The facility identified a census of 79 residents, with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to ensure staff responded appropriately with adequate supervision to prevent potential abuse and/or mistreatment of Resident (R) 1, a cognitively impaired resident. This placed R1 at risk for potential abuse and/or mistreatment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated 06/19/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognitive function. The MDS documented R1 had no behaviors during the look back period. The MDS documented R1 required moderate staff assistance with dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 required substantial staff assistance with bathing and donning footwear. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated 02/27/25, documented R1 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R1 had no behaviors during the look back period. The MDS documented R1 required moderate staff assistance with toileting hygiene, bathing, and dressing. The MDS documented R1 required supervision or touching assistance with all of her other activities of daily living. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/24, documented R1 had orientation, memory, and recall deficits. The CAA documented R1 had dementia, a change in mental status, and short and long-term memory loss. The Communication CAA, dated 06/19/24, documented R1 had difficulty understanding others and being understood by others. The CAA documented R1 suffered from cognitive loss and aphasia (a condition with disordered or absent language function). R1's Care Plan documented R1 had the potential for side effects related to the use of aspirin (a non-steroidal anti-inflammatory drug used to treat fever, pain, inflammation, and as an antithrombotic {medications used to prevent or treat blood clots}) and may be prone to bruising of unknown origin and directed staff to observe R1 for bruising (03/11/25). The care plan documented R1 had a bruise to her chest (07/18/24), a bruise to right lateral forearm (07/11/24), a bruise to her forehead (09/13/24), a bruise to her right wrist (10/08/24), a bruise to her forearm (12/13/24), a bruise to her right upper arm (01/29/25), two bruises to her right outer lower extremity (02/25/25). The care plan documented R1 had experienced traumatic events. R1 reported her husband had twisted her arm which led to bruising and this event happened over a month ago. The care plan directed staff not to discuss traumatic events with R1 as R1 was concerned about others knowing of her traumatic events (03/11/25). The Progress Note, dated 01/09/25, documented R1 often called her husband her brother. The Progress Note, dated 01/28/25, documented R1 continued to have multiple bruises from a fall on 12/30/24. The Progress Note, dated 01/29/25, documented nursing staff was helping R1 get dressed for the day and noted a new bruise on her right upper arm. The bruise measured 6.0 centimeters (cm) by 4.0 cm with a small, reddened area in the middle. When nursing staff assessed the area, R1 reached over and scratched the area. The bruise and small reddened area were consistent with R1 scratching her arm. The Progress Note, dated 02/04/25, documented the weekly skin assessment had been completed. R1 had multiple areas of bruising in various stages of healing. The Progress Note, dated 02/25/25, documented R1's skin assessment was completed that afternoon. Staff noted two small bruises next to one another on R1's right outer extremity. Bruises were reddish/purple and measured 2.5 cm by 2.0 cm and 1.5 cm by 1.0 cm. R1 communicated to staff she did not want staff to fuss over it. The administrator, director of nursing, R1's responsible party, and R1's primary care physician were notified of the bruising. The location of the bruising was consistent with wheelchair foot pedals or a walker during ambulation. The Progress Note, dated 04/01/25, documented bruising was noted to R1's right hand during her bath. The bruising measured 4.0 cm by 5.0 cm. R1 stated, Oh, that has been there a long time. When R1 was asked what happened, R1 stated, I probably swung my hand too fast and bumped it on something. R1's responsible party, administration, unit coordinator, and R1's primary care physician were notified of bruising. The edited Progress Note, dated 04/02/25 at 08:45 PM was documented as being a late entry (04/03/25 at 11:19 AM), edited on 04/03/25 at 11:23 AM, documented R1's husband visited R1 on 04/02/25 at approximately 08:45 PM. R1's husband reported he assisted R1 with getting ready for bed and while helping R1 get undressed, R1's arm got stuck in her sweater so he grabbed R1's arm to help pull her arm out of the sleeve. Evening staff reported a large bruise on R1's left forearm after R1's husband left her room. The bruising was dark blue/black in color with mild swelling noted to the area. R1's husband in to visit R1 again on 04/03/25, and LN H educated R1's husband to be cautious when assisting R1, as R1 bruised easily. LN H educated R1's husband staff would assist R1 to get ready for bed as R1 allowed. R1's primary care physician, administration, and R1's responsible party were notified of the new bruise. The EMR lacked any further documentation regarding the large black/purple bruise on R1's left forearm. LN G's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at approximately 08:45 PM, CNA M called LN G up to R1's living unit due to a bruise on R1's left forearm. LN G stated she went into R1's room and noted a bruise, dark in color, and edematous (swollen) on R1's left forearm. LN G stated she asked R1 what happened, and R1 replied, My brother got mad at me and twisted my arm! He gets mad a lot. CNA M told LN G R1 referred to her husband as her brother. LN G stated she reassured R1 she was okay. LN G stated she headed to the nurse's office to notify Administrative Staff A and told CNA M and CMA R to fill out witness statements when CMA R told LN G R1's husband had stopped by her medication cart when he was leaving and told CMA R he had lost his temper. LN G stated she called Administrative Staff A and informed her of the bruise and what the staff had reported. Administrative Staff A said, I don't believe that. Don't write up or chart anything, and I will have LN H (unit manager) follow up in the morning. LN G stated she told CNA M and CMA R what Administrative Staff A had said and told them to write a report and keep it with them. R1 was safe at that time, and her husband was gone. CMA R's Notified Witness Statement, dated 04/08/25, documented on 04/02/25 R1's husband came to visit R1 in her room. CMA R stated she checked on R1, and her husband was attempting to dress R1. CMA R stated she went back to her medication cart, and R1's husband stopped at her cart and asked if R1's condition was worsening. CMA R told R1's husband no R1 was about the same. CMA R stated that R1's husband said he lost his temper, and maybe he shouldn't have, and then left. About five to ten minutes later, CNA M came and told CMA R she had found a bruise on R1's left wrist, and R1 stated it came from her husband. CMA R stated she and CNA M called LN G to the unit to do an assessment. LN G called Administrative Staff A, and we were instructed not to report and not to do incident reports. CNA M's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at around 08:30 PM, R1 called CNA M into her room and asked CNA M if she could cover her new bruise. CNA M asked R1 how it had happened, and R1 said her husband had done it because he got mad. R1 stated her husband had grabbed her arm and applied pressure. CNA M stated she and CMA R reported the bruise to LN G, and LN G measured the bruise and called Administrative Staff A. Administrative Staff A said not to report it or make witness statements and that she would talk to LN H, the unit coordinator, and R1's husband the next day. R1's husband said it happened when he was taking R1's sweater off for bed, so they made that report of that statement because Administrative Staff A said she did not believe the first story, and R1's husband wouldn't do that. LN H's Notarized Witness Statement, dated 04/08/25, documented LN H had received a phone call on 04/02/25 in the evening from CMA R at approximately 08:52 PM. CMA R reported an incident regarding R1 and her husband. CMA R reported to LN H that R1's husband had come up to her before leaving and stated he should not have lost his temper. Staff went in to assess R1 and located a large bruise developing on R1's left forearm. CMA R reported R1 stated her husband had grabbed her arm. CMA R reported to LN H she had reported the incident to LN G. CMA R told LN H, LN G had reported the incident to Administrative Staff A and was told Administrative Staff A did not believe that is what happened, and to not make a report until Administrative Staff A and LN H were back in the office in the morning to investigate. CMA R reported to LN H that Administrative Staff A had told them not to document anything at that time, including witness statements. On the morning of 04/03/25, Administrative Staff A told LN H to investigate the incident. LN H noticed a very large bruise to R1's left arm. LN H asked R1 what had happened, and R1 stated her brother was in her room and grabbed her arm. LN H questioned R1 further, and R1 stated it was her husband who grabbed her arm. R1's husband was visiting R1 later that morning, and LN questioned R1's husband about what had happened. R1's husband reported he was getting R1 ready for bed, and her arm got stuck in her sweater, so he grabbed R1's arm to help remove her arm from the sweater. LN H told R1's husband that staff reported he had made a comment when he left the room; he shouldn't have lost his temper with R1. R1's husband did not say anything to LN H's statement. LN H educated R1's husband that staff would assist R1 get ready for bed, and if he felt himself getting irritated or angry in R1's presence, he needed to leave immediately, as this would not be tolerated. LN H informed R1 and her husband that R1's door would remain open while R1's husband visited, and staff would peek in on them frequently. LN H called R1's responsible party, her son, to discuss the incident. R1's responsible party agreed that staff should assist R1 with her bedtime routine and not her husband. Following the interviews, LN H reported her findings to Administrative Staff A. LN H told Administrative Staff A this incident should be reported, and Administrative Staff A told LN H it was outside of the reporting window and LN H needed to drop it. LN H stated she was concerned this was physical abuse due to the bruising that was left, and the statements made by R1 and her husband on the evening it happened. LN H stated she told Administrative Staff A it indeed needed to be reported and asked Administrative Staff A to go and look at the bruise herself. LN H stated she was unaware if Administrative Staff A had gone to look at R1's bruise. LN H stated she did what she was told and made the event and documentation to reflect what her superior told her to. LN H stated she asked Administrative Staff A what she wanted LN H to do about the bruise documentation, and Administrative Staff A told LN H to document R1's husband grabbed R1's arm while removing her sweater, but not to document what staff had reported regarding R1's husband losing his temper with R1. LN H was told the intervention would be for staff to assist R1 with her bedtime routine, as she allowed. LN H asked Administrative Staff A if she should add to the care plan that R1's bedroom door would remain open while R1's husband was visiting, and frequent visual checks while he was visiting R1, and was told not to. LN H stated due to being told to drop the incident and to leave it alone, she did what she was told. On 04/08/25 at 10:30 AM, observation revealed R1 sat in her recliner watching television. R1 had her sweatshirt sleeve pulled up on her left arm. R1's left forearm had a large purple bruise in various stages of healing. On 04/08/25 at 10:30 AM, R1 was very suspicious of this surveyor. R1 wanted to know why I wanted to know what happened to her arm. This surveyor pointed out a bruise on her upper shoulder and shared that her dog had caused the bruise when he jumped up on her. R1 appeared to relax and stated she got the bruise a couple of weeks ago and thought someone had grabbed her and pushed her, but she could not remember who. R1 stated that her left forearm hurt her. On 04/08/25 at 10:45 AM, CNA O stated she had not witnessed the event but had heard in report that R1's husband had grabbed her left forearm and bruised her when he was frustrated with her, and R1 had told the nurse what he had done. CNA O stated the reason R1 was admitted to the facility was because this kind of thing was happening to her in the couple's apartment at the facility. CNA O stated she could understand R1's husband getting frustrated with R1's dementia. CNA O stated she was not concerned about R1's husband hurting her, and the facility had done nothing to protect R1 from her husband. On 04/08/25 at 11:30 AM, LN H, the nurse manager of the unit R1 lived on, stated LN G, who was on duty that night, had called Administrative Staff A to let her know R1's husband had come out of R1's room and stated he and R1 had gotten into an argument. He had put his hands on R1 and caused a bruise on her left forearm. LN H stated that Administrative Staff A told LN G she did not believe her. Administrative Staff A told LN H to investigate the bruise on 04/03/25. R1 told LN H that her brother grabbed her arm and caused the bruise. R1's husband told LN H R1 had gotten her arm stuck in her sweater, and he had assisted her in getting her arm out of the sweater, which caused the bruise. LN H stated she was concerned for R1's safety with her husband visiting her and taking her out on excursions. LN H told Administrative Staff A that if this had happened outside the facility, it would have been domestic abuse, and the husband would have been arrested. LN H stated that Administrative Staff A told her to drop it and not report anything. LN H stated the facility had done nothing to protect R1 from her husband, and R1's husband visited two to three times a day. LN H stated she was scared of retribution from the facility and that she would lose her job. On 04/08/24 at 12:30 PM, CNA N stated she had heard about the incident in report the following morning, R1 had received a bruise on her forearm from her husband. CNA N stated she saw the bruise, and it was so black. CNA N stated CMA R from the evening shift was very upset about what had happened and was worried for R1's safety. On 04/08/25 at 01:30 PM, LN I stated she had been the nurse coming on the morning after the incident. LN I stated she went in to assess R1's bruise and asked R1 what had happened and R1 told LN I her brother had grabbed and twisted her arm. LN I stated R1 had dementia and it must have been traumatic to R1 for R1 to have the same story twelve hours later after the incident. On 04/08/25 at 02:00 PM, CMA R stated she had heard R1 and her husband arguing in the evening on 04/02/25, so she went into R1's room. R1 asked her to help her get changed for bed, but R1's husband told her no, he would do it and to just go. CMA R stated she went back to her medication cart to continue to pass medications and was standing at the cart when R1's husband left. CMA R stated that R1's husband stopped by her cart and asked her if R1's condition was getting worse, and CMA R stated no R1 was the same as she had been. CMA R stated that R1's husband then said, I lost my temper with her, and I shouldn't have lost my temper with her, and then left. CMA R stated CNA M had gone into R1's room, saw the bruise, and went and reported the bruise to her. CMA R said she and CNA M then called LN G and told LN G she needed to come up to assess R1's bruise. CMA R stated that LN G came out of R1's room and told CMA R and CNA M to fill out witness statements and that she was going to call Administrative Staff A to report the incident. CMA R stated LN G came back a short time later and told them she had been told by Administrative Staff A that she did not believe that happened, and to not report anything on the incident or have staff fill out any witness statements. CMA R stated she was fearful for R1's safety. CMA R stated she was scared she would lose her job at the facility for speaking out. On 04/08/25 at 02:15 PM, CNA M stated on 04/02/25 in the evening R1's husband had just left, and R1 put on her call light. CNA M went to R1's room and R1 pointed to her left forearm and said, Can you cover this up with something? I don't want to look at it. CNA M stated she asked R1 what had happened, and R1 stated her brother had gotten mad at her and grabbed her arm. CNA M stated she went right out to CMA R and told her about the bruise, and they then called LN G to come and assess R1. LN G assessed R1 and then told CNA M and CMA R to fill out witness statements. LN G then went to call Administrative Staff A and report the incident. LN G came back and told CNA M and CMA R she had been told not to document anything about the incident and not to have staff fill out witness statements. CNA M stated she was worried for R1's safety. CNA M asked if she was going to lose her job at the facility because she really liked it there. On 04/08/25 at 02:30 PM, when Administrative Staff A was asked about R1's bruise, Administrative Staff A signed into R1's chart on her computer and read the progress note about R1's bruise that occurred on 04/02/25. Administrative Staff A denied any reports of abuse related to R1's arm. Administrative Staff A reported that R1's husband reported it had occurred when he was helping R1 get her arm out of her sweater. When Administrative Staff A was asked if she had received any phone calls from staff with concerns regarding R1 on 04/02/25. Administrative Staff A stated she had received a phone call from LN G, who stated staff had concerns about abuse related to R1 and her husband. Administrative Staff A stated she stopped LN G and told her before she threw out the big A word, was there any reason to suspect abuse. Administrative Staff A told LN G she would have LN H assess R1 the next morning. Administrative Staff A confirmed she had not taken the allegation of abuse seriously and had not come to the facility to assess the situation, assess R1, or talk to staff. Administrative Staff A confirmed she had not reported the incident as an allegation of abuse, had not protected R1 from any further potential abuse and denied telling staff not to document the incident. On 04/08/25 at 06:00 PM, LN G stated she had been the nurse on duty the evening of the bruising incident. LN G stated she had been called to the unit by CMA R to assess R1's bruising to her left forearm. LN G stated that R1's arm was dark black and swollen, and R1 complained it was really painful. LN G stated that R1 asked her to please cover the bruise because she did not want to look at it. LN G stated that R1 stated her brother had gotten mad at her and grabbed her arm, causing a bruise. LN G stated she left R1's room, told CMA R and CNA N to fill out witness statements, and went to the office to call Administrative Staff A. LN G stated Administrative Staff A stated she did not believe what LN G was saying was true and LN G should not document the incident or the bruise and she would have LN H assess R1 and the situation in the morning. LN G stated she was agency staff and was worried that if she did not do what Administrative Staff A said, she would not be asked to come back to the facility. The facility's Resident Abuse, Neglect, and Exploitation Policy, revised October 2024, documented it was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents by implementing specific procedures. It was the policy of this facility that each resident would be free from abuse, neglect, exploitation, and misappropriation of property. Abuse included verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while residing in the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. Any suspicion of abuse resulting in significant injury would be reported to the State Agency within two hours and local law enforcement per agreement with the agency. It was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation. It was the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without fear of reprisal or retribution. The facility leadership would assess the needs of all residents residing in the facility to be able to identify concerns in order to prevent potential abuse. The facility failed to ensure staff responded appropriately with adequate supervision to prevent potential abuse and/or mistreatment of R1, a cognitively impaired resident. This placed R1 at risk for potential abuse and/or mistreatment. risk of abuse.

The facility identified a census of 79 residents with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to report an allegation of abuse for Resident (R) 1 immediately, but not more than two hours, to the required entities including Law Enforcement (LE) and the State Agency. This placed the resident at risk for unidentified and ongoing abuse or mistreatment. Findings included: - R1 ' s Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated 06/19/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognitive function. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 required substantial staff assistance with bathing and donning footwear. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated 02/27/25, documented R1 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with toileting hygiene, bathing, and dressing. The MDS documented R1 required supervision or touching assistance with all of her other activities of daily living. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/24, documented R1 had orientation, memory, and recall deficits. The CAA documented R1 had dementia, change in mental status, and short and long-term memory loss. The Communication CAA, dated 06/19/24, documented R1 had difficulty understanding others and being understood by others. The CAA documented R1 suffered from cognitive loss and aphasia (a condition with disordered or absent language function). R1 ' s Care Plan documented R1 had the potential for side effects related to the use of aspirin (a non-steroidal anti-inflammatory drug used to treat fever, pain, inflammation, and as an antithrombotic {medications used to prevent or treat blood clots}) and may be prone to bruising of unknown origin and directed staff to observe R1 for bruising (03/11/25). The care plan documented R1 had a bruise to her chest (07/18/24), a bruise to right lateral forearm (07/11/24), a bruise to her forehead (09/13/24), a bruise to her right wrist (10/08/24), a bruise to her forearm (12/13/24), a bruise to her right upper arm (01/29/25), two bruises to her right outer lower extremity (02/25/25). The care plan documented R1 had experienced traumatic events. R1 reported her husband had twisted her arm which led to bruising and this event happened over a month ago. The care plan directed staff not to discuss traumatic events with R1 as R1 was concerned about others knowing of her traumatic events (03/11/25). The Progress Note, dated 01/09/25, documented R1 often called her husband her brother. The Progress Note, dated 01/28/25, documented R1 continued to have multiple bruises from a fall on 12/30/24. The Progress Note, dated 01/29/25, documented nursing staff was helping R1 get dressed for the day and noted a new bruise on her right upper arm. The bruise measured 6.0 centimeters (cm) by 4 cm with a small, reddened area in the middle. When nursing staff assessed the area, R1 reached over and scratched the area. The bruise and small reddened area were consistent with R1 scratching her arm. The Progress Note, dated 02/04/25, documented the weekly skin assessment had been completed. R1 had multiple areas of bruising in various stages of healing. The Progress Note, dated 02/25/25, documented R1 ' s skin assessment was completed that afternoon. Staff noted two small bruises next to one another on R1 ' s right outer extremity. Bruises were reddish/purple and measured 2.5 cm by 2.0 cm and 1.5 cm by 1.0 cm. R1 communicated to staff she did not want staff to fuss over it. The administrator, director of nursing, R1 ' s responsible party, and R1 ' s primary care physician were notified of the bruising. The location of the bruising was consistent with wheelchair foot pedals or a walker during ambulation. The Progress Note, dated 04/01/25, documented bruising was noted to R1 ' s right hand during her bath. The bruising measured 4.0 cm by 5.0 cm. R1 stated, Oh that has been there a long time. When R1 was asked what happened, R1 stated, I probably swung my hand too fast and bumped it on something. R1 ' s responsible party, administration, unit coordinator, and R1 ' s primary care physician were notified of bruising. The edited Progress Note, dated 04/02/25 at 08:45 PM was documented as being a late entry (04/03/25 at 11:19 AM), edited on 04/03/25 at 11:23 AM, documented R1 ' s husband visited R1 on 04/02/25 at approximately 08:45 PM. R1 ' s husband reported he assisted R1 with getting ready for bed and while helping R1 get undressed R1 ' s arm got stuck in her sweater so he grabbed R1 ' s arm to help pull her arm out of the sleeve. Evening staff reported a large bruise on R1 ' s left forearm after R1 ' s husband left her room. The bruising was dark blue/black in color with mild swelling noted in the area. R1 ' s husband in to visit R1 again on 04/03/25 and LN H educated R1 ' s husband to be cautious when assisting R1 as R1 bruised easily. LN H educated R1 ' s husband staff would assist R1 to get ready for bed as R1 allowed. R1 ' s primary care physician, administration, and R1 ' s responsible party were notified of the new bruise. The EMR lacked any further documentation regarding the large black/purple bruise on R1 ' s left forearm. LN G ' s Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at approximately 08:45 PM, CNA M called LN G up to R1 ' s living unit due to a bruise on R1 ' s left forearm. LN G stated she went into R1 ' s room and noted a bruise, dark in color, and edematous (swollen) to R1 ' s left forearm. LN G stated she asked R1 what happened and R1 replied, My brother got mad at me and twisted my arm! He gets mad a lot. CNA M told LN G R1 referred to her husband as her brother. LN G stated she reassured R1 she was okay. LN G stated she headed to the nurse ' s office to notify Administrative Staff A and told CNA M and CMA R to fill out witness statements when CMA R told LN G R1 ' s husband had stopped by her medication cart when he was leaving and told CMA R he had lost his temper. LN G stated she called Administrative Staff A and informed her of the bruise and what the staff had reported. Administrative Staff A said, I don ' t believe that. [NAME] ' t write up or chart anything and I will have LN H (unit manager) follow up in the morning. LN G stated she told CNA M and CMA R what Administrative Staff A had said and told them to write a report and keep it with them. R1 was safe at that time and her husband was gone. CMA R ' s Notified Witness Statement, dated 04/08/25, documented on 04/02/25 R1 ' s husband came to visit R1 in her room. CMA R stated she checked on R1 and her husband was attempting to dress R1. CMA R stated she went back to her medication cart and R1 ' s husband stopped at her cart and asked if R1 ' s condition was worsening. CMA R told R1 ' s husband no R1 was about the same. CMA R stated R1 ' s husband said he lost his temper and maybe he shouldn ' t have and then left. About five to ten minutes later, CNA M came and told CMA R she had found a bruise on R1 ' s left wrist and R1 stated it came from her husband. CMA R stated she and CNA M called LN G to the unit to do an assessment. LN G called Administrative Staff A and we were instructed to not report and not to do incident reports. CNA M ' s Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at around 08:30 PM, R1 called CNA M into her room and asked CNA M if she could cover her new bruise. CNA M asked R1 how it had happened and R1 said her husband had done it because he got mad. R1 stated her husband had grabbed her arm and applied pressure. CNA M stated she and CMA R reported the bruise to LN G and LN G measured the bruise and called Administrative Staff A. Administrative Staff A said not to report it or make witness statements and she would talk to LN H, the unit coordinator, and R1 ' s husband the next day. R1 ' s husband said it happened when he was taking R1 ' s sweater off for bed so they made that report of that statement because Administrative Staff A said she did not believe the first story and R1 ' s husband wouldn ' t do that. LN H ' s Notarized Witness Statement, dated 04/08/25, documented LN H had received a phone call on 04/02/25 in the evening from CMA R at approximately 08:52 PM. CMA R reported an incident regarding R1 and her husband. CMA R reported to LN H R1 ' s husband had come up to her before leaving and stated he shouldn ' t have lost his temper. Staff went in to assess R1 and located a large bruise developing on R1 ' s left forearm. CMA R reported R1 stated her husband had grabbed her arm. CMA R reported to LN H she had reported the incident to LN G. CMA R told LN H, LN G had reported the incident to Administrative Staff A and was told Administrative Staff A did not believe that is what happened, and to not make a report until Administrative Staff A and LN H were back in the office in the morning to investigate. CMA R reported to LN H Administrative Staff A told them not to document anything at that time including witness statements. On the morning of 04/03/25, Administrative Staff A told LN H to investigate the incident. LN H noticed a very large bruise to R1 ' s left arm. LN H asked R1 what had happened and R1 stated her brother was in her room and grabbed her arm. LN H questioned R1 further and R1 stated it was her husband who grabbed her arm. R1 ' s husband was visiting R1 later that morning and LN questioned R1 ' s husband on what had happened. R1 ' s husband reported he was getting R1 ready for bed and her arm got stuck in her sweater, so he grabbed R1 ' s arm to help remove her arm from the sweater. LN H told R1 ' s husband staff reported he had made a comment when he left the room, he shouldn ' t have lost his temper with R1. R1 ' s husband did not say anything to LN H ' s statement. LN H educated R1 ' s husband that staff would assist R1 get ready for bed and if he felt himself getting irritated or angry in R1 ' s presence he needed to leave immediately as this would not be tolerated. LN H informed R1 and her husband R1 ' s door would remain open while R1 ' s husband visited, and staff would peak in on them frequently. LN H called R1 ' s responsible party, her son, to discuss the incident. R1 ' s responsible party agreed staff should assist R1 with her bedtime routine and not her husband. Following the interviews, LN H reported her findings to Administrative Staff A. LN H told Administrative Staff A this incident should be reported, and Administrative Staff A told LN H it was outside of the reporting window and LN H needed to drop it. LN H stated she was concerned this was physical abuse due to the bruising that was left, and the statements made by R1 and her husband on the evening it happened. LN H stated she told Administrative Staff A it indeed needed to be reported and asked Administrative Staff A to go and look at the bruise herself. LN H stated she was unaware if Administrative Staff A had gone to look at R1 ' s bruise. LN H stated she did what she was told and made the event and documentation to reflect what her superior told her to. LN H stated she asked Administrative Staff A what she wanted LN H to do about the bruise documentation and Administrative Staff A told LN H to document R1 ' s husband grabbed R1 ' s arm while removing her sweater but to not document what staff had reported regarding R1 ' s husband losing his temper with R1. LN H was told the intervention would be for staff to assist R1 with her bedtime routine as she allowed. LN H asked Administrative Staff A if she should add to the care plan R1 ' s bedroom door would remain open while R1 ' s husband was visiting and frequent visual checks while he was visiting R1 and was told not to. LN H stated due to being told to drop the incident and to leave it alone, she did what she was told. On 04/08/25 at 10:30 AM, observation revealed R1 sat in her recliner watching television. R1 had her sweatshirt sleeve pulled up on her left arm. R1 ' s left forearm had a large purple bruise in various stages of healing. On 04/08/25 at 10:30 AM, R1 was very suspicious of this surveyor. R1 wanted to know why I wanted to know what happened to her arm. This surveyor pointed out a bruise on her upper shoulder and shared her dog had caused the bruise when he jumped up on her. R1 appeared to relax and stated she got the bruise a couple of weeks ago and thought someone had grabbed her and pushed her but she could not remember who. R1 stated her left forearm hurt her. On 04/08/25 at 10:45 AM, CNA O stated she had not witnessed the event but had heard in report that R1 ' s husband had grabbed her left forearm and bruised her when he was frustrated with her and R1 had told the nurse what he had done. CNA O stated the reason R1 was admitted to the facility was because this kind of thing was happening to her in the couple's apartment at the facility. CNA O stated she could understand R1 ' s husband getting frustrated with R1 ' s dementia. CNA O stated she was not concerned about R1 ' s husband hurting her and the facility had done nothing to protect R1 from her husband. On 04/08/25 at 11:30 AM, LN H the nurse manager of the unit R1 lived on stated LN G, who was on duty that night, had called Administrative Staff A to let her know R1 ' s husband had come out of R1 ' s room and stated he and R1 had gotten into an argument. He had put his hands on R1 and caused a bruise to her left forearm. LN H stated Administrative Staff A told LN G she did not believe her. Administrative Staff A told LN H to investigate the bruise on 04/03/25. R1 told LN H her brother grabbed her arm and caused the bruise. R1 ' s husband told LN H R1 had gotten her arm stuck in her sweater and he had assisted her in getting her arm out of the sweater which caused the bruise. LN H stated she was concerned for R1 ' s safety with her husband visiting her and taking her out on excursions and told Administrative Staff A that if this had happened out of the facility it would have been domestic abuse and the husband would have been arrested. LN H stated Administrative Staff A told her to drop it and not report anything. LN H stated the facility had done nothing to protect R1 from her husband and R1 ' s husband visited two to three times a day. LN H stated she was scared of retribution from the facility and that she would lose her job. On 04/08/24 at 12:30 PM, CNA N stated she had heard about the incident in report the following morning R1 had received a bruise on her forearm from her husband. CNA N stated she saw the bruise and it was so black. CNA N stated CMA R from the evening shift was very upset about what had happened and was worried for R1 ' s safety. On 04/08/25 at 01:30 PM, LN I stated she had been the nurse coming on the morning after the incident. LN I stated she went in to assess R1 ' s bruise and asked R1 what had happened and R1 told LN I her brother had grabbed and twisted her arm. LN I stated R1 had dementia and it must have been traumatic to R1 for R1 to have the same story twelve hours later after the incident. On 04/08/25 at 02:00 PM, CMA R stated she had heard R1 and her husband arguing in the evening on 04/02/25 so she went into R1 ' s room. R1 asked her to help her get changed for bed, but R1 ' s husband told her no he would do it and to just go. CMA R stated she went back to her medication cart to continue to pass medications and was standing at the cart when R1 ' s husband left. CMA R stated R1 ' s husband stopped by her cart and asked her if R1 ' s condition was getting worse, and CMA R stated no R1 was the same as she had been. CMA R stated R1 ' s husband then said, I lost my temper with her and I shouldn ' t have lost my temper with her, and then left. CMA R stated CNA M had gone into R1 ' s room, saw the bruise, and came and reported the bruise to her. CMA R said she and CNA M then called LN G and told LN G she needed to come up to assess R1 ' s bruise. CMA R stated LN G came out of R1 ' s room and told CMA R and CNA M to fill out witness statements and that she was going to call Administrative Staff A to report the incident. CMA R stated LN G came back a short time later and told them she had been told by Administrative Staff A she did not believe that happened and to not report anything on the incident or have staff fill out any witness statements. CMA R stated she was fearful for R1 ' s safety. CMA R stated she was scared she would lose her job at the facility for speaking out. On 04/08/25 at 02:15 PM, CNA M stated on 04/02/25 in the evening R1 ' s husband had just left and R1 put on her call light. CNA M went to R1 ' s room and R1 pointed to her left forearm and said, Can you cover this up with something? I don ' t want to look at it. CNA M stated she asked R1 what had happened and R1 stated her brother had gotten mad at her and grabbed her arm. CNA M stated she went right out to CMA R and told her about the bruise, and they then called LN G to come and assess R1. LN G assessed R1 and then told CNA M and CMA R to fill out witness statements. LN G then went to call Administrative Staff A and report the incident. LN G came back and told CNA M and CMA R she had been told not to document anything about the incident and not to have staff fill out witness statements. CNA M stated she was worried for R1 ' s safety. CNA M asked if she was going to lose her job at the facility because she really liked it there. On 04/08/25 at 02:30 PM, when Administrative Staff A when asked about R1 ' s bruise, Administrative Staff A signed into R1 ' s chart on her computer and read the progress note about R1 ' s bruise that occurred on 04/02/25. Administrative Staff A denied any reports of abuse related to R1 ' s arm. Administrative Staff A reported that R1 ' s husband reported it occurred when he was helping R1 get her arm out of her sweater. When Administrative Staff A was asked if she had received any phone calls from staff with concerns regarding R1 on 04/02/25. Administrative Staff A stated she had received a phone call from LN G, who stated staff had concerns about abuse related to R1 and her husband. Administrative Staff A stated she stopped LN G and told her before she threw out the big A word, was there any reason to suspect abuse. Administrative Staff A told LN G she would have LN H assess R1 the next morning. Administrative Staff A confirmed she did not take the allegation of abuse seriously, did not come to the facility to assess the situation, assess R1, or talk to staff. Administrative Staff A confirmed she did not report the incident as an allegation of abuse, had not protected R1 from any further potential abuse, and denied telling staff not to document the incident. On 04/08/25 at 06:00 PM, LN G stated she had been the nurse on duty the evening of the bruising incident. LN G stated she had been called to the unit by CMA R to assess R1 ' s bruise on her left forearm. LN G stated R1 ' s arm was dark black and swollen and R1 complained it was really painful. LN G stated R1 asked her to please cover the bruise because she did not want to look at it. LN G stated R1 stated her brother had gotten mad at her and grabbed her arm causing the bruise. LN G stated she left R1 ' s room, told CMA R and CNA N to fill out witness statements, and went to the office to call Administrative Staff A. LN G stated Administrative Staff A stated she did not believe what LN G was saying was true and LN G should not document the incident or the bruise and she would have LN H assess R1 and the situation in the morning. LN G stated she was agency staff and was worried if she did not do what Administrative Staff A said she would not be asked to come back to the facility. The facility ' s Resident Abuse, Neglect, and Exploitation Policy, revised October 2024, documented it is the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents by implementing specific procedures. It was the policy of this facility that each resident would be free from abuse, neglect, and exploitation and misappropriation of property. Abuse included verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion and any physical or chemical restraint not required to treat the resident ' s medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while residing in the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. Any suspicion of abuse resulting in significant injury would be reported to the State Agency within 2 hours and local law enforcement per agreement with the agency. It was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation. It was the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without fear of reprisal or retribution. The facility leadership would assess the needs of all residents residing in the facility to be able to identify concerns in order to prevent potential abuse. The facility failed to report an allegation of abuse for R1 immediately, but not more than two hours, to the required entities including Law Enforcement (LE) and the State Agency. This placed the resident at risk for unidentified and ongoing abuse or mistreatment.

The facility identified a census of 79 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to immediately investigate an allegation of abuse for Resident (R) 1 and initiate protective measures to prevent further potential abuse until an investigation was completed. This deficient practice placed R1 at risk for ongoing abuse and/or mistreatment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated 06/19/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognitive function. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 required substantial staff assistance with bathing and donning footwear. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated 02/27/25, documented R1 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with toileting hygiene, bathing, and dressing. The MDS documented R1 required supervision or touching assistance with all of her other activities of daily living. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 6/19/24, documented R1 had orientation, memory, and recall deficits. The CAA documented R1 had dementia, a change in mental status, and short and long-term memory loss. The Communication CAA, dated 06/19/24, documented R1 had difficulty understanding others and being understood by others. The CAA documented R1 suffered from cognitive loss and aphasia (a condition with disordered or absent language function). R1's Care Plan documented R1 had the potential for side effects related to the use of aspirin (a non-steroidal anti-inflammatory drug used to treat fever, pain, inflammation, and as an antithrombotic {medications used to prevent or treat blood clots}) and may be prone to bruising of unknown origin and directed staff to observe R1 for bruising (03/11/25). The care plan documented R1 had a bruise to her chest (07/18/24), a bruise to right lateral forearm (07/11/24), a bruise to her forehead (09/13/24), a bruise to her right wrist (10/08/24), a bruise to her forearm (12/13/24), a bruise to her right upper arm (01/29/25), two bruises to her right outer lower extremity (02/25/25). The care plan documented R1 had experienced traumatic events. R1 reported her husband had twisted her arm, which led to bruising, and this event happened over a month ago. The care plan directed staff not to discuss traumatic events with R1, as R1 was concerned about others knowing of her traumatic events (03/11/25). The Progress Note, dated 01/09/25, documented R1 often called her husband her brother. The Progress Note, dated 01/28/25, documented R1 continued to have multiple bruises from a fall on 12/30/24. The Progress Note, dated 01/29/25, documented nursing staff was helping R1 get dressed for the day and noted a new bruise on her right upper arm. The bruise measured 6.0 centimeters (cm) by 4 cm with a small, reddened area in the middle. When the nursing staff assessed the area, R1 reached over and scratched the area. The bruise and small reddened area were consistent with R1 scratching her arm. The Progress Note, dated 02/04/25, documented the weekly skin assessment had been completed. R1 had multiple areas of bruising in various stages of healing. The Progress Note, dated 02/25/25, documented R1's skin assessment was completed that afternoon. Staff noted two small bruises next to one another on R1's right outer extremity. Bruises were reddish/purple and measured 2.5 cm by 2.0 cm and 1.5 cm by 1.0 cm. R1 communicated to staff that she did not want staff to fuss over it. The administrator, director of nursing, R1's responsible party, and R1's primary care physician were notified of the bruising. The location of the bruising was consistent with wheelchair foot pedals or a walker during ambulation. The Progress Note, dated 04/01/25, documented bruising was noted to R1's right hand during her bath. The bruising measured 4.0 cm by 5.0 cm. R1 stated, Oh, that has been there a long time. When R1 was asked what happened, R1 stated, I probably swung my hand too fast and bumped it on something. R1's responsible party, administration, unit coordinator, and R1's primary care physician were notified of bruising. The edited Progress Note dated 04/02/25 at 08:45 PM was documented as being a late entry (04/03/25 at 11:19 AM), edited on 04/03/25 at 11:23 AM, documented R1's husband visited R1 on 04/02/25 at approximately 08:45 PM. R1's husband reported he assisted R1 with getting ready for bed and while helping R1 get undressed R1's arm got stuck in her sweater so he grabbed R1's arm to help pull her arm out of the sleeve. Evening staff reported a large bruise on R1's left forearm after R1's husband left her room. The bruising was dark blue/black in color with mild swelling noted in the area. R1's husband in to visit R1 again on 04/03/25 and LN H educated R1's husband to be cautious when assisting R1 as R1 bruised easily. LN H educated R1's husband staff would assist R1 to get ready for bed as R1 allowed. R1's primary care physician, administration, and R1's responsible party were notified of the new bruise. The EMR lacked any further documentation regarding the large black/purple bruise on R1's left forearm. LN G's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at approximately 08:45 PM, CNA M called LN G up to R1's living unit due to a bruise on R1's left forearm. LN G stated she went into R1's room and noted a bruise, dark in color, and edematous (swollen) on R1's left forearm. LN G stated she asked R1 what happened, and R1 replied, My brother got mad at me and twisted my arm! He gets mad a lot. CNA M told LN G R1 referred to her husband as her brother. LN G stated she reassured R1 she was okay. LN G stated she headed to the nurse's office to notify Administrative Staff A and told CNA M and CMA R to fill out witness statements when CMA R told LN G R1's husband had stopped by her medication cart when he was leaving and told CMA R he had lost his temper. LN G stated she called Administrative Staff A and informed her of the bruise and what the staff had reported. Administrative Staff A said, I don't believe that. Don't write up or chart anything, and I will have LN H (unit manager) follow up in the morning. LN G stated she told CNA M and CMA R what Administrative Staff A had said and told them to write a report and keep it with them. R1 was safe at that time, and her husband was gone. CMA R's Notified Witness Statement, dated 04/08/25, documented on 04/02/25 R1's husband came to visit R1 in her room. CMA R stated she checked on R1, and her husband was attempting to dress R1. CMA R stated she went back to her medication cart, and R1's husband stopped at her cart and asked if R1's condition was worsening. CMA R told R1's husband no R1 was about the same. CMA R stated R1's husband said he lost his temper, and maybe he shouldn't have, and then left. About five to ten minutes later, CNA M came and told CMA R she had found a bruise on R1's left wrist, and R1 stated it came from her husband. CMA R stated that she and CNA M called LN G to the unit to do an assessment. LN G called Administrative Staff A, and we were instructed not to report and not to do incident reports. CNA M's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at around 08:30 PM, R1 called CNA M into her room and asked CNA M if she could cover her new bruise. CNA M asked R1 how it had happened, and R1 said her husband had done it because he got mad. R1 stated her husband had grabbed her arm and applied pressure. CNA M stated she and CMA R reported the bruise to LN G, and LN G measured the bruise and called Administrative Staff A. Administrative Staff A said not to report it or make witness statements and that she would talk to LN H, the unit coordinator, and R1's husband the next day. R1's husband said it happened when he was taking R1's sweater off for bed, so they made that report of that statement because Administrative Staff A said she did not believe the first story, and R1's husband wouldn't do that. LN H's Notarized Witness Statement, dated 04/08/25, documented LN H had received a phone call on 04/02/25 in the evening from CMA R at approximately 08:52 PM. CMA R reported an incident regarding R1 and her husband. CMA R reported to LN H R1's husband had come up to her before leaving and stated he shouldn't have lost his temper. Staff went in to assess R1 and located a large bruise developing on R1's left forearm. CMA R reported R1 stated her husband had grabbed her arm. CMA R reported to LN H she had reported the incident to LN G. CMA R told LN H, LN G had reported the incident to Administrative Staff A and was told Administrative Staff A did not believe that is what happened, and to not make a report until Administrative Staff A and LN H were back in the office in the morning to investigate. CMA R reported to LN H Administrative Staff A told them not to document anything at that time, including witness statements. On the morning of 04/03/25, Administrative Staff A told LN H to investigate the incident. LN H noticed a very large bruise to R1's left arm. LN H asked R1 what had happened, and R1 stated her brother was in her room and grabbed her arm. LN H questioned R1 further, and R1 stated it was her husband who grabbed her arm. R1's husband was visiting R1 later that morning, and LN questioned R1's husband about what had happened. R1's husband reported he was getting R1 ready for bed, and her arm got stuck in her sweater, so he grabbed R1's arm to help remove her arm from the sweater. LN H told R1's husband that staff reported he had made a comment when he left the room, he shouldn't have lost his temper with R1. R1's husband did not say anything to LN H's statement. LN H educated R1's husband staff would assist R1 get ready for bed, and if he felt himself getting irritated or angry in R1's presence, he needed to leave immediately, as this would not be tolerated. LN H informed R1 and her husband that R1's door would remain open while R1's husband visited, and staff would peek in on them frequently. LN H called R1's responsible party, her son, to discuss the incident. R1's responsible party agreed that staff should assist R1 with her bedtime routine and not her husband. Following the interviews, LN H reported her findings to Administrative Staff A. LN H told Administrative Staff A this incident should be reported, and Administrative Staff A told LN H it was outside of the reporting window and LN H needed to drop it. LN H stated she was concerned this was physical abuse due to the bruising that was left, and the statements made by R1 and her husband on the evening it happened. LN H stated she told Administrative Staff A it indeed needed to be reported and asked Administrative Staff A to go and look at the bruise herself. LN H stated she was unaware if Administrative Staff A had gone to look at R1's bruise. LN H stated she did what she was told and made the event and documentation to reflect what her superior told her to. LN H stated she asked Administrative Staff A what she wanted LN H to do about the bruise documentation, and Administrative Staff A told LN H to document R1's husband grabbed R1's arm while removing her sweater, but to not document what staff had reported regarding R1's husband losing his temper with R1. LN H was told the intervention would be for staff to assist R1 with her bedtime routine, as she allowed. LN H asked Administrative Staff A if she should add to the care plan R1's bedroom door would remain open while R1's husband was visiting, and frequent visual checks while he was visiting R1, and was told not to. LN H stated due to being told to drop the incident and to leave it alone, she did what she was told. On 04/08/25 at 10:30 AM, observation revealed R1 sat in her recliner watching television. R1 had her sweatshirt sleeve pulled up on her left arm. R1's left forearm had a large purple bruise in various stages of healing. On 04/08/25 at 10:30 AM, R1 was very suspicious of this surveyor. R1 wanted to know why I wanted to know what happened to her arm. This surveyor pointed out a bruise on her upper shoulder and shared that her dog had caused the bruise when he jumped up on her. R1 appeared to relax and stated she got the bruise a couple of weeks ago and thought someone had grabbed her and pushed her, but she could not remember who. R1 stated that her left forearm hurt. On 04/08/25 at 10:45 AM, CNA O stated she had not witnessed the event but had heard in report that R1's husband had grabbed her left forearm and bruised her when he was frustrated with her, and R1 had told the nurse what he had done. CNA O stated the reason R1 was admitted to the facility was because this kind of thing was happening to her in the couple's apartment at the facility. CNA O stated she could understand R1's husband getting frustrated with R1's dementia. CNA O stated she was not concerned about R1's husband hurting her, and the facility had done nothing to protect R1 from her husband. On 04/08/25 at 11:30 AM, LN H, the nurse manager of the unit R1 lived on stated LN G, who was on duty that night, had called Administrative Staff A to let her know R1's husband had come out of R1's room and stated he and R1 had gotten into an argument. He had put his hands on R1 and caused a bruise on her left forearm. LN H stated Administrative Staff A told LN G she did not believe her. Administrative Staff A told LN H to investigate the bruise on 04/03/25. R1 told LN H her brother grabbed her arm and caused the bruise. R1's husband told LN H R1 had gotten her arm stuck in her sweater, and he had assisted her in getting her arm out of the sweater, which caused the bruise. LN H stated she was concerned for R1's safety with her husband visiting her and taking her out on excursions, and told Administrative Staff A that if this had happened out of the facility, it would have been domestic abuse, and the husband would have been arrested. LN H stated that Administrative Staff A told her to drop it and not report anything. LN H stated the facility had done nothing to protect R1 from her husband, and R1's husband visited two to three times a day. LN H stated she was scared of retribution from the facility and that she would lose her job. On 04/08/24 at 12:30 PM, CNA N stated she had heard about the incident in report the following morning R1 had received a bruise on her forearm from her husband. CNA N stated she saw the bruise, and it was so black. CNA N stated CMA R from the evening shift was very upset about what had happened and was worried for R1's safety. On 04/08/25 at 01:30 PM, LN I stated she had been the nurse coming on the morning after the incident. LN I stated she went in to assess R1's bruise and asked R1 what had happened, and R1 told LN I her brother had grabbed and twisted her arm. LN I stated R1 had dementia, and it must have been traumatic to R1 for R1 to have the same story twelve hours later, after the incident. On 04/08/25 at 02:00 PM, CMA R stated she had heard R1 and her husband arguing in the evening on 04/02/25, so she went into R1's room. R1 asked her to help her get changed for bed, but R1's husband told her no, he would do it, and to just go. CMA R stated she went back to her medication cart to continue to pass medications and was standing at the cart when R1's husband left. CMA R stated R1's husband stopped by her cart and asked her if R1's condition was getting worse, and CMA R stated no, R1 was the same as she had been. CMA R stated R1's husband then said, I lost my temper with her and I shouldn't have lost my temper with her, and then left. CMA R stated CNA M had gone into R1's room, saw the bruise, and came and reported the bruise to her. CMA R said she and CNA M then called LN G and told LN G she needed to come up to assess R1's bruise. CMA R stated LN G came out of R1's room and told CMA R and CNA M to fill out witness statements and that she was going to call Administrative Staff A to report the incident. CMA R stated LN G came back a short time later and told them she had been told by Administrative Staff A that she did not believe that happened and to not report anything on the incident or have staff fill out any witness statements. CMA R stated she was fearful for R1's safety. CMA R stated she was scared she would lose her job at the facility for speaking out. On 04/08/25 at 02:15 PM, CNA M stated on 04/02/25 in the evening, R1's husband had just left, and R1 put on her call light. CNA M went to R1's room and R1 pointed to her left forearm and said, Can you cover this up with something? I don't want to look at it. CNA M stated she asked R1 what had happened, and R1 stated her brother had gotten mad at her and grabbed her arm. CNA M stated she went right out to CMA R and told her about the bruise, and they then called LN G to come and assess R1. LN G assessed R1 and then told CNA M and CMA R to fill out witness statements. LN G then went to call Administrative Staff A and report the incident. LN G came back and told CNA M and CMA R she had been told not to document anything about the incident and not to have staff fill out witness statements. CNA M stated she was worried for R1's safety. CNA M asked if she was going to lose her job at the facility because she really liked it there. On 04/08/25 at 02:30 PM, when Administrative Staff A was asked about R1's bruise, Administrative Staff A signed into R1's chart on her computer and read the progress note about R1's bruise that occurred on 04/02/25. Administrative Staff A denied any reports of abuse related to R1's arm. Administrative Staff A reported R1's husband reported it occurred when he was helping R1 get her arm out of her sweater. When Administrative Staff A was asked if she had received any phone calls from staff with concerns regarding R1 on 04/02/25. Administrative Staff A stated she had received a phone call from LN G, who stated staff had concerns about abuse related to R1 and her husband. Administrative Staff A stated she stopped LN G and told her before she threw out the big A word, was there any reason to suspect abuse. Administrative Staff A told LN G she would have LN H assess R1 the next morning. Administrative Staff A confirmed she did not take the allegation of abuse seriously, did not come to the facility to assess the situation, assess R1, or talk to staff. Administrative Staff A confirmed she did not report the incident as an allegation of abuse, had not protected R1 from any further potential abuse, and denied telling staff not to document the incident. On 04/08/25 at 06:00 PM, LN G stated she had been the nurse on duty the evening of the bruising incident. LN G stated she had been called to the unit by CMA R to assess R1's bruising to her left forearm. LN G stated R1's arm was dark black and swollen, and R1 complained it was really painful. LN G stated R1 asked her to please cover the bruise because she did not want to look at it. LN G stated R1 stated her brother had gotten mad at her and grabbed her arm, causing the bruise. LN G stated she left R1's room, told CMA R and CNA N to fill out witness statements, and went to the office to call Administrative Staff A. LN G stated Administrative Staff A stated she did not believe what LN G was saying was true and LN G should not document the incident or the bruise and she would have LN H assess R1 and the situation in the morning. LN G stated she was agency staff and was worried that if she did not do what Administrative Staff A said, she would not be asked to come back to the facility. The facility's Resident Abuse, Neglect, and Exploitation Policy, revised October 2024, documented it was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents by implementing specific procedures. It was the policy of this facility that each resident would be free from abuse, neglect, exploitation, and misappropriation of property. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while residing in the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. Any suspicion of abuse resulting in significant injury would be reported to the State Agency within two hours and local law enforcement, per agreement with the agency. It is the policy of this facility to prohibit and prevent abuse, neglect, and exploitation. It was the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without fear of reprisal or retribution. The facility leadership would assess the needs of all residents residing in the facility to be able to identify concerns in order to prevent potential abuse. The facility failed to immediately investigate an allegation of abuse for R1 and initiate protective measures to prevent further potential abuse until an investigation was completed. This deficient practice placed R1 at risk for ongoing abuse and/or mistreatment.

The facility had a census of 78 residents. The sample included 18 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide Resident (R) 25 and R277 complete information on the Notice of Medicare Non-Coverage (NOMNC) Form-10123 which informed the beneficiary of the right to an expedited review by a Quality Improvement Organization (QIO). This placed the residents at risk of uninformed decisions about their skilled services and the inability to appeal. Findings included: - A review of the CMS Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included directions for the beneficiary (resident or resident representative) to contact the QIO for questions regarding appeals. R277's NOMNC revealed Medicare Part A skilled services ended on 05/23/24. The facility provided CMS Form-10123 lacked the QIO name and contact information for R277. R25's NOMNC revealed Medicare Part A skilled services ended on 05/09/24. The facility provided CMS Form-10123 lacked the QIO name and contact information for R25. During an interview on 10/08/24 at 11:45 AM, Administrative Staff A verified staff were to insert the QIO name and phone number on each CMS Form-10123 when the resident was discharged from Medicare Part A services. The facility's Medicare Denial Notices policy, dated 09/2022, stated the facility would provide each resident with written notification with the necessary information to decide whether or not to appeal a decision to terminate Medicare care and services at least three days prior to the planned change in payor status or discharge. The Notice of Medicare Non-Coverage (NOMNC-form 10123) would include the instructions for filing an appeal along with the address and phone number of the appointed QIO. The facility failed to provide complete information on the NOMNC which informed the beneficiary of the right to an expedited review by the QIO. This placed the residents at risk of uninformed decisions about their skilled services and the inability to appeal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 78 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to prevent accidents for Resident (R) 5 when staff transported her in a wheelchair without footrests and R5 fell forward onto the floor and hit her head. This placed R5 at risk for injuries and increased pain. The facility also failed to ensure an environment free from accident hazards when staff failed to secure hazardous chemicals placing all confused, independently mobile residents at risk for accidental ingestion. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), macular degeneration (progressive deterioration of the retina), and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. R5 was dependent on staff for toileting and required substantial assistance with dressing, personal hygiene, mobility, and transfers. R5 had no functional impairment, no falls, and was dependent on staff while in the wheelchair. The Annual MDS, dated 08/14/24, documented R5 had severely impaired decision-making skills and was dependent upon staff for toileting, dressing, personal hygiene, and required substantial assistance with mobility, and transfers. R5 had no functional impairment, had one fall with injury, and was dependent upon staff while in the wheelchair. The Fall Risk Assessment, dated 04/23/24, documented R5 was at risk for falls. R5's Care Plan, dated 08/20/24 and initiated on 11/16/23, directed staff to place a floor mat beside the resident's bed, rearrange the room so one side of the bed was against the wall, and use a winged mattress. An update, dated 08/11/24, directed staff to use wheelchair foot pedals on the resident's wheelchair for all mobility and to consider relocation of the scale to the unit. The Fall Investigation, dated 08/11/24 at 10:30 AM, documented that staff transported R5 in her wheelchair from her household to another household to obtain her weight without foot pedals. As staff started to push her up the incline, R5 planted her feet on the ground, fell forward out of the wheelchair, and hit her head on the floor. R5 sustained a large hematoma (collection of blood trapped in the tissues of the skin or an organ, resulting from trauma) to the left side of her forehead and was sent to the emergency room (ER) by ambulance. The Nurse's Notes, dated 08/11/24 at 04:23 PM, documented R5 returned to the facility and all scans were negative for any fractures. The staff was directed to initiate neurological checks (a physical examination to identify signs of disorders affecting the brain, spinal cord, and nerves) per facility protocol. R5 denied pain or discomfort. The Nurse's Note, dated 08/11/24 at 08:26 PM, documented that R5 had a hematoma to the left side of her forehead that measured six centimeters (cm) by 10 cm in size, red with a scant amount of serosanguineous (semi-thick blood-tinged drainage) drainage. R5's forehead also had a red abrasion which measured four cm by four cm in size and staff attempted to apply a cold pack which R5 did not tolerate. R5 did not complain of pain or discomfort. The Nurse's Note, dated 08/13/24 at 01:51 PM, documented R5 had new bruising to the right eye that measured 2.5 cm by 0.5 cm, bruising to the left hand which measured 1.5 cm by 1.5 cm, and bruising to her right knee which measured six cm by 4.5 cm. The note documented that R5 moaned when getting out of bed with transfers. On 10/08/24 at 12:45 PM, observation revealed R5 in her wheelchair with her feet on her wheelchair pedals as Certified Nurse Aide (CNA) Q pushed R5 to a recliner in the living room area. Further observation revealed CNA Q placed the sit-to-stand lift sling (a material device used in conjunction with a hoist, to assist in safely transferring a person) around R5's waist, cued her to hold onto the handles of the lift as CNA O used the lift controller to raise R5 to a standing position and then transferred her into a recliner. On 10/08/24 at 01:00 PM, CNA O stated she was not working at the time of R5's fall, but had since been instructed to make sure the wheelchair pedals were on when R5 was taken anywhere in her wheelchair. On 10/09/24 at 09:30 AM, Licensed Nurse (LN) I stated that staff assisted R5 to another area of the facility to get her weight and they did not put wheelchair pedals on R5's wheelchair. LN I explained that R5 put her feet down as staff were pushing the wheelchair and the resident fell from the chair. LN I said R5 did have a hematoma but did not have any broken bones. LN I stated that although it was not care planned, wheelchair pedals were to be used for every resident in a wheelchair when being transported anywhere. On 19/09/24 at 11:54 AM, Administrative Nurse D stated staff should have put the pedals on R5's wheelchair. Adminstrative Nurse D stated that after R5's fall, the nurse put black bags on the backs of all the wheelchairs in the facility to ensure the pedals stayed with the wheelchair and staff had them placed on the wheelchairs. The facility's Fall Prevention undated policy documented that each elder at the facility would be provided services and care that ensured the environment remained as free from accident hazards as possible and each elder received adequate supervision and assistive devices to prevent accidents. The policy documented every elder would be assessed for the causal risk factors for falls at the time of admission, upon return from a health care facility, and after every fall in the facility. The interdisciplinary team would develop a plan for services to improve or maintain the elders' standing and sitting balance and other interventions to reduce the elder's risk for falls. The facility failed to ensure R5's environment remained free from accident hazards when they failed to put wheelchair pedals on R5's wheelchair. This placed the resident at risk for increased pain and further falls with injury. - On 10/08/24 at 03:35 PM, observation revealed the elevator on the main floor had a green button to push that deactivated the door alarm. Two staircases on the main floor (one on the left side of the hall across from the medication cart, and one to the right of the elevator) also had a green button to deactivate the door alarms. The staircases and elevator led to the lower floor of the facility where a maintenance shop was accessible through an unlocked double door. Observation revealed four spray bottles and four one-gallon jugs of hazardous chemicals accessible in the maintenance room. The facility identified two residents who were cognitively impaired, independently mobile, and resided on the main floor of the facility. On 10/08/24 at 03:35 PM, Social Services X verified the maintenance door was unlocked with no staff in that area and hazardous chemicals were accessible in the room. On 10/08/24 at 03:40 PM, Administrative Nurse D agreed the elevator and the exits to the stairways being accessible was a potential accident hazard. She stated the facility did not have any residents attempting to use the elevator or stairs without staff. On 10/09/24 at 08:00 AM, Administrative Staff A stated the stairs were fire exits. The facility's Fall Prevention Protocol policy, undated, stated each elder residing at this facility would be provided services and care to ensure the elder's environment remained as free from accident hazards as possible. The facility failed to ensure hazardous chemicals were not accessible to confused, independently mobile residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 78 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure a communication process between the hospice provider and the facility for one of two residents reviewed for hospice services, Resident (R) 29. This placed the resident at risk of not receiving adequate end-of-life care. Findings included: - R29's Electronic Medical Record (EMR) documented the resident had diagnoses of chronic obstructive pulmonary disease (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure, and cerebrovascular disease (conditions that affect blood flow to your brain). R29's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. The MDS documented R29 required partial to moderate staff assistance with toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, sitting to lying and lying to sit, sitting to stand and transfers, and supervision with ambulation and eating. The MDS noted that R29 received hospice services. R29's Care Plan, revised 09/04/24, documented the resident required supervision and limited staff assistance with activities of daily living (ADL). The care plan lacked mention of R29's hospice admission and guidance for staff regarding hospice services. The 07/02/23 Physician Order instructed staff to admit R29 to hospice service. On 10/08/24 at 08:15 AM, observation revealed R29 sat in a recliner in his room. He had his eyeglasses on, shoes on, and no signs or symptoms of pain. During an interview on 10/09/24 at 10:05 AM, Administrative Nurse D verified the facility care plan lacked a section regarding hospice services and stated it should have one. The Nursing Facility Hospice Services Agreement, dated October 2024, revealed hospice would provide a comprehensive set of services identified and coordinated by an interdisciplinary team to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and family members, as delineated in a specific plan of care in collaboration with the facility. The facility failed to ensure a communication process between the hospice provider and the facility for R29, to include a plan of care from the hospice and a description of the services provided, noting visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving adequate end-of-life care.

The facility had a census of 78 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to identify and dispose of expired medications appropriately. This deficient practice placed residents at risk for ineffective medications. Findings included: - On 10/07/24 at 02:59 PM, observation revealed the Harvest Household medication cart contained the following expired medications: A bottle of calcium supplements with an expiration date of 11/2023. A bottle of senior multivitamins (MVI) with an expiration date of 10/2023. A bottle of MVI with an expiration date of 06/2024. A bottle of magnesium oxide (supplement) with an expiration date of 08/2024. A bottle of D3 (vitamin) with an expiration date of 08/2024. A Metamucil (fiber laxative) canister with an expiration date of 08/2024. A bottle of bisacodyl (laxative) pills with an expiration date of 09/2024. A bottle of Preservision (vision supplement) with an expiration date of 09/2024. On 10/07/24 at 02:59 PM, Certified Medication Aide (CMA) R verified the dates on the expired medications. On 10/08/24 at 03:10 PM, Administrative Nurse D stated staff periodically inspected the medication carts to check the expiration date for medications. Administrative Nurse D stated staff should have removed the expired medications. She stated the nurse coordinators were also responsible for checking for expired medications and the pharmacist consultant checked medication carts monthly. The facility's Disposition of Unusable and Outdated Drugs policy, dated 03/2024, stated all discontinued, outdated, contaminated drugs would be returned to the provider pharmacy for proper disposal or destroyed onsite. Those drugs would be stored in an isolated area designated for the storage of unusable drugs until the drugs could be destroyed or returned. All drug storage areas of the facility would be inspected, including the emergency kit, for outdated drugs on a weekly basis by facility nursing staff and on a monthly basis by the contracted consulting pharmacist. The responsible staff member conducting the inspection would remove all outdated drugs from the area and record the type and amount of drugs removed. The facility failed to identify and dispose of expired medications appropriately, placing residents at risk of receiving ineffective medication.

The facility had a census of 78 residents and one kitchen. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 10/08/24 a 10:15 AM, observation in the kitchen revealed the following concerns: 1. Four upper and six lower wooden cupboards located by the three sinks had numerous different-sized scrapes on the outer surface. 2. Three wooden bottom cupboards and nine cupboard drawers located by the ice machine had numerous different-sized scrapes on the outer surface. 3. Two white fans on the wall had grayish debris on the blades. 4. The right door frame, located by the entrance to three sink areas, approximately four feet high, was missing a piece of trim. 5. A black trash can located to the left of the entrance door to the three sink areas had numerous different-sized streaks of brownish substance around the sides of it and on the lid. 6. Four bottom wooden and five upper cupboards located by the counter silver microwave, next to the bread rack, had numerous different size scrapes in the outer wood. 7. The mop board around the perimeter of the kitchen had numerous different-sized areas with a grayish-black substance on them. The facility's Kitchen Cleaning Sheet, had tasks listed for dietary staff to complete daily, weekly, and as used. On 10/08/24 at 12:30 PM, Certified Dietary Manager BB verified the above findings and stated the dietary aides had a cleaning schedule to follow. She said she was aware of the issues with the kitchen cupboards. The facility's Kitchen Cleaning and Sanitation of Dining and Food Service Areas Policy, revised 05/01/2013, documented that food service staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for the 78 residents who received their meals from the facility's kitchen. This placed the 78 residents at risk for foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to notify Resident, (R) 26's physician and the resident representative of a bruise of unknown origin on R26's inner thigh. This placed the resident at risk for emotional and physical decline. Findings included: - The Electronic Medical Record for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (a feeling of worry, nervousness or unease), and depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for toileting, dressing, and was independent with ambulation, transfers, and bed mobility. The MDS further documented R26 had physical behavior toward others four to six days, wandered one to three days, and had a wander guard (a security system to monitor residents who are at risk for elopement) bracelet. The Annual MDS, dated 01/26/23, documented R26 had severely impaired cognition and required supervision with ambulation, toileting, and independent with bed mobility and transfers. The MDS further documented R26 wandered one to three days, had no behaviors, and had a wander alarm daily. The Care Plan, dated 01/31/23, originated on 12/05/20, documented R26 may try to hit staff and others, may go into other resident rooms, and was not easily redirectable R26 may have altered level of consciousness, inattention, and disorganized thoughts. The care plan directed staff to document at the end of each shift how often and how the resident responded regarding her behaviors. The Nurse's Note, dated 01/16/23 at 08:52 PM, documented a Certified Nurse Aide (CNA) reported R26 had a bruise on her inner thigh but R26 was asleep when the nurse went to assess the resident. The note further documented the nurse was unable to assess the bruise and left a note for the dayshift to assess. The EMR lacked documentation an assessment was completed, or the physician and family were notified. On 04/24/23 at 03:09 PM, observation revealed R26 ambulated down the hall from her room, was pleasant and cooperated with staff. On 04/24/23 at 01:24 PM, Licensed Nurse (LN) G verified the physician and resident representative was not notified. On 04/25/23 at 09:45 AM, CNA M stated, R26 was often combative with staff but if you leave her alone for a while, then go back to assist her, she is more cooperative. CNA M further stated, you must report and bruise or skin tear to the nurse so she can fill out a report. CNA M stated she had never filled out any witness statement after she had reported a bruise. On 04/26/23 at 08:39 AM, Administrative Nurse D stated she expected staff to report the incidents to administration, physician, and family. The facility's Significant Changes in a Resident's Condition/Serious Medical Emergency policy, dated August 2007, documented the facility would notify a resident's attending physician of any significant change in a resident's condition or serous medical emergency that threatened the health, safety or welfare of a resident. If non-immediate change in a resident's condition, the resident's physician shall be notified of the non-immediate change immediately or as soon as practicable (but no later than 24 hours) after the physician shall be called. The facility shall notify the resident's family, legal guardian or responsible party whenever unusual circumstances such as accidents, sudden illness or disease arise. The facility failed to notify R26's physician and resident representative of a bruise of unknown origin, placing the resident at risk for emotional and physical decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to administration a bruise of unknown origin on an inner thigh and failed to report to the state agency bilateral bruising of unknown origin to wrists for one sampled resident, Resident (R) 26. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (a feeling of worry, nervousness or unease), and depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for toileting, dressing, and was independent with ambulation, transfers, and bed mobility. The MDS further documented R26 had physical behavior toward others four to six days, wandered one to three days, and had a wander guard (a security system to monitor residents who are at risk for elopement) bracelet. The Annual MDS, dated 01/26/23, documented R26 had severely impaired cognition and required supervision with ambulation, toileting, and independent with bed mobility and transfers. The MDS further documented R26 wandered one to three days, had no behaviors, and had a wander alarm daily. The Care Plan, dated 01/31/23, originated on 12/05/20, documented R26 may try to hit staff and others, may go into other resident rooms, and was not easily redirectable R26 may have altered level of consciousness, inattention, and disorganized thoughts. The care plan directed staff to document at the end of each shift how often and how the resident responded regarding her behaviors. The Nurse's Note, dated 01/16/23 at 08:52 PM, documented a Certified Nurse Aide (CNA) reported R26 had a bruise on her inner thigh but R26 was asleep when the nurse went to assess the resident. The note further documented the nurse was unable to assess the bruise and left a note for the dayshift to assess. The EMR lacked documentation an assessment was completed, or the physician and family were notified. The Event Report, dated 03/06/23, documented R26 had dark blue/purple bruises the size of a golf ball on the back of both of her wrists, had no swelling or pain, and R26 was regularly combative with staff. The report lacked documentation of how R26 obtained the bruises. The facility was unable to provide a completed investigation related to the bruises of unknown origin for either incident. On 04/24/23 at 03:09 PM, observation revealed R26 ambulated down the hall from her room, was pleasant and cooperated with staff. On 04/24/23 at 01:24 PM, Licensed Nurse (LN) G stated they had not completed any witness statements regarding the bruises on R26's wrists and could not say what exactly happened that caused the bruises. LN G verified there had not been an investigation and had not been reported for the bruise on the resident's inner thigh. On 04/25/23 at 09:36 AM, LN H stated if staff report a bruise or skin tear, a event report was completed and staff interviewed, witness statements, and documentation in the progress notes were also done. On 04/25/23 at 09:45 AM, CNA M stated, R26 was often combative with staff but if you leave her alone for a while, then go back to assist her, she is more cooperative. CNA M further stated, you must report and bruise or skin tear to the nurse so she can fill out a report. CNA M stated she had never filled out any witness statement after she had reported a bruise. On 04/26/23 at 08:39 AM, Administrative Nurse D stated she expected staff to do a thorough investigation for any bruises or injuries and reporting the incidents to administration, physician, and family. The facility ANE policy, dated October 2022, documented all allegations and reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown sours, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy further documented a report investigation and analysis would be completed, the information gathered and given to administration. Incidents in which a resident was injured or had the potential for injury and the cause of the incident was unknown will also be promptly investigated. Report all of the investigations to administration and/or his/her designated representative and to other officials in accordance with State law, including immediate or 24-hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report two separate incidents in which cognitively impaired R26 received bruises of unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate two separate areas of bruising for one sampled resident, Resident (R) 26, who had bilateral bruising of unknown origin to her wrists, and bruising of unknown origin to her inner thigh. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (a feeling of worry, nervousness or unease), and depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for toileting, dressing, and was independent with ambulation, transfers, and bed mobility. The MDS further documented R26 had physical behavior toward others four to six days, wandered one to three days, and had a wander guard (a security system to monitor residents who are at risk for elopement) bracelet. The Annual MDS, dated 01/26/23, documented R26 had severely impaired cognition and required supervision with ambulation, toileting, and independent with bed mobility and transfers. The MDS further documented R26 wandered one to three days, had no behaviors, and had a wander alarm daily. The Care Plan, dated 01/31/23, originated on 12/05/20, documented R26 may try to hit staff and others, may go into other resident rooms, and was not easily redirectable R26 may have altered level of consciousness, inattention, and disorganized thoughts. The care plan directed staff to document at the end of each shift how often and how the resident responded regarding her behaviors. The Nurse's Note, dated 01/16/23 at 08:52 PM, documented a Certified Nurse Aide (CNA) reported R26 had a bruise on her inner thigh but R26 was asleep when the nurse went to assess the resident. The note further documented the nurse was unable to assess the bruise and left a note for the dayshift to assess. The EMR lacked documentation an assessment was completed, or the physician and family were notified. The Event Report, dated 03/06/23, documented R26 had dark blue/purple bruises the size of a golf ball on the back of both of her wrists, had no swelling or pain, and R26 was regularly combative with staff. The report lacked documentation of how R26 obtained the bruises. The facility was unable to provide a completed investigation related to the bruises of unknow origin for either incident. On 04/24/23 at 03:09 PM, observation revealed R26 ambulated down the hall from her room, was pleasant and cooperated with staff. On 04/24/23 at 01:24 PM, Licensed Nurse (LN) G stated they had not completed any witness statements regarding the bruises on R26's wrists and could not say what exactly happened that caused the bruises. LN G verified there had not been an investigation for the bruise on the resident's inner thigh. On 04/25/23 at 09:36 AM, LN H stated if staff report a bruise or skin tear, a event report was completed and staff interviewed, witness statements, and documentation in the progress notes were also done. On 04/25/23 at 09:45 AM, CNA M stated, R26 was often combative with staff but if you leave her alone for a while, then go back to assist her, she is more cooperative. CNA M further stated, you must report and bruise or skin tear to the nurse so she can fill out a report. CNA M stated she had never filled out any witness statement after she had reported a bruise. On 04/26/23 at 08:39 AM, Administrative Nurse D stated she expected staff to do a thorough investigation for any bruises or injuries and reporting the incidents to administration, physician, and family. The facility ANE policy, dated October 2022, documented all allegations and reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown sours, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy further documented a report investigation and analysis would be completed, the information gathered and given to administration. Incidents in which a resident was injured or had the potential for injury and the cause of the incident was unknown will also be promptly investigated. The facility failed to investigate two separate incidents in which cognitively impaired R26 received bruises of unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop a baseline initial care plan (a care plan that includes the instructions needed to provided effective and person- centered care of the resident that meet professional standards of quality care) for Resident (R)185 who received dialysis services (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). This placed the resident at risk for complications related to uncommunicated care needs. Findings included: - R185's diagnoses included end stage renal disease (decline in kidney function) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R185's admission Minimum Date Set (MDS), dated [DATE], recorded the resident had a Brief Interview Status (BIMS) score of eight, indicating moderately impaired cognition. The MDS recorded the resident required limited assistance of one staff for bed mobility, transfers, and was independent with dressing, toileting, and personal hygiene. The MDS recorded the resident received dialysis treatment. The Care Area Assessments (CAA) were not completed due to admission [DATE]. R185's medical record lacked a baseline dialysis care plan. The Physician Order, dated 04/18/23, documented R185 had dialysis on Monday, Wednesday and Friday from 11:00 AM to 03:00 PM. It directed staff to monitor fistula for bruit (blowing or swishing sound heard which reflects the blood flow with a dialysis resident's shunt) and thrill (a fine vibration felt which reflects the blood flow by a dialysis resident's shunt) every shift. The facility lacked had a Dialysis Communication form the dialysis center on 04/19/23 and 04/24/23 and lacked a Dialysis Communication on 04/21/23. On 04/24/23 at 08:00 AM, observation revealed the resident dressed in street clothes and sat on the side of her bed eating breakfast. On 04/20/21 at 4:30 PM, Licensed Nurse (LN)G verified the facility lacked a care plan for dialysis. LN G verified the resident care plan lacked documentation the resident received dialysis services. On 04/24/23 at 02:30 PM, LN J verified the resident received dialysis three times a week and the facility did not send a communication sheet just a sheet for the dialysis facility to return a communication sheet when returned to the facility. The facility's Comprehensive Care Plan policy, dated June 2003, documented the facility would develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. A baseline care plan would be developed within 48 hours of admission, including initial goals, preference and services, as well as discharge goals of the resident. A copy of the care plan would be available upon request. The care plan would be prepared by the interdisciplinary team that includes a registered nurse, and other appropriate staff in disciplines as determined by the resident's needs, including a nurse aide, a representative of food and nutrition services and a Social Worker, and the resident, the resident's family or legal representative should participate in the care plan. Those in attendance are to sign the care plan review verification. The care plan would include any specialized services or specialized rehabilitation services. The facility failed to develop an initial care plan for R185 who received dialysis services, placing the resident at risk for inappropriate care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically related social services to attain to maintain the highest practicable physical, mental, and psychosocial well-being of Resident (R) 56 who exhibited depression and had behaviors. This placed R56 at risk for further decline in depression. Findings included: - R56's Electronic Medical Record (EMR) recorded diagnoses of pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), repeated falls and hypertension (elevated blood pressure). The Quarterly Minimum Data Set, dated [DATE], documented R56 had intact cognition, exhibited no behaviors, was independent with most activities of daily living (ADL) with exception of bathing which required extensive assistance of one staff. R56 had diagnoses of depression, received scheduled pain medication, insulin (medication used to treat elevated blood sugars), antidepressant (medication to treat depressions), anticoagulant (medication used to prevent clotting of blood), diuretic (medication to promote the formation and excretion of urine), and an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing ] and other mental emotional conditions) on a routine basis. The Care Area Assessment (CAA), dated [DATE], documented R56 had depression and confusion with behaviors that usually occurred in the evenings and mostly having to do with bathing needs, had pain and received an antidepressant and an antipsychotic. The Care Plan dated [DATE], documented R56 may verbalized and/or demonstrate unresolved grief. The care plan directed staff to encourage R56 to verbalize feelings, offer emotional support as accepted/desired, provide one to one visits, assess for presence and source of grief, and establish a trusting relationship. It directed staff to encourage R56 to express grief in one to one visits, recognize and reinforce strengths. It further directed staff to discuss the impact of R56's loss and how it related to her function, observe her grief reaction and encourage identification of productive coping mechanisms. The Physician Order, dated [DATE], directed staff to administer Seroquel (antipsychotic) 25 milligrams (mg) at bedtime for depression. The Physician Order, dated [DATE], directed staff to administer sertraline (antidepressant) 200 mg daily for depression. The Resident Mood Interview (PHQ-9), dated [DATE], documented R56 felt down, depressed or hopeless, two to six days of a seven day look back and R56 was tired or had little energy nearly every day. The Progress Note, dated [DATE] at 12:49 PM, documented R56 complained of pain and feeling weaker. Staff explained importance of getting out of her room and socialize with others to build strength to walk again. R56 initially agreed with staff recommendations, then later stated the reason she had not came out of her room because the area was loud, everyone was sick, staff filled the chairs with people who slept so not one else could join in the area and stated it was rude. R56 became angry and stated she did not want to talk about it . On [DATE] at 08:05 AM, R56 reported she nearly died due to congested heart failure and the physician saved her by removing 50 pounds of fluid. She verified she took insulin, diuretic and an antidepressant. She was cognitively intact and pleasant during interview. R56 stated she liked the facility staff and had stated staff are too busy to listen. R56 discussed at length her life experiences, religious beliefs, losses, and connecting with friends and family. On [DATE] at 01:45 PM Certified Nurse Aide (CNA) N reported R56 once in a while had behaviors and R56 had yelled at her and when that happened CNA told the resident she would leave and come back at a later time when she wanted to talk about the concern. On [DATE] at 08:24 AM, Licensed Nurse (LN) J reported R56 moods fluctuated from day to day. LN J verified R56 had been offered counselling in [DATE], but the resident declined, reporting she had not been depressed. LN J verified counselling had not been offered since. LN J verified R56 had depression and was possibly trying to process grief and losses. On [DATE] at 08:55 AM, Social Service X stated she had visited with R56 recognized R56 had depression. Social Services X said she was assisting the resident as the care plan directed but had not documented the few visits that were made with R56. On [DATE] at 09:26 AM, Administrative Nurse D stated the care plan and interventions should be done to support the resident in behaviors, loss and grief. The undated Social Service policy, documented the facility will provide medically related social services to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Assisting residents in voicing and obtaining resolution to grievance about treatment, living conditions, visitation rights and accommodation of needs. Social service staff will identify and promoting individualized non-pharmacological approaches to care that meet the mental ad psychosocial needs of with each resident, meeting the needs of resident who are grieving losses and coping with stressful events. Social service staff will provide social service or obtain needed services from outside entities including but not limited to the following: difficulty coping change or loss and need for emotional support. The facility failed to identify and provide medically related social services to attain or maintain the highest practicable physical, mental ad psychosocial well-being for R56 who had depression and personal loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census 81 resident. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a stop date for the use of an as needed antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for Resident (R) 40 which placed R40 at risk for inappropriate use of antianxiety medication. Findings included: - R40'sElectronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) disorder, traumatic hemorrhage (loss of a large amount of blood in a short period of time) of left cerebrum (largest portion of the brain), and restlessness and agitation. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R40 had severe cognitive impairment, inattention and disorganized thinking continuously present, altered level of consciousness fluctuating behavior, required extensive to total assistance of one staff member with activities of daily living (ADL), and was incontinent or urine and bowel. The MDS further documented R40 received routine antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), hypnotic (sleep inducing), and opioid (used to treat pain) medications. The Care Plan, date 03/15/23, documented R40 had diagnoses which included dementia, depression and pain. R40 had confusion, memory problems, attention span which fluctuated, look for family in hallways, call out wanting to go home, tearful, irritated, agitated, and upset about being at the facility. R40 may make rude comments, be mean to staff and other residents, hallucinated, and had inattention and disorganized thoughts. The care plan directed staff to encourage R40 to share her personal stories and experiences, offer spiritual support, music as desired, offered group activities in the neighborhood. The Physician Order, dated 02/10/23, directed staff to administer lorazepam 0.5 milligram (mg) tablet one to two tablets by mouth ever four hours prn for restlessness and agitation. The order lacked a stop date. The CP monthly medication review for March 2023 lacked evidence the CP identified and reported the lack of a stop date for the as needed lorazepam The Electronic Medication Administration Record (EMAR) documented R40 received prn lorazepam on 02/06/23. The EMAR review revealed R40 lacked administration of prn lorazepam for 03/2023 and 04/2023. On 04/24/23 at 01:50 PM, observation revealed R40 seated in her recliner in her room. On 04/26/23 at 08:18 AM, Licensed Nurse (LN) J stated prn antianxiety medication should have a stop date of 14 days of date ordered. LN J stated R40's had the prn lorazepam reordered for six months and lacked a stop date and was left opened ended. On 04/26/23 at 09:33 AM Administrative Nurse D verified the prn lorazepam should have had a stop date. The facility's Drug Regimen Review, dated 01/2017, documented the consultant pharmacist will preform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when requested by team members of the facility but no longer of prn prescriptions of psychotropic drugs to include anti-psychotic drugs for longer than fourteen days and prn medication to be discontinued for non-use. The facility failed to ensure the CP identified and report to the Director of Nursing, medical director and physician the need for a stop date for lorazepam. This placed R40 at risk for inappropriate use of psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 81 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40's as needed (prn) lorazepam (an antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic (altering mood or mind) medication use. Findings included: - R40'sElectronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) disorder, traumatic hemorrhage (loss of a large amount of blood in a short period of time) of left cerebrum (largest portion of the brain), and restlessness and agitation. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R40 had severe cognitive impairment, inattention and disorganized thinking continuously present, altered level of consciousness fluctuating behavior, required extensive to total assistance of one staff member with activities of daily living (ADL), and was incontinent or urine and bowel. The MDS further documented R40 received routine antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), hypnotic (sleep inducing), and opioid (used to treat pain) medications. The Care Plan, date 03/15/23, documented R40 had diagnoses which included dementia, depression and pain. R40 had confusion, memory problems, attention span which fluctuated, look for family in hallways, call out wanting to go home, tearful, irritated, agitated, and upset about being at the facility. R40 may make rude comments, be mean to staff and other residents, hallucinated, and had inattention and disorganized thoughts. The care plan directed staff to encourage R40 to share her personal stories and experiences, offer spiritual support, music as desired, offered group activities in the neighborhood. The Physician Order, dated 02/10/23, directed staff to administer lorazepam 0.5 milligram (mg) tablet one to two tablets by mouth ever four hours prn for restlessness and agitation. The order lacked a stop date. The Electronic Medication Administration Record (EMAR) documented R40 received prn lorazepam on 02/06/23. On 04/24/23 at 01:50 PM, observation revealed R40 seated in her recliner in her room. On 04/26/23 at 08:18 AM, Licensed Nurse (LN) J stated prn antianxiety medication should have a stop date of 14 days of date ordered. LN J stated R40's had the prn lorazepam reordered for six months and lacked a stop date and was left opened ended. On 04/26/23 at 09:33 AM Administrative Nurse D verified the prn lorazepam should have had a stop date. The facility's undated Psychotropic Medication Use policy, document Centers for Medicate and Medicaid Services (CMS) regulation state that each resident's drug regimen must ne free from unnecessary drugs and define what is considered an unnecessary drug. The resident's need for psychotropic medication will be monitored as well as when the resident received optional benefit from the medication and when medication dose can be lowered or discontinued. Both the physician and the nursing staff will evaluate the effectiveness of prn for psychotropic drug to manage behaviors. The facility failed to provide a stop date for the use of prn lorazepam for R40 placing the resident at risk for receiving unnecessary psychotropic medication.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a medications error rate of less than five percent (%). The facility medications error rate was 8.33 % placing the residents at risk for complications related to medications errors. Findings included: - Resident (R) 68's Physician Order, dated 05/09/22, directed staff to administer levothyroxine (medication that treats a condition in which the thyroid gland doesn't produce enough thyroid hormone), 75 microgram (mcg), one tablet, by mouth daily and give on an empty stomach. R68's Physician Order, dated 10/22/22, directed staff to administer Novolog, (a rapid-acting insulin that helps lower mealtime blood sugar spikes) 10 units, subcutaneous, 30 minutes before meals. On 04/24/23 at 08:02 AM, observation revealed Licensed Nurse (LN) I administered levothyroxine 75 mcg and Novolog 10 U medication to R68 after she had already ate her breakfast. On 04/24/23 at 08:15 AM, LN I verified she had not followed the physician orders correctly when she administered R68 her medications. On 04/26/23 at 08:45 AM, Administrative Nurse D stated the nurse should follow physician orders when administering medications. The facility's Medication Administration policy, dated May 2006, documented the facility would provide pharmaceutical services to meet the needs of each resident and the medications would be administered at the right time. The policy further documented, medication errors and drug reactions should be reported to the physician and pharmacist. The facility failed to ensure a medication error rate of less than 5% when facility's error rate was 8.33%. This placed the residents at risk for complications related to medication errors.

The facility had a census of 81 residents. Based on observation, record review and interview the facility failed to adhere to infection control for transmission based precautions (TBP-an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R)7, who had vancomycin resistant enterococci (antibiotic resistant bacterial infections), which placed the residents who received care from the exposed staff at risk for possible exposure of infection. Findings included: - On 04/24/24 at 04:00 PM observation revealed Certified Nurse Aide (CNA) O and CNA P entering the room of R7 who was on TBP. A sign was posted on the door giving instructions on personal protection equipment (PPE-gown and gloves). The room had a plastic tote with PPE supplies placed outside of the doorway. CNA O and CNA P entered the room wearing a surgical mask and transferred the resident from her wheelchair to the bed per sit to stand lift. The staff then assisted the resident with perineal cares and changed her brief. CNA O and CNA P verified they had not worn full PPE in the isolation room and were not aware they had to. On 04/24/23 at 4:20 PM observation revealed Licensed Nurse (LN) K donned (putting on) PPE gown, gloves and mask before entering R 7's room. CNA O and CNA P were also instructed by LN K they were to wear the PPE before caring for R7. LN K and CNA P entered R7's room and changed R7's left buttock wound dressing. The staff doffed (taking off) the PPE before exiting R7's room and placed in a plastic trash can inside of the resident's room. Staff cleansed their hands with antibacterial gel before exiting the resident's room. On 04/24/23 at 04:20 PM interview with LN K verified R 7's entrance door had a sign posted on the door with instructions for wearing appropriate PPE and a plastic tote with PPE outside the resident's door. LN K verified staff should wear appropriate PPE when providing cares for the resident. On 4/25/23 at 04:40 PM interview with Administrative Nurse D and Administrative Nurse E verified the staff should wear PPE when providing cares for R7 and verified they would immediately go and do some education with the staff in regard to the precautions and wearing PPE for the resident cares. Administrative Nurse E verified the aides would change their clothes before continuing to provide care for the residents for the rest of their shift. The facility's Vancomycin Resistant Enterococci (VRE) policy, undated, documented the facility would facilitate safe care of all residents and staff with unknown or suspected communicable disease. VRE can be transmitted by direct contact with a resident or by indirect contact with environmental surfaces or residents care items in the resident's environment. Resident with known or suspected communicable diseases would be placed in the appropriate type of isolation precautions consistent with Center for Disease Center recommendations and guidelines. Isolation equipment and supplies would be available at all times. All staff are responsible for complying with isolation precautions and for tactfully calling observed variances to policy to the attention of any person(s) not following the policy. VRE Contact Precautions require gloves with contact, gown when entering room, mask, discard soiled PPE in totally controlled and contained in plastic bags. Place instructional sign on the resident's door to direct inquires to nurse. Hands should be washed with antimicrobial soap after gloves removed. The facility failed to adhere to infection control standards and policies for R7 who required TBP for VRE, which placed placed the residents who received care from the exposed staff at risk for possible exposure of infection.

The facility had a census of 80 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to notify the physician of low blood sugars for one sampled resident, Resident (R) 4. Findings included: - R4's admission Minimum Data Set (MDS), dated 07/07/21, documented the resident had a Brief Interview for Mental Status (BIMS) score of five (severe cognitive impairment). The MDS documented R4 transferred and ambulated independently, had a diagnosis of diabetes (disease that impairs the body's ability to regulate blood sugar) and received insulin injections seven days a week. The Diabetic Care Plan, dated 07/07/21, directed staff to check R4's blood sugars as ordered by the physician, monitor for signs and symptoms of hypoglycemia (less than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The Physician's Standing Orders, dated 06/28/21, directed staff to assess and treat R4 if she had blood sugars less than 60 milligrams per deciliter (mg/dl), symptoms of hypoglycemia, and notify the physician. The Physician's Order, dated 09/15/21, directed staff to check R4's blood sugar levels upon rising in the morning and two hours after breakfast, lunch and supper. Review of R4's September 2021 Medication Administration Record (MAR) recorded the resident had the following blood sugar levels less than 60 mg/dl, and lacked physician notification: 09/21/21 at 07:18 PM - 41 mg/dl 09/22/21 at 02:37 PM - 48 mg/dl 09/23/21 at 05:14 PM - 38 mg/dl 09/27/21 at 08:28 PM - 39 mg/dl On 10/04/21 at 09:53 AM, observation revealed R4 ambulated with a walker and staff assistance in the hallway. On 10/04/21 at 10:08 AM, Licensed Nurse (LN) I stated staff should check R4's blood sugars as ordered by the physician, and follow the facility's hypoglycemic protocol to notify the physician if R4 had blood sugars less than 60 mg/dl. On 10/05/21 at 11:13 AM, Administrative Nurse D stated staff should check R4's blood sugar levels as ordered by the physician, and follow the facility's hypoglycemic protocol to assess, treat and notify the physician if R4 had blood sugars less than 60 mg/dl. The facility's Protocol for Hypoglycemia policy, dated 10/29/02, directed staff to check blood sugar levels as ordered by the physician, assess residents with blood sugars less than 60 mg/dl, and notify the physician. The facility failed to notify the physician of R4's blood sugars less than 60 mg/dl, placing the resident at risk for continued low blood sugars.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R) 62's Physician Order Sheet (POS), dated 08/04/21, documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), history of pulmonary embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream), and atherosclerotic heart disease (the build up of fats, cholesterol and other substances in and on the artery walls causing obstruction of blood flow). R62's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident was independent with all activities of daily living except for needing one staff limited assistance with dressing, toileting, and bathing. The resident was documented as receiving seven days of antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression) and seven days of anticoagulants (a class of medication that help prevent blood clots). R62's Quarterly MDS, dated 09/01/21, recorded the resident had a BIMS score of 15, indicating intact cognition. The resident required limited assistance of one staff for bed mobility, bathing, dressing, transfers, locomotion on the unit, toileting, and personal hygiene. The resident was independent with eating, walking in room, walking in corridor and locomotion off the unit. The resident was documented as receiving seven days of antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). The Care Area Assessment (CAA), dated 04/09/21, lacked any information regarding the administration of anticoagulants or history of pulmonary embolisms. R64's Anticoagulation Therapy Care Plan, dated 09/07/21, directed staff to observe for bleeding gums, bruising, epistaxis (bleeding from the nose), heavy bleeding, pink, red or dark brown urine, red or tarry black stools, and vomiting or spitting up blood. The Pharmacy Consult dated 04/26/21, recommended to the physician R62's International Normalized Ratio (INR) (test used to determine how long it takes blood to clot) was not therapeutic and the physician needed to adjust the warfarin dosage to maintain a therapeutic INR. The Physician Orders dated 05/18/21, directed staff to administer warfarin (an anticoagulant medication) 4 milligrams (mg) by mouth every day. The facility's Electronic Medical Record (EMR) lacked any order to discontinue the warfarin. The Nurse's Note dated 07/27/21, documented the facility had received a telephone order from the resident's physician to recheck a PT/INR (lab used to monitor the effectiveness of the medication warfarin) on 08/09/21. The Nurse's Note dated 08/09/21, documented R62's INR results was 4.4, which is abnormally high. The residents' physician was informed of the results and new orders were received to hold the warfarin dose that day and recheck the INR lab on 08/10/21. The Nurse's Note dated 08/10/21 at 07:44 AM, documented the facility had received a fax from the physician's office ordering the facility to hold the warfarin, perform INR on 08/10/21, call the results of the INR on 08/10/21, and not to resume warfarin until instructed. The Nurse's Note dated 08/10/21 at 09:36 AM, documented the facility had received a fax from the physician ordering the facility to hold warfarin tonight, start 2 mg of warfarin on Wednesday and Saturday, and administer 4 mg of warfarin the rest of the days of the week. The Nurse's Note dated 08/10/21 at 02:34 PM documented the INR result was 4.6, which was abnormally high, the results were called to the physician, and the facility would wait for a return call with orders. The Nurse's Note dated 08/10/21 at 03:50 PM documented new order received by the physician to hold the warfarin for two more days and then repeat the PT/INR on Friday. The EMR dated 08/13/21 documented R62's INR was 1.7. The Nurse's Note dated 08/13/21 documented the lab results were faxed to the physician. The EMR lacked any other documentation from the physician regarding restarting the warfarin or the facility contacting the physician about restarting the warfarin. On 09/30/21 INR lab results were obtained and the results were INR 1.1. The EMR lacked any documentation that R62 had received any warfarin from 08/09/21 through 10/05/21. On 10/04/21 at 12:15 PM, R62 stated that the bruises on his arms were from his blood being thin because he was on warfarin and had been on it for years. On 10/04/21 at 12:30 PM, Licensed Nurse (LN) I stated the resident was not on warfarin and had not been for the whole month of September. On 10/04/21 at 02:30 PM, LN K stated that the resident had asked her a couple of days ago what dose of warfarin he was on, she had checked, and the resident was not on warfarin. She meant to double check on it but then got busy and forgot. On 10/05/21 at 08:30 AM, Administrative Nurse D stated that she was in charge of obtaining all the PT/INR's and she had a calendar of when the PT/INR's were supposed to be drawn and then when the facility gets the results back, the PT/INR sheet was faxed to the doctor for orders. She stated that she realized on 09/29/21 that R62 had not had an INR drawn for September because she looked through her calendar and realized that his name was not on the list for INR draw. Then she stated that she started to investigate and realized that an INR had not been drawn since 08/13/21 and the resident had not been receiving his coumadin. She stated she had immediately called the doctor to get an order for an INR and was now waiting for orders from the doctor. On 08/13/21 she stated she was out of the office and another floor nurse faxed the results of INR and it fell through the cracks. Administrative Nurse D verified it was a big problem that the resident had not received his warfarin for a month a half and the facility should have realized that there was a problem. The facility's undated Anticoagulation Safety Policy, documented for warfarin therapy the following clinical information will be documented on the clinical record and/or PT/INR tracking form in the clinical record: indications for warfarin therapy, duration of warfarin therapy, therapeutic range, elder's age, medications history including previous anticoagulation therapy, nutritional status, and concurrent disease status. Baseline PT/INR must be obtained for all elders before dosing change is ordered. The facility failed to ensure physician orders were received regarding warfarin dosage after the PT/INR was obtained placing R62 at risk for developing pulmonary embolisms and having complications from atrial fibrillation. The facility had a census of 80 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to assess and treat Resident (R) 4's low blood sugars, and failed to provide scheduled anticoagulant medication (medication used to prevent blood clots) for R62. Findings included: - R4's admission Minimum Data Set (MDS), dated 07/07/21, documented the resident had a Brief Interview for Mental Status (BIMS) score of five (severe cognitive impairment). The MDS documented R4 transferred and walked independently, had a diagnosis of diabetes (disease that impairs the body's ability to regulate blood sugar) and received insulin injections seven days a week. The Diabetic Care Plan, dated 07/07/21, directed staff to check R4's blood sugars as ordered by the physician, monitor for signs and symptoms of hypoglycemia (less than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The Physician's Standing Orders, dated 06/28/21, directed staff to assess and treat R4 if she had blood sugars less than 60 milligrams per deciliter (mg/dl), symptoms of hypoglycemia, and notify the physician. The Physician's Order, dated 09/15/21, directed staff to check R4's blood sugar levels upon rising in the morning and two hours after breakfast, lunch and supper. Review of R4's September 2021 Medication Administration Record (MAR) recorded the resident had the following blood sugar levels less than 60 mg/dl, and lacked staff assessment, treatment or physician notification: 09/21/21 at 07:18 PM - 41 mg/dl 09/23/21 at 05:14 PM - 38 mg/dl On 10/04/21 at 09:53 AM, observation revealed R4 ambulated with a walker and staff assistance in the hallway. On 10/04/21 at 10:08 AM, Licensed Nurse (LN) I stated staff should check R4's blood sugars as ordered by the physician, and follow the hypoglycemic protocol to assess, treat and notify the physician if R4 had blood sugars less than 60 mg/dl. On 10/05/21 at 11:13 AM, Administrative Nurse D stated staff should check R4's blood sugar levels as ordered by the physician, and follow the facility's hypoglycemic protocol to assess, treat and notify the physician if R4 had blood sugars less than 60 mg/dl. The facility's Protocol for Hypoglycemia policy, dated 10/29/02, directed staff to check blood sugar levels as ordered by the physician, assess residents with blood sugars less than 60 mg/dl, and notify the physician. The facility failed to assess and treat R4's low blood sugars, placing the resident at risk for adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R22's Physician Order Sheet (POS) dated 07/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), weakness, unsteadiness on feet, and repeated falls. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident was independent with all activities of daily living. The assessment further revealed the resident had two or more falls without injury during the lookback period. The Significant Change MDS, dated 07/18/21, documented the resident had a BIMS score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident required limited to extensive assistance of one to two staff for bed mobility, transfer, walking in corridor, dressing, toilet use, personal hygiene, and bathing. The assessment further revealed the resident was unsteady and had one fall without injury, one fall with minor injury, and one fall with major injury during the lookback period. The Fall Care Area Assessment (CAA), dated 07/18/21, documented the resident required limited to total assist with bed mobility, transfers, ambulation, locomotion, dressing, toileting, grooming, and bathing. The resident used a walker and assistance of one to two staff taking a few steps. The assessment further documented the resident did not use her call light in spite of having frequent educations by staff and took down cue posters in her room encouraging her to use her call light. The Fall/Injury Assessment, dated 07/15/21 documented the resident had poor safety awareness and was a high risk for falls. The Fall Care Plan, dated 07/27/21, directed staff to maintain a clutter free pathway and safe environment, encourage her to use the call light for assistance, always keep all frequently used items within reach, remind resident to reach back before sitting, and use a soft call light. The Nurse's Note, dated 12/06/20 at 01:50 PM, documented staff heard someone yelling help and went to the resident's room and found resident lying on floor next to walker. The resident stated she took her shoes off and then attempted to ambulate to the bathroom with a walker. The resident had compression socks on that caused her to slip. The resident stated she landed on her left hip and back and was in excruciating pain. She denied hitting her head. She was assisted off of the floor with the assistance of three staff members and gait belt, and then placed in bed. The care plan was not updated with any interventions after this fall The Nurse's Note, dated 12/24/20 at 06:40 PM, documented staff heard the resident knocking and went into her room and found the resident seated on the floor behind her bedroom door. The lights were found to be off in the room. Active range of motion checked, and the resident was without pain. Staff assisted the resident back to bed and gripper socks changed. The night light was left on in the room. The care plan was not updated with any interventions after this fall. The Nurse's Note, dated 03/12/21 at 10:46 AM, documented the resident was found on the floor in her room with non-skid socks on and walker nearby in the entry of the bathroom. The resident stated, I fall again and again. No broken bones. The resident stated she did not hit her head and neurological checks were intact, range of motion in all extremities, and no deformities noted. The fall investigation intervention: provide frequent visual checks as resident likes her door closed. This intervention was not noted on the resident's care plan. The Nurse's Note, dated 04/30/21 at 07:44 AM, documented staff heard a commotion, went to the resident's room, and found the resident on the floor. The resident stated she was going to the bathroom to brush her hair and when she pulled the bathroom door open she fell backwards. No visible injuries at the time of the fall. The resident was using her walker and fell out of her shoes. Vital signs were stable. Fall investigation intervention included: Possibly move closer to the nurses' station. The note indicated this was a non-injury fall . The Nurse's Note, dated 05/26/21 at 03:50 PM, documented the resident was found on the floor. The resident stated she fell over backwards coming out of the bathroom. The resident stated she didn't know if she had hit her head. No bruising noted, and the resident had range of motion in all extremities The Nurse's Note, dated 06/10/21 at 04:55 PM, documented staff heard yelling from the resident's room. Resident was found seated on the floor in front of her recliner. The resident stated she missed her chair. No red areas or bruises noted. Staff assisted the resident to the recliner with two staff assistance. Care plan interventions directed staff to remind her to reach for her chair. The note indicated this was a non-injury fall . The Nurse's Note, dated 06/28/21 at 05:10 PM, documented staff found the resident seated in the middle of the floor. The resident stated she thought there was a chair behind her and tried to sit down. The resident complained of pain in her lower back and bilateral knees. The resident was adamant to go to the emergency room to make sure nothing was broken. Staff transferred the resident to a local emergency room The resident did not have any broken bones, but was found to have a urinary tract infection (UTI) and started an antibiotic. Fall investigation intervention included the resident had a UTI and received antibiotic therapy . The Nurse's Note, dated 07/03/21 at 04:45 PM, documented staff witnessed the resident attempting to sit down in the lobby and when she went to sit down in chair, she did not turn all the way around, and missed the chair. The resident screamed, Oh I fell! My hip! The resident was unable to straighten her leg. Staff transferred the resident to a local hospital. She had a left hip fracture and could not have surgery. Fall investigation intervention directed staff to intervene when the resident was up and moving for safety . The Nurse's Note, dated 09/06/21 at 08:15 PM, documented the resident was found on the floor seated on her buttocks with bare feet and her walker turned over near the door. The resident was bleeding from her left eyebrow. The resident stated she had tripped over the fall mat and fell on her face . The resident had a laceration that measured 1.2 centimeters (cm). Staff cleansed the laceration and applied closure strips. Left leg appeared to be shortened and rotated outwards and the thumb on the resident's right hand was swollen and bruised. Staff attempted range of motion to the lower extremities and the resident winced and appeared in pain, so staff stopped range of motion immediately. The resident transferred to the local Emergency Room. The resident sustained a broken right thumb. On 09/30/21 at 12:35 PM, observation revealed R22 sat in her room, in her wheelchair and tried to remove her jacket. R22 asked for assistance. Licensed Nurse (LN) J assisted R22 in locking her wheelchair breaks and assisted her to a standing position without a gait belt. The resident stated, I'm afraid I'm going to fall. LN J reassured R22 that she would not let R22 fall . On 10/04/21 at 10:30 AM, observation revealed R22 sat in a recliner out in the living room area where she attempted to get out of the recliner. An unidentified staff member intervened and assisted the resident to her room. On 09/30/21 at 12:45 PM, LN J stated the resident had multiple falls. One of the falls she had a hip fracture that was not surgically repaired. She had a decline in her activities of daily living after that fall. Prior to that fall she was independent with all of her activities of daily living, but now she needed one to two staff assistance. She received therapies, but cognitively she was not able to participate very well and plateaued. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings, but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated. When they have the risk type meetings staff should come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents falls. The facility's Accident Prevention Program policy, revised July 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident was a high risk for potential falls by the fall risk assessment, it will be documented in the care plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility's Comprehensive Care Plan policy, dated June 2019, documented the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed at determined intervals. The care plan will also be reviewed if the resident is hospitalized or experiences a significant change in physical or mental condition. The facility failed to update R22's care plan with interventions to prevent further falls, placing the resident at risk for further injury. - R48's Physician Order Sheet (POS), dated 08/03/21, documented diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), unsteadiness on feet, and displaced fracture(broken bone) of head of left radius (left wrist). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and the resident required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had one non-injury fall and one minor injury fall during the lookback period. The Fall Care Area Assessment (CAA), dated 05/19/21, documented the resident had problems at times understanding, had disorganized thoughts, and hallucinations. Her cognition was noted as being intact but fluctuated often. The resident was documented as being independent to extensive assistance with activities of daily living and used a walker for her unsteady gait which at times she would forget to use but would use the furniture in the room to make it from place to place in her room. The resident was documented as being at risk for falls related to her unsteady gait and use of antidepressant medications. Interventions were in place with the residents' independence being her priority. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident hallucinated and required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had two or more non-injury falls and two or more minor injury falls during the lookback period. The Fall Care Plan, dated 08/20/21, directed staff to encourage resident to call for staff when she feels unsteady, encourage use of non-skid socks or shoes when up in room, have bed at height were she can reach the floor, place gripper strips to the floor in front of bed, motion sensor on the wall, and floor mat next to the bed while resident is in the bed. The Fall/Injury Assessment, dated 07/13/21 documented the resident had poor safety awareness and was a high risk for falls. The Nurse's Note, dated 01/07/21 at 08:50 PM, documented R48 was found lying on the floor between the bed and wheelchair. When asked what happened the resident stated she needed to use the bathroom. Noted abrasion to left knee and skin tear to left elbow and she complained of pain when abrasion was touched. The resident was assisted by two staff to sit up then stand and transferred to her wheelchair. The resident tolerated activity well with no increased pain. A dressing was applied to her left elbow. The new intervention for this fall was to review the care plan. The Nurse's Note dated 04/30/21 at 12:45 AM, documented the resident was found lying on the floor with her head close to the bathroom door, laying on her left side, facing the window. Blood was noted to the floor and to the back of the resident's head. R48 was able to respond to the staff and was able to answer questions appropriately. Resident was helped to sit down after assessing her safety. Bleeding was noted to the back of the resident's head and a hematoma but unable to tell the size of the open area due to very tangled hair. EMS was notified and came to transport the resident to the local area hospital. The new intervention for this fall was to review the care plan. The Nurse's Note dated 05/05/21 at 01:30 PM, documented the resident was found seated on the floor leaning against her bed. Resident stated that she was in her closet picking out an outfit and was heading back to her bed when she lost her balance and fell. Resident's motion detector never went off. Resident stated that she did hit her head. Resident had no injuries or bruising related to this fall. There were no fall interventions on the fall investigation for this fall. The Nurse's Note dated 07/09/21 at 11:15 PM, documented resident found lying on her left side with her head toward bed and feet away from bed with bedside table parallel to bed between R48's head and the bed. R48 was facing the door with her left arm lying on the floor in front of her toward the door with obvious deformity of the wrist and her hand dropped lower than the wrist. R48 stated she was walking to the bathroom when she lost her balance and fell backwards hitting the back of her head on the bedside table. R48 denied pain to her head but rated her wrist pain as 10 out of 10. R48 would not allow the nurse to assess her wrist. The motion detector was not making any noise. R48 was transferred to a local area hospital via EMS. There were no fall interventions on the fall investigation for this fall. The Nurse's Note dated 07/12/21 at 11:35 PM, resident was found seated on her bottom in front of her bed. Res stated, I was trying to pick up my oxygen tubing and lost my balance, so I sat myself on the floor. No new injuries were noted. Res denied head involvement and denied pain or discomfort. The new intervention for this fall was to review the care plan. The Nurse's Note dated 08/05/21 at 02:00 AM, documented R48 was found seated upright on her buttocks in the bathroom doorway. She had a knot on the back of head and skin was intact. Resident was taking herself to the bathroom. The motion alarm did not sound despite it working and going off earlier in the shift. The new intervention for this fall was to review the care plan. On 09/30/21 at 10:33 AM, resident walked in her room with her walker and no shoes or socks on at the time. On 09/30/21 at 02:00 PM, Certified Nurse Aide (CNA) O stated the resident had been having a lot of falls. Part of the reason she had been having falls was she wanted to be as independent as possible, but she was also becoming more and more confused. CNA O stated she was unsure if the resident could remember to use her call light and ask for help. On 09/30/21 at 02:15 PM, Certified Medications Aide (CMA) R stated the resident knew enough to turn off her motion sensor before she got up and that was the reason that it didn't sound when she got up. The resident was getting more confused, but she wanted to maintain her independence. On 10/04/21 at 12:15 PM, Licensed Nurse (LN) I stated the resident fell all the time due to her refusal to call for assistance. She wanted to be independent but doesn't realize that she can't do everything that she used to do on her own anymore. LN I stated staff are supposed to update her care plan with new interventions for each fall. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings, but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated and when they have the risk type meetings staff are to come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents falls. The facility's Accident Prevention Program policy, revised July of 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident is considered to be a High Risk for potential falls by the fall risk assessment, it will be documented in the Care Plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility's Comprehensive Care Plan policy, dated June 2019, documented the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed at determined intervals. The care plan will also be reviewed if the resident is hospitalized or experiences a significant change in physical or mental condition. The facility failed to update R48's care plan with interventions to prevent further falls, placing the resident at risk for further injury. - R23's Physician Order Sheet (POS), dated 07/29/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by memory failure and confusion) and aftercare following implantation of right hip joint prosthesis. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four which indicated the resident was severely cognitively impaired. The assessment revealed the resident was independent to supervision with all activities of daily living except bathing, personal hygiene, and dressing which she required limited assistance of one staff. The assessment further revealed the resident had fallen in the last 2-6 months prior to the lookback period. The Significant Change MDS, dated 07/19/21, documented the resident had a BIMS score of four which indicated the resident was severely cognitively impaired. The assessment revealed the resident required limited to extensive assistance of one to two staff for bed mobility, transfer, walking in corridor, dressing, toilet use, personal hygiene and bathing; was totally dependent for locomotion on and off the unit and was independent with eating. The assessment further revealed the resident was unsteady and had one fall with major injury requiring surgery during the lookback period. The Fall Care Area Assessment (CAA) dated 07/19/21, documented the resident had a fall which resulted in a right hip fracture requiring surgery and triggered as significant change in care. The resident required supervision to total assist with bed mobility, transfers, ambulation, locomotion, dressing toileting, grooming, and bathing. The CAA further documented the residents' gait and balance are not steady and she is not able to stabilize without staff assist for standing, walking, and transfers. The resident has had three falls since her last MDS and one fall since her most recent admission. The resident may forget to call for assistance and will get up without staff assistance and has been moved to a room closer to the lobby area for closer supervision. The Fall Care Plan, dated 07/27/21, directed staff to maintain a clutter free pathway and safe environment, encourage her to use the call light for assist, always keep all frequently used items within reach , hi/low bed with floor mat, she may choose to sit herself on the floor and use posted cues as reminders. The Fall/Injury Assessment, dated 07/13/21 documented the resident had poor safety awareness and was a high risk for falls. The Nurse's Note, dated 10/17/20 at 12:35 PM, documented staff heard the fall of walker outside the med room. The nurse stepped out to look and noticed the resident seated on the floor facing the recliner she was seated on earlier. When asked what happened the resident stated I was trying to get out of my recliner using the walker, but I forgot to put the reclining chair back so I fell. The resident could not determine what side of body she fell on. She had no complaints of pain and was able to stretch feet with no problem. No noted injuries. The resident was able to walk with assistance and was reminded to wait for assistance before transfers. The record lacked documentation of interventions to prevent further falls. The Nurse's Note, dated 12/15/20 at 07:14 AM,documented the resident was found on floor in room seated on buttocks with blankets wrapped around legs. The fall mat was under bed but the resident was not on the mat. When asked what happened the resident stated I was looking for you. No signs and symptoms of pain or discomfort noted at this time. Resident was assisted up and back to bed with two staff assistance. The record lacked documentation of interventions to prevent further falls. The Nurse's Note, dated 01/27/21 at 09:20 PM, documented the resident came from room down to nurses station and stated that she had fallen in her room. She stated that she tripped over cords from the bed and she had fallen on the right side of her body. Resident stated that she did not hit her head. No areas of redness or bruising noted by this nurse at this time. Cords were rearranged under the resident's bed so as not to be a trip hazard in the future. Resident's bed was in lowest position, and safety mat was on the floor. The record lacked documentation of interventions to prevent further falls. The Nurse's Note, dated 07/03/21 at 12:59 PM, documented staff called this nurse and reported resident on the floor. Upon entry into unit resident was on the floor in the hallway on a mattress. Her upper body landed on the mattress, but her right knee hit the floor. There was an abrasion with a couple large bumps. The resident complained of pain of the right knee. Resident was able to bear weight and walk with little pain. She did not hit her head and stated she was going home and lost her balance. The fall investigation intervention: move the resident closer to the nurses' desk. This intervention was not noted on the resident's care plan. The Nurse's Note, dated 07/03/21 at 07:23 PM, documented the resident was heard yelling from her room. Resident seated on floor in middle of room. Stated, I can't walk. I can't stand on it, pointing to right knee. Knee continued to be swollen and bruised from earlier fall. Two staff assisted the resident to her wheel chair and then to the lobby. The resident was transferred to hospital in [NAME] for right hip fracture. The fall investigation intervention: moved resident closer to the sitting area and a floor mat. The Nurse's Note, dated 07/13/21 at 05:30 AM, documented CMA notified this nurse that resident was on floor in bedroom. Resident found on floor in between recliner and bed, stated that she did hit her head, had two small abrasions noted to left side of face, and purple/green bruising noted to lateral left eye. Skin tear to back of left hand, small skin tear to 1st finger on left hand, and two small skin tears to middle finger. The fall investigation intervention: moved closer to the nurses' desk. On 09/29/21 at 09:44 AM, observation revealed the resident got up by herself in her room without socks on, was very unstable on her feet, and did not use her walker which was at bedside to get up. On 09/30/21 at 12:29 PM, observation revealed the resident transferred by herself from a recliner in the living area of the unit with no staff around. The walker was beside the resident, she did not remember to grab it and began walking down the hallway. The resident made it half way down the hall in a very unsteady gait before staff intercepted her and assisted her back to her recliner in the day room. On 09/30/21 at 12:45 PM, Licensed Nurse (LN) J stated the resident has had multiple falls. One of the falls she had resulted in a hip fracture that was surgically repaired. She had a decline in her activities of daily living after that. Prior to that fall she was independent to supervision with all of her activities of daily living but now she needed one to two assistance. We did have her on therapies but cognitively she was not able to participate very well and plateaued. We did not report the fall when she had the hip fracture because it was witnessed. The mattress was leaning up against the hallway wall waiting for Hospice to come and pick it up. We are not sure whether she tripped on the mattress or if she ran into the mattress and ended up falling on it. We do take the BIMS into account when we decide not to report, but staff saw her land on the mattress. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated and when they have the risk type meetings staff are to come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents' falls. The facility's Accident Prevention Program policy, revised July 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident is considered to be a High Risk for potential falls by the fall risk assessment, it will be documented in the care plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility's Comprehensive Care Plan policy, dated June 2019, documented the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed at determined intervals. The care plan will also be reviewed if the resident is hospitalized or experiences a significant change in physical or mental condition. The facility failed to update R23's care plan with interventions to prevent further falls, placing the resident at risk for further injury. The facility had a census of 80 residents. The sample included 19 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise care plans for five of eight sampled residents, Resident (R) 76, R15, R22, R48, and R23 who had several falls with no new interventions. Findings included: - R76's Physician Order Sheet (POS), dated 07/29/21, documented diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory, confusion), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set, (MDS) dated [DATE], documented the resident had short term memory impairment, wandered daily and was independent with transfers, ambulation, and bed mobility. R76 had steady balance except when turning, had no functional impairment, and had no falls. R76's Quarterly MDS, dated 09/15/21, documented the resident had moderately impaired decision-making skills and required extensive assistance of one staff for bed mobility, limited assistance of one staff for transfers, and extensive assistance of two staff for ambulation. The MDS further documented inattention, disorganized thinking, unsteady balance, and no upper or lower functional impairment. R76 had two or more non-injury falls since the prior assessment. The Fall Risk Assessments, dated 03/25/21, 04/21/21, and 06/18/21, documented the resident a high risk for falls. The revised Fall Care Plan, dated 09/21/21, originally dated 04/21/21, directed staff to maintain a clutter free pathway, encourage the resident to use the call light for assistance, and always keep all used items within reach. The update, dated 05/04/21, documented the resident may require 1:1 to reduce the risk for falls. The update, dated 06/12/21, directed staff to educate the resident's spouse to call for assistance. The update, dated 07/03/21, directed staff to place dycem (a non-slip mat) in the resident's wheelchair. The Fall Investigation, dated 04/23/21, documented at 01:47 PM the resident fell while walking in her room. The investigation documented staff witnessed the resident ambulating in her room, holding a photo album and falling onto her buttocks. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 04/27/21, documented at 03:15 AM, the resident fell after she stood up from her recliner and lost her balance. The investigation documented the fall was unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated on 05/17/21, documented at 08:15 PM, the staff found the resident on her bathroom floor. The resident's middle finger on her left hand had an open area on it, bruising on her left arm, two abrasions (scraping or rubbing away of a surface by friction) on the left side of her back. and her right eye was beginning to swell. The investigation documented the resident was taken by ambulance to the emergency room (ER). The investigation documented the resident was non compliant with asking for assistance due to her cognition. (The record lacked documentation of interventions to prevent further falls.) The Nurse's Note, dated 05/18/21 at 02:18 AM, documented the resident returned from the ER via facility transportation. The note documented the resident was alert, but drowsy, was noted to have a 2-centimeter (cm) x 1 cm and 2 cm x 2.5 cm abrasions to her upper left back, 0.2 cm scab to her left knee, and left finger wrapped in coban (a self adherent compression bandage). The Fall Investigation, dated[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R22's Physician Order Sheet (POS) dated 07/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), weakness, unsteadiness on feet, and repeated falls. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident was independent with all activities of daily living. The assessment further revealed the resident had two or more falls without injury during the lookback period. The Significant Change MDS, dated 07/18/21, documented the resident had a BIMS score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident required limited to extensive assistance of one to two staff for bed mobility, transfer, walking in corridor, dressing, toilet use, personal hygiene, and bathing. The assessment further revealed the resident was unsteady and had one fall without injury, one fall with minor injury, and one fall with major injury during the lookback period. The Fall Care Area Assessment (CAA), dated 07/18/21, documented the resident required limited to total assist with bed mobility, transfers, ambulation, locomotion, dressing, toileting, grooming, and bathing. The resident used a walker and assistance of one to two staff taking a few steps. The assessment further documented the resident did not use her call light in spite of having frequent educations by staff and took down cue posters in her room encouraging her to use her call light. The Fall/Injury Assessment, dated 07/15/21 documented the resident had poor safety awareness and was a high risk for falls. The Fall Care Plan, dated 07/27/21, directed staff to maintain a clutter free pathway and safe environment, encourage her to use the call light for assistance, always keep all frequently used items within reach, remind resident to reach back before sitting, and use a soft call light. The Nurse's Note, dated 12/06/20 at 01:50 PM, documented staff heard someone yelling help and went to the resident's room and found resident lying on floor next to walker. The resident stated she took her shoes off and then attempted to ambulate to the bathroom with a walker. The resident had compression socks on that caused her to slip. The resident stated she landed on her left hip and back and was in excruciating pain. She denied hitting her head. She was assisted off of the floor with the assistance of three staff members and gait belt, and then placed in bed. The care plan was not updated with any interventions after this fall The Nurse's Note, dated 12/24/20 at 06:40 PM, documented staff heard the resident knocking and went into her room and found the resident seated on the floor behind her bedroom door. The lights were found to be off in the room. Active range of motion checked, and the resident was without pain. Staff assisted the resident back to bed and gripper socks changed. The night light was left on in the room. The care plan was not updated with any interventions after this fall. The Nurse's Note, dated 03/12/21 at 10:46 AM, documented the resident was found on the floor in her room with non-skid socks on and walker nearby in the entry of the bathroom. The resident stated, I fall again and again. No broken bones. The resident stated she did not hit her head and neurological checks were intact, range of motion in all extremities, and no deformities noted. The fall investigation intervention: provide frequent visual checks as resident likes her door closed. This intervention was not noted on the resident's care plan. The Nurse's Note, dated 04/30/21 at 07:44 AM, documented staff heard a commotion, went to the resident's room, and found the resident on the floor. The resident stated she was going to the bathroom to brush her hair and when she pulled the bathroom door open she fell backwards. No visible injuries at the time of the fall. The resident was using her walker and fell out of her shoes. Vital signs were stable. The fall investigation intervention included: Possibly move closer to the nurses' station. The note indicated this was a non-injury fall. The Nurse's Note, dated 05/26/21 at 03:50 PM, documented the resident was found on the floor. The resident stated she fell over backwards coming out of the bathroom. The resident stated she didn't know if she had hit her head. No bruising noted, and the resident had range of motion in all extremities The Nurse's Note, dated 06/10/21 at 04:55 PM, documented staff heard yelling from the resident's room. Resident was found seated on the floor in front of her recliner. The resident stated she missed her chair. No red areas or bruises noted. Staff assisted the resident to the recliner with two staff assistance. Care plan interventions directed staff to remind her to reach for her chair. The note indicated this was a non-injury fall. The Nurse's Note, dated 06/28/21 at 05:10 PM, documented staff found the resident seated in the middle of the floor. The resident stated she thought there was a chair behind her and tried to sit down. The resident complained of pain in her lower back and bilateral knees. The resident was adamant to go to the emergency room to make sure nothing was broken. Staff transferred the resident to a local emergency room The resident did not have any broken bones, but was found to have a urinary tract infection (UTI) and started an antibiotic. Fall investigation intervention included the resident had a UTI and received antibiotic therapy. The Nurse's Note, dated 07/03/21 at 04:45 PM, documented staff witnessed the resident attempting to sit down in the lobby and when she went to sit down in chair, she did not turn all the way around, and missed the chair. The resident screamed, Oh I fell! My hip! The resident was unable to straighten her leg. Staff transferred the resident to a local hospital. She had a left hip fracture and could not have surgery. Fall investigation intervention directed staff to intervene when the resident was up and moving for safety. The Nurse's Note, dated 09/06/21 at 08:15 PM, documented the resident was found on the floor seated on her buttocks with bare feet and her walker turned over near the door. The resident was bleeding from her left eyebrow. The resident stated she had tripped over the fall mat and fell on her face . The resident had a laceration that measured 1.2 centimeters (cm). Staff cleansed the laceration and applied closure strips. Left leg appeared to be shortened and rotated outwards and the thumb on the resident's right hand was swollen and bruised. Staff attempted range of motion to the lower extremities and the resident winced and appeared in pain, so staff stopped range of motion immediately. The resident transferred to the local Emergency Room. The resident sustained a broken right thumb. On 09/30/21 at 12:35 PM, observation revealed R22 sat in her room, in her wheelchair and tried to remove her jacket. R22 asked for assistance. Licensed Nurse (LN) J assisted R22 in locking her wheelchair breaks and assisted her to a standing position without a gait belt. The resident stated, I'm afraid I'm going to fall. LN J reassured R22 that she would not let R22 fall. On 10/04/21 at 10:30 AM, observation revealed R22 sat in a recliner out in the living room area where she attempted to get out of the recliner. An unidentified staff member intervened and assisted the resident to her room. On 09/30/21 at 12:45 PM, LN J stated the resident had multiple falls. One of the falls she had a hip fracture that was not surgically repaired. She had a decline in her activities of daily living after that fall. Prior to that fall she was independent with all of her activities of daily living, but now she needed one to two staff assistance. She received therapies, but cognitively she was not able to participate very well and plateaued. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings, but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated. When they have the risk type meetings staff should come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents falls. The facility's Accident Prevention Program policy, revised July 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident was a high risk for potential falls by the fall risk assessment, it will be documented in the care plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility failed to provide adequate supervision, staff assistance, and implement fall interventions to prevent falls for cognitively impaired R22, placing the resident at risk for further falls and injuries. - R48's Physician Order Sheet (POS), dated 08/03/21, documented diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), unsteadiness on feet, and displaced fracture(broken bone) of head of left radius (left wrist). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and the resident required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had one non-injury fall and one minor injury fall during the lookback period. The Fall Care Area Assessment (CAA), dated 05/19/21, documented the resident had problems at times understanding, had disorganized thoughts, and hallucinations. Her cognition was noted as being intact but fluctuated often. The resident was documented as being independent to extensive assistance with activities of daily living and used a walker for her unsteady gait which at times she would forget to use but would use the furniture in the room to make it from place to place in her room. The resident was documented as being at risk for falls related to her unsteady gait and use of antidepressant medications. Interventions were in place with the residents' independence being her priority. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident hallucinated and required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had two or more non-injury falls and two or more minor injury falls during the lookback period. The Fall Care Plan, dated 08/20/21, directed staff to encourage resident to call for staff when she feels unsteady, encourage use of non-skid socks or shoes when up in room, have bed at height were she can reach the floor, place gripper strips to the floor in front of bed, motion sensor on the wall, and floor mat next to the bed while resident is in the bed. The Fall/Injury Assessment, dated 07/13/21 documented the resident had poor safety awareness and was a high risk for falls. The Nurse's Note, dated 01/07/21 at 08:50 PM, documented R48 was found lying on the floor between the bed and wheelchair. When asked what happened the resident stated she needed to use the bathroom. Noted abrasion to left knee and skin tear to left elbow and she complained of pain when abrasion was touched. The resident was assisted by two staff to sit up then stand and transferred to her wheelchair. The resident tolerated activity well with no increased pain. A dressing was applied to her left elbow. The new intervention for this fall was to review the care plan. The Nurse's Note dated 04/30/21 at 12:45 AM, documented the resident was found lying on the floor with her head close to the bathroom door, laying on her left side, facing the window. Blood was noted to the floor and to the back of the resident's head. R48 was able to respond to the staff and was able to answer questions appropriately. Resident was helped to sit down after assessing her safety. Bleeding was noted to the back of the resident's head and a hematoma but unable to tell the size of the open area due to very tangled hair. EMS was notified and came to transport the resident to the local area hospital. The new intervention for this fall was to review the care plan. The Nurse's Note dated 05/05/21 at 01:30 PM, documented the resident was found seated on the floor leaning against her bed. Resident stated that she was in her closet picking out an outfit and was heading back to her bed when she lost her balance and fell. Resident's motion detector never went off. Resident stated that she did hit her head. Resident had no injuries or bruising related to this fall. There were no fall interventions on the fall investigation for this fall. The Nurse's Note dated 07/09/21 at 11:15 PM, documented resident found lying on her left side with her head toward bed and feet away from bed with bedside table parallel to bed between R48's head and the bed. R48 was facing the door with her left arm lying on the floor in front of her toward the door with obvious deformity of the wrist and her hand dropped lower than the wrist. R48 stated she was walking to the bathroom when she lost her balance and fell backwards hitting the back of her head on the bedside table. R48 denied pain to her head but rated her wrist pain as 10 out of 10. R48 would not allow the nurse to assess her wrist. The motion detector was not making any noise. R48 was transferred to a local area hospital via EMS. There were no fall interventions on the fall investigation for this fall. The Nurse's Note dated 07/12/21 at 11:35 PM, resident was found seated on her bottom in front of her bed. Res stated, I was trying to pick up my oxygen tubing and lost my balance, so I sat myself on the floor. No new injuries were noted. Res denied head involvement and denied pain or discomfort. The new intervention for this fall was to review the care plan. The Nurse's Note dated 08/05/21 at 02:00 AM, documented R48 was found seated upright on her buttocks in the bathroom doorway. She had a knot on the back of head and skin was intact. Resident was taking herself to the bathroom. The motion alarm did not sound despite it working and going off earlier in the shift. The new intervention for this fall was to review the care plan. On 09/30/21 at 10:33 AM, resident walked in her room with her walker and no shoes or socks on at the time. On 09/30/21 at 02:00 PM, Certified Nurse Aide (CNA) O stated the resident had been having a lot of falls. Part of the reason she had been having falls was she wanted to be as independent as possible, but she was also becoming more and more confused. CNA O stated she was unsure if the resident could remember to use her call light and ask for help. On 09/30/21 at 02:15 PM, Certified Medications Aide (CMA) R stated the resident knew enough to turn off her motion sensor before she got up and that was the reason that it didn't sound when she got up. The resident was getting more confused, but she wanted to maintain her independence. On 10/04/21 at 12:15 PM, Licensed Nurse (LN) I stated the resident fell all the time due to her refusal to call for assistance. She wanted to be independent but doesn't realize that she can't do everything that she used to do on her own anymore. LN I stated staff are supposed to update her care plan with new interventions for each fall. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings, but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated and when they have the risk type meetings staff are to come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents falls. The facility's Accident Prevention Program policy, revised July of 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident is considered to be a High Risk for potential falls by the fall risk assessment, it will be documented in the Care Plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility failed to provide adequate supervision, staff assistance, and implement fall interventions to prevent falls for R48, placing the resident at risk for further falls and injuries. - R23's Physician Order Sheet (POS), dated 07/29/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by memory failure and confusion) and aftercare following implantation of right hip joint prosthesis. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four which indicated the resident was severely cognitively impaired. The assessment revealed the resident was independent to supervision with all activities of daily living except bathing, personal hygiene, and dressing which she required limited assistance of one staff. The assessment further revealed the resident had fallen in the last 2-6 months prior to the lookback period. The Significant Change MDS, dated 07/19/21, documented the resident had a BIMS score of four which indicated the resident was severely cognitively impaired. The assessment revealed the resident required limited to extensive assistance of one to two staff for bed mobility, transfer, walking in corridor, dressing, toilet use, personal hygiene and bathing; was totally dependent for locomotion on and off the unit and was independent with eating. The assessment further revealed the resident was unsteady and had one fall with major injury requiring surgery during the lookback period. The Fall Care Area Assessment (CAA) dated 07/19/21, documented the resident had a fall which resulted in a right hip fracture requiring surgery and triggered as significant change in care. The resident required supervision to total assist with bed mobility, transfers, ambulation, locomotion, dressing toileting, grooming, and bathing. The CAA further documented the residents' gait and balance are not steady and she is not able to stabilize without staff assist for standing, walking, and transfers. The resident has had three falls since her last MDS and one fall since her most recent admission. The resident may forget to call for assistance and will get up without staff assistance and has been moved to a room closer to the lobby area for closer supervision. The Fall Care Plan, dated 07/27/21, directed staff to maintain a clutter free pathway and safe environment, encourage her to use the call light for assist, always keep all frequently used items within reach , hi/low bed with floor mat, she may choose to sit herself on the floor and use posted cues as reminders. The Fall/Injury Assessment, dated 07/13/21 documented the resident had poor safety awareness and was a high risk for falls. The Nurse's Note, dated 10/17/20 at 12:35 PM, documented staff heard the fall of walker outside the med room. The nurse stepped out to look and noticed the resident seated on the floor facing the recliner she was seated on earlier. When asked what happened the resident stated I was trying to get out of my recliner using the walker, but I forgot to put the reclining chair back so I fell. The resident could not determine what side of body she fell on. She had no complaints of pain and was able to stretch feet with no problem. No noted injuries. The resident was able to walk with assistance and was reminded to wait for assistance before transfers. The record lacked documentation of interventions to prevent further falls. The Nurse's Note, dated 12/15/20 at 07:14 AM,documented the resident was found on floor in room seated on buttocks with blankets wrapped around legs. The fall mat was under bed but the resident was not on the mat. When asked what happened the resident stated I was looking for you. No signs and symptoms of pain or discomfort noted at this time. Resident was assisted up and back to bed with two staff assistance. The record lacked documentation of interventions to prevent further falls. The Nurse's Note, dated 01/27/21 at 09:20 PM, documented the resident came from room down to nurses station and stated that she had fallen in her room. She stated that she tripped over cords from the bed and she had fallen on the right side of her body. Resident stated that she did not hit her head. No areas of redness or bruising noted by this nurse at this time. Cords were rearranged under the resident's bed so as not to be a trip hazard in the future. Resident's bed was in lowest position, and safety mat was on the floor. The record lacked documentation of interventions to prevent further falls. The Nurse's Note, dated 07/03/21 at 12:59 PM, documented staff called this nurse and reported resident on the floor. Upon entry into unit resident was on the floor in the hallway on a mattress. Her upper body landed on the mattress, but her right knee hit the floor. There was an abrasion with a couple large bumps. The resident complained of pain of the right knee. Resident was able to bear weight and walk with little pain. She did not hit her head and stated she was going home and lost her balance. The fall investigation intervention: move the resident closer to the nurses' desk. This intervention was not noted on the resident's care plan. The Nurse's Note, dated 07/03/21 at 07:23 PM, documented the resident was heard yelling from her room. Resident seated on floor in middle of room. Stated, I can't walk. I can't stand on it, pointing to right knee. Knee continued to be swollen and bruised from earlier fall. Two staff assisted the resident to her wheel chair and then to the lobby. The resident was transferred to hospital in [NAME] for right hip fracture. The fall investigation intervention: moved resident closer to the sitting area and a floor mat. The Nurse's Note, dated 07/13/21 at 05:30 AM, documented CMA notified this nurse that resident was on floor in bedroom. Resident found on floor in between recliner and bed, stated that she did hit her head, had two small abrasions noted to left side of face, and purple/green bruising noted to lateral left eye. Skin tear to back of left hand, small skin tear to 1st finger on left hand, and two small skin tears to middle finger. The fall investigation intervention: moved closer to the nurses' desk. On 09/29/21 at 09:44 AM, observation revealed the resident got up by herself in her room without socks on, was very unstable on her feet, and did not use her walker which was at bedside to get up. On 09/30/21 at 12:29 PM, observation revealed the resident transferred by herself from a recliner in the living area of the unit with no staff around. The walker was beside the resident, she did not remember to grab it and began walking down the hallway. The resident made it half way down the hall in a very unsteady gait before staff intercepted her and assisted her back to her recliner in the day room. On 09/30/21 at 12:45 PM, Licensed Nurse (LN) J stated the resident has had multiple falls. One of the falls she had resulted in a hip fracture that was surgically repaired. She had a decline in her activities of daily living after that. Prior to that fall she was independent to supervision with all of her activities of daily living but now she needed one to two assistance. We did have her on therapies but cognitively she was not able to participate very well and plateaued. We did not report the fall when she had the hip fracture because it was witnessed. The mattress was leaning up against the hallway wall waiting for Hospice to come and pick it up. We are not sure whether she tripped on the mattress or if she ran into the mattress and ended up falling on it. We do take the BIMS into account when we decide not to report, but staff saw her land on the mattress. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated and when they have the risk type meetings staff are to come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents' falls. The facility's Accident Prevention Program policy, revised July 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident is considered to be a High Risk for potential falls by the fall risk assessment, it will be documented in the care plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility failed to provide adequate supervision, staff assistance, and implement fall interventions to prevent falls for R23, placing the resident at risk for further falls and injuries. The facility had a census of 80 residents. The sample included 19 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, Resident (R) 76, R15, R22, R48, and R23. This placed the residents at increased risk for injuries related to accidents and/or hazards. Findings included: - R76's Physician Order Sheet (POS), dated 07/29/21, documented diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory, confusion), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set, (MDS) dated [DATE], documented the resident had short term memory impairment, wandered daily and was independent with transfers, ambulation, and bed mobility. R76 had steady balance except when turning, had no functional impairment, and had no falls. R76's Quarterly MDS, dated 09/15/21, documented the resident had moderately impaired decision-making skills and required extensive assistance of one staff for bed mobility, limited assistance of one staff for transfers, and extensive assistance of two staff for ambulation. The MDS further documented inattention, disorganized thinking, unsteady balance, and no upper or lower functional impairment. R76 had two or more non-injury falls since the prior assessment. The Fall Risk Assessments, dated 03/25/21, 04/21/21, and 06/18/21, documented the resident a high risk for falls. The revised Fall Care Plan, dated 09/21/21, originally dated 04/21/21, directed staff to maintain a clutter free pathway, encourage the resident to use the call light for assistance, and always keep all used items within reach. The update, dated 05/04/21, documented the resident may require 1:1 to reduce the risk for falls. The update, dated 06/12/21, directed staff to educate the resident's spouse to call for assistance. The update, dated 07/03/21, directed staff to place dycem (a non-slip mat) in the resident's wheelchair. The Fall Investigation, dated 04/23/21, documented at 01:47 PM the resident fell while walking in her room. The investigation documented staff witnessed the resident ambulating in her room, holding a photo album and falling onto her buttocks. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 04/27/21, documented at 03:15 AM, the resident fell after she stood up from her recliner and lost her balance. The investigation documented the fall was unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated on 05/17/21, documented at 08:15 PM, the staff found the resident on her bathroom floor. The resident's middle finger on her left hand had an open area on it, bruising on her left arm, two abrasions (scraping or rubbing away of a surface by friction) on the left side of her back. and her right eye was beginning to swell. The investigation documented the resident was taken by ambulance to the emergency room (ER). The investigation documented the resident was non compliant with asking for assistance due to her cognition. (The record lacked documentation of interventions to prevent further falls.) The Nurse's Note, dated 05/18/21 at 02:18 AM, documented the resident returned from the ER via facility transportation. The note documented the resident was alert, but drowsy, was noted to have a 2-centimeter (cm) x 1 cm and 2 cm x 2.5 cm abrasions to her upper left back, 0.2 cm scab to her left knee, and left finger wrapped in coban (a self adherent compression bandage). The Fall Investigation, dated 07/07/21, documented at 11:40 PM staff found the resident on the floor in her room. The investigation documented the resident had not been seated well in her recliner, slid out, and did not have any injuries. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 07/10/21, documented at 11:28 PM, the resident fell while ambulating to the bathroom. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 08/14/21, documented at 10:26 PM, the resident fell after she stood up from her wheelchair and attempted to ambulate. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/21/21, documented at 08:58 PM, the resident attempted to stand up by herself from the couch, lost her balance and fell. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/23/21, documented at 12:35 AM, staff found the resident on her fall mat beside t[TRUNCATED]