Based on record review and interview, the facility failed to ensure assessments were completed for 1 (#20) of 16 sampled residents whose assessments were reviewed.The administrator identified 55 residents resided in the facility. Findings: A 5-day assessment, dated 02/26/25, showed Resident #20 had a BIMS score of 13 which indicated their cognition was intact and active discharge planning was occurring for the resident to return to the community. A Transfer/Discharge Report, dated 03/14/25, showed Resident #20 had been discharged from the facility to home. Review of the assessments in the electronic clinical record did not show a discharge assessment had been completed. On 08/22/25 at 12:59 p.m., MDS coordinator #1 stated they had reviewed the electronic clinical record and should have completed a discharge assessment for Resident #20.

Based on record review and interview, the facility failed to accurately code a significant change MDS assessment for 1 (#41) of 14 sampled residents who were reviewed for accuracy of assessments. The administrator identified 55 residents resided in the facility. Findings:Resident #41's significant change assessment, dated 07/28/25, showed cognitively intact cognition with a BIMS score of 15. The assessment showed the life expectancy of less than 6 months coded as no.A physician's order, dated 07/22/25, showed to admit Resident #41 to hospice for late affect cerebrovascular accident.On 08/21/25 at 1:34 p.m., MDS coordinator #1 stated the significant change assessment was related to the resident going on hospice. They stated the resident went on hospice services on 07/22/25. MDS coordinator #1 reviewed the MDS and stated the MDS did not have life expectancy of six months coded and was not accurately coded to reflect the resident's status at that time.On 08/21/25 at 1:43 p.m., the administrator stated the MDS was expected to be coded accurately.

Based on record review and interview, the facility failed to insure an injury of unknown origin was reported to OSDH for one (#52) of three sampled residents reviewed for abuse. The DON identified a census of 58. Findings: An Abuse Prevention policy, updated 01/01/23, read in part, .[facility name] will make every attempt to protect our Resident's from abuse of any sort by striving to recognize signs and symptoms and potential for abuse or neglect .The facility has policies and procedures in place to identify events, such as suspicious bruising .Once a complaint or situation is identified involving .injuries of unknown source .the incident will be immediately reported .A full report will be prepared and forwarded to officials as required by state and federal regulations . Resident #52 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction and dysphagia. A Significant Change Resident Assessment, dated 01/11/24, documented Resident #58's cognition was moderately impaired. An Incident Report, dated 02/05/24 at 10:56 a.m., documented at approximately 9:30 a.m., CNA staff reported to the nurse to come to Resident #52's room. It documented upon entering the room, the nurse observed the resident in bed receiving incontinent care. It documented the nurse noted dark purple bruising with significant swelling to the resident's left labia majora and minora. It documented the area measured 15 cm in length and eight cm in width which was painful to touch. It documented the physician, DON, Care Coordinator, and POA were all notified. The report was prepared by LPN #1. A Skin/Wound Note, dated 02/06/24 at 5:35 a.m., documented Resident #52's groin area was checked. It documented ecchymosis seen to right side of groin and labia which was purple in color. It documented ecchymosis to the right thigh which was healing and pink in color. An Incident Note, dated 02/06/24 at 10:34 a.m., documented at approximately 9:30 a.m., CNA staff reported to the nurse to come to Resident #52's room. It documented upon entering the room, the nurse observed the resident in bed receiving incontinent care. It documented the nurse noted dark purple bruising with significant swelling to the resident's left labia majora and minora. It documented the area measured 15 cm in length and eight cm in width which was painful to touch. It documented the physician, DON, Care Coordinator, and POA were all notified. The note was created by LPN #1. A Nurses Note, dated 02/06/24 at 6:48 p.m., documented the resident had a right groin bruise and right inner thigh bruise. There was no State Reportable incident located for the above injury of unknown origin for Resident #52. On 04/03/24 at 2:11 p.m., CNA #3 stated if they saw any bruising on a resident that wasn't there the day before, they would immediately notify the charge nurse so they could assess the area. They stated the nurse would complete an incident report. They stated each staff member would also give a statement. On 04/03/24 at 2:15 p.m., CNA #2 stated they would notify their nurse anytime they identified bruising of unknown origin on a resident. On 04/03/24 at 2:17 p.m., LPN #1 stated if bruising of unknown origin was reported to them, they would assess the resident first to see the size and color. They stated they would complete an incident report and determine if the area was raised or painful. They stated they would ensure to inform the oncoming shift, the DON, Care Coordinator, family, POA, and physician. They stated the incident would automatically go in the pink book for Physician #1 to review. On 04/03/24 at 2:20 p.m., LPN #1 stated they remembered the incident involving Resident #52. They stated the CNA had removed the resident's brief during care, and the resident was noted to have a bruise in the pubis. They stated it was good size, and was the first time LPN #1 had seen it. They stated they completed an incident report on it and were never able to determine the cause of it. On 04/03/24 at 2:26 p.m., the DON stated if a resident was noted to have bruising of unknown origin, they would look to see how large the bruise was. They stated they would visit with the resident to see how they got the bruise. They stated if the resident was unable to report, the facility would do an additional investigation. The DON stated they would complete a State Reportable. On 04/03/24 at 2:28 p.m., the DON stated the facility would complete a State Reportable incident on any resident who had a bruise of unknown origin. On 04/03/24 at 2:29 p.m., the DON stated they were the person responsible for completing State Reportable incidents. On 04/03/24 at 2:31 p.m., the DON clarified the nurse note dated 02/06/24 was linked to the incident on 02/05/24. They stated the incident occurred on 02/05/24. On 04/03/24 at 2:36 p.m., the DON was asked what investigation was completed for the bruising of unknown origin. On 04/03/23 at 2:37 p.m., the DON reviewed the State Reportable incidents and did not locate one for the incident involving Resident #52 on 02/05/24. On 04/03/24 at 2:59 p.m., the DON stated they went to Care Coordinator #1 and obtained the facility investigation. The DON provided copied of an inservice related to reporting bruises held on 02/06/24. The DON also provided nine interviews conducted in conjunction with there investigation. The DON was unable to provide documentation OSDH was informed of Resident #52's injury of unknown origin.

Based on record review and interview, the facility failed to ensure a discharge summary was developed for one (#61) of three sampled residents reviewed for discharge. The DON identified a census of 58. Findings: Resident #61 had diagnoses which included pneumonia and bronchitis. A Discharge Summary and Plan policy, dated 12/16, read in part, .a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident . A Physician Order dated 01/10/24, documented the resident was to be discharged to an assisted living facility as of 01/16/24 with home health to include PT, OT, ST, skilled nursing and a home health aide. Resident #61 had no discharge summary in their medical record. On 04/04/24 at 2:00 p.m., the DON stated a discharge should include the condition of the resident, discharge rehabilitation potential, medications, orders, follow up directions, and reason for leaving. The DON stated it should have been in the progress notes and a discharge summary. The DON stated there was no documentation of the resident's discharge that could be located.

Based on record review and interview, the facility failed to obtain physician ordered labs for one (#56) of five sampled residents reviewed for unnecessary medications. The DON identified a census of 58. Findings: A Laboratory policy, undated, read in part, .It is the policy of this facility to ensure that laboratory .services meet the needs of the residents, that results are reported promptly to the ordering provider . Resident #56 had diagnoses which included severe protein-calorie malnutrition, hypertension, and chronic obstructive pulmonary disease. A Physician Order, dated 02/07/24, documented lab check chem eight for delirium one time only. There was no documentation in the resident's clinical record this lab was obtained. On 04/04/24 at 9:57 a.m., the DON stated if the physician wrote an order for a lab, staff would ensure the order was put in, place the order in the requisition book, and place it in the lab book for them to come and draw it. The DON stated lab came to the building Monday through Friday. On 04/04/24 at 10:38 a.m., the DON stated they were unable to find lab results for the chem eight ordered.

Based on observation and interview, the facility failed to ensure food items were properly secured, dated, and labeled for one of one kitchen observations. The DON identified a census of 58. Findings: A Food Receiving and Storage policy, dated 07/14, read in part, All foods stored in the refrigerator or freezer will be covered, labeled and dated .Other opened containers must be dated and sealed or covered during storage . On 04/01/24 at 9:55 a.m., bread in the dining room refrigerator was observed to have no label present. Dietary Aide #1 stated it was for the birds. On 04/01/24 at 10:03 a.m., a carton of au gratin potatoes was observed open and unlabeled in the dry storage area. The Food and Beverage Director stated the au gratin potatoes were opened and not labeled. On 04/01/24 at 10:07 a.m., frozen bread bowls and tri color pasta was observed in the walk in freezer. The Food and Beverage Director stated the frozen bread bowls and tri-color pasta had no expiration date or label.

Based on observation, record review, and interview, the facility failed to: a. speak to a resident in a respectful manner for one (#28); and b. ensure resident clothing labels were not visible for one (#39) of three sampled residents reviewed for dignity. The DON identified a census of 58. Findings: A Quality of Life-Dignity policy, revised 08/09, read in part, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Treated with dignity .means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall speak respectfully to residents at all times .Demeaning practices and standards of care that compromise dignity are prohibited . 1. Resident #28 had diagnosis which included Parkinson's and Dementia. On 04/02/24 at 9:10 a.m., CNA #6 was observed asking Resident #28 if they wanted to be fed like a baby, after the resident was observed sitting in wheel chair moving their fork around aimlessly in the air beneath the bedside table. On 04/02/24 at 9:23 a.m., Resident #28 was observed to be eating easily when the spoon was offered. On 04/02/25 at 10:02 AM, CNA #6 stated resident #28 usually went to the dining room and fed themselves. CNA #1 stated Resident #28 had commented they were not a baby when CNA #6 previously offered to assist them. On 04/02/24 at 10:19 a.m., Resident #28 was asked how it made them feel to be asked if they wanted to be fed like a baby. Resident #28's answer was not understood. On 04/03/24 at 2:51 p.m., LPN #2 stated Resident #28 had mentioned statements like I don't want you to feed me, but it had been a long time ago since they had stated that. They sated comments like do you want me to feed you like a baby would not be an appropriate statement at all. On 04/03/24 at 3:02 p.m., the DON stated it depended on the relationship between residents on how they would take the comment of Do you want me to feed you like a baby? 2. Resident #39 had diagnoses which included Alzheimer's disease and anxiety disorder. A Significant Change Resident Assessment, dated 02/29/24, documented the resident's cognition for daily decision making was severely impaired. On 04/01/24 at 10:16 a.m., Resident #39 was observed seated in their wheelchair. The resident's right sock they were wearing had her name label clearly visible. On 04/02/24 at 9:07 a.m., Resident #39 was observed seated in their wheelchair. The resident's right and left sock they were wearing had a label with their name on each one clearly visible. On 04/03/24 at 10:45 a.m., CNA #3 stated they treated resident's with dignity and respect by making sure the door was shut and the curtain was pulled every time they went in to change them. They stated if a resident was wearing a dress, they would place a blanket over them. They stated they would always go in with respect and ask them if they needed anything, make sure they had a drink in reach, and offer drinks to those who could not get one themselves. On 04/03/24 at 10:46 a.m., CNA #3 stated staff would take resident's personal items over to the laundry who would use a label press on the back side of the shirts and pants to label items. On 04/03/24 at 10:46 a.m., CNA #3 stated they would make sure all clothing residents came with were labeled and placed in their closets. On 04/03/24 at 10:47 a.m., CNA #3 stated they were unsure of the reason the top of the resident's socks were labeled unless they were skid free and they didn't want to label the skid free section. On 04/03/24 at 10:50 a.m., Laundry #1 stated when they pick up resident items to be laundered, they made sure clothes had resident names on them. They stated they had a label machine to print out labels. They stated they placed labels on the inside, back section by the brand name. They stated they tried to place it where it didn't look like a label was there when they were wearing it. Laundry #1 stated they didn't use the inside of the socks because it might bother them, They stated they placed labels on the outside so they could read it and they were not bothered by the label.

Based on record review and interview, the facility failed to revise care plans for two (#22 and #37) of 18 sampled residents reviewed for accuracy of care plans. The DON identified a census of 58. Findings: A Care Plans, Comprehensive Person-Centered policy, dated 12/16, read in part, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #37 had diagnoses which included aftercare following surgical amputation. A progress note, dated 01/15/24, documented Resident #37 was readmitted to skilled care after a left above knee amputation had been performed on 01/11/24. It documented a wound vac was to be in place for seven days. A Care Plan, revised 05/18/23, documented the resident has a venous ulcer of the left lower calf related to peripheral vascular disease. There was no care plan for wound care related to left above knee amputation. On 04/02/24 at 3:33 p.m., MDS Coordinator #1 stated they had started a Performance Improvement Project for care plans. MDS Coordinator #1 stated they care planned relevant new orders every day. 2. Resident #22 had diagnoses which included corticobasal degeneration and hypertension. A Quarterly Resident Assessment, dated 01/11/24, did not document the resident received hospice services. There was no physician order for hospice care in Resident #22's current order summary. A Care Plan, last reviewed 01/30/24, documented the resident had a terminal prognosis which was initiated on 06/12/21 with a goal for comfort to be maintained through the review date with a target date of 04/26/24. On 04/03/24 at 10:01 a.m., LPN #3 stated Resident #22 was on hospice services when they first came to the facility. They stated they were unsure of the exact discharge from hospice date, but they thought it was longer than a year ago. On 04/03/24 at 10:20 a.m., MDS Coordinator #1 stated they printed out orders every morning and used them to update care plans. They stated they had a morning meeting where the Care Coordinators printed a list of everything which needed to be updated related to residents on the hall. On 04/03/24 at 10:21 a.m., MDS Coordinator #1 stated they would complete a care plan for terminal prognosis when the resident received a terminal prognosis. On 04/03/24 at 10:22 a.m., MDS Coordinator #1 stated Resident #22 was not on hospice services. They stated they did not complete the resident's care plan, and the care plan was not updated. They stated they guessed when Resident #22 came off of hospice services, they did not remove it from the resident's care plan. MDS Coordinator #1 stated they had been at the facility approximately one month and had not been able to update every resident's care plan.

Based on observation and interviews, the facility failed to ensure harmful chemicals were secured. The Administrator identified six residents that required wander guards to be worn for safety. The DON identified a census of 58. Findings: On 04/01/24 at 9:58 a.m., an observation of 1/10 of a gallon container of dish detergent, 1/10 of a 32 oz. bottle of lime and calcium remover, 1/2 full spray bottle labeled with black marker cleaner with bleach, and a full 15 oz. aerosol can of stainless steel cleaner were observed sitting on top of the dishwasher in the room which connected the two dining rooms. A one gallon container of dish detergent and a one gallon container of sanitizer on a rack that was attached to the sink were also observed in the room. Both doors to the room were observed to be open. On 04/01/24 at 9:59 a.m., Dietary Aide #1 stated the residents don't come in the room. They stated the staff did not lock the door. On 04/01/24 at 12:08 p.m., the Dietary Manager stated there was no key, so the door did not get locked. They stated staff were in and out of the room all day. The Dietary Manager stated the door was only closed from around 7:00 p.m. to 7:00 a.m.

Based on record review and interview, the facility failed to develop a baseline care plan for one (#109) of two new admissions reviewed. The Administrator reported 121 residents had been admitted in the last year. Findings: A policy titled Care Plan - Baseline, dated 12/16, read in parts, . A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Res #109 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease, anxiety, and congestive heart failure. A baseline care plan was not developed for Res #109. On 02/23/23 at 4:00 p.m., the MDS coordinator reported a baseline care plan had not been completed for Res #109. On 02/23/23 at 4:10 p.m., the administrator reported the baseline care plan should have been completed within 48 hours of the resident's admission.

Based on record review, observation, and interview, the facility failed to follow physician's orders for two (#5 and #109) of two residents reviewed for oxygen therapy. The Administrator reported 13 residents received oxygen therapy. Findings: Res #5 was admitted with diagnoses which included atrial fibrillation, and hypertension. A physician's order, dated 11/12/21, documented in parts, .CHANGE NASAL CANNULA ON O2 . EVERY WEEK, DATE AND TIME . A physician's order, dated 11/16/22, documented in parts 02 at 2-4 L/M . On 02/21/23 at 10:15 a.m., Res #5 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/21/21 at 2:43 p.m., Res #5 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/22/23 at 1:05 p.m., LPN #2 reported the oxygen tubing was ordered to be changed every wednesday night. The LPN observed the oxygen tubing for Res #5 and stated it was dated 01/18/23. LPN #2 reported the oxygen tubing was not changed as ordered. On 02/22/23 at 2:15 p.m., the interim DON reported the oxygen tubing should have been changed as ordered. Res #109 was admitted with diagnoses which included chronic obstructive pulmonary disease, anxiety, and congestive heart failure. A treatment admiministration record, dated 02/23, documented the oxygen tubing had not been labeled and dated. A physician's order, dated 02/17/23, documented in part, oxygen 3lpm via nasal cannula every shift for dyspnea. A physician's order, dated 02/17/23, documented in parts, .change nasal cannula on 02 every week, date and time. On 02/21/23 at 10:08 a.m., Res #109 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/21/23 at 3:01 p.m., Res #109 was observed in their room with oxygen in use and the oxygen tubing was not labeled and dated as ordered. On 02/22/23 at 1:02 p.m., LPN #2 reported Res #109's oxygen tubing was not labeled and dated as ordered. On 02/22/23 at 1:13 p.m., the Administrator reported the tubing should have been labeled and dated as ordered.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#8 and #28) of two residents reviewed for falls and one (#27) of one resident who was reviewed for a PEG (feeding) tube. The Administrator reported 56 residents had falls in the last 12 months and one resident had a PEG tube. Findings: Res #8 was admitted with diagnoses which include hemiplegia and hemiparesis following a CVA and lack of coordination. An incident note, dated 04/17/22, read in parts, Resident found laying beside the bed on the fall mat . An incident note, dated 07/21/22, read in parts, .resident slipped out of her wheelchair onto floor . An incident note, dated 08/04/22, read in parts, Resident has been placed on post fall charting after attempting to transfer self without assistance . An incident note, dated 10/30/22, read in parts, .Resident observed sitting on buttocks on the floor . An incident note, dated 11/28/22, read in parts, Resident was found on the floor . An incident note, dated 12/02/22, read in parts, Resident was found on floor . An incident note, dated 12/12/22, read in parts, Resident was found on floor . An incident note, dated 12/16/22, read in parts, Resident found by this nurse on fall mat . An incident note, dated 12/25/22, read in parts, .Upon entering, observed resident sitting on her bottom in from of her W/C . An incident note, dated 02/5/23, read in parts, .resident sitting on floor . A quarterly assessment, dated 06/10/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). A quarterly assessment, dated 07/23/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). An annual assessment, dated 10/20/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). A quarterly assessment, dated 11/29/22, documented no falls since admission/entry, reentry, or the prior assessment (one fall should have been documented). Resident #28 was admitted with diagnoses which included abnormalities of gait and mobility. An incident report, dated 03/31/22, read in parts, .resident noted sitting on floor beside bed . An incident report, dated 04/10/22, read in parts, .Resident was found on the floor by her bed . An incident report, dated 05/18/22, read in parts, .sitting on floor in front of recliner . An incident report, dated 06/20/22, read in parts, .resident on floor mat beside bed . An incident report, dated 07/25/22, read in parts, .resident on floor .laying next to dresser . An incident report, dated 08/21/22, read in parts, .fell on previous shift . An incident report, dated 08/30/22, read in parts, .Resident found on floor . An incident report, dated 09/06/22, read in parts, .Resident rolled herself out of bed . An incident report, dated 09/08/22, read in parts, .resident observed sitting on floor . An incident report, dated 09/10//22, read in parts, .resident on floor mat beside her bed in her room . An incident report, dated 09/23/22, read in parts, .witnessed non-injury fall occurred at this time . An incident report, dated 10/27/22, read in parts, .CNA was able to control the fall and lowered her to the floor . An incident report, dated 11/22/22, read in parts, Resident observed laying on fall mat on her stomach . An incident report, dated 11/25/22, read in parts, Resident had a non-injury fall out of her bed . An incident report, dated 11/26/22, read in parts, Resident observed sitting on floor . An incident report, dated 02/01/23, read in parts, Resident had a fall on this shift . A quarterly assessment, dated 04/11/22, documented no falls since admission/entry, reentry, or the prior assessment (two or more falls should have been documented). A quarterly assessment, dated 08/05/22, documented no falls since admission/entry, reentry, or the prior assessment (two or more falls should have been documented). A quarterly assessment, dated 11/09/22, documented no falls since admission/entry, reentry, or the prior assessment (two or more falls should have been documented). On 02/24/23 at 8:30 a.m., the MDS Coordinator reported the falls for Res #8 and #28 should have been documented on their resident assessments. Res #27 was admitted with diagnoses which included gastrostomy, Parkinson's disease, and dementia. The Long-Term Care Facility Resident Assessment Instrument 2.0 User's Manual, dated October 2019, read in parts, .Mechanically Altered Diet: A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake .Therapeutic Diet: .diet intervention ordered by a health care practitioner as part of the treatment for a disease or clinical condition manifesting an altered nutritional status, to eliminate, decrease, or increase certain substances in the diet (e.g. sodium, potassium) .Therapeutic diets are not defined by the content of what is provided or when it is served, but why the diet is required. Therapeutic diets provide the corresponding treatment that addresses a particular disease or clinical condition . A physician's order, dated 10/11/22, read in part, NPO diet, N/A texture, N/A consistency. A physician's order, dated 11/20/22, read in parts, Isosource (nutritional formula) 1.5 Give 180ml via PEG tube 5x's daily . A nursing note, dated 10/16/22, read in parts, .Resident is NPO: all meds and nutrition administered via PEG . A nutrition/dietary note, dated 11/22/22, read in parts, .Weight is stable .Diet order is NPO. Continues with Isosource 180ml 5 times/day. No new nutrition interventions are needed. A quarterly assessment, dated 03/12/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A therapeutic diet was documented and should not have been. An annual assessment, dated 06/10/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A quarterly assessment, dated 09/07/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A significant change assessment, dated 10/01/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A significant change assessment, dated 10/17/22, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. A quarterly assessment, dated 01/16/23, documented Res #27 had a feeding tube and received 51% or more of their total calories through a tube feeding. A mechanically altered and therapeutic diet were documented and should not have been. On 02/23/23 at 11:05 a.m., LPN #1 stated, As long as Res #27 has been here they have been NPO and received nothing by mouth. On 02/23/23 at 11:10 a.m., CMA #1 reported Res #27 received nothing by mouth. On 02/24/23 at 8:27 a.m., the MDS Coordinator reported mechanically altered diet was documented because staff tried to give Res #27 food by mouth at one time. (MDS Coordinator was unable to provide documentation) The MDS Coordinator reported Res #27 was receiving a mechanically altered diet because the formula they received through the PEG tube was a liquid diet. The MDS Coordinator reported therapeutic diet was documented because Res #27's formula was high in protein and fiber.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#27) of one resident reviewed for a PEG tube, one (#28) of two residents reviewed for falls, and one (#42) of one resident reviewed for a venous ulcer. The Administrator reported one resident had a PEG tube, 56 residents had falls in the last 12 months, and one resident had a venous ulcer. Findings: A policy titled Comprehensive Assessment and the Care Delivery Process, dated 12/16, read in parts, .Define current treatments and services; link with problems/diagnoses . Res #27 was admitted with diagnoses which included gastrostomy, Parkinson's disease, and dementia. A physician's order dated, 10/11/22, read in parts, NPO diet . A physician's order dated, 10/11/22, read in parts, Check for PEG tube placement before medication and free water administration every shift . A physician's order dated, 10/11/22, read in parts, Elevate HOB 30 degrees at all times . A physician's order dated, 10/12/22, read in parts, Cleaned PEG tube site with wound cleanser, apply drain sponge, secure with tape every evening shift . A physician's order dated, 10/27/22, read in parts, Check for residual prior to each feeding. If >100ml, hold feeding and re-check in 1 hr. If < 100ml, provide feeding at that time . A physician's order dated, 11/11/22, read in part, Flush PEG tube with 200ml free water every 4 hours. A physician's order dated, 11/20/22, read in part, Isosource 1.5 Give 180ml via PEG tube 5x's daily . There was no nutrition/PEG tube care plan for Res #27. On 02/24/23 at 8:27 a.m., the MDS/Care Plan Coordinator reported Res #27 should have had a nutrition/PEG tube care plan to include the physician's orders related to the PEG tube. Res #28 was admitted with diagnoses which included abnormalities of gait and mobility. An annual assessment, dated 11/29/22, documented Res #28 had impaired ROM on one side and needed extensive assistance with transfers and bed mobility. The assessment documented Res #28 required limited assistance with walking, their balance with walking was not steady, and they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/28/22, 05/03/22, 08/03/22, 11/03/22 and 02/03/23, documented Res #28 was at high risk for falls. An incident report, dated 03/31/22, read in parts, .resident noted sitting on floor beside bed . An incident report, dated 04/10/22, read in parts, .Resident was found on the floor by her bed . An incident report, dated 05/18/22, read in parts, .sitting on floor in front of recliner . An incident report, dated 06/20/22, read in parts, .resident on floor mat beside bed . An incident report, dated 07/25/22, read in parts, .resident on floor .laying next to dresser . An incident report, dated 08/21/22, read in parts, .fell on previous shift . An incident report, dated 08/30/22, read in parts, .Resident found on floor . An incident report, dated 09/06/22, read in parts, .Resident rolled herself out of bed . An incident report, dated 09/08/22, read in parts, .resident observed sitting on floor . An incident report, dated 09/10//22, read in parts, .resident on floor mat beside her bed in her room . An incident report, dated 09/23/22, read in parts, .witnessed non-injury fall occurred at this time . An incident report, dated 10/27/22, read in parts, .CNA was able to control the fall and lowered her to the floor . An incident report, dated 11/22/22, read in parts, Resident observed laying on fall mat on her stomach . An incident report, dated 11/25/22, read in parts, Resident had a non-injury fall out of her bed . An incident report, dated 11/26/22, read in parts, Resident observed sitting on floor . An incident report, dated 02/01/23, read in parts, Resident had a fall on this shift . There was no fall care plan for Res #28. On 02/24/23 at 8:27 a.m., the MDS/Care Plan Coordinator reported Res #28 should have had a care plan for falls. Res #42 was admitted with diagnoses which included diabetes, venous insufficiency, and non pressure ulcer. A quarterly assessment, dated 12/03/22, documented Res #42 required assistance with activities of daily living, and had one venous ulcer. There was no venous ulcer care plan for Res #42. On 02/23/23 at 2:04 p.m., the MDS coordinator reported the care plan did not include the venous ulcer. On 02/23/23 at 2:16 p.m., RN #1 reported the care plan should have included the venous ulcer. On 02/23/23 at 4:09 p.m., the Administrator reported the venous ulcer should have been included in the care plan.

Based on record review and interview, the facility failed to ensure a fall care plan was revised for two (#8 and #13) of three residents reviewed for falls. The Administrator reported 56 residents had falls in the last 12 months. Findings: Res #8 was admitted with diagnoses which included lack of coordination, hemiplegia, and hemiparesis. A quarterly assessment, dated 11/29/22, documented Res #8 needed extensive assistance with bed mobility, transfers and ambulation. The assessment documented Res #8's balance with walking was not steady and they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/29/22, 06/29/22, 09/29/22, and 12/29/22, documented Res #8 was at high risk for falls. An incident note, dated 04/17/22, read in parts, Resident found laying beside the bed on the fall mat . An incident note, dated 07/21/22, read in parts, .resident slipped out of her wheelchair onto floor . An incident note, dated 08/04/22, read in parts, Resident has been placed on post fall charting after attempting to transfer self without assistance . An incident note, dated 10/30/22, read in parts, .Resident observed sitting on buttocks on the floor . An incident note, dated 11/28/22, read in parts, Resident was found on the floor . An incident note, dated 12/02/22, read in parts, Resident was found on floor . An incident note, dated 12/12/22, read in parts, Resident was found on floor . An incident note, dated 12/16/22, read in parts, Resident found by this nurse on fall mat . An incident note, dated 12/25/22, read in parts, .Upon entering, observed resident sitting on her bottom in from of her W/C . An incident note, dated 02/05/23, read in parts, .resident sitting on floor . A fall care plan for Res #8, last revised on 04/13/21, was not revised for the falls from 04/17/22 through 02/05/23. Res #13 was admitted with diagnoses which included lack of coordination, dementia, and abnormalities of gait. A quarterly assessment, dated 12/17/22, documented Res #13 was mildly cognitively impaired and required extensive assistance with activities of daily living. Incident reports, documented Res #13 had 11 falls from 08/25/22 through 01/03/23. A fall care plan developed on 08/02/22 was not revised for the falls from 08/25/22 through 01/03/23. On 02/22/23 at 3:10 p.m., the MDS coordinator reported the care plan had not been revised with each fall. On 02/23/23 at 3:54 p.m., the interim DON reported the care plan should have been revised with new interventions. On 02/23/23 at 4:04 p.m., the Administrator reported the care plan should have been revised with each fall. On 02/24/23 at 8:30 a.m., the MDS/Care Plan Coordinator reported they had not updated the care plan for Res #8 with each fall, and if they had been provided fall interventions they would have been care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. Res #27 was admitted on [DATE] with diagnoses which included gastrostomy, Parkinson's disease, and dementia. Physician's orders dated, 05/21/21 and 10/11/22, read in parts, NPO diet . An ADL Care plan, last revised on 08/16/21, read in parts, EATING: Provide finger foods when the resident has difficulty using utensils .Provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate . On 02/23/23 at 11:05 a.m., LPN #1 stated, As long as Res #27 has been here they have been NPO and received nothing by mouth. On 02/23/23 at 11:10 a.m., CMA #1 reported Res #27 received nothing by mouth. On 02/24/23 at 8:30 a.m., the MDS/Care Plan Coordinator reported the eating interventions should not have been care planned since Res #27 had been NPO since admission. Based on record review and interview, the facility failed to ensure: a. weights were obtained as ordered by the physician for one (#13) of one resident with congestive heart failure; b. a care plan was accurate for one (#27) of one resident reviewed for a PEG tube, and c. communication was documented between hospice and the facility for one (#38) of two residents on hospice. The Administrator reported 13 residents had congestive heart failure, one resident had a peg tube, and two residents were on hospice. Findings: a. Res #13 was admitted with diagnoses which included congestive heart failure. A physician's order, dated 08/03/22, documented in part, Daily Weight every day shift for CHF. A physician's order, dated 10/14/22, documented in parts, Lasix (a diuretic) Tablet 20 MG Give 1 tablet by mouth one time a day related to .CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE .give 60mg per day. A physician's order, dated 10/15/22, documented in parts, Lasix Tablet 40 MG .Give 1 tablet by mouth one time a day for CHF give with 20mg tab to equal 60mg dosing per day. A treatment administration record, dated December 2023, documented 27 weights out of 31 opportunities. Weights for 12/04/22, 12/11/22, 12/23/22, and 12/26/22 were not documented. A treatment administration record, dated January 2023, documented 25 weights out of 31 opportunities. Weights for 01/03/23, 01/04/23, 01/12/23, 01/16/23, 01/26/23, and 01/30/23 were not documented. On 02/22/23 at 3:10 p.m., CNA #1 reported Res #13 required daily weights. CNA #1 reported if the resident refused to be weighed it should have been documented on the treatment administration record. On 02/22/23 at 3:15 p.m., LPN #3 reported the daily weights had not been obtained and documented on the treatment administration record as ordered. On 02/22/23 at 3:59 p.m., the interim DON stated according to documentation the daily weights were not obtained and documented as ordered. On 02/22/23 at 4:02 p.m., the Administrator reported the weights should have been obtained and documented as ordered. b. Res #38 was admitted with diagnoses which included anxiety, hypertension, and dementia. A policy, titled End of Life Care, dated 07/17, read in parts, .Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed . A physician's order, dated 12/07/22, documented in parts, Admit to .Hospice . The hospice medical record for Res #38 did not contain documentation showing communication between the facility and hospice. On 02/23/23 at 10:20 a.m., LPN #1 reported the facility did not have documented communication with hospice. On 02/23/23 at 10:21 a.m., the MDS coordinator reported the facility did not have documented communication with hospice. On 02/23/23 at 10:24 a.m., the Administrator reported the facility should have had documented communication with hospice.

Res #28 was admitted with diagnoses which included abnormalities of gait and mobility. An annual assessment, dated 11/29/22, documented Res #28 had impaired ROM on one side, needed extensive assistance with transfers, and bed mobility. The assessment documented Res #28 required limited assistance with walking, their balance with walking was not steady, they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/28/22, 05/03/22, 08/03/22, 11/03/22 and 02/03/23, documented Res #28 was at high risk for falls. An incident report, dated 03/31/22, read in parts, .resident noted sitting on floor beside bed . An incident report, dated 04/10/22, read in parts, .Resident was found on the floor by her bed . An incident report, dated 05/18/22, read in parts, .sitting on floor in front of recliner . An incident report, dated 06/20/22, read in parts, .resident on floor mat beside bed . An incident report, dated 07/25/22, read in parts, .resident on floor .laying next to dresser . An incident report, dated 08/21/22, read in parts, .fell on previous shift . An incident report, dated 08/30/22, read in parts, .Resident found on floor . An incident report, dated 09/06/22, read in parts, .Resident rolled herself out of bed . An incident report, dated 09/08/22, read in parts, .resident observed sitting on floor . An incident report, dated 09/10//22, read in parts, .resident on floor mat beside her bed in her room . An incident report, dated 09/23/22, read in parts, .witnessed non-injury fall occurred at this time . An incident report, dated 10/27/22, read in parts, .CNA was able to control the fall and lowered her to the floor . An incident report, dated 11/22/22, read in parts, Resident observed laying on fall mat on her stomach . An incident report, dated 11/25/22, read in parts, Resident had a non-injury fall out of her bed . An incident report, dated 11/26/22, read in parts, Resident observed sitting on floor . An incident report, dated 02/01/23, read in parts, Resident had a fall on this shift . Fall interventions regarding the falls from 03/31/22 through 02/01/23 were not documented due to there being no fall care plan established for Res #28. On 02/22/23 at 3:10 p.m., the MDS coordinator reported the care plan for Res #13 had not been revised with each fall. On 02/23/23 at 3:54 p.m., the interm DON reported new interventions should have been in place for Res #13 after each fall to help prevent future falls. On 02/23/23 at 4:04 p.m., the Administrator reported the care plan for Res #13 should have been revised with each fall and implemented to help decrease risk for falls. On 02/24/23 at 8:30 a.m., the MDS/Care Plan Coordinator reported there should have been a fall care plan for Res #28. The MDS Coordinator reported they had not updated the care plan for Res #8 with each fall because they had not been provided with fall interventions. Based on record review and interview, the facility failed to follow their fall protocol policy for three (#8, 13, and #28) of three residents reviewed for falls. The Administrator reported 56 residents had falls in the last 12 months. Findings: A Falls - Clinical Protocol policy, revised March 2018, read in parts, .the staff .will identify pertinent interventions to try to prevent subsequent falls .staff will try various relevant interventions .staff .will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . Res #8 was admitted with diagnoses which included lack of coordination, hemiplegia, and hemiparesis. A quarterly assessment, dated 11/29/22, documented Res #8 needed extensive assistance with bed mobility, transfers, ambulation. The assessment documented Res #8's balance with walking was not steady and they required staff assistance for stabilization. The Morse Fall Scale, completed on 03/29/22, 06/29/22, 09/29/22, and 12/29/22, documented Res #8 was at high risk for falls. An incident note, dated 04/17/22, read in parts, Resident found laying beside the bed on the fall mat . An incident note, dated 07/21/22, read in parts, .resident slipped out of her wheelchair onto floor . An incident note, dated 08/04/22, read in parts, Resident has been placed on post fall charting after attempting to transfer self without assistance . An incident note, dated 10/30/22, read in parts, .Resident observed sitting on buttocks on the floor . An incident note, dated 11/28/22, read in parts, Resident was found on the floor . An incident note, dated 12/02/22, read in parts, Resident was found on floor . An incident note, dated 12/12/22, read in parts, Resident was found on floor . An incident note, dated 12/16/22, read in parts, Resident found by this nurse on fall mat . An incident note, dated 12/25/22, read in parts, .Upon entering, observed resident sitting on her bottom in from of her W/C . An incident note, dated 02/05/23, read in parts, .resident sitting on floor . A fall care plan, last revised on 04/13/21, did not contain fall interventions for the falls from 04/17/22 through 02/05/23. Res #13 was admitted with diagnoses which included lack of coordination, dementia, and abnormalities of gait. A quarterly assessment, dated 12/17/22, documented Res #13 was mildly cognitively impaired and required extensive assistance with activities of daily living. Incident reports documented Res #13 had 11 falls from 08/25/22 through 01/03/23. A fall care plan developed on 08/02/22 was not revised for the falls from 08/25/22 through 01/03/23.