiene and showering/bathing. The Resident Care Plan dated 1/25/24 identified Resident #38 as at risk for falls due to moderate dementia, behaviors, and poor safety awareness. Interventions included a comprehensive medication review, increased staff supervision, and placing the resident in the lounge if resident allow, as well as use of a Tab alarm. A nurse's note dated 2/11/24 at 3:30 AM identified Resident #38 was found on the floor mat next to his/her bed after calling out for help. No injuries noted. An observation note dated 2/11/24 at 5:09 AM did not include measures to be taken to prevent further falls. There were no revisions to the care plan noted. The state agency Reportable Event Form dated 2/11/24 identified Resident #38 had fallen without major injury. APRN notified. A nurse's note dated 2/13/24 at 6:46 AM identified Resident #38 was found sitting on floor mat next to his bed after motion detector alarmed. No injuries noted. An observation note dated 2/13/24 at 1:45 AM did not include measures to be taken to prevent further falls. There were no revisions to the care plan noted. A nurse's note dated 2/21/24 at 7:05 AM identified Resident #38 was found sitting on his floor mat next to his bed. No injuries noted. The state agency Reportable Event Form dated 2/21/24 identified Resident #38 had fallen without major injury. MD notified. Further, the form indicated that an addendum to the care plan was completed, however there was no care plan revision noted. However, review of risk for falls due to moderate dementia, behaviors, and poor safety awareness noted revisions to the care plan on 2/27/24 which included, the resident would not go to bed earlier than 8:00 PM, ambulated in the hall at least 3 times per day. A care plan revision on 3/6/24 included a perimeter mattress, low bed, and floor mats. A care plan revision on 3/8/24 included praying with the resident before bed. Interview and clinical record review with the DNS on 3/20/24 at 10:15 AM identified the supervisor, manager, and MDS Coordinator update the care plan with changes. The only time that the care plan gets updated after a fall is if there is a change to be made. The DNS also indicated interventions are not always to add to the care plan. The nursing team has vigorous conferences after falls to determine if there are any further interventions that can be instituted. They are verbal conferences, nothing is documented. Resident # 11 is impulsive and has advanced dementia. 3. Resident #57 had diagnoses included muscle weakness, osteoarthritis, and localized swelling to the left lower limb. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 as cognitively intact, required set up assist with eating, showering and supervision with dressing. The Resident Care Plan dated 1/31/24 identified Resident #57 required assistance with activities of daily living (ADL) and had a potential for weight fluctuations related to 3-4+ bilateral edema of the lower extremities. Interventions directed to provide supervision for walking, provide fluids with and between meals and monitor for signs of dehydration. The physician's orders dated 1/31/24 directed use of six-inch ACE bandages to wrap legs foot to knee every morning before getting out of bed and remove at bedtime. Observations made on 3/13/24 at 12:39 PM, 3/18/24 at 8:28 AM and 3/18/24 at 10:55 AM identified Resident #57 was out of bed with marked edema and without the benefit of ACE wraps. A review of the Medication Administration Record (MAR) dated 2/19/24 through 3/18/24 identified Resident #57 refused the ACE wraps on 33 occasions. An interview with Licensed Practical Nurse, LPN #2 on 3/18/24 at 10:55 AM identified Resident #57 often refused the ACE wraps to the bilateral lower extremities, and she was unsure what to do for refusals. LPN #2 identified she had not re-approached Resident #57 since h/her initial refusal to encourage h/her to have the wraps applied. An interview with the Director of Nursing (DNS) on 3/19/24 at 12:21 PM identified staff was aware that Resident #57 frequently refused h/her ACE wraps and that the care plan should have been revised to reflect this need. The care plan failed to identify a concern related to resident refusal of an ACE wrap with interventions on best approaches to reduce future refusals. A review of the facility policy for Resident Care Plans directed that the Resident Care Plan developed by the resident, family and staff shall ensure the maintenance of high quality, individualized care. The Care Pan may be reviewed and revised at any time indicated by the changing needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy, and staff interviews for 1 of 5 sampled residents (Resident #11) reviewed for accidents, the facility failed to ensure that neurological checks were completed to professional standards after a resident's unwitnessed falls per facility policy. The findings include: Resident #11 was admitted on [DATE] with a diagnosis that included heart failure, generalized muscle weakness, and repeated falls. The care plan dated 6/28/23 identified Resident #11 as at risk for falls related to a history of multiple falls. Interventions included arranging the resident's room so that necessary items are kept accessible, reminding the resident to use the call bell, ensuring adequate lighting, performing safety checks per policy, reviewing medications if needed, and re-evaluating the need for bed/chair alarms. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitively intact and independent in toileting, dressing, and ambulating. The MDS also identified Resident #11 as having no fall since admission. a.A facility Incident and Report and investigation dated 8/13/23 indicated on 8/13/23 at 1:30 PM, Resident #11 experienced an unwitnessed fall. Resident #11 was found lying on the floor in front of a chair. Resident #11 reported to facility staff that he/she had missed the chair when attempting to sit. A 24-hour neurological checks Flowsheet was completed post-fall, however, a neurological check for 8/14/23 at 9:15 AM and for 1:15 PM was not completed. b. A facility Incident and Report and investigation dated 9/24/23 identified on 9/24/23 at 6:45 PM, Resident #11 experienced an unwitnessed fall and was found lying on the floor in the resident's bathroom. Resident #11 reported to facility staff that he/she had lost his/her balance when reaching to wash his/her hands. A 24-hour neurological checks Flowsheet was completed post-fall; however, a neurological check for 9/25/23 at 2:15 PM and for 6:15 PM was not completed. c. A facility Incident Report and investigation dated 9/26/23 identified on 9/26/23 at 6:00 AM, Resident #11 experienced an unwitnessed fall and was found lying on the floor next to their bed. Resident #11 reported to facility staff that he/she was getting up to go to the bathroom, slipped, and fell. A 24-hour neurological checks Flowsheet was completed post-fall; however, neurological checks for 9/26/23 at 5:45 PM and for 9:45 PM were not completed. d. A facility Incident Report and investigation dated 1/18/24 identified on 1/18/24 at 9:45 AM, Resident #11 experienced an unwitnessed fall and was found sitting on the floor next to the bed. The resident reported to staff that he/she was trying to pull the recliner away from the wall and fell backward. A 24-hour neurological checks Flowsheet was not completed post-fall. e. A facility Incident Report and investigation dated 2/26/24 identified on 2/26/24 at 7:45 PM, Resident #11 experienced an unwitnessed fall and was found on his/her knees by the bed without shoes or socks. The resident reported to staff that he/she lost his/her balance taking off his/her jacket. The report further indicated the resident suffered a right second toe abrasion that measured 1.5 cm by 1.5 cm. A 24-hour neurological checks Flowsheet was completed post-fall; however, a neurological check for 2/27/24 at 3:30 PM and 7:30 PM was not completed. An interview and record review with the DNS on 3/20/24 at 11:00 AM identified the facility performed a neurological assessment for all unwitnessed falls. Additionally, the DNS identified that during the 11:00 PM to 7:00 AM shift, Resident #11 does not like being disturbed if he/she is sleeping and during that time, he/she will refuse an assessment. The DNS further indicated staff should still have attempted neurological assessments post-fall and documented any refusals. When a resident refuses a neurological check post-fall, the refusal would be documented in the nursing progress notes or directly on the 24-hour neurological check Flowsheet. No nursing progress notes were identified that indicated Resident #11 had refused neurological checks for 8/14/23 at 9:15 AM and 1:15 PM, 9/25/23 at 2:15 PM and 6:15 PM, 9/26/23 at 5:45 PM and 9:45 PM, or 2/27/24 at 3:30 PM and 7:30 PM. Additionally, the DNS could not identify why a neurological check Flowsheet was not completed post-fall on 1/18/24. The Neuro-check Policy for the facility indicated the policy's objective was to ensure appropriate monitoring of residents following a head injury or suspected head injury. The policy further indicated that the neurological assessments are documented on a paper Flowsheet for 24 hours. The assessments are done every 15 minutes for one hour, then every hour for 3 hours, and finally every 4 hours for 20 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview for 1 of 2 residents (Resident # 47) reviewed for at risk for pressure ulcer, the facility failed to consistently document turning and repositioning of the resident in accordance with facility practice. The findings include: Resident #47's diagnosis included fracture of the right femur, pressure ulcer of the sacrum, deep tissue damage of the left hip and right heel. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 had no pressure ulcers. The care plan dated 3/8/2024 indicated Resident #47 was at risk for unavoidable pressure or currently has an unavoidable pressure injury(ulcer) related to poor nutrition, immobility, and incontinence. Interventions included to provide stage appropriate wound care and controlled risk factors for prevention of additional ulcers, pain management and pressure reduction such as specialty mattress, chair cushions, heel protectors, incontinence products/supplies and nutritional supplements. A review of the progress notes dated 3-15-24 identified the following for the resident's wound assessment: Wound #1 Right Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm length x 5.5 cm width x 0 cm depth, with an area of 13.75 sq cm and a volume of 0 cubic cm. There was no drainage noted. Wound bed has 76-100% epithelialization. There is no change noted in the wound progression. Wound #2 Left Hip is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5cm length x 0.5cm width x 0 cm depth, with an area of 0.25 sq cm and a volume of 0 cubic cm. There was no drainage noted. Wound bed has 76-100% epithelialization. There is no change noted in the wound progression. The peri wound skin texture is normal. The peri wound skin moisture is normal. The peri wound skin color is normal. Wound #3 Coccyx is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2cm length x 2cm width x 0.1 cm depth, with an area of 4 sq cm and a volume of 0.4 cubic cm. There was no drainage noted. The wound is deteriorating. A physician's progress note dated 3/15/2024 at 6:42 PM indicated in part on 3/1 2024 identified the resident had a right heel deep tissue injury with declining nutrition and mobility. On 3/8/2024 a new left hip deep tissue injury and coccyx pressure ulcer stage 1. The progress notes on 3/15/2024 indicated the coccyx wound progressed to a stage 2 pressure ulcer. A review of the clinical record from 2/27/24 through 3/7/24 failed to reflect turning and repositioning of the resident in the clinical record per facility practice. Interview with the DNS on 3/19/24 at 10:00 AM identified the facility software did not include a section for the Nurse Aides to document turning and repositioning. The DNS indicated she would add a section in the software and educate staff. On 3/19/2024 at 10:50 AM an interview and record review with the MDS Coordinator (LPN #7) indicated the admission MDS assessment was completed on 2/27/2024 indicated Resident #47 had no pressure ulcers. The pressure ulcer was noted on 3/1/2024 (18 days ago) Resident #47 was found to have a pressure ulcer. On 3/8/24 the development of two new pressure ulcers occurred and on 3/15/24 the coccyx wound declined to a stage 2 pressure ulcer). LPN #7 further indicated Resident #47 developed 3 pressure ulcers, most likely had weight loss. Interview with the DNS on 3/19/24 at 10:00 AM identified the facility software did not include a section for the Nurse Aides to document turning and repositioning. The DNS indicated she would add sections in the software and educate staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews , facility documentation, facility policy and interviews for the 2 of 5 sampled resident reviewed for accidents for (Resident # 10), the facility failed to ensure that staff conducted safety checks as directed by the manufacture to ensure the alarm was functional and for (Resident # 11), the facility failed to ensure fall assessment was completed after every fall per facility policy. The findings included: 1. Resident #10 's diagnoses included dementia, abnormalities of gait, and rheumatoid arthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 as severely cognitively impaired and required moderate assistance for toilet transfer, maximal assistance for showering, and moderate assistance for upper body dressing. A physician's order dated 8/25/23 directed to use a Tab alarm for safety when the resident was unattended. The Resident Care Plan dated 8/25/23 identified falls as a problem. Interventions included use of a Tab alarm, to anticipate resident needs, and to complete safety checks per policy. A nurse's note dated 10/2/23 at 6:45 AM identified Resident #10 was found lying on the floor with a complaint of right hip pain. Resident # 10 was noted lying on her/his back with her/his head and shoulders up against the dresser. Review of the state agency Reportable Event line Summary Report dated 10/7/23 identified the Resident # 10's Tab alarm did not sound. Review of flow sheets for the period of 10/1/23 through 10/31/23 failed to identify functionality checks for the Tab alarm as directed by manufacturer. Interview with DNS and RN #1 on 3/18/24 at 11:20 AM identified: Resident #10 fell shortly after safety rounds. The Nurse Aide (NA) was in the room at 5:00 AM and the resident fell at 6:45 AM. The Tab alarm was in place but malfunctioned that night. The Tab alarm is magnetic and is supposed to detach from resident and it did not at the time of the floor. They were unsure if Resident # 10 was holding the alarm, not sure where the alarm was found in relation to the resident. The NAs are supposed to check functionality and complete safety rounds at the beginning and the end of each shift. The checks are not logged. The charge nurse will ask the nurse aides if safety checks were completed. The DNS was unsure if they were completed the night in question. Resident #10 fell immediately after safety rounds. The DNS indicated the Tab alarm continues to be used by Resident #10. The DNS was also unsure if checking the Tab alarm was on the care card. The DNS indicated care cards are discarded weekly and the facility has no history of the information. Interview with LPN #5 on 3/19/24 at 1:51 PM (charge nurse) at the time of the fall identified the NA went to get the LPN as Resident #10 was on the floor. LPN #5 went into the room and found the resident lying on the floor. LPN #5 could not recall where the alarm was located at the time of the fall. LPN #5 identified that safety check forms are in the NA books, and they should be checking off on them. Currently the nurse aides are signing off on a paper form to indicate that the alarm was checked for functionality. The oncoming and off going NAs check the functionality together. LPN #5 is not sure if this system was in place in October 2023 when the resident fell. Interview with the DNS 3/19/24 at 2:10 PM to review the Tab alarm manufacturer's guidelines which state to test the Tab alarm before each use. Further, the DNS identified this task was done by the NAs, however at the time of Resident #10's fall they were not documenting the checks. Currently the system is for the NAs to document the checks on a paper log, the DNS will review to ensure they were done and then throws the paper away. A telephone interview with NA #2 on 3/20/24 at 11:23 AM identified s/he was working the night of the fall but doesn't remember if s/he was assigned to the resident. NA # 2 further indicated s/he knew the resident had fallen while attempting to go to the bathroom. Resident #10 was on the floor when NA #2 entered the room. NA # 2 stated the Tab alarm was still attached to Resident # 10 but was alarming if s/he remembered correctly. A telephone interview with NA #3 on 3/20/24 at 2:30 PM identified Resident #10 did not fall any time s/he cared for the resident. NA # 3 indicated s/he did not remember the events on 10/2/24 related to Resident #10. Review of the Safety Device/Monitoring policy dated 1/10/21 directed, in part, Aide will complete every shift walking rounds to check the functioning of safety devices. Review of the Manufacturer's guidelines for the [NAME] Magnetic Pull-Cord Alarm recommendations include testing the alarm to determine that the system is operating correctly, and that the battery is charged before each use. 2. Resident #11 was admitted on [DATE] with a diagnosis that included heart failure, generalized muscle weakness, and repeated falls. The care plan dated 6/28/23 identified Resident #11 as at risk for falls related to a history of multiple falls. Interventions included arranging the resident's room so that necessary items are kept accessible, reminding the resident to use the call bell, ensuring adequate lighting, performing safety checks per policy, reviewing medications if needed, and re-evaluating the need for bed/chair alarms. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitively intact and independent in toileting, dressing, and ambulating. The MDS also identified Resident #11 as having no fall since admission. a. A facility Incident and Report and investigation dated 8/13/23 indicated on 8/13/23 at 1:30 PM, Resident #11 experienced an unwitnessed fall. Resident #11 was found lying on the floor in front of a chair. Resident #11 reported to facility staff that he/she had missed the chair when attempting to sit. A review of clinical record and facility documentation failed to identify a new fall risk assessment was completed for the 8/13/23 fall. b. A facility Incident and Report and investigation dated 9/24/23 identified on 9/24/23 at 6:45 PM, Resident #11 experienced an unwitnessed fall and was found lying on the floor in the resident's bathroom. Resident #11 reported to facility staff that he/she had lost his/her balance when reaching to wash his/her hands. A review of clinical record and facility documentation failed to identify a new fall risk assessment was completed for the 9/24/23 fall. c. A facility Incident Report and investigation dated 9/26/23 identified on 9/26/23 at 6:00 AM, Resident #11 experienced an unwitnessed fall and was found lying on the floor next to their bed. Resident #11 reported to facility staff that he/she was getting up to go to the bathroom, slipped, and fell. A review of clinical record and facility documentation failed to identify a new fall risk assessment was completed for the 9/26/23 fall. d. A facility Incident Report and investigation dated 1/18/24 identified on 1/18/24 at 9:45 AM, Resident #11 experienced an unwitnessed fall and was found sitting on the floor next to the bed. The resident reported to staff that he/she was trying to pull the recliner away from the wall and fell backward. A review of clinical record and facility documentation failed to identify a new fall risk assessment was completed for the 1/18/24 fall. e. A facility Incident Report and investigation dated 2/26/24 identified on 2/26/24 at 7:45 PM, Resident #11 experienced an unwitnessed fall and was found on his/her knees by the bed without shoes or socks. The resident reported to staff that he/she lost his/her balance taking off his/her jacket. The report further indicated the resident suffered a right second toe abrasion that measured 1.5 cm by 1.5 cm. A review of clinical record and facility documentation failed to identify a new fall risk assessment was completed for the 2/26/24 fall. f. A facility report and investigation dated 3/5/24 identified that on 3/5/24 at 3:05 PM, Resident #11 was found sitting on the floor in the resident's bathroom. The resident reported to staff that he/she misjudged the distance when transferring from the toilet to the rollator. A post-fall observation assessment in the medical record dated 3/5/24 did not identify any potential factors that may have contributed to the fall and did not indicate any measures taken to prevent future falls. A review of the clinical record and facility documentation failed to identify a new fall risk assessment was completed for the 3/5/24 fall. g. A facility report and investigation dated 3/13/24 identified that on 3/13/24 at 8:50 PM, Resident #11 was found sitting on the floor in the resident's bathroom. The resident reported to staff that he/she reached over his/her walker to reach his/her pajamas, lost his/her balance, and fell backwards, hitting his/her head. A post-fall observation assessment dated [DATE] identified the resident did not have shoes or socks. A review of the clinical record and facility document did not identify a new fall risk assessment was completed for the 3/13/24 fall. An interview and policy review with the DNS on 3/18/24 at 12:13 PM identified that fall risk assessments are completed on admission, quarterly, and with significant changes. The DNS also indicated that a fall risk assessment is not completed after every fall because once a resident is a fall risk, they remain a fall risk. The DNS further indicated that there must have been an error in the policy because staff will only complete the fall observation, which is the post-fall assessment, and that the current policy is the most updated. The facility's current Fall Prevention Policy (with revision date 6/2019) indicated that a fall risk assessment is completed quarterly, annually, and whenever a resident has experienced a fall. Additionally, the policy indicated that the fall risk assessment was in addition to the fall assessment following a fall.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 residents, (Resident #38) reviewed for unnecessary medications, the facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. The findings include: Resident #38 had diagnoses that included anxiety disorder and depression. The admission MDS assessment dated 1/31 24 identified Resident #38 was moderately cognitively impaired and dependent with ADL assist. The RCP dated 2/7/24 identified Resident #38 utilized psychotropic drugs related to anxiety, depression, and dementia. Interventions directed to attempt gradual dose reductions as prescribed and refer to APRN (psychiatric) consults. The physician's orders dated 2/24/24 directed Trazadone 50 mg every 8 Hours PRN (as needed) for agitation with no identified date of discontinuation. A Pharmacy Consult dated 3/4/24 recommended including a 'stop' date for the PRN use of Trazadone with no documented provider response. An interview with the DNS on 3/20/24 at 1:13 PM identified all pharmacy recommendations that should have been responded to by the provider. After surveyor inquiry, the Pharmacy Consult dated 3/4/24 included a documented signature from the provider (no date). A review of the facility policy for Pharmacy Consults directed that monthly pharmacy consults were to be submitted by the pharmacy before the end of each month and reviewed by the practitioner to identify irregularities in medication regime and review recommendations. The practitioner may choose to fill out the sheet pharmacy consult and/or write an order in the chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for 1 of 4 residents reviewed for medication administration opportunities (Resident #57), the facility failed to ensure medications were administered timely and medication errors did not exceed 5%. The findings include. Resident #57's diagnosis included localized swelling and edema, vitamin deficiency and left knee effusion (excess fluid buildup in the knee joint). The physician's order dated 4/17/2023 directed vitamin C 250 mg tablet to be administered orally once daily at 8:00AM. The physician's order dated 11/2/2023 directed Vitamin D3 capsule (600 international units) be given orally daily at 8:00 AM. The physician's order dated 12/19/2023 directed Hydrochlorothiazide 25 mg tablet one orally be given once daily at 8:00 AM for edema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated in part Resident #57 was cognitively intact. The care plan dated 1/31/2024 indicated Resident #57 with increased weight with potential for weight fluctuations related to bilateral lower leg edema. Interventions including in part, a low sodium diet. On 3/19/2024 at 9:30 AM an observation medication administration was made with LPN # 2 for Resident #57. The medications administered were Hydrochlorothiazide (a diuretic) 25 milligrams, one whole tablet administered by mouth, Vitamin C 25 mg one tablet by mouth and Vitamin D3, 3 half tablets of 10 mcg (400 iu, international units), to make 600 iu, given by mouth. An interview and record review of the medication administration history with the DNS on 3/19/2024 at 10:35 AM indicated the hydrochlorothiazide, vitamin C and Vitamin D3 were administered 30 minutes late. The DNS indicated the medications were administered outside the allotted time (1 hour before and 1 hour after the scheduled time). An interview with LPN #2 would be needed to determine the reason. An interview with LPN #2 indicated the reason medications for Resident #57 were administered 30 minutes late because he/she was unable to administer medications for 30 residents safely in the time given. The DNS indicated he/she would look at adjusting the medication administration times to make the administration times for the nurses manageable. The facility policy labeled Medication Administration dated 1/2024 indicated in part, all medications are properly administered and documented via the Electronic Medication Administration Record (EMAR) per the physician or nurse practitioners' orders and medications administered following the five rights of Medication Administration, right drug, right dose, right resident, right route, and right time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for of 1 of 5 residents, (Resident #52) reviewed for medication administration, the facility failed to ensure a resident was free from a significant medication error following the administration of an unprescribed reduced dose of insulin. The findings include: Resident #52's diagnoses included type II diabetes mellitus and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 as cognitively intact, independent with bed mobility, supervision with transfer, toileting, and ambulation. The Resident Care Plan Dated 2/29/24 identified Resident #52 as type II diabetes mellitus. Interventions directed to monitor diet, laboratory values, glucose monitoring and the physician/Nurse Practitioner would review Resident #52's diabetic medications, sliding scale orders, Accu-Check (blood glucose monitoring) schedule, diet, and individualized orders for glycemic management accordingly. The physician's orders dated 3/1/24 directed Humalog insulin (fast acting hormone used in the treatment of diabetes mellitus) to be administered based on a sliding scale (parameters that determine dosage based on blood sugar reading) four times a day. The sliding scale directed the following dosage based on blood sugar reading at 7:30 AM, 11:30 AM, 4 :30 PM and 8:00 PM: If Blood Sugar is less than 60, call MD. If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is 401 to 450, give 12 Units. If Blood Sugar is greater than 450, give 14 Units. If Blood Sugar is greater than 450, call the physician. The Medication Administration History dated 3/11/24 identified the prescribed (6 units) of insulin was not administered with a notation that read, 'Resident insisted on 4 units only, not 6 per sliding scale. A nurse's note completed by Licensed Practical Nurse, LPN #4 dated 3/12/24 at 7:43 AM identified at 8:00 PM (on 3/11/24), Resident #52's blood sugar was 300 milligrams per deciliter, mg/dl (normal 80-100), requiring 6 units of insulin. Resident #52 refused and requested 4 units of Humalog insulin, stating s/he did not want the blood sugar level to be low during night. Patient teaching provided; 6 units were encouraged. Blood sugar at 12:00 AM (on 3/12/24) was 212. The blood sugar early morning 397. Resident #52 was asymptomatic. The supervisor was notified. A re-check of the blood sugar at 5:45 AM was 432 and 12 units of Humalog (insulin) were given per Advanced Practice Registered Nurse (APRN) order. Resident #52's next recorded blood sugar at 7:30 AM was 283 with 6 units of insulin administered with no other documented intervention. An interview with LPN #4 on 3/18/24 at 9:42 AM identified she was the assigned charge nurse working 7:00 PM - 7:00 AM from 3/11/24 to 3/12/24. LPN #4 reported she checked Resident #52's blood sugar at 8:00 PM and determined s/he would require 6 units of insulin. Resident #52 refused the 6 units but agreed to receive 4 units which she administered. LPN # 4 reported she did not notify the evening/night shift supervisor, or the physician, further stating she should have notified them. LPN #4 did report to the day shift nurse manager, Registered Nurse #1 prior to leaving on the morning of 3/12/24. An interview with the Director of Nursing Services, DNS on 3/18/24 at 10:01 AM identified she was unaware the medication error had occurred. The DNS indicated nurses should not change medications dosages without first notifying the physician. An interview with APRN #1 identified that she provided routine medical services to Resident #52. APRN #1 indicated she was not notified at any time Resident #52 refused the prescribed dose of insulin and was instead administered a reduced dose. APRN #1 indicated she would expect to be notified if a resident refused a prescribed medication. An interview with RN #1 on 3/18/24 10:14 AM identified LPN #4 reported to her Resident #52 did not receive a full dose of insulin and that she could not recall notifying APRN #1 of the medication error but would have documented the event in the clinical record. An interview with APRN #2 on 3/21/24 at 12:36 PM identified she was the afterhours provider on call on 3/12/24 who did not provide routine services to Resident #52 and could not recall being contacted by the facility. APRN #2 indicated that although the short acting insulin would have been out of a resident's system in 4-6 hours, nursing staff should be contacting a provider for orders if the resident was preferring a reduced dose. A review of the facility policy for Medication Errors directed the medications are to be administered according to physician orders. All medication errors are to be reported to the supervisor, Director of Nursing and Assistant Director of Nursing and the attending physician will be notified. Examples of medication errors include the wrong dose or omission of an ordered dose. Efforts to interview the Medical Director were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and staff interview for 1 of 5 residents reviewed for Unnecessary Medications, the facility failed to ensure clinical records were complete and accurate containing pharmacy recommendations. The findings include: Resident #32's diagnosis included dementia with psychotic disturbance, anxiety, and depressive episodes. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #32 was cognitively impaired and received antipsychotic and antidepressant medications. The care plan dated 1/23/2024 indicated resident received psychotropic medications including psychotropic Drugs. Interventions included: to monitor mood and response to the medications, consult with the psychiatric APRN, to conduct an Abnormal Involuntary Movement Scale assessment (AIMS) every 6 months and assess and record effectiveness and side effects of the medication. Interview and record review with the DNS on 3/20/2024 at 10:30 AM indicated a monthly pharmacy review was completed and a recommendation was made on 12/4/2024. However, the recommendation could not be found or evidence that the recommendation had been addressed by the physician. The facility policy labeled Medication Regimen dated 1/2024 indicated in part within 24 hours of the medication regimen review, the consultant pharmacist provides a written report to the physicians for each resident reviewed identified as having a non-life-threatening medication irregularity which includes the resident's name the name of the medication, the identified irregularity and the pharmacist's recommendation then provides the Director of Nursing Services and Medical Director a written signed, and dated copy of all medication regimen reports. The policy further indicated copies of medication regimen review reports, including the physicians' responses, are maintained as part of the permanent medical record.

Based on review of facility documentation, interview, and facility policy, the facility failed to ensure the Medical Director attended Quality Assurance Performance Improvement (QAPI) meetings quarterly. The findings include: On 3/21/24 at 11:20 AM an interview and facility document review indicated QAPI meeting occurred every three months. Although, the Medical Director was on the list of members that were required to attend the QAPI meeting quarterly there was no evidence of the Medical Director's attendance at the QAPI meeting found from January 2023 through 3/21/2024(one year, 2 months). The DNS indicated the Medical Director is aware of his/her need to attend the meetings but may not have been able to attend the meeting. The Medical Director is updated at the medical staff meetings. Evidence of the medical staff meetings was requested but not provided. On 3/21/2024 at 11:44 AM attempts to reach the Medical Director via phone were unsuccessful. The facility policy labeled Quality Assurance Performance Improvement (QAPI) indicated in part the QAPI program is a comprehensive program designed to drive the decision making within the organization to promote excellence on quality of care, quality of life, resident choice, person driven care and resident transitions. The policy further indicated the QAPI Committee would consist of members including in part the Medical Director.

Based on review of the facility Infection Control Program, facility policy and interview, the facility failed to ensure infection control policies and procedures were reviewed annually. The findings include: A review of the facility's infection Control policies and procedures during the survey identified the facility failed to provide documented evidence that policies were reviewed annually. An interview and facility documentation review with the Director of Nursing Services on 3/13/24 at 1:00 PM identified the facility never previously required a documented review of current policies and procedures. Although requested, a policy for the review of policies and procedures was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a tour of the kitchen, facility policy, and staff interview, the facility failed to ensure that expired food was discarded. The findings included: A tour of the kitchen on 3/15/24 at 10:30 AM with the Director of Dining Services identified the following in the dry storage room and the overflow dry storage room: a. 12- 6 lb. cans of beets expired 12/28/23. b. 6-6 lb. cans of corn expired 12/28/23. c. 3- 8.8 boxes of [NAME] Chickpea Rotini expired 8/21/23. An interview with Director of Dining Services on 3/15/24 at 10:45 AM identified he checks the food storage monthly for expiration dates and discards outdated food. Further, all dietary staff should be checking dates. The Director of Dining Services could not explain why the expired foods were not discarded. Review of the Dietary Services policy dated 7/28/21 directs in part, all food must have a date when it is opened and dated when it is stored. Most recent dates are utilized first, and new orders are stocked to the back of the rotation to prevent expiration.

A review of the Facility Assessment sheet failed to ensure the facility assessment included therapeutic facility pets and individualized resident pets to meet the needs of the residents and failed to ensure the therapy pets were up to date with vaccinations and veterinary visits per facility policy. The findings included: Interview and review of facility document with the Director of Recreation on 3/21/2024 at 10:50 AM indicated 2 cats live in the facility (Cat #1 and Cat #2) and are available to all residents one of which had documentation of up-to-date vaccination for rabies and wellness examination, no distemper (Cat #1) and the other (Cat #2)was overdue for Rabies vaccine since 2020( initial vaccine 11/4/2019 due for booster 10/4/2020( 3 years 5 months ago) then the three year rabies vaccine was due 11/3/2022 ( 2 years 4 months ago). Further review of facility documentation identified Cat #2's last wellness exam was 11/4/2019 (3 years 5 months ago) and no evidence of a distemper vaccine. After surveyor inquiry, the Recreation Director indicated Cat #2 had an appointment scheduled with the veterinarian the of the interview. The Recreation Director further indicated one resident in the facility (Resident #58) was in possession of a pet cat (Cat#3) who lived in the resident's room whose family member cared for the cat's needs. An interview with the DNS on 3/21/2024 at 10:52 AM indicated Cat #3 was (older) and an emotional support pet for Resident #58. Cat 3 veterinarian visit was managed by the resident's family therefore the facility would not have any records of vaccination or health records. An interview with the Director of Recreation on 3/21/2024 at 11:00 AM indicated s/he would request the health record for Cat 3 from Resident # 58's family. After surveyor inquiry the documentation for Cat #3 was provided and noted as up to date with rabies vaccine and wellness exam, no evidence of a distemper vaccine. The facility policy labeled Pet Policy and Agreement dated 1/2024 indicated in part residents of the cottages or independent living apartments (no indication of pets kept in the skilled nursing facility) may keep a single pet subject to the regulations and procedures established by the facility owners and use of service or support animals is subject to the requirements of the Service and Support animal Policy. The policy further indicated in part, pets do not include Service or Support Animals and a pet cat must have current veterinary health record, distemper, and rabies shots. The facility policy labeled Service and Support animal Policy and Agreement indicated in part a support animal is an animal selected to play an integral part of a person's treatment process that demonstrates a good temperament and reliable predictable behavior. The animal is provided to the individual with a disability by a healthcare or mental health professional that is incorporated a treatment process to assist in alleviating symptoms of the individual's disability and further indicated a support animal is not a pet subject to the Pet Policy and agreement. The policy further indicated the resident must be responsible for the care of the animal, annual clean bill of health and immunized against diseases common to the type of animal. The facility Recreation policy labeled Community Pets, dated 1/2024, indicated in part resident cats would be jointly cared for daily by the recreation staff and nursing staff. The policy further indicated the Recreation Director would be responsible for the cat's wellbeing, shots, and licenses. The Facility assessment dated 1/2024, indicated in part it provided care and services for residents with psychiatric/mood disorders but made no mention of services and care offered based on resident needs as to support animals.

Based on facility documentation review, facility policy and interviews, the facility failed to ensure nurses were assessed to be competent in intravenous (IV) therapy. The findings include: A review of the nursing IV competencies identified that the last review was completed on 12/23/22. An interview with the Staff Educator on 3/19/24 at 9:59 AM identified she was responsible for ensuring IV competencies are provided annually. The Staff Educator became aware that IV competencies were outdated sometime after July 2023 when she became employed at the facility. The Staff Educator felt she herself needed training in IV certification before educating staff and discussed the concern with the Director of Nursing Services who indicated the need would be addressed. The Staff Educator further identified she had not yet received training. An interview with the DNS on 3/19/24 at 11:16AM identified IV competencies should be completed according to policies. A review of the facility policy for Skills Assessment/Continued Competencies directed all employees will have specific skills assessed to assure competency. The skills are to be assessed each year and reported to the Governing Board by the Administrator at least annually and kept in the employee's personnel file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility's documentation review, facility's policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for dignity, the facility failed to ensure the resident was treated in a dignified manner. The findings include: Resident # 1's diagnoses included adjustment disorder, somatoform disorder, anxiety, cardiomegaly, and hypertension. The Resident Care Plan (RCP) dated 9/28/2022 identified Resident #1 was alert and appropriate. He/she had an anxiety disorder, adjustment disorder, and a somatoform disorder. His/her altered mood status is evidenced through repeatedly calling out, making false accusations regarding staff, and attention-seeking behavior. Interventions directed that Resident #1 would be cared for in a gentle and respectful manner by all staff. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicative of no cognitive impairment and was totally dependent for ADLs. A Facility Reportable Event report dated 11/11/2022 identified that Resident #1's Power of Attorney (POA) was on the video monitoring system that was placed in Resident #1's room (placed by POA) when he/ she observed LPN #1 being verbally abusive to Resident #1. LPN #1 was immediately removed from the building. Interview with LPN #1 on 12/01/2022 at 12:25 PM identified that NA #1 accompanied her into Resident #1's room. She identified that Resident #1 was always calling on the call light. LPN #1 further identified that as she walked into the room Resident #1 started apologizing that he/she was sorry and she playfully responded, no you are not. She denied having any further conversation with Resident #1 and denied she told Resident #1 he/she was the most impatient person she had ever met. She identified that she did not mean to hurt or disregard the resident's feelings. Interview with DNS on 12/01/2022 at 12:40 PM identified that the tone in which LPN #1 spoke to Resident #1 was not acceptable. The DNS identified that when the incident was witnessed by POA, he/she called and reported observation immediately, NA#1 also notified the supervisor, and LPN #1 was immediately escorted out of the unit and out of the facility, she notified the agency that LPN #1 was removed from facility's schedule. Interview with NA #1 on 12/01/2022 at 1:00 PM identified LPN #1 went into Resident #1's room and turned on the overhead light. She identified LPN #1 did not greet Resident #1, but instead LPN #1 said to Resident #1, you are the most impatient person I have ever met. NA #1 further identified that when Resident #1 apologized and said I'm sorry, and LPN #1 responded no you are not . NA #1 further identified that LPN #1 did not yell or shout, she was just disrespectful and should not have said that to the resident. Review of facility's Resident's Right: Dignity and Self Determination Policy directed in part, that the Resident had the right to be treated with consideration, respect, and full recognition their dignity and individuality regardless of age, race, religion, gender, condition, sexual orientation, or type of illness. Resident #1 and POA was disrespected by LPN when she told he/she was the most impatient person she ever met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accident, the facility failed to notify the physician timely after a resident experienced an accident which resulted in injury. The findings include: Resident #1's diagnoses included diabetes, neuropathy, atherosclerosis bilateral legs, heart failure, hypertension, cerebral infarction, chronic kidney disease, respiratory failure, chronic pain, dementia, Alzheimer ' s disease, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 out of fifteen, indicative of severe cognitive impairment, had no behavioral symptoms and required extensive assistance with transfer and locomotion on unit. The Resident Care Plan (RCP) dated 10/17/22 identified Resident #1 had significant visual impairment with visual hallucinations related to diagnosis of [NAME] Bonnet. Interventions directed to assist the resident when needed to prevent injury, announce your arrival in resident ' s presence and provide adequate lighting. The nurse ' s note dated 11/8/22 at 6:30 PM was recorded as late entry and identified that Resident #1 ' s left foot/lower extremity struck doorway to the room. During assessment lower extremity was warm with positive pedal pulses, no redness noted with painless ROM. The resident offered no complaints of pain. The nurse ' s note dated 11/8/22 at 9:54 PM identified Resident #1 was in wheelchair being assisted out of dining room and while passing through bedroom doorway his/her left foot was jolted against the door jamb. The resident initially complained of my foot hurts. Left foot and ankle was not swollen, red, warm to touch and skin was intact. Tylenol was administered at 7:00 PM and the resident had no further complaints. The Reportable Even Form dated 11/8/22 at 5:30 PM identified Resident #1 ' s left foot hit doorway and was bent backward. The nurse ' s note dated 11/9/22 at 12:31 PM identified that APRN was notified regarding the resident ' s left foot hitting door jamb while entering his/her room last evening on 11/8/22. Order for X-ray of left ankle and foot was obtained. The nurse ' s note dated 11/10/22 at 6:39 AM identified the resident ' s left lower extremity with discoloration and skin was intact. The resident flinched his/her foot upon movement. The nurse ' s note dated 11/10/22 at 10:58 AM identified Resident #1 continued with left foot pain and was shouting in pain ouch during care and with transfer. X-ray was not taken at that time. Scheduled Tylenol was not effective. Blood pressure was elevated, MD #1 was notified and new order for Lisinopril 10 mg and blood work was obtained. X-ray of left foot and ankle was obtained on 11/10/22 (no time identified) and results interpreted by a physician at 4:55 PM. Conclusion identified nondisplaced fracture of the distal third of the tibia and no other bony abnormality identified. The nurse ' s note dated 11/10/22 at 5:45 PM identified Resident #1 had fracture of left distal tibia. APRN was notified, new order for pain medication was obtained. Pillow splint was applied to left lower extremity; the resident was calling out in pain with any movement of left lower extremity. Review of Doctor ' s Order Sheet dated 11/10/22 identified orders for Oxycodone 5 mg for left lower leg pain, pillow splint to left lower leg and STAT orthopedic appointment on 11/11/22. The nurse ' s note dated 11/10/22 at 8:00 PM Resident #1 was with increased complaint of pain during care despite Oxycodone administration. RN #2 called APRN to discuss possibility of having left lower extremity fracture splinted in the emergency room instead of waiting until tomorrow. 911 was called and the resident was transferred to the hospital. Review of the emergency room documentation dated 11/10/22 identified Resident #1 had posterior splint applied to his/her left leg extending from the posterior mid-thigh to the foot and the resident returned to the facility on [DATE]. Review of orthopedic note dated 11/14/22 identified Resident #1 reportedly was in wheelchair and his/her leg was struck going through a door sustaining fracture, this occurred several days ago. The resident had externally rotated his/her bilateral lower extremities at his/her hips. Unable to obtain X-ray of his/her leg in the office, the resident required a hoyer lift and was in a wheelchair, unable to be put on the exam table and was sent to the hospital emergency room for repeated X-ray of his/her left leg. Further review identified X-ray obtained on 11/14/22 noted distal tibial shaft with butterfly fragment fracture with no significant displacement nor angulation and noted proximal fibula fracture. Plan included to continue the use of long-leg posterior splint and add U-splint involving the lower leg for further stabilization. Interview with Rehabilitation Manager on 11/29/22 at 11:08 AM identified Resident #1 was unable to propel himself/herself in the adaptive wheelchair provided by the facility, therefore facility staff was pushing the resident in the adaptive wheelchair. Interview with RN #1 on 11/29/22 at 2:57 PM identified he observed NA #2 pushing Resident #1 in his/her adaptive wheelchair into his/her room on 11/8/22. Further interview identified that the resident's legs really did not fit properly on the wheelchair and he observed the resident's left leg slightly bumped the door frame. RN #1 stated the resident had chronic pain, received Tylenol and he did not hear the resident yell out in pain. During assessment the resident denied pain and had good range of motion in the left foot/ankle, therefore he did not notify the MD or APRN about the incident. Interview with DNS on 11/29/22 at 3:30 PM identified when Resident #1 complained of left foot pain after the incident on 11/8/22, she obtained an order for STAT (immediate) portable X-ray for the resident's left foot and ankle to be complete at the facility on 11/9/22. The X-ray company changed STAT X-ray to a routine that was completed on 11/10/22 and the MD or APRN were not notified that the X-ray will not be done until the next day. The DNS further identified that although APRN was aware that portable X-ray department was not dependable, the facility should have had notified the APRN on call for any further orders. Interview with NA #2 on 11/29/22 at 4:10 PM identified she was pushing Resident #1 in his/her adaptive wheelchair to his/her room, but when she was turning in the hallway at the entrance to the resident ' s room, the resident ' s left foot slipped to the side and off the elevated foot pedal. The left foot became caught up on a door jamb and bent backward. NA #2 kept pushing the resident in his/her adaptive wheelchair and lifted it to go over the threshold. Further interview with NA #2 identified that Resident #1 ' s legs were spread out like a letter V, and although she was aware to be careful while pushing the wheelchair through the door, she was not looking at the resident ' s feet. NA #2 stated that when Resident #1 yelled out, she realized that something was wrong, she stopped and looked, that is when she noted that the resident ' s left foot hit the door jamb and bent backward. NA #2 pulled the resident in his/her customized wheelchair back, straightened out and pushed the resident back into his/her room. NA #2 notified charge nurse LPN #1 of the incident immediately. Interview and written statement review with NA #1 on 11/30/22 at 11:20 AM identified she observed on 10/8/22 Resident #1's left foot got caught on the door jamb and the wheelchair kept going forward. The resident was complaining of left ankle pain for about an hour after the incident. Interview with MD #1 on 11/30/22 at 11:43 AM identified he had not been made aware when Resident #1 hurt his/her left foot on 11/8/22. MD #1 further identified that if he had been made aware, he would have assessed the resident and give an order to apply ice, to elevate, pain management, and possibly X-ray to be done. Further interview identified that he had not been made aware when the facility was unable to obtain left foot X-ray that was requested STAT (immediately) on 11/9/22. The resident might have been sent out to the clinic or to the hospital for evaluation and X-ray may have been completed on the same day. Review of facility Reportable Events/Accidents/Incidents Policy directed in part, if an incident had occurred which resulted in injury, and has the potential for requiring physician intervention, a significant change in the resident ' s physical. Mental, or psychosocial status, a need to alter treatment significantly, or a decision to transfer or discharge the resident from the facility the attending physician is notified immediately, and the ambulance called. The policy further directed if no significant injury has occurred, first aid is administered, and the physician and the family are notified at the earliest convenient time by the charge nurse.

On 10/14/21 at 9:30 AM, during document review, the surveyor was not provided with documentation by the Maintenance Representative or the Administrator that identified that the facility had a comprehensive water management plan in place as required by S&C 17-30 ALL. The facility had results of tests that were conducted but had no record of a committee, meeting minutes, or areas of the facility that are a concern.

Based on observation and interview during a tour of the Dietary Department, the facility failed to document monitoring of sanitizing concentrations and ensure that dishwasher temperatures met the minimum requirements. The finding included: During tour of Dietary Department on 10/18/21 at 9:25 AM with the Food Service Director (FSD) the following was identified. 1. The three compartment sink was noted to lack daily testing/ monitoring documentation of the chemical sanitizer solution (concentration level). 2. The dishwasher was noted to fail meeting minimum required temperature. Washing temperature was noted at 140 degrees (manufacturer instructions identified a required temperature as 160 degrees for the wash cycle). The rinse cycle was noted to be at 172 degrees (manufacturer instructions identified a required temperature 180 degrees for the rinse cycle). 3. Two serving scoops were noted to be stored and immersed within the packaged food item (one in the flour and one in the sugar). Interview and review with the FSD on 10/18/21 at 12:46 PM indicated that she immediately switched to utilizing plastic and paper as a precautionary measure. Additionally, the dishwasher was adjusted by facility maintenance to low temperature/chemical mode as well as requesting for ECOLAB for evaluation of the machine. FSD indicated that she was unable to provide chemical sanitizing monitoring documentation and that the dishwasher temperature should have been 160/180 degrees for the wash and rinse. Review of facility Dietary Department infection control policy identified in part that non-food items are not to store in with food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy and procedures and interviews for one of two residents (R #381) reviewed for abuse, the facility failed to notify protective services timely of a potential for elder abuse. The findings include: R #381's diagnoses included dementia without behavioral disturbance, bipolar disorder, history of falls, and muscle weakness. The admission MDS assessment dated [DATE] identified that R #381 was moderately confused, had difficulty focusing attention, disorganized thinking, and rejected care four to six (4 to 6) days but not daily). Review of facility documentation dated 7/9/18 identified disorder of behavior by visitor/Person #3, and emotional distress caused to R #381, and the police were notified. Review of the investigation identified Person #3 was intrusive on R #381's care causing difficulty completing assessments or carrying out physician orders. The investigation identified that on 7/5/18, during a resident care conference (RCC) Person #3's behaviors were erratic and escalating: Person #3 was agitated, slamming items on the table, pushed the table, was in staff's personal space, was loud, and staff reported they were fearful of Person #3. Further review identified that a State Trooper was requested to assist, and he/she spoke with Person #3. DON #1 reviewed the facility policy for removal from the facility for violence with Person #3, and he/she verbalized understanding. Review of the written statement dated 7/6/18 by DON #1 identified she spoke with R #381's POA and his/her spouse and was told that Person #3 had allegedly been physically and verbally abusive to R #381 in the past, and the facility initiated supervised visits. Review of a written statement by DON #1 dated 7/11/18 identified she received a call from the State Police regarding Person #3 requested a police escort to visit R #381 in the facility. When Person #3 arrived in the lobby for a supervised visit, with no police present, he/she was loud, disruptive, inappropriate and intimidating to staff. Facility staff called the State Police, who responded to the building. State Police informed Person #3 if they were called to the facility again, Person #3 would be arrested. The Resident Care Plan (RCP) dated 7/11/18 identified that R #381 displayed signs and symptoms of mood distress as evidenced by increased forgetfulness, agitation and anxiousness when interacting with a visitor with interventions that directed to provide support and encouragement, and if possible allow the resident to have control over situations. Review of the physician's note dated 7/13/18 at 12:33 pm identified that R #381 was advised if he/she was discharged home without 24-hour care, the discharge would be unsafe, and would be Against Medical Advice (AMA). R #381 stated she would stop eating for five (5) days so he/she would die, and that she/he was not trying to commit suicide but knows other ways that he/she could. Further review of the physician note identified transfer to hospital to evaluate intellectual capabilities to determine if risk to self. Review of the clinical record, facility documentation and interviews with the Director of Social Services (DSS) on 5/31/18 at 11:58 AM identified that R #381 lived with Person #3, and Person #3 was loud and threatening when visiting R #381. The DSS stated that Person #3 was loud and threatening, and often was outside the building watching staff at different times of the day. The DSS further stated that one day she saw Person #3 in the lobby, wearing a large backpack, and yelling at the receptionist. The police were called, and spoke with Person #3 about his/her behaviors and searched his backpack and then Person #3 left the building. The DSS stated that she felt threatened by Person #3. Review of the clinical record, review of facility documentation and interviews with the Administrator, DON and ADON on 5/31/19 at 1:36 PM identified that staff were fearful of Person #3, and on 7/5/18 during the Resident Care Conference, Person #3 was acting erratic, aggressive, pushed the table in the room, and staff were upset. The ADON stated supervised visits in the lobby were instituted because staff were afraid to have Person #3 on the nursing unit. The Administrator stated he had witnessed Person #3 be verbally aggressive toward R #381 and belligerent toward staff on 7/10/18 when he/she was in the lobby and the police were called. Further interview identified that Person #3 was observed at different times watching staff for extended periods of time from outside the building. The ADON identified that the police were called to the building again on 7/13/18 as a precaution in the event Person #3 arrived at the facility prior to R #381's transfer to the hospital. The ADON stated they were notified by the POA on 7/6 and 7/13/18 that Person #3 allegedly had a history of verbally and physically abusing R #381. Although when R #381 was transferred to the hospital for evaluation and the facility expected R #381 to return to the facility, the facility was unable to provide documentation that they had notified the hospital of the allegation and history of abuse. The facility received information on 7/16/18 that R #381 was discharged from the hospital to home on 7/13/18, and the facility did not notify Adult Protective Services of the discharge home and the allegation of a history of verbal and physical abuse by Person #3 (whom R #381 resided with). The DON stated that Adult Protective Services should have been notified. Interview with Receptionist #1 on 6/6/19 at 10:39 AM identified she was the receptionist on 7/10/18 when Person #3 was visiting. Receptionist #1 indicated that Person #3 was unruly, unreasonable, would go off the handle quickly, was impulsive and very aggressive. Receptionist #1 stated she was worried about safety and called the Director of Maintenance and the Administrator. Subsequent to surveyor inquiry, APS was notified. Review of facility Abuse Policy directed in part, residents are protected from abuse from, staff, volunteers, family members, legal guardians, friends, and other individuals. The policy further directed if the Supervisor feels ham has or potential could occur, the person causing the abuse will be asked to leave the facility, and the Social Worker is notified and proper notification of the State Ombudsman's office occurs. Review of facility Resident Rights Policy directed in part, residents have the right to be free from verbal, physical, and mental abuse. Interview with the DON identified there was no facility policy for notification of Adult Protective Services for surveyor review, however the expectation was that when the facility was aware R #381 was discharged to home from the hospital, Adult Protective Services should have been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policies and procedures and interviews for one of three residents (R #378) reviewed for accidents, the facility failed to ensure interventions were implemented to prevent a fall, and/or that the facility failed to ensure monitoring was completed after a fall. The findings include: R #378's diagnoses included Alzheimer's disease, syncope, and a history of falls prior to admission. The Resident Care Plan (RCP) dated 10/15/18 identified that the resident was a fall risk with interventions directed to use an alarm to notify staff of the resident movement that could cause a fall, and motion detector alarm. The admission MDS assessment dated [DATE] identified that R #378 was confused, required extensive assistance of two staff for ambulation, used a wheelchair/walker, and was on hospice services. a. Review of facility incident report dated 10/16/18 at 8:00 AM identified R #378 had an unwitnessed fall in the hallway, was found on his/her left side, and had a two (2) centimeter (cm) skin tear on the left temple, and a 1 x 1.3 cm skin tear on the left forearm. The report identified that R #378 had been walking unattended prior to the fall. Although the report identified a motion detector was in use, the report did not identify if the motion detector sounded an alarm. The nurse's note dated 10/16/18 at 8:26 AM identified R #378 was found on his/her left side in the hallway. The note further described a motion detector was in place at the time of the fall and had been activated, but the alarm did not sound. Review of the clinical record and interview with the DON and ADON on 5/30/19 at 11:15 AM identified that R #378 required extensive assistance of two (2) staff for ambulation, was not self-mobile in the wheelchair, and could not have moved the motion detector him/herself. Further interview identified that although the motion detector was in use at the time, it was not placed correctly to sound an alarm to alert staff if R #378 attempted to get up without staff assistance. In addition, the motion detector should have been placed where it would alarm so if R #378 attempted to get up they would hear the sound. Review of facility Resident Care Plan Policy directed in part, the care plan guides and directs staff in all aspects of resident centered care. b. Review of the clinical record and facility documentation identified that although the neurological (neuro) assessments were documented after the unwitnessed fall on 10/16/18 with a head injury, and every four hour assessments were completed for sixteen hours, neuro assessments were not completed every four hours for a total of twenty hours in accordance with facility policy. Review of the clinical record and interview with the DON and ADON on 5/30/19 at 11:15 AM identified that although neuro checks were completed every four hours for sixteen hours, the facility did not complete the every four hour neuro checks for a total of twenty hours. The DON indicated that neuro assessments should have been completed for a total of twenty hours and the neuro signs documentation sheet did list the required times, it did not provide a line cueing the nurse when to complete the neuro checks. c. Review of facility incident report dated 10/18/18 at 2:30 PM identified R #378 had an unwitnessed fall in the lounge and was found on his/her left side with no injury noted. The report further identified R #378 could have hit his/her head. Review of the clinical record identified although neurological (neuro) assessments were documented after the unwitnessed fall on 10/18/18, and every four hour assessments were completed for sixteen hours, neuro assessments were not completed every four hours for a total of twenty hours in accordance with facility policy. Review of the clinical record and interview with the DON an ADON on 5/30/19 at 11:15 AM identified that although neuro checks were completed every four hours for sixteen hours, the facility did not complete the every four hour neuro checks for a total of twenty hours. The DON indicated that they should have been completed as indicated. Subsequent to surveyor inquiry, the neuro signs documentation sheet was updated to include a space for each time neuro assessments are required. Review of facility Head Trauma/Neuro Changes/Neuro-Check Policy directed in part, that following a known or suspected head injury and all unwitnessed falls, neuro checks are initiated as following: every 15 minutes for one hour, every one (1) hour for three (3) hours, every four (4) hours for twenty (20 hours to be completed at twenty-four (24) hours.