**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and implement an individualized care plan to prevent decline in range of motion for 1 (Resident #29) of 2 residents reviewed with limited range of motion. The findings included: The facility policy, Plan of Care revised July 2023 noted, It is the policy of Cypress Cove to develop and implement a comprehensive person-centered care plan for each resident . that are identified in the resident's comprehensive assessment . Review of the clinical record for Resident #29 revealed an admission date of 8/3/22 with diagnoses including Dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. The Quarterly MDS assessment with a target date of 11/10/23 noted Resident #29 had functional limitation of upper extremities on both sides. Resident #29 had contractures (chronic loss of joint mobility), multiple sites. The care plan with an effective date of 12/6/2020 and revised on 12/8/22 noted the resident had limited physical mobility related to contractures in the upper and lower extremities. The interventions with an effective date of 12/6/20 included monitoring, documenting, and reporting as needed any signs or symptoms of immobility, contractures forming or worsening. The care plan did not list interventions to prevent further decline in range of motion. On 1/16/24 at 10:48 a.m., Resident #29 was observed in bed. Both hands were contracted, closed in a fist. Resident #29 was not wearing any splints or hand rolls to prevent further decline in range of motion of the resident's hands. On 1/16/24 at 11:54 a.m., Resident #29 was observed sitting up in her Broda (specialized positioning) chair with both hands closed in a fist. There were no splints, positioning devices or hand rolls visible in the room. On 1/17/24 at 9:08 a.m., Resident #29 was observed in bed with her hands tightly closed. In an interview, Certified Nursing Assistant (CNA) Staff F said, we used to put wash clothes in her hands. On 1/17/24 at 10:03 a.m., and 12:01 p.m., Resident #29 was observed with Licensed Practical Nurse (LPN) Staff C. Resident #29's hands remained in a closed fist. The resident had no rolls or splints in either hand. Staff C said, sometimes we roll towels for her hands. On 1/18/24 at 8:22 a.m., CNA Staff M said, We roll wash clothes to put in her hands whenever we remember. On 1/18/24 at 9:00 a.m., Staff L, Registered Nurse (RN) said the specific care plan interventions for Resident #29 related to the contractures were resident is dependent on staff for feeding, dressing, and transfers. Therapy will reassess quarterly and as needed if there is a change or weakness. On 1/18/24 at 12:00 p.m., the MDS coordinator said the care plan says all they were doing was monitoring for worsening skin breakdown and notify staff she has upper and lower extremity contractures. Hoping there are no complications like skin breakdown, thrombus and reporting to the doctor. On 1/18/24 at 12:24 p.m., the Director of Nursing (DON) said she would expect to see hand strengthening exercise, massage, wash cloth rolls in the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide care and services to prevent the decline in range of motion for 1 (Resident #29) of 2 sampled residents with functional limitation in range of motion. The findings included: A review of the Restorative Nursing Programs health care policy (R-12) revised June 2018 provided by the facility stated, Cypress Cove strives to provide maintenance and restorative services designed to maintain or improve a resident's ability to the highest practicable level. The procedure documented, Nursing personnel are training on basic, maintenance or restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include maintaining proper positioning and body alignment, assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate. Review of the clinical record for Resident #29 revealed an admission date of 8/3/22. Diagnoses included Dementia, and muscle weakness. The admission minimum data set (MDS) assessment dated [DATE] noted the resident scored 00 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. Resident #29 required the extensive assistance of two for bed mobility and was totally dependent on 2 persons for transferring, dressing, and bathing. Resident #29 had no impairment of upper extremities including shoulder, elbow, wrist, and hand. The Quarterly MDS assessment with a target date of 11/10/23 noted Resident #29 had impaired range of motion on both upper extremities (shoulder, elbow, wrist, hand). The care plan initiated on 12/6/20 and revised on 1/3/24 noted the resident had limited physical mobility related to contractures (chronic loss of joint mobility) in the upper and lower extremities. The interventions initiated on 12/6/20 included monitoring, documenting, and reporting as needed any signs and symptoms of immobility; contractures forming or worsening. A Social Service Progress note dated 4/26/2023 documented family in agreement for Occupational Therapy to evaluate for wheelchair positioning and contracture management. Team in agreement with plan of care. On 1/16/24 at 10:48 a.m., Resident #29 was observed in bed. Resident #29's right and left hands were closed in a fist. Resident #29 was not able to respond to attempt to interview. Resident #29 was not wearing any hand splints or devices. On 1/16/24 at 11:54 a.m., Resident #29 was observed sitting up in her Broda (specialized positioning) chair. Resident #29's left, and right hands remained closed in a fist. Resident #29 was not wearing any splints or devices to the hands. On 1/17/24 at 9:08 a.m., Certified Nursing Assistant (CNA) Staff F said, We used to put wash clothes in her hands. Resident #29 was observed in bed with her left and right hands closed in a fist. On 1/17/24 at 10:03 a.m., Resident #29 was observed with Licensed Practical Nurse (LPN) Staff C. Resident #29's left, and right hands were closed in a fist. The resident was not wearing any splint or devices to the hands. Staff C said, sometimes we roll towels for her hands. On 1/17/24 12:01 p.m., Resident #29 was observed with her right and left hands closed in a fist. The resident was not wearing hand splints or rolled towels in her hands. On 1/18/24 at 8:22 a.m., CNA Staff M said, We roll the wash clothes to put in her hands whenever we remember. On 1/18/24 at 9:00 a.m., Registered Nurse (RN) Staff L said the specific care plan interventions for Resident #29 related to the contractures were resident is dependent on staff for feeding, dressing, and transfers. Therapy will reassess quarterly and as needed if there is a change or weakness. On 1/18/24 at 9:14 a.m., the Director of Rehab (DOR) said all residents are screened quarterly or more often if there is a referral from nursing. Residents will remain on the restorative program as long as needed. Once discharged they are monitored weekly for functional changes. All quarterly screenings are documented in the screening book. On 1/18/24 at 9:30 a.m., review of the screening book provided by the DOR failed to reveal quarterly therapy screenings for Resident #29 for the year 2023 or 2024. On 1/18/24 at 10:11 a.m., the Director of Restorative Services said Resident #29 was not on a restorative program. She confirmed there were no interventions in place addressing the resident's contractures. She said nursing staff should do light range of motion and keep the resident's nails trimmed. She said, I would think there should be specific interventions. We have had others with foam rolls, cones, but I don't see anything in place in this care plan. On 1/18/24 at 11:04 a.m., the DOR verified the lack of screening for Resident #29. The DOR said the resident should have been screened in July 2023, October 2023, and January 2024. On 1/18/24 at 11:43 a.m., the Occupational Therapist said she had not seen Resident #29 for quarterly screenings or restorative programming, and the nurse should have sent a referral. The Occupational Therapist said Resident #29 would benefit from custom or prefabricated splints for her hands. On 1/18/24 at 12:00 p.m., the MDS coordinator verified there were no specific interventions in the care plan related to Resident #29's contractures other than basic skin care. On 1/18/24 at 12:24 p.m., The DON said she would expect to see care plan interventions such as hand strengthening exercise, massage and wash cloth rolls for Resident #29. On 1/18/24 at 12:42 p.m., the Occupational Therapist verified Resident #29 was not receiving services for the hand contractures.

Based on observation, review of facility policy and staff interviews, the facility failed to ensure expired medications were not retained longer than the expiration date in 1 of 2 medication storage rooms observed and 1) medication cart of 3 medication carts observed. This has the potential for expired medications to be administered to residents. The findings included: The facility policy and procedure Medication Storage (revised 8/23) documented All medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdates, defective or deteriorated medications with worn, illegible or missing labels. On 1/16/24 at 10:09 a.m., during an observation of the 2nd floor medication room with Licensed Practical Nurse (LPN) Staff B revealed an emergency insulin box located in the locked compartment of the medication refrigerator. The emergency insulin box contained 1 Humulin insulin injectable pen with an expiration date of 12/11/23. LPN staff B confirmed the insulin had expired. Photographic evidence obtained. On 1/16/24 at 10:29 a.m., during an observation of 2nd floor [NAME] Hall medication cart with LPN Staff C revealed a plastic pharmacy medication bag with 2 Albuterol AER/HFA inhalers. The expiration date on the inhalers was 12/23. LPN Staff C confirmed the inhalers had expired. Photographic evidence obtained. On 1/18/24 at 8:52 a.m., in an interview, the Pharmacy Consultant said he was at the facility monthly and checks the emergency drug kits including the insulin. The Pharmacy Consultant said he checked the emergency drug kits at his last visit on 12/20/23 and was not aware the Humulin insulin had expired on 12/11/23. On 1/18/24 at 5:15 p.m., the Director of Nursing said she had contacted the pharmacy to replace the emergency insulin box on 1/16/24 because the Humulin insulin had expired. She said she checks the medication refrigerators and the medications including the emergency drug box every day. The Humulin insulin had an expiration date of 12/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments in a timely manner for 16 residents (Residents #1, #2, #3. #6, #12, #17, #19, #20, #26, #29, #35, #37, #39, #40, #43 and #44) of 16 residents reviewed. The finding included: Record review for Resident #1's MDS assessments revealed the Quarterly MDS dated [DATE] was transmitted 1/16/24, 32 days after completion. The Annual MDS dated [DATE] was transmitted on 10/10/23, 26 days after completion. Record review for Resident #2's MDS assessments revealed the Quarterly MDS dated [DATE] was transmitted on 1/17/24, 49 days after completion. Record review for Resident #3's MDS assessments revealed an admission assessment dated [DATE] was transmitted on 10/10/23, 28 days late. The Quarterly MDS dated [DATE] was transmitted and accepted on 1/16/24, which was 34 days late. Record review for Resident #6's MDS assessments revealed an Annual MDS dated [DATE] was export ready but still not transmitted as of 1/17/23 which was 56 days late. Record review for Resident #12's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/16/24, which was 44 days late. Record review for Resident #17's MDS assessments revealed a Quarterly assessment dated [DATE] was transmitted on 1/16/24, which was 46 days late. Record review for Resident #19's MDS assessments revealed a Significant Change MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 86 days late. Record review for Resident #20's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 54 days late. Record review for Resident #26's MDS assessments revealed a Discharge Return not anticipated MDS dated [DATE] was not transmitted as of 1/17/24, which was 125 days late. Record review for Resident #29's MDS assessments revealed a Quarterly MDS dated [DATE] was not transmitted as of 1/17/24, which was 54 days late. Record review for Resident #35's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted from the facility as of 1/17/24, which was 56 days late. Record review for Resident #37's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/16/24, which was 47 days late. Record review for Resident #39's MDS assessments revealed an Annual MDS dated [DATE] was transmitted on 1/16/24, which was 32 days late. Record review for Resident #40's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 55 days late. Record review for Resident #43's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/9/24, which was 33 days late. Record review for Resident #44's MDS assessments revealed an admission MDS dated [DATE] was transmitted on 10/3/23, which was 19 days late. The Discharge MDS dated [DATE] was not transmitted and accepted until 1/9/24, which was 25 days late. On 1/17/24 at 1:11 p.m., in an interview MDS coordinator Staff L stated she started her position as MDS coordinator in July of 2023 and was still learning the regulations related to MDS assessments. On 1/17/24 at 1:36 p.m., in an interview the Director of Nursing verified the MDS assessments for Residents #1, #2, #3. #6, #12, #17, #19, #20, #26, #29, #35, #37, #39, #40, #43 and #44 had not been transmitted within the specified time frame in accordance with the Resident Assessment Instrument (RAI) manual. On 1/17/24 at 4:14 p.m., the Executive Director stated he expected MDS assessments to be completed and transmitted within the specified time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the clinical record for Resident #8 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE]. The assessment noted Resident #8 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated severe cognitive impairment. The resident needed substantial/maximal assistance with all activities of daily living (ADLs). Review of Resident #8 care plan with a revision on 1/15/2024 after the fall was Therapy to evaluate wheelchair safety. Other interventions to prevent a fall in place 06/22/2023 Place Call don't fall signs in room, 7/05/2023 Ensure call light is easily within resident's sight while he is in bed, 2/17/2023 Keep call light within reach-instruct on its use and remind/re-educate to use call light as needed, and 8/10/2023 Falling Star program. Review of incident reports: Resident #8 unwitnessed fall out of wheelchair on 1/13/2024. Note states fall was unwitnessed at approximately 3:00 p.m. after the family left him. He slipped out of his wheelchair. No complaints of pain, no skin tears or major injuries noted. He stated he did not hit his head. Interventions in place at time of incident 1:1 supervision. The new intervention in place is to increase rounding. Note text: new intervention is for therapy to evaluate wheelchair safety. No new interventions to educate the family to notify staff when leaving so they can check on the resident, since his fall happened after the family left. On 1/16/24 at 10:15 a.m., Resident #8 was observed in a wheelchair at end of the bed with the call light out of reach on the bed. Resident stated he is to call for help when he needs to get up. Resident #8 was not able to reach for the call light upon request. Photographic evidence obtained. On 1/16/24 at 1:00 p.m., Resident #8's spouse stated Resident #8 fell out of his chair on 1/13/2024 but did not sustain any injuries. She felt that a wedge should be put on his wheelchair so that he doesn't have to always try and push himself back into the wheelchair. On 1/16/24 at 2:57 p.m., Resident #8 was observed asleep in bed with call light on the floor. Photographic evidence obtained. On 1/16/24 at 3:00 p.m., Licensed Practical Nurse Staff B said the resident used two call lights. She verified one of the call lights was on the floor and not within sight or reach of the resident. She pointed to a call light under the resident's pillow. The call light was not within the resident's sight as per the care plan dated 7/5/23. On 1/16/24 at 3:13 p.m., CNA Staff G, Said the yellow dot is fall risk on door. She said fall risk usually sit in hallway to have a set of eyes on the resident. She doesn't know what pink dot is. On 1/16/24 at 3:29 p.m., Registered Nurse (RN) Staff H Supervisor said it is on trust that the staff is increasing rounds on a resident. On 1/17/24 at 9:27 a.m., LPN Staff C stated pink means dnr, red is alarm, yellow is don't know, falling star at risk for fall. When is time to check on them she makes rounds every hour and CNAs are up and down the hall. There is no documentation that they round. The purpose of signs are to identify the resident issue. On 1/17/24 at 10:00 a.m. CNA Staff F said falling star means fall risk, do not leave them by themselves and no walk by themselves. On 1/18/24 at 9:22 a.m., in an interview the DON said increase rounding is: RN's and CNAs alternate rounds every two hours; they should increase to every 30 minutes. The DON confirmed there was no documentation of the increase rounds, they were just told to increase rounds Review of the facility Falling Star Program revised June 2018 revealed After a resident sustains a second fall within a 30-day period, a red star will be placed on the doorframe of the resident's room. Interventions included: Not to be left unattended during toileting, grooming, bathing, sitting on the edge of the bed, and dressing; will be assisted with all transfers and ambulation. Review of the Caution and Fall Program revised February 2020, Residents at risk for falls will be identified to all staff members through a yellow dot on the doorframe. Residents should not be left completely unattended during toileting, grooming, bathing, and dressing. Staff should remain in the vicinity but do not have to be within arm's reach or within view of resident. Review of the medical record for Resident #206 revealed a fall and hospitalization prior to admission to the facility. Review of the hospital record revealed resident #206 suffered from dizziness for one year and multiple falls. His hemoglobin in the hospital was low and the resident suffered from delirium (episodes of confusion). The resident was admitted to the facility for rehabilitation. The facility's comprehensive assessment with a reference date of 12/1/23 revealed an elderly resident, admitted on [DATE] who required assistance for walking. The diagnoses included anemia (low red blood levels) and orthostatic hypotension (low blood pressure during position changes.) Review of the facility progress notes revealed Resident #206 fell 3 times at the facility: 11/18/23, 12/11/23, and 1/2/24. Review of the fall incident on 11/18/23 at 9:00 a.m. revealed the resident was alone in the bedroom when he fell. The resident tried to make a phone call and fell. The facility steps to prevent recurrence were apply lotion for skin hydration and place a Call Don't Fall sign in the bedroom and bathroom to remind the resident to use the call bell for assistance. Other interventions initiated on 11/20/23 to prevent falls were anticipating and meeting needs; caution program; ensure appropriate footwear while walking or using wheelchair; keep bed in low position; keep call light in reach, instruct on use and remind resident to use it; safe environment; slide personal items within reach; update fall risk review quarterly; assist resident with toileting and transfer using the wheelchair and walker. Review of the fall incident on 12/11/23 at 6:00 a.m. revealed the resident was alone in the bedroom when he fell. The resident lost his balance. The facility step to prevent recurrence was increased rounding. The care plan was updated to include placing a sign to remember to position foley bag (drainage bag from catheter inserted in the bladder) accordingly prior to ambulation. Review of the fall incident on 1/2/24 at 5:00 p.m. revealed the resident was alone in the bedroom when he fell. The resident stated he wanted to sit on the floor. After staff got him sitting on the bed, he started to slouch forward, so they laid him down quickly. After the resident returned to baseline, he started saying he fell off the bed. The staff noted this was switching stories. The steps taken to prevent a recurrence: assist with ambulation, which the resident was previously care planned for and labs ordered to rule out a urinary tract infection (UTI). Review of the facility progress notes from November 2023 - January 2024 revealed Resident #206 suffered periods of confusion and pulled out his urinary catheter twice while at the facility. The psychiatrist noted the resident suffered from dementia, impaired ability to remember, think or make decisions that interfere with doing everyday activities. Review of the care plans did not include increased supervision for the resident. Review of the facility progress notes from November 2023 - January 2024 revealed the resident suffered gait, balance, and wandering issues, sometimes wandering into the bedroom of others. The staff were to assist the resident as necessary for transferring. There were no directions for increased supervision of the resident. Review of the Standard of Care Agenda dated 1/4/2024 revealed the facility removed Resident #206 from the falling star program. He has had 1-3 falls in the last 30 days. The Resident is ambulating independently. Delirium seems to have cleared. On 1/16/24 at 10:32 a.m., during an interview with Resident #206 in his bedroom, he said he fell at home but did not recall any falls at the facility. The resident's room was the very last room at the end of the hall farthest from the nursing station. The call bell was in reach and the Call Don't Fall sign was on the wall near the bed. On 1/17/24 at 8:33 a.m., Resident #206 said his memory is not too good and he cannot remember some things that are said. He said he lived with his wife and wants to go home. He said he always gets up and uses the bathroom by himself with the walker if he remembers. He said he only falls when he trips on something. During the interview, the resident was lying in bed wearing street clothes and shoes. The resident's walker was in the doorway of the bathroom approximately 5-10 feet from the resident. The resident said he left the walker in the bathroom doorway. The wheelchair was in the room next to the credenza, but not in reach of the resident. He said he did not remember falling at the facility. He said if he needed to go to the bathroom he would just get up and use the walker and go himself and would not call the staff to help him. He said they don't come in and check on him very often. On 1/17/24 at 9:36 a.m., observed yellow dot on the doorframe of the resident's room. On 1/17/24 at 9:44 a.m., CNA Staff R said the yellow dot means the resident is a frequent faller and pulled out her instruction sheet. The sheet did not indicate how many times staff needed to check the resident. On 1/17/24 at 11:58 a.m., the Director of Rehab the resident has safety awareness issues and is not aware of his limitations. He said it does not matter how many signs you place in the room; the resident will get up and walk without calling for assistance. The director said the resident is not getting therapy. On 1/17/24 12:40 p.m., Resident #207 observed walking down hallway with walker. There were no staff in the area. On 1/17/24 12:59 p.m. CNA Staff T said she knows the resident is a fall risk and she should check on him. She said there is no special time or routine for checking. On 1/17/24 1:28 p.m., Licensed Practical Nurse (LPN) Staff O said staff should be checking resident every hour, but that is not written anywhere. She said the resident uses the call bell for toileting assistance and staff cannot leave until he is finished. She said there are no special instructions for supervision. On 1/18/24 at 8:46 a.m., observed resident in his room awake in bed. The Call Don't Fall sign was on the wall near the bed. The resident said you should call them on the phone before you do something where you may fall. The resident said he does not use the call bell, almost always uses the walker for ambulation unless he forgets. He said staff do not check on him. On 1/18/24 at 8:52 a.m., observed resident up in room walking without the walker. There were no staff in the room or in the hallway near the room. On 1/18/24 at 10:08 a.m., the MDS (Minimum Data Set) Coordinator said criteria for the Falling Star Program was two falls in one month. She said the resident had two falls in one month but was removed from the Falling Star Program. On 1/18/24 at 11:59 a.m., the Director of Nursing (DON) said Resident #206 was confused and was tripping over the urinary catheter bag when he was first admitted . The Assistant Nursing Home Administrator said they have safety concerns about the resident tripping when he goes home and that is why he is still at the facility. The Transitions of Care Coordinator said Resident #206 has short term memory deficits. The DON said the Resident #206 has no safety awareness. The DON said there has been no increase in supervision for Resident #206. She said between the CNAs and nurses they should be checking the resident every hour, but there are no specific instructions for that. Based on observation, record review, review of facility's policies and procedures, residents, resident's representatives and staff interviews, the facility failed to ensure adequate supervision to ensure safety and prevent falls for 3 (Residents #42, #8 and #206) of 3 residents reviewed for falls. The findings included: The facility policy Fall Review Program (revised 7/23) documented the facility strives to identify those residents at risk for falls, to provide a system of evaluation, reevaluation, and implementation of measures to reduce the potential for falls/additional falls. All residents will be reviewed for fall risk on admission/readmission and after an actual fall, and quarterly thereafter. For residents with 2 or more falls within the past 30 days will be placed on the Falling Star Program: A white round magnet with a red star will be placed on the residents door frame. The resident must not be left alone during toileting, grooming and bathing. Resident placement on the Falling Star program will be incorporated on the resident's care plan. Review of the clinical record for Resident #42 revealed an admission date of 9/20/23. Diagnoses included Parkinson's disease, muscle weakness and difficulty walking. The admission MDS (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/3/23 showed resident #42 had a Brief Interview for Mental Status score of 12 out of 15 which indicated moderate cognitive impairment. The care plan initiated on 9/25/23 showed Resident #42 was a high risk for falls related to gait/balance problems and a history of falls. The interventions included: encourage resident to rest in recliner before dinner initiated 1/15/24. Physical therapy (PT) eval: modify wheelchair (dropped) to promote safety, initiated 1/9/24. Clear indication made on remote to identify which button reclines initiated 10/23/2023. Encourage staff to communicate with resident when they are going to provide care initiated 10/25/2023. PT to treat as ordered initiated 11/6/2023. Dycem (non-slip mat) provided for wheelchair (w/c) placement to prevent sliding and promote safety initiated 11/29/2023. Dycem provided to recliner for placement to prevent sliding and promote safety initiated 12/28/2023. Therapy to assess w/c and cushion for recommendations to ensure safety initiated 1/4/2024. Call Don't Fall signs in resident room and bathroom as reminder to use call bell initiated 9/25/2023. Anticipate and meet the resident's needs initiated 9/25/2023. Ensure that the resident is wearing appropriate footwear i.e. brown leather shoes, non-skid socks etc.) when ambulating or mobilizing in w/c. Date initiated: 9/25/23. Falling Star Program initiated 10/23/2023. Keep bed in low position initiated 9/25/2023. Keep call light within reach-instruct on its use and remind/re-educate to use call light as needed initiated 9/25/2023. Resident should not be left alone during toileting, grooming, bathing. Staff should remain in the vicinity but do not have to be within arm's reach. On 1/17/24 at 12:18 p.m., in an interview Resident #42's wife said he falls all the time that is why he is here. He has Parkinson's and poor balance and in his mind he thinks he is still independent, but he is not. He also started sliding out of the wheelchair. He likes to be in the wheelchair so he can get around on his own. I have asked for therapy to try and work with him again and see if they can help him. Fall #1. Review of the facility Incident Report showed Resident #42 had a fall on 9/22/23 at 2:00 a.m. The incident report showed the resident was observed on the floor next to the wheelchair (w/c). The resident sustained a skin tear to the left elbow. The report documented the steps taken to prevent recurrence was increased rounding. Fall #2. Review of the facility Incident Report showed Resident #42 had a fall on 10/23/23 at 9:00 a.m. The incident report showed the resident was observed on the floor next to the wheelchair. The report documented the steps taken to prevent recurrence was increased rounding. Fall #3. Review of the facility Incident Report showed Resident #42 had a fall on 10/28/23 at 10:00 a.m. The incident report showed the resident was observed sitting on the floor next to his bed and wheelchair. The report documented the steps taken to prevent recurrence, was resident education. Fall #4. Review of the facility incident report showed Resident #42 had a fall on 11/28/23 at 6:00 p.m. The incident report showed the resident was found sitting on his bottom in the bedroom. He stated he fell off his wheelchair trying to pick up his remote off the floor with a grabber. The report documented the steps taken to prevent recurrence, was resident education. Fall #5. Review of the facility incident report showed Resident #42 had a fall on 12/23/23 at 11:00 a.m. The incident report showed the resident was in the lift chair and the chair started to raise/tilt forward, and he slid out of the chair and onto the floor. The report documented the steps taken to prevent recurrence, Assist with ambulation. Fall #6. Review of the facility incident report showed Resident #42 had a fall on 12/30/23 at 1:00 p.m. The incident report documented Resident was found on the floor while talking to his daughter. Resident stated he slid off his wheelchair because the cushion was pushed back due to him moving around. No injuries, no complaints of pain. The report documented the steps taken to prevent recurrence, resident education. Fall #7. Review of the facility incident report showed Resident #42 had a fall on 1/2/24 at 9:00 a.m. The incident report documented Resident was sitting on the floor by his bed, unlocked wheelchair close by him, alert, able to explain what happened, according with him he was trying to reposition himself in wheelchair, cushion was too far forward, ended up sitting on the floor. The report documented the steps taken to prevent recurrence, resident education. Fall #8. Review of the facility Incident Report showed Resident #42 had a fall on 1/4/24 at 4:00 p.m. The incident report documented Resident had a fall. Unwitnessed fall. Resident found sitting on floor next to wheelchair, said he slid out of wheelchair onto floor. The report documented the steps taken to prevent recurrence, resident education. Fall #9. Review of the facility incident report showed Resident #42 had a fall on 1/11/24 at 5:00 p.m. The incident report documented Resident found sitting on his bottom near the wheelchair. The resident stated, I was dozing and fell out of the chair. The report documented the steps taken to prevent recurrence, assist to recliner for naps. Fall #10. Review of the facility incident report showed Resident #42 had a fall on 1/14/24 at 2:00 a.m. The incident report documented Resident found on bathroom floor. The report documented the steps taken to prevent recurrence, assist with ambulation. On 1/16/24 at 3:14 p.m., the door to Resident #42's room was closed, there was a white circle with a red star on the door frame. On 1/16/24 at 3:45 p.m., in an interview Registered Nurse (RN) Supervisor Staff H said the red star on the door frame indicated the falling star program. Staff H said the Falling Star program meant the resident was not to be left alone in the bathroom. When asked what frequent rounding meant as a fall intervention she said, we round all the time, and we look in the rooms as we walk by but there was no documentation of the rounds. The RN said there was no schedule for the frequent rounding. On 1/17/24 at 9:04 a.m., in an interview RN Staff E said the star on the door frame indicated the falling Star program. Staff E said it meant the resident was a fall risk. She said, I do round all the time, and on the night shift the residents are checked every hour. On 1/17/24 at 9:22 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said the falling star program meant a resident was a fall risk and you don't leave the resident alone in the bathroom. On 1/17/24 at 2:24 p.m., in an interview the Assistant Skilled Nursing Facility Administrator Risk Manager said, The process when a resident had a fall is we review the documentation, speak to the staff who may have seen or heard anything, and talk to the resident. We find the most applicable intervention and update the care plan, we put a new intervention in place. The Falling Star Program is used when someone has had more than 3 falls in 30 days. It means the resident is not to be left alone in the bathroom, that is the main part of the Falling Star program. When asked what else the staff are expected to do for someone on the falling star program, she said, I don't know. I will have to check on that. On 1/18/24 at 9:22 a.m., in an interview the Director of Nursing (DON), said the Falling Star program was initiated if the resident has had two or more falls within 30 days. It alerts the staff the resident is a fall risk. It alerts staff that the resident should not be left alone on the toilet or in an unsafe area alone. The staff are not to leave the resident alone when grooming, bathing, or sitting on the side of the bed. The DON said increased rounding meant the CNAs do every two-hour rounding and the nurses are encouraged to do every two hours rounds so someone is laying eyes on the resident every hour. The DON said there was no documentation of the increased rounding and no way of knowing if the increased rounding was effective or ineffective. She said on the incident report the nurse puts an intervention in place and then the Interdisciplinary Team goes over it and we see if the intervention is effective for the resident or needs to be changed. The DON said Resident #42 had not come to the realization that he needs help. It is very hard for him to come to us and ask for help. She said I would encourage him to watch TV in the day room, but he refuses. I spoke with his wife a week or so ago about having a companion to sit with him, but she won't pay for it. The DON said the resident's wife has a schedule for her visits and she can't come and sit with him more frequently. She said We just asked his wife to remind him over and over not to get up without using the call light. Our next intervention would have to be a 1-1 sitter at specific times. The DON agreed the current interventions were not effective in preventing falls for Resident #42.

Based on observation, record review, resident and staff interview the facility failed to complete an assessment to determine the ability to self-administer medications for 1 (Resident #28) of 1 resident observed with unsecured medication at the bedside. The facility also failed to promote the resident's right and assess the resident's ability to self-administer medications for 1 (Resident #28) of 1 resident who requested to self-administer medications. The findings included: Review of the policy and procedure titled Self-Administration of Medication issued 11/1/01, last revised 6/2018 showed: Policy It is the policy of Cypress Cove to provide guidelines allowing residents to self-administer drugs safely and correctly when they request unless such practice is deemed unsafe. Residents may self-administer physician ordered bedside drugs after the interdisciplinary team has determined that this practice is safe. Guidelines: 1. If the resident requests to self-administer drugs, the nurse will notify the Director of Nursing or designee. The Director of Nursing or designee will complete the 'Self-Medication' form, and explain to the resident that the form will be reviewed by members of the interdisciplinary team. On 9/8/20 at 9:37 a.m., an unsecured bottle of Nitroglycerin tablets (medication used to treat episodes of chest pain) was observed on Resident #28's dresser. He said the cardiologist prescribed the medication and told him to carry it at all times in case he experienced chest pain. Resident #28 said the nurses at the facility managed his medications and they were aware he carried the nitroglycerin. Resident #28 said no one gave him a locked box to safeguard the medication. On 9/8/20 at 9:40 a.m., during an interview Licensed Practical Nurse Staff D verified the observation and said Resident #28 did not have an evaluation for self-administration of medications. She said the Nitroglycerin was not included in the physician's orders. On 9/10/20 at 10:55 a.m., during an interview Resident #28 said he'd been carrying his Nitroglycerin for the past 10 years but the nurse suddenly took it away from him and said it was against the rules to have it with him. He said the nurse told him to ask for the medication when he wanted it. Resident #28 said It doesn't make sense. Whatever happened to common sense? I leave the facility to go get chemotherapy for pancreatic cancer. If I have chest pain and I need a nitro when I am away from the facility I would have to call here and wait for the nurse to bring it to me. Resident #28 also said he was supposed to receive Creon before each meal and had to ask for it. He said he'd asked the nurse several times to let him carry the Creon so he can take it when he was away from the facility, but they had refused. Creon was a prescription medicine used to treat people who could not digest food normally because their pancreas did not make enough enzymes. Resident #28 said if he knew they would take his medications and not allow him to carry them, he would have hidden them. Resident #28 said when he went to the treatment center, he was away from the facility for 4 to 5 hours and ate at the treatment center, but he did not get the Creon. Review of the Medication Administration Record (MAR) for 8/2020 revealed 4 entries (8/5/20; 8/12/20; 8/26/20 and 8/28/20) at 11:00 a.m., where the nurse indicated Resident #28 was absent from the facility without medications. Review of the MAR for 9/2020 revealed on 9/2/20 and 9/9/20 at 11:00 a.m., the nurse documented the resident was absent from the facility without medications. On 9/10/20 at 11:30 a.m., during an interview the Director of Nursing said she was not aware the resident wanted to self-administer his medications. She said when he left the facility and he's going to be gone for a long time the facility sent a lunch with him. She verified the resident did not receive the Creon as ordered when he left the facility to go to the treatment center. On 9/10/20 at 12:20 p.m., during an interview the Dietary Manager said when Resident #28 left the facility for his treatments they generally sent a sandwich with him. On 9/10/20 at 1:15 p.m., the Director of Nursing said the facility did not have a plan in place to ensure Resident #28 received the necessary Creon as ordered with his lunch meal when he was away from the facility at lunch time for his chemotherapy. She said the facility did not notify the physician that Resident #28 had not been receiving the medication as ordered.

Based on record review and resident and staff interview the consultant pharmacist failed to make recommendation for medication omission during the monthly drug regimen review for 1 (Resident #28) of 6 residents reviewed for unnecessary medications. The findings included: The facility's policy and procedure for Quality Reporting: Drug Regimen Review issued on 9/25/18 showed The pharmacy consultant will review the medical record for documentation that supports that a drug regimen review was conducted, and that any clinically significant medication issues identified were addressed in a timely manner. On 9/10/20 at 10:55 a.m., during an interview Resident #28 said he was supposed to receive Creon before each meal and had to ask for it. Creon was a prescription medicine used to treat people who could not digest food normally because their pancreas did not make enough enzymes. He said he'd asked the nurse several times to let him carry the Creon so he can take it when he was away from the facility, but they had refused. Resident #28 said when he went to the treatment center for chemotherapy, he was away from the facility for 4 to 5 hours. He ate at the treatment center but, he did not get the Creon. Review of the Medication Administration Record (MAR) for 8/2020 revealed 4 entries (8/5/20; 8/12/20; 8/26/20 and 8/28/20) at 11:00 a.m., where the nurse indicated Resident #28 was absent from the facility without medications. Review of the MAR for 9/2020 revealed on 9/2/20 and 9/9/20 at 11:00 a.m., the nurse documented the resident was absent from the facility without medications. On 9/10/20 at 11:30 a.m., during an interview the Director of Nursing said she was not aware the resident wanted to self-administer his medications. She said when he left the facility and he's going to be gone for a long time the facility sent a lunch with him. She stated, I've seen it myself. She verified on the MAR the resident did not receive the Creon as ordered when he left the facility to go to the treatment center. On 9/10/20 at 12:20 p.m., during an interview with the Dietary Manager she said when Resident #28 left the facility for his treatments they gave him a lunch to take with him. she said generally it's a sandwich. On 9/10/20 at 1:15 p.m., the Director of Nursing said the facility did not have a plan in place to ensure Resident #28 received the necessary Creon as ordered with his lunch meal when he was away from the facility at lunch time for his chemotherapy. She said the facility did not notify the physician Resident #28 had not been receiving the medication as ordered. Review of the Consultant Pharmacist's Medication Regimen Review for 8/2020 revealed no recommendation for Resident #28. On 9/10/20 at 1:30 p.m., during an interview the Consultant Pharmacist said if she had noticed they were not giving the medication when he went to the cancer center, then she would have made the recommendation for him to receive it. On 9/10/20 at 2:10 p.m., during a second telephone interview the Consultant Pharmacist said she reviewed Resident #28's MARs but did not notice the omissions. She said if she had she would have certainly said something to the facility. The Consultant Pharmacist said she reviewed the clinical record and did not see documentation that Resident #28 suffered from any gastrointestinal symptoms. She also reviewed the medication insert and it says they cannot double the next dose to make up for the missed dose of medication. She repeated she did not notice the missed doses of Creon but would have made a recommendation if she had seen it. Although, she did say she did not think the few omissions were significant.

Based on observation, interview, and review of the facility's medication storage policy the facility failed to appropriately manage expired drugs and biologicals for 2 of 2 med cart reviews. The findings included: Policies and procedures-Pharmacy Services for Nursing Facilities 2006 American Society of Consultant Pharmacists and MED-PASS, INC. (Revised January 2018) When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating. 2. The nurse will check the expiration date of each medication before administering it. 3. No expired medication will be administered to a resident. 4. All expired medications will be removed from active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. 1. On 9/9/20 at 10:47 a.m., a side by side review of the medication cart in the [NAME] Unit was conducted with Registered Nurse Staff B on the [NAME] Unit. There was an opened bottle of Pro-Stat Liquid Protein- Nutrition Management (Concentrated protein for wound care) opened on 9/8/20, with an expiration date of 6/26/20. 2. On 9/9/20 at 1:25 p.m., a side by side review of cart in [NAME] Unit was conducted with Licensed Practical Nurse Staff C on the [NAME] Unit. There was an opened bottle of Geri-Tussin DM (a cough suppressant expectorant), with an expiration date of 4/20. On 9/10/20 at 10:53 a.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing who confirmed the findings.