Every finding on record at Accel at Longmont Health and Rehab, LLC

Based on observations, record review and interviews, the facility failed to ensure residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#5) of three residents reviewed out of seven sample residents. Specifically, the facility failed to ensure Resident #5 was treated with dignity and respect during incontinence.Findings include:I. Facility policy and procedureThe Promoting/Maintaining Resident Dignity policy, dated 4/11/25, was provided by the chief nursing officer on 8/12/26 at 11:00 a.m. It read in pertinent part, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. It is also said in part in the policy. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered.II. Resident #5A. Resident statusResident #5 age [AGE], was admitted on [DATE], According to the August 2026 computerized physician's orders (CPO) diagnosis included mild dementia, anxiety, cognitive communication deficit, muscle weakness, pain, other muscle spasm and age related osteoporosis.The 4/7/26 minimum data set (MDS) assessment revealed Resident #6 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident had upper and lower extremity limitations. The resident was dependent on staff for bathing, toileting, dressing and grooming tasks. The resident had had occasional pain.B. Resident interviewResident #5 was interviewed on 8/12/26 at 11:14 a.m. Resident #5 said she was receiving care on 8/4/26 by two certified nurse aides (CNA) who caused her pain during care when one of the CNA roughly pulled a towel out from under her buttocks. She said the staff did not stop to talk to her about where her pain was or what they could do to relieve her pain. She said instead the staff just talked to each other and proceeded with care. Resident #5 said she was most concerned with the CNA's dismissing and not listening to her. C. Record reviewThe bathing assistance care plan focus, initiated 6/30/25, revealed the resident needed assistance with bathing. Pertinent interventions included encouraging as much participation and interaction by the resident as possible during care, giving clear explanations of all care and activities prior to and as they occur and providing consistency in care to provide comfort with activities of daily living. A facility investigation, dated 8/9/26, document that Resident #5 made an allegation that two residents were rough with her during care provided on 8/4/26. The facility investigation revealed that while providing incontinence care for Resident #5 the method of care caused the resident pain and left her feeling ignored. After the care assistance ended the resident told another CNA who was not present during care, that CNA #2 went too fast while providing care and did not talk directly to her when she indicated the care was causing her pain. The investigation documentedAlthough the CNA's stopped and observed the resident for signs of an injury or a wound when she yelled out ouch, they continued care stating to one another it looks fine without consulting with her about her expression of pain. The resident told the facility she felt like the CNAs dismissed her feelings; and the problem she had with that was the CNAs attitude of dismissing her like it was not a big deal.III. Staff interviewsCNA #2 was interviewed on 8/12/26 at 9:30 a.m. CNA #2 said she provided care to the resident on the day she complained of pain during incontinence care. CNA #2 said Resident #5 was having repeated episodes of diarrhea, which was unusual and believed that the resident buttocks was sore from wiping because she did not have any wounds on her buttocks. CNA #2 said when the resident complained of pain she then looked at the resident's buttocks and did not see any evidence of a wound or source of pain; she was not sure what was causing the resident's pain. CNA #2 said she did not talk to the resident but instead she and the other CNA discussed the condition of the resident's skin and continued care. CNA#2 said she was educated by nursing leadership after the incident that she now knows she should have talked to the resident about her complaints of pain.The chief nursing officer was interviewed on 8/12/26 at 11:30 a.m. The chief nursing officer said when the resident reported the rough care they immediately removed the staff from caring for the resident while they investigated the resident's allegation. The chief nursing officer said upon the completion of the investigation, facility leadership determined that the incident stemmed from a caregiver miscommunication which led to the resident feeling dismissed. The chief nursing officer said the nursing leadership immediately reviewed methods of care with the two CNAs who were alleged to have provided rough care to the resident and provided the CNA education on proper care response and had the CNAs provide return demonstration for each type of care assistance. The chief nursing officer said the CNA's were assessed to be competent with care after the education. The nursing home administrator (NHA) was interviewed on 8/12/26 at 12:45 p.m. The NHA said he believed the resident this incident was a dignity issue resulting from miscommunication. He did not realize the resident still felt disrespected by the incident.

Based on observations, record review and interviews, the facility failed to have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the officials in accordance with State law, including to the State Survey Agency timely, for one of three allegations of abuse.Specifically, the facility failed to:-Conduct a thorough investigation of an allegation of sexual abuse by a staff member towards Resident #1 and submit a finalized investigation to the State Agency in the required time allotted; -Examine all available evidence and complete a root cause analysis of the evidence to prevent repeated incidents of Resident #1 alleging sexual abuse; and,-Assess other potential mental health factors affecting Resident #1's beliefs about sexual intimacy that could leave her vulnerable to becoming a victim of sexual abuse.Findings include:I. Facility Policy and ProcedureThe Abuse, Neglect and Exploitation policy, revised 5/6/26, was provided by the chief nursing officer on 8/12/26 at 11:00 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Investigation of Alleged Abuse, Neglect and Exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include:-Identifying staff responsible for the investigation;-Exercising caution in handling evidence that could be used in a criminal investigation ( not tampering or destroying evidence);-Investigating different types of alleged violations;-Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;-Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and-Providing complete and thorough documentation of the investigation.II. Allegation of sexual abuse of Resident #1 by certified nurse aide (CNA) #1 The facility investigation, dated 8/11/26, documented Resident #1 told CNA #7 that on 7/15/26 at 8:40 a.m. she and CNA #1 had consensual sex in the facility while she was receiving personal care assistance by CNA #1 after an incontinent episode. The investigation documented CNA #1 was suspended for a few days, but was allowed to return to work before the investigation was finished. After the allegation, Resident #1 was to receive care from two CNAs at all times to ensure transparency and reduce risk of misinterpretation. Staff were to ensure clear communication and explain each step of care before and during interactions to promote understanding and reduce anxiety. Staff were to promote professional boundaries by avoiding behaviors that could be misinterpreted as intimate or inappropriate. Additionally, staff were to document and provide all care interactions according to facility policy.-There was no documented evidence that the facility interviewed Resident #1 after the allegation was made to gain details and insight into the details of where, when and how the abuse occurred. The investigation report contained an undated signed testimonial statement from CNA #1. The statement documented Resident #1 asked CNA #1 if he could put his number in her phone. CNA #1 told the resident he could not. No sexual remarks were made. -However, there was no evidence that the facility took steps to question CNA #1 about the resident's allegation that he had sexual intercourse with the resident, if the allegation was true or where he was when he provided the resident's personal care on the day in question. A signed investigation statement from CNA #7, dated 7/18/26, documented that CNA #7 was aware of the allegation between Resident #1 and CNA #1. CNA #7 had no concerns about the quality of Resident #1's care.-CNA #7's statement did not reveal the exact allegation that Resident #1 reported the date of the alleged incident, the name of the CNA who allegedly abused her or what was the nature and detail of the allegation.The investigation findings documented CNA #1 denied the allegation and stated that hewould never do such a thing.-However, it is not clear what CNA #1 denied as it was not documented.The facility concluded the allegation of sexual abuse allegation was unsubstantiated due to Resident #1's history of mental disorders, other residents and staff denied having seen or witnessed similar behaviors from CNA #1, and the fact that this resident had a roommate that does not recall an incident occurring in the room.-However, many details of the incident were not investigated by the facility. There was no interview statement conducted with Resident #1's roommate and it is uncertain if the roommate was even in the room when this alleged incident was to have occurred or even if the incident occurred in the resident's room.-When interviewed during the survey, from 8/12/26 to 8/13/26, Resident #1 said the incident occurred during a shower (see resident interview below).III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included delusional disorder with strange and inexplicable behavior, altered mental status, alcohol dependence and cognitive communication deficit. The 7/7/26 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interviewResident #1 was interviewed on 8/12/26 at 10:32 a.m. Resident #1 denied that she was in a relationship with anyone in the facility. Resident #1 said she was new to the facility and had mutual intimacy with CNA #1. She said she asked CNA #1 for a shower and that was when they had sexual intercourse. Resident #1 became upset with questions about her alleged intimate relationship with CNA #1 and she did not want the interview to continue. She said she did not want to get CNA #1 in trouble and did not want him to lose his job.Resident #1 said she did not see CNA #1 anymore and she was going home today.C. Record reviewThe care conference summary, dated 7/2/26 at 4:20 p.m., revealed Resident #1 verbalized her favorite activity was engaging in sexual activity and she was in an active sexual relationship with her boyfriend.The psychosocial needs care plan, dated 7/21/26, documented sexual intimacy was of great importance and personal interest to the resident. Interventions included respecting the resident's right to express sexuality and maintain personal relationships; reinforcing the importance of privacy as needed, supporting the resident's dignity, confidentiality, and personal choices; and, monitoring the resident's behaviors for concerns related to consent, safety, or changes in cognition and concerns per facility policy.-However, the care plan did not include an intervention to educate the resident about personal boundaries and appropriate staff and resident relationships.IV. Staff interviews CNA #1 was interviewed on 8/12/26 at 12:00 p.m. CNA #1 said the director of nursing (DON) called him on his day off and suspended him pending an investigation about allegations made about him putting his phone number into Resident #1's phone. CNA #1 said when Resident #1 asked him for his phone number, he told her he could not put his number into her phone. He said he was not aware that he was accused of having sexual intercourse with Resident #1 and denied the allegation. CNA #1 said this was new information to him. CNA #1 said after the initial allegation that he was asked by Resident #1 for his phone number, he was no longer able to provide care to Resident #1, although he still worked on the unit with other residents.The chief nursing officer was interviewed on 8/12/26 at 11:00 a.m. The chief nursing officer said the facility's leadership team investigated Resident #1's allegation of sexual abuse immediately after the allegation was made. The chief nursing officer said after the allegation was unsubstantiated, CNA #1 was allowed to return to work but no longer provided care to Resident #1. -However, CNA #1 worked on the same hallway where Resident #1's room was located.The nursing home administrator (NHA) was interviewed on 8/13/26 at 12:45 p.m. The NHA said he was new to the facility and new to his role as a NHA. He said he was learning about conducting investigations of abuse and as soon as he was alerted that the previous NHA failed to complete and submit the finalized investigative report for Resident #1's allegation against CNA #1 to the State Agency, he completed the investigation. He said he was working with his consultants to learn to conduct thorough investigations.

Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#1) one resident reviewed out of seven sample residents.Specifically, the facility failed to:-Thoroughly assess Resident #1's identified trauma triggers; -Ensure individualized care approaches were provided for Resident #1 to prevent re-traumatization, and,-Develop a care plan focus to address Resident #1's identified trauma care need.Findings include:I Facility Policy and Procedure:The Trauma Informed Care policy, dated 6/15/25, was provided by the chief nursing officer on 8/12/26 at 11:00 a.m. It read in pertinent part, It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will work to facilitate the principles of trauma informed care which include: safety ensuring residents have a sense of emotional and physical safety, trustworthiness and transparency efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident, peer support and mutual self-help - if practicable, assist the resident in locating and arranging to attend support groups (potentially hosted by the facility) which are organized by qualified professionals, collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care, empowerment, voice and choice ensuring that resident's choice and preferences are honored and that residents are empowered to be active participants in their care and decision-making, including recognition of, and building on resident's strengths. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others.The Comprehensive Care Plan policy, dated 4/11/25, was provided by the chief operating officer on 8/12/26 at 11:00 a.m. It read in pertinent part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Individualized interventions for trauma survivors that recognize the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.II. Resident #1 A. Resident statusResident #1, under 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included delusional disorder with strange and inexplicable behavior, altered mental status, alcohol dependence and cognitive communication deficit. The 7/7/26 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record reviewA trauma screen interview, dated 7/2/26, documented Resident #1 had repeated disturbing memories, thoughts, or images of a stressful experience from the past. The care plan documented Resident #1 had a history of trauma which impacted them negatively. The care plan documented triggers that had the potential to retraumatize the resident include The paragraph then asked the assessor to specify the identified triggers and each sign and symptoms of a trigger; however, the assessor did not add that information to the care plan intervention section. -However, the assessment did not specify and identify details of possible retraumatization or give any signs or symptoms of trauma response. A psychosocial assessment, dated 7/2/26, documented the resident reported she had a history of delusions and alcohol dependence as well as the following concerns:-Psychological factors including mental health conditions, trauma/post traumatic stress disorder (PTSD), substance abuse, behavioral issues, self-efficacy deficits, lack of coping skills; and, -Social factors include lack of social support, strained family relationships, social isolation, desire for community involvement, desire for physical/sexual intimacy while in the facility, sexual identity concerns. The assessment documented the resident presented with indicators that she experienced past trauma but failed to identify the possible source of the trauma. The resident appeared to present with a trauma trigger and became emotional when discussing her father and family. Review of the resident's baseline care plan, dated 7/5/26, did not reveal a care focus for trauma informed care.The resident's comprehensive care plan, dated 7/7/26, documented a care focus for Resident #1's risk for psychosocial distress. Interventions included social services to assess psychosocial needs and coping with admission and as needed, monitoring for changes in mood, behaviors, or cognition and communicating concerns to the interdisciplinary team and coordinating with nursing, therapy, provider, and psychiatry/behavioral health as indicated. The care plan documented a care focus that the resident identified sexual intimacy as an important personal interest. Interventions included respecting the resident's right to express sexuality and maintain personal relationships reinforcing the importance of privacy as needed, supporting the resident's dignity, confidentiality, and personal choices, monitoring for concerns related to consent, safety, or changes in cognition, and report concerns per facility policy. The care plan documented social services would provide ongoing support and review resident preferences. -The care plan failed to include a care focus for trauma informed care. The history and physical physician's note, dated 7/8/26, documented Resident #1 had a history of alcohol use, associated delusional disorder and erratic behavior that was schizoid type. The resident refused blood work for diagnostic purposes because she said she was traumatized in the hospital. A sexual activity capacity for consent, dated 7/21/26, was initiated but the assessment was not conducted. No part of the assessment form was completed. III. Staff interviewThe chief nursing officer was interviewed on 8/12/26 at 1:30 p.m. The chief nursing officer said the social service director who started the trauma informed care assessment was no longer working in the facility and she was not sure why the resident did not have a care plan for trauma informed care when her assessment indicated the resident had past trauma issues. She said she would review the resident's record and update the care plan as indicated. CNA #4 was interviewed on 8/13/26 at 11:23 a.m. CNA #4 said she noticed a lot of the residents at the facility had a history of trauma and were triggered during care resulting in refusal of care assistance. CNA #4 said when a resident was triggered by trauma causing them to yell or refuse care she would leave the room to allow the resident to calm down and try to reapproach the resident later. She said she would also report the resident's change in behavior to the nurse.Registered Nurse (RN) #1 was interviewed on 8/13/26 at 11:26 a.m. RN #1 said a resident's past trauma experiences may continue to affect the resident in the present and cause them to experience distress or other behavioral expressions. She said the staff should be aware of a resident's known trauma and trauma triggers to avoid actions or situations that may trigger a trauma-related response and lead to negative response. RN #1 said she would know about a resident's history of past trauma and appropriate intervention to provide if there was a care plan interventions for trauma informed care. She said this would allow the staff the opportunity to provide care in a manner to lessen the effect of past trauma. CNA #5 was interviewed on 8/13/26 at 11:40 a.m. CNA # 5 said he was a new employee and did not know all the residents well. She said facility and nursing leadership would inform the staff if they are getting a new resident that has trauma before the transfer or admission so they would be prepared. She said as a CNA, they were not supposed to do things that cause them to trigger their trauma. RN #2 was interviewed on 8/13/26 at 11:50 a.m. RN #2 said nursing staff were responsible for monitoring and charting unusual resident behaviors in the residents record when they notice any behaviors. RN #2 said they were also responsible to report the resident's behavioral expressions to the incoming staff to ensure appropriate care to prevent negative effects towards the resident.

Based on record review and interviews, the facility failed to ensure one (#11) of six residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of 22 sample residents.Specifically, the facility failed to coordinate a safe discharge for Resident #11.On 4/12/26, the facility issued Resident #11 a one hour notice to pack her belongings and leave the facility due to an uninvestigated allegation that Resident #11 was providing other residents with opioids (a class of powerful drugs that carry a high risk of dependence and overdose). The facility failed to coordinate services needed to meet her medical needs, failed to ensure the resident was discharged with her prescribed medications, and failed to ensure the resident was discharged to a safe location. Resident #11 did not have a safe place to discharge and ended up homeless after the facility discharged the resident.The facility's failure to ensure Resident #11 was discharged to a safe location, had services to meet the resident's medical needs arranged, and had access to her prescribed medications created the likelihood for serious harm. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 4/12/26 Resident #16 alleged that that Resident #11 gave Resident #16 a narcotic medication. The facility did not investigate the allegation and instead told Resident #11 she could wait for the police to do an investigation or she could leave the facility immediately. The resident was provided an immediate discharge notice on 4/12/26. The discharge notice revealed Resident #11 was being discharged because the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident and the health of individuals in the facility would otherwise be endangered. The notice documented a 30-day notice was not provided to Resident #11 because she posed an immediate danger to the health and safety of other individuals in the facility. The notice documented Resident #11 discharge to her son's home. -However, Resident #11 did not discharge with her son and did not have a location to discharge too. The resident slept in her friend's truck for a few days and then was homeless. She went to the emergency department on the evening of 4/12/26 for her medications. However, when the hospital reached out to the facility to confirm the physician's orders for medication, there was no answer and the resident was not provided with her medications. She returned to the emergency department twice the next day (4/13/26) and still was unable to get her medications. -Review of Resident #11's electronic medical record (EMR) did not reveal any physician's orders indicating the resident was safe to discharge from the facility, physician's orders for the resident to discharge with her medications, a reconciliation of the resident's medications and medication list, or a discharge summary. The facilities failures to ensure Resident #11 was discharged to a safe location, had services arranged to meet the resident's medical needs, and had access to her prescribed medications created the likelihood for serious harm. B. Imposition of immediate jeopardy On 7/27/26 at 2:16 p.m. the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure a safe discharge for Resident #11. C. Facility plan to remove immediate jeopardy On 7/27/26 at 6:45 p.m. the facility submitted a plan to remove the immediate jeopardy. The removal plan read: 1. Corrective action On 7/27/26 an audit of all discharge documentation for the past 90 days was completed by the director of nursing (DON) or designee in order to determine if any other residents were discharged without physician ordered medications, coordinated services to meet the resident's needs, and a safe discharge location. On 7/27/26 an audit of all involuntary and immediate discharges over the past 90 days was conducted by the DON or designee to ensure all requirements were met. All discharge plans within the following 72 hours were reviewed on 7/27/26 by the NHA, the DON, the social services director (SSD) and the director or rehabilitation to ensure that the resident will have ordered medications, services coordinated to meet the resident's needs and a safe discharge location. 2. Systemic changes Beginning on 7/27/26 the SSD will coordinate care plan meetings with residents and families for all residents preparing to discharge. Resident's goals, barriers to discharge, safety concerns, and all other issues will be discussed with the resident and/or their responsible party. The SSD will ensure that the resident will have proper access to a safe discharge location by confirming the location of discharge with the resident and the family. Residents will not be discharged without participating in a meeting and all discussion will be documented in the resident's medical record by the SSD. Beginning on 7/27/26, the NHA revised the Discharge Planning Process policy to include that no involuntary/immediate discharges may occur without documented interdisciplinary team (IDT) review, medical director review, and the NHA's approval. The revision of the policy was communicated to the facility's IDT. Beginning on 7/27/26, the DON or designee will oversee resident and family orientation on medical conditions and medication administration. Resident and family orientation, as well as discharge planning, will occur at least three days prior to the resident's discharge home in a manner in which the resident and the responsible party can understand. Beginning on 7/27/26, the director of rehabilitation or designee will conduct home evaluations prior to discharge as deemed necessary, to ensure the resident's home is safe and hazard free. Each resident will receive individualized preparation, orientation, and education based on the findings from the home visit. 4. Monitoring Beginning on 7/27/26 the regional director of clinical services provided education to all department heads and licensed nurses on regulations surrounding the discharge planning process, including involuntary and immediate discharges, ensuring safe discharges are adequately coordinated, and transfer discharge including the Involuntary Discharge and the Discharge Planning Process policies. This education will become part of new hire education for all department heads and will also be conducted annually. Beginning on 7/27/26 the SSD or designee will audit all discharges for three months to ensure that residents will be discharged with physician ordered medications, as well as prescriptions for medications that are not ordered to be discharged with the resident, services are coordinated to meet the resident's needs and that the resident will be discharged to a safe location. Beginning on 7/27/26 the SSD or designee will review any resident who has had a notice of involuntary/immediate discharge issued to ensure proper discharge planning has been completed, including provision of physician ordered medications and/or prescriptions for medications that are not ordered to be discharged with the resident, services are coordinated to meet resident's needs and that the resident will be discharged to a safe location by confirming the location of discharge with the resident and family. D. Removal of the immediate jeopardy Based on the facility's plan above, the immediate jeopardy was removed on 7/27/26 at 6:45 p.m. However, deficient practice remained at a D level, no actual harm with potential for more than minimal harm. II. Facility policy and procedure The Transfer and Discharge policy and procedure, revised 4/11/25, was received from regional nurse consultant #2 on 7/9/26 at 3:57 p.m. It read in pertinent part, The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for transfer or discharge will be provided by a physician. Orientation for transfer will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner the resident can understand. III. Resident #11 A. Resident status Resident #11, age less than 65, was admitted on [DATE] and discharged on 4/12/26. According to the April 2026 computerized physician orders (CPO), diagnoses included major depressive disorder, systemic lupus erythematosus (an autoimmune disease where the body attacks healthy tissues), rheumatoid arthritis, and viral hepatitis. The 4/12/26 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident did not have any physical or verbal behavioral symptoms directed towards others. The assessment documented the resident required setup or cleanup assistance from staff for all activities of daily living (ADL) and most mobility tasks. The resident required supervision or touching assistance for car transfers and walking ten feet. The assessment documented the resident was taking high-risk medications, including opioids, anti-depressants and an antibiotic. B. Resident #11 interview Resident #11 was interviewed on 7/27/26 at 10:10 a.m. via telephone. Resident #11 said on 4/12/26, the NHA told her she had one hour to get packed and be gone from the facility. She said on the morning of the discharge, a resident made an allegation that she (Resident #11) was giving the other resident her pills. Resident #11 said that was not true, since the nurse watched her take her medications. She said her male friend picked her up from the facility and she slept in his truck for a couple of days. She said she then lived on the streets. She said she went to the emergency department the evening of the discharge (4/12/26) for her medications as she thought they would be able to give her her medications. She said when the hospital reached out to the facility to confirm the physician's orders for her medications, there was no answer and she was not provided with her medications. She said she returned to the emergency department twice the next day (4/13/26), but the hospital refused to give her her prescribed medications. C. Frequent visitor interviews Frequent visitor #1 was interviewed on 7/6/26 at 9:45 a.m. Frequent visitor #1 said Resident #11 was going through the process of appealing her discharge from the facility. Frequent visitor #1 said Resident #11 was homeless at the time of the interview and was going from couch to couch in her friends' homes. Frequent visitor #2 was interviewed on 7/9/26 at 10:09 a.m. Frequent visitor #2 said the facility accused Resident #11 of taking drugs and sharing pain medication, and when the resident asked for a drug test, the facility initiated a discharge, citing the safety of others. Frequent visitor #2 said another resident accused Resident #11 of giving her medications and Resident #11 was discharged without an investigation. Frequent visitor #2 said Resident #11 denied sharing pain medications. Frequent visitor #2 said Resident #11 had been rehospitalized after her discharge because one of the medications she needed to take, prednisone, had not been provided to her at the time of the discharge. C. Record review The discharge care plan, initiated 2/27/26, documented Resident #11 would remain at the facility for long-term care due to her inability to care for herself outside of this setting. The substance use care plan, initiated 2/8/26, revealed Resident #11 was at risk for complications related to potential substance and alcohol use. Resident #11 was observed with a bag of methamphetamine. Pertinent interventions included notifying Resident #11's physician and monitoring her if there was suspicion of intoxication, referring the resident to mental health services for substance use treatment, and searching the resident's room if there was reasonable suspicion of substance use. Resident #11 was educated on the facility's drug and alcohol policy and expressed understanding. A progress note, dated 2/8/26 at 9:06 a.m., revealed an unidentified certified nurse aide (CNA) found a small bag of a crystal substance in Resident #11's room. The CNA was moving Resident #11's laundry and the bag fell out of the resident's sock. Resident #11 denied all knowledge of the substance and said it must have been her friend's. She said she would tell her friend not to come back. The substance was locked in the narcotic box and the charge nurse was notified. A progress note, dated 2/8/26 at 1:02 p.m., revealed the police department confirmed the substance in the bag tested positive for methamphetamines. Resident #11's physician was notified, a urine toxicology sample was collected, and her physician's orders for narcotics were held. -However, a review of the laboratory (lab) results in the resident's EMR revealed the resident's toxicology screen was negative for all substances. An IDT progress note, dated 2/10/26 at 9:52 a.m., revealed the IDT met to discuss Resident #11 having been found with methamphetamines in her room. Risk factors included Resident #11's arthritis pain, depression and lupus. Preventative measures put in place prior to the incident included monitoring the resident for any signs or symptoms of substance abuse. New interventions included providing Resident #11 with education on the facility's drug and alcohol policies. A progress note, dated 2/23/26 at 5:02 p.m., revealed Resident #11 met with the SSD to discuss the transitions program (a program which specializes in assisting residents when moving from a nursing facility back to the community). Resident #11 said she was comfortable at the facility. Resident #11 had not talked about moving in with her daughter recently. A progress note, dated 4/12/26 at 9:40 p.m., revealed Resident #11 had been discharged home with her family. A discharge notice, dated 4/12/26, revealed Resident #11 was being discharged on 4/12/26. The notice documented Resident #11 was being discharged because the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident and the health of individuals in the facility would otherwise be endangered. The notice documented a 30-day notice was not provided to the resident because she posed an immediate danger to the health and safety of other individuals in the facility. The notice documented Resident #11 would be living with her son, and was signed by the resident and the operations manager on 4/12/26. -The notice did not provide the electronic or physical mailing address of the facility personnel who handled appeal notices. -Review of Resident #11's EMR did not reveal any physician's orders indicating the resident was safe to discharge from the facility, physician's orders for the resident to discharge with her medications, a reconciliation of the resident's medications and medication list, or any discharge summary. III. Staff interviews The operations manager was interviewed on 7/8/26 at 1:48 p.m. The operations manager said he was working at the facility on 4/12/26 when a resident (Resident #16) approached him and told him she had gotten oxycodone from Resident #11. The operations manager said he found out Resident #11 had given the other resident the oxycodone. The operations manager said Resident #11 had a history of drug possession and suspected drug use, so the facility issued an immediate discharge because her behaviors were then involving other residents and their safety. The operations manager said initially he threatened Resident #11 with an immediate discharge, but said he would drop the discharge notice if the resident consented to the police coming in to investigate the situation. He said Resident #11 elected to leave the facility. The operations manager said Resident #11 was discharged from the facility to her son's home a few hours after the incident was discovered. The operations manager said he did not want to kick Resident #11 out, but the resident did not want the police to be involved. The operations manager said Resident #11 had since appealed her discharge, but her appeal had been denied. The operations manager said he thought Resident #11 was telling on herself by not wanting to be involved in a police investigation. The operations manager said Resident #11 had previously been found to have illicit substances on her person and said he knew she had a history of issues with substances. The operations manager said the facility was not able to verify/unable to prove if Resident #16 had actually received oxycodone, but substantiated the allegation of Resident #11 providing her with the medication based on Resident #11's history of substance possession within the facility. The operations manager said the facility staff suspected Resident #11's son was supplying her with the medication. The operations manager said he had also offered to have Resident #11 submit for a urine toxicology screening to prove her innocence, but the resident declined that. The operations manager said Resident #16 had a physician's order for oxycodone so they could not test her to see if she had any of the medication in her system. He said the resident did not exhibit any signs or symptoms of having received an extra dose of oxycodone. Registered nurse (RN) #1 was interviewed on 7/9/26 at 1:04 p.m. RN #1 said Resident #11 had a history of substance abuse but mostly kept to herself and stayed in her room. RN #1 said a lot of the other residents liked to hang out in Resident #11's room. RN #1 said Resident #16 accused Resident #11 of giving her drugs at one point. RN #1 said Resident #16 liked to stir the pot and make accusations. The SSD was interviewed on 7/9/26 at 1:26 p.m. The SSD said Resident #11 kept to herself and was in the transitions program. The SSD said Resident #11 had admitted to the facility from the community and had pain and arthritis. The SSD said she could not recall much about Resident #11 other than that she rested a lot due to her rheumatoid arthritis and other diagnoses, and she was out of the facility a lot. The SSD reviewed Resident #11's EMR and found a consent for the resident to receive mental health services, but said she could not find any referrals for the resident for mental health or substance use services. The SSD said for residents with substance use disorders, she would offer the resident a packet of information regarding alcoholics anonymous and offer them behavioral health services. The SSD said the facility had only created one behavioral contract with one resident. The SSD said the IDT met to discuss what options the facility had tried for the resident, including non-pharmacologic interventions and therapeutic passes, and initiated behavioral contracts as a last resort. The SSD said she did not like the idea of discharging a resident and not knowing they had a safe place to go to. The SSD said after Resident #11 discharged , she tried to find another placement for the resident and sent an emergency referral. The DON, the NHA, the operations manager and regional nurse consultant #1 were interviewed together on 7/9/26 at 1:56 p.m. The DON said Resident #11 was found to have given a narcotic medication to another resident. The DON said the facility staff offered to start an investigation or let Resident #11 leave against medical advice. The DON said the nursing staff had previously found illicit substances in Resident #11's room but the resident claimed it was not hers. The operations manager said Resident #11 told him on the day of her discharge (4/12/26) that she had a history of substance use but was trying to remain clean and sober. The operations manager said the facility was aware of her history of substance use prior to 4/12/26. The DON said she had provided Resident #11 with education about the facility's drug and alcohol policies after the resident was found with illicit substances. The DON said usually whenever the facility was aware of a resident's history of substance use or drug abuse, the facility would refer the resident to behavioral health providers. The DON said Resident #11 was alert and oriented, and received anti-inflammatory medications for her arthritis and opioid medications for her pain. The DON said Resident #11 was able to manage her own medications. The DON said Resident #11 left the faciity on 4/12/26 without her medications. The DON said she could not recall when Resident #11 received her medications after her discharge, but thought it was the next day or maybe a few days after 4/12/26 when Resident #11 came back to the facility to ask for her medications. The DON said Resident #11's physician said it was okay for the resident to have all of her medications besides her narcotic medications. The DON and regional nurse consultant #1 reviewed Resident #11's EMR and said they did not see any progress notes or physician's orders indicating Resident #11 could discharge with her medications. The DON and regional nurse consultant #1 both said residents needed a physician's order to discharge with their medications. The DON said generally when a resident was going to be discharged from the facility, the IDT would meet and open a discharge evaluation and each department would fill out a section of the discharge summary. The DON said the physician needed to write an order for discharge which described where the resident would be discharging to and indicated whether the resident would discharge with their medications. The operations manager said the facility did conduct an investigation following Resident #16's allegation. The operations manager said Resident #16 already had a physician's order for oxycodone so they could not do a urine toxicology screening for Resident #16. He said Resident #11 had already left the facility before the facility's administration staff could search her belongings to see if the resident had any other illicit substances in her possession. The operations manager said the facility did notify the police department, but the police department did not come to the facility and said there was no further investigation needed since Resident #16 already took the medication she was allegedly given by Resident #11. The operations manager said he had a conversation with Resident #11 and said the facility either had to have the police come to the facility and investigate Resident #16's allegation or issue Resident #11 an immediate discharge notice. The DON and the NHA both said Resident #11 refused to submit to a police investigation. The DON said the facility had not initiated any behavior contracts with Resident #11. Regional nurse consultant #1 said she saw a progress note in Resident #11's EMR which revealed a behavioral health services provider was scheduled to come to the facility to evaluate Resident #11. Regional nurse consultant #1 said she could not see any documentation in Resident #11's EMR which revealed the resident had actually been seen by the behavioral health services physician or any follow-up notes after 3/17/26. The operations manager said Resident #11's son came to pick her up and said the resident would be staying with him. The operations manager said Resident #11's son said his house would be safe for the resident. The operations manager said Resident #11's son told the facility he did not want the resident to live in his house long-term but said it was safe for her in the meantime. -However, the operations manager said in an earlier interview that the facility staff had suspected Resident #11's son was supplying her with illicit substances (see interview above). The operations manager said Resident #11's immediate discharge was dependent on Resident #16's claim that Resident #11 gave her oxycodone. The DON said the instance with Resident #16 was the first instance Resident #11 had been accused of giving another resident medications. The DON said when the police came to the facility in February 2026 to investigate Resident #11's bag of illicit substances, the police officer told the DON that having illicit substances in the facility could get the facility shut down. The DON said Resident #11 did not have any history of any other behaviors. The DON said Resident #11 sometimes had people coming in and staying the night in her room, or she would go out of the facility and come back late at night. The DON said the facility was not aware the resident was homeless. The operations manager said Resident #11 had appealed her discharge with the facility on 4/21/26 and was denied. The operations manager said he received notification on 5/6/26 that Resident #11 was appealing her discharge with the facility's grievance committee. He said the grievance committee had also denied her appeal. The medical director was interviewed on 7/27/26 at 12:42 p.m. The medical director said Resident #11 was dealing drugs to other residents. He said he had a discussion with the IDT about a behavior contract for the resident. He said if a concern caused issues with other residents or involved other residents, he thought it was standard to discharge a resident if other residents were at risk. He said he was not aware that Resident #16's allegation was not substantiated against Resident #11. He said he was not aware Resident #11's 2/8/26 toxicology screen was negative. He said he thought it was substantiated and agreed with the discharge. He said he would discuss immediate discharges with the IDT.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for five (#10, #13, #14, #24 and #8) of six residents reviewed for grievances out of 22 sample residents.Specifically, the facility failed to provide timely follow-up on grievances reported by Resident #10, Resident #13, Resident #14, Resident #24 and Resident #8 or their representatives.Findings include:I. Facility policy and procedureThe Resident and Family Grievances policy and procedure, implemented 4/11/25, was received from regional nurse consultant #2 on 7/9/26 at 3:57 p.m. It read in pertinent part, The grievance officer is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, and issuing written grievance decisions to the resident. The facility will make prompt efforts to resolve grievances.II. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, type 2 diabetes, chronic respiratory failure and vascular dementia.The 4/1/26 minimum data set (MDS) assessment revealed the resident had significant cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The resident required partial to moderate assistance from staff for most activities of daily living (ADL).B. Resident representative interviewResident #10's representative was interviewed on 7/9/26 at 9:51 a.m. The resident's representative said she had filed a lot of grievances with the facility regarding Resident #10's incontinence care, not following care conference agreements, medication errors, diet textures and lack of assistance. The resident's representative said the facility's response to her grievances had not been good. The resident's representative said the week prior she had attended a care conference during which she had highlighted several ongoing problems with Resident #10's care. The resident's representative said the director of nursing (DON) said she would address her concerns that Monday (7/6/26) but the resident's representative still had not heard from her. The resident's representative said when the facility finally got around to answering her grievances they called her to tell her their action plan, had her come in to the facility and sign the grievance to say the issue was resolved. The resident's representative said she was not going to sign any more grievances unless she actually felt the grievance was resolved. The resident's representative said the facility's grievance process was frustrating to say the least. The resident's representative said she had filed approximately 20 grievances in the span of a year, but said she stopped submitting them for a while because she felt the facility was not doing anything with them. The resident's representative said she felt like the facility was not listening to her concerns and not changing anything.C. Record reviewA grievance form, dated 6/6/26, revealed Resident #10's representative submitted a grievance regarding Resident #10's diet texture.The grievance findings summary documented the facility had contacted Resident #10's physician to repeat a swallow study in order to see if her diet could be liberalized. A written decision was issued on 6/16/26 and the grievance was signed on 6/16/26 by Resident #10's representative, the social services director (SSD) and the nursing home administrator (NHA).-However, the written decision was not issued until 10 days after Resident #10's representative filed the grievance.III. Resident #13A. Resident statusResident #13, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included chronic congestive heart failure, acute respiratory failure, and chronic obstructive pulmonary disease.The 6/1/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required partial to maximal assistance from staff for most ADLs.B. Resident representative interviewResident #13's representative was interviewed on 7/9/26 at 12:43 p.m. The resident's representative said it seemed like it took the facility a while to get back to her about any grievances she submitted on behalf of Resident #13. The resident's representative said she submitted one grievance where it took the facility nearly five months for the facility to respond. The resident's representative said there was an instance a few months ago in which Resident #13 was improperly transferred and nearly had a fall as a result. The resident's representative said she submitted a grievance regarding the situation and it took a long time for the facility to get in touch with her. The resident's representative said the facility usually took so long to get back to her about the grievances she submitted that she would forget what the issue was that she initially had concerns about.C. Record reviewA grievance form, dated 5/4/26, revealed Resident #13's representative had submitted a grievance. The concern listed was that a new certified nurse aide (CNA) was working with Resident #13 and attempted to assist the resident into the bathroom. The CNA did not engage the brakes on the mechanical lift and Resident #13 began to fall. Resident #13 was supposed to be transferred with two people.The grievance summary of findings revealed the administration confirmed the CNA did not properly engage the brakes on the mechanical lift and that Resident #13 did require two people to assist her during transfers. The nursing staff were reeducated on Resident #13's transfer status and proper transfers.A one-to-one inservice on transfers for the CNA involved in the transfer was attached to the grievance and dated 5/22/26.Resident #13's representative documented she was not satisfied with the resolution of the grievance on 5/28/26 as she noted the CNA performing the transfer was repeatedly told by Resident #13 that she needed two people to assist her during transfers. Resident #13's representative noted no amount of extra training would benefit the situation as it was a matter of integrity.The form documented the SSD had discussed the grievance in detail during Resident #13's care conference on 6/8/26 and noted Resident #13's representative still refused to sign the grievance. A written decision was issued on 6/8/26 and was signed by the grievance official (the SSD) and the nursing home administrator (NHA) on 6/8/26. -However, the decision was issued 35 days after Resident #13's representative had submitted it, and did not include any information regarding follow-up of the concerns Resident #13's representative documented on 5/28/26.IV. Resident #14A. Resident statusResident #14, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included coronary artery disease, generalized muscle weakness and cognitive communication deficits.The 2/7/26 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15. The resident required partial to substantial from staff for most ADLs.B. Resident representative interviewResident #14's representative was interviewed on 7/9/26 at 11:13 a.m. The resident's representative said it took the facility a long time to get back to her about any grievances she submitted on behalf of Resident #14. The resident's representative said it took the facility five weeks to get back to her about her most recent grievance and said the concern still had not been fixed. The resident's representative said the SSD told her she was overwhelmed with grievances. The resident's representative said when she tried to address her concerns with the staff in person they did not want to hear about the issue then, so they told her to write a grievance. The resident's representative said it felt like the facility was tired of hearing from her. The resident's representative said if she felt like an issue from a grievance was not resolved, the SSD would tell the resident's representative she would talk with the staff and get back with her. The resident's representative said she felt like she was at a dead end.C. Record reviewA grievance form, dated 5/10/26, revealed Resident #14's representative filed a grievance regarding floors in the dining room being sticky and the dining room not having paper towels or coffee available. The grievance findings summary revealed staff were provided education on maintaining the dining room atmosphere. Supplies, including coffee and paper towels, were in place. Regular cleaning of the dining room was in place, and the director of maintenance was to monitor the dining room atmosphere.A written decision was issued on 5/12/26. Resident #14's representative documented she was satisfied with the resolution of the grievance and signed the grievance on 5/25/26, and the SSD and NHA signed the grievance on 5/20/26.-However, the grievance was not signed by Resident #14's representative until 15 days after the grievance was filed. A grievance form, dated 6/23/26, revealed Resident #14's representative filed a grievance regarding delays in Resident #14's ADL care and the floors of the facility being sticky.The grievance findings summary revealed Resident #14's call light was not consistently in reach and the floors were confirmed to be sticky. ADL timing concerns were partially validated based on staffing workflow. The issues identified required follow-up to support safety and timeliness of care. The grievance was signed on 6/29/26 by the SSD and the NHA. -However, no written decision was issued, and Resident #14's representative did not sign the grievance or document whether or not she was satisfied with the resolution. Additionally, the grievance was not signed by the SSD or NHA until six days after it was initially filed.V. Resident #24A. Resident statusResident #24, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included osteoarthritis, congestive heart failure and atrial fibrillation.The 4/8/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required setup or cleanup assistance from staff for most ADLs.B. Record reviewA grievance form, dated 5/22/26, revealed Resident #24 submitted a grievance related to breakfast meal service. Resident #24 documented his breakfast was served late every day which was causing him to miss his transportation each morning. The grievance findings summary revealed Resident #24's meal ticket would be served first during meal service. A written decision was issued 6/16/26. Resident #24 documented he was satisfied with the results of the grievance and signed the grievance on 6/16/26 along with the SSD and NHA.-However, a written decision was not issued until 25 days after Resident #24 initially filed the grievance.VI. Resident #8A. Resident statusResident #8, age less than 65, was admitted on [DATE] and discharged to another facility on 6/11/26. According to the June 2026 CPO, diagnoses included type 1 diabetes with diabetic neuropathy.According to the 6/11/26 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for most ADLs.B. Record reviewA grievance form, dated 5/21/26, revealed Resident #8 submitted a grievance which documented he had not gotten his breakfast or lunch trays on multiple occasions. The grievance findings summary revealed there had been a few instances in which the kitchen did not have the ingredients to make what Resident #8 had requested or did not have his meal ticket. The dietary staff were educated on how to handle issues with missing ingredients.A written decision was issued on 5/30/26 and the form documented Resident #8 was satisfied with the resolution. A note on the grievance form revealed Resident #8 was not available to sign the grievance form and did not answer his phone when the facility attempted to call him.-However, the written decision was issued nine days after the resident filed the grievance, and marked as resolved despite the facility not being able to make contact with the resident.VII. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 7/9/26 at 9:09 a.m. CNA #4 said if a resident had a concern she would fill out and turn in a grievance form.CNA #5 was interviewed on 7/9/26 at 9:19 a.m. CNA #5 said if a resident or their family voiced a concern she would tell the nurse about it, and the nurse would handle it. CNA #5 said she never had to fill out a grievance form because if a resident was missing an item she was usually able to find it fairly quickly.CNA #6 was interviewed on 7/9/26 at 9:35 a.m. CNA #6 said if a resident or their family voiced a concern she would let the nurse know. CNA #6 said she had never filled out a grievance form and said she did not know when she would need to fill out a grievance form.Licensed practical nurse (LPN) #3 was interviewed on 7/9/26 at 12:58 p.m. LPN #3 said if a resident or their family expressed a concern or said they were missing an item, she would fill out a grievance form and let the DON know.The SSD was interviewed on 7/9/26 at 1:26 p.m. The SSD said the facility had a grievance binder and grievance tracking log. The SSD said whenever someone submitted a grievance it was supposed to be turned in to her first. The SSD said grievances were discussed each morning during the staff's morning meeting, and she would pass out the grievances to their respective departments. The SSD said the facility's individual departments were supposed to work to resolve the issue and said she was supposed to follow up and ensure it was complete. The SSD said ideally the issue would be resolved sometime between 72 hours and seven days after the grievance was submitted.The SSD said she had taken over as the grievance official at the beginning of March 2026. The SSD said she had found some old grievances that had not been followed up on because they had not been documented in the grievance tracker.The SSD said she had dropped the ball on some of the grievances that were submitted over the weekend, as the grievances were sometimes then distributed to their respective department before she could review them. The SSD said she tried to go through her grievance tracker if grievances came up during the facility's angel rounds or if a number of grievances are received about the same issue, and look to make sure all of the grievances in the tracker were completed and see if she had missed any.The SSD said the facility's grievance process is supposed to be set up in a way that she (the SSD) received the grievances first before they get distributed. The SSD said if the family member or resident still was not satisfied she would follow up with them and tried to have them document why they were dissatisfied. The SSD said she tried to follow up with family members in that case whenever they visited next. The SSD said she verbally brought up when people were dissatisfied with the grievance resolution during interdisciplinary team (IDT) meetings so the team could brainstorm solutions. The SSD said once the grievance has a record conclusion or finding, she would present the resident or their family member with the grievance and have them sign and date it.The DON, the NHA and regional nurse consultant #1 were interviewed together on 7/9/26 at 1:56 p.m. The DON said any staff member could help a resident fill out a grievance form if the resident has a concern, and the grievance form would then be turned in to the SSD. The DON said the SSD reviewed grievances during the facility's morning meetings before distributing the grievance to the proper department. The DON said the facility's goal was to follow-up on the grievance within 72 hours as often as possible.The DON said sometimes the resident or their family member were still not satisfied with the conclusion of the grievance. The DON said if the resident or their family member were not satisfied with a specific staff member she would remove the staff member from that resident's service. The NHA said the facility also reviewed grievances during their daily afternoon meetings. The NHA said when a resident or their representative were still dissatisfied, they would meet with the SSD to determine a root cause of the issue or set up a care conference with the resident and their representative to talk about and continue to address their issues. The DON said the facility had experienced some turnover in staffing and had started providing the staff with education on grievances and returning grievances to the SSD in a timely manner. Regional nurse consultant #1 said the facility had started a performance improvement plan on grievance processes that day and had also started their staff education on grievances that day (7/9/26).-However the facility did not identify or begin to address the issues in the facility grievance process until 7/9/26 (during the survey process).

Based on record review, and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#15) of three residents reviewed for notifications out of 22 sample residents.Specifically, the facility failed to provide timely written notification of room changes to Resident #15 and/or the resident's representative in a language the resident could understand.Findings include:I. Facility policy and procedureThe Change of Room or Roommate policy, undated, was provided by the regional clinical resource #2 on 7/9/26 at 3:57 p.m., The policy read in pertinent part, It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. Before making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands, and will include the reason(s) why the move or change is required.II. Resident #15A. Resident statusResident #15, age [AGE], was admitted to the facility on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included anxiety disorder, depressive episodes, muscle weakness, history of falling, and transient ischemic attack (stroke). The 4/22/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment indicated that the staff should not conduct an assessment for mental status.She was independent with eating. She required substantial to maximal assistance with oral hygiene, showers and bathing, and upper- and lower-body dressing and chair-to-bed transfers. She was dependent on staff for toileting hygiene. The MDS assessment indicated her preferred language was Korean.B. Record reviewThe communication care plan, initiated 7/26/25, revealed the resident was at risk for impaired cognitive function/dementia. The notice of room change notification form, dated 5/20/26, revealed a verbal okay via phone call was obtained from the guardian of Resident #15 to change rooms for census needs. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #15's electronic medical record (EMR) to indicate the facility provided the resident with written notification of the room change in her preferred language.The notice of room change notification form, dated 5/29/26, revealed a verbal okay via phone call was obtained from the guardian of Resident #15 to change rooms for census needs. The form documented consent was given verbally and was signed by the SSD.-However, there was no documentation in Resident #15's EMR to indicate the facility provided the resident with written notification of the room change in her preferred language.The notice of room change notification form, dated 6/3/26, revealed a verbal okay via phone call was obtained from the guardian of Resident #15 to change rooms for census needs. The form documented consent was given verbally and was signed by the SSD.-However, there was no documentation in Resident #15's EMR to indicate the facility provided the resident with written notification of the room change in her preferred language.C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/7/26 at 1:10 p.m. RN #1 said Resident #15 did not speak English very well. She said the resident could answer simple yes or no questions in English. She said the resident's primary and preferred language was Korean. She said if there were room changes that need to be communicated to the resident, the facility staff would use Google translate. She said the SSD was responsible for informing the resident about the room change and documenting it in the resident's EMR. The SSD was interviewed on 7/7/26 at 1:18 pm. The SSD said Resident #15 changed rooms because of facility census needs. She said she notified the resident's guardian every time there was a facility-initiated room change. She said the resident did not speak English. She said she would use Google translate to communicate with the resident if needed. She said she always used Google Translate because she was unsure if the facility had a translation service. She said she did not inform the resident of the room changes, because the guardian said she would inform the resident of the room change. She said she should have made an attempt to inform the resident of the room change via Google translate.The director of nursing (DON) and regional clinical resource #2 were interviewed together on 7/7/7 at 2:15 p.m. The DON said if the resident was agreeable to a room change, the SSD would provide written notification to the resident with a five-day notice of appeal. She said the room change notification documentation would be completed by the SSD. She said documentation would be available in the resident's EMR either in the progress notes or on an uploaded room change notification form.Regional clinical resource #2 said a performance improvement plan was initiated recently because the facility identified that the lack of documentation was not being uploaded in the residents' charts regarding room changes. She said she would reeducate the SSD immediately regarding the importance of informing the resident directly and documenting it in the resident's EMR.

Based on record review and interviews, the facility failed to notify the resident's next of kin when there was a significant change in the resident's condition for one (#12) of three reviewed out of 22 sample residents. Specifically, the facility failed to notify the resident's next of kin in a timely manner when Resident #12 passed away.Findings include:I. Facility policy and procedureThe Change of Condition policy and procedure, dated 3/3/26, was provided by the regional clinical resource #2 on 7/9/26 at 3:57 p.m. It read in pertinent part, A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting), impacts more than one area of the resident's health status, requires interdisciplinary review and/or revision to the care plan. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source, there is a significant change in the resident's physical, mental, or psychosocial status; to include active substance use/abuse, there is a need to change the resident's room assignment, a decision has been made to discharge the resident from the facility, and/or it is necessary to transfer the resident to a hospital/treatment center. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.II. Resident #12A. Resident statusResident #12, age less than 65, was admitted on [DATE] and passed away on 4/19/26 at the facility. According to the April 2026 computerized physician orders (CPO), diagnoses included polyneuropathy, type two diabetes without complications, and unspecified protein-calorie malnutrition.The 2/16/26 minimum data set (MDS) assessment showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out 15.B. Next of kin interviewResident #12's next of kin was interviewed on 7/8/26 at 11:50 a.m. She said that the conversations between her and the facility social worker were very few and far between. She said when the resident admitted to hospice, he did not contact his family, because he did not want to be a burden on his family members. She said she thought it was because he did not want to be a burden and that he understood that he was going to die. She said one time, the facility social worker had called her to give her the facility phone number. Resident #12's next of kin said she gave the phone number to multiple friends and family members and none of them (including herself) were able to get through. She said the phone would just ring and ring and no one would pick up. She said she was contacted by the facility two days after Resident #12 passed away. She said she was surprised and disappointed the facility had not contacted her sooner. She was told that Resident #12's body had been taken to the county coroner's office. She said because she lived out of state, she did not realize that there were three different county coroner's offices. She said she called all three of them and none of them had Resident #12's body. She said during the time that she was trying to locate Resident #12's body, she continued to try and contact the facility. She said when she called the facility the phone would just ring and ring. She said she eventually called the local police to go to the facility to find out what was going on. She said she got a phone call after the police went to the facility. She said when the social worker called her she was told that hospice had been called in when Resident #12 passed away and that Resident #12 was taken to a funeral home. She said the social worker gave her the phone number to the hospice provider. She said she tried calling the hospice provider, but they never picked up or called her back. She said she then began calling each funeral home and mortuary to locate Resident #12's body. She said she eventually got a call back from one stating that they had Resident #12's body. She was told by the mortuary that she was listed as his next of kin. She said it was heartbreaking not knowing where Resident #12's body was. She said Resident #12 had his wife's ashes in his belongings at the facility when he passed away. She said the mortuary helped her coordinate with getting his ashes and her ashes shipped out to her. She said the facility did not help with that at all. She said she had to call the police to go out to the facility two more times to get any kind of call back from the facility. She said she was told by the facility that they had tried calling Resident #12's son. She said that Resident #12 and his son had not been in contact with each other for a while. III. Record reviewResident #12's care plan was initiated on 5/19/26 (31 days after he passed) documented Resident #12 needed to identify a medical power of attorney. The care plan documented the resident had the cognitive ability to appoint an agent. The care plan further documented the resident was on hospice care. A social services note, dated 10/29/25, documented that Resident #12's son wanted to be removed from the resident's contact list and to be removed as the financially responsible party. -Review of Resident #12's EMR revealed the facility failed to remove the son as the resident's emergency contact #2.A weight change note, dated 2/13/26, documented that staff stated Resident #12 had worsening mood/motivation following recent family issues. -However, there was no documentation of the family issues. A social services note, dated 2/16/26, documented that verbal consent was obtained to contact Resident #12's sister (next of kin), who lived out of state, for support. -However, there was no documentation on what was discussed with his sister. A social services note, dated 2/27/26, documented that palliative care and hospice services were discussed with Resident #12 as well as having a medical power of attorney. The note documented that a good candidate would be his sister. The note documented that Resident #12 was agreeable. -However, the EMR did not have any further documentation of his sister agreeing or disagreeing to be his medical power of attorney or any documentation of Resident #12 disagreeing to have her as his medical power of attorney. A social services note, dated 3/4/26, documented that a referral for hospice care was being prepared.A physician's order documented that Resident #12 was admitted to hospice on 3/4/36. A nurse's note, dated 4/19/26 at 6:09 p.m., documented that Resident #12 was found by a certified nurse aide (CNA) unresponsive. The note documented that Resident #12 was a do-not-resuscitate (DNR). The note documented Resident #12 did not have a heartbeat, was not breathing and did not have a pulse. The note documented that hospice was notified and arrived about 30 minutes later and finalized all the paperwork needed for the mortuary to come and pick up the body of Resident #12. A nurse's note, dated 4/20/26 at 8:42 a.m., documented Resident #12 was found in bed unresponsive on 4/19/26 at 6:20 p.m. Resident #12 was assessed by two nurses and then hospice was notified. The hospice nurse arrived to the facility at 7:44 p.m. and the county coroner was notified by the hospice nurse. The county coroner pronounced Resident #12's death at 7:55 p.m. The note documented that, per hospice, Resident #12 did not authorize family contact. A social services note, dated 4/20/26, documented that social services called the resident's son who was listed as the emergency contact #2 and left a voice message. A social services note, dated 4/21/26, documented that social services called the resident's son and left a voice message. -However, the 10/29/25 progress note documented the son did not want to be the resident's emergency contact (see above).IV. Staff interviewsThe director of nursing (DON) was interviewed on 7/7/26 at 3:43 p.m. The DON said the hospice staff communicated with the facility through email, verbally, and communication binders. She said depending on what hospice company the resident was with, either the hospice company or the facility notified the family of the death. She said that Resident #12 was alert and oriented and did not want his family notified. She said that Resident #12's son was very angry at the resident. The social services director (SSD) was interviewed on 7/7/26 at 4:28 p.m. The SSD said that she currently had Resident #12's belongings. She said that Resident #12's son wanted them to throw them out. She said the facility did not have any documentation that Resident #12 did not want his family to be notified of his death. She said she had gotten verbal permission from Resident #12 to call his sister (his next of kin) on 2/16/26. She said when she spoke to his sister it sounded like she was ready to be his medical power of attorney. She said she did not document the conversation that she had with his sister. She said she said Resident #12's son was never taken off as emergency contact #2. She said she would contact the hospice care company and get their documentation on Resident #12 not wanting to notify his family. -The hospice documentation was uploaded to Resident #12's EMR on 7/8/26 during the survey process (see record review above).V. Facility follow-up On 7/13/26 at 1:31 p.m., an attestation was sent by the regional clinical resource #1. The attestation documented that the SSD recalled Resident #12 expressing that he did not want his family notified upon his passing. The attestation documented that the conversation happened in the presence of a hospice care consultant. It further documented that the SSD did not document Resident #12's statement. The attestation documented that upon review of the hospice documentation, the resident was consistently referred to as being estranged from his family.-However, the SSD said during the survey that she did not document the conversation (see interviews above).On 7/13/26 at 6:26 p.m., a hospice coordination note was sent by the regional clinical resource #1. The note dated 4/1/26, documented that Resident #12's son had been visiting him but Resident #12 did not want to add him as his power of attorney or on the contact list. The note documented that Resident #12 did not want his family to be updated. -However, hospice documentation was not received until 7/8/26 (during the survey).

Based on record review and interviews, the facility failed to ensure two (#4 and #16) of six residents reviewed for abuse out of 22 sample residents were kept free from abuse.Specifically, the facility failed to:-Protect Resident #4 from verbal abuse by Resident #5; and,-Protect Resident #16 from sexual abuse by Resident #4.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy and procedure, revised 5/6/26, was received from regional nurse consultant #2 on 7/9/26 at 3:57 p.m. It read in pertinent part, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.II. Incident of verbal abuse between Resident #4 and Resident #5A. Facility investigation The facility investigation, dated 5/8/26, was provided by regional nursing consultant #2 on 7/7/26 at 9:03 a.m. The investigation revealed the following:On 5/8/26, Resident #4 reported to facility staff that Resident #5 had verbally threatened him. Resident #4 said Resident #5 had called him a pervert and said he (Resident #5) would dismember his penis and crush his skull. Resident #4 expressed fear for his safety as a result of those statements.The residents were separated. Resident #5 was put on 15-minute checks for closer monitoring and was referred to a mental health services provider. Monitoring was additionally initiated for Resident #4 and measures were taken to support Resident #4 and address his concerns. An interview with Resident #4, dated 5/8/26, revealed Resident #4 said Resident #5 threatened him, called him a pervert, and said he was going to dismember Resident #4's penis and crush his skull in five days.An interview with Resident #5, dated 5/8/26, revealed Resident #5 did not deny Resident #4's allegations and said he did call Resident #4 a pervert. Resident #5 said if Resident #4 did not leave him alone in five days he would crush his skull.The facility substantiated the abuse allegation based on staff documentation and the residents' interview statements. The investigation documented though there was no evidence of physical injury, Resident #5's behavior resulted in emotional distress for Resident #4 and required immediate intervention by the facility staff.The investigation documented a statement from the operations manager, undated, which revealed prior to 5/8/26, Resident #4 and Resident #5 were observed interacting regularly and appeared friendly. On 5/8/26 Resident #4 approached the operations manager and told him he felt nervous after Resident #5 told him he would have a biker gang put his head on the flagpole. The operations manager spoke with Resident #5 who was surprised Resident #4 had taken his comment as a threat, as he did not intend to threaten the resident. The operations manager documented he saw Resident #4 and Resident #5 speaking together on 5/9/26 and Resident #5 apologized and said he did not mean for his comments to be interpreted as threatening. The operations manager spoke with Resident #4 who said he felt better after talking with Resident #5. -However, the facility substantiated the allegation of verbal abuse, and verbal abuse did occur between Resident #5 and Resident #4 after Resident #5 made specific threats of bodily harm toward Resident #4.B. Resident #5 (assailant)1. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included major depressive disorder, generalized anxiety disorder and attention-deficit hyperactivity disorder.The 6/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup or cleanup assistance from staff for most activities of daily living (ADL).The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Record reviewThe psychotropic medication care plan, revised 5/22/26, revealed Resident #5 used psychotropic medications. Pertinent interventions included administering the medications as ordered and reporting lack of effectiveness or breakthrough behaviors.A behavior care plan, initiated 5/20/26, revealed Resident #5 demonstrated difficulty maintaining appropriate interpersonal boundaries and engaged in negative verbalizations or discussions about other residents, contributing to potential psychosocial distress and risk for resident-to-resident conflict. Resident #5 had a history of interpersonal concerns noted in communal living environments. Pertinent interventions included providing Resident #5 education on appropriate boundaries and respectful communication with peers, monitoring for signs of interpersonal conflict, and providing interventions as needed to address social skills and coping strategies.A progress note, dated 4/23/26 at 6:57 p.m., revealed Resident #5 was yelling at a nurse because a behavioral health provider had not seen him yet that day. Resident #5 appeared increasingly anxious and was going in and out of the facility repeatedly. A progress note, dated 5/3/26 at 11:20 p.m., revealed Resident #5 was observed by nursing staff with a strong odor consistent with marijuana use and demonstrated restless, intermittent agitation and repeated pacing in and out of the facility.A behavior note, dated 5/4/26 at 5:33 p.m., revealed Resident #5 had an appointment with an outside dental services provider. While there, Resident #5 admitted to their staff he was drinking alcohol and smoking marijuana each day. The dentist called the facility and Resident #5 became belligerent with the dental staff and cursed at the dentist. The dental services provider communicated to the facility Resident #5 was no longer welcome at their clinic due to his behaviors. Resident #5 was picked up by facility transportation at a liquor store. A change in condition note, dated 5/8/26 at 12:56 p.m., revealed Resident #5 was evaluated by the nursing staff for a change in condition. Resident #5 was documented as having physical aggression, verbal aggression, personality changes and was a danger to himself or others. Resident #5 was disruptive upon his return to the facility and stated to a staff member that he was very drunk and went down the street to drink. Resident #5 then yelled nonsensical ramblings at a staff member. Resident #5 then said he wanted to know why another resident (Resident #4) was still in the building and said he would cut his penis off. Resident #5 additionally told the nursing home administrator (NHA) that he was going to bash (Resident #4)'s skull in five days.A progress note, dated 5/8/26 at 6:54 p.m., revealed Resident #5 was noted to be intoxicated with alcohol as evidenced by his slurred speech, smell of alcohol and verbal aggression. The NHA and the director of nursing (DON) were aware. Resident #5's physician was notified and his medications were held.A progress note, dated 6/23/26 at 11:05 p.m., revealed Resident #5 returned to the facility from the emergency room that evening. The emergency medical technicians transporting Resident #5 relayed to facility staff that the resident had tested positive for alcohol over the legal limit and possible methamphetamines. The emergency medical technicians found a pocket knife on Resident #5's person which was placed in the facility nurse's medication cart for safe keeping.A psychiatric evaluation note, dated 6/25/26 at 8:00 a.m., revealed Resident #5 was seen by his psychiatrist. Resident #5 had a history of major depressive disorder, anxiety disorder, post traumatic stress syndrome (PTSD) and history of stimulant misuse. Facility staff reported Resident #5 had an increase of aggression and had been identified drinking alcohol. C. Resident #4 (victim)1. Resident statusResident #4, age less than 65, was admitted on [DATE] and discharged to another facility on 6/27/26. According to the June 2026 CPO, diagnoses included bipolar disorder, cognitive communication deficits, traumatic brain injury, depression and paraphilia (intense, persistent sexual interest or urges involving atypical objects, situations, activities, or non-consenting individuals).The 6/15/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident required setup or cleanup assistance from staff for all ADLs.The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Record review-Review of Resident #4's electronic medical record (EMR) revealed no documentation related to the verbal abuse incident with Resident #5 on 5/8/26 (see investigation above).D. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/9/26 at 1:04 p.m. RN #1 said Resident #5's behaviors depended on the day and he was unpredictable. RN #1 said Resident #5 used to yell at staff and other residents, but said his behavior had gotten better over time. RN #1 said Resident #5 could generally be redirected when having behaviors by having a conversation with him, but said the resident was manipulative and would push the limits on any facility rules.The DON and the NHA were interviewed together on 7/9/26 at 1:56 p.m. The DON said Resident #5 was generally a nice guy, but became belligerent when he was under the influence. The DON said Resident #5 became verbally abusive toward staff when he was under the influence and was not redirectable. The DON said the facility staff had found paraphernalia in Resident #5's room, including alcohol bottles, and had offered the resident sobriety resources. The DON said Resident #5 was very coercive and had broken a lot of the facility's rules. The DON said the facility had recently had to call for police assistance with Resident #5 and the police had found drug paraphernalia and pills on the resident's person. The DON and the NHA said Resident #5 and Resident #4 were roommates but had started to not get along, so Resident #4 was moved to a different room. The DON said the facility had initiated a behavior contract with Resident #5 as his behavior could affect other residents and the facility staff.III. Incident of sexual abuse by Resident #4 toward Resident #16A. Facility investigationThe facility investigation, dated 6/13/26, was provided by regional nurse consultant #2 on 7/7/26 at 9:03 a.m. The investigation revealed the following:On 6/13/26 at 10:00 a.m. Resident #16 reported via grievance form that Resident #4 had touched her inappropriately during breakfast the day prior (6/12/26). The residents were separated and assessed, and Resident #4 was placed on one-to-one supervision by staff.An interview with Resident #16, dated 6/13/26, revealed Resident #4 touched inside Resident #16's shirt and made contact with her breast. Resident #16 described the touch as unwanted and not consensual. An interview with Resident #4, dated 6/13/26, revealed Resident #4 acknowledged he had touched Resident #16 and said he thought she was comfortable with the interaction because they were friends. The facility substantiated the abuse allegation based on the interviews from both residents.B. Resident #4 (assailant)1. Record reviewA behavior care plan, dated 3/5/26, revealed Resident #4 had a history of inappropriate sexual behaviors. Pertinent interventions included monitoring Resident #4 for impulsive or sexualized behaviors, using redirection to maintain boundaries, and providing one-to-one supervision while awake with staff remaining within line of sight at all times.The safety awareness care plan, initiated 5/25/26, revealed Resident #4 had impaired judgement and decreased safety awareness related to his history of traumatic brain injury. Pertinent interventions included providing supervision, cueing and redirection as needed for safety and appropriate decision making, reinforcing safe behaviors, and monitoring for changes in mood, behaviors of function.A nursing summary evaluation, dated 4/20/26, revealed Resident #4 had experienced multiple behavioral episodes at the time. Resident #4 had to be redirected by nursing staff about exhibiting sexual behaviors, attempting to kiss staff members and speaking inappropriately.A progress note, dated 4/28/26 at 3:23 p.m., revealed nursing staff had to redirect Resident #4 for being in other people's personal space and attempting to kiss another resident.A progress note, dated 6/16/26 at 7:11 a.m., revealed Resident #4 was being monitored each shift for behaviors after he touched a female resident's breasts. Review of Resident #4's June 2026 CPO revealed the following order:Monitor episodes of verbal outbursts, hypersexual behaviors, extreme mood swings, manic episodes and difficulty concentrating and record non-pharmacologic interventions each shift for anti-psychotic medication monitoring, ordered 2/18/26.Review of Resident #4's May 2026 treatment administration record (TAR), from 5/1/26 to 5/31/26, revealed the following:-Resident #4's behavior monitoring was not recorded for 13 out of 62 total opportunities; and,-Resident #4 had 14 documented behavioral episodes during the period.Review of Resident #4's June 2026 treatment administration record (TAR), from 6/1/26 to 6/27/26, revealed Resident #4's behavior monitoring was not recorded for seven out of 54 total opportunities.C. Resident #16 (victim)1. Resident statusResident #16, age less than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses hemiplegia and hemiparesis (weakness and paralysis on one side of the body), major repressive disorder, cognitive communication deficits, panic disorder, generalized anxiety disorder and adjustment disorder.A 3/26/26 BIMS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15.The 4/16/26 MDS assessment revealed the resident required substantial to maximal assistance from staff for most ADLs. The MDS assessment documented the resident did not have physical behaviors directed at others. The assessment documented the resident had verbal behaviors directed at others and other behavioral symptoms not directed toward others on one to three days of the seven day assessment period.2. Resident interviewResident #16 was interviewed on 7/9/26 at 10:37 a.m. Resident #16 said there was another resident at the facility a while ago who touched her, but he had since left the facility. Resident #16 said the other resident (Resident #4) had touched her breasts and tried to go into her shirt to grab her breast. Resident #16 said Resident #4 did this because he thought they were friends, but Resident #16 said they were not that close, so she reported him to the facility. Resident #16 said the incident made her feel violated and said she was glad Resident #4 was no longer in the facility. Resident #16 said she thought Resident #4 felt they were close because his girlfriend was her roommate, and Resident #4 touched her roommate like that too.3. Record reviewThe psychosocial care plan, revised 6/16/26, revealed Resident #4 had a psychosocial wellbeing problem due to being inappropriately touched. Pertinent interventions included allowing the resident time to answer questions and verbalize her feelings, consulting with pastoral care, social services and psychiatric services, and assessing and monitoring her psychosocial wellbeing.A progress note, dated 6/13/26 at 1:45 p.m., revealed Resident #16 reported being touched inappropriately by another resident during breakfast the day prior (6/12/26). Resident #16 verbalized concerns regarding the incident. Resident #16 was assessed and provided with emotional support and reassurance. The incident was then reported to the DON and abuse coordinator. Resident #16 said another resident was sitting next to her at a table in the dining room when he suddenly intentionally reached for her breasts. Resident #16 said she told him to stop, and when she looked away he tried to touch her underneath her shirt and put his hand under her shirt. Resident #16 told him to stop again and left the dining room.A progress note, dated 6/25/26 at 1:15 p.m., revealed Resident #16 was seen by her psychiatrist. Resident #16 had a depressed mood and said she had not been feeling well since she had an altercation with another resident. Resident #16 had anxiety.A progress note, dated 6/29/26 at 8:33 a.m., revealed Resident #16 was seen on 6/25/26 by her psychiatrist due to her incident with another resident (Resident #4). Resident #16 reported an increase in anxiety. The psychiatry team recommended starting sertraline (an antidepressant) for anxiety and depression.D. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 7/9/26 at 12:58 p.m. LPN #3 said for residents who exhibited behaviors, she would monitor the resident for behaviors each shift, document any behaviors they had in the TAR, and let the DON know if the resident had any behavioral episodes. RN #1 was interviewed on 7/9/26 at 1:04 p.m. RN #1 said Resident #4 had a traumatic brain injury, was very friendly and liked to help people. RN #1 said Resident #4 tried to kiss her hand at one point but she established a boundary with him and that never happened again. RN #1 said Resident #4 had a girlfriend at the facility but said she only ever saw them holding hands.The DON, the NHA and the operations manager were interviewed together on 7/9/26 at 1:56 p.m. The DON said Resident #4 had hypersexuality due to his traumatic brain injury. The DON said Resident #4 had a tendency to reach out at people, which other people interpreted as groping. The DON said she had worked with Resident #4 to try to practice doing high-[NAME] and fist-bumps instead of reaching out, and she had provided education to the resident related to appropriate interactions multiple times. The DON said Resident #4 did make contact with Resident #16's breast. The DON said Resident #4 was subsequently put on one-to-one supervision by staff until he was discharged to another facility. The DON said Resident #4 had a history of being sexually inappropriate but could be redirected. The DON said Resident #4 thought he and Resident #16 were okay because he thought they were friends. The DON said Resident #16 initially reported feeling distressed because of the situation, so the facility had a psychiatrist evaluate her, but she said the resident did not have any long-term impacts or psychological distress.The operations manager said he had spoken with Resident #4 several times after the incident and Resident #4 denied having any malicious intent in the situation. The operations manager said Resident #16 initially yelled and pulled away when Resident #4 touched her and she reported the situation to the facility the following day (6/13/26).

Based on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene to two (#10 and #22) of four residents reviewed for services to maintain the highest practicable quality of life out of 22 sample residents. Specifically, the facility failed to ensure:-Resident #10 received timely incontinence care; and,-Resident #22 received his scheduled bed baths.Findings include:I. Facility policy and procedureThe Activities of Daily Living policy and procedure, dated 4/11/25, was provided by regional clinical resource #2 on 7/9/26 at 3:57 p.m. It read in pertinent part: Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care, transfer and ambulation, toileting, eating to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.II. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes without complications, and vascular dementia. The 4/1/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident needed partial to moderate assistance with toilet transfers and toilet hygiene. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. B. Resident representative interviewResident #10's representative was interviewed on 7/6/26 at 12:46 p.m. She said Resident #10 has had five urinary tract infections (UTIs) since she was admitted to the facility in December 2025. She said Resident #10 was often left in her bed and recliner wet in urine. She said Resident #10 could walk with a walker and to the bathroom with the standby assistance of staff. She said Resident #10 was on a toileting program and should be taken to the toilet every two hours. She said staff were not doing that as evidenced by the toileting log. She said the toileting log was hanging in the bathroom behind the door. C. ObservationsDuring a continuous observation on 7/7/26, beginning at 9:18 a.m. and ending at 2:44 p.m., the following was observed: At 9:18 a.m. certified nurse aide (CNA) #2 assisted Resident #10 out of the common area to her room. At 9:26 a.m. CNA #2 came out of Resident #10's room and removed her gloves at the nurse's cart, after providing incontinence care. At 10:16 a.m. Resident #10 was asleep in her recliner and staff had not checked on her since being taken to the bathroom at 9:26 a.m. At 10:41 a.m. Resident #10's toileting log was observed hanging in her bathroom. There was a sign next to the log stating that Resident #10 needed to be toileted every two hours due to enlarged ventricles and because she was unable to tell when her bladder was full. The toileting log starting on 7/2/26, documented she had been toileted on:7/2/26 at 1:00 p.m. and 2:14 p.m.7/3/26 at 7:20 a.m., 10:30 a.m., 1:30 p.m., 4:20 p.m., and 7:45 p.m.7/4/26 at 6:37 a.m., 10:30 a.m., 1:15 p.m., and 4:00 p.m.7/5/26 at 6:55 a.m., 10:00 a.m., and 3:00 p.m.7/6/26 at 7:20 a.m., 9:20 a.m., and 1:00 p.m.7/7/26 at 7:25 a.m.At 11:23 a.m. staff had not checked on Resident #10. Resident #10 was sleeping in her recliner. At 12:11 p.m. staff had not checked on Resident #10. Resident #10 was sleeping in her recliner. At 12:36 p.m. an unidentified nurse and an unknown visitor went into her room, the door was left open and they did not offer to take her to the restroom. At 12:53 p.m. an unidentified laundry staff member delivered Resident #10's laundry and closed the door as she left Resident #10's room. At 1:03 p.m. an unidentified staff member entered Resident #10's room to deliver her lunch. The unidentified staff member assisted Resident #10 with her lunch tray by making sure it was in front of her and all the items were uncovered. The staff member then exited the room and closed the door. The staff member did not offer to take Resident #10 to the bathroom. At 1:40 p.m. an unidentified housekeeper went into her room and began to clean, Resident #10 was sleeping in her recliner and not eating her lunch. At 1:45 p.m. the unidentified housekeeper exited the room and closed the door behind her. At 2:14 p.m. Resident #10 remained in her room and the staff had not checked on her or offered toileting At 2:39 p.m. CNA #1 opened Resident #10's door and closed it behind her. At 2:44 p.m. Resident #10 was sitting on the toilet. -The facility failed to offer the resident toileting for five hours and 18 minutes hours from 9:26 a.m. to 2:44 p.m.D. Record reviewThe bowel and bladder care plan initiated on 8/6/25 revealed Resident #10 had actual or potential for incontinence related to diuretic use, dementia, diverticulosis, diabetes, decreased mobility, and dysphagia. Pertinent interventions included notifying the nursing staff if Resident #10 was incontinent during activities, monitoring fluid intake to determine if natural diuretics such as coffee, tea, or cola were contributing to increased urination and incontinence, monitoring for signs and symptoms of UTIs, monitoring/documenting/reporting any possible causes of incontinence, and offering to toilet every two hours utilize yellow toileting log placed in resident's bathroom hanging inside the door. Review of the July 2026 CPO revealed the following physician's order:Providing frequent and toileting throughout the shift, ordered on 1/15/26. -However, observations and review of the toileting log in the resident's bathroom revealed the resident was not toileted every two hours (see observations above).E. Staff interviewsCNA #2 was interviewed on 7/7/26 at 3:05 p.m. CNA #2 said she toileted residents every two to four hours. She said that the nurses would let the CNAs know when a resident was on a toileting schedule. She said that Resident #12 was on a toileting schedule and she was to be toileted every two hours. -During the interview, the toileting log in the resident's room was observed with CNA #2. The log indicated the resident was toileted at 10:30 a.m. However, the resident was toileted at 9:26 a.m. (see observations above). CNA #1 was interviewed on 7/7/26 at 3:12 p.m. CNA #1 said Resident #10 was supposed to be toileted every two hours. She said that night shift did not fill out the toileting log. Licensed practical nurse (LPN) #2 was interviewed on 7/7/26 at 3:26 p.m. LPN #2 said residents should be checked, changed, and toileted every two hours. She said she knew when a resident was on a toileting program because there was an order for it in their chart. She said that Resident #10 was on a toileting program and should be toileted every two hours. She said there was a toileting log in her bathroom. She said she did not check the log to see if it was being filled out. The director of nursing (DON) was interviewed on 7/7/26 at 3:43 p.m. The DON said residents should be toileted every two hours. She said there were two different toileting programs. She said there was one where the log was hung up in the bathroom, which was the preference of the family and then the other one was where the CNAs entered the information into the computer. She said she needed to educate her staff on filling out the sheets in the bathrooms. She said Resident #10 should have been taken to the bathroom every two hours. III. Resident #22A. Resident statusResident #22, age [AGE], was admitted on [DATE]. According to the July 2026 CPO diagnoses included acute and chronic respiratory failure with hypoxia (inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood), chronic diastolic (congestive) heart failure, and morbid (severe) obesity due to excess calories. A 6/30/26 BIMS assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Resident interviewResident #22 was interviewed on 7/8/26 at 10:34 a.m. He said he had not had a bed bath since he was admitted on [DATE]. He said he was unable to get out of bed, which was why he preferred bed baths. He said the facility had not told him why he had not had a bath yet. During the interview, the resident's hair was unbrushed and greasy.C. Record reviewReview of Resident #22's electronic medical record (EMR) revealed his showers were to be on Monday, Wednesday, and Saturday.-However, review of the EMR did not reveal any documentation indicating the resident had been showered since we was admitted on [DATE].D. Staff interviewsCNA #1 was interviewed on 7/8/26 at 10:48 a.m. CNA #1 said that Resident #22 should have been getting his bed baths on Monday, Wednesday, and Saturday during the evening shift. She said after reviewing the electronic medical record (EMR) he had received a bed bath on 6/30/26, which was the day that he was admitted . She said she did not see any other documentation regarding his baths. CNA #2 was interviewed on 7/8/26 at 11:05 a.m. CNA #2 said that she could not find any records of Resident #22 refusing his baths or any records of him receiving his baths since he was admitted to the facility. The DON and regional clinical resource #1 were interviewed together on 7/8/26 at 12:20 p.m. She said that CNAs documented showers in the EMR. She said the assistant director of nursing (ADON) looked at the shower refusal sheets and cross-referenced the refusals in the computer system. She said that showers also included bed baths. She said that upon admission, the residents were asked their preferences on days and times of their showers. She said the resident's shower days and times were based on the resident's preferences. She said she was unsure of when Resident #22's shower days were. Regional clinical resource #1 said she reviewed Resident #22's EMR and his documented shower days were Monday, Wednesday, and Saturday on the evening shift. The DON said it looked like his showers were uploaded incorrectly into the computer system so, his shower was not coming up under the CNA's task. She said that CNAs should be documenting residents' shower refusals and when the showers were given. She said that showers should never be skipped.

Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#13 and #8) of four residents reviewed for medication errors out of 22 sample residents.Specifically, the facility failed to ensure physician orders were transcribed correctly for Resident #13 and Resident #8. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G et.al, Fundamentals of Nursing, 10th ed., (2023). Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Medication Reconciliation policy and procedure, implemented 4/11/26, was provided by regional Clinical Resource #2 on 7/9/26 at 3:57 p.m. It read in pertinent part, This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than five percent. Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay. Medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. New orders require a second nurse to cosign the orders, indicating review of the orders for accuracy. Perform 24-hour chart checks to verify all new orders have been addressed. III. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE] and was readmitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included acute on chronic congestive heart failure (CHF), morbid obesity, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and hypertension (high blood pressure). The 6/1/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance with toileting hygiene, personal hygiene, toilet transfers, and bed-to-chair transfers. She required partial/moderate assistance with showering/bathing, rolling left and right, lying to sitting on the bed side, and sitting to standing. She required setup or clean-up assistance with oral hygiene and was independent with eating. The assessment revealed the resident was taking a diuretic medication, a high-risk drug class, per pharmacological classification. B. Resident and resident representative interviews Resident #13's representative was interviewed on 7/6/26 at 2:30 pm. She said the director of rehabilitation stopped her session today because she was wheezing. She said she requested that Resident #13 be seen by the nurse practitioner (NP). She said the NP came to assess Resident #13 and said she had wheezing in her lungs. She said the NP said the resident was not taking any of her Lasix (diuretic) medication, because it was not a current order in her CPO. The resident;s representative said the NP conveyed to her that Resident #13 was never supposed to stop taking her Lasix medication. The resident's representative said Resident #13 had been taking Lasix medication on a long-term basis continuously for multiple years for CHF. The resident's representative said she did not know why Resident #13 was not taking her daily dose of Lasix. She said Resident #13 had a recent doctor's appointment with her pulmonologist and received a three day order to increase her Lasix, and then resume her previous daily dose. The resident's representative said she was not sure if resident #13's Lasix dose was transcribed correctly after she visited with the pulmonologist. Resident #13 was interviewed on 7/6/26 at 2:53 p.m. Resident #13 said she noticed she felt short of breath for the past week. She said she would tell the nurses about her symptoms and was given a breathing treatment. She said the breathing treatment would help her breathing for a short time. She said she had also been feeling more tired than normal the past week or so and had some swelling in her abdominal area. She said she did not tell the nurses about her swelling, because she thought it would just go away. Resident #13 said she had been taking the Lasix medication for a very long time and was unsure of the exact number of years. She said she was not aware she was not taking her daily Lasix dose. C. Record review Resident #9's care plan, revised 7/2/25, revealed she was on diuretic therapy related to CHF. Pertinent interventions, initiated 6/19/25, included administering diuretic medications as ordered by physician, monitoring for side effects and effectiveness, monitoring for other medications that may interact, monitoring/documenting/reporting adverse reactions to diuretic therapy such as dizziness, postural hypotension, fatigue, and an increased risk for falls, reporting pertinent lab results to physician especially hematocrit, sodium, and potassium. Review of Resident #13's June 2026 CPO revealed the following physician's orders: Furosemide oral tablet 40 mg (Lasix), give two tablets by mouth in the morning for CHF for three days. Ordered on 6/23/26. Furosemide oral tablet 40 milligrams (mg) (Lasix), give one tablet by mouth in the evening for CHF for three days. Ordered on 6/23/26. Furosemide oral tablet 40 mg (Lasix), give one tablet by mouth, two times a day for CHF. Ordered on 5/22/26. Discontinued on 6/23/26. The 6/23/26 pulmonologist paperwork documented the following physician's order: Increase furosemide 40 mg for three days, to two tablets in the morning and one tablet in the evening for three days. After three days, go back to one tablet in the morning and one tablet in the evening. -However, the Lasix order that was entered on 6/23/26 did not match the physician's orders to continue the Lasix after the temporary three-day dose increase. IV. Staff interviews The NP was interviewed on 7/6/26 at 3:05 p.m. The NP said she had been the provider for Resident #13 for one year. She said the resident had a history of chronic pulmonary edema and CHF. She said the resident's representative approached her because the resident was having difficulty breathing during her physical therapy session. She said when she assessed the resident, she noticed the resident was having difficulty breathing. She said she listened to the resident's lungs and heard wheezing and crackles at the bases bilaterally. She said those lung sounds indicate the resident was having some fluid buildup in her lungs. She said she checked the resident's medication and discovered the resident lasix ordered had been discontinued. She said the medication order should have never been stopped because she had chronic pulmonary edema. She said if the resident did not take her Lasix, fluid could build up in her lungs and could result in the resident having increased fluid around her lungs that could cause difficulty with her breathing. She said the resident should have had weekly weight monitoring. She said the medication Lasix could have a significant impact on weight, because not taking the medication could result in increased fluid accumulation in the body. She said monitoring the resident's weight could indicate if the medication was effective. The director of rehabilitation was interviewed on 7/6/26 at 3:05 pm. The director of rehabilitation said he worked with Resident #13 today. He said he had to stop the therapy session today (7/6/26)because the resident was having difficulty breathing. He said he reported the breathing difficulty to the nursing staff and requested a breathing treatment for the resident. He said he tested the resident's oxygen level to be 93% while she was on one liter per minute of oxygen via nasal cannula. He said he would document the resident's breathing problems in the resident's electronic medical record (EMR). Licensed practical nurse (LPN) #1 was interviewed on 7/7/26 at 10:00 a.m. LPN #1 said when a resident returns to the facility from an outside appointment, she would give the paperwork to the assistant director of nursing (ADON) and the DON for them to do a second review. She said the second order review was to ensure the orders were transcribed into the resident's EMR correctly. She said she had worked with Resident #13 twice, but was not very familiar with her medication history. She said Resident #13 had breathing difficulty yesterday and was given a breathing treatment. She said she did not ask the resident how often she had breathing difficulty or the onset of her breathing difficulty. The director of nursing (DON) and regional clinical resource #1 were interviewed together on 7/7/26 at 12:40 p.m. The DON said if a resident had a new physician's order when returning from an outside provider, the nursing staff would transcribe the new orders into the EMR. She said a second nurse would review and verify that the new orders were transcribed correctly before it was placed on the resident's medication administration record (MAR). She said the second verification review was an important step to ensure the medication orders were transcribed accurately to prevent medication errors. The DON said the intradisciplinary team would run a new order audit every day to review any new medication orders for facility residents. The DON said the medication error for Resident #13 was discovered on 7/6/26. She said the resident's representative reported to the nurse that Resident #13 was not feeling well and having some breathing difficulty. She said this information was reported to the NP in-house. The DON said the NP assessed Resident #13, reviewed her medication records, and discovered that the resident was not taking her Lasix medication. She said the resident was taking Lasix for over a year to treat her CHF. The DON said Lasix was used as a diuretic to prevent fluid accumulation in the lungs and the rest of the body. The DON said Resident #13 had a pulmonary apt on 6/22/26 and received new orders to increase Lasix for three days, and then resume her previous dose afterwards. She said the resident had not received her Lasix for nine days. She said the resident's last dose of Lasix was on 6/26/25. She said the resident did not receive her Lasix dose due to an error in the medication being transcribed. The DON said there were several missed steps that contributed to the medication error. She said the medication was not transcribed correctly, no nurse completed a second check of the new medication order, and there were no new order audit reports run for the resident. The DON said she was responsible for running the new order report audits. She said she did not remember why she missed this very important step in the order transcription process. The DON said as a result of the resident not taking her Lasix medication, the resident could have had fluid buildup in her lungs and the rest of Resident #13's body. She said this could have resulted in labored breathing, lowered oxygen levels, and irregular electrolyte levels. The DON said the NP placed a new order to restart the resident on her previous dose of Lasix, daily weights, lab work, and vital signs every shift. She said after the medication error was discovered, the nursing staff notified the resident's primary care provider. Regional clinical resource #1 said the new order audit was done to ensure the order was accurate, the duration of the medication was accurate, appropriate monitoring was in place, and the resident care plan was updated as needed. She said a risk assessment document was completed, and education was started on 7/6/26 for the nursing staff about the process of transcribing new orders when the resident returns from the outpatient doctor's appointments. The pharmacist consultant was interviewed on 7/7/26 at 3:21 pm. She said she had worked at the facility for two months. She said she conducted medication reviews for current facility residents monthly and upon admission. She said if Resident #13 was not given her Lasix medication, she could have elevated edema (increased fluid buildup in the body's tissues), weight gain, and increased blood pressure. She said Lasix was a diuretic and prevents fluid accumulation around the heart and lungs. IV. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE], discharged to the hospital on 4/28/26, readmitted on [DATE] and discharged to another facility on 6/11/26. According to the June 2026 CPO, diagnoses included type 1 diabetes with diabetic neuropathy. According to the 6/11/26 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for most ADLs. The assessment indicated the resident received hypoglycemic medications including insulin. B. Record review The diabetes care plan, initiated 5/1/26, revealed Resident #8 had diabetes. Pertinent interventions included notifying Resident #8's physician with any concerns and providing medications as ordered. Review of the April 2026 CPO revealed the following orders: Insulin glargine (an extended-release insulin) 100 units per milliliter (ml), inject 15 units subcutaneously two times a day for diabetes, hold for blood sugar readings under 100 micrograms (mcg) per ml, ordered 4/22/26 and discontinued 4/27/26. Insulin glargine 100 units per ml, inject 16 units subcutaneously two times a day for diabetes, ordered 4/29/26 and discontinued 4/29/26. A progress note, dated 5/12/26 at 3:20 p.m., revealed Resident #8 readmitted to the facility at 10:55 a.m. that day (5/12/26) from the hospital. Resident #8's medications were reconciled with the provider and entered into his electronic medical record (EMR). A hospital Discharge summary, dated [DATE], revealed several of Resident #8's medications had not changed during his hospitalization and he was to continue them as ordered. The discharge summary listed the following orders: -Insulin glargine 100 units per milliliter (ml), inject 16 units into the skin two times a day; and, -Insulin lispro 100 units per ml, inject sliding scale into the skin three times daily before meals. A physician's note, dated 5/13/26, revealed Resident #8 was seen by his physician following his readmission to the facility. Resident #8 was concerned he was not getting a proper insulin dose. Resident #8 returned from the hospital on only a sliding-scale insulin dose with no extended release insulin. Resident #8 was an insulin-dependent diabetic and was previously receiving 15 units of glargine twice a day. The physician noted Resident #8 was worried about his insulin as he understood his disease, and the physician promised the resident he would review his chart and start him on extended release insulin. Resident #8 was upset about not being on an extended-release insulin. Review of the May 2026 CPO revealed the following orders: Insulin glargine 100 units per ml, inject 10 units subcutaneously two times a day for diabetes, hold for blood sugar readings under 100 micrograms (mcg) per ml, ordered 5/13/26 and discontinued 5/14/26. Insulin glargine 100 units per ml, inject 16 units subcutaneously two times a day for diabetes, ordered 5/13/26. Review of Resident #8's May 2026 medication administration record (MAR), from 5/1/26 through 5/31/26, revealed Resident #8 did not receive any doses of long acting insulin on 5/12/26 or during the day shift on 5/13/26. C. Staff interviews The DON was interviewed on 7/8/26 at 12:37 p.m. The DON said when a resident readmitted to the facility from the hospital, they follow the physician's orders from the hospital, verify the medications with the facility's physician and assess the resident. The DON said one nurse would enter the resident's orders from the hospital admission packet and a second nurse would confirm the orders. The DON said Glargine was a long-acting insulin. The DON said Resident #8 had physician's orders for both long-acting and short-acting insulin, but it was not transcribed correctly when he returned from the hospital. The DON said the long-acting insulin had a scheduled administration. The DON said since Resident #8's readmission she had begun educating the nursing staff on inputting orders. LPN #3 was interviewed on 7/9/26 at 12:58 p.m. LPN #3 said she was not sure who put in physician's orders when a resident returned from the hospital. LPN #3 said short-acting insulin worked to lower blood glucose levels within thirty minutes while long-acting insulin took a few hours to begin working. LPN #3 said long-acting insulin was crucial and said a resident could not miss a dose as it could affect their blood glucose levels.

Based on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#7) of three residents reviewed for change of condition assessments out of 25 sample residents.Resident #7, who was diagnosed with alcoholic polyneuropathy (nerve damage that causes pain, tingling, and numbness in the limbs), history of traumatic brain injury, congestive heart failure (CHF), type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites (liver disease without fluid in the abdomen), hypertension (high blood pressure), long term use of anticoagulants (blood thinners), and alcohol use with unspecified alcohol-induced disorder was admitted from the hospital to the facility on 7/17/25.Specifically, on 1/27/26 Resident #7 signed out of the facility at 8:30 a.m. and was returned to the facility at approximately 2:30 p.m. by the police due to intoxication (when alcohol or drugs impair your mental and physical abilities). The facility failed to thoroughly assess Resident #7 and ensure he received care. Although the resident had a change of condition, no change of condition assessment was completed, there was no registered nurse (RN) assessment documentation and the staff did not call his physician or guardian. The facility failed to assess the resident, call the physician, or send to the hospital and he died at the facility three hours later on 1/27/26 at approximately 5:30 p.m. of respiratory failure, aspiration event and alcoholism according to the death certificate.In addition, the facility failed to have an alcohol use or an intoxication care plan for Resident #7.The facility failed to address a significant change of condition when Resident #7 returned to the facility intoxicated and required a wheelchair transport from the front door to his room, normally he used no mobility devices. The facility's failure to assess and monitor the resident's alcohol use and change in conditions, failure to document changes, and failure to seek medical treatment when required and notify the resident's physician, contributed to serious harm for Resident #7 and death. The potential for further serious resident harm if the facility's system for assessing, monitoring, documenting and communicating changes were not immediately corrected. Findings include:I. Immediate jeopardyA. Findings of immediate jeopardyReview of Resident #7's alcohol use, monitoring records, assessment documentation and staff interviews revealed the facility failed to take immediate and comprehensive steps following discovery of Resident #7's intoxication.There was no evidence the facility thoroughly investigated the incident to uncover and address root cause analysis and uncover why the nurses did not complete a change in condition assessment.The facility's failure to implement an immediate and comprehensive review of the facility's system and response to Resident #7's intoxication, placed residents at risk for serious harm if not immediately corrected. B. Facility notice of immediate jeopardyOn 3/3/26 at 5:40 p.m. the temporary emergency licensed nursing home administrator (NHA) who was also acting as the fulltime director of nursing (DON), the chief nursing officer (CNO) of the south region, the regional director of clinical operations (RDCO), and the regional vice president of operations (RVPO) were notified that the facility's failure to identify and respond to the worsening condition of Resident #7 created an immediate jeopardy situation. -Cross-reference F727 Failure to employ a fulltime DON when the DON became the temporary fulltime NHA (temporary permit for emergency situations 12/30/25 to 3/30/26).C. Facility plan to remove immediate jeopardyOn 3/4/26 at 3:49 p.m. the facility submitted a final plan for removal of the immediate jeopardy. The plan read: 1. Identification of residents affected or likely to be affected:The facility took the following actions to prevent any additional residents from suffering an adverse outcome.-The NHA notified the facility medical director of the incident on 3/3/26.-Starting on 3/3/26 nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were not identified.-A 30 day look back of current and discharge residents audit was initiated on 3/3/26 to ensure that if residents had a change in condition, the facility policy was followed.During the review, it was identified that one current resident did not have the required 72-hour alert monitoring order in place. This order would have increased nursing oversight to include monitoring for signs and symptoms of decline or infection and to notify PCP (primary care physician) if it shows signs of worsening and would be documented on the TAR and in progress notes every shift for three days. The assigned nurse was educated on 3/3/26 regarding the expectation to timely initiated 72-hour alert monitoring order promptly after completing the elnteract change in condition evaluation to ensure appropriate ongoing assessment and oversight by nursing staff was completed each shift for the full 72-hour period. The 72 hour change in condition alert monitoring order was initiated for the resident identified above. The 72-hour monitoring order would be triggered to alert the nurse per the frequency indicated by the physician (such as once per shift, every two hours, every 15 minutes, etc). The monitoring included nursing assessment based on the clinical condition being monitored, which may include vital signs, monitoring for pain or injuries, monitoring for signs or symptoms of infection, or any other relevant clinical information based on the change of condition.2 . Actions to prevent occurrence/recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring.-The resident change in condition and notification of changes policies and procedures were reviewed by the CNO for clinical accuracy on 3/3/26. No changes to policies were needed.-Beginning on 3/3/26 and ongoing all nursing staff will be educated by the DON/designee on appropriately addressing changes of condition including nursing assessment, monitoring of ongoing medical or physical condition, physician and family notification requirements, physician orders, and facility policies and procedures. Staff members were not permitted to work a shift until education was completed.-Beginning on 3/4/26 new hires (licensed nurses and nurse aides) will be educated on change of condition and physician and family notification requirements, as well as facility policies and procedures, during orientation.-Starting on 3/3/26 the DON/designee will conduct audits five times/week for three months of the 24-hour report and progress note report. These audits would ensure that if residents experienced a change of condition that facility policies andprocedures were followed. DON/designee would conduct daily nursing staff huddles, Monday through Friday, to monitor for change in resident condition.-Starting on 3/4/26 clinical and administrative oversight/supervision by regional director of clinical services and regional vice president will be conducted daily for four weeks, then weekly for three months to ensure all education and audits are completed and accurate. DON was educated on 3/3/26 by the CNO on appropriately addressing changes of condition including nursing assessment, monitoring of ongoing medical or physical condition, physician and family notification requirements, physician orders, and facility policies and procedures.-Starting on 3/4/26 the DON/designee will also complete chart audits as follows: three residents weekly for four weeks, then two residents weekly for two weeks, then two residents a month for two months. These audits will ensure that there are detailed observations and gathering of relevant and pertinent information for the provider to include vital signs and completed assessment of resident, and other information prompted by the elnteract change of condition evaluation and documenting in resident's medical record, notifying physician and family of change of condition.-The Regional Director of Clinical Services/RDCS will visit the facility two times per month to provide general oversight and monitoring of the plan.D. Removal of immediate jeopardyBased on the facility's plan above, the immediate jeopardy was removed on 3/4/26 at 4:25 p.m. However, deficient practice remained at a G level, actual harm, isolated. II. Explanation of Resident #7's incident and facility care expectationsA. Professional reference - IntoxicationThe Anesthesia Guide, Acute alcohol intoxication - management and treatment, updated 8/27/25, retrieved on 3/11/26, from https://anesthguide.com/topic/alcohol-intoxication/, it read in pertinent part, Acute alcohol intoxication is the most common of all poisonings, with thousands of cases occurring every month. Ordinary alcohol intoxication gradually progresses into alcohol poisoning without a specific threshold. Vomiting and diarrhea are common with alcohol intoxication, sometimes leading to airway aspiration. Fluid and electrolyte disturbances are common during prolonged drinking. Hypokalemia, hyponatremia, and hypomagnesemia are relatively common in alcohol abuse. In acute care, these electrolyte imbalances should be monitored. The most common cause of death due to alcohol intoxication is respiratory depression with hypoxia, lung atelectasis, and airway aspiration of stomach contents. Hypothermia is also common in fatal alcohol intoxication. All patients, including those intoxicated with alcohol, have the right to good general care and to be treated with respect. Determine the appropriate level of care, but keep in mind that consciousness and breathing may fluctuate suddenly. In uncomplicated alcohol intoxication , a sick bag, fluids, sleep under observation, and antacids may be sufficient. In more severe cases of intoxication or when complicating factors are present, the situation is different: Closely monitor consciousness and breathing; administer oxygen; suction the mouth and throat if there is an increase in mucus; support breathing and circulation as needed (ensure a clear airway, treat hypoxia/hypercapnia, fluids). If paradoxical breathing is present, better airway conditions are needed, and intubation is usually required. Monitor body temperature; treat acute confusion and motor agitation; administer fluids, either orally or intravenously. Poisoned patients typically need rehydration with IV (intravenous) fluids; administer buffered glucose solutions. If necessary, correct electrolyte imbalances. In case of hypothermia, provide warming. If airway aspiration is suspected, order a chest X-ray and administer antibiotics for a respiratory infection. Consider prophylaxis for delirium and generalized seizures. Gastric lavage and activated charcoal are administered only in cases of mixed poisoning with medication when the patient arrives within one hour of ingestion. Free airways: The airway may be partially or fully obstructed in alcohol intoxication. Securing a free airway is the highest priority. Suction the mouth and throat if there is an increase in mucus. Nasal or oropharyngeal airways are the first-line devices. Be aware that nasal airways may cause severe nosebleeds, and the risk of nosebleeds is increased in alcohol intoxication (due to alcohol's vasodilating effect). The patient's position should be in the recovery position, with the tongue pulled forward through a firm jaw thrust. Patients who cannot maintain a free airway in the supine position or are unresponsive should be monitored in an intensive care unit. Breathing: avoid hypoxia and hypercapnia by administering liberal amounts of oxygen.B. Facility policy and procedureThe Resident Change of Condition/Status policy and procedure, implemented 3/3/26, was provided by the DON/acting NHA on 3/4/26 at 10: 26 a.m. It read in pertinent part, To address changes in a resident's condition or status, this facility will provide the necessary care andtreatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Policy explanation and compliance guidelines:1. The nurse will notify the resident's attending physician or physician on call when there has been a change in a resident's condition or status. This can include, but is not limited to:a. an accident or incident involving the resident;b. the discovery of injuries of an unknown source;c. an adverse reaction to medication;d. a significant change in the resident's physical/emotional/mental condition; to include activesubstance use/abuse.e. a need to alter the resident's medical treatment significantly;f. refusal of treatment or medications two or more consecutive times;g. need to transfer the resident to a hospital/treatment center;h. discharge without proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the resident's condition.2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting);b. impacts more than one area of the resident's health status;c. requires interdisciplinary review and/or revision to the care plan; and3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gatherrelevant and pertinent information for the provider to include vital signs and complete assessment of resident, and other information prompted by the eINTERACT Change of Condition Evaluation.4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source;b. there is a significant change in the resident's physical, mental, or psychosocial status; to include active substance use/abuse.c. there is a need to change the resident's room assignment;d. a decision has been made to discharge the resident from the facility; and/ore. it is necessary to transfer the resident to a hospital/treatment center.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.9. A 72-hour monitoring order should be put into place to monitor the status of change in resident's condition.III. Resident incident1. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 1/27/26 (deceased ). According to the January 2026 computerized physician orders (CPO), diagnoses included alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites, hypertension, long term use of anticoagulants and alcohol use with unspecified alcohol-induced disorder.The 1/16/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 5 out of 15. He required partial/moderate assistance with toileting hygiene, shower/bathing, upper and lower body dressing, rolling left/right, sitting to lying down, lying to sitting on side of bed, sitting to stand, chair to bed transfers, and toilet transfers. He required setup or clean-up assistance with eating, oral hygiene, personal hygiene, and walking. He did not require any mobility devices for walking.The assessment revealed there were no behavioral symptoms or rejection of care.B. Record reviewReview of Resident #7's comprehensive care plan revealed there was no care plan related to use of alcohol, intoxication or potential for substance use. There were no interventions related to his history of alcohol abuse and consuming alcohol while away from the facility. Record review revealed there was no documented discussion with the resident/resident guardian concerning hospice or palliative care.The January 2026 CPO revealed the following orders:Potential for substance use. Monitor for the following (change from baseline): Red eyes, dry mouth, lack of coordination, slowed reaction time, slurred speech, anxiety or paranoia, confusion, hallucinations, violent behavior, change in mood, irritability, increased sex drive, lack of inhibition, falls, dizziness, vomiting, needle marks, dilated or constricted pupils, breath and/or clothing smells, excessive talking. If any noted, write a progress note and notify the physician, every shift. Order date 9/22/25.-In the month of January 2026 the TAR documented that the resident had had no substance use behaviors indicating no pattern for Resident #7 in the month of January. Apixaban oral tablet five MG (milligrams) (Apixaban). Give 1 tablet by mouth two times a day for atrial fibrillation, order date 9/22/25. Gabapentin tablet 600 MG. Give one tablet by mouth three times a day for neuropathy, order date 9/22/25.Carvedilol oral tablet 25 MG (Carvedilol). Give one tablet by mouth two times a day for hypertension at breakfast and dinner, order date 12/16/25.Dapagliflozin propanediol oral tablet 5 MG (Dapagliflozin Propanediol). Give two tablets by mouth in the morning for diabetes mellitus, order date 12/30/25.-Significant medications with increased risks due to alcohol consumption included Dapagliflozin propanediol for diabetes, Apixaban (blood thinner), Carvedilol for high blood pressure, and Gabapentin for neuropathy. Review of the facility sign out/in sheet revealed, Resident #7 signed out of the facility on 1/27/26 at 8:30 a.m. and was signed back in by a nurse at 2:30 p.m. The MOST (Colorado Medical Orders for Scope of Treatment) in form revealed the resident was a no CPR (cardiopulmonary resuscitation): do not attempt resuscitation. Which was signed by the legal guardian on 11/7/25 and the physician signed on 11/11/25.Record review revealed there was no documentation that the legal guardian was notified that Resident #7 had returned to the facility intoxicated. Record review revealed there was no documentation that the physician was notified that Resident #7 had returned to the facility with a change of condition-intoxication.Record review revealed there was no documentation that a change of condition assessment had been performed by the nurse upon Resident #7's return to the facility intoxicated.Record review revealed there was no documentation in the progress notes what time Resident #7 had returned back to the facility and his intoxication condition upon return to the building or how he got to his bed. -Record review and interviews (see below) failed to reveal that the resident was assessed upon his return to the facility or that his condition was documented and monitored between 2:30 p.m. and 5:30 p.m. There was also no evidence the resident's physician was notified of his change of condition.The 1/27/26 at 1:33 p.m. police dispatch call for service report revealed in pertinent part, that a caller at a hotel in Longmont reported that a male (later identified as Resident #7) was yelling for help and the male was on the ground. The caller passing by was not wanting to get close to him. The male had a shopping cart on the sidewalk. The male was still yelling for help, unknown what was going on with the male, the male was wearing a black coat. No weapons seen, the caller was 20 yards away. The male was still yelling. The male was laying down now, yelling for help. A third caller to police dispatch was saying male was saying he needed help getting up. The male was identified as Resident #7 and was returned to his facility on 1/27/26 at 2:04 p.m.-Record review revealed there was no documentation that the facility conducted a post-fall evaluation/assessment of Resident #7 after he was brought back to the facility by the police.The 1/27/26 at 6:26 p.m. nurses note revealed that the resident was visualized in his room lying face down next to his bed at approximately 5:30 p.m. The resident was unresponsive to verbal stimuli and sternal rub. The DON/acting NHA and charge nurse were alerted. Vitals were attempted, no pulse and no heart rate upon auscultation. Emergency services alerted by another nurse, guardian notified by DON/acting NHA and coroner notified by another nurse on duty. The physician pronounced the time of death at 5:30 p.m. The funeral home was notified by the charge nurse. The facility awaits the coroner to examine the body for transport.An IDT (interdisciplinary team) note dated 2/4/26 (one week after the event) revealed that on 1/27/26 at 8:30 a.m. Resident #7 signed himself out of the facility. Later the same day (no time given), the police department returned the resident to the facility. Officers reported the resident was intoxicated. Police assisted the resident in removing his shoes and coat and helped him into bed. The resident was observed to be resting in his room afterward (not specified). At 5:30 p.m., during dinner service, the certified nursing aide (CNA) entered the resident's room to deliver his dinner tray. The resident was found face down on the floor, unresponsive.The CNA immediately notified the nurse on duty. The physician pronounced the time of death at 5:30 p.m.The death certificate revealed the date of death was 1/27/26 at 5:30 p.m. and cause of death was respiratory failure, aspiration event, and alcoholism as recorded by Resident #7's PCP.IV. Staff interviewsThe frequent visitor was interviewed on 3/2/26 at 2:05 p.m. and she said she found out from a family member that there had been an unexpected death in the facility. The frequent visitor said she went and asked the DON/acting NHA about it and was told that Resident #7 had come home to the facility intoxicated on 1/27/26 at 2:30 p.m. and the police brought him home and helped him get into bed. The frequent visitor said she told the DON/acting NHA that she needed to do an occurrence report for an unexpected death and for Resident #7 coming back intoxicated. The frequent visitor said the DON/acting NHA did not think she needed to and was not aware that it was required. The frequent visitor said the DON/acting NHA finally did submit an occurrence report to the State eight days after Resident #7's death which meant the body was gone. The frequent visitor said Resident #7's unexpected death should have been investigated with an autopsy and toxicology reports. The frequent visitor said she was amazed to see no set of vitals when Resident #7 returned to the building on 1/27/26 with the police.The DON/acting NHA was interviewed on 3/2/26 at 4:03 p.m. she said that Resident #7 had had a history of homelessness and his guardian said he liked to go out and this was the first facility that he considered a home. The DON/acting NHA said Resident #7 was alert and oriented to know if he got intoxicated he would call the facility for a pick up. The DON/acting NHA said the Resident #7 was never really confused, when he came back in after being out he was still alert. The DON/acting NHA said on 1/27/26 she spoke briefly with the police officer who brought Resident #7 back to the facility and he said that Resident #7 was wandering around by a hotel. The DON/acting NHA said she did see Resident #7 when he came back and the officer spoke with his primary nurse (LPN) #2. The DON/acting NHA said when Resident #7 went out in the mornings he would often come back and take a nap, he was not always intoxicated, sometimes he would go out and pan handle. The DON/acting NHA said if a resident came back with alcohol intoxication she would look for impaired speech, impaired balance, smell on his breath, pupils would be dilated and then the nurse would know to hold his medications. The DON/acting NHA said she would want the nurse to take an intoxicated resident's vitals and do a full assessment including his skin. The DON/acting NHA said she did not know if there was a nurse assessment after Resident #7 was brought back to the facility by the police. The DON/acting NHA said LPN #2 had said she did not notice anything about Resident #7. The DON/acting NHA said the police officer found him with beer but she did not know if he had other substances in his system. The DON/acting NHA said she would have wanted the nurse to have completed a change of condition assessment with suspected substance abuse and would also put in an alert to watch for signs and symptoms and hold his medications. The DON/acting NHA said the nurse should have put in a progress note for Resident #7, completed a head to toe assessment, and take his vitals. The DON/acting NHA said in addition the nurse should have notified the guardian and his PCP about Resident #7's change of condition. The DON/acting NHA said a risk management report was not done until 2/4/26. The DON/acting NHA said there was no alcohol use care plan in place but there should have been in order to alert the nurses and so they would know what intervention to implement when Resident #7 was intoxicated. The DON/acting NHA said the plan now moving forward was for anyone who was suspected of intoxication to complete a full change of condition assessment, risk management report, vitals and notification of PCP and guardian/emergency contact/POA (power of attorney). The DON/acting NHA said she would definitely provide education to the nurses about monitoring for signs and symptoms and what to look for with intoxication. The DON/acting NHA said she could start that education today and start educating all the shifts. RN #2 was interviewed on 3/2/26 at 5:08 p.m. she said she was not working on the day that Resident #7 died. RN #2 said she was not aware of any other current residents who had intoxication issues. RN #2 said she would assess if a resident was intoxicated by doing a thorough assessment and looking at indicators such as smell, agitated behaviors, slurred speech, red eyes, sometimes more talkative, but alcohol was a sedative. RN #2 said if a resident came in intoxicated she would first notify the physician, DON and family member/guardian. RN #2 said she would then do a change of condition assessment including all vitals and skin evaluation. RN #2 said it would be important to do a thorough assessment to make sure the resident was okay and healthy and to give the information to the physician who may give a treatment order. RN #2 said they would conduct the skin evaluation because if a resident had gone out and fallen the staff would want to know in order to keep them safe. RN #2 said it was important to check the residents vitals because if blood pressure was too high, maybe alcohol poisoning, check for hydration, look for consciousness, and heart rate especially since alcohol affects the central nervous system and could also lead to a fall.CNA #2 was interviewed on 3/2/26 at 5:25 p.m. she said she had heard that Resident #7 passed away but she did not see him on that day or the police.CNA #3 was interviewed on 3/2/26 at 5:27 p.m. she said she was Resident #7's CNA on the day he passed away. CNA #3 said he went out in the morning and came back and she saw the police around the DON/acting NHA's office. CNA #3 said no one said anything to her, she did not know anything about his intoxication and was not even aware when he had returned. CNA #3 said she did not know if the police had come down the hall or if the police had put Resident #7 to bed. CNA #3 said close to dinner time she was handing out tickets for the next day's food orders and saw him in bed asleep. CNA #3 said there was another CNA, she did not remember who, and that CNA took in his food tray for dinner and found Resident #7 on the floor in his room, unresponsive. CNA #3 said that Resident #7 typically would not come back to the facility intoxicated, she may have seen that two times in the eight months that she had worked there.The maintenance director (MTD) was interviewed on 3/2/26 at 5:36 p.m. he said on 1/27/26 he did not see the police bring back Resident #7 to the facility. The MTD said he had seen the police in the building before at other times but not on that day. CNA #1 was interviewed on 3/3/26 at 8:50 a.m. and she said she was the staff member who discovered Resident #7 on the floor in his room the day he died [DATE]). CNA #1 said she delivered Resident #7's dinner tray around the end of the shift between 5:30-6:00 p.m. and found Resident #7 face down, holding onto the end of the leg of the bed, and the lights in his room were off. CNA #1 said when the nurses turned him over his body vomited. CNA #1 said the nurses did some checks and assessments and later the DON/acting NHA came. CNA #1 said Resident #7's head was toward the head of the bed and she did not smell anything or see blood. CNA #1 said she initially thought he had just had a fall. CNA #1 said she had heard about the police bringing Resident #7 into the facility, but did not see them and had no idea about how Resident #7 got back to his bed. CNA #1 said she saw Resident #7 in the morning of 1/27/26, he had come out of his room and was asking for towels and was joking around and then said she never saw him again. CNA #1 said that Resident #7 was not intoxicated in the morning and was in a good mood. CNA #1 said she had worked in the facility for about one year and had never seen him drunk/intoxicated. CNA #1 said the Resident #7 walked without an assistive device. Licensed practical nurse (LPN) #1 was interviewed on 3/3/26 at 9:00 a.m. she said she heard from CNA #1 and LPN #2 that Resident #7 was down on the floor. LPN #1 said she went to Resident #7's room and saw him laying flat, face down on the floor. LPN #1 said that LPN #2 assessed him and touched him and said he was cold. LPN #1 said she called the DON/acting NHA and the assistant director of nursing (ADON). LPN #1 said she noticed Resident #7's mouth was blue, with mucus, and he had urinated so his pants were wet. LPN #1 said she had worked in the facility since August of 2025 and had not noticed Resident #7 drunk/intoxicated, but said he may have drunk alcohol but never to the point of being intoxicated. LPN #1 said Resident #7 usually walked back from wherever he went and she had not noticed the police bringing him back to the facility.The ADON was interviewed on 3/3/26 at 9:29 a.m. she said she was working on the day shift on 1/27/26. The ADON said Resident #7's guardian had said he was allowed to go out and would sign in/out when he went. The ADON said she did not see Resident #7 come back to the facility with the police on the afternoon of 1/27/26 but she thought that LPN #2 had. The ADON said she did not see the resident come in but said usually when he came back he would go and lay down. The ADON said she had worked in the facility since June 2025 and said Resident #7 had admitted [DATE] but over that time she had not seen him totally intoxicated, but could smell that he may have had a few drinks sometimes. The ADON said to assess for alcohol intoxication or poisoning she would look at respirations, call the physician, and get an order to hold his medications and do a total head to toe assessment including a change of condition evaluation, risk management report and alert monitoring. The ADON said she would also look for slurred speech and unstable walking however she did not see Resident #7 return to the building. The ADON said that evening, on 1/27/26, she was called to come to Resident #7's room because he was lying down on the floor, his head was toward the head of the bed. The ADON said there were no vital signs, she did not see any blood, bruises or scratches. The ADON said she did not remember smelling anything but saw a littl

Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#9) of three residents reviewed for medication errors out of 25 sample residents.Resident #9 readmitted to the facility after being hospitalized from [DATE] to [DATE]. Upon return to the facility, the facility failed to ensure that metolazone (a diuretic), which was entered into the electronic medical record (EMR) as a daily scheduled order instead of as needed (PRN), was not administered to Resident #9. The resident received the medication scheduled daily over eight days instead of PRN (based upon a weight gain of five pounds (lbs) over baseline). Thereafter, Resident #9 developed a change in condition for significant weight loss and the resident experienced severe and significant weakness, fatigue, discomfort, excessive somnolence, tiredness and exhaustion, as well as hypokalemia (low potassium).Specifically, the facility failed to ensure the resident was administered medications per physician's orders. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al, Fundamentals of Nursing, 10th ed., (2023). Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Facility policy and procedureThe Medication Error policy and procedure, implemented [DATE], was provided by the chief nursing officer on [DATE] at 11:28 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medications will be administered as follows:-According to physician's orders;-Per manufacturer's specifications regarding the preparation, and administration of the drug or biological; and,-In accordance with accepted standards and principles which apply to professionals providing services.III. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE], and was readmitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included acute on chronic congestive heart failure (CHF), morbid obesity, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and hypertension (high blood pressure).The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance with toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, sit to lying, toilet transfers and bed to chair transfers. She required partial/moderate assistance with rolling left and right, lying to sitting on the bed side and sitting to standing. She required setup or clean-up assistance with eating and oral hygiene. She used a manual wheelchair for mobility with supervision or touching assistance.The assessment revealed the resident was taking a diuretic medication, a high-risk drug class, per pharmacological classification.B. Resident and resident representative interviewsResident #9's representative was interviewed on [DATE] at 8:36 a.m. She said the dietitian had approached her about Resident #9's weight loss and said the resident might need a protein shake and that the nurse practitioner (NP) had stopped the incorrect medication. The resident's representative said she asked the director of nursing (DON)/acting nursing home administrator (NHA) which medication was incorrect and she told her that metolazone was supposed to be PRN. The representative said the facility had administered the medication as a scheduled medication instead of following the parameters. The representative said Resident #9's baseline weight was 190 pounds (lbs). She said Resident #9 had lost significant weight from the medication error. She said Resident #9 was harmed because she had gotten so weak and could not regain her strength. The representative said Resident #9 told her with tears in her eyes that she just could not hang on any longer and she did not know what was wrong because she had never been this tired and exhausted before. The representative said she did not know at the time that there was a medication error that had lasted eight days. She said she felt like they were losing her and she was giving up. The representative said if registered nurse (RN) #2 had not noticed Resident #9's weight loss and spoken up to the NP, the resident would have died. She said she would not have known the cause of death and she would have just blamed it on COVID-19. The representative said the facility did not alert her of the medication error. She said she had to ask the facility about the error. The representative said when Resident #9 returned from the hospital on [DATE], she gave the hospital discharge paperwork (hard copy) to the assistant director of nursing (ADON) because the facility's phone lines were down that day. The representative said that the ADON took the discharge paperwork and typed everything (all the physician's orders) into the computer. She said that was how the incorrect medication got entered into the facility system for the resident to receive metolazone daily instead of PRN, which contributed to the resident's weakness and weight loss. Resident #9 was interviewed on [DATE] at 11:03 a.m. Resident #9 said it made her feel sad that the facility made a mistake and gave her the wrong medication. Resident #9 said she had felt weak and sick since returning from the hospital and it was one thing after another. C. Record reviewResident #9's diuretic therapy related to CHF care plan, revised [DATE], revealed pertinent interventions, initiated [DATE], included to administer diuretic medications as ordered by physician, to monitor for side effects and effectiveness; monitor for other medications that may interact; monitor/document/report adverse reactions to diuretic therapy such as dizziness, postural hypotension, fatigue, and an increased risk for falls; report pertinent lab results to physician especially hematocrit, sodium, and potassium. Review of Resident #9's [DATE] and February 2026 CPO revealed the following physician's orders:Spironolactone (diuretic) oral tablet 25 milligrams (mg). Give 25 mg by mouth one time a day for CHF, ordered [DATE]. Furosemide (Lasix - diuretic) oral tablet 40 mg. Give two tablets by mouth one time a day for CHF, ordered [DATE] and discontinued [DATE]. Potassium Chloride ER tablet extended release 20 MEQ (milliequivalent). Give two tablets by mouth one time a day for hypokalemia. Order date [DATE], discontinue date [DATE].Metolazone tablet 2.5 mg. Give one tablet by mouth one time a day for weight gain related to pulmonary edema and CHF take 30 minutes before Lasix. Notify primary care physician (PCP) for weight gain over 5 lbs over baseline, ordered date [DATE] and discontinued date [DATE].-However, the metolazone order that was entered on [DATE] did not match the physician's hospital discharge orders. The [DATE] hospital discharge paperwork documented the following physician's order:Metolazone 2.5 mg tablet. Commonly known as: Zaroxolyn for pulmonary edema due to chronic heart failure. Take 2.5 mg metolazone once daily, as needed, for weight gain 5 lbs over baseline. Take 30 minutes prior to Lasix.Resident #9's [DATE] and February 2026 medication administration records (MAR) were reviewed and documented that the metolazone 2.5 mg was administered once daily from [DATE] to [DATE] (for eight days), despite the resident not having a 5 lbs weight change. The February 2026 MAR documented that the resident's weight was not taken prior to administering the metolazone medication on [DATE] and [DATE]. Record review of the resident's weights revealed the following:-On [DATE] the resident's weight was 190.3 lbs;-On [DATE] the resident's weight was 190.2 lbs;-On [DATE] the resident's weight was 188.2 lbs. (Date the resident was sent to hospital);-On [DATE] the resident readmitted from the hospital and no weight was obtained;-On [DATE] the resident's weight was 188.8 lbs;-On [DATE] the resident's weight was 189.0 lb;.-On [DATE] the resident's weight was 186.2 lbs;-On [DATE] the resident's weight was 186.0 lbs;-On [DATE] no weight was recorded;-On [DATE] no weight was recorded;-However, the resident was administered the medication on [DATE] and [DATE], despite the facility failing to obtain a weight to determine if the PRN medication was needed.-On [DATE] weight was 186 lbs; and,-On [DATE] weight was 176.6 lbs.-The resident's weight the day after she was readmitted from the hospital, was 188.8 lbs on [DATE]. On [DATE] when the medication error was discovered her weight was 176.6, which was a difference of 12.2 lbs. -However, per the resident representative's interview (see above) Resident #9's baseline weight was 190 lbs, which indicated a 13.4 lbs weight loss. The [DATE] progress note revealed Resident #9 reported nighttime breathing difficulty and the on-call physician recommended hospital evaluation. The resident was transported to the hospital.The [DATE] progress note revealed Resident #9 was readmitted to the facility via stretcher accompanied by the daughter following an acute inpatient hospitalization. The resident was admitted with a documented history of MDRO (multidrug-resistant organism) and prior COVID 19 infection. The note documented current laboratory data indicated intermediate susceptibility to a carbapenem resistant organism (a class of last-resort antibiotics typically used to treat severe infections). Per infection prevention protocol and state guidance, the resident was placed on contact and droplet precautions upon admission. The resident remained on enhanced barrier precautions to continue for the duration of indwelling foley catheter use. The [DATE] progress note revealed Resident #9 was exhibiting significant weakness. The note documented she had been excessively sleepy during therapy today. The residents' vital signs were taken. The physician was notified immediately.The [DATE] change of condition note documented the resident had an abnormal weight change. The resident's weight was 176.6 lbs. The nurse received orders to discontinue the scheduled metolazone and keep metolazone as PRN if the resident gained weight 5 lbs from the baseline.The [DATE] eInteract change in condition evaluation was completed and revealed the resident's weight was 176.6 lbs. The nurse received orders to discontinue the current scheduled metolazone and start metolazone as PRN if the resident gained weight 5 lbs from the baseline.The [DATE] weight change note revealed the resident's current weight was 177.2 lbs, which indicated the resident had weight loss. The note revealed the resident was triggering for significant weight loss and a reweigh was requested. The weight was reviewed with nursing, resident, and daughter. The resident had a decline following recent COVID-19 infection and hospitalization. The resident was also receiving three diuretics (one discontinued on [DATE]). The representative reported significant weakness and fatigue. The resident reported a fair appetite. The staff were documenting the resident was consuming 50% to 75% of her meals. The representative requested oral supplements and the resident was in agreement to take. The plan was to implement 120 milliliters (ml) Med pass (oral nutrition supplement) BID (twice a day) to provide 510 kilocalorie (kcals) and 20 gram protein for 30 days. The dietitian would closely monitor.The [DATE] nurse note revealed the entry reflected follow up communication and actions taken in the days after the resident's episode of severe weakness while receiving metolazone in addition to scheduled Lasix and Spironolactone. During this period, the resident demonstrated significant weakness, with vital signs remaining within normal limits and no dizziness, chest pain, or shortness of breath reported. The provider was notified and stated she was not concerned at that time, noting the resident was already on scheduled diuretics and that vital signs were stable. No new orders were issued other than continued monitoring. A follow up call was made to the pharmacy for clarification regarding the metolazone order. The pharmacy reported they did not always receive hospital discharge orders directly and entered medications based on information provided during reconciliation. The pharmacy also stated they did not add parameter labels for conditional diuretics and advised that nursing staff ensure parameters were reviewed and followed during administration. Nursing staff were educated on conditional diuretics, including the need to verify weight based parameters prior to administration and to document the triggering parameter when applicable. The resident continued to be monitored for hydration status, intake, urine output, and changes in strength. No acute decline noted. The provider to be notified of any change in condition.The [DATE] alert charting note revealed receiving metolazone and potassium daily instead of PRN. The note documented the nursing staff was monitoring for acute changes, weakness, abnormal vital signs, weight loss, every shift for three days. The [DATE] at 10:11 a.m. IDT (interdisciplinary team) note revealed that the medication error was noted when Resident #9 returned from the hospital with a physician's order for metolazone 2.5 mg to be given PRN and administered only when the resident gained weight over 5 lbs. The error was identified on [DATE] and the root cause was identified as medication reconciliation was not completed upon admission. Education was provided to the floor staff. New interventions implemented included all medications must be verified by two nurses.-The IDT note incorrectly documented that the medication error was identified on [DATE], when per record review, it was identified on [DATE]. However, the alert charting was not activated until [DATE] and the resident's labs were not collected until [DATE]. The [DATE] nurse note revealed the NP was notified regarding the medication error. Per the NP, the resident was okay to stay on potassium daily due to the resident receiving 80 mg of Lasix. Metolazone was changed into PRN and to administer if the resident gained weight of 5 lbs from resident baseline weight. order updated on EMR. Upon assessment, the resident appeared to be within her baseline, vital signs were stable with no major adverse effect noted. The medical director was notified and aware of the incident.On [DATE] the nurse alert note revealed Resident #9 had received metolazone and potassium daily instead of PRN. The note documented the nursing staff were monitoring for acute changes, weakness, abnormal vitals, weight lost, every shift for three days. The [DATE] laboratory result report revealed the residents potassium was low at 3.2 milliequivalents per liter (mEq/L). (The normal range for potassium is 3.5 to 5.1 mEq/L.)On [DATE] the nurse note revealed recent lab results were reviewed by the physician's assistant and received an order for potassium ER 20 mEq one time only, order updated in the EMR. The resident was encouraged to drink plenty of fluids.IV. Staff interviewsRegistered nurse (RN) #2 was interviewed on [DATE] at 5:08 p.m. RN #2 said there was a medication error with Resident #9 that started on [DATE] when the resident came back from hospital. RN #2 said she discovered the medication error on [DATE] after noticing the resident's significant weight loss. RN #2 said she told the NP and they corrected it. RN #2 said the error was that the ADON entered the metolazone medication into the computer as scheduled daily instead of PRN. RN #2 said there should have been two nurses for the entry of medication orders to double check the orders and prevent errors. RN #2 said the risk to Resident #9 if she had continued to be administered the wrong medication order was weight loss, weakness, hospitalization, and possible death. RN #2 said she had also asked the dietitian to check on Resident #9's weight.The ADON was interviewed on [DATE] at 9:47 a.m. The ADON said when Resident #9 returned to the facility from the hospital on [DATE], the phone lines were down and had been down for a few days. The ADON said she did not know why the phone lines were down but she had tried to call for labs and noticed she was unable to. The ADON said normally the hospital would call to give report but they were unable to, so they gave the discharge packet to Resident #9's daughter. The ADON said she did not know why admissions staff did not get the paperwork ready electronically through the hospital charting system EMR and process the admission. The ADON said the normal process was for the admissions staff to upload the hospital discharge orders into the EMR into the miscellaneous section and then the nurses would print out and enter into the EMR orders section and then two nurses put in the orders to verify the orders. The ADON said on [DATE] when Resident #9 came back from the hospital she just entered the orders in only without a second nurse double checking. The ADON said another nurse was going to double check the orders but it did not get done and she did not know why. The ADON said the second double check was important to catch errors and prevent errors.The ADON said a medication error ended up occurring for a PRN metolazone medication. She said the order was put in as scheduled daily instead. The ADON said the medication error was discovered nine days later on [DATE]. The ADON said the physician was notified of the error on [DATE] that the metolazone was scheduled daily versus put in as PRN based on the resident's weight. The ADON said per the representative, Resident #9's baseline weight was 190 lbs. The ADON said the IDT note and the risk management report were completed on [DATE] although she did not know why it was entered so late after discovering the error on [DATE] (five days later). The ADON said the risk to Resident #9 for taking the metolazone medication daily instead of PRN was losing weight and she did lose weight. The ADON said in addition, weakness was also a side effect and the possibility of sodium and potassium depletion. The ADON said the facility completed a lab draw after discovering the error and found that Resident #9's potassium level was low. The ADON said Resident #9 was just coming back from hospitalization and recovering from Covid-19 so she was already weak and the medication error added a little bit of an exacerbation of the weakness with this error. The ADON said the error occurred for about eight days before being corrected. The ADON said Resident #9's weight loss from her 190 lbs baseline to 176 lbs on [DATE] was about 14 lbs. The ADON said when the resident went to the hospital on [DATE], she weighed 188 lbs, which indicated she sustained a 12 lbs weight loss in 13 days. The ADON said the reason the medication reconciliation did not happen was because the resident was admitted on a Friday and the medication reconciliation was usually done the next day, so that was not happening on the weekend. The ADON said that residents admitted to the facility on the weekends and on Fridays and there was education done that the floor nurses needed to verify the orders. The ADON said Monday through Friday, the DON and herself verified all the orders but there was a risk for the weekends so the nurses were educated to verify with two nurses. The DON/acting NHA was interviewed on [DATE] at 10:33 a.m. The DON/acting NHA said the medication error for Resident #9 was discovered on [DATE] and the resident was receiving the medication in error for eight days. The DON/acting NHA said when the medication error was discovered they completed an incident/risk management report and a change of condition alert with monitoring for three days. The DON/acting NHA said the medication error was discovered by a floor nurse when she weighed Resident #9 and it was low so she alerted the physician that her weight was low. The DON/acting NHA said the physician discovered the medication error and gave an order to discontinue the scheduled daily metolazone and correct the order to be PRN when the resident gained more than 5 lbs from baseline. The DON/acting NHA said the consequences from receiving the medication daily when not needed was weight loss, which Resident #9 had, and weakness, especially if the error had continued for a prolonged period. The DON/acting NHA said Resident #9 was already weak after being at the hospital with a UTI (urinary tract infection) and COVID-19, so the staff started using two person transfers for Resident #9 when she returned from the hospital. The DON/acting NHA was sure the medication error did not help her with her weakness. The DON/acting NHA said on [DATE], when Resident #9 returned from the hospital, the phone lines were down. The DON/acting NHA said the questions of why the phones were down would need to be asked of the admissions/former operations manager for dealing with that situation. The DON/acting NHA said usually they were able to view the admission paperwork through the EMR/hospital charting system and the hospital would also send a hard copy of the discharge paperwork. The DON/acting NHA said what usually happened with a hard copy was the nurses entered the medications into the computer and then another nurse was supposed to double check the orders to prevent an entry error. The DON/acting NHA said on that day the ADON put in the orders for Resident #9 but there was no second nurse review but she had provided education to the nurses to double check and they now did audits. The DON/acting NHA said she did not realize there was a break in the system so there was a new admissions checklist, and the audits were newly implemented and the second nurse verifications could happen on the weekends and everyday.Primary care physician (PCP) #2 was interviewed on [DATE] at 9:34 a.m. PCP #2 said he had been working in the facility for one month but would be retiring and going back to urgent care work. PCP #2 said that related to the medication error for Resident #9 and the medication metolazone, it was a special diuretic and worked like a turbo charger since the resident was already receiving the diuretic Lasix. PCP #2 said the metolazone medication was not typically used by itself but in combination with other medications. PCP #2 said the metolazone medication order was supposed to be PRN for when the resident gained 5 lbs from her baseline. PCP #2 said the side effects of the medication were weight loss and the speed of weight loss, noting the resident lost 10 lbs in one day which was very hard to do and could contribute to weakness. PCP #2 said that Resident #9 had a multi-factorial global decline and it was possible that the medication error if continued could cause the resident to die, it was possible but not likely or probable. PCP #2 said he did not think that Resident #9 suffered permanent harm from the medication error, but there was a recognition that something had gone wrong and that error was caught in time. The pharmacist was interviewed on [DATE] at 4:20 p.m. The pharmacist said the biggest side effect of giving the metolazone to Resident #9 when not needed, would be an electrolyte abnormality, the drug worked by pulling water from the kidneys and could also get a low potassium lab in synergetic effect with use of the furosemide (Lasix). The pharmacist said additionally, the side effects would definitely be some weight loss and 13 lbs would be considered significant. The pharmacist said electrolyte imbalance was directly related to dizziness and muscle cramps as one affects the other in a chain reaction. The pharmacist said if the medication was administered incorrectly (by being given when not needed) for eight days, it would be a moderate error and would continue to increase the electrolyte depletion and would require close monitoring.

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis.Specifically, the facility did not designate an RN to serve as the DON on a full-time basis, after the current DON was reassigned to be the temporary emergency licensed nursing home administrator (NHA) on 12/30/25 to 3/30/26. Cross-reference F684: The facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident's change in condition when indicated, resulting in the death of the resident. Findings include:I. Record reviewReview on 2/26/26 of the acting NHA license revealed an active temporary permit for emergency situations issued 12/30/25 with expiration on 3/30/26. The review of the facility staffing list on 3/4/26 revealed there was no full time DON in the building. The facility's DON job position description, undated but signed by the DON on 10/23/25, was provided by the acting NHA on 3/5/26 at 6:34 a.m. It read in pertinent part, The primary purpose of this job position is to plan, organize, develop and direct the operations of the nursing department in accordance with federal, state and local standards, guidelines and regulations to ensure that the highest quality of resident care is maintained at all times. The director of nursing services reports to the nursing home administrator and regional nurse consultant. Reporting to this position are: registered nurses, licensed practical nurses, certified nurse assistants. The director of nursing services' primary responsibility is to ensure the provision of quality nursing care on a 24-hour basis to the residents of the facility in accordance with federal, state and local standards and regulations. The director of nursing services is responsible for the recruitment and hiring of licensed personnel and managing the nursing staff schedule. This position monitors the job performance of the nursing staff andrecommends employee promotions and terminations to the nursing home administrator. The director of nursing services monitors the staffing levels of the facility to ensure all resident needs can be met safely and in a timely manner. The director of nursing services is responsible to oversee the implementation of nursing service objectives, policies and procedures. T The director of nursing services is responsible for managing all clinical systems of the facility and participating as the lead committee member for these systems including but not limited to: the infection prevention and control program, psychotropic system and controlled substance management, skin and weight system, risk management system, hospice program liaison, Implements nursing service objectives, policies and procedures to maintain quality nursing care and ensure all federal, state and local guidelines and regulations are followed at all times II. Staff interviewsThe chief nursing officer (CNO) was interviewed on 3/4/26 at 10:39 a.m. She said that the full time temporary NHA was also acting as the full time DON. Licensed practical nurse (LPN) #1 was interviewed on 3/4/26 at 3:39 p.m. She said she did not know that the DON had been appointed as the temporary NHA. LPN #1 said the DON was her supervisor. Registered nurse (RN) #2 was interviewed on 3/4/26 at 3:46 p.m. She said she did not know the DON had been appointed as the temporary NHA. RN #2 said she was not notified and there had been no announcement and the DON was her supervisor. The full time temporary NHA was interviewed on 3/4/26 at 4:55 p.m. She said she was the full time temporary NHA starting on 12/30/25 and she was also serving as the full time DON. She said there was no one else appointed. The temporary NHA said the census was low enough and she had two unit managers and an assistant director of nursing (ADON) who was an LPN who helped her with the clinical duties and audits. The temporary NHA said she also had an infection preventionist (IP) who helped with wound care and other clinical portions. The acting NHA said that as the administrator she did occurrence reporting to the state, she was the abuse coordinator and did the abuse investigations. The acting NHA said she led out in the stand up meetings however she had not made an announcement to her staff that she was the acting NHA and the DON. The CNO and the acting NHA were interviewed together on 3/4/26 at 5:08 p.m. The CNO said again that the full time temporary NHA was also acting as the full time DON however she did not know there was a regulation preventing that. The CNO said the regulation did make sense that there should be a full time DON working at least 40 hours per week. The CNO said she would work on what they needed to do. The CNO said there had not been an announcement to the staff concerning the temporary NHA appointment but they should have told the staff because the acting NHA was also the abuse coordinator and staff needed to report to the acting NHA. The CNO said there was no signage that the acting NHA was the abuse coordinator. The acting NHA said the residents and family also did not know that she was the temporary acting NHA. The acting NHA said it would be important to tell the residents and families so they would know who to go to if they had concerns. The acting NHA said it would be beneficial to let the residents and staff know that she was the acting NHA and would make that announcement right away.The CNO said she would immediately have a regional clinical RN step in as the fulltime DON and be present in the facility full time until the new NHA began.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care by not assessing, monitoring, documenting, and communicating a resident's change in condition when indicated that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm. Findings include:I. Facility policy and procedureThe Quality Assurance and Performance Improvement (QAPI) policy, implemented 5/25/25, was provided by the chief nursing officer (CNO) on 3/9/26 at 11:28 a.m. It read in pertinent part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Develop and implement appropriate plans of action to correct identified quality deficiencies. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. The QAPI committee must review all plans of correction written. The QAPI plan will address the following elements: Design and scope of the facility's QAPI program and QAPI Committee responsibilities and actions. Policies and procedures for feedback, data collection systems, and monitoring. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: Tracking and measuring performance. Establishing goals and thresholds for performance improvements. Identifying and prioritizing quality deficiencies. Systematically analyzing underlying causes of systemic quality deficiencies. Developing and implementing corrective action or performance improvement activities. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. A prioritization of program activities that focus on resident safety, health outcomes, autonomy, choice and quality of care, as well as high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves. The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified. Program development guidelines: Program design and scope - The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correctF684 Quality of careDuring the recertification survey on 9/11/25 F684 was cited at a D scope and severity, a potential for more than minimal harm, isolated.During the recertification survey on 8/29/24 F684 was cited at a D scope and severity, a potential for more than minimal harm, isolated. III. Cross-reference citationsCross-reference F684: The facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident's change in condition when indicated, resulting in the death of the resident. The facility's failure to provide quality of care put residents in a situation where a serious outcome occurred and created an immediate jeopardy situation. IV. Staff interviewsThe medical director (MD) was interviewed on 3/5/26 at 11:27 a.m. He said he was in the facility at least twice a month. The MD said the role he provided while in the facility was to talk to the administrator and the director of nursing (DON) and look at any special cases. The MD said he would plan to provide any education to the staff as indicated. The MD said he received and reviewed reports that were provided to him of any resident cases that needed to be reviewed. The MD said based on the facility he would be there tomorrow or the next week to follow up and provide oversight and follow up suggestions to the nursing home administrator (NHA), DON and regional directors. The MD said he reviewed any resident records that were presented to him as needing review. The MD said he reviewed policies and made changes to policies based on what was presented to him during QAPI. The MD said he had been the medical director at the facility for a few months. The MD said that the facility had informed him on 3/3/26 that the survey team had called immediate jeopardy for F684 quality of care regarding an unexpected death. The MD said he was not made aware that the DON was also acting as the full-time temporary emergency licensed NHA from 12/30/25 to 3/30/26. The MD said there had been a lot of leadership changes at the facility. The MD said his understanding and thoughts about the nature of the IJ situation was that there was a dilemma when finding the balance between a resident going out and doing what they want and not letting them go out in order to keep them safe since this was their home and the challenge became could they go out. The MD said as far as monitoring and evaluating the resident who came back intoxicated it depended if it was routine or not but the documentation and processes needed to be improved and he had talked to the facility about that. The MD said his recommendation for the facility's next steps would be a deep dive and a deep clean regarding the game plan going forward. The MD said that since he was now aware that the DON was also acting as the NHA, there needed to be a lot of process improvement and standardization, The DON/acting NHA was interviewed on 3/5/26 at 4:54 p.m. She said the last QAPI meeting was on 2/24/26 and prior to that it was held 1/8/26. The DON/acting NHA said the QAPI committee met monthly and the committee included all the required members plus other staff members such as the pharmacist, therapy and social services. The DON/acting NHA said problems that were brought up, such as through occurrences, grievances, resident council, PIP, plan of corrections the committee was aware of the issues. The DON/acting NHA said that some issues they work on were standard topics such as admissions, discharges, falls, hiring/staffing and abuse. The DON/acting NHA said the infection preventionist (IP) gives a report on wound care, antibiotic stewardship and infections. The DON/acting NHA said she brought up call lights at every meeting. The DON/acting NHA said she educated the committee so they knew what corrective actions had been implemented and she tried to capture everyone on every shift and anything identified by the audits. The DON/acting NHA said she brought up grievances and would now be bringing up the grievance process for improvement. The DON/acting NHA said they had an audit tool for every department and there were graphs that mapped our progress and there was a spreadsheet that helped them track progress on the issues. The DON/acting NHA said as far as change of condition evaluations they were doing that for skin alterations and falls and the staff knew that came with a risk management report and neurological checks. But they were new to the other types of change of condition assessments, which would include a thorough assessment, notification to physician and family/guardian. The DON/acting NHA said they would now add change of condition evaluation to QAPI as there were more types of changes of condition.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three units. Specifically, the facility failed to: -Ensure staff performed hand hygiene after emptying the resident's catheter and prior to providing incontinence care for Resident #4;-Ensure staff followed appropriate infection control guidelines and ensured the facility's shower chair was cleaned after use and not covered in stool prior to being used by Resident #4; and,-Ensure the facility's hot water heater was functioning appropriately in order to launder residents' clothes and linens at the appropriate water temperature.Findings include: I. Failed to ensure staff performed hand hygiene prior to providing incontinence care and cleaning shower chair after use appropriately for Resident #4. A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 12/13/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Observations On 12/10/25 at 11:15 a.m. there was a sign on Resident #4's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 12/10/25 at 11:17 a.m. Resident #4 was lying on his bed. He had an indwelling urinary catheter draining yellow urine attached to his bed. On 12/10/25 at 11:40 a.m. certified nurse aide (CNA) #3 was gathering facility supplies to assist Resident #4 with his shower. CNA #3 obtained a shower chair and placed it outside the room of Resident #4. The shower chair was soiled and visibly covered with stool. On 12/10/25 at 11:45 a.m. CNA #3 assisted an unidentified staff member with incontinent care for Resident #4 in preparation for his requested shower. CNA #3 proceeded to empty Resident #4's foley catheter. After emptying Resident #4's foley catheter. CNA #3 did not change her gloves or perform hand hygiene, but instead use the same gloves to assist with incontinence care for Resident #4. C. Staff interviews CNA #3 was interviewed on 12/10/25 at 11:55 a.m. CNA #3 said it was facility policy for her to have changed her gloves after emptying Resident #4's foley catheter. She said she was expected to have removed her gloves, wash her hands and don a fresh, clean pair of gloves before assisting with incontinence care. CNA #3 said she did not have any additional gloves in her pocket or in the resident's room. She said it was the responsibility of the nursing staff to make sure residents' rooms were stocked with plenty of personal protective equipment (PPE). CNA #3 said it was the facility's expectation to clean a shared shower chair after each use. CNA #3 said she used the shower chair earlier this morning (12/10/25) when showering another facility resident. CNA #3 said she forgot to clean the shower chair after use earlier and said that was unacceptable. She said it was important to maintain a clean environment for Resident #4 because he had wounds on his bottom and he could get an infection. The infection preventionist (IP) was interviewed on 12/11/25 at 11:52 a.m. The IP said all of the nursing staff had been provided education and training regarding effective infection control protocols. The IP said if the nursing staff were to ever run out of gloves or any other type of PPE, they should use the call bell to call for assistance and have another staff member provide them with additional supplies. The IP said not changing gloves and not performing hand hygiene between care tasks was unacceptable. The IP said she would provide education on infection control standards immediately. The IP said the soiled shower chair should never had arrived to Resident #4's room without being thoroughly cleaned with disinfectant wipes first. The director of nursing (DON) was interviewed on 12/15/25 at 12:46 p.m. The DON said the facility had an infection control policy in place that the nursing staff was expected to follow. The DON said it was extremely important to maintain infection control standards to prevent the spread of harmful infection-causing bacteria to the residents of the facility. The DON said the staff should wash or disinfect their hands before and after emptying residents' foley catheters and before and after assisting with incontinence care. II. Failed to ensure the facility's water heater was functioning appropriately to launder residents' clothes and linens at the appropriate water temperature A. Professional reference According to the CDC's Guidelines for Environmental Infection Control in Health-Care Facilities - Laundry and Bedding, 1/8/24, retrieved on 12/22/25 from https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html, Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. Dilution and agitation in water remove substantial quantities of microorganisms. Soaps and detergents function to suspend soils and also exhibit some microbicidal properties. Hot water provides an effective means of destroying microorganisms. A temperature of at least 160 degrees Fahrenheit (F) for a minimum of 25 minutes is commonly recommended for hot-water washing. B. Observations On 12/10/25, it was observed that the facility's primary water heater was broken. The nursing home administrator (NHA) confirmed this fact and reported that a repair order had been placed to replace the broken unit. The facility was utilizing two industrial-sized washing machines. The laundry aide reported that the water temperature during wash cycles was sixty eight degrees Fahrenheit. This temperature was substantially below the threshold required for effective sanitation and infection control. On 12/10/25, all resident clothing and linens, except for certain linens, will be laundered in the rehabilitation area. This area is not equipped with industrial washers and dryers and instead utilizes a domestic washer and dryer to process some of the facility's residents' clothing and linens. It was further observed that laundry operations in the rehabilitation area are not maintaining appropriate infection control or isolation measures for soiled clothing and linens. In addition, there is no physical barrier separating the laundry area from resident spaces, thereby failing to uphold required isolation precautions. C. Staff interviews The NHA was interviewed on 12/11/25 at 10:50 a.m. The NHA said the laundry services, particularly those conducted within the rehabilitation area, did not meet required standards. He said the laundry operations in the rehabilitation area failed to isolate soiled linens and adequately separate the laundry area from residents and staff, creating infection prevention challenges. The NHA said the facility's laundry practices fell below minimal standards and constituted noncompliance with regulatory requirements. The laundry aide was interviewed on 12/11/25 at 11:00 a.m. The laundry aide said the main laundry facility's water heater was broken and had been broken for three weeks. She explained that she managed the laundry services by rotating and prioritizing laundry to ensure residents had clean items. She said the facility has been using the rehabilitation area's washer and dryer to assist with laundering certain items because the washer in the rehabilitation area had a separate water heater supply. The laundry aide emphasized that she made every effort to maintain cleanliness and resident dignity, but acknowledged that the facility did not currently have a functioning water heater in the main laundry facility to meet regulatory expectations. She said she tried to do her best within these constraints to make sure that residents received clean clothes and linens, though it was not always in the quantity or frequency that would be ideal.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#5) of three residents out of nine sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #5.Findings include:I. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included chronic respiratory failure, sleep apnea, muscle weakness, chronic obstructive pulmonary disorder (COPD) and depression. The 10/2/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required moderate assistance with toileting, bathing, dressing and set up assistance with eating and oral hygiene. B. Resident observation and interviewOn 12/10/25 at 1:00 p.m. Resident #5 was observed sitting in his wheelchair in his room. An albuterol respiratory inhaler was observed on the bedside table next to Resident #5. Resident #5 said staff at the facility allowed him to keep the albuterol inhaler at his bedside. He said he preferred to have the medication available after his meals and any other time he needed to use it. Resident #5 said he was not aware of an assessment being conducted to determine if he was able to safely administer his own medications. He said he had taken the medication for years prior to coming to the facility. Resident #5 said he did not remember if he used his inhaler medication today (12/10/25). C. Record reviewThe respiratory care plan, initiated 10/1/25, documented Resident #5 had altered respiratory status with difficulty breathing related to COPD. Interventions included monitoring the resident for signs and symptoms of respiratory distress and reporting to physicians as needed, administering medications or inhalers as needed and monitoring for effectiveness and side effects. -The care plan did not indicate that Resident #5 was able to self-administer his albuterol inhaler.A review of Resident #5's December 2025 CPO revealed the following physician's order:Albuterol Sulfate HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) microgram (mcg)/actuation (act), two puffs inhaled orally every four hours as needed for COPD, ordered 9/29/25. -A review of Resident #5's electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #5 was able to safely administer his own medications.-The EMR did not reveal a physician's order for Resident #5 to self-administer the albuterol inhaler and approval for it to be kept at the resident's bedside. II. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/10/25 at 1:31 p.m. LPN #1 said Resident #5 always administered his own albuterol inhalers. LPN #1 said there should have been an assessment completed to make sure he was capable of administering his own medication. She said if the resident had a self-administration of medications assessment, the assessment would be located in the resident's EMR. -However, there was no self-administration of medications assessment in Resident #5's EMR. Registered nurse (RN) #1 was interviewed on 12/11/25 at 11:10 a.m. RN#1 said she only worked at the facility a couple of times a month. She said she was unaware of Resident #5 being in possession of his inhaler. She said medications should not be left at the bedside without a physician's order. RN #1 said before a resident was able to self-administer their own medication, the nursing staff should determine if the resident knew how to administer their own medications correctly through an assessment. RN #1 said she could not recall if a specific assessment was required in the facility's policy for self-administration of medications. The director of nursing (DON) was interviewed on 12/15/25 at 10 am. The DON said if a resident had requested to self-administer medication, the nursing staff would be responsible for completing a self-administration assessment. She said there should also be a physician's order in the EMR for the resident to be allowed to self-administer medications. She said the resident's care plan should reflect the resident's ability to self-administer their own medications. The DON said she was familiar with Resident #5 because he often requested to administer his own medications. The DON said she was unsure if a medication self-administration assessment was completed for Resident #5.

Based on observation, record review, and interviews, the facility failed to ensure that clean linens were provided in sufficient quantities for residents in two of three linen storage closets. Specifically, the facility failed to ensure there were enough clean linens for residents.Findings include:I. ObservationsOn 12/10/25 at 1:30 p.m., the linen storage closet located in hallway 100 was observed to contain six flat sheets, ten large comforter sheets, four pillowcases, and five blankets. No fitted sheets were present in the storage closet at the time of the observation.On 12/10/25 at 1:40 p.m., the linen storage closet located in hallway 200 was observed to contain three flat sheets, four large comforter sheets, and thirteen blankets. No pillowcases or fitted sheets were present in the storage closet at the time of the observation.II. Resident interviewsResident #1 was interviewed on 12/10/25 at 10:10 a.m. Resident #1 said linens were often unavailable or insufficient for residents because the facility did not have any clean linens.Resident #2 was interviewed on 12/10/25 at 12:48 p.m. Resident #2 said the facility appeared to lack an adequate supply of linens. She said there were not enough clean linens available to meet the needs of all residents. She said the facility had consistently failed to maintain sufficient linens and described this as an ongoing issue.III. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 12/10/25 at 2:30 p.m. CNA #3 said the facility did not maintain an adequate supply of linens. She said she first observed the shortage following the purchase of the facility by a new company. She said due to the insufficient supply, staff were required to collect soiled linens and have them laundered to provide residents with clean linens and regular blankets.The laundry aide was interviewed on 12/11/25 at 11:00 a.m. The laundry aide said the facility did not consistently have enough linens to provide each resident with a full set of sheets as needed. She said due to the shortage of linens, she managed by rotating and prioritizing linens to ensure residents had clean items, even though supplies remained limited. She said she made every effort to uphold cleanliness and resident dignity; however, she acknowledged that the facility's linen inventory was insufficient to fully meet regulatory expectations. She said, despite these constraints, she was committed to doing her best to ensure that residents received clean linens, though not always in the quantity or frequency that would be ideal.The maintenance director (MTD) was interviewed on 12/15/25 at 12:30 p.m. The MTD said he began working at the facility approximately four years ago but only recently assumed his current role. He said he was officially hired as the MTD three weeks ago, and since taking over, he had become aware of ongoing issues with clean linens. He said the situation affected the facility's compliance with regulatory requirements, which mandate that residents live in a safe, sanitary, and comfortable environment.The NHA was interviewed on 12/12/25 at 12:15 p.m. The NHA said the facility had a shortage of linens. He said he was aware of the current linen shortage affecting the facility and said he had already contacted the corporate office regarding the issue. He said an order for additional linens had been placed to ensure an adequate supply for all residents and said the shipment of new linens was expected to arrive during the week of 12/15/25. The NHA said the new shipment of linens was anticipated to resolve the shortage of linens and restore appropriate linen availability for resident care.

Based on observations, record review interviews, the facility failed to ensure residents were kept free from abuse, as one (#2) of four residents reviewed for abuse out of the nine sample residents.Specifically, the facility failed to protect Resident #2 from abuse by Resident #3.Findings include:I. Incident of abuse of Resident #2 by Resident #3 on 12/7/25A. Facility investigationThe facility's investigation, dated 12/7/25, documented that the dietary manager (DM) witnessed a resident to resident altercation between Resident #3 and Resident #2 in the dining room during meal service, during which Resident #3 struck Resident #2 on the right arm. The DM immediately reported the incident to the nursing staff. Nursing staff assessed Resident #2 in the comfort of her room following the event, and the initial assessment identified what appeared to be a pinch mark on Resident #2's right arm; the resident also reported arm pain. Resident #2 was reassured and monitored for any changes in condition or discomfort. Resident #3 was placed on one to one supervision with certified nurse aide (CNA) #2 to prevent further incidents and ensure the safety of all residents. Resident #2 reported that on 12/7/25, she took a sugar packet from Resident #3's dining table and that Resident #3 then went to Resident #2's table, reached out, and grabbed Resident #2's right arm. Staff intervened immediately to separate the residents and escorted Resident #3 back to her room. Resident #2 described pain in her right arm, and staff observed bruising to her right upper arm following the incident. The facility documented the injury with photographs of Resident #2's right arm, and facility actions consisted of immediate intervention, notification, and documentation.The facility conducted a skin assessment of Resident #2 and documented three vertical fingernail marks to the resident's right arm, including one open area measuring 0.1 centimeters (cm) by 0.5 cm with no active bleeding, localized redness to the posterior right arm measuring 1 cm by 1 cm, an approximately quarter sized bruise to the right wrist, and a redness mark at the base of the posterior head; these findings were recorded in the resident's electronic medical record (EMR) with the assessment.B. Resident #3 (assailant)1. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included cerebral infarction due to unspecified occlusion or stenosis of the right anterior cerebral artery, lack of coordination, hemiplegia, and hemiparesis following infarction affecting the left non-dominant side, dysphagia following cerebral infarction, apraxia following infarction, vascular dementia with behavioral disturbance, and adjustment disorder with mixed disturbance of emotions and conduct.The 11/10/25 minimum data set (MDS) assessment revealed the resident was cognitively intact, with a brief interview for mental status (BIMS) score of eight out of 15. The resident was independent with activities of daily living (ADL).The MDS assessment documented that the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Record reviewReview of Resident #3's behavior care plan, initiated 10/31/25 and revised 11/1/25, revealed the resident had episodes of yelling, cursing, and throwing objects, including plates and trays, when the resident was served a diet with an inappropriate texture. Interventions included administering medications as ordered, monitoring for side effects, assessing effectiveness, anticipating and meeting the resident's needs, and intervening to protect the rights and safety of others by approaching the resident calmly, diverting attention, and removing the resident from the triggering situation when necessary. The 12/7/25 nurse progress note revealed Resident #3 informed facility staff that she was involved in an altercation with Resident #2. She reported that she grabbed Resident #2's arm after Resident #2 took sugar packets from her table, as documented in the facility's record report.C. Resident #2 (victim)1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included schizoaffective disorder, Parkinson's disease, other seizures, and mild cognitive impairment.The MDS assessment revealed the resident was cognitively intact, with a brief interview for mental status score (BIMS) of 14 out of 15. The resident does require assistance with ADLs.The 10/6/25 MDS assessment documented that the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Resident interview and observationsOn 12/10/25 at approximately 11:00 a.m. Resident #2 and his family member were interviewed regarding the incident involving Resident #2 and Resident #3 on 12/7/25. Resident #2's family member said Resident #3 routinely entered the facility's dining room unattended. During the interview, Resident #3 was observed entering the dining room without staff supervision, despite having been placed on one on one supervision on 12/7/25. Resident #3 remained unsupervised for approximately three to four minutes before CNA #2, the staff member assigned to provide one on one supervision, entered the dining room area and wheeled Resident #3 to her preferred dining table, located approximately 10 feet from Resident #2 and her family member. Resident #2 and her family member said that Resident #3 had entered the dining area without staff supervision at the time of the incident on 12/7/25. Resident #2 was interviewed again on 12/11/25 at 12:48 p.m. Resident #2 said Resident #3 had previously been involved in conflicts with other residents. Resident #2 said that on 12/7/25, she approached Resident #3's dining table and removed a sugar packet. Resident #2 said Resident #3, who was wheelchair bound, then went to Resident #2's dining table, reached out, and grabbed Resident #2's right arm immediately after the sugar packet was taken. Resident #2 said a kitchen staff member responded to the commotion, intervened, and separated the residents, after which Resident #3 was escorted back to her room. Resident #2 said her right arm was painful following the incident and she later observed a bruise on her upper right arm.Resident #2's family member was interviewed again on 12/10/25 at 1:35 p.m. Resident #2's family member said Resident #2 reported that on 12/7/25 at approximately 11:05 a.m., she received a telephone call from the director of nursing (DON) informing her that Resident #2, had been assaulted by another resident (Resident #3) in the dining room. The family member said that the DON advised her she had contacted the appropriate individuals in accordance with the facility's policy and had notified law enforcement. The family member said the facility photographed Resident #2's right arm for documentation and investigative purposes.III. Staff interviewsThe social services director (SSD) was interviewed on 12/11/25 at 10:42 a.m. The SSD said Resident #2 approached Resident #3's dining room table, removed sugar or sugar packets, and returned to her own table. The SSD said Resident #3 became upset, wheeled herself to Resident #2's table, and engaged in physical contact by either grabbing or striking Resident #2's right arm. The SSD said there was not a direct witness to the incident, but she received reports from staff and residents. The SSD said during subsequent interviews conducted by other staff and the SSD, Resident #3 acknowledged that she did grab Resident #2's arm. She said following the incident, facility administration implemented immediate interventions by placing Resident #3 on one to one observation and care. The SSD said CNA #2 was assigned on 12/9/25 to provide continuous supervision to ensure resident safety and reduce the risk of recurrence.The NHA was interviewed on 12/11/25 at 2:00 p.m. The NHA said a full facility investigation was initiated promptly following the incident between Resident #2 and Resident #3. He said all pertinent parties, including nursing staff, dietary staff, and supervisory personnel, were interviewed as part of the investigative process, and that all required notifications were made with appropriate documentation completed in accordance with facility policy. The NHA said nursing staff conducted medical assessments of both Resident #2 and Resident #3 immediately after the incident. The NHA said Resident #2 was evaluated for injury and discomfort, and Resident #3 was assessed for behavioral status and any contributing factors. The NHA said as an immediate protective measure, Resident #3 was placed on one to one supervision to prevent further incidents and ensure resident safety. He said the one-to-one intervention would remain in place until nursing staff completed a reevaluation of Resident #3's behavioral and clinical needs. He said based on the results of the reevaluation, the facility would determine whether additional interventions were necessary. The NHA said additional interventions may include collaboration with the SSD, psychiatry, and the facility's physician to review Resident #3's care plan, behavioral supports, and any potential modifications to interventions or monitoring.

Based on observations, record review and interviews, the facility failed to provide respiratory services for two (#4 and #5) of three residents reviewed out of nine sample residents. Specifically, the facility failed to:-Ensure Resident #4's bilevel positive airway pressure (BiPAP) machine was set up and monitored and adjusted by the physician in order for the resident to utilize it at night; -Ensure Resident #4's care plan included the use of a BiPAP machine and settings; and, -Ensure Resident #5's physician's orders included application of his continuous positive airway pressure (CPAP) machine at night.Findings include:I. Resident #4A. Resident statusResident #4, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included quadriplegia (loss of motor function from the neck down), neurogenic bowel, neuromuscular dysfunction of the bladder, sleep apnea (breathing stops while asleep) and narcissistic personality disorder. The 10/20/25 minimum data set (MDS) assessment revealed Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required moderate assistance to roll side to side, and required substantial assistance with eating, hygiene, bathing, toileting, and dressing. He was dependent on staff assistance for transfers and used a motorized wheelchair for mobility. B. Resident interviewResident #4 was interviewed on 12/10/25 at 11:00 a.m. Resident #4 said he was admitted to the facility with his BiPAP machine, but he had not used it for approximately two months because the settings were incorrect. He said he had not used it because he had not seen a respiratory physician to adjust the settings. He said he slept poorly most nights and was tired throughout the day because he did not have his BiPAP machine working correctly. Resident #4 was interviewed a second time on 12/11/25 at 10:19 a.m. Resident #4 said he did not wear his BiPAP machine again last night (12/10/25) because he was scared of the machine not working correctly. He said he had only seen a respiratory therapist one time during his stay at the facility. He said the respiratory therapist did not place his BiPAP machine on the correct settings, and it still needed to be adjusted. Resident #4 said the facility should be following the same setting he had when he was admitted to the hospital prior to coming to the facility. He said the infection preventionist (IP) came into his room early this morning (12/11/25) and asked him what were the correct settings for his BiPAP machine. He said he became frustrated because he relied on the facility staff to know this information. C. Record reviewThe respiratory care plan for Resident #4, initiated on 7/22/25 and revised on 10/1/25, revealed the resident was at risk for altered respiratory status and difficulty breathing related to quadriplegia, left humerus fracture, atrial fibrillation and sleep apnea. Pertinent interventions included encouraging sustained deep breaths by using demonstration and emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation, using an incentive spirometer placed close for convenient resident use, maintaining a clear airway by encouraging the resident to clear his own secretions with effective coughing and if secretions could not be cleared, suction as ordered/required to clear secretions (initiated 7/22/25), monitoring for signs and symptoms of respiratory distress and reporting to physician as needed (initiated 7/22/25), monitoring/documenting/reporting abnormal breathing patterns to physician such as increased respiratory rate, decreased respiratory rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring (initiated 7/22/25), positioning the resident with proper body alignment for optimal breathing pattern (initiated 7/22/25), teaching the resident when to inhale and exhale while doing strenuous activities (initiated 7/22/25), and assisting the resident to change position routinely to facilitate lung expansion (initiated 7/22/25). The pulmonary clinic after visit summary revealed Resident #4 went to his pulmonology appointment on 11/25/25. The physician's notes revealed that the resident attended the appointment without his BiPAP machine. The notes indicated Resident #4 would require another appointment and he would need to bring his BiPAP machine, along with all of his associated equipment to download and adjust the BiPAP settings as needed. The physician's note recommended deactivating the smart stop feature as his machine would turn off in the middle of the night if there was excessive leaking. Resident #4 would need assistance putting on his BiPAP mask and ensuring it was adequately sealed each night at bedtime. His BiPAP mask would need to be taken on and off with the hooks. The Velcro on the BiPAP mask should only be adjusted if there was excessive leaking. Resident #4's machine would need to be filled with distilled water nightly, equipment would need to be cleaned weekly and supplies replaced regularly. -However, there was no record of Resident #4 attending a follow-up visit to the pulmonology clinic. -Additionally, the respiratory care plan and December 2025 CPO did not reflect the above physician's orders. -Review of Resident #4's comprehensive care plan revealed no specific care plan focus for Resident #4's BiPAP.Review of Resident #4's December 2025 CPO revealed the following physician's orders: Apply BiPAP on automatic setting at bedtime, ordered 9/23/25.Rinse BiPAP mask and air-dry daily after use in the morning, ordered 9/25/25.II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included chronic respiratory failure, sleep apnea, muscle weakness and depression. The 10/2/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required moderate assistance with toileting, bathing, dressing and set up assistance with eating and oral hygiene. B. Resident interviewResident #5 was interviewed on 12/10/25 at 1:00 p.m. Resident #5 said he took care of his CPAP machine himself. He said he had worn his CPAP every night for multiple years prior to coming to the facility. He said the facility nursing staff did assist him much with his CPAP machine with duties such as application of his mask at night or refilling the distilled water container. C. Record reviewThe respiratory care plan, initiated 10/1/25, documented Resident #5 had altered respiratory status with difficulty breathing related to COPD. Interventions included monitoring for signs and symptoms of respiratory distress and reporting to physicians as needed, administering medications or inhalers as needed and monitoring for effectiveness and side effects. The resident required oxygen settings at two liters per minute (LPM) via nasal cannula. The care plan indicated the resident had a CPAP and staff were to apply four liters of continuous oxygen at bedtime to keep saturations at 90%. A review of Resident #5's December 2025 CPO revealed the following physician's orders:Ensure that the resident has CPAP on before going to bed. Resident able to apply CPAP without assistance at bedtime, ordered 12/10/25 at 2:18 p.m. during the survey. Ensure to clean CPAP masks, water chambers and tubing with soap and water every morning, ordered 12/10/25 at 2:23 p.m., during the survey.Nursing respiratory CPAP: CPAP at automatic setting with oxygen at four liters per minute, with or without humidification. CPAP scheduled start at 9:00 p.m. and discontinue at 6:00 a.m. to meet the goal of eight hours each night at bedtime, ordered 12/10/25 at 2:17 p.m., during the survey Oxygen: apply oxygen up to four liters per minute via nasal cannula to CPAP to keep saturation above 90% at bedtime, ordered 9/29/25. -However, review of Resident #5's electronic medical record (EMR) revealed no detailed CPAP physician's orders in place until 12/10/25, during the survey. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 12/11/25 at 10:11a.m. CNA #1 said she had worked at the facility for two weeks. She said she had not received any training from the facility in regards to care for a resident who used a CPAP machine or BiPAP machine. She said she would refer the care for those devices to the nurse on duty. She said she was unfamiliar if there was a facility policy regarding those specific devices. The IP was interviewed on 12/11/25 at 11:52 a.m. The IP said she was in charge of staff training for resident care. She said she was going to give staff education, starting on 12/11/25, and training for medical devices such as CPAP machines and BiPAP machines. The IP said her goal was to make sure that all staff was competent with the required task, in addition to ensuring resident safety. She said the respiratory devices were not used without a physician's order in the individual residents EMR. The IP said the physician's orders needed to be in the resident's EMR to prevent a resident from becoming respiratory compromised. She said the physician's orders should include settings specific to each resident and their respiratory device. The IP said the nurses were responsible for knowing how to place the CPAP machines and BiPAP machines on the residents each night and checking for any leaks from the mask. The director of nursing (DON) was interviewed on 12/15/25 at 12:46 p.m. The DON said Resident #4 was very independent and would schedule and reschedule his own pulmonology appointments. The DON said she was unsure why the resident had canceled two of his follow-up appointments with the pulmonologist regarding his BiPAP machine settings. The DON said the nurses were supposed to follow up on the reason Resident #4 canceled his pulmonologist appointment. The DON said a potential negative outcome would be the resident continued to miss important appointments, and his sleep apnea symptoms started to worsen. The DON said she would immediately speak with Resident #4 to address his concerns regarding attending his pulmonology appointments. The DON said she would also ensure Resident #5 had physician's orders in his EMR specific to his CPAP machine.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#15 and #42) of seventeen residents out of 36 sample residents.Specifically, the facility failed to:-Ensure Resident #15 was administered pain medication as ordered;-Implement effective interventions to prevent Resident #15 from running out of her medication; and,-Offer and administer scheduled and as-needed medication for pain as ordered for Resident #42.RESIDENT #15Resident #15 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure, schizoaffective disorder (mental illness), bipolar disorder (mental illness), muscle weakness, frequent pain and limited range of motion. The facility failed to ensure Resident #15, with a diagnosis of chronic pain, was assessed for pain accurately and administered pain medications as ordered. The resident reported increased levels of pain.Resident #15's pain assessment documented the resident had pain, which affected her day-to-day activities. On 9/8/25, the resident reported she did not always get her pain medication as ordered on time. She said her pain affected her sleep and her ability to get around. The resident said she had not slept in two days.Due to the facility's failure to ensure Resident #15's pain medications were consistently administered as ordered and promptly, the resident sustained increased pain on 9/8/25 and was transported to the hospital via stretcher at approximately 4:00 p.m. for chronic pain.RESIDENT #42Resident #42 was admitted to the facility on [DATE] with diagnoses of quadriplegia (loss of motor function from the neck down), neurogenic bowel, neuromuscular dysfunction of the bladder and narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance). The resident had chronic pain related to quadriplegia, a left humerus fracture and decreased mobility.On 9/10/25 RN #2 documented Resident #42 did not receive a scheduled dose of gabapentin (nerve pain medication) because he was out of the facility. On the evening of 9/10/25, Resident #42 was yelling he was in pain and swearing at staff in the vicinity of RN #2. RN #2 informed the resident he could have a dose of Ibuprofen (pain medication), which the resident refused because he said it would not help. RN #2 failed to offer the resident his missed dose of gabapentin or an as needed dose of methocarbamol (a muscle relaxer medication) and Resident #42 continued to yell about his pain.On 9/11/25 at 8:23 a.m. Resident #42 rated his pain level at an 8 out of 10 requested a dose of PRN ibuprofen and a dose of PRN methocarbamol from licensed practical nurse (LPN) #2. When LPN #2 cautioned the resident about taking multiple pain medications close together, Resident #42 said he had taken them before and he was fine. LPN #2 said she would be back with his medication. Resident #42 could be heard moaning and calling out for help while he waited for his medication, however, no staff entered the resident's room. LPN #2 had not returned to the resident's room by the end of the continuous observation at 9:57 a.m., over an hour and a half after Resident #42 requested the as needed pain medications. At 8:23 a.m. Resident #42 pushed his call light. The call light was responded to by LPN #2 at 8:24 a.m. Resident #42 reported pain and requested PRN medication. LPN #2 completed a pain assessment using a 1 to 10 pain scale. Resident #42 rated his pain level at an 8 out of 10 during the conversation. LPN #1 offered Resident #42 his PRN Ibuprofen or PRN Methocarbamol (a muscle relaxer) and Resident #42 requested both medications. LPN #2 reminded Resident #42 he recently received his morning scheduled medications for pain and cautioned Resident #42 about taking multiple medications close together. Resident #42 said he had taken them before and he was fine. LPN #2 said she would be back with his medication.Due to the facility's failure to ensure Resident #42 received his PRN pain medications in a timely manner after the resident reported a pain level of 8 out of 10, the resident experienced unnecessary pain for an extended period of time.Findings include: I. Facility policy and procedure The Pain Management policy, revised 4/11/25, was provided by the regional vice president of operations. on 9/11/25 at 1:26 p.m. The policy read in pertinent part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility will utilize a pain assessment tool, tailored to the resident's cognitive status, to assist staff in consistently evaluating a resident's pain. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain, and course of illness to determine the most appropriate analgesic therapy for pain. Consider evidence-based practice tools to assist in the assessment of the resident's pain. Consider administering medication around the clock instead of PRN (as needed) or combining longer-acting medications with PRN medications for breakthrough pain. II. Resident #15 A. Professional reference According to the manufacturer's instructions for Belbuca, 10/16/22, retrieved on 9/16/25 from https://medlineplus.gov/druginfo/meds/a616019.html, Belbuca is used to relieve severe and persistent pain in people who are expected to need an opioid and cannot be treated with other pain medications. Belbuca should not be used to treat mild or moderate pain, short-term pain, or pain that can be controlled with medication taken as needed. Buprenorphine (Belbuca) is a class of medications called opiate partial agonists. It works by changing the way the brain and nervous system respond to pain. B. Resident status Resident #15, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, schizoaffective disorder, bipolar disorder, muscle weakness, frequent pain and limited range of motion. The 8/1/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident did not exhibit any rejection of care behaviors and was dependent on staff for transfers, locomotion, dressing, toileting, and personal hygiene. The assessment indicated the resident was on a scheduled pain medication regimen and had experienced pain frequently. C. Resident interview Resident #15 was interviewed on 9/8/25 at approximately 9:23 a.m. The resident said she was in a lot of pain. She said she had a headache, back pain and both of her knees hurt. She said her pain medication was usually given to her late. The resident said she was scheduled to receive pain medication at 8:00 a.m., and it was not administered until 1:00 p.m. The resident said there were several occasions that she had to wait until late in the afternoon before she received her morning medication. Resident #15 said range of motion (ROM) exercises and massages had helped in the past to alleviate her leg pain. She said the staff did not offer her those interventions. D. Observation On 9/8/25 at approximately 4:25 p.m., Resident #15 was observed on a stretcher being transported by emergency medical services (EMS). EMS said the resident was being transported to the hospital for complaints of severe leg pain. E. Record review The pain management care plan, initiated on 7/26/25, revealed Resident #15 had actual pain related to decreased mobility, chronic respiratory failure, sleep apnea and schizophrenia. Interventions included identifying and recording previous pain history and management of the pain and its impact on the resident's function and anticipating the resident's need for pain medication. -Review of Resident #15's care plan did not reveal documentation regarding Resident #15's preferred non-pharmacological pain interventions of ROM exercises and massages (see interview above). Review of Resident #15's September 2025 CPO revealed the following physician's order: Belbuca buccal film 75 microgram (mcg), place and dissolve one film orally twice a day (at 9:00 a.m. and 6:00 p.m.) for chronic pain, ordered 9/2/25. The 9/8/25 hospital report revealed Resident #15 was admitted to the hospital with left leg pain and chest pain as well. On arrival, the resident appeared chronically ill. The note documented she had mild leg swelling on the left side. The swelling appeared chronic and was noted on the right side as well, but she had more pain in the left knee. Upon arrival, the resident's vital signs were reassuring. She was ordered her previous oxycodone pain medication and a plan for an ultrasound to evaluate for deep vein thrombosis (DVT). The note documented there were no signs of trauma, and the resident had not had any falls or injury. Review of Resident #15's September 2025 (from 9/1/25 to 9/5/25) medication administration record (MAR) revealed the following: -On 9/2/25, the resident was administered her 6:00 p.m. dose of Belbuca at 9:39 p.m.; and, -On 9/5/25, the resident was administered her 6:00 p.m. dose of Belbuca at 9:16 p.m. Further review of Resident #15's September 2025 (from 9/6/25 to 9/11/25) MAR revealed the following: -On 9/9/25 the resident missed her morning dose of Belbuca; -On 9/9/25 the resident missed her morning and evening doses of Belbuca; and, -On 9/10/25 the resident missed her morning dose of Belbuca. Review of Resident #15's electronic medical record (EMR) revealed the following progress notes: The 9/9/25 nursing progress note, documented at 8:57 a.m., revealed Resident #15's Belbuca was out of stock. The 9/9/25 nursing progress note, documented at 10:56 p.m., revealed the resident's Belbuca was pending delivery from the pharmacy. The 9/10/25 nursing progress note, documented at 10:23 a.m., revealed the resident's Belbuca was out of stock. The progress note documented the resident's pain was 2 out of 10. The 9/10/25 nursing progress note, documented 6:08 p.m., revealed the medication was unavailable. The note documented the nurse spoke with the pharmacy and the medication would be delivered that evening. The 9/11/25 nursing progress note, documented at 9:00 a.m., revealed the morning dose of Belbuca was not given. The 9/11/25 nursing progress note, documented at 6:15 p.m., revealed Resident #15 stated her Belbuca was not effective and the resident requested new pain medication. The nurse notified the director of nursing (DON) and the physician. The note documented the physician did not recommend changing the resident's medication. F. Staff interviews Registered nurse (RN) #1 was interviewed on 9/10/25 at 10:47 a.m. RN #1 said when a medication was low on stock, she would reorder the medication through the pharmacy and notify the DON and the physician. She said she could utilize the emergency stock medication dispensing machine to obtain medications if medications were out of stock by calling the pharmacy and obtaining the verification code to access the machine. She said a resident who did not receive their pain medications for a few days could potentially develop increased pain, anxiety and an increase in blood pressure, which could lead to hospitalization. Regional director of clinical services #1 was interviewed on 9/10/25 at 4:20 p.m. Regional director of clinical services #1 said Resident #15 had a physician's order for Belbuca 75 mcg, twice a day. She said the resident reported the medication was ineffective and the facility had notified the physician of the resident's concerns. She said the physician said that she would not change the order until she met with the resident to discuss her plan of care and completed a review of her pain regimen. Regional director of clinical services #1 said the medication should have been ordered by the nursing staff when it was out of stock. Regional director of clinical services #2 was interviewed on 9/11/25 at 11:27 a.m. Regional director of clinical services #2 said the Belbuca was out of stock and the resident missed her doses of the medication from 9/9/25 to 9/11/25. She said the side effects of stopping an opiate could lead someone to become uncomfortable, anxious, experience headaches and an increase in the resident's pain. Regional director of clinical services #2 said the nurses were responsible for ordering residents' medication before the medication ran out. Regional director of clinical services #2 said the facility had access to Belbuca in the emergency stock medication dispensing machine. She said the nurses should have ordered the medication before running out. She said missing scheduled pain medication and administering pain medication past their scheduled times could result in increased pain, agitation and increased behaviors. Regional director of clinical services #2 said she would ensure all nurses were trained on appropriate MAR documentation, the medication reordering process, the time frame for reordering medications and also receive training on ordering requests in order to ensure residents were not missing their ordered medications. Regional director of clinical services #2 said she would monitor to ensure residents were receiving their pain medications promptly. III. Resident #42 A. Resident status Resident #42, age less than 65, was admitted on [DATE]. According to the September 2025 CPO, diagnoses included quadriplegia, neurogenic bowel, neuromuscular dysfunction of the bladder and narcissistic personality disorder. The 8/21/25 MDS assessment revealed Resident #42 was cognitively intact with a BIMS score of 15 out of 15. He required moderate assistance to roll side to side and required substantial assistance with eating, hygiene, bathing, toileting, and dressing. He was dependent on staff assistance for transfers and used a motorized wheelchair for mobility. B. Resident interview Resident #42 was interviewed on 9/9/25 at 9:29 a.m. Resident #42 said the physician at the facility was no longer willing to prescribe him opioid medication that he used to take at his previous facility. Resident #42 said he frequently spent hours with intense pain after requesting pain medication from staff with the current physician's orders. Resident #42 said sometimes he requested pain medication in the evening and did not receive any PRN medication until the next morning. Resident #42 said he frequently felt more anxious and irritable because he was in pain and it felt like nobody cared. Resident #42 said some days he did not get out of bed because he was in too much pain. C. Observations On 9/10/25 at 5:36 p.m. Resident #42 was in his motorized wheelchair in the common area next to the nurses' station. Resident #42 was calling out for help, yelling he was in pain and swearing at the staff in the nurses' station. RN #2 was standing at the medication cart approximately 15 feet away from Resident #42. The nursing home administrator (NHA) approached Resident #42 to ask what he could do to help. Resident #42 told the NHA he was in pain and the physicians in the facility would not do their job and treat his pain. The NHA offered to transport Resident #42 to the hospital due to his severe pain. Resident #42 said he was willing to go, but did not think it would help. The NHA talked to RN #2 about offering Resident #42 as needed (PRN) pain medication. RN #2 offered Resident #42 his PRN dose of ibuprofen. Resident #42 refused the dose, telling RN #2 it was not going to help. Resident #42 continued to yell and swear at staff and an unidentified resident commented on how upset Resident #42 appeared. -RN #2 did not provide Resident #42 with his missed dose of gabapentin or offer the resident a PRN dose of methocarbamol (see record review below). During a continuous observation on 9/11/25, beginning at 7:56 a.m. and ending at 9:57 a.m., the following was observed: At 8:23 a.m. Resident #42 pushed his call light. The call light was responded to by LPN #2 at 8:24 a.m. Resident #42 reported pain and requested PRN medication. LPN #2 completed a pain assessment using a 1 to 10 pain scale. Resident #42 rated his pain level at an 8 out of 10 during the conversation. LPN #2 offered Resident #42 his PRN ibuprofen or PRN methocarbamol and Resident #42 requested both medications. LPN #2 reminded Resident #42 he recently received his morning scheduled medications for pain and cautioned Resident #42 about taking multiple medications close together. Resident #42 replied he had taken them before and he was fine. LPN #2 replied that she would be back with his medication. At 8:36 a.m. Resident #42 was heard from the hallway moaning and calling out for help in his bed. No staff members responded to the resident's room. At 8:45 a.m. Resident #42 was heard again from the hallway calling out for help. Resident #42 was heard crying in his room. No staff members responded to the resident's room. At 9:57 a.m. LPN #2 had yet to return to Resident #42's room and no other interventions had been provided to Resident #42 for management of his pain. D. Record review Resident #42's pain care plan, initiated 7/22/25 and revised 9/8/25, revealed Resident #42 had chronic pain related to quadriplegia, a left humerus fracture and decreased mobility. The goal for the care plan was for Resident #42 to not have an interruption to normal activities due to pain. Interventions included an implanted baclofen pump (pain pump), anticipating the need for pain relief and responding immediately to any complaint of pain, notifying the physician if interventions for pain were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain, administering pain medication as ordered and utilizing nonpharmacological interventions of repositioning, deep breathing, diversional activities and offering snacks or fluids. Review of Resident #42's September 2025 CPO revealed the following physician's orders: Gabapentin 300 milligram (mg) capsule. Take one tablet by mouth three times a day for pain related to quadriplegia, ordered 9/5/25. Ibuprofen 600 mg tablet. Take one tablet by mouth every six hours as needed for pain, ordered 8/8/25. Methocarbamol 500 mg tablet. Take one tablet by mouth every six hours as needed for muscle spasms related to muscle weakness, ordered 9/5/25. Review of Resident #42's September 2025 MAR (from 9/1/25 to 9/10/25) revealed that on 9/10/25, RN #2 documented Resident #42's scheduled dose of gabapentin was not administered because the resident was out of the building at an appointment. -However RN #2 did not offer Resident #42 his missed dose of scheduled gabapentin despite the resident reporting pain (see observations above). Further review of Resident #42's September 2025 MAR (from 9/1/25 to 9/10/25) revealed that on 9/11/25, Resident #42 did not receive PRN medication for pain until 10:41 a.m., over two hours after he originally requested pain medication (see observations above). E. Staff Interviews LPN #2 was interviewed on 9/11/25 at 10:03 a.m. LPN #2 said she still planned to administer Resident #42 his pain medication, but she had not been able to return to his room yet because she was working with other residents. LPN #2 said she had not heard him calling out or she would have responded to him. Regional director of clinical services #2 was interviewed on 9/11/25 at 1:42 p.m. Regional director of clinical services #2 said she was made aware of Resident #42's behaviors in the common area during the late afternoon on 9/10/25. She said she was not aware Resident #42 did not receive his scheduled gabapentin earlier in the day or that he was not offered one of his PRN medications for pain during a pain crisis. She said she was not sure if the missed interventions would have managed his pain or reduced his behaviors. She said they had given these medications to the resident before and Resident #42 continued to request opioid medication and continued to yell or threaten others. Regional director of clinical services #2 said due to his psychiatric diagnosis of narcissistic personality disorder, Resident #42 made multiple threats to the in-house physicians when he was told they wanted to taper him off of his opioid pain medication. She said because Resident #42 continued to make threats after the physician attempted to explain his reasoning on multiple occasions, the physician at the facility documented on 9/2/25 that he was signing off from managing any aspects of Resident #42's care or pain management. She said since then, the facility referred the resident to a pain management clinic.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards for two (#8 and #7) of two residents reviewed for dialysis out of 36 sample residents. Resident #8 was admitted on [DATE] for long-term care with diagnoses of end-stage renal disease, dependence on renal dialysis and type 2 diabetes mellitus.The 6/3/25 dialysis communication form (a form used for communication between the facility and the dialysis center) revealed the resident's central venous catheter (CVC) site (dialysis access site) was bloody and the resident pulled on the catheter line. The form documented that the dialysis center requested that the facility contact them. However, there was no documentation in Resident #8's electronic medical record (EMR) to indicate that the facility attempted to communicate with the dialysis center. Resident #8's weekly nursing skin assessment documentation did not identify the resident had skin impairments related to her CVC dialysis access site. The 6/3/25 weekly skin assessment failed to even identify that the resident had a CVC site in her chest.On 6/28/25, Resident #8 was sent to the hospital from the dialysis center due to blood all around the CVC site, there was swelling to the area and the resident complained of pain. The resident was hospitalized for five days for recurrent hemodialysis line infection, gram-positive cocci bacteremia (an infection in the bloodstream) and chest wall cellulitis (bacterial infection that affects the deeper layers of the skin). Furthermore, the facility failed to follow up in a timely manner related to the dialysis center's request (on 8/7/25) to schedule Resident #8 for the placement of an arteriovenous fistula (AVF - a surgical procedure that creates a connection between an artery and a vein to provide access for hemodialysis) due to the resident's recurrent CVC infections and start the resident on antibiotics in a timely manner, per the dialysis center's request on 9/9/25. Additionally, the dialysis communication forms for Resident #8 and Resident #7, who was also receiving hemodialysis treatment, were not completed consistently and thoroughly. Specifically, the facility failed to: -Consistently monitor and document the condition of Resident #8's dialysis access site in order to prevent an infection in her hemodialysis line, which resulted in a five day hospital stay for the resident;-Ensure recommendations and communication from the dialysis center were consistently addressed in a timely manner, specifically a recommendation for a fistula (a surgical connection between a vein and artery used for dialysis) placement and starting an antibiotic medication for Resident #8; -Consistently and thoroughly complete and maintain dialysis communication forms between the facility and the dialysis center for Resident #8 and Resident #7; and,-Ensure thorough documentation was completed consistently on Resident #8's medication administration records (MAR) for the resident's dialysis-related physician's orders.Findings include: I. Facility policy and procedure The Hemodialysis policy and procedure, revised 4/11/25, was provided by the regional vice president of operations on 9/8/25 at 4:34 p.m. It revealed in pertinent part, The facility will coordinate and collaborate with the dialysis facility to assure that there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications.The facility will ensure the physician's order for dialysis includes the type of access for dialysis, the dialysis schedule, the nephrologist, the dialysis facility name and phone number, transportation arrangements to and from the dialysis facility, any medication administration or withholding of specific medications prior to dialysis treatments, any fluid restriction if ordered by the physician.II. Resident #8A. Resident status Resident #8, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included vascular dementia, end-stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus and cellulitis of the chest wall. The 7/13/25 minimum data set (MDS) assessment revealed that the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required a wheelchair. She required set up assistance with eating and oral hygiene. She required substantial assistance with toileting and showering. She required moderate assistance with personal hygiene. The assessment indicated the resident received dialysis while at the facility. The assessment did not indicate that the resident had any skin issues. B. Resident interview Resident #8 was interviewed on 9/8/25 at 10:30 a.m. Resident #8 said the facility did not have her ready for dialysis frequently. She said the facility did not tell her what time she needed to be ready. She said she was supposed to have a fistula placed but her dialysis site was infected about a month ago. She said she scratched herself all over her body, including around her dialysis access site because her skin itched. During the interview, a whiteboard was observed in Resident #8's room. The whiteboard indicated that the resident needed to be in a button-up shirt and ready by 10:30 a.m. on Tuesdays, Thursdays and Saturdays.C. Record review 1. Failed to consistently monitor and document the condition of Resident #8's dialysis access site in order to prevent an infection of her hemodialysis line, which resulted in a five day hospital stay for the residentReview of Resident #8's dialysis care plan, initiated 6/20/25 and revised 9/8/25 (during the survey), revealed the resident was dependent on dialysis related to end-stage renal failure via a dialysis port. Interventions included checking and changing the dressing daily at the access site, not drawing blood or taking a blood pressure in the arm with the graft, monitoring intake and output, monitoring, documenting and reporting as needed new or worsening peripheral edema. -However, the resident had a central venous catheter (CVC) on her chest, not a graft (access site) on her arm that would affect taking a blood pressure. Review of Resident #8's skin integrity care plan, initiated on 6/20/25 and revised 8/8/25, revealed the resident was at risk for impaired skin integrity related to chronic kidney disease, a decline in mobility and the need for assistance with transfers. She had old and new scratch marks and rashes all over her body related to dry skin. Interventions included consulting a dietitian, ensuring the resident's nails were clipped, evaluating for bowel incontinence, evaluating for edema, evaluating for urinary incontinence, evaluating the resident's skin for areas of blanching or redness, evaluating for redness or excoriation, moisturizing skin as needed and monitoring for signs and symptoms of infection. -However, the care plan did not include personalized interventions to prevent the resident from scratching the affected areas of her skin, including around the dialysis access site in her chest. A review of Resident #8's weekly skin assessments from 6/3/25 through 6/24/25 revealed the following: The 6/3/25 weekly skin assessment did not reveal there was a dialysis access site on the resident's chest or dry, patchy skin anywhere on the resident's skin. The 6/10/25 weekly skin assessment revealed there was a dialysis access site on the resident's chest and dry patchy skin on the upper arms, back, sides and legs. The assessment said there was treatment in place for the dry patchy skin. The 6/17/25 weekly skin assessment revealed the resident's skin was intact and there were no skin impairments observed. The skin assessment did not identify that the resident had a dialysis access site on her chest.The 6/24/25 weekly skin assessment revealed there were scattered linear scabs all over the resident's body and she had dry skin. The assessment said there was a treatment in place for the skin concerns. The skin assessment did not identify that the resident had a dialysis access site on her chest.-However, the 6/24/25 did not identify where on the resident's body the scabs were located. Resident #8's 6/3/25 dialysis communication form (a form used to communicate between the facility and the dialysis center) was reviewed. The dialysis center section (the section the dialysis center completed to communicate to the facility) documented the dialysis access site dressing was bloody and the central venous catheter (CVC) site had bloody trauma to it. The dialysis center documented that Resident #8 appeared to have pulled on the catheter line. The dialysis center requested for the facility to please contact the clinic and the clinic phone number was provided on the form. -However, there was no documentation in the resident's EMR to indicate the facility addressed the dialysis center's request to contact them.The 6/5/25 physician's note revealed Resident #8 had pruritus (an uncomfortable sensation that triggers the urge to scratch the affected areas). The note revealed the resident had widespread skin excoriation from scratching. Lotions and hydrocortisone were ordered. The physician thought the excoriation was caused by the heat and wetness of the resident's skin. According to the note, the resident had globally significant excoriation of her bilateral lower extremities, arms and chest. The physician recommended that moisturizers be applied as able. The note documented the physician added Atarax (an oral medication used to treat skin reactions) and doxepin (an oral medication used to help treat pruritus) was started in October 2024. The note documented it was difficult to tell if any of the resident's skin excoriations were infected.-However, review of Resident #8's EMR, from 5/13/25 through 9/10/25, did not reveal that the resident had been administered Atarax or doxepin.Additionally, the resident's 6/3/25 and 6/17/25 weekly skin assessments failed to identify the resident's skin issues, despite the physician's note indicating the resident had globally significant excoriation on her bilateral lower extremities, arms and chest on 6/5/25 (see skin assessments above) The 6/17/25 physician note revealed Resident #8 had a painful rash that was resolved. The note documented that on 5/27/25, the resident had itching and scratching, causing bleeding and hydrocortisone cream was ordered. The physician recommended systemic treatment instead of applying hydrocortisone cream to her entire body.-However, there was no documentation that indicated the resident had been administered a systemic treatment for her recurring skin issues and, per the weekly skin assessments, the skin concern was again present on 6/24/25 (see skin assessments above).The 6/28/25 nurse note revealed Resident #8 was transferred to the hospital for evaluation, per the dialysis center during her dialysis treatment in the afternoon. The 6/28/25 dialysis center visit note revealed Resident #8 was brought to the dialysis chair and was noted to have blood on her shirt. The note indicated there was blood all around the CVC dialysis access site and the dressing was half on the access site. The dressing was removed and the access site was noted to have a significant swelling around the CVC with blood draining with movement of the resident. The resident complained of pain with touching. The physician was notified and Resident #8 was transferred to the hospital for further evaluation. The 7/3/25 hospital discharge summary note revealed Resident #8 was hospitalized for five days. The final diagnoses were recurrent hemodialysis line infection, gram-positive cocci bacteremia (an infection in the bloodstream) and chest wall cellulitis. 2. Failed to ensure recommendations and communication from the dialysis center were consistently addressed in a timely mannerResident #8's 6/3/25 dialysis communication form was reviewed. The dialysis center section documented the resident's dialysis access site dressing was bloody and the CVC site had bloody trauma to it. The dialysis center documented that Resident #8 appeared to have pulled on the catheter line. The dialysis center requested for the facility to please contact the clinic and the clinic phone number was provided on the form. -However, there was no documentation in the resident's EMR to indicate the facility addressed the dialysis center's request to contact them. The 8/7/25 dialysis center physician's order revealed the facility was to schedule an arteriovenous fistula (AVF) placement for Resident #8. There was handwriting on the form that said to please schedule as soon as possible (ASAP). -A review of Resident #8's September 2025 CPO revealed an appointment was scheduled for the AVF placement on 9/3/25 at 1:12 p.m., three weeks after the dialysis center requested the appointment. The 9/9/25 dialysis center physician's order revealed Resident #8 was to start on cephalexin (an antibiotic medication) 500 milligrams (mg), twice a day for five days due to the yellowish color of the resident's CVC site. Review of Resident #8's September 2025 MAR revealed the following physician's order: Cephalexin 500 mg. Take 500 mg by mouth two times a day for cellulitis around the dialysis catheter for five days, ordered 9/11/25 (during the survey and two days after the physician's order was given by the dialysis center). 3. Failed to consistently and thoroughly complete and maintain dialysis communication forms between the facility and the dialysis center Resident #8's dialysis communication forms were reviewed from 6/2/25 to 9/10/25. Each dialysis communication form had three sections on one and half pages of paper where pertinent dialysis related information was to be documented. The first section of the communication form was to be filled in by the facility before dialysis with the resident's name, date of birth , room number and their physician. On the left side of the first section was the dialysis date and time. The middle of the section included what medications were administered prior to dialysis, what meals and snacks were sent, the shunt or the catheter location and status, and any additional information. On the right side of the first section were vital signs, which included pain temperature, pulse, respirations, blood pressure and oxygen saturation levels. A facility nurse's signature was required on the bottom of the first section. -There was no section to include the resident's pre-dialysis weight. The second section of the communication form was to be filled out by the dialysis center staff. The documentation included the resident's weight pre- and post-dialysis, the time dialysis started and ended, fluids removed, meals and snack intake, the shunt or catheter location and status and any other concerns. There was a section for physician's orders and recommendations. A dialysis nurse signature was required. On the right side of the first section were vital signs, which included pain, temperature, pulse, respirations, blood pressure and oxygen saturation levels.The third section of the communication form was to be filled in by the facility after dialysis. The section included the post-dialysis date and time, the shut and catheter location and status, if the catheter dressing was intact, if there was bleeding, and the general condition of the resident. On the right side of the first section were vital signs, which included pain, temperature, pulse, respirations, blood pressure and oxygen saturation levels. A signature was not required. Review of Resident #8's dialysis communication forms, from 6/2/25 to 9/10/25, revealed the following: The 8/19/25, 8/26/25 and 8/28/25 pre-dialysis sections were left blank in their entirety. The 6/5/25 and 6/10/25 pre-dialysis sections did not have a dialysis time or a dialysis catheter status documented.The 6/7/25 pre-dialysis section left the medication administered prior to dialysis, meal and snack sent and additional information sections blank. The 6/12/25 pre-dialysis section left the dialysis time blank, the meals and snacks section blank and the catheter status blank. The 6/14/25 and 6/21/25 pre-dialysis sections had no documentation for the medications administered, dialysis catheter location and status and additional information. The 6/24/25 pre-dialysis section had no documentation for the resident's date of birth , the room number, the dialysis catheter status and the dialysis time. The 6/26/25 and 7/17/25 pre-dialysis sections had no documentation for the resident's date of birth , the room number, the medications administered, the meals and snacks sent and the dialysis catheter status The 7/5/25, 7/10/25 and 7/15/25 pre-dialysis sections had no documentation for the dialysis time, the medications administered, the meals and snacks sent and the dialysis catheter status.The post-dialysis section of Resident #8's dialysis communication form was left blank in its entirety on 6/12/25, 8/19/25, 8/26/25 and 8/28/25. The post-dialysis section dialysis shunt/catheter location/status was left blank on 6/3/25, 6/5/25, 6/10/25, 6/14/25 and 6/24/25. The post-dialysis section vital signs were left blank on 6/5/25.The post-dialysis section time was left blank on 6/5/25, 6/7/25, 6/10/25 and 7/8/25.The post-dialysis section nurse signature and time was left blank on 8/16/25.There was no post-dialysis section documented for 7/10/25. The section was missing or cut off. The facility was unable to provide dialysis communication form records for Resident #8 for September 2025. 4. Failed to ensure thorough documentation was completed consistently on MARs for dialysis related physician's orders Review of Resident #8's September 2025 CPO revealed the following physician's orders:Nepro (nutritional supplement for dialysis patients), in the morning, daily. Document milliliters (ml) consumed, ordered 6/2/25. Monitor the hemodialysis port site for signs and symptoms of infection, edema and bleeding upon return from dialysis. Notify the doctor if any signs were noted. If the site was bleeding, apply pressure for 15 minutes and notify the doctor if bleeding does not stop, ordered 7/4/25. Dialysis. -The above physician's order above did not reveal when the resident's dialysis was ordered or what days and time the resident went to dialysis. Hydrocortisone cream 2.5% (percent) cream. Apply to affected areas topically two times a day for atopic dermatitis, initially ordered 5/30/25.-The physician's order did not include a dose to direct the nursing staff on how much medication to apply to the resident or where to specifically apply it. Wound care: left chest dermatitis. Cleanse areas with wound cleanser and normal saline. Gently pat to dry. Apply triamcinolone cream (topical steroid cream) to affected areas. Leave open to air every shift and as needed. Report to the doctor if signs and symptoms of skin infection are noted. Every shift for dermatitis per wound care provider, ordered 8/25/25. Review of Resident #8's June 2025, July 2025, August 2025 and September 2025 MARs revealed the following: -There was no documentation to indicate dialysis treatment occurred on 7/1/25 through 9/10/25. -There was no documentation to indicate the Nepro supplement was administered on 6/29/25 through 9/10/25. -There was no documentation to indicate the amount consumed for the Nepro supplement on 6/2/25 through 6/10/25, 6/12/25 through 6/22/25, 6/24/25, 6/26/25, 6/28/25 and 6/29/25. -There was no documentation to indicate the hydrocortisone cream was administered on 8/4/25, 8/18/25, 8/29/25, 9/3/25 and 9/10/25. -There was no documentation to indicate monitoring of the resident's hemodialysis port site was observed on 8/1/25, 8/3/25, 8/4/25, 8/10/25, 8/14/25, 8/16/25, 8/18/25, 9/3/25, 9/5/25, 9/6/25 and 9/20/25. -There was no documentation to indicate wound care to the resident's left chest dermatitis was administered on 9/1/25, 9/3/25, 9/5/25, 9/6/25 and 9/10/25. III. Resident #7A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included end-stage renal disease, diabetes mellitus with diabetic chronic kidney disease, schizotypal disorder and dementia in other diseases. According to the 9/12/25 MDS assessment, the resident was cognitively intact with a BIMS score of 13 out of 15. He used a wheelchair. He required set up assistance with eating and oral hygiene. He was dependent on staff assistance with toileting and required supervision with personal hygiene. He required maximal assistance with showering. The 9/12/25 assessment indicated the resident received dialysis. B. Resident interview Resident #7 was interviewed on 9/8/25 at 2:12 p.m. in his room. Resident #7 said he went to dialysis on Tuesdays, Thursdays and Saturdays. He said he had to tell the nursing staff when to have him ready for dialysis. He said if he did not tell them, he would not be ready in time to go to dialysis. He said the facility gave him a protein bar as a snack when he went to dialysis but he said he did not like the protein bars they gave him. He said the facility knew he did not like the protein bars but they did not do anything about it. He said sometimes the dialysis center refused to give him dialysis because his Hoyer lift sling was not placed in the right position by the facility staff. He said it had happened three times. He said he had to wait in the lobby until the facility returned to pick him up. He said it had taken the dialysis center a long time to get a hold of someone at the facility to pick him up. He said he cried because he felt like he was going to die. He said he was a diabetic and his blood sugar was low. He said he ended up being okay. During the interview, there was a bag of Nugo protein bars observed on the resident's dresser underneath the window and one protein bar on the bedside table next to the resident's bed. There were eleven protein bars with flavors of peanut butter, orange and banana. There was no whiteboard to indicate when the resident needed to be ready for dialysis. C. Record review The dialysis care plan, initiated 6/18/25 and revised 9/8/25 (during the survey) revealed the resident had dialysis related to end stage renal failure. The care plan revealed the name of the dialysis center, dialysis appointments on Tuesday, Thursday and Saturday at 12:45 p.m. and dialysis right chest port. Interventions included checking, changing and documenting dressing daily at the dialysis access site, not drawing blood or taking blood pressure in the arm with the graft, monitoring labs and reporting to the doctor as needed, monitoring, documenting and reporting as needed for signs and symptoms of bleeding, bacteremia and septic shock (a life threatening condition when the body's immune system overreacts to an infection), monitoring, documenting and reporting as needed for new and worsening peripheral edema. Review of Resident #7's September 2025 CPO revealed the following physician's order:Dialysis appointment: Tuesday, Thursday, Saturday. Appointment time: 12:45 p.m. Please have a packet ready with a face sheet and medication list, ordered 8/28/25. Review of Resident #7's dialysis communication forms, from 6/2/25 to 9/10/25, revealed the following: The 6/3/25 pre-dialysis section had no documentation for the dialysis time. The 6/5/25 pre-dialysis section had no documentation for the meal and snack and there was no nurse's signature.The 6/7/25 and 6/28/25 pre-dialysis section had no documentation for the meal and snack.The 6/10/25, 6/12/25, 6/21/25, 7/1/25 and 7/12/25 pre-dialysis sections had no documentation for the time, the meal and snack, and the dialysis catheter location and status. The 6/14/25 pre-dialysis section had no documentation for the medications and the dialysis catheter location and status. The 6/24/25 pre-dialysis section had no documentation for the medications, the meal and snack, the dialysis catheter location and status, the additional information section and there was no nurse's signature.The 6/26/25 pre-dialysis section had no documentation for the date of birth , the room number, the meal and snack, the dialysis catheter and the additional information section.The 7/5/25 and 7/10/25 pre-dialysis sections had no documentation for the time, the medications, the meal and snack, the dialysis catheter status and the additional information section. The 7/8/25 pre-dialysis section had no documentation for the date and time and the meal and snack. The 7/17/25 pre-dialysis section had no documentation for the time, the dialysis catheter location and status and the additional information section.The 7/26/25, 7/31/25 and 8/5/25 pre-dialysis sections had no documentation for the meal and snack, the catheter location and status and the additional information section and there was no nurse's signature. The 9/2/25 and 9/4/25 pre-dialysis sections had no documentation for the time, the physician, the medications, the meal and snack, the dialysis catheter location and status and the additional information section.The 9/9/25 pre-dialysis section had no documentation for the time and the meal and snack. The post-dialysis section of Resident #7's dialysis communication form was left blank in its entirety on 6/5/25, 7/12/25, 7/17/25, 7/26/25, 7/31/25, 8/5/25, 8/19/25, 8/26/25 and 9/2/25. IV. Staff interviewsThe dialysis center's licensed clinical social worker was interviewed on 9/10/25 at 2:22 p.m. The licensed clinical social worker said Resident #8 had had a physician's order for a fistula placement for months. She said every time a fistula placement was scheduled, the resident's dialysis access site was infected and the appointment had to be cancelled. She said the last time the dialysis center requested for a fistula to be placed was at least six weeks ago (August 2025). She said they used the dialysis center's physician's orders and communication forms to communicate with the facility. She said it was important for the facility to schedule the fistula appointment as soon as possible for Resident #8 because the earliest the surgery center was available for an appointment was about one to two weeks out. She said after the fistula was placed, the dialysis center would have to wait for the site to heal before using it as the access point for the resident's dialysis. She said a fistula was important for two reasons. She said a fistula provided better dialysis access than a catheter access site and there was less chance of an infection occurring. The dialysis center's registered nurse (RN) was interviewed on 9/10/25 at 2:39 p.m. The dialysis center RN said residents who came from a facility should have a communication form completed by the facility when they arrived for dialysis treatment. She said the pre-dialysis section was important to be completed because the dialysis center addressed any concerns when the resident was at the dialysis center. She said if the dialysis center sent the resident back to the facility with a new physician's order for an antibiotic, the facility should call the dialysis center to review the order. She said the antibiotic should be started the same day it was ordered by the dialysis center or the following day. She said Resident #8 had had itching around her chest dialysis site for several months. She said Resident #8 did not leave the site alone and she said it was an infection waiting to happen. She said Resident #8 had dementia on and off and she thought Resident #8 did not like having something hanging from her chest and that was why she scratched around the site. The dialysis center RN said the resident's scratching caused her infection. She said the resident's June 2025 to July 2025 hospitalization was due to the cell wall infection at the resident's chest dialysis access site. She said the dialysis line infection had happened three to four times in the past several months.The registered dietitian (RD) was interviewed over the phone on 9/11/25 at 11:53 a.m. The RD said she had worked at the facility twice. She said it was standard practice to document that nutritional supplements were administered and how much was consumed. She said it was important because if the resident was not consuming the supplements, she wanted to know to if she should stop the order, see if the resident was losing weight and see why the resident was not consuming the supplements. She said a resident was on Nepro supplement because dialysis residents were at risk for not consuming enough calories and Nepro helped keep the resident's weight stable. The RD said she had reviewed Resident #8's EMR. She said the nursing staff was not documenting if the resident's Nepro was administered and how much was consumed by the resident. She said she had revised the Nepro order on 9/10/25, during the survey. Registered nurse (RN) #1 was interviewed on 9/11/25 at 2:26 p.m. RN #1 said she knew a resident had dialysis based on their treatment administration records (TAR). She said the TAR had the days and time the resident had dialysis. She said when a resident went to dialysis, they were sent with a folder that included a dialysis communication form. She said the dialysis communication form had three sections and she said she filled out the top section before the resident went to dialysis. She said she was responsible for obtaining the resident's pre-dialysis vital signs and making sure the resident's dialysis access site was intact. She said she documented the information on the dialysis communication form. RN #1 said the dialysis communication form went with the resident to dialysis. She said the dialysis center was responsible for completing the middle section of the communication form. RN #1 said when the resident returned from dialysis, she was responsible for obtaining the resident's vital signs and making sure the dialysis access site was intact. She said she documented the information on the third section (post-dialysis section) of the dialysis communication form. She said if the resident came back with new physician's orders or recommendations, she verified the orders with the dialysis center and the facility's physician and then entered the physician's orders into the resident's EMR. She said once the dialysis communication form was completed, the form was placed in a file at the nurses' station for the director of nursing (DON) to review. She said if the dialysis center ordered a fistula placement, the DON was responsible for coordinating the appointment with the surgical center. -The DON was unavailable for an interview during the survey. Regional director of clinical services #2 was interviewed on 9/11/25 at 3:22 p.m. Regional director of clinical services #2 said when a resident went to dialysis, they were sent with a folder that included a dialysis communication form. She said the dialysis communication form had three sections and she said the nursing staff filled out the top section before the resident went to dialysis. She said the nursing staff was responsible for obtaining the resident's pre-dialysis vital signs and making sure the resident's dialysis access site was intact. Regional director of clinical services #2 said the dialysis communication form went with the resident to dialysis. She said the dialysis center was responsible for completing the middle section of the communication form. Regional director of clinical services #2 said when the resident returned from dialysis, the nursing staff was responsible for obtaining the resident's vital signs and making sure the resident's dialysis access site was intact. She said nursing staff documented the information on the third section of the communication form. She said if the resident came back with new physician's orders or recommendations, the nurse verified the orders with the dialysis center and the facility's physician and then entered the physician's orders into the resident's EMR. She said once the dialysis communication form was completed, the form was placed in a file at the nurses' station for the DON to review. She said if the dialysis center ordered a fistula placement, the nurse was responsible for coordinating the appointment with the surgical center. She said if the nurse was unable to schedule the appointment, the unit manager or the DON would schedule the

Based on interviews, record review, and observations, the facility failed to provide two of five residents (#85 and #140) out of 24 sample residents, with the timely and necessary treatment and services to prevent and manage facility-acquired deep tissue pressure injuries (DTI) that resulted in the development of infection and sepsis, and required hospitalization . Cross-reference F880 (Infection Prevention and Control), F882 (Infection Preventionist) and F867 (Quality Assurance and Performance Improvement). RESIDENT #85 Resident #85, who had a diagnosis of diabetes, kidney disease, and generalized muscle weakness, was admitted to the facility on [DATE] for rehabilitation and strengthening. Resident #85 was assessed on admission with intact skin of the lower extremities, feet, and heels, and a stage 2 pressure injury to her coccyx/sacrum. She was evaluated at moderate risk of developing pressure injuries due to a history of previous pressure injury and stroke. On 11/16/23, nine days after admission, a weekly skin assessment documented bilateral heel discoloration. However, the resident's primary care physician (PCP) did not become aware of the resident's skin condition until 11/20/23. In a note that day, the PCP documented the resident had deep tissue injury (DTI) changes to both heels and right lower extremity cellulitis (skin infection), ascending on the right calf. The resident was sent to the hospital where she was diagnosed with cellulitis and sepsis from cellulitis, as well as a trauma injury to the right big toe, a stage 3 pressure injury on her coccyx/sacrum, and unstageable pressure injuries to her right and left heel. She was treated with intravenous (IV) antibiotics and spent a week in the hospital, including one day in the intensive care unit (ICU). Record review revealed the facility failed to provide the resident with timely and necessary services to prevent the development of the resident's heel wounds and to promote the healing of her coccyx/sacral wound. Specifically: -While an 11/16/23 assessment revealed discoloration to bilateral heels and a nursing note the same day documented the physician was notified of the resident's DTI injuries, a change of condition assessment was not completed, and a PCP note on 11/20/24, four days later, indicated the physician was unaware of the heel wounds, citing new wounds on feet have not been seen before. -While the resident's care plan for skin integrity was initiated on 11/7/23, and included interventions to assist the resident in turning and repositioning frequently and to off-load heels, there was insufficient evidence these interventions were implemented. Further, the discovery of bilateral heel discoloration on 11/16/23 did not trigger the facility to consider new interventions to prevent further skin breakdown despite being noted as a problem on the care plan. -While a review of the medication and treatment administration records (MAR and TAR) revealed orders for the resident's coccyx/sacral wound, there was no treatment order for the resident's heels in November 2023. RESIDENT #140 Resident # 140, who had a diagnosis of sacral fracture, peripheral vascular disease, and idiopathic neuropathies, was admitted to the facility on [DATE]. Resident #140 was admitted to the facility with intact skin on the lower extremities, feet, and heels. At the time of admission, he was assessed at mild risk for pressure injuries due to a history of skin tears, stroke, and left-sided weakness. On 8/12/24, two days after admission and during the wound care nurse (WCN) assessment, a blister to the right foot, DTI was noted. On 8/21/24, nine days later, the wound care physician assessed the resident and documented the resident had a large DTI on his right first toe and right heel. On 8/25/24, the daily skilled nurse's note read the resident's right foot had become edematous and painful to touch with bruising to the right fourth toe and new right foot swelling with edema and pain. On 8/27/24, Resident #140 developed altered mental status, fever, and chills and was sent to the hospital where he was diagnosed with cellulitis due to an infected right heel wound. He spent one night in the ICU and was administered IV antibiotics. Record review revealed the facility failed to provide the resident with timely and necessary services to prevent and manage the resident's pressure injuries. Specifically: -Record review revealed no evidence the resident's heels were off-loaded, even though heel off-loading was documented on his admission care plan. -Record review revealed the resident's daily skilled notes failed to accurately reflect the resident's skin condition. -Record review revealed staff failed to ensure the physician was timely notified of resident changes in condition. The facility's systemic failure to provide Resident #85 and Resident #140 with timely interventions and necessary treatment and services to prevent and manage pressure injuries created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy RESIDENT #85 The facility failed to prevent the development of pressure injuries for Resident #85. The resident was admitted to the facility on [DATE]. She was identified to be at moderate risk for pressure injuries due to her diagnosis of diabetes and kidney disease. Although she had a stage 2 coccyx/sacral wound, she did not have any injuries on her legs, feet, or heels. However, an 11/16/23 assessment revealed discoloration to bilateral heels, and on 11/20/23, a physician's note revealed the nurse asked the physician to see lesions on the resident's feet. The note read the resident had new deep tissue injury DTI) wounds to both heels and ascending cellulitis to the right calf. The physician wrote that the resident is a diabetic and was at risk for diabetic foot infection that could threaten life or limb. The resident was sent to the emergency room for further evaluation. While in the hospital, the resident was diagnosed with cellulitis and sepsis from cellulitis as well as a trauma injury to the right big toe, a stage 3 coccyx/sacral pressure injury, and unstageable pressure injuries on her right and left heel. The resident was hospitalized for a week but her wounds did not heal and she was admitted to hospice on 11/28/23. Record review revealed the facility failed to provide the resident with timely and necessary services to prevent the development of the resident's heel wounds and to promote the healing of her coccyx/sacral wound. Specifically: -While an 11/16/23 assessment revealed discoloration to bilateral heels and a nursing note the same day documented the physician was notified of the assessment, a change of condition assessment was not completed, and a physician note on 11/20/24, four days later, indicated the physician was unaware of the heel wounds, citing new wounds on feet have not been seen before. -While the resident's care plan for skin integrity was initiated on 11/7/23, and included interventions to assist the resident in turning and repositioning frequently and to off-load heels, there was insufficient evidence these interventions were implemented. Further, the discovery of bilateral heel discoloration on 11/16/23 did not trigger the facility to consider new interventions to prevent further skin breakdown despite being noted as a problem on the care plan. -While a review of the medication and treatment administration records (MAR and TAR) revealed orders for the resident's coccyx/sacral wound, there was no treatment order for the resident's heels in November 2023. RESIDENT #140 Resident #140 was admitted to the facility on [DATE]. He did not have any wounds on his legs and feet. On 8/12/24, the WCN completed a skin assessment and noted a blister to right foot, DTI. On 8/21/24 the wound care physician (WCP) documented the resident had an unstageable deep tissue injury (DTI) to the right first toe, and unstageable DTI to the right heel. Record review revealed the facility failed to provide the resident with timely and necessary services to prevent the development of the resident's pressure injuries. Specifically: -Record review revealed no evidence the resident's heels were off-leaded, even though heel off-loading was documented on his admission care plan. -Record review revealed the resident's daily skilled notes did not accurately reflect the condition of the resident's skin. -Record review revealed staff failed to ensure the physician was timely notified of resident changes in condition. The medical director (MD) was interviewed about Resident #85's and #140's DTIs that developed after admission. The MD said that all pressure-related injuries were avoidable if appropriate care had been provided. She said if residents developed pressure-related injuries it meant interventions for prevention were not followed. She further said, even though both residents had comorbidities, such as diabetes for Resident #85 and vascular disease for Resident #140, all developed pressure injuries were avoidable. The facility's systemic failure to provide Resident #85 and Resident #140 with timely interventions and necessary treatment and services to prevent and manage pressure injuries created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions. B. Notice of immediate jeopardy On 8/28/24 at 11:30 a.m., the nursing home administrator (NHA) was informed of the findings of immediate jeopardy under F686, Pressure Injuries. C. Facility plan to remove immediate jeopardy The facility submitted a plan to remove the immediate jeopardy on 8/28/24 at 6:17 p.m. The plan read: All residents in the facility identified as high risk for skin breakdown based on their risk assessment score started and completed 8/28/24. Identify responsible staff/what action taken: Resident #85 is no longer in (the facility) and will not be assessed. Risk assessment for Resident #140 was not assessed due to being admitted to the hospital on 8/27/24. The regional nurse consultant (RNC) immediately on 8/28/24 provided education to wound nurse on implementation of interventions based on risk scores. All nurses and certified nurse aid(e)s scheduled today will be educated on implementation of pressure injury prevention interventions and will be completed by the end of 8/28/24. A full facility skin sweep was conducted on 8/28/24 assessing current residents'skin conditions and will be documented as completed by 8/28/24. Pressure Ulcer Risk assessments will be completed on current residents to identify those at high risk for skin breakdown and interventions put in place by the end of 8/28/24. Interventions will be implemented on 8/28/24 to prevent the development of new wounds or deterioration of existing wounds. Interventions will be added to certified nurse aid(e)s Point of Care Device for documentation by the end of 8/28/24. Minimum Data Set nurse is auditing care plans for residents identified as high risk for appropriate interventions and will make changes as necessary by the end of 8/28/24. Staff that have not received the education will be provided with education on implementation of pressure injury prevention interventions prior to the start of their next shift, and followed up on by the administrator. Nurse will round on assigned residents twice per shift to verify interventions are being followed by staff and turn in the audit form to DON/designee at the end of their shift. All newly admitted patients receive a skin assessment and Risk assessment completed on admission. Necessary interventions are put in place at the time a need is identified. The admission will be reviewed in the next morning clinical meeting. Skin assessments are done weekly ongoing, and the risk assessment is completed weekly three times after admission then quarterly and with change of condition. D. Removal of immediate jeopardy The facility plan was accepted by the state survey agency on 8/28/24 at 6:17 p.m., based on the systemic changes outlined in the above plan to ensure pressure injuries would be immediately addressed through assessment, monitoring, and treatment. The immediate jeopardy situation was removed; however, the deficient practice remained at a G level, isolated, actual harm. II. Professional references A. Classification of pressure injuries According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 7/30/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 1214, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort, damage to superficial nerves and blood vessels, and contractures. III. Facility policy The Prevention of Pressure Injuries policy and procedure, revised July 2018, was received from the regional nurse consultant (RNC) on 8/27/24 at 12:27 p.m. It read in pertinent part: Any significant abnormal findings are reported to the resident physician and resident or responsible party. Abnormal findings are to be documented in the medical record. Actions taken to be documented in the medical record, along with a summary of all notified with their responses. Care plans will be updated on a routine basis and with significant changes in condition. IV. Resident #85 A. Resident status on admission Resident #85, age older than 65, was admitted to the facility on [DATE] from the hospital. According to the November 2023 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus and chronic kidney disease. The 11/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. She required substantial to maximal assistance from two staff members for transfers. The care plan for skin integrity was initiated on 11/7/23 with interventions to turn and reposition frequently, off-load heels, and position the resident properly. The medication administration (MAR) and treatment administration records (TAR) for November 2023 revealed there were no treatment orders for the resident's heels. A skin assessment completed on admission (11/7/23) revealed Resident #85 had a stage 2 coccyx/sacral wound; however, her skin was intact to her lower extremities, heels, and feet. A review of the daily skilled nurse's notes revealed no documentation of any changes in the resident's skin before 11/16/23 (see below). A review of daily skilled nurses notes for November 2023 mentioned that coccyx/sacral wound care was ordered; however, there was no mention of skin breakdown to the resident's heels from 11/8/23-11/11/23. There was no daily skilled note documented for 11/15/23. B. Resident status following admission - Skin changes identified on 11/16/23 - development of a pressure injury to the resident's right heel - facility failures 1. Skin changes identified on 11/16/23 An occupational therapy note, dated 11/16/23, nine days after admission, read in pertinent part, bleeding right heel during therapy session. A weekly skin assessment dated [DATE] documented discoloration to bilateral heels and a laceration to the right foot. A note by licensed practical nurse (LPN) #4 on 11/16/23 at 6:22 p.m. documented, Resident notified nurse of open skin area on right heel. Fluid filled blister broke, deep tissue injury (DTI) visible. Primary care physician (PCP) power of attorney (POA), wound nurse notified. 2. Facility failures The weekly skin assessment on 11/16/23 (see above) did not document the description and measurements of new skin wounds. (It also did not document how the resident obtained the laceration.) The care plan was revised on 11/16/23 with a mention of heel discoloration and skin tear. However, the care plan did not document the location (right or left heel) of the discoloration. Further, no additional interventions were added to the care plan to address the new pressure wound. Review of the resident's record from admission on 11/7/23 to 11/16/23 revealed no evidence that the care plan intervention for off-loading (see above) was followed. A review of the resident's record revealed that although the nurse's note documented the PCP was notified of the resident's right heel injury and skin tear on 11/16/23 (see above), there was no documentation of PCP follow-up or of additional attempts to notify the PCP of the resident's skin breakdown. C. Discovery on 11/20/23 - development of additional pressure injuries and cellulitis - facility failures 1. On 11/20/23 at 7:15 p.m., a physician progress note written by PCP #1 documented in part: [A]sked to see lesions on feet that may not wait for wound care. New wounds on feet have not been seen before. Resident #85 has DTI changes (approx 6 centimeters) to bilateral heels and lateral calcaneal (large bone at the end of the foot), ascending cellulitis on the right calf. Right calf is tender, mildly warm and red. At risk for diabetic infection that may threaten life or limb. Ascending erythema (redness of skin) is also a concern for cellulitis (skin infection). Resident #85 to be sent to the emergency room for evaluation to rule out osteomyelitis (inflammation of the bone due to infection). The admission hospital record, dated 11/21/23, revealed the resident was diagnosed with cellulitis and sepsis from cellulitis. Upon admission to the hospital, the following wounds were identified: trauma injury to the right big toe measured 2.0 by 2.0 by 0.1 cm, stage 3 pressure injury on coccyx/sacrum 3.0 by 3.0 by 0.2 cm, unstageable (pressure injury) on right heel measured 5.5 by 15.5 cm, and unstageable (pressure injury) on left heel measured 4.5 by 5.5 cm. The hospital record revealed the resident was administered intravenous (IV) antibiotics and spent a week in the hospital including one day in the intensive care unit (ICU). 2. Facility failures A review of the resident's progress notes, daily skilled nurses's notes, and skin assessments revealed there was no further documentation of discoloration to the resident's heels after 11/16/23 until the physician's note above on 11/20/23. A review of the resident's November MAR and TAR revealed no orders addressing the skin breakdown of the resident's heels identified on 11/16/23. The resident's record revealed daily skin assessments were not completed with accuracy to ensure Resident #85's pressure injuries were timely managed. Further, the facility failed to ensure timely notification to the PCP after the evidence of a DTI was identified on 11/16/23. D. Interviews 1. The facility's MD was interviewed on 8/28/2024 at 8:52 a.m. The MD said the pressure injuries Resident #85 developed had been facility-acquired and were preventable. She said pressure injury wounds developed when protocol and care plans were not being followed by staff. The MD further said the expectation was that any change of condition (in the resident's skin) would have been documented and reported the same day to either an on-site physician or the on-call team. 2. The wound care physician (WCP) was interviewed on 8/28/24 at 4:13 p.m. The WCP said she had initially observed Resident #85 on 11/8/23 to have only a stage 2 coccyx/sacral wound. She said she was unaware the resident had been hospitalized on [DATE] due to a wound infection. The WCP said she had no reason to believe Resident #85 was at risk of developing heel wounds as she was not bed-bound. She concluded that the resident's heel wounds were unavoidable because the resident had a diagnosis of diabetes. -However, see above. The resident entered the facility without any pressure injuries to her heels, review of the resident's record revealed daily skin assessments were not completed with accuracy, there was no evidence the resident was turned and repositioned as care planned, and new interventions were not considered when the resident's bilateral heel discoloration,/DTI was identified. 3. Physician assistant (PA) #1 was interviewed on 8/29/24 at 9:40 a.m. PA #1 said that the pressure injuries Resident #85 developed were facility-acquired and had proper interventions been completed the injuries should not have developed. V. Resident #140 A. Resident record review, observations, and interview Resident #140, age older than 65, was admitted to the facility from the hospital on 8/10/24. According to the August 2024 CPO, his diagnoses included sacral fracture, peripheral vascular disease, and idiopathic neuropathies. According to the 8/16/24 MDS assessment, the resident was alert and oriented with a BIMS score of 15 out of 15. Resident #140 was interviewed on 8/27/24 at 9:20 a.m. Resident #140 said he developed multiple wounds on his right foot after he was admitted to the facility. Resident #140 said he had not had anything wrong with his foot before being admitted . Resident #140 said he developed a wound on his right heel from his feet being pushed against the footboard of the bed. (Per the MDS assessment, the resident's height was 6 feet 4 inches.) The resident said he also developed sores on his toes because the staff did not help him move. Resident #140 said the staff was not consistent with dressing changes. He said staff routinely told him that he would see a WCN or physician, but he had not seen either the wound nurse or the physician when he asked to see them to answer his questions. Observations revealed Resident #140 lying in the bed with his feet touching the footboard. His right heel was covered with a blue foam boot. There was a purple discoloration on the tip of his right first toe and a white piece of tape on his right second toe labeled with a nurse's initials, dated 8/25. B. Resident status on admission A skin assessment completed on admission on 8/10/24 revealed Resident #140's skin was intact, except for a skin tear and hematoma to his left elbow. A care plan for physical mobility, initiated on 8/10/24, revealed the resident had impaired mobility due to a history of stroke and history of cardiovascular disease. Interventions included to provide an appropriate level of assistance. The 8/16/24 MDS assessment revealed the resident's level of assistance was substantial to maximal assistance and two staff assistance for transfers. A care plan for skin breakdown was initiated on 8/10/24, revealing that the resident was at risk for actual skin breakdown due to a history of stroke and cardiovascular disease and a history of bruising and skin tears. -Although the care plan noted the resident was confined to a chair most of the time, required extensive assistance with bed mobility and transfers, and had left-sided weakness, he was assessed at mild risk for skin breakdown. -Interventions initiated on admission 8/10/24 included off-loading heels, positioning the resident properly, inspecting skin and completing a head-to-toe assessment every week and documenting results, as well as inspecting skin daily with care and bathing, and reporting any changes to the nurse. C. Resident status after admission - development of pressure injury on the resident's right heel, right first toe - facility failures 1. Skin breakdown 8/12/24 On 8/12/24, two days after admission, a WCN assessment read in part, blister to right foot, DTI. On 8/12/24, the care plan was updated to add a new blister. -However, the location and the cause were not documented and the update did not reference DTI. Further, no new interventions were added to the care plan, and the resident's orders were not updated with any new treatments until 8/14/24 when the wound care physician (WCP) assessed the resident (see below). On 8/14/24, the WCP documented an unstageable DTI to the right great toe, measuring 1.0 by 0.5 centimeters (cm), and trauma injury to the right second toe. The WCP recommended to cleanse the wound daily, apply skin prep, off-load, and avoid constrictive footwear, and the orders for daily wound care were entered on the MAR. Notwithstanding the above documentation by nursing and the WCP of skin breakdown, the August 2024 daily skilled nurse's notes section revealed no documented skin concerns from 8/12/24 to 8/16/24. Further, there were no documented daily skilled nurse's notes on 8/15/24 and 8/17/24. On 8/15/24, the resident was ordered to receive sugar-free liquid protein (Prostat) 30 milliliters (ml) by mouth two times a day for wound healing (unstageable DTI). -Although a review of the resident's MAR for August 2024 revealed the Prostat was documented as routinely given, an interview with LPN #1 on 8/27/24 at 8:48 a.m. revealed the resident frequently refused the liquid protein, preferring a protein shake provided by his family. (A refusal was observed on 8/27/24 at 8:48 a.m.) -However, the resident's record revealed no evidence that the resident's refusals and preference for another protein supplement were communicated to the PCP. On 8/17/24, the resident's care plan was updated again to turn and reposition the resident frequently. -However, despite the resident's mobility limitations, there was no evidence that repositioning was offered to the resident, and staff interviews (see below) indicated it was unclear how frequently it was to be done. See also the resident interview above; Resident #140 said that the staff did not help him move. 2. Skin breakdown 8/21/24 On 8/21/24, the WCP documented Resident #140 still had an unstageable DTI to the right great toe that measured at 0.9 by 1.0 dcm, trauma injury to the right second toe, but also a new pressure wound unstageable DTI on the right heel that measured 3.0 x 6.0 cm. Orders were entered for right heel wound care every three days, cleanse with wound cleanser, and pat dry. Apply foam dressing and off-load while in bed. On 8/22/24, the care plan was updated with interventions to off-load heels as allowed and apply boot to the right foot when out of bed. -However, none of the care plan updates after admission indicated staff had considered the resident's height and the footboard on his bed. See resident interview and observation above. On 8/25/24, the daily skilled nurses note documented concerns for a right heel wound, right second toe wound, and bruising to the right fourth toe with new right foot swelling (edematous +3 and painful to touch). 3. Change of condition 8/27/24 On 8/27/24 (during the survey), the care plan was updated with an intervention to document weekly treatments and to include measurements for every wound. However, on this date, the resident experienced a change in condition and was transferred to the hospital. Specifically: On 8/27/24 at 3:19 p.m., LPN #1 documented that during therapy it was observed that Resident #140 was altered from baseline and unable to complete tasks normally. Vital signs were taken and revealed that Resident #140 had a fever (100.7 F) and hypotension (a low blood pressure of 97/65). The physician was notified of Resident #140's status and the resident was sent to the emergency department via ambulance. The hospital emergency room records dated 8/27/24 at 8:24 p.m. read in pertinent part, cellulitis of right lower limb, severe sepsis without septic shock, purulent (pus-like drainage which is a sign of infection) drainage along heel with streaking erythema superiorly. Resident #140 was admitted to the ICU and treated with antibiotics. D. Interviews 1. The WCN was interviewed on 8/27/24 at 2:29 p.m. The WCN said she conducted a skin assessment on newly admitted residents but was not aware of a timeframe for her assessment to occur. She said Resident #140's heel tissue had been closed during the first skin assessment she conducted on 8/12/24. Therefore, the resident's heel wound would be considered facility-acquired. The WCN said the WCP mentioned the toe wounds may have bee[TRUNCATED]

Based on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for three (#3, #5 and #6) of four residents reviewed out of 11 sample residents. Resident #3 was a known fall risk and the facility failed to consistently implement interventions to prevent her falls. After the resident had a fall on 11/12/23 in the morning, the facility implemented gripper socks/shoes. Subsequently, the resident had another fall on 11/12/23 due to her slipping on the floor and did not have appropriate footwear. The facility failed to initiate and complete neurological assessments, STAT (urgent, rush) x-rays ordered timely to the service provider, communicate to nursing staff/providers the resident had significant pain levels with movement and investigate the root cause. The resident was sent to a hospital for treatment and had pelvic and sacral bone fractures. Resident #5 was a known fall risk and the facility failed to implement effective interventions to prevent her falls. The resident fell on [DATE] when she tried to use a mobile book cart to ambulate to the bathroom. The resident sustained a hip fracture. She fell again on 7/23/23 in a similar manner when she tried to use the bedside table to ambulate. The facility failed to ensure neurological assessments were performed after the resident returned from the hospital for both falls. In addition, the facility failed to ensure Resident #6 was transferred appropriately using a gait belt that caused a fall and neurological assessments were consistently done after she hit her head during the fall. Findings include: I. Facility policy/procedures and facility form The Fall Management policy, reviewed 1/12/2020, was provided by the nursing home administrator on 12/26/23 at 10:17 a.m. The policy revealed the facility would identify each resident who was at risk for falls, would plan care and implement interventions to manage falls. The facility would manage falls by providing an environment that was free from potential hazards. A resident fall management program would be implemented that educated staff in creative, functional strategies while recognizing resident's rights and their need to maintain the highest practical level of function. A fall could be defined as, when a resident was found on the floor, a resident slid to the floor unassisted, a resident rolled off the bed or chair onto the floor, a resident fell off or out of equipment/apparatus used for therapy or a transfer. A fall also included when a resident tripped or slipped and complained of or sustained bodily injury or an episode where a resident lost his or her balance and would have fallen, were it not for staff intervention (intercepted fall). A fall might also be reported by a resident, visitor, or family member. The procedures included that: qualified staff assessed all residents for fall risk through the Admission Nursing Assessment form upon admission, quarterly, and with a significant change; upon determination that the resident was at risk, the qualified staff created an individualized plan of care that included the appropriate preventative interventions to reduce the potential for a fall; part of the management program was the implementation of visual identifiers for those residents at risk; if a fall occurred, the qualified staff assessed for injury from the fall, immediately investigated the reason and determined the intervention to prevent future falls, complete the Incident/Accident Report; the resident's physician and family were notified; all reports of resident falls within the facility were monitored through the quality assurance and performance improvement (QAPI) process within the community at the Standards of Care Meeting; and data was also reported in the community's monthly QAPI Meeting. This policy did not include any information to implement and complete neurological assessments in a timely manner. The Neurological Record Time Tracker form, not dated, was provided by the director of nursing (DON) on 12/27/23 at 4:01 p.m. The purpose of this form was to only help each shift keep track when neurological assessments were due. All neurological assessments and vital signs were to be documented in the facility's computer system and not on paper. Nursing staff were to write on this document, when the neurological assessments were due and to check them off when they were completed. The neurological assessment frequency was every 15 minutes' times 4, every 30 minutes' times 4, every 1 hour times 4, every 4 hours' times 4 and every 8 hours' times 4. II. Resident #3 A. Resident status Resident #3, age over 65, was admitted on [DATE] and discharged on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included a non-displaced fracture of the seventh cervical vertebra with routine healing, dementia, altered mental status, lack of coordination, muscle weakness, cognitive communication deficit, abnormalities of gait/mobility, pain and age related osteoporosis with current pathological fracture with routine healing. The 11/15/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15 with no behaviors. The resident's admission functional abilities/goals for mobility revealed the resident required partial to moderate staff assistance for sit to stand transfers, chair to bed or bed to chair transfers and toileting transfers. B. Record review Care plan for fall risk was initiated on 11/20/23 related to a fall on 11/12/23, history of hypertension and a high fall risk score on 11/11/23. This was evidenced by generalized weakness, mildly/moderate impaired cognitive status and limited need for transfer assistance. Some of the interventions included, for the resident to wear appropriate footwear when out of her room, administer first aid as needed, anticipate the resident's needs, check the resident frequently, assess the contributing factors related to a fall history, keep the call light and most frequently used personal items within reach, remind the resident to call when needing assistance, splint/brace to be used to stabilize extremity, assess medications for contributing factors, assist the resident with toileting as needed, assess for potential fall-related injury prevention (circumstances, location, medication, new or worsening medical problems), assess/monitor vital signs, include orthostatic blood pressure readings, neurological assessment, evaluate for head, neck, spine, and/or extremity injuries, monitor the use of anticoagulants which create a significant risk for serious injury, complete a physical exam for potential injuries, ensure the resident's clothing did not cause tripping, ensure rubber-soled, heeled shoes or non skid slippers were worn (11/13/23) and resident's family did not want resident to wear gripper socks (11/13/23). Fall risk assessment dated [DATE] at 4:47 a.m. revealed a score of nine or high risk. 1. Fall one Nurse note dated 11/12/23 at 4:43 a.m. by a licensed practical nurse (LPN) #1 revealed this nurse was notified by a certified nurse aide (CNA) the resident was sitting on the floor. This nurse observed the resident sitting up on her bottom next to the right side of her bed. The resident was barefoot in the dark room. The resident said she was trying to get up to adjust her legs and slid out of the bed. A registered nurse (RN) was notified and the assessment was completed. There was no sign of injury at this time. The resident's neurological assessments, vital signs and ranges of motion were within normal limits. The resident was transferred back into bed by this nurse and a CNA. The resident's call light was within reach. Incident/accident report dated 11/12/23 at 4:43 a.m. revealed the resident had an unwitnessed fall in her room at 3:45 a.m. This nurse was notified by a CNA that the resident was sitting on the floor. LPN #1 observed the resident sitting up on the floor, on her bottom next to the right side of the bed. The resident was barefoot in her dark room. The resident said she was trying to adjust her legs and slid out of bed. The resident was self-transferring from her bed and did not have on non-skid socks (inappropriate footwear). A RN was notified and the assessment was completed. There were no apparent injuries and the resident had a pain level of zero. Neurological assessments were implemented. The resident was transferred back into bed by this nurse and a CNA. The resident was currently in bed with a call light within reach. The interdisciplinary management team (IDT) section revealed this was a newly admitted resident with significant cognitive deficit and poor safety awareness. The resident was barefoot and attempted to transfer from her bed independently. The new intervention would be to have the resident wear gripper socks, when she was not wearing shoes. Neurological assessments were started on 11/12/23 at 3:45 a.m. and concluded on 11/12/23 at 2:30 p.m. Each of the 13 neurological assessments for fall one were completed according to the facility's electronic neurological assessment program. Fall risk assessment dated [DATE] at 6:44 p.m. revealed a score of seven or high risk. 2. Fall two Nurse note dated 11/12/23 at 6:57 p.m. by LPN #1 revealed this nurse was notified by a resident's family member that a resident had fallen in the dining room. This nurse observed the resident lying on her right side in the dining room. The resident said she got up because she wanted to get out of the chair and slipped due to a slick floor. The resident said she did hit her head at the time of the fall. A RN was notified. The resident's ranges of motion (ROM) and neurological assessments were within normal limits. The resident was hypertensive at the time of the fall and her oxygen saturations were observed to be low. The resident was transferred back into her wheelchair by staff. Oxygen was started to increase saturation levels. Pain assessment dated [DATE] at 6:49 p.m. revealed a score of zero. The assessment did reveal the resident had a headache at this time that was described as achy. Incident/accident report dated 11/12/23 at 6:57 p.m. revealed the resident had an unwitnessed fall in the dining room at approximately 6:08 p.m. LPN #1 was notified by a resident's family member that a resident had fallen in the dining room. This nurse observed the resident lying on her right side in the dining room. The resident said she got up because she wanted to get out of the chair and slipped due to a slick floor. The resident also states she did hit her head at time of fall. A RN was notified. The resident's ranges of motion and neurological assessments were within normal limits. The resident was hypertensive at the time of the fall and her oxygen saturations were observed to be low. The resident was transferred back into her wheelchair by staff. Oxygen was started to increase saturation levels. The IDT's section revealed this resident was nearly admitted and was impulsive at times. The resident attempted to get out of her chair and ambulate without assistance. The new intervention was for the resident to have appropriate footwear on when she was out of her room to ensure resident safety. -However, the intervention for the fall that morning was for the resident to have gripper socks and/or shoes. Neurological assessments for fall two started on 11/12/23 at 6:08 p.m. and concluded on 11/15/23 on the night shift. There were a total of 21 neurological assessments to be completed by the nursing staff for the second fall. Eleven neurological assessments were completed according to the facility's electronic neurological assessment program. -Ten neurological assessments were not completed according to the computer generated neurological assessment program for a specific date and time. The nursing staff documented the resident was not available on 11/12/23 at 9:53 p.m., 10:53 p.m., 11:53 p.m., and also on 11/15/23 during the night shift (four of the missing eleven times). The resident was in the facility during those specific dates and times. Nurse note dated 11/13/23 at 6:42 a.m. revealed this nurse called a named service contractor to request a STAT (immediate, quick) x-ray to the resident's right hip/femur/pelvis due to pain post fall. This pain was consistent throughout the night and during transfers. A physician's assistant (PA) approved the request for the STAT x-ray. The resident was currently in a wheelchair at the nurse's station. PA progress note dated 11/14/23 at 11:32 a.m. revealed the resident had a choking episode at the time she arrived at the facility. The resident was unable to speak and unable to get a good cough. This episode slowly improved and her airway was cleared prior to emergency services arriving at the facility. There was no need to do the Heimlich maneuver. By the time the emergency services arrived at the facility, she had cleared the blockage and was breathing better. The resident declined transport to the hospital because she had cleared her blocked airway before they had arrived. -The note did not mention the resident's two falls on 11/12/23. Physician's history and physical note dated 11/15/23 at 1:30 p.m. revealed the resident was admitted to the facility for convalescence and rehabilitation. The resident had upper thoracic spine pain and on work-up was found to have a seventh thoracic (T7) compression fracture with approximately 60% height loss. The resident had terrible osteoporosis throughout the cervical thoracic and lumbar spine. -The note did not reveal any information on the resident's two falls or the choking incident. The radiographic service provider completed the x-ray on 11/14/23 at 2:01 p.m. related to pain in the right hip and leg. The x-rays were reviewed by a physician on 11/14/23 at 3:34 p.m. The pelvic x-ray impression did not reveal any fractures or dislocations of the pubic rami (pelvic) or the bilateral hip joints. The right hip x-ray impression did not reveal any fractures or dislocations and the pubic rami were intact. The right femur x-ray impressions did not reveal any fractures or dislocations and the hip joint was grossly intact. A nursing note dated 11/15/23 at 7:37 a.m. (late entry for 11/14/23) revealed the DON noticed the order for a STAT x-ray and called to the mobile radiology provider to verify that the order had been placed. The order had not been placed as of this time and the DON placed the STAT order and notified the resident's provider. PA progress note dated 11/15/23 at 12:38 p.m. revealed this was a follow up visit for a chest x-ray after the choking episode and leg pain after a fall. The staff feel the resident would benefit from a scheduled muscle relaxer. The resident had a diagnosis of a compression fracture (T7-T8) and was having back pain. The resident was now better from her previous choking episode. The resident's diagnosis of pain was reported as stable. -This note did not mention the resident's x-rays impressions on 11/14/23. Nurse note dated 11/15/23 at 3:30 p.m. revealed the as needed follow up for an oxycodone 5 milligrams tablet, administer orally every four hours, as needed, for moderate pain (4-6) administered at 1:29 p.m., was ineffective for the resident's pain of 8 out of 10 on the pain scale. Physician's order dated 11/15/23 at 4:04 p.m. revealed to transfer the resident to the hospital related to pain. A nursing note dated 11/15/23 at 4:19 p.m., by the DON, revealed the resident had increased anxiety and panic related to severe pain that increased with the fall on 11/12/23. The resident also had a choking episode this morning and was now requiring oxygen to keep saturations above 90%. The resident's provider was notified of the resident's increased pain and oxygen needs. An order was received to send the resident to the hospital emergency room for evaluation and treatment. The resident's family was at bedside and in agreement. Nurse note dated 11/15/23 (note timed) by a LPN revealed the PA was notified and ordered the resident be transported to a named hospital emergency department due to severe pain in the right hip and leg. At 3:30 p.m., the resident was transported by emergency medical technicians (EMTs) using a stretcher. The resident's power of attorney (POA) was present. This note was electronically signed on 11/20/23 at 11:19 a.m., by the DON. The hospital's admission documentation dated 11/15/23 at approximately 4:30 p.m. revealed the resident fell two days ago and had negative outpatient x-rays. The resident had worsening pain and difficulty weight bearing. The PA at the facility was consulted and admission for pain management was arranged. The resident was admitted to the emergency department (ED) after a mechanical fall. The resident's most recent fall was on 11/12/23 and was seen in urgent care and had a negative x-ray report. The resident was admitted to medicine service for pain management. Computer tomography (CT) and x-rays were obtained. Hospital orthopedics were consulted for evaluation and treatment of sacral bone fracture and an inferior pubic rami fracture (pelvis). This was the initial encounter for the closed non-displaced fracture of the sacrum and an initial encounter for the closed fracture of the ramus of the right pubis. The patient was seen in consultation by orthopedic surgery and the fractures were deemed to be non-operative. Nurse note dated 11/20/23 at 12:25 p.m. (late entry for 11/13/23) by the DON revealed she was the nurse manager on call and received a call from LPN #1 regarding the resident's fall in the dining room. The resident did not complain of any pain. LPN #1 and the DON performed the assessment of the resident. The resident had baseline ranges of motion in the lower extremities and her back brace was in place. The resident had no identified shortening of either lower extremity and no internal or external rotation of either extremity. The DON requested LPN #1 to start neurological assessments according to facility protocol. C. Staff interviews LPN #1 was interviewed on 12/26/23 at 8:26 p.m. She said the resident was a high fall risk. She said the resident had an unwitnessed fall on 11/12/23 at 4:43 a.m. The resident fell in her room and did not have any injuries. She said the resident stood up and slipped on a dry floor. The resident did not have any socks on her feet at this time. LPN #1 said she did an assessment of the resident, called the DON over the phone and gave her a report. The DON gave permission to move the resident from the floor to her bed. She said it took herself and two CNAs to move the resident with the use of a gait belt. She said neurological assessments were started. LPN #1 said the resident had a second fall in the dining room on 11/12/23 at 6:57 p.m. with no injuries. The LPN did the physical assessment, called the DON and gave a report over the phone. The DON said it was okay to move the resident from the floor to a wheelchair. She said it took herself and two CNAs to move the resident with the use of a gait belt. She said neurological assessments were started. LPN #1 said on several neurological assessments for the resident's second fall, she documented the resident was unavailable; when the resident was asleep. She said there was absence of computerized neurological assessments at the specified dates/times for the resident's fall in the dining room. She said for unwitnessed falls with head injuries, neurological assessments were conducted to look for widening pulse pressure, differences in pupils of the eyes, alertness and if the resident became sleepy. She said if neurological assessments were not completed, the resident might experience unnoticed hemorrhages, fractures, brain bleeds, body bleeds, abnormal ranges of motion and they might die. LPN #1 said on 11/13/23 at 6:42 a.m. she called the resident's provider and requested a STAT x-ray of the resident's right hip/femur/pelvis due to pain after a fall. The resident had consistent pain throughout the night and during transfers. The resident's PA approved the request for the STAT x-ray. She said she did not call the x-ray services. She said she passed the x-ray order to the oncoming nurse for the next shift. She said the x-rays taken on 11/14/23 were negative for fractures. She said she did not call the resident's family regarding the x-ray findings. She said she did, however, call the resident's family for the fall in the resident's room and for the fall in the dining room. She said she was not aware of the hospital findings of fractures. She said the nurse note dated 11/15/23 by the DON as a late entry for 11/14/23 at 7:37 a.m. related to a STAT x-ray order verification; the order had not been placed. The STAT x-ray order was placed at this time and the provider was notified of the delay. The medical director (MD) was interviewed on 12/27/23 at 8:00 a.m. She said she observed the resident one time. She said portable x-rays were typically of bad quality and they only get one view. She said portable x-rays at times did not demonstrate fractures. She said hospital x-rays and CT scans would demonstrate the actual problems. She said STAT x-ray services should occur in less than four hours. The DON was interviewed on 12/27/23 at 9:43 a.m. She said the resident had poor cognition and safety awareness. She said the resident was a high fall risk. She said both falls were on 11/12/23. She said the resident was not immediately sent to the hospital emergency room because there were no noted injuries and/or pain at the time of the falls. The DON said the resident's first unwitnessed fall was on 11/12/23 at 3:45 a.m. in the resident's bedroom. The resident was ambulating to the bathroom by herself. She said the resident did not receive any injuries from this fall. She said LPN #1 did the resident's assessment, called the DON and they assessed the resident together. She said the resident had a second unwitnessed fall on 11/12/23 at 6:08 p.m. in the dining room. The resident pushed her wheelchair back, stood up and fell . She said LPN #1 assessed the resident after the fall and called the DON. There were no observed injuries from this fall. The DON said the resident did complain of pain on 11/13/23 to her provider. The DON said a LPN received an order for a STAT x-ray on 11/13/23 at 6:42 a.m. The LPN did not call the x-ray service provider. The DON said she saw the x-ray order lying on the desk at the nurse's station. She said she called the x-ray service company and was notified the x-ray order had not been received. She said she ordered the x-ray on 11/14/23 at approximately 9:00 a.m. and the x-ray services were completed at 2:01 p.m. The x-rays were read by a physician at 3:34 p.m. She said the x-rays demonstrated the resident did not have any fractures. She said a STAT x-ray should be taken in four hours or less. The DON said when a nurse checked a box in the computer that neurological assessments should be started, the computer would automatically auto-populate (generate) the sequences of dates/times the neurological assessments should be conducted. She said there were missing neurological assessments for the second fall on 11/12/23 at 6:08 p.m. She said the staff documented the resident was not available, when the resident was in the facility. She said a resident should be awakened, if they were sleeping, to complete the neurological assessments. The nursing staff should not document the resident was not available, when they were sleeping. She said the resident had the right to refuse and the documentation should show a refusal. The DON said all of the neurological assessments should have been completed according to the computerized sequence. She said neurological assessments were conducted to observe for alteration in the resident's mentation, pupil reactivity, bleeding, muscle strength, pain, ranges of motion and for stable vital signs. She said if the assessments were not completed the nursing staff might not recognize a brain bleed, swelling of the brain, limitation in ranges of motion, increased pain and the potential for death. The DON said on 11/14/23 at 11:32 a.m. emergency medical services (EMS) arrived at the facility related to a choking episode the resident had in the dining room. The resident was not taken to the ER at this time. She said by the time the ambulance got here, the resident had cleared the obstruction and was breathing better. She said on 11/15/23 at 4:19 p.m. she wrote a progress note that revealed the resident had increased anxiety and panic related to severe pain that increased with the fall on 11/12/23. The resident had a choking episode this morning and was now requiring oxygen to keep saturations above 90%. The resident's provider was notified of the resident's increased pain and oxygen needs. An order was received to send the resident to the ER for evaluation and treatment. The resident's family was at bedside and in agreement. Nursing staff notified the PA, who ordered the resident be transported to the ER. The resident was transported due to severe right hip/leg pain at 3:50 p.m. utilizing a stretcher and emergency medical technicians (EMTs). The DON said she talked with the resident's son on 11/15/23 about his concern regarding her anxiety. She said she also talked with the resident's provider, who had observed the resident on this date. She said in the afternoon, a CNA was taking the resident's vital signs and observed low oxygen saturation levels. The CNA wanted an assessment from an agency nurse but did not feel the nurse was taking her seriously. The DON went and assessed the resident. The DON said the resident was crying, anxious, pointed to her lower back bottom area and said she was in pain. The pain was worse during transfers and better with not moving. The resident's son was present and the DON talked with both of them. The DON felt that the resident should go to the ER, even though the previous x-rays were negative. She said the resident at first did not want to go; however, the resident and the son eventually agreed to have the resident sent to the ER. The DON said there had been times that portable x-rays did not demonstrate anything and hospital diagnostics did demonstrate issues. The DON said the fall interventions in place, were to ensure the resident's bed was in the lowest position, frequent checks, encourage the resident to wear shoes and the use of non-skid socks. The resident's son did not want her to wear non-skid socks because she was from Hawaii and he felt that it would be safer for her to go barefooted. -However, this was added to the care plan on 11/13/23 after the resident had fallen twice and there was no education on the risks associated with the resident continuing to go barefoot and fall risk. The DON said on 11/16/23 during a quality assurance performance improvement (QAPI) falls meeting, the resident's incident reports were reviewed and discussed. The PA was interviewed on 12/27/23 at 11:34 a.m. He said the resident fell on Sunday (11/12/23). He said he was called on 11/13/23 at 6:42 a.m. to approve a request for STAT x-rays, which he did. He said the physician notes dated 11/13/23 at 1:30 p.m. did not mention the falls on 11/12/23. He said on 11/14/23 at 8:00 a.m. the resident was choking in the dining room, was able to clear the food and emergency medical services were called. He said the Heimlich maneuver was not performed. He said EMS arrived, the family member was in the dining room and told him that a mobile x-ray service was already coming to take x-rays. Since an x-ray service was to be completed today, the family member agreed to also have a chest x-ray taken at the same time in the facility. The PA offered the resident and the family member to have the resident sent to the hospital emergency room for the x-rays and they declined. He said he did an assessment of the resident and she did not have any pain on palpation of her hips. The PA said he was not in the facility when the x-ray technicians arrived. He said the family member came up to him and asked about the x-rays impressions on 11/15/23 at approximately 9:00 a.m. He said he reviewed the x-ray report and the chest x-rays were clear with no pneumonia. The PA said all of the portable x-rays of the hip, pelvis and femur were also normal with no fractures. The PA said each time he had observed and talked with the resident, she did not complain of pain. He said when he palpated the resident's pelvis, she did not mention any concerns with this area. The PA said on 11/15/23 he talked with facility therapy services related to the resident having some back pain when they moved her and about muscle spasms. The pain was not going down her leg. The PA said he was not told by therapy that the resident had significant pain, when he asked if the pain was coming from her back. They felt a muscle relaxant would be beneficial and he ordered a muscle relaxant. The PA said when the resident's family member told him the resident was yelling out in pain related to her leg; he was unable to recreate the pain the family member talked about. The PA said on 11/15/23 at approximately 4:00 p.m. he received a call and was told the resident was yelling out in uncontrolled pain and he ordered the resident to be sent to the ER. The occupational therapist (OT) was interviewed on 12/27/23 at 2:11 p.m. She said she had worked with the resident. She said based on her behaviors, the resident had significant pain with sit to stand transfers. She was unable to verify the location of the pain. Her note on 11/15/23 at 2:52 p.m. revealed the resident was emotional. She worked with the resident with her activities of daily living (ADLs) to help calm her down. She said she was unsure if she knew the resident had fallen twice on 11/12/23. The physical therapist (PT) was interviewed on 12/27/23 at 2:26 p.m. She said on 11/14/23 at 4:39 p.m. she wrote a therapy note that read the resident was on the toilet in her bathroom and had pulled the call light. She and a student decided to help the resident off the toilet. They used a named steady machine (the resident pulled themselves up to stand). This was a two person and a machine transfer. She said the resident complained of severe (very vocal yelling/groaning) pain and pointed to her right hip just at the femur head. The resident did not point to the sacral area. She said she typically told nursing staff if a resident was in severe pain. She wrote a therapy note on 11/15/23 at 4:09 p.m. that the resident had severe pain from sitting to standing (unable to remain standing). She said she talked with the PA related to the resident's muscle spasms in the low back interfering with therapy. She said she asked the PA if there was anything that could be given to the resident for muscle spasms. III. Resident #5 A. Resident status Resident #5, age over 65, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included displaced intertrochanteric fracture of the right femur with routine healing, orthopedic aftercare, wedge compression fracture of a lumbar vertebrae, fracture of the superior rib on the right pubis, presence of right artificial hip, unsteadiness of feet, pain, bradycardia, metabolic encephalopathy (brain disorder), personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The 5/29/23 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of eight out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review Fall risk assessment dated [DATE] revealed a score of 12 or high risk. Care plan for being a fall risk related to a fall with a fracture on 7/13/23 and 7/14/23, history of hypertension, high fall risk was updated on 12/26/23 (during the survey). This was evidenced by right lower extremity weakness, mildly/moderate cognitive impairment, wears glasses, limited transfer assistance. Some of the interventions were administ

Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for one (#1) out of three sample residents. Resident #1 was admitted on [DATE] with a diagnosis of hepatic encephalopathy, a nervous system disorder brought on by severe liver disease; when the liver does not work properly, toxins build up in the blood. These toxins can travel to the brain and affect brain function. Resident #1 had a physician's order for lactulose (a laxative medication which assists in eliminating ammonia from the body) 20 grams/30 milliliters (ml) oral solution 30 ml by mouth four times per day for hepatic encephalopathy. On 6/9/23, Resident #1 was noted to have a decline in mental status. The resident was minimally responsive to stimuli and was unable to answer questions or open her eyes. Resident #1 was sent to the hospital per family request. At the hospital, it was discovered that Resident #1's ammonia level was 122 umol (micromole)/L (liter). Per the hospital lab work, a normal ammonia level range was 9-30 umol/L. Resident #1's ammonia level prior to admitting to the facility on [DATE] was 22 umol/L. During investigation to determine the cause of Resident #1's high ammonia level, it was discovered that the resident had missed several doses of her lactulose medication because the medication was unavailable. Facility staff did not notify the pharmacy to reorder the medication until the morning of 6/9/23, the same day the resident was sent to the hospital. Additionally, the physician was not notified that the resident was out of the lactulose medication, and licensed practical nurse (LPN) #2 gave the resident another laxative medication without a physician's order as she was under the erroneous assumption that Resident #1 was receiving lactulose for constipation and not for hepatic encephalopathy. The facility failed to notify the pharmacy or the physician in a timely manner that Resident #1 was out of lactulose medication and had missed several doses. Due to the facility's failures, Resident #1 suffered a toxic buildup of ammonia in her body which resulted in an intensive care unit (ICU) stay during her hospitalization . Findings include: I. Professional reference According to the American Liver Foundation (3/16/23) Treating Hepatic Encephalopathy, retrieved on 8/7/23 from https://liverfoundation.org/liver-diseases/complications-of-liver-disease/hepatic-encephalopathy/treating-hepatic-encephalopathy/, Hepatic encephalopathy (HE) is a condition that causes temporary worsening of brain function in people with advanced liver disease. When your liver is damaged it can no longer remove toxic substances from your blood. These toxins build up and can travel through your body until they reach your brain, causing mental and physical symptoms. HE is a serious but treatable condition if caught early and treated promptly. Symptoms often resolve when triggering factors are treated. It's important to continue treatment for as long as necessary to keep HE from coming back. Once symptoms become severe, HE can quickly worsen and become a medical emergency resulting in prolonged hospitalization . Lactulose works by drawing water from your body into your colon, which softens stools and causes you to have more bowel movements. This helps to lessen the absorption of toxins in your intestines by flushing toxins out of your system. It reduces the amount of ammonia in your blood by drawing the ammonia into the colon where it is removed from the body and helps during HE recurrences and makes them less likely to occur. The best way to reduce the risk of HE recurrence is to manage your liver disease and stay on maintenance therapy with lactulose, as directed by your doctor. II. Facility policy and procedure The policy for medication administration was requested from the nursing home administrator (NHA) three times between 8/3/23 and 8/7/23. The NHA did not provide the policy. III. Resident #1 status Resident #1, age 76, admitted on [DATE] and discharged to the hospital on 6/9/23. According to the June 2023 computerized physician orders (CPO), diagnoses included hepatocellular carcinoma (liver cancer), cirrhosis of the liver, and hepatic encephalopathy. The 5/30/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, and personal hygiene. She required two-person extensive assistance for toilet use. IV. Record review A review of Resident #1's June 2023 CPO revealed a physician's order for lactulose 20 grams/30 ml oral solution 30 ml by mouth four times per day for hepatic encephalopathy. The order had a start date of 5/26/23. Review of Resident #1's medication administration records (MAR) from 5/26/23 through 6/9/23 revealed the resident did not receive the lactulose medication on 6/7/23 at 8:00 p.m., 6/8/23 at 8:00 a.m. and 6/8/23 at 8:00 p.m. -The MAR documented the resident received the lactulose medication on 6/8/23 at 12:00 p.m. and 4:00 p.m., however, during the facility's investigation of the missed medication doses LPN #2 stated that she had given the resident a different laxative medication without a physician's order at those administration times and the resident did not actually receive the correct medication. -Review of Resident #1's comprehensive care plan, initiated 5/26/23, revealed the resident did not have a care plan to monitor for her diagnosis of hepatic encephalopathy or have any interventions in place for staff to monitor the resident for signs of ammonia toxicity such as confusion and disorientation, excessive sleeping and changes in consciousness. Review of Resident #1's electronic medical record (EMR) revealed the following physician progress note: 6/7/23: Resident is seen in their private room resting comfortably. Resident's plan and progress was discussed with nursing staff, primary team, and therapy. Resident is making progress in therapy. Resident tells me that she's feeling better this morning. She is asking for her lactulose. She tells me that her pain has been better since starting gabapentin. She denies any pain currently. She tells me since starting gabapentin her pain has been mild. She denies any new or worsening musculoskeletal or neurological pain complaints. No uncontrolled pain reported by nursing or therapy. She denies any side effects to gabapentin. No new issues with bowel or bladder control. denies any chest pain, cough, nausea, vomiting, diarrhea, constipation, fever, or chills. is eating well and sleeping well. no further questions or concerns. -Despite the physician's progress note documentation that Resident #1 was asking for her lactulose, no follow up was done by the physician or the facility to ensure the resident's medication was available. Review of Resident #1's EMR revealed the following nurse progress notes: 6/7/23: Placed call to pharmacy regarding resident being out of lactulose. -The progress note was documented by LPN #2 as a late entry on 6/9/23 at 12:21 p.m. (after Resident #1 had been transferred to the hospital and admitted ). 6/8/23: Placed call to pharmacy regarding resident being out of lactulose. Pharmacy staff stated that medication will be delivered on the next run. Resident alert and oriented, no signs/symptoms of discomfort or changes. -The progress note was documented by LPN #2 as a late entry on 6/9/23 at 12:22 p.m. (after Resident #1 had been transferred to the hospital and admitted ). 6/9/23 at 3:56 a.m: Resident's mental status has declined. She does not make eye contact. You have to like bring her back into the conversation. She will answer 'yes' but then she kind of fades off. She was taking her medications whole with no issues, would take the cup and put them in her mouth and take them but I could not get her to open her mouth or hold the cup this evening. Also was kicking at certified nurse aide (CNA) during being changed. Will inform the physician of the change in status. Also called the pharmacy about her lactulose that is not here and they once again said it would be on the next run. Resident denies any pain. When asked she says 'I'm fine, how are you?'. She has been very restless. Was able to get a couple of her medications down her and she is finally resting at this time. Vital signs within normal limits. Will continue to monitor. -Despite the progress note documenting the provider would be notified, notification to the provider did not occur until after 7:00 a.m. 6/9/23 at 7:30 a.m. (documented as a late entry on 6/9/23 at 3:01 p.m.): This nurse went to assess resident related to LPN stating the resident had an acute change of condition. Upon assessment, the resident noted to look as though she was sleeping, she would grimace with some stimuli, however she wasn't able to answer questions or fully open her eyes. Vital signs stable, breathing was normal with no dyspnea or labored breathing. Provider and family notified. Family said they would be right in. Once the family arrived the resident wouldn't wake up for him either and he requested the resident go to the hospital. Provider notified of the family's preference and received an order to transfer. 6/9/23 at 7:33 a.m: Provider notified of change in condition. Stated to call the family. This nurse called the family and they stated they would be right in. 6/9/23 at 7:50 a.m. (documented as a late entry on 6/9/23 at 2:55 p.m): At 7:50 a.m., resident was transferred to hospital per power of attorney (POA) request. Provider aware, POA at facility at time of transfer and escorted resident to the hospital. 6/9/23 at 12:34 p.m.: Call received from hospital that resident is being admitted . MAR faxed to the hospital at hospital request. Review of documents from Resident #1's hospitalization on [DATE] revealed the following: History of present illness: Patient is a [AGE] year old female. Patient unable to provide history as she is altered. Per facility and son, had been maintained on lactulose after discharge but ran out, has not been getting lactulose for several days. This morning they could not wake her up and she was turning more yellow. Had just been admitted for fall and discharged to rehabilitation. Per son, they missed some doses but he is not sure how many. Assessment/Plan: History of hepatic encephalopathy and patient presented altered with ammonia level of 122 up from 22 a couple weeks ago, per report rehabilitation facility ran out of lactulose several days prior, had been doing well on regular lactulose, CT head normal. V. Interviews Registered nurse (RN) #1 was interviewed on 8/3/23 at 12:59 p.m. RN #2 said she was an agency nurse and had only worked at the facility for two days. She said if medications were not available the pharmacy and the physician should be notified. LPN #1 was interviewed on 8/3/23 at 1:12 p.m. LPN #1 said if medications were not available the pharmacy and the physician should be notified and the nurse should check the emergency medication kit in the facility to see if the medication was on hand. The nursing home administrator (NHA) and the assistant director of nursing (ADON) were interviewed together on 8/3/23 at 2:05 p.m. The ADON said the night nurse noticed Resident #1 was out of lactulose on the evening of 6/7/23 and informed the day nurse (LPN #2) about it. She said the night nurse did not notify the physician or the pharmacy about the medication not being available. The ADON said LPN #2 also did not notify the physician or the pharmacy about the unavailable medication and Resident #1 missed at least four doses of the medication. She said LPN #2 admitted that she gave the resident another laxative medication in place of the lactulose which was unavailable. She said the Resident #1 did not have a physician's order for the medication that was given and the medication would not have been as effective as the lactulose for eliminating ammonia from the body. The ADON said if a resident's medication was unavailable, the nurse should notify the pharmacy immediately to reorder the medication. She said the physician should also be notified immediately that the resident had missed doses of the medication and see if the physician wanted to prescribe another medication until the unavailable medication was delivered from the pharmacy. The ADON said the process for notifying the pharmacy and the physician when medications were unavailable was part of the nurse's orientation checklist, however, the ADON looked at the checklists and confirmed that the information was not specifically mentioned on the checklist. The NHA said the facility investigated the missed doses of lactulose and concluded Resident #1 had missed at least four doses of the medication. She said LPN #2 admitted she had given an alternative laxative without a physician's order in place of the lactulose. The NHA said LPN #2 did not call the pharmacy or notify the physician that the resident had missed some doses of the lactulose. She said the pharmacy and the physician should be notified immediately if medications were unavailable and a resident missed doses of medication. The NHA said the director of nursing (DON) completed a competency evaluation for medication administration with LPN #2 following the incident with Resident #1. She said all nurses were educated on the proper procedures regarding who to notify when residents' medications were unavailable. The pharmacy consultant (PC) was interviewed on 8/3/23 at 2:40 p.m. The PC said the pharmacy had not received a call from the facility to reorder the lactulose medication for Resident #1 until the morning of 6/9/23. He said the pharmacy refilled the medication and it was sent to the facility later that same day. He said he was unaware the resident had missed any doses of the medication.

Based on record review and interviews, the facility failed to ensure one (#5) of three residents received adequate supervision to prevent accidents out of six sample residents reviewed. The facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #5. Resident #5 was identified as a fall risk within the comprehensive care plan. The facility failed to identify the resident's patterns throughout the day and failed to have personalized and effective interventions in place to prevent falls. The fall risk care plan was put into place on 12/6/22 which identified the resident as a fall risk. On 12/6/22, Resident #5 fell in her room and complained about left hip pain. An x-ray was ordered for her hip and pelvis. She was mildly confused after she fell . The facility updated her fall risk care plan to include assisting the resident with activities of daily living and assisting the resident with toileting, however did not determine the root cause of the falls nor add any additional person-centered interventions. The resident fell again, twice on 12/12/22, for which she sustained a fracture to the left hip. Cross-reference F659: the facility failed to ensure an assessment was completed by a registered nurse (RN) following a fall. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, reviewed 1/12/22, was provided by the nursing home administrator (NHA) on 3/15/23 at 2:00 p.m. It revealed, in pertinent part, Upon determination that the resident is at risk, the qualified staff creates an individualized plan of care that includes the appropriate preventative interventions to reduce potential for fall. II. Resident #5 A. Resident status Resident #5, age 82, was admitted on [DATE] and discharged on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included Parkinson's disease, neuropathy, fracture of sacrum, unsteadiness on feet, weakness, need for assistance with personal care and repeated falls. The 12/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of eight out of 15. She required extensive assistance of two with transfers, dressing, toileting and personal hygiene. It indicated that the resident had sustained a fall in the last month and had a fracture related to a fall within the last six months. B. Record review The cognitive deficit care plan, initiated on 12/5/22, documented the resident had cognitive deficit related to decision-making. The interventions included monitoring the resident for any changes or decline in cognitive status, allowing the resident to make simple decisions, allowing the resident ample time to absorb and respond to information and avoiding changes in the resident's environment. The impaired physical mobility care plan, initiated on 12/5/22, documented the resident needed maximum assistance with activities of daily living (ADLs). The interventions included providing an occupational and physical therapy evaluation as needed and providing the appropriate level of assistance to promote the safety of the resident. The fall risk care plan, revised on 12/13/22, documented the resident was at risk related to a high fall risk score. The interventions included administering first aid as needed, assessing the contributing factors to the resident's fall history, assessing for potential fall-related injury prevention, assessing medications for contributing factors, assisting the resident with activities of daily living (ADL) as needed, assisting the resident with toileting as needed, keeping the call light and most frequently used personal items within reach, keeping the resident's glasses clean and fit with adequate prescription, making sure that the staff members were aware that the resident was at high risk for falls, and provide a physical therapy referral as needed. -The fall risk care plan did not include any individualized person-centered interventions. It did not document the resident's daily routine nor input from the resident's family to determine effective interventions to prevent falls and injuries. The 12/6/22 fall risk assessment revealed the resident required assistance for mobility, transfers and was non-weight bearing. It also indicated that she had sustained a fall in the last six months. -The resident scored an 11 out of 18, which indicated the resident was a high fall risk and interventions should have been promptly put into place. However, based on the comprehensive fall care plan, person-centered interventions were not put in place, even though the facility was aware the resident had a history of falls and was at a high fall risk. 1. Fall incident on 12/6/22 The 12/6/22 nursing progress note documented at 3:56 p.m. Resident #5 was found on the floor in her bedroom and complained of left hip pain. The physician was notified and ordered an x-ray of the pelvis and hip. -It did not indicate the facility had determined the root cause of the fall. 2. Fall incidents on 12/12/22 The 12/12/22 nursing progress note documented at 3:22 p.m. the resident told the nurse that she slid down to the ground (unknown from where) and was laying on the floor next to the bed on her back. -The care plan revealed that the following interventions were added: administering first aid as needed, assessing for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, assessing medication for contributing factors, and keeping glasses clean and fit with an adequate prescription. -There was no documentation to determine the root cause of the fall, nor a person-centered immediate intervention to prevent additional falls or potential injuries. The 12/12/22 nursing progress note documented at 3:29 p.m., only seven minutes following the first fall, the resident had sustained another fall. The certified nurse aide (CNA) found the resident, on the right side of her body, lying on the floor, away from the bed. She had a new bruise on her left upper extremity close to her elbow. -There was no documentation to determine the root cause of the fall. The December 2022 medication administration record (MAR) revealed that the resident reported generalized pain on 12/13/22 at 7:00 a.m. Her pain level was a 2 out of 10 (with 10 being the worst pain on the scale). -On 12/14/22, two days after the resident sustained two falls, the resident reported severe pain to her left hip. Oxycodone 5 milligrams (mg) was administered on 12/14/22, however the resident reported the pain medication did not provide any relief. -The physician ordered an x-ray of the hip. The preliminary findings showed distortion to the left femoral head. The doctor was notified and the resident was sent to the hospital. The resident did not return to the facility. -The 12/14/22 finalized x-ray report documented an impacted displaced left-sided subcapital fracture to the left hip. The facility failed to determine the root cause of the falls for Resident #5 and put effective person-centered interventions into place to prevent the resident from continued falls and subsequent fracture. C. Staff interviews CNA #1 was interviewed on 3/15/23 at 12:28 p.m. She said that the care plan provided information if a resident was considered a high fall risk She said a resident who was a high fall risk should be checked on frequently throughout the day. She said following a fall, a huddle would occur to determine things they could put in place to prevent future falls. Licensed practical nurse (LPN) #4 was interviewed on 3/15/23 at 12:31 p.m. She said for residents who were considered a high fall risk, potential interventions included increasing the frequency of checking on the resident, adding fall mats and a stoop mattress (lipped mattress with raised edges). She said the NHA, director of nursing (DON), assistant director of nursing (ADON) and MDS coordinator determined the interventions put into place following a fall. She said the interventions should be documented on the comprehensive care plan and in the nurse's notes. LPN #4 said the interventions should be based on the resident and individualized. She said the CNAs were notified of interventions verbally and on the white board inside the resident's room. It would also be documented in the plan of care for CNAs. The DON was interviewed on 3/15/23 at 12:44 p.m. The DON said following a fall, the staff had a huddle meeting to talk about the circumstances of the fall, put an immediate intervention into place, complete an incident report and perform a change of condition assessment. The DON reviewed the comprehensive care plan for Resident #5 and confirmed person-centered interventions were not put into place upon the resident's admission or following the fall sustained on 12/6/22 to prevent additional falls. She said Resident #5 had been admitted to the facility following a sustained fall at home. She said Resident #5 was a high fall risk upon admission to the facility.

Based on interviews and record review, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for two (#9 and #10) out of 10 sample residents reviewed for dignity. Specifically, the facility failed to ensure Residents #9 and #10 experienced a dignified living and were assisted to and from the toilet in a manner that met individual toileting needs. In addition, the facility failed to ensure Resident #9 was treated and spoken to in a dignified manner. Resident #9, who required extensive assistance from two staff using Sara Stedy Sit to Stand Manual Lift with transfers and was non-weight bearing on her right lower extremity, said a certified nurse aide (CNA) declined to take her to the bathroom at night. She said she was told to pee in her depend (adult brief). Resident #9 said she felt very embarrassed and humiliated when she had an accident waiting soiled for staff to change her adult brief. She said I feel neglected and dehumanized. Resident #10's family member said her grandmother, who required extensive assistance from staff with all transfers, was seated at the edge of bed for four hours in the middle of the night, soiled, waiting for staff to take her to the bathroom and change her adult brief. Findings include: I. Resident #9 A. Resident status Resident #9, age above 65, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/13/22 minimum date set (MDS) assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score 14 out of 15. No rejection of care was noted. She required extensive assistance of one staff with bed mobility, dressing, toilet use and personal hygiene, extensive assistance of two persons with transfers. She was totally dependent on staff with bathing. She was frequently incontinent of urine. B. Record review The Impaired Physical Mobility care plan, updated 9/29/22, revealed the following interventions: -assist as needed with applying and removing splint/brace; -assist as needed with wheelchair mobility; -CNA will assist with maintaining/improving resident's ability to safely transfer to and from bed, chair and toilet with daily participation in ADLs (activities of daily living); -give resident as many choices as possible concerning care; and, -provide appropriate level of assistance to promote safety of resident. -The care plan did not address two staff transfers for the resident (see MDS assessment above). On 8/16/22, a nurse documented, (Resident) had follow up appointment with surgeon at (orthopedic clinic) today. From report staples were removed to RLE (right lower extremity). Orders for (Resident) to remain NWB (non-weight bearing) on RLE (right lower extremity), no ROM (range of motion) to R (right) knee, [NAME] (total range of motion) brace locked and straight at all times. On 8/29/22, a physician documented, txf (transfer) with sara stedy (lift) . bathing max A (maximum assistance), toileting max A Decreased ROM RLE (range of motion right lower extremity). R (right) knee hinged brace locked in extension . Rehab precautions: high fall risk (fall precautions per facility protocol(s)) . C. Resident interview Resident #9 was interviewed on 9/28/22 at 7:50 p.m. She said not all staff treated her with respect and dignity. She said she had long waits to have staff answer her call light. She said the night before last a certified nurse aide (CNA) refused to transfer her to the toilet. She said the CNA told her she had other people to take care of and would not come anymore. She said she was told to pee in her depend and staff will check on her every two hours and change her. She said I did not wear a depend at home before my surgery and now I had to pee in my diaper and wait soaked and wet to the mercy of staff to come and change me. She said I kind of got used to it. She said she felt neglected, upset, embarrassed and humiliated. She said the staff needed to use the Sara Stedy Lift with all transfers because she was a non-weight bearing on her right leg and was also wearing an immobilizing brace on that leg. She said the CNA also told her she did not know how to use the lift and that there was only one staff on the night shift who was familiar with the Sara Stedy Lift. She said when she called for help after an incident, she was soaked with urine, the CNA raised her voice and said I was just here half an hour ago. The resident expressed how care concerns and the way staff treated and spoke to her created feelings of diminished dignity and respect. The resident said she reported her care concerns to the social worker. D. NHA interview Resident #9 reported staff concerns were reported to the nursing home administrator (NHA) on 9/28/22 at 8:30 p.m. The NHA said she would immediately start the investigation. The NHA was interviewed again on 9/29/22 at 8:42 a.m. He said he spoke to Resident #9, looked at the nursing staff schedule and learned the CNA who declined to assist Resident #9 that night was an agency staff. He said he reported to the staffing agency the allegation that involved a specific CNA. The NHA said the CNA would not return to the facility. II. Resident #10 A. Resident status Resident #10, age 92, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/7/22 MDS assessment revealed the resident had clear speech and usually was able to understand others. Her cognitive status was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. No rejection of care was noted. She required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use and personal hygiene, extensive assistance of one person with eating. The lower extremities range of motion was impairment on one side. She was occasionally incontinent of bladder and bowel. B. Record review 1. Care plans The Fall Risk care plan, dated 9/7/22, revealed the following interventions: -assess contributing factors related to fall history; -assist resident with ADLs as needed; -assist resident with toileting as needed; and, -keep call light and most frequently used personal items within reach. The Impaired Physical Mobility care plan, included the following intervention: -provide appropriate level of assistance to promote safety of resident. The At Risk for Problems with Elimination care plan dated 9/26/22, revealed the following interventions: -check resident every two hours and assist with toileting as needed; -keep call light within reach and remind resident to call for assistance; and, -provide pericare after each incontinent episode. -The care plan did not address two staff transfers for the resident (see MDS assessment above). 2. Nursing notes On 9/5/22 a nurse documented, Resident in bed sleeping at this time . Resident was assisted x2 (with two persons) to the bathroom several times through the night to void . On 9/7/22 at 12:59 a.m., a nurse documented, During q hour (every hour) checks, Pt (patient) was found in a sitting position by her bed. When asked what she was doing Pt (patient) stated she was trying to get into bed. This nurse let her know that she was in bed and Pt (patient) stated 'then I don't know where I was going.' Pt assessed and no injuries noted. Pt stated she slipped from her bed and did not hit her head on anything. On 9/7/22 a nurse documented, (Resident) found at 0615 (6:15 a.m.) during neuro (neurological) checks trying to get out of bed on her own. This nurse provided education and assistance to transfer to w/c (wheelchair) for use of bathroom. After transfer back to bed from bathroom via w/c (wheelchair) placed call light within reach and instructions for (Resident) to use call light. Will continue to monitor hourly and as needed. C. Family interview A family member of Resident #10, who was highly involved in the resident's life, was interviewed on 9/28/22 at 8:15 p.m. She said the facility allowed her to place a camera in resident's room and she was able monitor her grandmother's care from her phone. She said the resident recently suffered from a urinary tract infection and was frequently trying to transfer self to the bathroom. She said her grandmother's cognition was impaired, was at high risk for falls and she required staff assistance with all transfers. She said she visited her grandmother daily and spent many hours with her to ensure her safety in the facility. She said the staff was supposed to check on her grandmother every hour, however most of the time they did not check on her for longer than two hours. She shared the camera recording from 9/21/22 and said her grandmother got up from bed four times between 7:00 p.m. and 9:00 p.m. She said there was no staff with her. She said she called the facility and asked the nurse to go and check on her grandmother. She said there were a couple occasions she observed her grandmother had tried to get out of bed and go to the bathroom, she called the facility but could not reach any staff. She said she drove to the facility at night to ask the staff to check on her grandmother more often. She also shared the camera recording from 9/22/22 and said her grandmother was seated at the edge of her bed between 12:12 a.m. until 3:48 a.m. She said a nursing staff member went to the room at 4:23 a.m. and changed her grandmother's adult brief, it was soaked with urine through the bed sheets. She said she was very upset because of diminished dignity and respect in the care her grandmother was receiving in the facility. She said she did not have a chance to talk to the facility staff about the incidents on 9/21/22 and 9/22/22. D. NHA interview The NHA was interviewed on 9/29/22 at 11:10 a.m. He said he was not aware of the incidents with Resident #10's care. He said the staff should check on the resident every 15 minutes and he would talk to the director of nursing (DON) about it. He said the resident should be moved to a room closer to the nursing station for easier staff monitoring. E. Staff interviews A facility staff member who declined to identify him/herself was interviewed on 9/26/22 at 12:40 p.m. The staff member said there was not not enough nursing staff to care for the residents and the care had been progressively worse. The staff member said the corporate office declined to open one or two more CNA positions and the facility was using agency staff daily, every shift there were at least two staffing agency CNAs and nurses. The staff member said the CNAs did not have time to take residents to the bathroom and frequently residents were left soiled with urine. The staff member said there were many residents who required two persons transfers, however there was no other staff available and one CNA needed to perform an unsafe transfer. The staff member said if the occupational therapists didn't do most of the showers, residents would not get their showers for a few days. The staff member said the therapy staff was getting residents up in the mornings to help the nursing staff. CNA #1 was interviewed on 9/26/22 at 12:54 p.m. She said she worked day shifts most of the time. She said she was aware that on night shifts some of the nursing staff would rush through providing care to residents, and who would not take the time to listen to resident concerns. She said it was difficult to find available staff to help with two person transfers for some residents. An agency staff, CNA #2 was interviewed on 10/2/22 at 7:40 p.m. She said it was her first time in the facility. She said she was told by another CNA on which unit she will work. She said she did not receive any kind of orientation to the facility before her shift. She said the agency required all mandatory training, including dignity, completed on time or she would not be able to work. She said she did not know any of the residents on her assigned unit. She was not aware which resident required two staff assistance with transfers or which resident needed frequent checks. The social service director (SSD) was interviewed on 10/3/22 at 11:15 a.m. She said Resident #9 participated in her care conference on 9/21/22. She said during the meeting the resident brought some care concerns to the facility staff. She said the resident complained of food being cold when served, pain medication administration and call lights not answered timely. She said she did not remember Resident #9's reporting to her an incident with the night shift CNA. Licensed practical nurse (LPN) #1 was interviewed on 10/3/22 at 11:30 a.m. She said she was Resident #10's ambassador to communicate her care needs within the facility. She said the resident's family was frequently talking to her about their concerns related to the care, however she was not aware of Resident #10 being left at night unattended and not changed on 9/22/22. She said Resident #10 definitely needed to be monitored closely. The director of nursing was interviewed on 10/3/22 at 11:40 a.m. She said she was new to the facility. The DON said it was the expectation that each resident was treated with respect and no staff were to refuse to care for a resident. She said all call lights were to be answered immediately. She said during shift change the offgoing staff should verbally exchange information about residents' care to the oncoming staff. She said the nurses can see all treatment information about residents on the treatment administration record (TAR) on the computers and should share it with CNAs. She said there was a Red Folder at the nurses' desk which included orientation to temporary employees. The folder included training, incident documentation and emergency contacts. She said the agency staff should read the information in the Red Folder prior to the shift and sign the signature sheet. The Red Folder's signature sheet was reviewed in the presence of the DON. The folder contained two agency staff signatures dated 9/24/22 and 9/28/22. On 10/2/22 six agency staff were observed working in the facility. Their names were not noted in the Red Folder. The NHA was interviewed on 10/3/22 at 12:03 p.m. He said the permanent facility staff received abuse, neglect and dignity training during general orientation before their first shift. She said in May 2022 the facility conducted a skills fair for all staff that included extensive abuse, neglect and dignity training. He said the agency staff did not receive the training in the facility, however the training was available from the staffing agency on request.

Based on observations, record review and interviews, the facility failed to ensure two (#1 and #3) of three residents reviewed for accidents received appropriate supervision and remained free from accident hazards. Resident #1, with a history of falling frequently, was admitted to the facility on [DATE] after she fell and broke her hip. The facility failed to ensure the care plan was updated with the resident specific interventions before the resident fell , failed to ensure the staff consistently followed new interventions implemented after each fall, and failed to complete a thorough investigation after her falls. Due to the facility failures, after the resident's fifth fall, she was admitted to the hospital sustaining major injuries which included broken nose, fractured upper jaw, broken teeth, arm fracture and multiple bruising and injuries to soft tissue on her face. Furthermore, the resident was readmitted to the facility on [DATE], where she fell an additional two times sustaining injury of hematoma on the left side of the head and abrasion to the left knee. Cross-reference F684 for failure to report injuries to the physician and provide immediate medical care after the fall for Resident #1. Additionally, Resident #3 had a history of [REDACTED]. After her second fall in the facility on 11/21/2020 the resident's care plan was not updated with new interventions. Findings include: I. Facility policies and procedures The Fall Management policy, with effective date on February 2020, was provided on 12/9/2020 by the nursing home administrator (NHA). The policy read in pertinent part Upon determination that the resident is at risk, the qualified staff creates an individualized plan of care that includes the appropriate preventative interventions to reduce potential for fall. If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls. II. Resident #1 A. Resident status Resident #1, age 92, was admitted on [DATE] and readmitted [DATE] from the hospital. According to the December 2020 computerized physician orders [REDACTED]. The 10/14/2020 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of seven out of 15. The resident did not display any behaviors, hallucinations, and did not reject the care. She required assistance from one person for bed mobility, dressing, and personal hygiene. She required extensive assistance of two people for transfers, locomotion, toilet use, and bathing. Her balance during transition and walking was not steady, she was able to stabilize with staff assistance. She used a walker and wheelchair for mobility. She was incontinent of bowel and bladder, and she was not on the toileting program. B. Record review The care plan (CP) initiated on 10/11/2020, and revised on 12/2/2020, revealed the resident was at risk for falls. Interventions included to assist the resident with all needs, anticipate resident needs, make sure glasses were clean, call light within the reach, and grip socks were on. Fall #1 on 10/13/2020 According to the nurses note on 10/13/2020, the resident sustained [REDACTED]. The incident report was initiated on 10/13/2020, it was completed and signed by NHA on 11/4/2020 with interdisciplinary team (IDT) notes. The IDT notes read Resident found on floor by nursing and CNA (certified nurse aide). Resident reports she fell when she tried to stand up. She does not think she hit her head. CNA and nursing helped resident up into chair. Immediate interventions included: well lit, non cluttered room, call light in reach, needed and desired items in reach/easy access. The resident's care plan was updated on 10/13/2020 with interventions to keep call light and most frequently used personal items within reach. Fall #2 on 10/23/2020 According to the nurses note on 10/23/2020 at 3:06 p.m. the resident was found laying on the floor next to her bed. Resident stated she was getting up to use the restroom. Residents call light was within reach and the bed was in the lowest position. The IDT team review of the fall on 10/23/2020, signed by NHA on 11/04/2020, revealed the resident attempted to go to the bathroom and fell . The resident's cognition was moderately impaired, and varied during the day. The resident required assistance for all mobility due to impaired cognition/dementia, poor awareness of current abilities and safety risks. Immediate interventions included to continue current interventions, and to apply non-skid shoes when in wheelchair and gripper socks when in bed. The resident's care plan was not updated on 10/23/2020 with recommended interventions to use non-skid shoes when in a wheelchair and gripper socks when in bed. Fall #3 on 11/3/2020 According to the nurses note on 11/03/2020, resident found sitting on the floor beside her bed. Resident stated she slipped while attempting to get out of bed to close her blinds. The resident was assessed by a nurse, no injuries were noted. The incident report was initiated on 11/03/2020, it was completed and signed by NHA on 11/4/2020 with interdisciplinary team (IDT) notes. The IDT notes read resident was found sitting on the floor by her window by therapist after she stated she ambulated to window to close blinds. Resident stated she was closing blinds to block the sun. The resident's care plan was updated on 11/04/2020 with intervention to anticipate all needs before leaving the room, including the lightning. Fall #4 on 11/6/2020 There were no nursing progress notes documenting the resident had a fall on 11/6/2020. The IDT note completed on 11/9/2020 revealed that the IDT team met to discuss the fall on 11/6/2020. The incident report initiated on 11/6/2020 documented that resident sustained [REDACTED]. Resident was trying to transfer from bed to chair. Resident denies hitting head. Does report hitting her right elbow and found bruising here. The incident report was signed by NHA on 11/9/2020, it did not include any new interventions. The resident's care plan was updated on 11/6/2020 with intervention to toilet resident as needed. Fall #5 on 11/10/2020 According to the nurses note on 11/10/2020 at 7:57 a.m., registered nurse (RN) #4 was notified by CNA that a resident had a fall, upon entering the room the patient was seen laying on the floor prone with her head toward the wall and the oxygen concentrator next to her head. Patient did not have on slipper socks or pants with a brief half on. Blood was noted on the floor under the patient's face. Upon exam the patient denied back, hip or pelvic pain. Patient was then helped to roll on to her back and complained of pain to the right upper arm and inability to move her arm away from her body. Upon exam it was noticed that the patient had blood on her face with active bleeding from mouth and nose. A gait belt was placed on the patient and with the help of the other nurse and the CNA patient was placed on sitting on the side of the bed. Upon further exam it was noted that the patient bit her lip and has a broken tooth that went through the upper lip. No bruising or obvious sign of break noted to upper arm or shoulder noted. Patient continued to state she could not move her arm away from her body. Bleeding was stopped and the patient was taken to the shower to be cleaned up. Neurological exam noted no deficits. The incident report initiated on 11/10/2020 revealed that the resident had a fall around 6:45 a.m. The fall was unwitnessed, the resident sustained [REDACTED]. The note of the environment indicated that the floor was wet and slippery and the resident was not wearing appropriate footwear. The investigation of events and interventions documented in review of the above nursing note on how resident was found in her room, to continue current interventions and to send resident to the hospital for evaluation. There were no notes indicating the wet floor and absence of proper footwear was investigated by the IDT team. The incident report did not provide any details if the resident's call light was on, when she was last seen by CNA or nurse, what position her bed was in, and any other contributing factors. According to the emergency room medical record, the resident was admitted [DATE]. She presented with facial bruising, and complaints of right shoulder pain. The CT (computer tomography) scan revealed the resident had nasal fracture, upper jaw fracture, right upper arm fracture with multiple bone splinters, lip laceration and an open [MEDICAL CONDITION]. Resident was admitted to the hospital for observation and spent two days there. After two days, the resident was readmitted back to the long-term care facility to continue her rehabilitation. Fall #6 on 11/23/2020 There were no nursing progress notes that the resident had a fall on 11/23/2020. The note read that the family was contacted and notified that the resident had a fall. The incident report initiated on 11/23/2020 documented that resident sustained [REDACTED]. Resident had been in the chair having lunch, and the care staff heard a loud noise and went into the room and found the resident on the floor. Attempted to get out of the wheelchair without assistance. Assessment completed- no new injury identified. The resident does not have safety retention - and needs constant redirection and queuing. Neurological checks were listed as an immediate intervention, and to continue all previous interventions as well. The incident report was signed by NHA on 11/28/2020, with a note that IDT met to review the fall and all the previous interventions should be continued. No new interventions were noted on the incident report. The resident's care plan was updated on 11/23/2020 with intervention to assist the resident during meal times. Fall #7 on 11/29/2020 According to the nurses progress note on 11/29/2020 the resident was found on the floor. No injuries were found after assessment. The resident's call light was within the reach, she did not use it prior to self transfer. According to the late entry nurses notes (entered 12/2/2020), the resident was found on the floor in her room on 11/30/2020 near the doorway. Resident said she fell off her chair and bumped her head on the door. Hematoma on the left side of the head, and dime size abrasion to the left knee were observed by the nurse. The incident report initiated on 11/29/2020 included the above nurses note. It was unclear if the resident had two falls, or one fall that was documented differently (with injury or without injury). Immediate interventions included x-ray on the right shoulder with no additional injuries. No other interventions were documented. C. Resident interview and observations Resident #1 was observed sleeping in her bed on 12/9/2020 around 2:00 p.m. The resident's bed was in a low position, call light on the blanket within reach. The resident opened her eyes to voice. She said she was doing ok, when asked about a bruise under her left eye and a small foam dressing on left forearm, she said she did not remember. She was not able to recall the fall or any circumstances about it. Resident #1 was observed on 12/10/2020 around 11:30 a.m. Resident was resting in bed with her eyes closed, her bed was not in a low position and there were no safety mats on the floor. CNA #3 was informed about the position of the bed at the same time. She entered the room, lowered the bed and put safety mats around it (see interview below). D. Staff interviews CNA #3 was interviewed on 12/10/2020 at 11:42 a.m. She said she was regularly working on this unit and was familiar with all residents. She said Resident #1 had a fall a few weeks ago with injuries to her right arm and currently required one person assistance with all tasks. She said the resident was confused often and did not always use her call light for help. She said the resident was on frequent checks which meant that she checked on her every time she passed in the hallway. She said she did not know who assisted the resident to bed earlier and why her bed was not in a low position. She said her bed should always be in a low position with mats on the floor for safety because the resident attempted several unassisted transfers before. -The interventions of fall mats on the floor, frequent checks and her bed in lowest position was indicated on the resident's fall care plan. LPN #4 was interviewed on 12/10/2020 at 11:50 a.m. She said Resident #1 was a high fall risk because she had several falls before. She said the resident did not always use her call light. She said current interventions were to make sure the bed was in a low position, mats around on the floor, and call light with the reach. She said nurses and CNAs were doing frequent checks on the resident, but they did not document how often and who checked on the resident. She said nurses kept the medication cart closer to the resident's room to keep an eye on the resident when they were passing medications. -The interventions of fall mats on the floor, frequent checks, having the medication cart close to the resident's room and her bed in lowest position were indicated on the resident's fall care plan. The DON and ADON were not available for an interview on 12/10/2020. RN #3, who was an RN manager on duty in the building on 12/10/2020, and the staff development coordinator (SDC), were interviewed in the presence of LPN #3 on 12/10/2020 around noon. RN #3 said she was not familiar with the resident and could not speak about the details of her falls or any interventions that were in place. LPN #3 said she was familiar with resident and participated in all IDT meetings related to the falls of Resident #1. She said the IDT team met regularly to discuss new interventions for the resident, and all interventions were documented on the care plan. She said the facility tried different things to keep the resident safe and physical and occupational therapy were constantly working with the resident as well. She said she was in charge of updating the care plan with all new interventions after the IDT meeting. The rehab manager was interviewed on 12/9/2020 at 2:30 p.m. She said the resident was working with therapy three to four days a week. The resident was able to ambulate up to 125 feet with one person assist prior to her fall on 11/10/2020, currently she was ambulating up to 80 feet with the same assistance. She said the resident was always a high risk for falls and she was never safe. She said the resident had a memory deficit and was not able to remember the tasks; to aid her with that, printed reminders were put in her room such as to call for assistance before transfers. She said the resident was not compliant with the sling on her right arm, frequently took it off and said her hand did not hurt. She said the resident was not always purposeful in her movements, and at times impulsive, she said anti-roll brakes were applied to her chair to prevent it from rolling back when the resident attempted to get up. She said the resident was working well with therapy, and making slow progress. The physician assistant (PA) was interviewed on 12/09/2020 at 1:42 p.m. He said the resident had significant dementia, she previously have had multiple falls in the facility and at home. He believed the facility had all possible interventions in place to keep the resident safe. He said the resident continued to fall and was at risk for falls in the future due to impared cognition, poor decision making and safety awareness, and the desire to move. He said an individual person who was always present with the resident all the time could prevent some falls. The NHA was interviewed on 12/09/2020 at 4:03 p.m. She said everything that was listed under IDT review was currently implemented. III. Resident #3 A. Resident status Resident #3, age 92, was admitted on [DATE]. According to the December 2020 computerized physician orders [REDACTED]. According to the 10/13/2020 MDS assessment, the resident had mild cognitive impairment with a BIMS score of 10 out of 15. She did not exhibit any behaviors of inattention or disorganized thinking. She required extensive assistance of two people with bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. Her gait was not stable, she was able to stabilize with staff assistance only. She used a walker and wheelchair for ambulation. The resident was occasionally incontinent of the bladder and bowel, she was not on the toileting program. She had a history of [REDACTED]. B. Record review The care plan for falls was initiated on admission 10/11/2020, indicating resident was at risk for falls due to the history of falls and history of [MEDICAL CONDITION], her fall risk score was marked as high and was measured on 11/15/2020 after resident had fall #1 in the facility (see below). Interventions included to assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems. After the resident sustained [REDACTED]. Fall #1 on 11/15/2020 According to the incident report on 11/15/2020, the resident had a fall at 2:00 p.m. Resident was having a window visit and when finished, the resident stated that she was hanging up the phone and her foot got caught on the wheel chair and she fell out of her wheelchair hitting her head. Resident was found on her right side on the floor. Resident received first aid to the wound on her right brow, it was cleansed and steri stripped. Interventions included keeping the bed in a low position and making sure the resident has non skid, well fitting shoes. Implemented interventions were not specific to the circumstances of the resident's fall. It was not clearly documented what shoes the resident was wearing during the fall. Fall #2 on 11/21/2020 According to the incident report on 11/21/2020, the resident had a fall around 7:45 in the morning. The summary of the incident read: Resident was checked on this morning while doing rounds and was found on the floor laying on her back wrapped in her bed sheets. Resident said she had been calling for help and could not reach her call light. Resident is not in pain at this time, she did state she bumped her head during the fall but did not lose consciousness. Upon exam the resident has a bump to the back part of her head, only hurts to the touch. Residents exam is otherwise normal, neuros normal, resident able to help transfer to wheelchair without difficulty. All extremities moveable, no complaint of pain at this time, resident able to communicate without difficulty, responding appropriately, alert to herself and surroundings. Resident was in soiled clothing, cleaned resident up afterwards, neuros being assessed, physician aware, family notified. Immediate interventions included to make sure call light was within the reach. No additional interventions were implemented. The investigation of the fall lacked details, it was unclear if the resident's bed was in a low position during the fall, where the call light was and if it was on or off. The resident's care plan was not updated with new interventions on or after 11/21/2020. C. Resident interview and observations The resident was interviewed on 12/10/2020 around 10:00 a.m. She was lying down in her bed. The bed was not in a low position. She was not able to recall the events of the fall, she said she had a fall but could not remember when it was and if she got hurt. The resident said she was almost ready to go home and was working with therapy daily. She said she was able to self transfer from wheelchair to bed and back, but was not allowed to do so independently. She said at times she did do it by herself because she could not wait long enough for someone to come in and help her to the bathroom. D. Staff interviews CNA #2 was interviewed on 12/10/2020 around 11:00 a.m. She said Resident #3 was self transferring herself often. She said on many occasions she walked into her room to answer the call light and observed the resident had independently transferred. She said Resident #3 was alert, and able to use the call light. She said the staff did not keep her bed in a low position because she was not a high risk for falls and able to use the call light. -However, the intervention of keeping her bed in the lowest position was added after her fall on 11/15/2020 (see above). CNA #4 was interviewed on 12/10/2020 around 11:20 a.m. She said the resident was at risk for falls and nurses and CNAs were doing frequent checks, which they did not document anywhere. She said the resident was able to use the call light and frequently transferred independently. -However, frequent checks were not indicated on her fall care plan as an intervention. LPN #5 was interviewed on 12/10/2020 around 11:25 a.m. She said the resident was on frequent checks by nursing staff, she was at risk for falls, but she was alert, oriented and was able to use the call light. She said the resident was not on low bed precautions. She said all interventions on the resident care plans were updated by the management team after daily meetings. She said she did not make any changes to the resident care plans. -The bed in lowest position was an intervention to her 11/15/2020 fall and frequent checks were not included in her fall care plan. The DON was not available for an interview on 12/20/2020.

Based on record review and interviews, the facility failed to ensure two (#86 and #88) of six residents reviewed for accidents out of 24 sample residents remained as free from accident hazards as possible. Resident #88 sustained five falls in the facility within a month of his admission. The facility identified the resident's numerous fall risks (recent stroke with left sided weakness, severe cognitive impairment, limited range of motion, occasional incontinence) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize his risks and keep him safe from injury. The resident's fifth fall in the bathroom on 5/26/19 resulted in multiple rib fractures. Resident #86 reported a fall. There was no evidence the fall was investigated to prevent a reoccurrence. Findings include: Facility policies and procedures The Fall Prevention Program policy was provided on 6/18/19 at 2:10 p.m. by the nursing home administrator (NHA). The policy revealed a resident would be assessed for a fall risk as part of the nursing assessment. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall would receive appropriate care and investigation of the cause. A. Resident #88 Resident #88, age 92, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/26/19 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) exam was not conducted. The resident did not have any acute onset of mental status change. He did not display any behaviors and did not reject the care. The resident required extensive two + staff physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He was always continent of bowel and occasionally incontinent of bladder. Resident had limited range of motion in his left upper and lower extremities. The fall section on admission was not completed. 1. Resident status on admission - At high risk to fall a. Family interview The resident's daughter was interviewed on 6/17/19 at 11:33 a.m. She said when her father was admitted to the facility (5/4/19), she told the nurses he was at high risk for falls. She said her father had a fall later that night after she left the facility. Then, he had four more falls and fell a fifth time on 5/26/19 when he was left alone in the bathroom. She said he was found there on the floor. He was transferred to the emergency department where he was diagnosed with [REDACTED]. b. Facility record review revealed the facility knew Resident #88 was at high risk for falls, identifying multiple fall risks on admission. According to the admission report dated 5/4/19, the resident was at high risk for falls with a score of 11. According to the admission note on 5/4/19, the resident arrived on a stretcher and admitted to skilled unit. Has been living at independent living facility and even driving until he had a stroke on Monday. Left sided weakness, incontinent of bowel and bladder. He is aware when he needs to void at most times and does attempt to get out of bed. High fall risk. Totally dependent. Responds verbally. Disoriented to place and time. The admission assessment dated [DATE] indicated resident required maximum assistance with most activities of daily living (ADLs). c. Facility response to identified risks on admission The 5/4/19 assessment note (see above) did not include what interventions were put in place after it was identified by the admitting nurse that the resident was at high risk for falls. However, the following care plans (CP) were initiated after admission: -A CP initiated on 5/4/19 and revised on 5/8/19, revealed the resident had cognitive deficit due to long-term memory loss, and BIMS score of seven that indicated severe cognitive impairment. Interventions included to monitor for any changes or decline in cognitive status, and to offer resident two simple choices to reduce the stress of decision making and increase resident's sense of autonomy. -A CP initiated on 5/14/19 and revised on 5/30/19, revealed the resident was at risk for falls due to the history of falls. Interventions included adequate lighting, provide night light if needed, prompted toileting, assess for unmet needs such as hunger, thirst, pain, and toileting needs to prevent unassisted transfer. -A CP initiated on 5/4/19, and revised on 5/17/19, revealed the resident had impaired physical mobility due to the history of stroke and left sided weakness. He was dependent for transfers and was not able to assist with transfers. Interventions included to assist as needed with wheelchair mobility, high back wheelchair that reclines for comfort and safety, and to provide appropriate level of assistance to promote safety of the resident. 2. Facility failure to develop and communicate effective interventions based on thorough investigations after falls 5/5, 5/14, 5/15, and 5/24/19, to minimize the resident's risks and keep him safe from injury. Record review revealed the facility failed to comprehensively evaluate Resident #88's multiple falls in order to care plan effective, resident-specific interventions to address his known fall risks and to keep him safe from additional falls and injury. a. Fall #1 on 5/5/19 (the day after admission) According to the nurses' progress note dated 5/5/19, the resident sustained [REDACTED]. Stated he was attempting to get self up and wash his face. He is alert, in no apparent distress and no injury noted . Transferred to (wheelchair) and patient requesting to go to (the dining room) for lunch. Reminded patient to use call lite and bed left in low position at all times. An incident report dated 5/5/19 contained the same note as above by the nurse. Interventions included well-lit non-cluttered room, call light in reach, and bed in low position. The supervisor investigation of events and interventions section included an electronic signature from the NHA and the director of nursing (DON). Failure in facility response: The incident report did not document the details regarding the location of the call light, the position of the bed, the footwear the resident was wearing and any other items present in the room that may have contributed to the resident's fall. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (left sided weakness, limited range of motion, severe cognitive impairment) and on a comprehensive review of the 5/5/19 fall contributed to the lack of effective interventions to prevent another fall. b. Fall #2 on 5/14/19 According to the incident report dated 5/14/19, the resident had an unwitnessed fall on 5/14/19 at 2:05 p.m. Description of the incident read: resident slipped out of the (wheelchair), found sitting on the floor. Interventions included well-lit room, non-cluttered environment, nonskid shoes, bed in low position, and mat at bedside. No nurses' progress notes were located regarding this incident, other than a note that read the resident was receiving Tylenol as needed for pain. Failure in facility response: The incident report did not document the details regarding the location of the call light, the resident's footwear, and any other items present in the room that may have contributed to the resident's fall. The care plan for falls, while initiated on this date, failed to include all of the interventions noted in the incident report above, as well as failed to include the interventions that reflected consideration of the details regarding the location of the call light, the resident's footwear, and any other factors, such as wheelchair positioning, that may have contributed to the resident's fall. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (left sided weakness, limited range of motion, severe cognitive impairment) and on a comprehensive review of the 5/14/19 fall, contributed to the lack of effective interventions to prevent another fall the next day. c. Fall #3 on 5/15/19 According to the incident report dated 5/15/19, the resident had an unwitnessed fall on 5/15/19 at 6:10 p.m. Description of the incident read: family member came to this nurse and stated that (resident) was on the floor. Upon entering room (resident) was in sitting position with (wheelchair) behind him. (Resident) was sitting on the pedals of (wheelchair). When asked what happened, (resident) stated he slipped out of the chair. There were no nurses' progress notes regarding this fall. However, the record revealed therapy screen notes that included a recommendation for high back reclining wheelchair. Other interventions included to continue skilled therapy, call light in place, educate on calling for assistance, and nursing to provide frequent checks. Failures in facility response: While the resident's care plan (updated 5/17/19) referenced the high back wheelchair (see above), the care plan did not include the intervention that staff were to provide frequent checks of the resident or define for staff what frequent checks meant. Moreover, the incident report did not document the details regarding the placement of the call light, the footwear the resident was wearing, and any other items present in the room that may have contributed to his fall. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (left sided weakness, limited range of motion, severe cognitive impairment), failure to add planned interventions to the care plan, and failure to comprehensively review the 5/15/19 fall, contributed to the lack of effective interventions to prevent resident experiencing another fall. d. Fall #4 on 5/24/19 According to the incident report dated 5/24/19, resident had a fourth unwitnessed fall on 5/24/19 at 7:00 p.m. Description of an incident read: (Resident) was being put to bed by certified nurses' aide (CNA) and was sitting in bed, CNA went to get urinal and found (resident) on the floor. Interventions included education to staff not to leave resident on the side of the bed, and to make sure he was wearing grip socks for transfers. Resident was put on prompt toileting schedule and increased rounding by staff. Failures in facility response: The above interventions, to not leave the resident on the side of the bed and to ensure the resident wore grip socks for transfers, were not added to the resident's care plans (see above). Increased rounding by staff was not defined or distinguished from the intervention frequent checks noted following the resident's 5/15/19 fall (see above). The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (left sided weakness, limited range of motion, severe cognitive impairment), failure to add planned interventions to the care plan, contributed to the resident experiencing an additional fall with injury. e. Fall #5 on 5/26/19 According to the incident report dated 5/26/19, the resident had an unwitnessed fall on 5/26/19 at 3:30 p.m. (a.m.) Description of the incident read: Approx. 3:30 (a.m.) nurse was at med cart and bathroom light came on and then there was a calling out for help. Found by nurse lying on (the) bathroom floor. Complaining of chest pain. Several of staff assisted him into his (wheelchair) and moved him just outside the bathroom and proceed to have projectile vomiting. During assessment he said he did bump his head. Pupils unequal, left eye reacting and right eye not reacting. (Physician) notified and was told to send him to the hospital. He also (complained of) (left) arm and back pain and pain on inspiration. 3. Failure to implement care planned interventions (assess for unmet needs, provide appropriate level of assistance) and recommended interventions documented on the incident reports to prevent unassisted transfers and to promote resident safety. The electronic medical record computerized ADL coding report (a medical information system used by CNAs to record all care that was provided to the resident during specific time) was reviewed for Resident #88. It revealed long periods of time between CNA assistance with ADLs, even though the resident was assessed to require maximum assistance with most ADLs (see admission assessment above) and he was to be checked frequently. Specifically: -The day of the resident's first fall, 5/5/19 at 12:15 p.m., he was assisted with personal hygiene and toileting at 6 a.m., 4:19 p.m., and 10 p.m. There was no record the resident was assessed or assisted with ADLs anytime between 6 a.m. and 12:15 p.m. when he was found on the floor. -The day of the resident's second fall, 5/14/19 at 2:05 p.m., the resident was assisted with personal hygiene and toileting at 2 p.m. (time of the fall) and 2:38 p.m. There were no other time stamps to show the resident was assessed or assisted that day. -The day of the resident's third fall, 5/15/19 at 6:10 p.m., the resident was assisted with personal hygiene and toileting at 6 a.m. and 5:20 p.m. There were no other time stamps for that day although the incident report for this fall included nursing providing frequent checks. -The day of the resident's fourth fall, 5/24/19 at 7:00 p.m., the resident was assisted with personal hygiene and toileting at 10:55 a.m., 9:53 p.m., and 10 p.m. There were no records the resident was assisted to the bathroom prior to the fall and no record of frequent checks or increased rounding. -The day of the resident's fifth fall on 5/26/19 at 3:00 a.m., resident was assisted with personal hygiene and toileting at 1 p.m. There were no other time stamps for that day. The above report demonstrated that interventions that were recommended after the fourth fall on 5/24/19, such as prompt toileting schedule and increased rounding by staff were not implemented by nurses and CNAs. 5. Hospital record review According to a computerized tomography (CT) scan performed on 5/26/19 in the emergency department, the resident had acute fractures of left fourth through ninth ribs (5 ribs). According to the hospital discharge summary, dated 5/30/19, the resident was admitted to the hospital after he had a mechanical fall in the long term care facility. He sustained multiple rib fractures and required aggressive [MEDICAL CONDITION] treatment. 6. Staff interviews Staff interviews revealed residents with weakness on one side should not be left alone. -Registered nurse (RN) #1 was interviewed on 6/20/19 at 10:56 a.m. She said residents were assessed on admission for fall risk. High fall risk residents were placed closer to the nurses' stations and were on frequent checks by nurses and CNAs. She said anyone with a history of stroke and with weakness on one side will be a high fall risk. She said due to the weakness on one side, such residents should not be left alone by staff in the position they can fall from; that position would be on the side of the bed or toilet. She said such residents should be assisted in the bathroom and not be left alone. -RN #2 was interviewed on 6/20/19 at 11:20 a.m. He said residents at risk for falls were frequently checked by staff members, like every 30 minutes. He said it was shared responsibility between nurses and CNAs. He said residents after a stroke with one sided weakness should not be left alone in the bathroom at any time. -The physical therapy director, was interviewed on 6/19/19 at 11:28 a.m. She said Resident #88 was discharged to an acute care hospital and therapy was interrupted by an emergency event. She said she worked with resident and she was familiar with his physical abilities. She said she would not recommend leaving him alone in the bathroom or in a situation where he would be willing to transfer as he was not able to balance independently. CNA interviews revealed information regarding a resident's care and CNA provision of care was documented on a tablet. -CNA #5 was interviewed on 6/20/19 at 10:56 a.m. She said prior to providing care to the resident, she reviewed the resident's care plan on her tablet. She said all the tasks that a resident required were listed on the tablet and she was able to sign those tasks after she provided the care. She said on the busy days when care provided but not recorded timely, they could log in from the desk computer and make changes after the shift. -CNA #3 was interviewed on 6/20/19 at 11:07 a.m. She said she relied on her tablet for information regarding new residents and care they required. She said she documented all care on the tablet. She said residents that were high fall risk would have a special care plan that would describe in detail what should and should not be done. The director of nursing (DON) was interviewed on 6/18/19 at 1:38 p.m. He said the management team had noticed the pattern of the falls for Resident #88 after his third fall. He said they also identified that some CNAs that were working with resident did not have access to the tablet and therefore were not able to read and sign the tasks. He said a performance improvement plan (PIP) was put in place and provided a copy. B. Resident #86 Resident #86, age 60, was admitted on [DATE] and discharged to an assisted living facility on 5/3/19. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. According to the 5/3/19 MDS assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He did not exhibit any behaviors of inattention or disorganized thinking. Resident #86 required limited assistance and supervision of one person with transfers, toilet use, and ambulation in the room. He used a wheelchair for ambulation. The CP initiated on 3/7/19, and revised on 3/20/19, revealed the resident was at risk for falls due to the history of falls. Interventions included: to assess contributing factors related to fall history (fell down the stairs at daughter's house in wheelchair on 3/7/19), and to assess environment to maximize safety: keep pathways clutter free. The CP initiated on 3/7/19, and revised on 3/20/19, revealed the resident was taking medications for [MEDICAL CONDITION] and was at risk for falls due to [MEDICAL CONDITION]. Interventions included to assess for fall risk and prevention plan if needed, and to administer medications. The physical therapy director, was interviewed on 6/19/19 at 11:28 a.m. She said the resident was able to self transfer but was encouraged to call for assistance with transfers and repositioning. He was working with therapy on independent transfers, and walking with assistance. She said resident had unstable gait pattern, he was impulsive at times, and ambulated with two wheel walker. She said in therapy resident was working on fall recovery, as he wished to discharge to an assisted living facility. She said resident was young and strong enough to get himself off the floor. 1. Report of a fall The resident's daughter was interviewed on 6/17/19 at 2:30 p.m. She said her dad called her on 4/22/19 and told her he had fallen. She said she reported it to the DON on 4/24/19. She said her dad had the date written down, so he would remember the date it happened. When she reported it to the DON, she was told there was no incident report and went back to his work without telling her he would follow up. She said he never called and gave her information about her dad's report of a fall. A progress noted by physician dated 4/25/19 reads: Nurse asks me to assess for fall. He did not mention this to me yesterday when we spoke. Chief Complaint: Had a fall in his room on Monday. There is a spot on his wall that looks like something (possibly wheelchair) bumped into it. He states he slid out of WC (wheelchair) and bumped into the wall, he denies any injury. No HA (headache), no neck pain. 2. Failure to have evidence the reported fall was investigated to prevent a reoccurrence. RN #2 was interviewed on 6/20/19 at 11:20 a.m. He said the facility would start fall investigation when residents or anyone else notified staff about the fall. After the investigation, all falls and incident reports were reviewed by management team and the director of nursing (DON). Nurses' notes were reviewed between (MONTH) and (MONTH) 2019. There were no notes about a fall by the resident in (MONTH) 2019. The incident report regarding the fall on 4/24/19 was requested from DON. DON stated there were no incident report for that date. The DON confirmed Resident #86 had communicated to him that he had a fall; he said resident told him that he flipped in his wheelchair. The DON said he did his own investigation and wrote a note, but no longer could locate that note. He said he also talked to someone in physical therapy department (he could not recall who he talked to) and they told him Resident #86 would not be able to get up by himself after the fall. He said he thought it was very unlikely that the fall actually happened even though he said the resident had not made any false allegations in the past and was alert and oriented to time, place and staff. The DON was not able to locate any notes on the investigation of the fall by the end of the survey.