Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNOC) document and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) document prior to the end of service date for 1 of 3 residents reviewed for beneficiary notification. (Resident 44) Findings include: The NOMNOC and SNF ABN documents for Resident 44 were reviewed on 2/4/25 at 8:50 a.m. a. The NOMNOC document indicated Resident 44's Medicare Part A coverage of services would end on 8/22/24 and Medicare would not pay for the current Medicare skilled services after the date of 8/22/24. The document indicated Resident 44 had the right to request an appeal. The appeal would need to be requested no later than noon of the day before the effective end of service date of 8/22/24. Resident 44 was provided with the NOMNOC document on 9/9/24, 13 days after the end of service date. b. The SNF ABN document indicated Resident 44's Medicare Part A Skilled coverage of services would end on 8/21/24 and beginning on 8/23/24, the services of Physical Therapy and Occupational Therapy would be out of pocket cost. Resident 44 was provided with the SNF ABN document on 9/9/24, 15 days after the end of service date. During an interview, on 2/3/25 at 9:09 a.m., the Social Service Director indicated therapy staff were out of town when Resident 44's beneficiary notices were due. The documents should have been provided to the resident 48 hours prior to the end of service date to give the resident time to appeal the decision. A current facility policy, titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated as last revised September 2022 and received from the Director of Nursing on 2/4/25 at 11:00 a.m., indicated .Residents are informed in advance when changes will occur to their bill .The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events .Termination-In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated .If the resident's Medicare covered Part A stay or when all of the Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end 3.1-4(f)(1)(A) 3.1-4(f)(1)(B) 3.1-4(f)(2)

Based on observation, interview and record review, the facility failed to ensure privacy was provided during a medication administration for 1 of 1 resident reviewed for privacy. (Resident 19) Findings include: During an observation, on 1/30/25 at 10:41 a.m., Resident 19 was sitting in a wheelchair on her side of a shared room. QMA 5 was observed to administer eye drops to Resident 19. The privacy curtain had not been pulled to obscure the view of a visitor on the other side of the shared room. The visitor had an unobstructed view of the care being provided to Resident 19. At that time, QMA 5 indicated the privacy curtain should have been closed when providing all care. During an interview, on 2/4/25 at 3:19 p.m., the Director of Nursing indicated the facility followed the state and federal regulations. A current facility policy, titled Resident Rights, dated as revised in February 2021 and received from the Director of Nursing on 1/31/25 at 8:55 a.m., indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to .privacy and confidentiality 3.1-3(p)(2) 3.1-3(p)(4)

Based on interview and record review, the facility failed to ensure care plan meetings were scheduled with the resident and/or resident's representative for 2 of 8 residents reviewed for care plan meetings. (Resident 36 and 37) Findings include: 1. During an interview, on 1/30/25 at 10:33 a.m., a family member for Resident 36 indicated they had not attended a care plan meeting for a year. The clinical record for Resident 36 was reviewed on 2/3/25 at 9:11 a.m. The diagnoses included, but were not limited to, severe dementia with mood disturbance, major depressive disorder, and mood disorder. The last documented care plan meetings were held on 3/14/24 and 6/28/24. 2. During an interview, on 1/30/25 at 10:29 a.m., a family member for Resident 37 indicated they had not had a care plan meeting in a year. The clinical record for Resident 37 was reviewed on 2/3/25 at 9:15 a.m. The diagnoses included, but were not limited to, age-related physical debility, constipation, and pain. The last documented care plan meeting was held on 5/6/24. During an interview, on 2/3/25 at 9:12 a.m., the Social Services Worker indicated care plan conferences were to be completed quarterly and a note was to be put into the medical record. During an interview, on 2/3/25 at 12:02 p.m., the Social Services Worker indicated she did not have any care plan notes for the missed care plan meetings. She did talk with the families and if they told her everything was o.k. or if they did not want a care plan meeting then she did not schedule a meeting. She was aware that a care plan meeting needed to be done, and the invite to the meeting needed to be sent to the responsible party/Power of Attorney and the resident. If they did not want to attend, she was to document the information. During an interview, on 2/4/25 at 3:19 p.m., the Director of Nursing indicated the facility followed the state and federal regulations. A current facility policy, titled Care Planning, dated as revised in March 2022 and received from the Executive Director on 2/3/25 at 1:34 p.m., indicated .The interdisciplinary team is responsible for the development of the resident care plans 3.1-35(a) 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure the physician was notified when blood sugars were out of the physician ordered parameters for 1 of 1 resident reviewed for quality of care. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 2/3/25 at 1:32 p.m. The diagnoses included, but were not limited to, type 2 diabetes, edema, and chronic kidney disease. A physician's order, dated 7/8/24, indicated to obtain Accu Checks (blood sugar checks) 4 times a day and to call the physician when the blood sugars were less than 70 or greater than 400. A review of Resident 34's blood sugars indicated the following results: On 12/18/24, the resident's blood sugar was 69. On 12/28/24, the resident's blood sugar was 65. On 12/28/24, the resident's blood sugar was 425. On 1/5/25, the resident's blood sugar was 51. There was no documentation the physician was notified of the blood sugars which were out of the physician ordered parameters found in the resident's record. During an interview, on 2/4/25 at 3:18 p.m., the Director of Nursing (DON) indicated she could not find any notification for the blood sugars and the nurse should have notified the physician. During an interview, on 2/5/25 at 11:09 a.m., the DON indicated she could not find any notifications for the blood sugars in the record. A current facility policy, titled Charting and Documentation, dated as revised in 2017 and received from the DON on 2/4/25 at 3:17 p.m., indicated .Documentation of procedures and treatments will include care-specific details, including .notification of family, physician or other staff, if indicated 3.1-37(a)

Based on interview and record review, the facility failed to ensure staff obtained a resident's weight weekly to monitor for weight loss according to the physician's order and to correctly document the weights in the medical record for 1 of 3 residents reviewed for nutrition. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 2/4/25 at 1:29 p.m. The diagnoses included, but were not limited to, Barrette's esophagus, anorexia, and nutritional deficiency. A nutritional note, dated 9/12/24, indicated the Registered Dietitian (RD) recommended to begin weekly weights for closer weight loss monitoring. A progress note, dated 9/12/24, indicated a new order had been placed for weekly weights. A physician's order indicated Resident 8 was to be weighed weekly in the morning, every Monday, for weight loss starting 9/16/24. A nutritional note, dated 11/7/24, indicated the RD would continue weekly weights for closer monitoring and would follow up with Resident 8's intakes, weekly weights, and labs as available. The resident's medical record was missing documentation for the weekly weights in the months of September, November, January, and February. A review of a weight summary indicated that the facility did not obtain weekly weights in the months of September, November, December, January, and February. During an interview, on 2/4/25 at 2:21 p.m., Licensed Practical Nurse 4 indicated when a resident had an order for weekly weights, the weights were documented on a form kept at the nurse's station and given to the unit manager when completed. During an interview, on 2/4/25 at 2:24 p.m., the Assistant Director of Nursing (ADON) indicated the weekly weight order should have been discontinued because Resident 8 was no longer followed by the RD. During an interview, on 2/4/25 at 3:18 p.m., the Director of Nursing (DON) indicated the resident was no longer being followed by the RD and the weekly weights should have been discontinued in October. She indicated the RD reviewed the note from 11/7/24 and acknowledged she documented to continue the weekly weights but given the stable weights the RD should have discontinued the order for the weekly weights. The order remained active, and the weights should have continued to be obtained according to the order. During an interview, on 2/4/25 at 3:39 p.m., the RD indicated the order for weekly weights should have been discontinued. The RD did not remove orders from the clinical record and noticed the order was still active when she visited Resident 8 in November. The RD documented to continue the weekly weights because the order was still active, and she thought the facility was still monitoring Resident 8's weights. A current facility policy, titled Nutrition Risk and Weight Loss Management, dated as last reviewed/revised February 2024 and received from the DON on 2/5/25 at 8:20 a.m., indicated .Nursing assistant or designated personnel will weigh residents per policy .Residents are weighed at least monthly unless there is a physician's order otherwise. The IDT or RD can request weights be completed weekly for monitoring as a nursing measure A current facility policy, titled Charting and Documentation, dated as revised 2017 and received from the DON on 2/4/25 at 3:17 p.m., indicated .Documentation in the medical record will be objective .complete, and accurate 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure a physician's order was clear and accurate related to the correct oxygen liter flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 10) Findings include: During an observation, on 1/31/25 at 9:58 a.m., Resident 10's oxygen flow rate was on 2-liters. The clinical record for Resident 10 was reviewed on 2/3/25 at 1:30 p.m. The diagnoses included, but were not limited to, chronic obstructed pulmonary disease (COPD), chronic respiratory failure, and essential hypertension. A physician's order, dated 1/8/25, indicated the oxygen flow rate was to be at 4 liters per minute via nasal cannula. The order summary indicated the oxygen flow rate was to be at 2 liters per minute via nasal cannula. The order had 2 different oxygen liter flow rates. During an interview, on 2/3/25 at 1:48 p.m., Licensed Practical Nurse (LPN) 3 indicated the oxygen order was not a titration order. She thought the resident was to be on 4 liters but did not see the 2 liters listed in the order summary. She would have to clarify the order because she was not sure. During an interview, on 2/3/25 at 1:55 p.m., the Director of Nursing (DON) indicated she was not sure what the oxygen flow rate was supposed to be, and she would have to check. During an interview, on 2/3/25 at 2:11 p.m., the DON indicated Resident 10 was supposed to be on 4 liters of oxygen. A facility policy, titled Oxygen Administration, dated as revised in October 2010 and received from the DON on 2/4/25 at 3:20 p.m., indicated .Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate per physician order 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure a two (2) handle cup was available for a resident's coffee for 1 of 1 resident reviewed for adaptive equipment. (Resident 1) Findings include: During an observation of the morning meal, on 2/3/25 at 8:35 a.m., Resident 1 was observed in the dining room. She had two handle cups for her milk, juice and water with lids, but an insulated cup with only one handle for coffee. During an interview, on 2/3/25 at 8:25 a.m., the Dietary Manager (DM) indicated she was aware the resident needed two (2) handle cups for her drinks, but she did not think about the coffee and the facility did not have a two-handle insulated cup. The therapy department indicated the resident needed two handle cups to hold the cup better. She would need to talk with management because the facility would need to order the cup. During an observation, on 2/5/25 at 8:33 a.m., Resident 1 was in the dining room eating her meal without assistance. She was noted to have milk, juice and water in two handle cups, but no coffee. During an interview, on 2/5/25 at 8:33 a.m., the Dietary Manager indicated Resident 1 did not have coffee because the facility did not have insulated cups with two handles and coffee could not be put in the regular two handle cups because the heat from the coffee could be felt through the cups. The clinical record for Resident 1 was reviewed on 2/5/25 at 8:53 a.m. The diagnoses included, but were not limited to, weakness, heart failure, and a need for assistance with personal care. A care plan, initiated on 12/5/24 and dated as last revised on 2/3/25, indicated the resident was at a nutritional risk and she was to use adaptive equipment to assist with feeding herself. A facility document, titled Occupational Therapy Treatment Encounter Note(s), with a date of service of 1/2/25 indicated an order was written for two handle mugs with lids to increase the resident's independence, oral intake, and to decrease spillage. A physician's order, initiated on 1/31/25, indicated 2 handle mugs with all meals. During an interview, on 2/4/25 at 1:06 p.m., the Therapy Manager indicated the resident was using two handle cups to promote independence with activities of daily living (basic self-care tasks performed daily such as eating). The resident was currently using two handle cups with no lids when she was discharged from therapy. A current facility policy, titled Activities of Daily Living (ADLs), Supporting, dated as revised in March 2018 and received from the Director of Nursing on 2/4/25 at 3:19 p.m., indicated .Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish 3.1-21(h)

Based on interview and record review, the facility failed to ensure documentation was complete and accurately reflected the care provided for 2 of 2 residents reviewed for accurate documentation. (Resident 46 and 1) Findings include: 1. The clinical record for Resident 46 was reviewed on 2/5/25 at 10:19 a.m. The diagnoses included, but were not limited to, insomnia, chronic kidney disease, and fever. A physician's order, initiated on 1/3/25, indicated to give Dayvigo (a medication used to treat insomnia) 10 milligrams at bedtime for insomnia. Documentation of the administration of the medication was not charted on 1/10/25 and 1/25/25. A physician's order, initiated on 1/3/25, indicated to monitor the resident's vital signs twice a day. Documentation of the treatment was not charted on the Medication and Treatment record for 1/31/25 for the second shift. 2. The clinical record for Resident 1 was reviewed on 2/5/25 at 8:53 a.m. The diagnoses included, but were not limited to, weakness, heart failure, and a need for assistance with personal care. A physician's order, initiated on 11/29/24, indicated to monitor for signs and symptoms of side effects from psychoactive drugs every shift and to notify the physician if side effects were present. There was no documentation for the monitoring found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. A physician's order, initiated on 11/29/24, indicated to monitor for signs and symptoms of anti-coagulant medications (used to thin the blood) every shift. There was no documentation for the monitoring found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. A physician's order, initiated on 11/29/24, indicated to assess the resident for pain every shift. There was no documentation for the assessment found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. A physician's order indicated the resident was to be weight bearing (standing/walking) as tolerated on her bilateral lower extremities every shift. There was no documentation for the monitoring found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. During an interview, on 2/5/25 at 9:19 a.m., the Assistant Director of Nursing indicated the facility determined a need to implement checking the documentation in the Medication and Treatment records due to missing documentation. A current facility policy, titled Charting and Documentation, dated as last revised in July of 2017 and received from the Director of Nursing on 2/4/25 at 3:17 p.m., indicated .The following information is to be documented in the resident medical record .Medications administered .Treatments or services preformed 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure the bed hold policy was provided to the resident and/or responsible party at the time of the hospital transfer for 1 of 1 resident reviewed for hospitalization. (Resident 54) Finding includes: The record for Resident 54 was reviewed on 1/18/24 at 2:34 p.m. Diagnoses included, but were not limited to, acute respiratory failure, congestive heart failure (CHF), atrial fibrillation, atherosclerotic heart disease of native coronary artery (a narrowing of the artery), hypertensive heart, and chronic kidney disease. A nursing progress note dated 11/16/23 at 10:41 a.m., Licensed Practical Nurse (LPN) 2 indicated the resident had an oxygen saturation of 65 to 78 percent on 4 liters of oxygen. The resident was tired with rapid breathing, shaking, and back pain. The Nurse Practitioner was called, and an order was received to send the resident to the hospital for evaluation. The resident's daughter who was also the resident's power of attorney was called and updated on the resident's condition and the order to transfer the resident to the hospital. There was no bed hold policy or transfer documentation in the record. During an interview, on 1/18/23 at 3:30 p.m., the ADON (Assistant Director of Nursing) indicated she was unable to find any documentation the bed hold policy was provided to the resident or resident representative when the resident was hospitalized . She indicated when a resident transferred to the hospital a bed hold policy and resident information should be given to the resident/resident representative. A current policy, titled Transfer or Discharge, Facility-Initiated, dated 10/2022 and received from the ADON on 1/18/24 at 5:25 p.m., indicated .residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, the resident's return is generally expected .notice of transfer is provided to the resident/representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements) .notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer .notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments .nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge 3.1-12(a)(25)(A) 3.1-12(a)(25)(B) 3.1-12(a)(26)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with compression gloves had a physician's order, a care plan and staff were educated on the use of the compression gloves for 1 of 2 residents reviewed for edema (Resident B), and failed to ensure an unlicensed staff member did not move a resident before reporting an incident and having the resident assessed for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: 1. During an observation, on 1/11/24 at 12:09 p.m., the Resident B was noted to have edema in his hands with compression gloves on both hands. During an observation, on 1/16/24 at 2:29 p.m., the resident did not have compression gloves on his hands. His bilateral hands are edematous. The clinical record for Resident B was reviewed on 1/16/24 at 11:23 a.m. The diagnoses included, but were not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with neuropathy, and idiopathic peripheral autonomic neuropathy. There was no physician's order for the compression gloves. A therapy progress note, dated 12/26/23, indicated the DON (Director of Nursing) and the NP (Nurse Practitioner) requested bilateral compression gloves for increased swelling in the resident's hands. The Occupational Therapy Assistant applied bilateral compression gloves with ¾ finger length to allow for monitoring of the fingertips. The resident was educated on the purpose of the compression gloves. There was no documentation the staff was educated on the use of the compression gloves. A review of the Medication Administration and Treatment Records, for 12/2023 through 1/17/24, indicated the compression gloves were not documented in the records. There was no care plan for the use of compression gloves. During an interview, on 1/18/24 at 1:24 p.m., the ADON (Assistant Director of Nursing) indicated the resident had the compression gloves for edema in his hands. The compression gloves were not documented on the medication or treatment records. She was not aware of how the information for donning and doffing the compression gloves were shared with staff.2. A facility reportable incident report, dated 6/24/23 at 11:01 p.m., indicated Resident C experienced a fall while showering in her restroom (assisted). Following the fall/shower, the resident was noted with increased pain/swelling to left knee and complaint of neck pain during the nursing assessment. The resident was transported to the hospital for further evaluation and treatment. A written statement of events, untitled, dated 6/24/23 and not timed, by Certified Nurse Aide (CNA) 4 indicated CNA 4 was giving Resident C a shower between 7:00 to 7:30 p.m. The resident was placed on the shower chair. The CNA turned around and took the soap off the paper towel dispenser. When the CNA turned around, the resident was slipping out of the shower chair. The CNA tried to rush to her and ended up slipping causing the chair to come off its legs and tilt backwards. The resident hit her head. CNA 4 placed her hand on the back of the resident's neck and the other under her thigh. The CNA positioned the resident back on the shower chair and noticed the resident had blood on the top of her head. CNA 4 continued to give the resident a shower and rinsed the blood from the resident's head. She then transferred the resident into her wheelchair and pushed the resident to the side of her bed. The CNA bumped the resident's knee on the bathroom door frame. CNA 4 dressed the resident and transferred the resident into her bed. The resident was complaining of pain. The statement did not indicate the CNA notified the nurse before moving the resident or continuing the shower. A written statement of events, untitled, undated, and not timed, by LPN 5, indicated LPN 5 went into the pantry to get applesauce and found CNA 4 putting ice in a small trash bag. The CNA explained it was for Resident C and the CNA thought she bumped the resident's leg on the doorway. LPN 5 went into the resident's room and asked the resident what happened. The resident indicated she fell. The nurse asked the CNA if she fell, and the CNA stated she did not fall. When LPN 5 was completing her assessment, she noticed a small bag of ice on the resident's neck and the resident's forehead was bleeding with a small hematoma. The statement did not indicate how long after the shower the nurse was told the resident needed to be assessed. The clinical record for Resident C was reviewed on 1/16/24 at 10:06 a.m. The diagnoses included, but were not limited to, dementia, depression, and osteogenesis imperfecta (inherited disorder characterized by fragile bones). An admission Minimum Data Set (MDS) assessment, dated 3/23/23, indicated the resident was rarely/never understood. Her cognitive skills for decision making were severely impaired. She was dependent on staff for showering, bathing, and transfers. A care plan, initiated on 3/15/23, indicated the resident was at risk for falls. The interventions included, but were not limited to, alert the provider if a fall occurred, and initiate frequent neuro checks and bleeding evaluation per the facility protocol. A nursing progress note, dated 6/24/23 at 10:00 p.m., documented as a late entry, indicated the nurse was informed by CNA 4 she bumped the resident's knee on the bathroom door after completing a shower when exiting the bathroom. The CNA indicated Resident C needed ice. LPN 5 asked the resident if she was okay, and the resident stated she fell. LPN 5 noted the resident had pain to the left knee, a small skin tear to the right upper arm with a small amount of bleeding, and the left hand was discolored. The nurse did a head-to-toe assessment and noted the resident had a hematoma with a small laceration on the forehead. The progress notes did not indicate the time the head-to-toe assessment was completed. A hospital report, dated 6/25/23 at 12:27 a.m., indicated the resident arrived at the emergency department by the Emergency Medical Services (EMS), the resident sustained a fall at the nursing home, the resident's history was unclear, and the resident did not normally ambulate independently. A facility post event Interdisciplinary Team (IDT) note, dated 6/28/23 at 11:36 p.m., indicated the type of event was an intercepted fall. CNA 4 was assisting the resident with a shower. CNA 4 turned to the sink to grab soap and the resident started to slip out of the shower chair. CNA 4 was assisting the resident back in the shower chair and the chair tipped backwards. The CNA grabbed the resident around the back and neck area to prevent the resident from falling hard on the floor. The resident was assisted upright in the shower chair and the shower was completed. The CNA assisted the resident into her wheelchair. While exiting the bathroom, the CNA hit the resident's knee on the door frame. The resident was assisted into bed and complained of knee pain. A head-to-toe assessment found a hematoma, skin tear, and pain to the knee. The post fall note did not include how the time difference between the intercepted fall and the nursing head-to-toe assessment. There were no progress notes found in the resident's record to indicate the time the resident was sent out to the emergency department. A Certified Nursing Assistant (CNA) job description signed on 6/1/23 by CNA 4, indicated the essential job duties included, but were not limited to, assisting with resident with room moves, transfers, reports changes in condition or new concerns to the nurses, and other duties assigned by the nurse within the CNA scope of practice. A General Orientation Verification form, signed by CNA 4 on 6/6/23, indicated accidents were to be reported immediately to the supervisor. During an interview, on 1/17/24 at 9:18 a.m., the Director of Nursing (DON) indicated, on 6/24/23 at 10:00 p.m., the nurse on duty contacted her and indicated the CNA gave Resident C a shower. When CNA 4 was assisting the resident to her bed, CNA 4 bumped the resident's knee on the door frame. The DON asked the nurse if she had concerns with the resident and the nurse stated the resident was in bed. The nurse went to assess the resident and noticed something on her hand and on her head. The DON asked the nurse if the resident was in pain and talked to CNA 4 asking if the resident fell. CNA 4 indicated the resident did not fall. The CNA was giving the resident a shower and the resident was sitting on the shower chair. CNA 4 turned to get the soap. When CNA 4 turned around, the resident was slipping out of the chair. The CNA hurried over to help the resident and repositioned her back into the shower chair. CNA 4 then took the resident out of the bathroom and bumped her knee on the door. The DON asked the nurse to do a head-to-toe assessment and the nurse found a small laceration on top of her head and a small skin tear on the resident's right hand. The left knee had some swelling, and the resident was complaining of neck pain. The DON told the nurse to notify the physician and send the resident to the hospital. The DON called the daughter multiple times until she was able to talk to her and explained to the daughter, she was going to further investigate the incident. The resident was at the hospital from [DATE] to 7/7/23. During an interview, on 1/17/24 at 11:28 a.m., the DON indicated what was reported to her was the resident did not fall. During an interview, on 1/17/24 at 11:59 a.m., LPN 5 indicated around 8:30 p.m., she was getting pudding out of the pantry and saw CNA 4 putting ice in a plastic trash bag for Resident C. CNA 4 had bumped the resident's knee on the door coming out of the bathroom. LPN 5 and CNA 4 went to the resident's room and found the resident asleep in the bed. The nurse pulled down the blanket, did not see anything, and left the room to give medications. LPN 5 returned to the room around 9:00 p.m. She did a head-to-toe assessment and asked the resident what happened. Resident C indicated she fell and was in pain. LPN 5 called the DON who instructed her to call the physician and send the resident to the hospital. During an interview, on 1/20/24 at 2:50 p.m., a family member of Resident C indicated there was confusion on what had happened to the resident. The facility contacted the family member, on 6/24/23 at 10:58 p.m., by voice mail. The facility was sending the resident out to the hospital due to complaints of neck pain. At first, the family member was told by the facility staff a CNA was giving the resident a shower and, on the way, out of the bathroom bumped the resident's knee on the door frame. The resident at the time of the transfer should have been assisted by more than one staff member. When the resident was assessed in the emergency room, the resident was found to have a contusion on the front of her head and one on the back of the head, a C1 fracture, a left distal femur fracture, and a potential right femoral neck fracture. The resident had not been the same cognitively since the fall. A current policy, titled Using a Mechanical Lifting Machine, received from the ADON on 1/18/24 at 11:23 a.m., indicated .the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift .at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift A current policy, titled Fall Prevention and Management, dated as revised 6/2021 and received from the Clinical Support Nurse on 1/16/24 at 11:47 p.m., indicated .An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person .An evaluation of all the causal factors leading to a resident fall should be completed .Head to toe evaluation by a licensed nurse is completed before the resident is moved . Documentation will include report/event report completion, the nurse's notes, and a fall investigation This Federal tag relates to Complaint IN00416352. 3.1-37(a)

Based on interview and record review, the facility failed to notify the physician of a significant weight change and a 5 pound or more weight gain per the physician's orders for 2 of 3 residents reviewed for nutrition. (Resident D and 26) Findings include: 1. The record for Resident D was reviewed on 1/16/24 at 2:29 p.m. Diagnoses included, but were not limited to, muscle weakness, pain, anxiety disorder, and depression. A care plan indicated the resident was at nutrition risk. The interventions included, but were not limited to, monitor weights as ordered. The resident had the following weights: 1. On 10/22/23, the resident's weight was 109.0 pounds. 2. On 1/8/24, the resident's weight was 95.0 pounds. The resident had a 12.84% weight loss in 3 months. There was no documentation of the physician being notified of the significant weight loss. A nursing progress note, dated as a late entry on 1/16/24 at 1:00 p.m., indicated the Assistant Director of Nursing (ADON) discussed the resident's weight loss and no new orders were received. During an interview, on 1/16/24 at 4:35 p.m., the ADON indicated she notified the Nurse Practitioner (NP) and the Registered Dietician (RD) of the weight change. When residents have a significant weight loss, the resident needed to be re-weighed and the physician notified. The ADON indicated she spoke with the NP, on 1/9/24, and did not chart the conversation until 1/16/24 at 1:00 p.m. 2. The record for Resident 26 was reviewed on 1/17/24 at 10:25 a.m. Diagnoses included, but were not limited to, unspecified CHF (congestive heart failure), unspecified dementia, and hypertension. A current order, with a start date of 11/28/23, indicated to weigh the resident every day at the same time of day with the same scale. Notify the physician of a 3-pound weight gain in 24 hours or a 5-pound weight gain in 1 week. A weight log indicated the following: 1. On 11/29/23, the resident's weight was 140.3 pounds. 2. On 12/1/23, the resident's weight was 145.0 pounds. 3. On 12/1/23, the resident's weight was 146.8 pounds. There was a greater than 5-pound weight gain in less than 1 week from 11/29/23 to 12/1/23 and no notification to the provider was found in the resident's electronic chart. During an interview, on 1/17/24 at 3:35 p.m., the DON (Director of Nursing) indicated the provider signed the CHF log when they came in and when they notified the provider. During an interview, on 1/18/24 at 9:52 a.m., the ADON (Assistant Director of Nursing) indicated she could not find the CHF log for the time period the weight gain occurred. A current policy, titled Weight Assessment and Intervention, dated as revised 3/2022 and received from the DON on 1/17/24 at 3:41 p.m., indicated .Weights are recorded in each unit's weight record chart and in the individual's medical record. Any significant weight change since last weight assessment is retaken for confirmation. If the weight is verified, nursing will notify the dietitian. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe A current policy, titled Heart Failure-Clinical Protocol, dated as revised 11/2018 and received from the DON on 1/18/24 at 4:00 p.m., indicated .Daily weight monitoring may be ordered for residents with heart failure. Notification of significant weight changes to be followed per physician's order. 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated and a physician's order for oxygen was obtained for 4 of 5 residents reviewed for respiratory care. (Residents 6, 41, 206 and 10). Findings include: 1. During an observation, on 1/11/24 at 1:53 p.m., the oxygen tubing and humidifier bottle for Resident 6 was not dated. The record for Resident 6 was reviewed on 1/16/24 at 10:23 a.m. Diagnoses included, but were not limited to, shortness of breath, history of acute respiratory failure with hypoxia, and unspecified congestive heart failure. A current order, with a start date of 11/2/23, indicated to change and date oxygen tubing and humidifier bottle in the evenings every Wednesday. During an interview, on 1/11/24 at 2:46 p.m., the Clinical Support Nurse indicated the oxygen tubing was not dated. 2. During an observation, on 1/11/24 at 2:38 p.m., Resident 41 was wearing oxygen, and the oxygen tubing was not dated. The record for Resident 41 was reviewed on 1/16/24 at 9:22 a.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and anxiety disorder. There was no physician's order for the resident to wear oxygen or to change the oxygen tubing. During an interview, on 1/16/24 at 11:38 a.m., the DON (Director of Nursing) indicated there was not an order for the resident to wear oxygen. 3. During an observation, on 1/16/24 at 12:35 p.m., the oxygen tubing for Resident 206 was not dated. The record for Resident 206 was reviewed on 1/16/24 at 2:23 p.m. Diagnoses included, but were not limited to, sepsis, type 2 diabetes, and history of trans ischemic attack (TIA). A current order, with a start date of 1/9/24, indicated the resident wore oxygen at 2 liters per minute continuously. A current order, with a start date of 1/9/24, indicated to change the oxygen tubing weekly every Wednesday night. During an interview, on 1/11/24 at 2:48 p.m., the Clinical Support Nurse indicated the resident's oxygen tubing was not dated. 4. During an observation, on 1/11/24 at 2:38 p.m., Resident 10 was not wearing oxygen and the oxygen tubing and humidifier bottle was not dated. The record for Resident 10 was reviewed on 1/12/24 at 9:22 a.m. Diagnoses included, but were not limited to congestive heart failure, atrial fibrillation, and obstructive sleep apnea. A physician's order, dated 10/3/23, indicated oxygen at 2 liters per nasal cannula during the day as tolerated. A physician's order, dated 11/2/23, indicated to change the oxygen tubing twice a week. During an interview, on 1/11/24 at 1:32 p.m., LPN 2 indicated she did not know why the resident was not wearing his oxygen and the oxygen tubing was not dated. The oxygen tubing was changed by the night shift nurse and should be dated and initialed. A current policy, titled Oxygen Administration, dated as revised 10/2010 and received from the Clinical Support Nurse on 1/11/24 at 3:38 p.m., indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the resident's care plan to assess of any special needs of the resident. Assemble the equipment and supplies as needed .Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. Tubing will be changed routinely and as needed/indicated 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician and resident representative of an unwitnessed fall until six (6) day after the event had occurred for 1 of 3 residents reviewed for notification of change. (Resident C) Finding includes: The record for Resident C was reviewed on 11/28/22 at 2:04 p.m. Diagnoses included, but were not limited to, unspecified dementia severe with anxiety, unspecified dementia severe with mood disturbance and age-related physical debility. There was no documentation in the record to indicate the physician or resident representative had been notified of the fall on the day of the incident, 10/29/22. During an interview, on 11/29/22 at 8:42 a.m., the Director of Nursing indicated the facility was not aware Resident C had fallen until during an investigation related to an injury to the resident's right shoulder. They interviewed LPN 2 and found out Resident C had fallen. They had an event report filled out by LPN 2 and the interdisciplinary team did make a note of the fall. LPN 2 informed the facility of the fall during the interview, on 11/04/22, via telephone. LPN 2 should have written a progress note and notify the physician, as well as the family. During an interview, on 11/29/22 at 9:59 a.m., the Director of Nursing indicated the event report was not completed by LPN 2, until 11/04/22, and it should have been completed on the day of the fall. The family and physician were notified on 11/03/22; they should have been notified the day of the fall. During a telephone interview, on 11/29/22 at 10:18 a.m., LPN 2 indicated Resident C had an un-witnessed fall on 10/29/22. She indicated she did not notify the physician or family because she was busy, and the day got away from her. She forgot to document a progress note. Her responsibility was to do an assessment, do the neurological checks and to make a note. She did go to the facility on [DATE] to complete the event report. The resident fell on a Saturday (10/29/22) and she did not report it. The first notification of the fall, to the facility, was on 11/04/22. A facility policy, titled Change in a Resident's Condition or Status, dated as revised in February 2021 and provided by the Director of Nursing on 11/29/22 at 10:54 a.m., indicated .The nurse will notify the resident's attending physician or physician on all when there has been a(an) .accident or incident involving the resident This Federal tag relates to Complaint IN00395442. 3.1-5(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents were assisted to eat, in the dining room, with dignity, when staff stood over them during the meal for 1 of 11 randomly observed resident for meal service. (Resident 69) Finding includes: On 10/31/22 from 11:35 a.m. to 12:13 p.m., during a random dining observation, 11 residents were observed to be seated in the dining room waiting for lunch to be served. Resident 69 was observed as she sat in a Broda (specialized high-back) chair at the dining table, in the second-floor main dining room. On 10/31/22 at 12:16 p.m., Licensed Practical Nurse (LPN) 2 was observed as she stood up next to the left side of Resident 69, were she was seated. The resident's meal tray was served to the table. LPN 2 opened the containers and prepped the meal by removing the lids and plastic wrap from the dishes, to assist the resident. LPN 2 then stood over Resident 69, when she placed bites of food in her mouth. At 12:22 p.m., LPN 2 sat down on the stool and finished assisting the resident with her meal. During an interview, on 10/4/22 at 2:14 p.m., the Director of Nursing (DON) indicated staff should sit down when feeding a resident for dignity reasons. A current policy, titled Assistance with Meals, dated 3/22 and received from the DON on 11/1/22, indicated .for residents who cannot feed themselves would be fed with attention to safety, comfort, and dignity . The policy directed staff to not stand over the resident while assisting them with eating. 3.1-3(t)

Based on interview and record review, the facility failed to complete the Comprehensive Annual 14-day Assessment in accordance with the Resident Assessment Instrument (RAI) for 2 of 11 residents reviewed for comprehensive assessments. (Resident 16 and 17) Findings include: 1. A review of the Minimum Data Set (MDS) admission Assessment-14 day for Resident 16 indicated an ARD with a created date of 6/7/22, and submission date of 7/18/22. A review of the medical record showed the admission MDS Assessment for Resident 16 had not been completed or submitted in accordance with the RAI manual. 2. A review of the MDS admission Assessment-14 day for Resident 17 indicated an ARD with a created date of 3/9/22, observation date of 3/29/22, and submission date of 5/2/22. A review of the medical record showed the admission MDS Assessment for Resident 17 had not been completed or submitted in accordance with the RAI manual. During an interview, on 11/1/22 at 9:58 a.m., the MDS Coordinator indicated the 14-day annual assessment had not been completed or submitted on time. The facility got behind on submissions due to illness within the department. During an interview, on 11/1/22 at 2:09 p.m., the Director of Nursing (DON) indicated the facility would refer to the RAI for the timing of submissions. During an interview, on 11/01/22 at 2:46 p.m., the Administrator indicated he was not aware of any recent concerns in the last few months regarding late MDS submissions. The facility had not completed audits or reviewed MDS submission in the QAPI program. During an interview, on 11/1/22 at 4:33 p.m., the DON indicated the Corporate MDS Coordinator had identified a concern regarding late submission of the MDS. The facility policy, titled MDS completion and submission Timeframes, dated as revised on 7/17, indicated the facility would conduct and submit resident assessment in accordance with current federal and state submission timeframes. 3.1-31(b) 3.1-31(d)(1)

Based on interview and record review, the facility failed to complete and submit the Quarterly 14-day Assessment in accordance with the Resident Assessment Instrument (RAI) for 1 of 11 residents who were reviewed for Quarterly assessments. (Resident 17) Finding includes: A review of the Minimum Data Set (MDS) Quarterly Assessment-14 day for Resident 17, dated 6/20/22, was created on 5/31/22, and had a submission date of 7/25/22. A review of the MDS Quarterly Assessment-14 day for Resident 17, dated 9/13/22, was created on 10/3/22, and had a submission date of 10/18/22. During an interview, on 11/1/22 at 9:58 a.m., the MDS Coordinator indicated the 14-day quarterly assessment had not been completed or submitted on time. The facility got behind on submission due to illness within the department. During an interview, on 11/1/22 at 2:09 p.m., the Director of Nursing (DON) indicated the facility would refer to the RAI for the timing of submissions. During an interview, on 11/01/22 at 2:46 p.m., the Administrator indicated he was not aware of any recent concerns in the last few months regarding late MDS submissions. The facility had not completed audits or reviewed MDS submission in the QAPI program. During an interview, on 11/1/22 at 4:33 p.m., the DON indicated the Corporate MDS Coordinator had identified a concern regarding late submission of the MDS. A current facility policy, titled MDS completion and submission Timeframes, dated as revised 7/17, indicated the facility would conduct and submit resident assessment in accordance with current federal and state submission timeframes. 3.1.-31(d)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a change of condition, ensure the physician's order was followed, and ensure the physician was notified of a change of condition for 1 of 2 residents reviewed for quality of care. (Resident 28) Finding includes: The record for Resident 28 was reviewed on 10/27/22 at 3:09 p.m. Diagnoses included, but were not limited to, chronic kidney disease (disease of the kidneys leading to renal failure), congestive heart failure (when the heart can not pump enough blood), acute respiratory failure (when fluid builds up in the air sacs in your lungs), sepsis (complication of an infection), cardiogenic shock (when your heart cannot pump enough blood and oxygen to the brain and other vital organs), multiple myeloma (cancer of plasma cells) and bacteremia (presence of bacteria in the bloodstream). A care plan, with a printed date of 11/2/22 at 11:21 a.m., indicated to: a. Administer medications as ordered. b. Assess vital signs, labs, and weights as ordered and notify the physician as indicated. c. Observe for complications of chest pain, dyspnea, edema, wheezing, and consult the physician as indicated. The vital signs for Resident 28 were reviewed and indicated the following: a. On 10/20/22 at 8:45 p.m., her blood pressure was 119/68. b. On 10/21/22 at 10:22 p.m., her blood pressure was 104/55. c. On 10/21/22 at 8:45 p.m., her blood pressure was 107/72. d. On 10/22/22 at 10:22 p.m., her blood pressure was 104/55. e. On 10/22/22 at 12:51 p.m., her blood pressure was 99/56. f. On 10/23/22 at 8:23 p.m., her blood pressure was 99/58. g. On 10/23/22 at 2:53 p.m., her blood pressure was 76/46. h. On 10/23/22 at 7:51 p.m., her blood pressure was 77/44. A nurse progress note, dated 10/22/22 at 5:31 a.m., indicated Resident 28 had no complaints of pain, discomfort, or distress. A condition change nurse progress note, dated 10/23/22 at 10:23 p.m., indicated Resident 28 had a change of condition. Her blood pressure was 77/50, heart rate was 60 and respirations were 16. Resident 28 had a history of renal failure, was very pale and was not eating or drinking. The physician and health representative were notified and she was sent to the hospital for evaluation. A review of Resident 28's record indicated the physician was not notified on 10/23/22, until eight hours after her blood pressure was first recorded low at 76/46 at 2:53 p.m. A Hospital Discharge summary, dated [DATE] at 11:00 a.m., indicated Resident 28 was brought to the Emergency Department by Emergency Medical Services for weakness and had shortness of breath for the past few days which worsened on 10/28/22. The Discharge Summary indicated Resident 28 had been admitted to the hospital for septic shock presumably due to a complicated urinary tract infection with a history of extended spectrum beta-lactamase (ESBL). The resident did present to the Emergency Department with hypotension (low blood pressure) and required intravenous (IV) fluids and antibiotics. The urine culture had no growth to the date of discharge date . The diltiazem (antihypertensive drug) was changed from an immediate release to an extended release since her blood pressures were on the lower side. A nurse note, dated 11/1/22 at 3:29 p.m., indicated Resident 28 had an admitting diagnosis of hypotension and acute renal failure. During an interview, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/2/22 at 9:26 a.m., they indicated Resident 28 had multiple hospital admission during the stay at the facility. The DON indicated Resident 28 was a risk for hospitalization related to her kidney failure. When Resident 28 had a change in condition, her blood pressure and pulse were affected. During an interview, on 11/2/22 at 4:55 p.m., the DON indicated Resident 28 had an order for staff to monitor her blood pressure and hold her diltiazem when her systolic blood pressure was below 90. During an interview, on 11/3/22 at 10:53 a.m., the DON indicated the physician was not notified when Resident 28 had a blood pressure of 76/46 recorded at 2:53 p.m., and a blood pressure of 77/44 at 7:51 p.m. Her expectation for staff would be to notify the physician with changes of condition and document in the resident's progress note. A current facility policy, titled Acute Condition Change - Clinical Protocol, with a revised date of 8/18, indicated nursing staff would make a detailed observation and collect pertinent information to report to the physician. The nursing staff would contact the physician based on the urgency for the situation. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure the physician was notified when a medication was not filled by the pharmacist upon their admission as ordered to help address pain for 1 of 1 new resident reviewed for pain management. (Resident 193) Finding includes: During the initial tour of the facility, on 10/27/2022 at 11:38 a.m., alert and oriented Resident 193 was found in her room, sitting in a wheelchair. During an interview, at this time, the resident indicated she was new to the facility. She had recently suffered a stroke which had affected her left arm and leg, leaving her without movement to the left side of her body. During the interview, Resident 193 continually adjusted her left arm, rubbed her arm and attempted to hold her arm in place while she grimaced in pain. When questioned, the resident indicated she had increasing pain to her left shoulder and arm following her stroke which caused her to be unable to sit up in her chair for long periods of time. The record for Resident 193 was reviewed on 10/31/2022 at 10:02 a.m. Diagnosis included, but were not limited to, hypertension, obesity, seizures, hemorrhagic cerebral vascular event (stroke) with residual deficits and left side hemiplegia. Resident 193's baseline plan of care was received and reviewed on 11/03/2022 at 9:31 a.m. A problem of Pain Management with a goal of Experience less pain was observed. Interventions to this goal included, but were not limited to, drug interventions, assess pain tolerance and non-drug interventions. At the time of her admission, initial physician orders included an order for baclofen (a muscle relaxant) 20 mg (milligrams) three times a day for muscle spasms. A physician progress note, dated 10/28/2022 at 2:44 p.m., indicated .Left frontal hemorrhagic CVA (stroke) with left sided neglect, hemiparesis, spasticity, and contracture to the left hand. Baclofen 20 mg tid (three times a day) stopped on admission by pharmacist and hasn't had for a week so will restart 5 mg tid x 3 days, then 10 mg po (by mouth) tid x 3 days, then 20 mg po tid. Called and left message for pharmacist that she is to be on both due to significant spasticity . During an interview, on 11/02/2022 at 2:06 p.m., the ADON indicated discharge orders from the hospital, at the time, the resident was admitted to the facility included baclofen 20 mg three times a day, however this medication was not filled by the pharmacy due to an interaction with another muscle relaxant the resident was also prescribed. Documentation lacked the physician was aware the resident was not receiving the baclofen as ordered from the time of admission until reordered by the physician on 10/28/2022. A current facility policy regarding development of initial baseline plans of care was requested on 11/02/2022 at 3:34 p.m., however the policy and procedure was not received prior to, or at the time of exit from the facility on 11/04/2022 at 5:05 p.m. 3.1-37(a)

Based on interview and record review, the facility failed to monitor a resident's blood pressure as ordered by the physician when administering a mediation used to treat high blood pressure for 1 of 5 residents reviewed for unnecessary medications. (Resident 87) Finding includes: The record for Resident 87 was reviewed on 10/31/22 at 2:43 p.m. Diagnoses included, but were not limited to, high blood pressure and heart failure. A current care plan, undated, indicated the resident had a diagnoses of hypertension and heart failure. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 10/14/22, indicated the resident was to receive Hydrochlorothiazide (a medication used to treat high blood pressure and heart failure) 12.5 milligrams every day for heart failure and to hold the medication if the resident's systolic blood pressure (the top number of a blood pressure which measures the amount of pressure in your arteries) was less than 100. The MAR (Medication Administration Record) was reviewed, for 10/22, and there were not any documented blood pressure readings correlated to when the resident received the Hydrochlorothiazide. During an interview, on 10/31/22 at 2:30 p.m., the Director of Nursing indicated there was not any documentation the resident's blood pressure was taken at the time when the medication was administered but it was her assumption nursing would take the resident's blood pressure prior to giving the medication. A current policy, titled Administering Medications, dated as revised 12/2012 and provided by the Director of Nursing on 11/01/22 at 2:30 p.m., indicated .3. Medications must be administered in accordance with the orders .8. The following information must be checked/verified for each resident prior to administering medications: b. Vital signs, if necessary 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure the diagnoses were appropriate for the use of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications (Residents 69 and 75). Findings include: 1. The record for Resident 69 was reviewed on 10/27/22 at 1:34 p.m. Diagnoses included, but were not limited to, depression (a mood disorder which causes a persistent feeling of sadness and loss of interest), vascular dementia (decline in thinking skills caused by conditions which block or reduce blood flow to various regions of the brain), bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and anxiety. Physician's orders indicated Resident 69 had orders for: a. Depakote Sprinkles (used to treat mental, mood conditions (such as manic phase of bipolar disorder) 125 mg (milligram) capsule, delayed release (2 capsules (250 mg)) by mouth twice a day. b. Buspirone (used to treat anxiety disorders ) 7.5 mg tablet (1 tab) tablet by mouth twice a day. c. Oxycodone 5 mg tablet (2.5 mg (1/2 tablet)) every four hours as needed for pain. d. Aripiprazole (an antipsychotic) 2 mg tablet (1) tablet. e. Lorazepam (an anti-anxiety) 2 mg/mL oral concentrate (0.5 mL) two times a day and as needed every four hours for anxiety and restlessness. A care plan indicated the resident had: a. Resident 69 was at risk for side effects from psychotropic medications. The care plan indicated to monitor for side effects, complete AIMS, pharmacy consult, GDR all psychotropic medications, monitor targeted behaviors and obtain consents for psychotropic medications. b. A mood disorder and manic episodes, bipolar disorder, anxiety and insomnia. The care plan indicated she had anxious expressions at times displayed by biting her nails, yelling out, garbled verbal noises, crying and combative with care. She took an anti-convulsant (Depakote) and lorazepam. Staff were to give the medications as ordered and to observe and notify the physician as needed for potential side effects. During an interview, with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Consulting Pharmacist (CP), on 11/2/22 1:15 p.m., the DON and ADON indicated no risk and benefits was completed for Resident 69 who had taken antipsychotics. 2. The record for Resident 75 was reviewed on 11/02/22 at 12:00 p.m. Diagnoses included, but were not limited to, dementia, restlessness and agitation and senile degeneration of the brain. A care plan indicated the resident had anxiety and directed staff to administer medication per physician's order and for staff to monitor for potential side effects and report to the physician. Physician's orders, dated 7/7/22, indicated Resident 75 was prescribed: a. Seroquel (an antipsychotic) 25 mg tablet by mouth daily for restlessness and agitation. b. Fentanyl (a narcotic) 12 mcg/hour patch for anxiety disorder. A Medication Management Review (MMR) report, dated 9/21/22, had recommended a gradual dose reduction of the Seroquel for Resident 75. During an interview, on 11/2/22 1:15 p.m., the Pharmacist indicated the Seroquel was being used for restlessness and agitation and was an off label use for Resident 75. Anxiety was the wrong diagnosis used for Fentanyl. During an interview, with the DON, ADON and the CP, on 11/2/22 1:15 p.m., the CP indicated the Seroquel was being used for restlessness and agitation and was an off label use for Resident 75. The anxiety was the wrong diagnosis for Fentanyl. The DON and ADON indicated no risk and benefits was completed for Resident 75 who had taken antipsychotics. During an interview, the hospice Nurse Practitioner (NP) indicated she had seen Resident 75 in September for a recertification visit. The resident did not make eye contact or communicate with her during the visit. No medication changes had been made since March of 2022. The family had requested to not have a reduction in Resident 75's medication. A recent publication of PDR.net indicated .Seroquel (quetiapine) was indicated for the treatment of bipolar disorder, including mania, bipolar depression and major depressive disorder .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Seroquel in this population should be avoided if possible due to an increase in morbidity and mortality . A recent publication of PDR.net indicated .Depakote was indicated for the treatment of bipolar disorder including mania .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Depakote in this population should be avoided if possible due to an increase in morbidity and mortality A current policy, titled Antipsychotic Medication Use, with a revision date of 12/16, indicated antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period of time and or subject to a gradual dose reduction and review. Additionally, antipsychotic medication would not be used for symptoms of restlessness, impaired memory, anxiety, insomnia, crying alone, nervousness and uncooperativeness. 3.1-48(a)(4)

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5 percent, based on medication errors observed during 3 of 31 opportunities for errors, during a random medication administration observation, resulting in a medication error rate of 9.68 percent. (Residents 146, 143 and 86) Findings include: 1. During a random medication administration observation, beginning on 11/1/2022 at 8:30 a.m., Licensed Practical Nurse (LPN) 3 was observed to prepare levothyroxine (a thyroid hormone) 100 mcg (microgram) tablet and punched it out into a medication cup for Resident 146. LPN 3 poured a cup of water, locked the medication cart and computer, picked up the medication up containing Resident 146's medication, and walked into her room were Resident 146 was seated in her recliner. On 11/1/22 at 8:31 a.m., LPN 3 gave Resident 146 her levothyroxine medication and held a cup of water for her to drink. At 8:33 a.m., Resident 146's breakfast tray had been delivered into her room and was set up for her to eat. Resident 146 was observed, at 8:39 a.m., to be eating her breakfast. During an interview, at this time, LPN 3 indicated she was unsure Resident 146 had a specific time to administer her levothyroxine medication. Her breakfast had been delivered. Resident 146's order did not have a specific time for administration of medication, because she had a window from 6:00 a.m., to 10:00 a.m. The record for Resident 146 was reviewed on 11/1/22, at 8:35 a.m. A physician's order indicated the resident was to receive levothyroxine 100 mcg tablet one time daily for hypothyroidism. A Medication Summary document from electronic medical record, dated 10/22, indicated Levothyroxine should be taken by mouth as directed by the doctor, on an empty stomach, and 30 minutes to 1 hour before breakfast. The summary further indicated, the absorption of levothyroxine in the stomach was decreased when taken at the same time as calcium, iron, some foods and other drugs. 2. During a medication observation, beginning on 11/1/22 at 8:52 a.m., LPN 3 was observed to prepare 10 medications for Resident 143. LPN 3 reviewed the orders for Resident 143 and punched the medications into a medication cup. One of the order's indicated she was to take Methotrexate three 2.5 mg (milligram) tablets. LPN 3 was unable to locate the medication in the med cart and she indicated she would have to contact the pharmacy because the medication was not available. The record for Resident 143 was reviewed on 11/1/22 at 10:00 a.m. A physician's order indicated the resident was to receive Methotrexate three 2.5 mg tablets for rheumatoid arthritis (a chronic inflammatory disorder affecting many joints). A Medication Summary document from electronic medical record, dated 3/22, indicated Methotrexate was used to treat rheumatoid arthritis During an interview, on 11/2/22 at 1:00 p.m., the Director of Nursing (DON) indicated staff should administer medication as ordered by the physician and pharmacy recommendations. The DON would not indicate her expectation for administering Levothyroxine and food intake when asked. 3. During a medication administration observation, on 10/31/22 at 12:22 p.m., LPN 1 dialed the amount of insulin needed to cover the resident's blood sugar from the resident's Kwik pen (a pre filled cartridge of insulin which is attached to a needle for administration) and indicated she was ready to give the resident her insulin. She was not observed to prime (remove the air) from the insulin needle. During an interview, at that time, LPN 1 indicated she was not aware she needed to prime the needle and she was never educated on the process. The record for Resident 86 was reviewed on 10/31/22 at 3:00 p.m. Diagnoses included, but were not limited to, diabetes mellitus, hypertension (high blood pressure) and pain. A physician's order, dated 10/30/22, indicted the resident was to receive insulin at 7:30 a.m., 12:30 a.m., and 5:30 p.m., dependent upon the resident's blood sugar at that time. A current policy, titled Insulin Pen Administration, dated as revised on 08/2017 and provided by the Director of Nursing on 11/01/22 at 2:30 p.m., indicated .9. Attach the needle to the end of the pen and prime pen. 10. Prime pen by dialing the dose knob to select 2 units. Then hold pen upright and tap cartridge to remove any air bubbles. Net depress the dose knob until 0 is seen in the dose window and hold doses knobby for 5 seconds. You should see insulin at the tip of the needle. A current policy, titled Administering medications, dated 12/12, indicated medications must be administered in accordance with the order including any required time frame. 3.1-48(c)(1)

Based on observation, interview and record review, the facility failed to ensure proper hand hygiene was completed with the distribution of food and assistance with feeding in accordance with the professional standards for food service safety for 2 of 2 staff members randomly observed during food service. (An unidentified staff member and LPN 2) Findings include: 1. During an observation, on 10/31/22 at 12:06 p.m., an unidentified staff member walked into the dining room, up to the food service window. She used her right hand to sweep over her bangs and tucked hair behind her right ear. The staff member grabbed a tray with a resident's lunch and left the dining room to carry to the room. She did not perform hand hygiene at no time after she touched her hair and before she grabbed the resident's tray. 2. During an observation, on 10/31/22 at 12:15 p.m., Licensed Practical Nurse (LPN) 2 was observed to walk next to Resident 69 with a glove on her right hand, bent over and picked up a knitted blanket off the floor behind her. At 12:16 p.m., LPN 2 touched her N95 mask with her right gloved hand. LPN 2 then started to remove the lids and plastic wrap from the food items, picked up the spoon and started to feed Resident 69. LPN 2 did not perform hand hygiene at any time after she picked up the blanket off the floor. During an observation, on 10/31/22 at 12:29 p.m., Resident 69's blanket had fallen on the floor behind her. At 12:30 p.m., LPN 2 reached down to the floor with her right hand and placed the blanket on the back of Resident 69's chair. LPN 2 did not perform hand hygiene at any time after she picked up the blanket off the floor. During an interview, on 10/4/22 at 2:14 p.m., the Director of Nursing (DON) indicated staff should perform hand hygiene before they assisted Resident 69 with meals, when they picked up an object off the floor or when touching their hair or mask. A current policy, titled Assistance with Meals, dated 3/22, indicated employees would engage in hand hygiene after contact with objects or after personal contact with hair, face, or personal protective equipment. 3.1-21(i)(3)

Based on interview and record review, the facility failed to complete, encode and transmit a Discharge Minimum Data Set (MDS) assessment for 10 of 11 residents reviewed for resident assessment. (Resident 1, 2, 3, 4, 5, 6, 7, 8, 11 and 16) Findings include: 1. A review of the MDS Discharge Assessment-14 day for Resident 1 indicated a discharge date of 5/24/22, was created on 10/28/22, and had not been submitted at the time of the survey. A review of the medical record indicated the Discharge MDS for Resident 1 had not been submitted in accordance with the RAI manual. 2. A review of the MDS Discharge Assessment-14 day for Resident 2 indicated a discharge date of 6/29/22, was created on 10/28/22, and had not been submitted at the time of the survey. A review of the medical record indicated the Discharge MDS for Resident 2 had not been submitted in accordance with the RAI manual. 3. A review of the MDS Discharge Assessment-14 day for Resident 3 indicated a discharge date of 6/16/22, and submission date of 10/28/22. A review of the medical record indicated the Discharge MDS for Resident 3 had not been submitted in accordance with the RAI manual. 4. A review of the MDS Discharge Assessment-14 day for Resident 4 indicated a discharge date of 6/21/22, and submission date of 10/31/22. A review of the medical record indicated the Discharge MDS for Resident 4 had not been submitted in accordance with the RAI manual. 5. A review of the MDS Discharge Assessment -14 day for Resident 5 indicated a discharge date of 6/20/22, and submission date of 10/28/22. A review of the medical record indicated the Discharge MDS for Resident 5 had not been submitted in accordance with the RAI manual. 6. A review of the MDS Discharge Assessment-14 day for Resident 6 indicated a discharge date of 6/28/22, was created on 10/28/22, and had not been submitted at the time of the survey. A review of the medical record indicated the Discharge MDS for Resident 6 had not been submitted in accordance with the RAI manual. 7. A review of the MDS Discharge Assessment-14 day for Resident 7 indicated a discharge date of 8/15/22, and submission date of 10/28/22. A review of the medical record indicated the Discharge MDS for Resident 7 had not been submitted in accordance with the RAI manual. 8. A review of the MDS Discharge Assessment -14 day for Resident 8 indicated a discharge date of 9/6/22, and submission date of 10/20/22. A review of the medical record indicated the Discharge MDS for Resident 8 had not been submitted in accordance with the RAI manual. 9. A review of the MDS Discharge Assessment-14 day for Resident 11 indicated a discharge date of 7/7/22, and the discharge had not been submitted at the time of the survey. A review of the medical record indicated the MDS for Resident 11 had not been completed or submitted in accordance with the RAI manual. 10. A review of the MDS Discharge Assessment-14 day for Resident 16 indicated an ARD with a date of 6/24/22, was created on 10/31/22, and had not been submitted at the time of the survey. A review of the medical record indicated the MDS for Resident 16 had not been completed or submitted in accordance with the RAI manual. During an interview, on 11/1/22 at 9:58 a.m., the MDS Coordinator indicated the 14-day discharge assessment had not been completed or submitted on time. The facility got behind on submission due to illness within the department. During an interview, on 11/1/22 at 2:09 p.m., the Director of Nursing (DON) indicated the facility would refer to the RAI for the timing of submissions. During an interview, on 11/01/22 at 2:46 p.m., the Administrator indicated he was not aware of any recent concerns in the last few months regarding late MDS submissions. The facility had not completed audits or reviewed MDS submission in the QAPI program. During an interview, on 11/1/22 at 4:33 p.m., the DON indicated the Corporate MDS Coordinator had identified a concern regarding late submission of the MDS. During an interview, on 11/1/22 at 3:33 p.m., the Administrator indicated if the resident's discharges were submitted late, it could affect the facility census and cause an error on the Payroll Based Journal (PBJ) report. A current facility policy, titled MDS completion and submission Timeframes, dated as revised 7/17, indicated the facility would conduct and submit resident assessment in accordance with current federal and state submission timeframes. 3.1-31(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed fall interventions and completed a root cause analysis for 4 of 4 residents reviewed for accidents. (Resident 17, 32, 35 and 69 ) Findings include: 1. During an observation, on 10/21/22 at 9:31 a.m., Resident 17 was found seated, in her Broda chair, leaning over to her left side of the arm rest. During an observation, on 10/28/22 at 10:34 a.m., Resident 17 was observed lying, in bed, facing the wall covered with a blanket. At the foot end of the blanket, the call light was attached to her blanket. The fall mat was standing up on its side next to the wall away from Resident 17. The record for Resident 32 was reviewed on 10/31/22 at 10:30 a.m. Diagnoses included, but were not limited to, dementia and a history of falls. An Event report, dated 8/29/22 at 12:20 p.m., indicated Resident 17 had an unwitnessed fall and was found on the floor in front of the closet in her room. Immediate interventions were implemented to provide 30-minute checks for days. A Unit Manager Event Review report, dated 8/29/22, indicated Resident 17 was confused and had a fall. The report indicated the root cause for the fall was staff performance and a new intervention was for staff education to be provided. An Event report, dated 10/15/22 at 7:00 p.m., indicated Resident 17 had an unwitnessed fall and was found on the floor. Immediate interventions were implemented to provide one to one supervision, promptly lay down after meals and frequent checks. A Unit Manager Event Review report, dated 10/15/22, indicated Resident 17 was confused and had a fall. The report lacked indication a root cause was completed, or a new intervention was placed after review. A fall risk assessment was completed, on 10/17/22, and indicated Resident 17 was a high risk for falls. A care plan, with a print date of 11/3/22, indicated Resident 17 had a risk for falls related to impaired balance, impaired cognition and a history of falling. The care plan indicated: a. Not to leave the resident alone in her room when up in her wheelchair. b. Assist with mobility as needed. c. Assist to walk as desired. d. Obtain a soft touch call light. e. Keep the bed in a low position. f. Do not leave her alone in the bathroom. g. Anticipate needs as indicated and give frequent cues. h. Identify specific interventions to aid in prevention of falls. i. Place the call system and most frequently used items within reach of the resident. j. Bed against the wall and a fall mat beside the bed. k. Check and change each round and toilet as needed. l. Promptly lay down after meals. During an interview, with Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/3/22 at 9:30 a.m., the DON indicated she was not sure if a call light to the end of a blanket would work for alerting the staff if Resident 17 was to attempt to get out of bed. The fall mat should be placed next to Resident 17 while she was in bed and staff would provide checks throughout the day to ensure she was safe. 2. During an observation, on 11/1/22 at 10:19 a.m., Resident 32 was observed, in the hallway, directly in front of the nursing station. A hospice nurse was observed standing in front, to the left side of the nursing station, just past the wall and out of view of the resident. No staff were observed in either hallway which had direct view of the resident. Resident 32 was in her wheelchair, her wheels were unlocked when she attempted to stand and hit her head on the sling attachment bar of the Hoyer lift. The stabilizing leg was stuck between the wheels. She sat back down in her wheelchair and continued to push the wheel but was unable to move the chair free. Resident 35 stood back up and attempted to step away unsteadily from the wheelchair. Resident 35 was prompted to sit down and staff were prompted to intervene and assist the resident. The record for Resident 32 was reviewed on 11/1/22 at 10:30 a.m. Diagnoses included, but were not limited to, dementia, aphasia (a loss of ability to understand or express speech). A Quarterly Minimum Data Set (MDS) assessment, dated 10/17/22, indicated Resident 32 had a severe cognitive impairment with inattention, disorganized thinking, had two falls and impaired vision. She required extensive physical assistance of one staff for assistance with transfers and locomotion on the unit. A care plan indicated Resident 32 was at risk for falls due to impaired balance, impaired cognition, history of falling, and impaired vision. The care plan indicated: a. Provide cues and supervision while ambulating. b. Obtain a soft touch call light. c. Encourage activities in the afternoon. d. Provide Resident 32 orientation to the room and call system. e. Use fall mat at bedside. f. Keep bed in low position. g. Bed against the wall. h. Dycem in recliner. i. Offer to toilet after meals. A Unit Manager Event Review report, dated 5/20/22, indicated Resident 32 had a fall. She was found on the floor by housekeeping staff playing with hats. The root cause determined Resident 32 had a diagnosis of dementia and was reaching, forgets limitation and had poor safety judgement. A wheelchair evaluation was added as an intervention. A nurse progress note, dated 6/6/22 at 1:45 p.m., indicated Resident 32 had an unwitnessed fall and was found in her room, on the floor. Interventions added for Resident 32 was for the staff to place the call light in reach. A nurse progress note, dated 7/3/22 at 7:45 a.m., indicated Resident 32 had an unwitnessed fall and was found down, on the floor, in the hallway. Interventions added for Resident 32 was for the staff to place the call light in reach. An Event report, dated 8/25/22 at 2:05 p.m., indicated Resident 32 was found on the floor, in her room, asleep with her blanket over her. A Unit Manager Event Review report, dated 8/25/22, indicated Resident 32 had a fall. A new intervention was added to offer Resident 35 a coca cola and to assist to toilet at bedtime and early morning. The review lacked indication a root cause was completed. A post fall follow up progress note, dated 10/29/22, indicated Resident 32 had a fall in the second-floor hallway, on 10/28/22 at 6:00 p.m., when she was found lying on her left side in front of her wheelchair yelling out for help. The progress notes further indicated 15-minute checks was initiated. Resident 32's care profile, undated, indicated she was a fall risk, put the bed in the low position and against the wall, fall mat at bedside, a soft touch call light, wheelchair within reach of the bed, dycem to recliner and a nightlight in her room. The care profile lacked indication staff were to offer a coca cola, provide cues and supervision while ambulating. A root cause analysis was requested and not provided for the falls on 6/6/22, 7/3/22 and 8/25/22. During an interview, on 11/1/22 at 10: 22 a.m., Nursing Assistant (NA) indicated Resident 32 had her wheelchair stuck in the Hoyer lift leg and could have fallen if staff did not intervene. During an interview, on 11/1/22 at 10:25 a.m., the Assistant Director of Nursing (ADON) indicated Resident 32 was at risk for falls and had fallen in the past. Resident 32 was able to ambulate at times but used the handrails for support. Resident 32 could have fallen and sustained an injury when she got her wheelchair stuck in the Hoyer lift and attempted to free it on her own. The Hoyer lift should have been stored in the appropriate resident's bathroom instead of in the hallway. During an interview, on 11/3/22 at 9:30 a.m., the DON and ADON indicated Resident 32 was a fall risk and required assistance from staff for transfers. The staff should keep the call light within reach for Resident 32 to use and staff should be providing checks throughout the day for safety. 3. During an observation, on 10/27/22 at 12:42 p.m., Resident 35 was found sitting up with the head of the bed up. She was observed, above her left eye, to have a one and half inch bruise and down past her left cheek was red and bruised. She had an abrasion on the bridge of her nose. Above her left eye were five steri-strips, soaked through with blood, which covered a wound. During an observation, on 10/28/22 at 9:36 a.m., Resident 35 was heard yelling out please, please, help, help. Upon entering Resident 35's room, she was observed seated in her reclining chair, in her room, with the feet elevated. The call light was hanging over the bedrail of her bed more than 9 feet away from the resident. No staff were observed near her room. During an observation, on 10/28/22 at 10:46 a.m., Resident 35 was found lying in her bed with her eyes closed. Her call light was found lying on the floor near the top right wheel of the exit side of the bed. The bed was in the low position. During an observation, on 11/1/22 at 9:45 a.m., Resident 35 was heard calling out help, help me and was found in her room seated in the reclining chair with the footrest elevated. The over the bed table was positioned over her lower legs. She had both her legs over the left side of her footrest. Her call light was tucked inside the cushion on the left side of the reclining chair beneath her left hip. Resident 35 indicated she was tired and wanted to go to bed. The record for Resident 35 was reviewed on 10/31/22 at 9:30 a.m. Diagnoses included, but were not limited to, dementia and repeated falls. A Quarterly Minimum Data Set (MDS) assessment, dated 8/4/22, indicated Resident 35 had a severe cognitive impairment and demonstrated no behaviors. She required extensive physical assistance of one staff person to assist with bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. She had falls with injuries and used a wheelchair for locomotion. A care plan indicated Resident 35 was a fall risk and indicated to: a. Apply anti-rollbacks to wheelchair. b. Keep bed against the wall c. Place Fall mat at bedside. d. On 12/4/21, staff were to keep her wheelchair within reach when she was in bed. e. On 11/26/21, staff were to obtain a soft touch call light. f On 11/28/21, staff were to offer and assist resident to lay down after meals. g. On 11/27/21, staff were to assist her to wear hipsters to aide in prevention of hip injury and apply in a.m. h. Place the call system and most frequently used items within resident's reach. i. Provide resident orientation to room and call system. j. On 1/17/21, staff were to offer and assist with toileting a minimum of every two hours while awake. k. On 12/10/21, staff were to encourage and assist resident to sit in her recliner after dinner. l. On 12/13/21, therapy was to provide dycem for wheelchair. m. On 11/29/21, staff were to ensure bed controls are secured in appropriate and safe place while resident was in bed. n. On 12/15/21, staff were to supervise resident during meals. o. On 10/1/22, staff were to offer, Resident 35, 15-minute checks until management review and allow to sleep as long as possible before meals. Resident 35's care profile, undated, indicated she was a fall risk and needed antiroll backs to the wheelchair, bed in the lowest position, fall mat at bedside, a soft touch call light, wheelchair within reach of the bed, and dycem to the wheelchair. Staff were to place the call light and items used frequently within reach, encourage activities, supervise during meals, lay down after meals, offer early bedtime, offer to get up if awake and not to leave the resident alone in the bathroom. A review of the facility's falls, in the past 6 months, indicated Resident 35 had 11 falls from May to October 2022. A Resident Incident Assessment indicated Resident 35 had an unwitnessed fall on 5/25/22 at 4:00 p.m., when she was found sitting, in her bathroom, on the floor. She sustained skin tears to her left knee and elbow. Post fall interventions included to have the resident, in her wheelchair, at the nurse's station and to have a call light in reach when in her room. A Resident Incident Assessment indicated Resident 35 had an unwitnessed fall on 6/2/22 at 10:10 a.m., when she was found lying on the left side, on her floor, near her bed. Post fall, the facility added interventions to place her bed against the wall and the aide was too standby when the resident was toileting. A Resident Incident Assessment indicated Resident 35 had a fall on 7/16/22 at 10:00 a.m., at the nurse's station. The resident pushed against the wall, tilted her wheelchair and fell on her left side. She hit the outer left side of her eye and sustained a skin tear to her left knee. Post fall 30-minute checks were added to Resident 35 interventions. A Resident Incident Assessment indicated Resident 35 had a fall, in the hallway, on 8/4/22 at 2:30 p.m. The resident was incontinent of loose stool at the time of fall. She sustained a 1.0 cm laceration to her left forehead and her left knee was skinned. Post fall additional interventions of 15-minute checks for 15 days were added. She was also sent to the emergency room for evaluation. A Unit Manager Event Review report, dated 8/4/22, indicated Resident 35 had a fall with injury. The report indicated the root cause was related to toileting, weakness, poor safety judgement and wheelchair not dumped. The report indicated a new intervention was initiated by the facility for staff to offer to lie down after activities and provide 15 minute checks. An occupational therapy (OT) initial assessment, dated 7/28/22, indicated they had completed a wheelchair evaluation due to the history of frequent falls. The assessment indicated Resident 35 was a fall risk and had precautions for falls, cognitive impairment and she was hard of hearing. OT indicated the resident to have 24/7 nursing assistance. An OT daily treatment note, dated 8/10/22, indicated Resident 35 had an unwitnessed fall on 8/2/22, when she attempted to stand from her wheelchair. Her leg rests were not in place at the time of the fall. Staff were educated on the importance of leg rest for fall prevention. A Resident Incident Assessment indicated Resident 35 had a fall, on 8/23/22 at 4:00 p.m., where she was found in her room on floor. Post fall additional interventions of frequent checks, with nurse, and spoke to son were added. A Unit Manager Event Review report, dated 8/23/22, indicated Resident 35 had a fall. The report indicated a lack of a root cause. A new intervention for staff to encourage short sleep cycles (naps) during the daytime hours. A Resident Incident Assessment indicated Resident 35 had a fall, on 9/1/22 at 8:00 p.m. She was found by a Certified Nursing Assistant (CNA) on the floor in her room. Resident 35 had sustained an abrasion to her left elbow. Post fall interventions added for Resident 35 were one-to-one supervision, frequent checks, bed in low position with a fall mat in place, call light in reach and toilet every two hours. A Unit Manager Event Review report, dated 9/1/22, indicated Resident 35 had a fall with a head injury. The report indicated the root cause was related to staff performance. The report lacked a new intervention was initiated by the facility. A Resident Incident Assessment indicated the resident had a witnessed fall in her bathroom, on 9/16/22 at 7:30 a.m., when she fell off the toilet after she had bent down to pull up her pants. She sustained a 2.5 cm (centimeter) by 5 cm laceration to the left side of her forehead and a skin tear to the bridge of her nose. the resident had steri-strips and dressing applied to her injuries. Post fall interventions added for Resident 35 were one-to-one supervision, frequent checks, bed in low position with a fall mat in place, call light in reach and toilet every two hours. The assessment lacked indication Resident 35 had been evaluated at the emergency room after she sustained a head injury. A Unit Manager Event Review report, dated 9/16/22, indicated Resident 35 had a fall with injury. The report indicated the root cause was related to toileting, balance and staff performance. A new intervention of staff education was indicated for Resident 35. A Resident Incident Assessment indicated Resident 35 had a fall, on 10/1/22 at 11:15 a.m., in a room when she had propelled herself and flipped the wheelchair over on top of herself. Post fall, the facility placed an intervention to take resident to bed per her request. A Unit Manager Event Review report, dated 10/1/22, indicated Resident 35 had a fall with injury. The report lacked indication of a root cause. A Resident Incident Assessment indicated Resident 35 had a fall at the nurse's station, on 10/27/22 at 7:00 a.m. Resident 35 was up in her wheelchair when she attempted to get out of the chair and landed on her face. She sustained a 0.1 cm by 0.1 cm by 0.1 cm laceration to her forehead. The facility added the intervention for staff to clean wound and apply steri -strips. A root cause analysis was requested and not provided for the fall on 10/27/22. 4. During an observation, on 10/27/22 at 2:05 p.m., Resident 69 had significant amount of bruising to her right side of her face which covered from her jaw line up past her forehead. A large black colored bump was just above her right eyebrow. She had her right hand up to her forehead rubbing the black colored bump. During an observation, on 10/28/22 from 9:25 a.m., to 9:53 a.m., Resident 69 was seated in a reclining Broda chair at the nursing station, rubbing her forehead and eye. She had facial grimacing while she was rubbing her head. No staff were observed at the nurse's station until 9:53 a.m., when an aide came up to take Resident 69 back to her room. The record for Resident 69 was reviewed on 10/31/22 at 9:30 a.m. Diagnoses included, but were not limited to, dementia, subdural hemorrhage, muscle weakness, macular degeneration and repeated falls. Resident 69's care profile, undated, indicated she was a fall risk and staff were to keep the bed in the lowest position, use a fall mat at bedside, place in recliner when in room and the resident was not to be in her wheelchair alone when she was in her room. The staff were to use Dycem to the wheelchair when she was in her room alone, offer activities, put the bed next to the wall and use a soft touch call light. A Physical Therapy (PT) Discharge summary, dated [DATE], indicated Resident 69 had dementia with memory impairment and was a fall risk. She had a right arm fracture on 2/24/22. A physician progress note, dated 9/9/22 at 9:49 a.m., indicated Resident 69 was hospitalized from [DATE] to 5/28/22, for an unwitnessed fall resulting in right temporal and tentorial subdural hematomas. She sustained a left maxillary fracture and a left periorbital hematoma. Resident 69 had fractures of the first and second vertebral body and a right first rib fracture. An Event Report, dated 10/18/22, indicated Resident 69 had an unwitnessed fall with a right side hematoma. The resident was found face down, on the floor of the room, in front of the Broda chair. The root cause indicated the resident scooted forward. Interventions added to Resident 39 was for staff to provide 15-minute checks for three days. A Unit Manager Event Review report, dated 10/19/22, indicated Resident 69 had a fall with injuries. The report indicated the root cause was related to decreased safety awareness. The report lacked indication new interventions were added after the manager review. An Event Report, dated 10/19/22 at 8:10 a.m., indicated Resident 69 had an unwitnessed fall and was found lying on her right side on the floor near her chair. She had a 4 cm by 4 cm hematoma to her right side of head and bruising to her forehead and under her right eye. Interventions prior to the fall included to assess for pain, use specialized call light and keep the call light within reach. Immediate interventions implemented were for the staff to get the resident up right before meals and neuro checks were initiated. A Unit Manager Event Review report, dated 10/19/22, indicated Resident 69 had a fall with injuries. The report indicated the root cause was related to decreased safety awareness. The report lacked indication new interventions were added after the manager review. An Occupational Therapy evaluation, dated 11/1/22, indicated Resident 69 was a fall risk, had an overall decrease in overall strength and functional activity tolerance. She received daily assistance with all self-care task and functional mobility. During an interview, on 11/3/22 at 10:45 a.m., the ADON indicated the Administrator was the person at the facility to report incidents related to falls and fractures. The incident investigation report lacked indications Resident 69 sustained fractures after her fall on May 23, 2022. Resident 69 was a fall risk and sustained a hematoma on 10/19/22. During an interview, on 11/3/22 at 10:45 a.m., the DON indicated her expectation for staff would be to follow the residents care plan and provide the supervision and assistance as directed for each resident. During an interview, on 11/4/22 at 4:30 p.m., the Administrator indicated the facility had identified resident falls as a concern and was currently reviewed in the quality assurance and performance improvement (QAPI) meetings. A review of the falls in the last six months for second floor report, undated, indicated a total of 87 falls had occurred from 4/2/22 to 10/27/22. A current facility policy, titled Falls and Fall Risk, Managing, dated 3/18, indicated staff were to identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. 3.1-45(a)(2)