Brookdale Westlake Village

Based on interviews, record review, and review of facility policy, the facility failed to update service plans to reflect fall interventions. This affected one resident (#51) of three residents reviewed for service plans. The facility census was 50.

Findings include:

Review of the medical record for Resident #51 revealed she was admitted to the facility on 02/27/25 with diagnoses that included primary generalized osteoarthritis, sick sinus syndrome, hypertension, and repeated falls.

Additional review of Resident #51's medical record revealed she had a Brief Interview for Mental Status (BIMS) score of 10 that indicated she was alert and oriented with cognition impairment. Resident #51 required assistance from staff for activities of daily living (ADLs) and was discharged on 12/26/25 due to death in the facility.

Review of the service plan dated 02/27/25 revealed Resident #51 was a fall risk, required assistance with ADLs, and had cognition impairment with memory loss. Review of the service plan revealed interventions that included using activities to increase observation, assist with ADLs and utilize a transfer bar for bedside mobility. There were no interventions to increase frequency of resident monitoring or rounding.

Review of Resident #51's physician orders dated 12/26/25 revealed an order for utilization of a walker and/or wheelchair as an assistive device for safety and mobility. There were no orders for frequent or increased monitoring.

Review of the progress note dated 03/01/25 at 9:00 P.M. revealed Resident #51 was confused and attempted to get out of bed without calling for assistance. Resident #51 was unable to bend her legs to adjust to the sitting position. The top half of her body was lying on the bed with her legs straight and her feet touching the floor.

Review of the physician progress note dated 03/25/25 at 10:18 P.M. revealed Resident #51 had difficulty getting out of bed, required more assistance, and likely needed a hospital bed. Resident #51 had a history of falls, required a hospital bed due to a regular bed not fitting her needs and frequent positional changes.

Review of the progress note dated 04/03/25 at 2:55 P.M. revealed Resident #51 fell in her room while trying to transfer from a chair to her recliner. Resident #51 was transported to the hospital.

Review of the progress note dated 04/04/25 at 1:22 P.M. revealed Resident #51 was admitted to the hospital with a subdermal hematoma, required assistance of two for all ADLs and unable to walk multiple steps with a walker.

Review of the progress note dated 05/13/25 at 12:41 P.M. revealed Resident #51 had difficulty and an unsteady time transferring and using a rollator.

Review of the progress note dated 06/24/25 at 12:48 P.M. revealed Resident #51 was found in the sitting position, on the floor, with her back against the door. Resident #51 lost her balance and fell backwards.

Review of the physician progress note dated 06/25/25 at 9:42 P.M. revealed Resident #51 tried to get out of bed and fell.

Review of the progress note dated 06/26/25 at 6:30 P.M. revealed Resident #51 was found lying on her back in the middle of her room, near her bed. Resident #51's Power of Attorney (POA), who observed the fall via camera, stated Resident #51 attempted to sit on her walker and fell backwards. Resident #51 banged on a trashcan with something trying to get someone's attention. Resident #51 was transported to the hospital.

Review of the progress note dated 06/27/25 at 12:53 A.M. revealed Resident #51 was out of the building and returned at approximately 12:30 A.M. after being transported to the hospital due to sustaining a fall.

Review of the progress note dated 07/05/25 at 6:15 P.M. revealed Resident #51 fell and was found lying on her back with face upward on the floor in her room in front of her recliner. Resident #51's POA revealed she observed the fall on camera and Resident #51 had to use her grabber to bang on something to get someone's attention.

Review of the progress note dated 07/28/25 at 5:21 P.M. revealed Resident #51 fell after trying to sit in her chair.

Review of the progress note dated 09/03/25 at 8:40 P.M. revealed Resident #51 fell and was found in her room lying on the floor next to her bed.

Review of the progress note dated 10/26/25 at 6:00 P.M revealed Resident #51 fell and was found sitting on the floor with her back against the wall in her room. Resident #51's walker was in front of her and her scooter was to the left of her.

Review of the progress note dated 12/06/25 at 5:45 P.M. revealed Resident #51 was lying horizontal in bed with her feet off the bed.

Review of the progress note dated 12/18/25 at 12:51 P.M. revealed Resident #51 requested to get up and walk to her chair but was reminded that she had not been able to walk for days and the last time she attempted to walk, she almost had a fall.

Review of all progress notes dated from Resident #51's admission until her death revealed she had multiple falls, difficulty with ambulating and/or bed mobility and was a high risk for falls.

Review of the post-fall evaluations dated 06/25/25 and 10/27/25 revealed Resident #51 had interventions to increase the frequency of monitoring including, but not limited to, rounds and group activities with no end date.

Review of the service plan dated 02/27/25 revealed Resident #51 did not have interventions to increase resident monitoring or rounding.

Interview on 01/22/26 at 1:40 P.M. with Care Partner (CP) #604 revealed Resident #51 was a fall risk and always tried to get out of bed. Resident #51 always had her feet out of bed.

Interview on 01/22/26 at 1:50 P.M. with Licensed Practical Nurse (LPN) #605 revealed Resident #51 was at risk for falls. Resident #51 constantly yelled, pressed her call button, and had her feet hanging out of bed. Resident #51 required repositioning and often wiggled around in bed, and required frequent rounding.

Interview on 01/22/26 at 2:11 P.M. CP #511 revealed she was familiar with Resident #51 who required total care for all ADLs. Resident #51 required to be checked and changed, dressed, provided all meals, was a fall risk and she could no longer walk. Resident #51 would throw her legs out of bed and believed she could walk but she was not able to due to weakness. The resident also required a mechanical lift for transfers. Resident #51 required frequent checks and on the night of her death, no one entered her room to check on her.

Interview on 01/22/26 at 5:01 P.M. with the Executive Director (ED) and the Director of Nursing (DON) revealed that despite Resident #51's intervention of increased frequent rounding, staff only rounded every three to four hours. The ED revealed Resident #51 was a fall risk, but she could not recall her risk level. The DON confirmed Resident #51 did not have an updated service plan to include frequent rounding or monitoring at the time of the interview.

Review of the facility policy labeled Service Plan Process Policy

Based on interviews, record review, and review of a Self-Reported Incident (SRI), manufacturer's instructions and facility policy, the facility failed to provide adequate resident supervision and implement fall interventions to decrease the risk of falls. This affected one resident (#51) of three residents reviewed for care and treatment. The facility census was 50.

Findings include:

Review of the medical record for Resident #51 revealed she was admitted to the facility on 02/27/25 with diagnoses that included primary generalized osteoarthritis, sick sinus syndrome, hypertension, and repeated falls.

Additional review of Resident #51's medical record revealed she had a Brief Interview for Mental Status (BIMS) score of 10 that indicated she was alert and oriented with cognition impairment. Resident #51 required assistance from staff for activities of daily living (ADLs) and was discharged on 12/26/25 due to death in the facility.

Review of the service plan dated 02/27/25 revealed Resident #51 was a fall risk, required assistance with ADLs, and had cognition impairment with memory loss. Review of the service plan revealed interventions that included using activities to increase observation, assist with ADLs and utilize a transfer bar for bedside mobility. There were no interventions to increase frequency of resident monitoring or rounding.

Review of Resident #51's physician orders dated 12/26/25 revealed an order for utilization of a walker and/or wheelchair as an assistive device for safety and mobility. There were no orders for frequent or increased monitoring.

Review of the physician orders dated 05/20/25 revealed an order to apply an external urinary collection device every night at bedtime once Resident #51 was in bed and to remove it in the morning upon rising.

Review of the manufacturers' instructions for use of the external urinary collection device, undated, revealed it was to be repositioned and/or checked at least every two hours.

Additional review of the physician orders dated 05/20/25 and thereafter revealed no orders for frequent or increased monitoring.

Review of the progress note dated 03/01/25 at 9:00 P.M. revealed Resident #51 was confused and attempted to get out of bed without calling for assistance. Resident #51 was unable to bend her legs to adjust to the sitting position. The top half of her body was lying on the bed with her legs straight and her feet touching the floor.

Review of the progress note dated 03/25/25 at 1:58 P.M. revealed Resident #51 stated she pressed her call pendant for help during the middle of the night, and no one came. Resident #51 was educated on how to utilize the call pendant properly and the battery was replaced.

Review of the physician progress note dated 03/25/25 at 10:18 P.M. revealed Resident #51 had difficulty getting out of bed, required more assistance, and likely needed a hospital bed. Resident #51 had a history of falls, required a hospital bed due to a regular bed not fitting her needs and frequent positional changes.

Review of the progress note dated 04/03/25 at 2:55 P.M. revealed Resident #51 fell in her room while trying to transfer from a chair to her recliner. Resident #51 was transported to the hospital.

Review of the progress note dated 04/04/25 at 1:22 P.M. revealed Resident #51 was admitted to the hospital with a subdermal hematoma, required assistance of two for all ADLs and unable to walk multiple steps with walker.

Review of the progress note dated 05/13/25 at 12:41 P.M. revealed Resident #51 had difficulty and unsteady time transferring and using rollator.

Review of the physician progress note dated 05/27/25 at 9:59 P.M. revealed Resident #51 scored poorly on the mini-mental status exam with a score of less than 20 out of 30 indicating underlying dementia.

Review of the progress note dated 06/24/25 at 12:48 P.M. revealed Resident #51 was found in the sitting position, on the floor, with her back against the door. Resident #51 lost her balance and fell backwards.

Review of the physician progress note dated 06/25/25 at 9:42 P.M. revealed Resident #51 tried to get out of bed and fell.

Review of the progress note dated 06/26/25 at 6:30 P.M. revealed Resident #51 was found lying on her back in the middle of her room, near her bed. Resident #51's Power of Attorney (POA), who observed the fall via camera, stated Resident #51 attempted to sit on her walker and fell backwards. Resident #51 banged on a trashcan with something trying to get someone's attention. Resident #51 was transported to the hospital.

Review of the progress note dated 06/27/25 at 12:53 A.M. revealed Resident #51 was out of the building and returned at approximately 12:30 A.M. after being transported to the hospital due to sustaining a fall.

Review of the progress note dated 07/05/25 at 6:15 P.M. revealed Resident #51 fell and was found lying on her back with face upward on the floor in her room in front of her recliner. Resident #51's POA revealed she observed the fall on camera and Resident #51 had to use her grabber to bang on something to get someone's attention.

Review of the progress note dated 07/28/25 at 5:21 P.M. revealed Resident #51 fell after trying to sit in her chair.

Review of the progress note dated 09/03/25 at 8:40 P.M. revealed Resident #51 had a fall and was found in her room lying on the floor next to her bed.

Review of the progress note dated 10/26/25 at 6:00 P.M revealed Resident #51 fell and was found sitting on the floor with her back against the wall in her room. Resident #51's walker was in front of her and her scooter was to the left of her.

Review of the progress note dated 10/27/25 at 5:18 A.M. revealed Resident #51 did not sleep well throughout the night and woke up every hour.

Review of the progress note dated 11/27/25 at 5:27 A.M. revealed Resident #51 had increased confusion overnight, came out for breakfast at 2:00 A.M., but was easily redirected back to bed.

Review of the progress note dated 12/06/25 at 5:45 P.M. revealed Resident #51 was lying horizontal in bed with her feet off the bed.

Review of the progress note dated 12/18/25 at 12:51 P.M. revealed Resident #51 requested to get up and walk to her chair but was reminded that she had not been able to walk for days and the last time she attempted to walk, she almost had a fall.

Review of the progress note dated 12/26/25 at 8:18 A.M. revealed Resident #51 had expired.

Review of the progress note dated 12/26/25 at 12:17 P.M. revealed Resident #51 body was picked up by the coroner's office.

Review of the progress note dated 01/22/26 at 11:17 A.M., late entry for 12/26/25, revealed Resident #51 was found with her upper torso facing the left side of her bed with her head near the head of the bed and lower body on the floor with her legs extended towards the foot of the bed. Resident #51 was absent of vital signs, and her body was released to the coroner. Review of the progress note revealed it was entered into Resident #51's medical record approximately 28 days after her discharge from the facility.

Review of all progress notes dated from Resident #51's admission until her death revealed she had multiple falls, difficulty with ambulating and/or bed mobility and was a high risk for falls.

Review of the post-fall evaluations dated 06/25/25 and 10/27/25 revealed Resident #51 had interventions to increase the frequency of monitoring including, but not limited to, rounds and group activities with no end date.

Review of the SRI dated 12/26/25 revealed the facility reported an allegation of an injury of unknown source regarding Resident #51. Resident #51 was found absent of vital signs on the left side of her bed with her upper body off the floor leaning against the bed, buttocks on floor, legs extended with feet towards the end of the bed and torso twisted (chest and abdomen towards bed) and right arm and hand between mattress and hospital bed frame above the halo bar. Resident #51's head had slipped partially under the halo bar. Resident #51 was incontinent of stool. Resident #51 was checked and changed at approximately 11:30 P.M. and was visually observed from the doorway at approximately 2:00 A.M. Resident #51 was found deceased at approximately 5:30 A.M. when staff entered room to administer medications. Review of the SRI revealed Resident #51 body was picked up by the coroner and a report was pending.

Interview on 01/22/26 at 1:40 P.M. with Care Partner (CP) #604 revealed Resident #51 was a fall risk and always tried to get out of bed. Resident #51 always had her feet out of bed.

Interview on 01/22/26 at 1:50 P.M. with Licensed Practical Nurse (LPN) #605 revealed Resident #51 was at risk for falls. Resident #51 constantly yelled, pressed her call button, and had her feet hanging out of bed. Resident #51 required repositioning and often wiggled around in bed and required frequent rounding.

Interview on 01/22/26 at 2:11 P.M. CP #511 revealed she was familiar with Resident #51 who required total care for all ADLs. Resident #51 required to be checked and changed, dressed, provided all meals, was a fall risk and she could no longer walk. Resident #51 would throw her legs out of bed and believed she could walk but she was not able to due to weakness. The resident also required a mechanical lift for transfers. Resident #51 required frequent checks and on the night of her death, no one entered her room to check on her.

Interview on 01/22/26 at 2:48 P.M. with CP #810 revealed she was a State Tested Nursing Assistant (STNA) and had a higher level of training than CPs. She received her certification she was taught rounding on residents every two hours, but the facility educated her to round every three to four hours. CP #810 was very familiar with Resident #51 who was a high fall risk, required checks and changes and safety checks. Resident #51 frequently threw her legs out of bed and attempted to get herself up. Resident #51 thought she could walk but she could no longer walk but in her mind she believed she could. CP #810 stated when she completed her rounding on Resident #51, at approximately 12:30 A.M. on 12/26/25, she stood at the counter, saw the resident's feet, but did not physically walk into the room to do a thorough check. CP #810 checked on Resident #51 again at approximately 2:00 A.M. but verified she did not enter the room. Instead, she peeked in from the doorway and saw her feet in the bed. CP #810 was unaware of Resident #51's fall interventions and stated Resident #51 was last on her list to be rounded on.

Interview on 01/22/26 at 4:29 P.M. with Resident #51's POA revealed Resident #51 was a high fall risk, required the use of a mechanical lift, and required frequent checks. Resident #51 had a camera in her room for observation and/or care provided. The facility was aware that Resident #51 constantly attempted to get out of bed and threw her legs out of bed. Resident #51 was seen being put in bed at approximately 8:30 P.M. on 12/25/25 and the next time the camera (motion detected) was activated was at approximately 6:00 A.M. the following morning when Resident #51 was found on the floor. POA stated no staff had entered her room throughout the entire night and was subsequently found by the next shift. POA revealed on multiple occasions Resident #51 would fall in her room and would have to bang on something to get staff attention or she would have to call the facility to inform staff Resident #51 was on the floor.

Interview on 01/22/26 at 5:01 P.M. with the Executive Director (ED) and the Director of Nursing (DON) revealed the facility followed a protocol of rounding the units every three to four hours but revealed the policy for rounding was every four to six hours. The DON stated Resident #51 and all other residents received rounding checks every three to four hours. The DON verified that despite Resident #51's intervention of increased frequent rounding, staff only rounded every three to four hours. The ED revealed Resident #51 was a fall risk, but she did not recall her risk level. The DON confirmed Resident #51 received a check and change between 11:00 P.M. and 11:30 P.M. CP #810 rounded on Resident #51 between 2:00 A.M. and 2:30 A.M. but only peeked from the doorway, did not turn on the light and did not approach due to not wanting to wake the resident up.

Interview on 01/28/26 at 1:14 P.M. with Medication Technician (MT) #802 revealed Resident #51 utilized an external urinary collection device at night and required checks and changes to ensure its proper positioning and that the device was still intact. Resident #51 was a fall risk and during the night shift, staff checked on her every four to six hours. Resident #51 was very weak and could not walk. She required safety checks due to her declining state towards the end of her life. On the night of her death, MT #802 entered Resident #51's room and did not see her in bed. Instead, the resident was found on the floor with her right hand stuck between the mattress, her head underneath the halo bar, sheets and blankets scrunched up around her face with her body stiff and her partially blue. MT #802 arrived for her shift at 2:00 A.M. due to the facility needing coverage for the night shift. MT #802 could not confirm the last time Resident #51 was checked and changed or rounded on.

Review of the facility policy labeled, Incontinence Care

Based on interview, record review, review of manufacturer instruction, and review of the facility policy the facility failed to ensure Resident #40's physician orders were followed for diabetes management, glucose monitoring, and wound care. This affected one resident (Resident #40) out of three residents reviewed for wounds and diabetes management. The facility census was 39.

Findings include:

Review of Resident #40's medical record revealed an admission date of 07/12/23 and diagnoses included aphasia following nontraumatic intracerebral hemorrhage, type two diabetes mellitus and chronic kidney disease. Resident #40 was discharged from the facility on 03/21/24.

Review of Resident #40's Personal Service Assessment dated 07/12/23 revealed Resident #40 did not have memory loss or cognitive impairment and did not have difficulty with orientation to person, place, or time.

Review of Resident #40's Service Plan dated 07/12/23 included Resident #40 needed service coordination. Resident #40 would receive service coordination with assistance. Interventions included Resident #40 used a private companion. Resident #40 had urinary and bowel incontinence. Resident #40 would be able to manage his bowel and bladder incontinence with assistance. Interventions included Resident #40 needed additional help because of uncontained bladder and bowel accidents, and examples included washing, cleaning up after accidents, showering, changing clothes, laundering soiled clothes, linens; Resident #40 used incontinence products. Resident #40 required bathroom assistance. Resident #40 would be able to use the bathroom with assistance. Interventions included Resident #40 was unable to use the bathroom on his own and required assistance.

Further review of Resident #40's Service Plan dated 07/12/23 revealed Resident #40 had diabetes mellitus. Resident #40 would receive monitoring, assistance and education. Interventions included Resident #40's provider would be notified of any indicators of decline.

Review of Resident #40's Physician, Healthcare Provider Plan of Care dated 08/06/23 revealed Resident #40's diagnoses included hemorrhagic stroke with left-sided weakness, but did not specify when this occurred.

a). Review of Resident #40's diabetes instructions dated 08/15/23 and written by Nurse Practitioner (NP) #243 revealed check blood sugar before breakfast and dinner, Metformin (antidiabetic medication) 1000 milligram (mg), give one tablet with breakfast and one tablet with dinner, Glipizide (antidiabetic medication) 10 mg, give one tablet with breakfast and one tablet with dinner, and do not give if blood sugar was less than 90 mg per deciliter (dL) or if not eating a meal, for low blood sugar less than 70, give one tube of dextrose gel, and re-check glucose in 15 minutes. If still less than 70 give another tube of dextrose gel and if more than 70 give a snack with protein and carbohydrate or eat a meal. If Resident #40's blood sugar continued to be less than 70, call 911 and go to the ER (Emergency Room). If Resident #40's blood sugar was more than 400, wash hands, recheck blood sugar and if remained above 400 go to the ER. Target blood sugar was 90-200 mg/dL. If blood sugar was more than 200 increase physical activity and increase water intake.

Review of Resident #40's physician orders dated 08/15/23 revealed dextrose 15 gram (Gm) per 37.5 Gm squeeze tube, take contents of one tube (15 Gm glucose) by mouth as needed for low blood sugar, check blood sugar in 15 minutes and repeat dose if still low.

Review of Resident #40's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 08/15/23 through 10/26/23 did not reveal evidence Resident #40's blood sugars were checked twice a day per physician instructions.

Review of Resident #40's medical record including MAR, TAR, progress notes, physician orders, and Service Plan from 08/15/24 through 03/14/24 did not reveal evidence diabetic instructions and physician orders for low blood glucose were documented and implemented (only on 01/06/24 and 02/21/24).

Review of Resident #40's physician orders dated 10/23/23 revealed glucose sensor Freestyle Libre 3, use glucose sensor supply item as directed. The indication for use was diabetes.

Review of Resident #40's medical record including physician orders, MAR, TAR and Service Plan from 10/23/23 through 03/14/24 did not reveal evidence Resident #40's had the Freestyle Libre 3 glucose sensor or evidence of instructions for the use of the Freestyle Libre 3 glucose sensor.

Review of Resident #40's progress notes dated 10/31/23 timed 5:35 A.M. written by Licensed Practical Nurse (LPN) #210 included Resident #40 had an electronic accucheck machine now (Libre 3 glucose sensor), throughout the night it beeped and stated his blood glucose was 89. LPN #210 assessed Resident #40 and he said he felt fine and normal and did not appear to be in distress or sweaty. Upon looking at his chart, no further instructions regarding glucometer readings. Would pass it on and continue to monitor.

Review of Resident #40's progress notes from 10/31/23 through 03/14/24 did not reveal further documentation regarding Resident #40's electronic accucheck machine or instructions regarding glucometer readings (except on 11/20/23).

Review of Resident #40's MAR dated 10/26/23 through 03/14/23 revealed many days when Resident #40's blood sugar was documented as above 200, and the range was 220 to 364. There was no evidence Resident #40's diabetic instructions or physician orders were followed when his blood sugar was above 200 (except on 01/06/24). There was no evidence Resident #40's physician was notified.

Review of Resident #40's Libre 3 glucose monitoring reports dated 10/27/24 through 03/14/24 revealed many days when the glucose readings were less than 90 and greater than 200 (outside the target range included in diabetic instructions), and the range was 59 to 375. There was no evidence in Resident #40's medical record including progress notes (only on 01/06/24 and 02/21/24) or MAR that physician orders or diabetic instructions were followed, or Resident #40's physician was notified of high or low blood sugars.

Review of Resident #40's progress notes dated 11/20/23 at 5:52 P.M. revealed sensor not on, daughter in to change it.

Review of Resident #40's progress notes dated 01/06/24 at 6:08 A.M. revealed blood sugar was high last night, 280, drank lots of water and it was going back into normal range.

Review of Resident #40's progress notes dated 02/21/24 at 4:59 P.M. revealed Power of Attorney (POA) #238 called Health and Wellness Coordinator (HWC) #207 and stated Resident #40's low blood sugar monitor was alarming on her phone. Resident #40's blood sugar was 85, apple juice was given per daughter.

Review of Resident #40's progress notes dated 03/14/24 at 9:21 P.M. revealed Resident #40's daughters were taking him to the hospital due to blood sugars increasing to 400.

Interview on 10/28/24 at 10:25 A.M. of POA #238 revealed she talked to the facility many, many times about Resident #40's care. POA #238 stated she mostly communicated with HWD #237, and towards the end of Resident #40's stay at the facility she emailed Executive Director (ED) #234, but ED #234 thought HWD #237 was handling the issues. POA #238 stated something that troubled her and caused a lot of stress was when Resident #40's blood sugar monitor for low and high blood sugars alarmed, it was very difficult to call the nurses because the facility phone was not answered and often rolled over to voicemail. When that happened, it said the voice mail was full and she was unable to leave a message. Resident #40 used a continuous glucose monitor called a Libre 3 which was managed with a mobile device, the mobile device was in Resident #40's room, and he wore a Sensor for the monitoring system. POA #238 stated she had an app for the monitoring system on her cell phone and her sister's cell phone, and the facility had an active monitor which was by the headboard of his bed. POA #238 indicated the monitor could be visually checked to see what Resident #40's blood sugar was at any time. POA #238 stated there were thresholds for high and low blood sugars and they would get alarms and notifications when his blood sugars were low and high, and it was very scary. POA #238 stated she would get a notification that Resident #40's blood sugar was high or low 24 hours a day. When she received a notification about Resident #40's blood sugar POA #238 would wait to see if anyone at the facility responded, and she had to call regularly because there was no response from the staff. POA #238 stated she would call the independent living area because the phone there was answered, and the independent living staff would call the Assisted Living area and have the nurses check on Resident #40. POA #238 indicated that most of the time the staff would give Resident #40 apple juice, leave the room right away and not come back to check on him. POA #238 stated she did not sleep well and I slept with an ear to the bed because she was worried about Resident #40's blood sugars. POA #238 indicated the alarm sounded in Resident #40's room, and if aides and nurses walked by the room they could hear the alarm.

Interview on 10/28/24 at 11:21 A.M. of Family Member (FM) #241 revealed she had no doubt that if the family had not hired around the clock private aides Resident #40 would have died, and the facility did not manage his diabetes at all!

Interview on 10/29/24 at 8:17 A.M. of HWC #207 revealed Resident #40 had a Libre 3 glucose monitoring system, his daughter's phones had an app connected to the monitoring system, and Resident #40 had a cell phone above his head by the headboard of the bed. HWC #207 stated the cell phone beeped if Resident #40's blood sugars were high or low, and POA #238 would call and notify them. When the blood sugars were low they gave Resident #40 a snack which were stocked in his room. The nurses would return in 30 minutes to check his blood sugar, and this should be documented in a progress note. HWC #207 indicated Resident #40's daughter educated the nurses on how to look at the device, and there was manufacturer instructions kept in his room. HWC #207 indicated the Libre Sensor was to be changed weekly and it was on the MAR. HWC #207 stated Resident #40's MAR should have information regarding the Libre 3 monitoring system.

Interview on 10/30/24 at 10:50 A.M. of Executive Director (ED) #234 revealed the facility received orders three ways and one way was the family brought back a physical prescription, the facility would fax the prescription to pharmacy, pharmacy filled the order, put it in the system and the system pushed the order to the facility resident electronic record. ED #234 stated a verbal order from the physician could be received and it would be faxed to pharmacy, filled, and pushed to their system. The third way to receive orders was the provider sent the orders directly to the pharmacy and it was put in the pharmacy system. ED #234 indicated Resident #40's provider sent orders electronically to the pharmacy. Resident #40's daughter brought supplies for the Libre 3 monitoring system and changed the Sensor. ED #234 confirmed Resident #40's physician orders found in his electronic record miscellaneous area had diabetic instructions, physician orders, and orders for the Libre 3 glucose monitoring system which were missed by the nurses and not placed in the physician orders, MAR or Service Plan, and someone should have followed up to make sure the orders were addressed. ED #234 confirmed Resident #40 had a continuous monitor which beeped when glucose levels were low or high but stated even if the alarm was going off and they had parameters they we not in the room 24 hours a day, seven days a week and confirmed the facility did not have a system in place for monitoring when Resident #40's glucose levels were low or high. ED #234 stated the facility did not have a way to check the monitor for beeping when they were not in the room.

Interview on 10/30/24 at 12:14 P.M. of POA #238 revealed she most often spoke with HWC #207 about Resident #40's glucose monitoring system and she definitely spoke to the nurses about the Libre 3 glucose monitoring system, and communicated where the cell phone should be kept, but she could not remember which nurses. POA #238 stated she placed a sign near Resident #40's headboard. POA #238 indicated when facility staff changed the Sensor, HWC #207 took care of it.

Interview on 10/30/24 at 12:17 P.M. of HWC #207 revealed I never changed the Sensor, the family always did it.. HWC #207 stated she could not remember any in-services given to the staff regarding Resident #40's Libre 3 continuous glucose monitoring system.

Review of the Freestyle Libre 3 continuous glucose monitoring system user's manual included the system was indicated for measuring interstitial fluid glucose levels in people (age four and older) with diabetes mellitus. The App and Sensor were designed to replace blood glucose testing in the self-management of diabetes, including dosing of insulin. The Sensor automatically stopped working after 14 days of wear and had to be replaced.

b. Review of Resident #40's physician orders dated 10/23/23 revealed skin cleanser solution, apply three sprays externally every day as needed for cleansing of the skin.

Review of Resident #40's physician orders dated 12/22/23 revealed phytoplex hydraguard topical cream, apply a sufficient amount externally as needed for skin irritation.

Review of Resident #40's MAR and TAR dated 10/23/23 through 03/14/24 did not reveal evidence physician orders for skin cleanser solution ordered on 10/23/23 and phytoplex hydraguard topical cream ordered on 12/22/23 were implemented and followed.

Review of Resident #40's Skin Observation Form dated 01/01/24 revealed his skin was intact with no open areas.

Review of Resident #40's progress notes from 01/01/24 through 01/19/24 did not reveal evidence Resident #40 had open areas or moisture associated skin damage (MASD) on his skin.

Review of Resident #40's progress notes dated 01/19/24 through 02/15/24 did not reveal Resident #40's physician was notified of incontinence associated dermatitis (IAD)/MASD and treatment orders obtained.

Review of Resident #40's Skin and Wound Evaluation dated 01/19/24 revealed Resident #40 had MASD, and the type was Incontinence Associated Dermatitis (IAD). The IAD was located on Resident #40's sacrum, medial and was in-house acquired. The evaluation indicated IAD was present for one week, but the exact date was not documented. Measurements were length 1.0 centimeter (cm), width 0.5 cm and the depth was not applicable. The evaluation stated the area was improving, and treatment was peri cream and frequent changes.

Review of Resident #40's Skin and Wound Evaluation dated 02/02/24 revealed Resident #40 had IAD to his sacrum, medial and was in-house acquired. The exact date the wound was acquired was not documented. Measurements were length 2.4 cm, width 1.9 cm and depth was not applicable, and the area was improving. The wound was cleansed with soap and water and there was no dressing. Moisture barrier was used.

Review of Resident #40's progress notes dated 02/12/24 timed 11:18 A.M. revealed Resident #40's three small red, open skin sites to his left upper buttocks remained unchanged and were clean with no drainage noted.

Review of Resident #40's progress notes dated 02/15/24 at 7:51 P.M. revealed Resident #40 went to his primary care physician (PCP) on this date for wounds on his bottom. New orders for Triad hydrophilic application. Apply every two hours and with brief changes. The zinc based ointments should never be applied while sores were open and healing. Clean with warm water and soap with every change prior to applying application.

Review of Resident #40's physician orders dated 02/16/24 revealed Triad wound dressing topical paste, apply a sufficient amount externally twice a day for wound care.

Review of Resident #40's physician orders dated 02/16/24 revealed the following were the recommendations for Resident #40's Triad paste. Gently clean with barrier wipes prior to applying Triad, apply Triad paste to diem thickness, allow to dry for three to five minutes, may remove soiled cream and apply fresh, twice weekly gently remove completely and re-apply.

Review of Resident #40's MAR and TAR dated 02/16/24 through 03/14/24 did not reveal physician recommendations for Triad paste to gently clean with barrier wipes prior to applying Triad, apply Triad paste to diem thickness, allow to dry for three to five minutes, may remove soiled cream and apply fresh, twice weekly gently remove completely and re-apply were implemented and followed.

Review of Resident #40's Skin and Wound Evaluation dated 02/16/24 revealed Resident #40 had IAD to the sacrum, medial and was in-house acquired and the exact date was not documented. Measurements were length 1.4 cm, width 1.1 cm and depth was not applicable. Treatment was hydrophilic wound dressing paste (Triad).

Review of Resident #40's progress notes dated 02/18/24 timed 10:50 A.M. revealed Resident #40's orders (from 02/16/24) and two new orders were noticed by the nurse. Triad wound paste, apply twice daily was one of the new orders.

Review of Resident #40's MAR revealed physician orders for Triad hydrophilic wound paste ordered on 02/16/24 were not followed until 02/20/24 at 8:00 P.M.

Review of Resident #40's progress notes dated 02/28/24 timed 10:14 A.M. revealed private caregiver completed cleansing of Resident #40's buttocks and reported the right upper buttocks wound sites were smaller, dry, pink, with no increased redness and no drainage observed.

Interview on 10/28/24 at 10:25 A.M. of POA #238 revealed she talked to the facility many, many times about Resident #40's care. POA #238 stated she mostly communicated with HWD #237, and towards the end of Resident #40's stay at the facility she emailed ED #234, but ED #234 thought HWD #237 was handling the issues. POA #238 stated Resident #40 was taken by the family to his primary care physician for two incidents of treatment for bed sores, orders were sent to the facility, but the orders were not followed. POA #238 indicated the bed sores were very painful for Resident #40 and he was unable to get out of bed.

Interview on 10/28/24 at 11:21 A.M. of Family Member (FM) #241 revealed the facility did not follow physician orders regarding Resident #40's incontinence care and she did not know if the facility staff ever saw Resident #40's bedsores because the aides hired by the family told the facility aides and nurses about the bedsores.

Interview on 10/29/24 at 10:24 A.M. of HWC #207 revealed when Resident #40 returned from his physician appointment on 02/15/24 his daughter brought back Triad paste and told HWC #207 it needed to be applied every two hours with brief changes, and they told her not to apply the Triad to the open areas. When Resident #40's orders were received the orders indicated to apply Triad two times daily. HCW #207 documented in the progress notes what the daughter told her and forgot to say the daughter provided the information.

Interview on 10/29/24 at 2:20 P.M. of HWC #207 confirmed Resident #40's Skin and Wound Evaluation dated 01/19/24 indicated he had the wound for about a week, but HWC #207 had no knowledge of the wound before 02/02/24 when it was brought to her attention by the aides that Resident #40 had open areas. HWC #207 confirmed the evaluation said he had the wound about a week and stated she could not explain why nothing was done from 01/19/24 through 02/02/24. HWC #207 indicated she contacted Resident #40's daughter on 02/12/24 about Resident #40's wounds on his buttocks because the family could contact the physician, and get a response much faster than when the facility contacted the physician. Resident #40's daughter told HWC #207 she would make an appointment and take Resident #40 to be evaluated. HWC #207 stated she did not remember if Resident #40's daughter knew about his wounds before 02/12/24 because HWD #237 did wound rounds and she did not know what HWD #237 did. HWC #207 indicated Resident #40 was a heavy wetter and we check residents every two to four hours.

Interview on 10/30/24 at 10:50 A.M. of ED #234 confirmed Resident #40's physician orders for skin cleanser and phytoplex hydraguard top cream were missed, had not been followed as ordered and were not documented on Resident #40's MAR.

Review of the facility policy titled Medication and Treatment Administration revised 07/2024 included medication administration and or treatment should be provided in a safe and timely manner, and as prescribed by the residents physician, healthcare provider.

This violation is an example of non-compliance investigation under OH00157740.

Based on review of facility fire drill documentation and staff interview, the facility failed to conduct fire drill as required. This had potential to affect 38 of 38 residents in the facility.

Findings include:

On 10/02/24 at 1:45 P.M. review of fire drill documentation with the Administrator indicated fire drills were not completed as required. The facility could not provide documentation to support a first shift fire drill was completed during the second quarter of 2024.

Interview with the Administrator verified no documentation of completion of a first shift fire drill for the second quarter of 2024. Interview on 10/02/2024 at 3:33 P.M. with the Maintenance Director revealed he could not locate documentation that a first shift fire drill was completed in the second quarter of 2024.

Review of the facility policy last revised April 2022 revealed fire drills were to be conducted on a monthly basis with every shift participating at least once per quarter or as per state regulation. The Executive Director (ED) or designee was responsible for planning and conducting the fire drills per state regulation.

Based on observation, interview and record review, the facility failed to ensure carpet was clean, linoleum was maintained in good repair, and that lint was removed from dryer lint traps as needed. This affected 38 of 38 residents.

Findings include:

1. Observation on 09/30/24 at 11:35 A.M. while on a facility tour with the Administrator revealed numerous stains on the carpets on the first and second floor main hallways. The stains were of various shapes and sized. In addition the linoleum in the laundry room had a tear the size of a football in front of the washer.

Interview with the Administrator at the time of the observations verified the numerous stains on the carpets on the first and second floor and the hole in the linoleum in front of the washer in the laundry room. The Administrator stated the carpets were professionally cleaned in July 2024 by an outsourced carpet cleaning company but had become stained again.

Interview on 09/30/24 at 3:20 P.M. with the Director of Housekeeping confirmed the dark spots and streaks on the carpet on the first and second floor hallways. She stated the carpets were professionally cleaned by an outsourced carpet cleaning company in July 2024 and the facility recently purchased carpet cleaners.

Review of the outsourced professional carpet cleaning service document revealed the carpeting in the hallways of the first and second floors were cleaned July 2024.

Review of the resident council meeting minutes dated 07/15/24 revealed the residents felt the carpet stains were due liquids spilling out of full garbage bags that caregivers were dragging through the hallways and past the dining room.

Review of the facility policy, Encapsulation: interim carpet cleaning dated December 2023 revealed the high traffic areas such as the lobby, entryway, dining room, resident programs, hallways, discover rooms/sales area, associate break room, conference room and elevator were to be cleaned monthly. Quarterly carpet cleaning for the medium traffic area such as the den/TV room, living room, game room, offices of the first floor and other common areas. Low traffic areas were to be cleaned annually included resident apartments and low traffic offices. Encapsulation and extraction should not be done at the same time. These were minimum frequencies. Some areas could need done more often.

2. Observation of the laundry room on 09/30/24 with the Administrator revealed the dryer lint trap had a significant amount of lint build up.

Review of the procedure entitle, Fresh Impressions-Resident and Contaminated Laundry AL/IL/MC

Based on observation, record review, review of camera video footage, review of the facility policy, and interview, the facility failed to ensure Resident #40 and Resident #31 were treated with respect and dignity. This affected two residents (#31 and #40) of three residents reviewed for incontinence and dignity. The facility census was 39.

Actual Harm began on 01/21/24 at 9:20 A.M. when Caregiver #202 was providing care for Resident #40 and spoke to him in a loud, mean, rude and threatening voice while providing care and told him to Stop it or you won't get care today and continued through 01/24/24 at 2:43 A.M. when Caregiver #235 answered Resident #40's call light and rudely asked what do you want and refused to assist him to the bathroom as he requested two times and in a loud, rude, mean, threatening voice told him I am not caring and use your brief and I am not getting you up at 2:03 A.M. to use the bathroom. The family of Resident #40 stated it was so humiliating for him and based on the reasonable person concept, persons in a similar situation would experience psychosocial harm with feelings of anger, humiliation, distress and a lack of self worth.

Findings include:

Review of Resident #40's closed medical record revealed an admission date of 07/12/23 with diagnoses including aphasia following nontraumatic intracerebral hemorrhage, type two diabetes mellitus and chronic kidney disease. Resident #40 was discharged from the facility on 03/21/24.

Review of Resident #40's Personal Service Assessment dated 07/12/23 revealed Resident #40 did not have memory loss or cognitive impairment and did not have difficulty with orientation to person, place, or time.

Review of Resident #40's Service Plan dated 07/12/23 revealed Resident #40 needed service coordination. Resident #40 would receive service coordination with assistance. Interventions included Resident #40 used a private companion. Resident #40 had urinary and bowel incontinence. Resident #40 would be able to manage his bowel and bladder incontinence with assistance. Interventions included Resident #40 needed additional help because of uncontained bladder and bowel accidents, and examples included washing, cleaning up after accidents, showering, changing clothes, laundering soiled clothes, linens; Resident #40 used incontinence products. Resident #40 required bathroom assistance. Resident #40 would be able to use the bathroom with assistance. Interventions included Resident #40 was unable to use the bathroom on his own and required assistance.

Review of Resident #40's Physician, Healthcare Provider Plan of Care dated 08/06/23 revealed Resident #40's diagnoses included a hemorrhagic stroke with left-sided weakness, but did not specify when this occurred.

Review of Resident #40's Service Plan dated 12/12/23 revealed Resident #40 had behavior management. Resident #40 would be able to manage his behaviors with assistance. Interventions included use the positive physical approach, use Resident #40's preferred name, a calm and gentle voice, yes or no questions, and be aware that even positive interactions with visitors, residents and staff might cause reluctance to accept care due to stress or fatigue; consider approaching Resident #40 at a different time or use a different staff member to provide care; provide support to family regarding common nature of these behaviors in residents with dementia, cognitive, or memory loss. There were no interventions for two caregivers to be in the room when care was provided.

Review of Resident #40's undated Care Aide Schedule and Tasks, which had been posted in Resident #40's room and was provided to the surveyor by Resident #40's daughter, revealed Resident #40 had moderate cognitive decline, dementia and could sometimes be verbally inappropriate. The Care Aide Schedule and Tasks indicated please not to take this personally and know that it was a condition of dementia and Resident #40's stroke related mental capabilities. In such instances, staff were to state that the conversation was inappropriate and try to redirect.

Review of camera footage from Resident #40's room dated 01/20/24 at 6:53 A.M. revealed Resident #40 lying in bed and Caregiver #229 providing care for Resident #40. Resident #40 said something about his call light being on and Caregiver #229 stated oh, you were ringing? the girls only got here at 6:30 A.M. Resident #40 stated I have been ringing for an hour and a half. Caregiver #229 stated the problem is the girls don't want to come in here anymore because you are inappropriate and touch them in places they don't want to be touched, but you have never been inappropriate with me. Caregiver #229 continued with the other aide said she didn't want to work with you, no one wants to be your aide. The other aide said you touched her under her breast this morning, she hated it and got all verbal with you and told you not to, it's a big mess. Caregiver #229 stated I am pretty much the only one who will take you

Based on record review and interview, the facility failed to ensure physician orders were obtained for Resident #47's right knee skin tear wound following a fall and failed to ensure the right knee skin tear wound was assessed and monitored adequately for healing and evidence of an infection. This finding affected one (Resident #47) of three residents reviewed for falls.

Findings include:

Review of Resident #47's medical record revealed the resident was admitted on 11/28/23 and discharged on 02/03/24 with diagnoses including muscle weakness, difficulty in walking and history of falling.

Review of Resident #47's progress note dated 01/25/24 at 4:00 A.M. revealed at 3:10 A.M. a fall occurred in the resident's room and near the chair. Signs of a skin tear of the right knee was identified because of the fall and the emergency contact was notified.

Review of Resident #47's progress note dated 01/25/24 at 10:49 A.M. indicated the nurse called the daughter and reported the resident's fall during the nightshift. A message was left on the voicemail and no bruising was identified.

Review of Resident #47's progress note dated 01/30/24 at 5:27 A.M. revealed the resident rolled out of bed and no injuries were noted.

Review of Resident #47's physician orders, medication administration records (MARS) and treatment administration records (TARS) from 01/25/24 to 01/31/24 did not reveal evidence of skin tear wound treatments or monitoring of the resident's right knee skin tear (obtained during the fall on 01/25/24).

Interview on 02/07/24 at 6:20 A.M. with Resident Care Associate (RCA) #929 indicated she worked dayshift on 01/31/24 and Resident #47 was on her assignment. She stated she tried to get the resident out of bed for breakfast and the resident had a definite change in condition. RCA #929 stated Resident #47's right knee appeared reddened, and it looked like a dime sized pimple was on the knee which was crusted with a black head and appeared to have a hole in it. She confirmed a bandage was observed on the right knee, but the redness and hole were visible.

Interview on 02/07/24 at 8:42 A.M. with Health and Wellness Director #937 confirmed Resident #47 sustained a right knee skin tear following the resident's fall on 01/25/24 at 3:10 A.M. and the skin tear was cleaned and bandaged. She denied wound care orders were implemented for Resident #47's right knee skin tear to prevent infection and she denied the right knee skin tear was adequately monitored to ensure the right knee skin tear was healing.

Telephone interview on 02/07/24 at 10:36 A.M. of Licensed Practical Nurse (LPN) #921 with the Health and Wellness Director #937 in attendance indicated she worked dayshift on 01/31/24 and Resident #47 had difficulty awakening and his right knee appeared reddened. LPN #821 confirmed a dressing was on the right knee and she suspected the right knee was infected because the knee appeared reddened, and the resident had a change in mental status. She confirmed she sent Resident #47 to the hospital on 01/31/24 at approximately 9:00 A.M. to 9:30 A.M. for a change in mental status but no documentation of the resident's care and interventions were placed in the medical record for the resident's change in condition and subsequent transfer to the hospital.

Review of the Fall Management Policy revised 10/2023 indicated to notify the resident's physician for evaluation, care and treatment if indicated and document in the resident's record; notify the resident's family/responsible party and document in the resident record; and document the resident's fall/injuries, resident response, and interventions taken.

This violation represents non-compliance investigated under Complaint Number OH00150672.