Every finding on record at Apple Rehab Laurel Woods

Based on clinical record review, facility documentation/policies, and interviews for one (1) sampled resident (Resident #1) reviewed for accidents, the facility failed to ensure a severely cognitively impaired resident who required total assistance with meals due to significant tremors and fluctuating lethargy was protected from injury associated with access to a meal tray containing hot soup prior to staff being present to provide the required feeding assistance. Specifically, the facility placed a meal tray containing hot soup within Resident #1's reach before staff were present to provide feeding assistance. As a result, Resident #1 attempted to self-feed, spilled the hot soup onto the right thigh, and sustained a blistering burn requiring medical and wound treatment. The findings include:Resident #1's diagnoses included metabolic encephalopathy, cognition communication deficit, diabetes mellitus, schizoaffective disorder, and post-traumatic stress disorder. An Occupational Therapy progress note dated 6/8/2026 by OT #1 identified Resident #1 was seen for lunch and ate half a cheeseburger and a couple French fries requiring total feed assistance. Resident #1 was significantly limited by tremors. The note directed to discontinue adaptive equipment (AE) for meals as Resident #1 was unable to use the AE due to tremors.The Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6) and required a substantial/maximum assistance with activities of daily living (ADLs) (including eating) and transfers.The physician orders dated 7/1/26 directed a total mechanical lift with assistance of two for all transfers to an adapted tilt-in-space wheelchair with appropriate support. Resident #1 was to be repositioned for comfort using the wheelchair's tilt feature and maintained in a fully upright position during all meals. The orders directed total assistance with all meals due to physical limitations.The Resident Care Plan (RCP) dated 7/9/2026 identified Resident #1 as at risk for nutritional decline related to multiple medical problems and significant weight loss. Interventions included providing assistance with cutting food and meals as ordered, providing the prescribed diet, obtaining an OT consultation as needed, monitoring intake and output, providing nutrition education, and monitoring for signs of increased difficulty chewing or swallowing and reporting changes to the physician.The Facility Reported Incident Form and investigation dated 7/29/26 at 5:35 PM identified Resident #1 required total assistance with meals and assistance with transfers and ADLs. During the evening, a meal tray was placed on the bedside table, and Resident #1 attempted to feed him/herself without assistance which caused a soup spill onto the upper right thigh resulting in redness and blistering. Resident #1 was assessed, the provider was notified, and wound care was initiated following evaluation by the in-house provider and wound physician. Following the incident, dietary and nursing staff were educated to ensure meal trays for residents requiring feeding assistance were not placed within the resident's reach until nursing staff were present and available to provide feeding assistance. The wound consultation note dated 7/30/26 by MD #1 identified a new burn wound to Resident #1's right lateral thigh resulting from hot liquid. The burn measured 7.2 cm x 3.5 cm, with intact serous blisters and no drainage, erythema, induration, or other signs of infection. Resident #1 reported pain of 2/10 at rest. Treatment included cleansing the burn wound, applying Silvadene, and covering it with clean dressing daily and as needed. MD #1 recommended ongoing observation, nutritional optimization, protection of the area, and avoidance of friction, shearing, and trauma.Interview with the Director of Rehabilitation (DOR) on 8/19/26 at 10:20 AM identified that, prior to the 7/29/26 incident, Resident #1 required total assistance with feeding/meals due to tremors and fluctuating lethargy. The DOR indicated the level of assistance was required for safety and staff should not have placed the meal tray within reach on 7/29/26 due to the risk of injury from hot food or liquids.Interview with the Director of Dietary (DOD) on 8/19/26 at 11:00 AM identified that soup is temperature-checked in the kitchen prior to distribution, with an expected temperature of 165-180 F. The DOD identified that dietary staff deliver meal trays to residents, except for residents identified as feeds. Dietary slips identified residents requiring feeding assistance, and those trays are placed at the nurses' station for nursing staff to retrieve and provide assistance. The DOD stated that, to his knowledge, dietary staff did not place Resident #1's meal tray at the bedside on 7/29/26.Interview with RN #1 and the ADON on 8/19/26 at 12:35 PM identified that the facility's investigation was unable to determine which staff member placed Resident #1's meal tray at the bedside. RN #1 described the facility's process whereby dietary staff distribute meal trays to residents, except for residents identified as requiring feeding assistance; those trays were placed at the nurses' station until nursing staff were available to provide feeding assistance. Following the incident, dietary and nursing staff were educated that trays for residents requiring feeding assistance were not to be placed within the resident's reach unless staff were present to provide assistance. The facility also initiated weekly mealtime audits and Quality Assurance and Performance Improvement (QAPI) monitoring to ensure compliance with the process.Although attempted, interviews with the DON and Administrator were not obtained.Review of the Feeding Assistance Policy identified residents requiring feeding assistance will receive care in a respectful and person-centered manner. The facility staff will ensure that the resident is receiving the prescribed diet and any ordered adaptive equipment or feeding techniques are utilized. Residents requiring 1:1 feeding assistance will receive continuous supervision and assistance during meals according to the plan of care. Remove meal trays promptly when feeding is complete.Review of facilities corrective action documentation identified that, following the incident, all dietary and nursing staff were educated on ensuring meal trays for residents requiring direct feeding assistance were not placed within the resident's reach unless staff were present to provide assistance. The facility identified all residents requiring direct feeding assistance as potentially affected and implemented random weekly mealtime audits for 30 days or until substantial compliance was achieved, with results reviewed through QAPI. The DNS or designee was responsible for monitoring compliance. Based on review of the facilities corrective action documentation, staff education, audit process, and QAPI monitoring activities, the facility was determined to have achieved past non-compliance. The facility identified the date of compliance as of 8/3/26.

Based on observations, interviews, review of the clinical record and facility policy, for 3 of 3 sampled residents (Resident #8, Resident #24, and Resident #55) reviewed for pressure ulcers, for Resident #8 and Resident #24, the facility failed to wear appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) high contact care activities, and for Resident #8 and Resident #55, failed to perform appropriate hand hygiene according to infection control practices for Enhanced Barrier Precautions (EBP). The findings include: 1. Resident #8's diagnoses included cellulitis of buttock, obesity, chronic congestive heart failure, atherosclerosis of extremities, and hypertension. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #8 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, required setup or clean-up assistance with eating, and substantial/maximal assistance with toileting and personal hygiene. The Resident Care Plan in effect from 12/30/25 through 1/27/26 identified Resident #8 was on EBP in addition to the facility's standard precautions because of a higher risk of infection. Interventions included placement of an EBP sign outside the resident's room, clean hands, place on a gown and gloves, and clean hands again. a. A physician order in effect from 12/30/25 through 1/27/26 directed to follow EBP for an open wound to the buttock for infection control purposes. Interview and observation of Nursing Assistant (NA) #4 on 1/27/26 at 1:25 PM identified her entering Resident #8's room to perform personal care, wearing gloves, without the benefit of placing on a gown. NA #4 identified an EPB sign located outside of the room, indicated she needed to place on a gown prior to entering, but failed to do so as she forgot, adding Resident #8 was not assigned to her and she was just trying to help. b. A physician's order dated 1/8/26 directed to apply Gentamicin Sulfate External Ointment 0.1% to the right buttock wound topically every day and evening shift for wound care. Cleanse prior with wound cleanser, followed by Calcium Alginate, followed by a dry clean dressing. Interview and observation of Licensed Practical Nurse (LPN) #10 on 1/29/26 at 11:22 AM identified her entering Resident #8's room to perform wound care. Although an EBP sign was present outside Resident #8's door, LPN #10 failed to cleanse her hands, and failed to place on gloves and a gown prior to entering. Observation during wound care identified LPN #10 placed on gloves without cleansing her hands, removed the resident's old dressing removed her gloves and placed on a new pair of gloves without the benefit of cleansing or sanitizing her hands. LPN #10 verbalized she knew the resident was on EBP but forgot to follow the facility's EBP policy as she didn't notice the residents EBP sign outside of his/her door. LPN #10 stated she forgot to cleanse her hands in between taking off the dirty gloves and placing on the clean gloves prior to placing the clean dressing but should have. Interview with Regional Registered Nurse (RN) #3 at 11:37 AM identified that LPN #10 should have performed hand hygiene and applied appropriate PPE, which included gloves and a gown prior to providing wound care to Resident #8. RN #3 identified she was going to speak with Registered Nurse (RN) #4 to attempt to implement improvements and increase adherence to the facility's EBP policy. 2. Resident #24's diagnoses included Pressure Ulcer (PU) of the Sacral Region, Stage 4. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Resident #24 required maximum assistance for eating, toileting hygiene, shower/bathe self, transferring, and upper and lower body dressing. The Resident Care Plan in effect from 1/2/26 through 1/22/26 identified EBP in use. Interventions included hanging an EBP sign outside of the room, providers must wear a gown and gloves for the following high-contact resident care activities: dressing, bathing showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and everyone must clean their hands including before entering and when leaving the room. A physician's order in effect from 1/2/26 through 1/22/26 directed the facility to use EBP due to the presence of a wound every shift for infection control purposes. Observation on 1/22/26 at 10:09 AM outside of Resident #24's room identified an EBP sign directing PPE be worn during high-contact activities which included toileting. Nurse Aid (NA) #2 entered Resident #24's room carrying washcloths, towels, and bed linens but failed to apply PPE prior to entering. NA #2 was observed to leave the room indicating that she had changed Resident #24 due to bowel incontinence. Interview of NA #2 on 1/22/26 at 10:40 AM identified that NA #2 had not worn appropriate PPE while performing Resident #24's incontinent care stating, No I didn't wear a gown to change Resident #24; I only used gloves. NA #2 indicated she was aware of the sign and should have used a gown when performing Resident #24's incontinent care. 3. Resident #55's diagnoses included multiple sclerosis, abnormal posture and nonspecific skin eruption. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, was dependent on staff for eating, dressing and transfers, was at risk for developing pressure ulcers, and had moisture associated skin damage. The Resident Care Plan dated 12/22/25 identified Resident #55 was at risk for an alteration in skin integrity related to decreased mobility from multiple sclerosis, and incontinence of bowel and bladder. Interventions included providing wound care as ordered and monitoring skin for signs and symptoms of breakdown. A physician's order dated 1/8/26 directed to cleanse Resident #55's bilateral buttocks with normal saline, followed by bacitracin, followed by Calcium Alginate covered by a dry clean dressing twice a day and as needed for wound care. Observation of the Enhanced Barrier Precaution sign posted outside Resident #55's room instructed that everyone must clean their hands including before entering and when leaving the room. Observation and interview with Licensed Practical Nurse (LPN) #5 on 1/27/26 at 10:54 AM identified she placed on a gown but failed to perform hand hygiene following the gown placement. LPN #5 entered the room with wound care supplies in hand, then applied gloves without the benefit of cleansing prior to glove application. After removing Resident #55's dirty wound dressing and placing it in the trash receptacle, she continued to perform the treatment without the benefit of removing the soiled gloves, cleansing her hands, or applying clean gloves. LPN #5 identified that hand hygiene should have been performed before entering, after care, and after exiting Resident #55's room. Although LPN #5 identified she received hand hygiene education she could not identify why she did not perform hand hygiene or why she did not change her gloves when going from the dirty dressing to placing a clean dressing during wound care. Interview with Registered Regional Nurse (RN) #3 on 1/29/26 at 11:22 AM identified that hand hygiene should be performed prior to application of personal protective equipment, per the Enhanced Barrier Protection (EBP) policy. Review of the Enhanced Barrier Precautions Policy revised May 2024 directed in part that staff will perform hand hygiene and apply personal protective equipment prior to providing high contact care (which included wound care). Review of the Handwashing Policy revised November 2017 directed in part that staff will wash hands after removing gloves and after contact with wound dressings. Review of the Treatment Process policy directed in part to perform hand hygiene, apply clean gloves, remove and dispose of the dressing, remove gloves, perform hand hygiene then apply clean gloves. The Enhanced Barrier Precautions Policy effective 4/1/24, last revised 5/5/24 directed in part, that the facility will implement EBP during high-contact resident care activities for any resident with an indwelling medical device (e.g. central lines, urinary catheters, feeding tubes, and tracheostomies) or chronic wounds (e.g. pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers), regardless of MDRO (Multi-Drug Resistant Organisms) colonization or infection status. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include dressing, bathing/showering/providing hygiene, transferring (with the exception to transfers in common areas), changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy, etc.), and wound care. Appropriate signage for EBP will be visible. Appropriate PPE and hand sanitizer will be readily accessible for use. Staff will perform hand hygiene and don (place) PPE before providing high-contact care to the resident. Staff will doff (take off) PPE, perform hand hygiene after providing high-contact care to the resident and place PPE in a trash receptacle located in resident's room.

Based on interviews, review of the clinical record, review of documentation, and facility policy for 1 of 3 sampled residents, (Resident #19) reviewed for abuse, the facility failed to report bruises of unknown origin to the State Agency (SA). The findings include:Resident #19's diagnoses included hyperlipidemia, unspecified sequelae of cerebral infarction, and Post-Traumatic Stress Disorder (PTSD).The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment, was dependent on staff for toileting and shower/bathing self and required substantial/maximal assistance for transfers. The Resident Care Plan (RCP) dated 9/13/24 identified Resident #19 was at risk for falls related to impaired balance. Interventions included staff to put the call bell within reach when the resident was in bed or bedside chair, to receive Physical Therapy (PT)/Occupational Therapy (OT) as ordered, and for staff to offer assistance with toileting at bedtime. A nursing note dated 10/7/24 at 9:32 PM and investigation identified that Resident #19 was observed with a purple-colored bruise to his/her left flank (area between the ribs and hip). Resident #19 was unable to identify how the bruises occurred and the investigation did not conclusively identify the cause other than the resident was known to lean to the left.A nursing note dated 1/14/25 at 1:44 AM and investigation identified that Resident #19 was observed with 2 bruises to his/her upper posterior right arm. Resident #19 was unable to identify how the bruises occurred and the investigation did not identify a cause. Review of the state agency's incident reporting system failed to identify the observations of bruises of unknown origin on 10/7/24 and 1/14/25 were reported.Interview with the Director of Nurses (DNS) and Assistant Director of Nurses (ADNS) on 1/28/26 at 2:41 PM identified that the DNS and ADNS were responsible for reporting incidents to the State Agency (SA). Additionally, the DNS indicated that she thought she did not have to report the incidents to the SA unless the facility substantiated abuse from their investigation. The DNS and ADNS indicated that they would report all bruises of unknown origin to the SA in the future.Review of the undated abuse policy directed, in part, staff must identify and report any suspicious bruising, patterns of injury, or behavioral changes that may indicate abuse. The DNS or designee will notify the residents family, physician, Department of Public Health (DPH), and local police as needed. A follow-up report, including conclusions and any actions taken, will be submitted online to DPH within five (5) days of the alleged incident.

Based on observations, review of the clinical record, facility policy, and interviews for 2 of 3 sampled residents (Resident #45 and Resident #64) reviewed for Activities of Daily Living (ADL), the facility failed to provide hygiene assistance for staff dependent care. The findings include:1. Resident # 45's diagnoses included diabetes with diabetic neuropathy (nerve damage), muscle weakness and dysphagia (swallowing difficulty).The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 had a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment, and was totally dependent on staff with eating, hygiene, and toileting, and was always incontinent of bowel and bladder.The Resident Care Plan dated 12/30/25 identified Resident #45 required assistance with ADLs due to weakness did not get out of bed, was bed bound at home, and refused showers. Interventions included if care was refused remind the resident of the importance but honor his/her right to refuse, offer assistance as needed with washing, bathing, dressing, toileting and oral hygiene, and offer comfort bed bath if refused a bath/shower. Observation on 1/21/26 at 12:39 PM identified Resident #45's fingernails were very long.Observation on 1/27/26 at 10:05 AM identified Resident #45's fingernails were long with brown debris under the fingernails.Interview with Nurse Aid (NA) #4 on 1/27/26 at 1:59 PM identified she had not cleaned or cut Resident #45's fingernails today yet but she would.2. Resident #64's diagnosis included metabolic encephalopathy, chronic respiratory failure with hypoxia (inadequate oxygen), hemiplegia (paralysis) and hemiparesis (weakness) following cerebral vascular disease affecting the left non-dominant side.The annual Minimum Data Set assessment dated [DATE] identified Resident #64 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment and required partial moderate assistance with eating and was totally dependent on staff for hygiene, dressing, toileting, transfers, and was always incontinent of bowel and bladder.The Resident Care Plan dated 12/2/25 identified Resident #64 required ADL assistance, continence fluctuated, may refuse to be shaved and would inform staff when shaving assistance was requested; choose to stay in bed most days. Interventions included if refused assistance please remind Resident #64 of the importance of care but honor the right to refuse. Required assistance with daily washing, dressing, grooming, bathing, and mouth care.Observation on 1/21/26 at 12:24 PM identified that Resident # 64 had long fingernails and was unshaven. Resident #64 identified that s/he wanted to be shaven and was not growing a beard.Observation on 1/27/26 at 10:08 AM identified Resident #64's beard area had been trimmed but was not clean shaven. Resident #64 wanted to be clean shaven and fingernails remained long. Resident #64 was agreeable to having nails trimmed. Resident #64's shaving supplies were observed in the nightstand.Observation on 1/28/26 at 9:34 AM identified Resident #64's fingernails remained long with debris underneath.Interview, observation, and review of clinical records with LPN #8 on 1/28/26 at 10:46 for Resident #45 and Resident #64 identified that showers had been received as documented in the clinical record and failed to indicate any refusals during the month of January 2026. LPN #8 stated that the expectation for showering included washing hair, shaving, and fingernail cleaning and trimming. Observation of Resident #45 with LPN #8 identified that Resident #45's fingernails were long, with debris underneath and nail care was needed. Observation of Resident #64's fingernails identified debris underneath and that shaving hygiene assistance was needed to which Resident #64 was agreeable. LPN #8 could not explain why Resident #45 nor Resident #64's fingernails were long and unclean with a brown substance underneath or why Resident #64 was unshaven. Subsequent to surveyor inquiry, LPN #8 indicated she would direct NA #4 to provide the necessary care to both Resident #45 and Resident #64.Interview and record review with the Director of Nursing (DNS) and Assistant Director of Nursing (ADNS) on 1/28/26 at 1:52 PM identified Resident #45 and Resident #64 had showers as documented in the clinical record but could not explain why nail care and shaving had not been provided. The DNS further indicated that the expectation was to provide nail care and shaving on shower days, this care should also be provided as needed.Subsequent observations of both Resident #45 and #64 identified nail care and shaving had been provided.Attempts to interview NA #5 were unsuccessful.Review of the AM Care/ADL policy dated 12/9/14 directed, in part, nursing staff will assist with AM care for each resident daily as needed. Shave resident if needed unless otherwise indicated using regular razor or personal electric razor. Provide fingernail care including trimming nails if needed. If residents refused care, please reapproach, and notify the nurse. Document all care given as well as care refusals in POC (electronic medical record).

Based on observations, interviews, and record review for 1 of 3 sampled residents (Resident #55) reviewed for pressure ulcers, the facility failed to ensure a pressure-reducing mattress was set per the physician's orders for a dependent resident with wounds. The findings include:Resident #55's diagnoses included multiple sclerosis, abnormal posture, and nonspecific skin eruption.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, and was dependent on staff for eating, dressing and transfers. Additionally Resident #55 was always incontinent, was at risk for developing pressure ulcers, had moisture associated skin damage and was receiving skin and ulcer/injury treatments that included a pressure reducing device.Review of the quarterly skin evaluation dated 12/9/25 identified Resident #55 had a Braden Scale (pressure ulcers risk assessment) score of 14 indicating he/she was at high risk for pressure ulcers.The Resident Care Plan dated 12/22/25 identified Resident #55 was at risk for an alteration in skin integrity related to decreased mobility from multiple sclerosis, and incontinence of bowel and bladder. Interventions included providing wound care as ordered, monitoring skin for signs and symptoms of breakdown, and a pressure reducing mattress when in bed.A physician's order dated 1/6/26 directed for a low air loss mattress, check function each shift and set to 173 pounds.A review of the Medication Administration Record dated 1/6/26 through 1/27/26 identified nurse initials reflecting day, evening and night shift nurses had checked function, and the low air loss mattress was to be set at 173 pounds.A review of the wound care specialist progress note dated 1/22/26 at 10:45 AM identified Resident #55 was receiving treatments as recommended with the wound to the left buttock resolved and a reoccurrence of the moisture associated skin damage to the right buttock. (per wound assessment reports, Resident #55 had recurring moisture associated skin damage to bilateral buttocks since October 2025). Additionally, the progress note identified the wound measured 1.22 centimeters (CM) by 1.2 cm by 0.1 cm with a moderate amount of serosanguinous (bloody/watery) drainage. A new treatment to cleanse the wound, apply bacitracin followed by calcium alginate with silver to the base of the wound and secure with a dry clean dressing twice a day was recommended.Observations on 1/21/26 at 10:00 AM and at 1:54 PM, and on 1/22/2026 at 12:50 PM identified Resident #55 in bed with the pressure reducing mattress set to 450 pounds (205 kg), and a white sticker on top of the pump reading 200 lbs. Interview and observation with Licensed Practical Nurse (LPN) #5 on 1/27/26 at 10:54 AM identified that the pressure relieving mattresses were checked by the charge nurses, but she could not identify what Resident #55's pressure mattress should have been set to, what the white sticker indicating 200 lbs. on top of the pump referred to, or where she could find the information.Interview and record review with Infection Prevention Registered Nurse (RN) #4 on 1/27/26 at 1:25 PM identified that it was the facility policy to provide residents with pressure relieving mattresses if they had a wound or for comfort, with physician's orders dictating the appropriate weight setting for residents with wounds. Additionally, review of Resident #55's electronic health record identified that he/she had a pressure relieving mattress that should be monitored for function and should have been set to 173 pounds.Although requested, the facility failed to provide a policy on mattresses, pressure reducing devices, low air loss mattresses or pressure alternating mattresses.

Based on interviews, record review, and policy review for the only sampled resident (Resident #7) reviewed for hemolytic treatments, the facility failed to follow a hemolytic treatment center directive for a fluid restriction and failed to monitor intake/output amounts. The findings include:Resident #7's diagnoses included end stage renal disease, hypertension, and peripheral vascular disease.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, was independent with eating and personal hygiene and was receiving hemolytic treatment.The Resident Care Plan dated 1/23/25 identified Resident #7 received hemolytic treatments due to chronic renal disease and was at risk for bleeding, infection, and septic shock. Interventions included fluid restriction as per the physician orders, intake and output as ordered/per policy, and to watch for signs and symptoms of fluid overload and report to the physician.The physician's order dated 1/6/26 directed a fluid restriction of 1200 milliliters (ml).A review of the physician's orders for January 2026 failed to direct intake/output monitoring.The Nutritional assessment dated [DATE] directed a fluid restriction of 1200 ml identifying it was per the hemolytic treatment registered dietician.Review of the Physician/Advanced Practice Registered Nurse (APRN) notes dated 1/6/26 through 1/28/26 failed to identify Resident #7 was on a fluid restriction, failed to address fluid restriction compliance, and failed to indicate that intake/output was being monitored.Review of nursing progress notes dated 1/6/26 through 1/28/26 failed to identify Resident #7 was on a fluid restriction, had maintained fluid restriction compliance, or that intake/output was being monitored.Review of the Nurse Aid Resident Assignment failed to identify Resident #7 was on a fluid restriction or intake/output monitoring was required.Interview and record review with Licensed Practical Nurse (LPN) #6 on 1/27/26 at 10:24 AM identified it was facility policy to follow fluid restriction and intake/output for residents per the physician's orders. Review of Resident #7's electronic health record with LPN #6 identified a physician's order for a fluid restriction of 1200 ml, however further review failed to identify that an order to monitor intake/output was in place or that intake/output monitoring had occurred or was documented. Although LPN #6 could not identify why Resident #7's intake/output was not being monitored, it should have been due to the fluid restriction orders.Interview and record review with the Director of Nurses (DNS) on 1/27/26 at 1:52 PM identified it was facility policy for intake/output to be monitored if a resident was identified as dehydrated, not eating, or was on a fluid restriction. Additionally, the facility policy for a fluid restriction required a physician's order and that nursing would monitor the resident's intake/output so that the restriction would be maintained. Review of Resident #7's electronic health record with the DNS identified he/she had a physician's order for a 1200 ml fluid restriction, which was determined by the hemolytic treatment center. The DNS failed to identify intake/output was being monitored or documented for Resident #7 but should have been. Additionally, the DNS identified the fluid restriction order was put in as a diet order instead of a monitoring order which did not trigger the intake/output to be monitored or documented.Interview with the hemolytic treatment center, Registered Dietician, on 1/28/26 at 10:41 AM identified that Resident #7 had been on a 1200 ml fluid restriction since 1/6/26, and that was communicated to the facility's Registered Dietician. Additionally, the hemolytic center Registered Dietician identified that failure in adhering to a fluid restriction could result in Resident #7 having an increased blood pressure, weight gain due to fluid retention, and there was a concern that fluid overload might lead to hospitalization.Interview and record review with APRN #1 on 1/28/26 at 11:56 AM identified it was her practice to follow recommendations from the hemolytic center and the renal physician for a plan of care for hemolytic treatment residents. APRN #1 indicated that she did not usually check on intake/output and fluid restrictions. Additionally, even though the intake/output was not being tracked she identified she was in agreement with the plan of care currently being provided because Resident #7 did not exhibit symptoms of fluid overload and blood pressure fluctuations were considered normal for a hemolytic treatment resident.Review of the Hemolytic Treatment Policy directed, in part, that the facility is responsible for providing pre and post dialysis care to the resident while at the facility. Additionally, the procedure specified to maintain fluid restrictions as ordered, monitor intake/output and notify the physician and dialysis if the resident is non-compliant with fluid restrictions.Review of the Intake & Output Monitoring Policy directed in part to ensure timely identification of hydration risk and appropriate use of intake/and output monitoring as a targeted clinical intervention, based on individualized resident needs and assessment findings.

Based on observations, review of clinical records, and facility policy for 1 of 7 sampled residents reviewed for medication administration, the facility failed to ensure that delayed release medications were not crushed resulting in a medication error rate above 5% (11.11%). The findings include:Resident #20's diagnoses included chronic obstructive pulmonary disease, dementia with psychotic disturbance and atherosclerotic heart disease.Physician's orders dated 12/15/25 directed in part, to administer Aspirin 81 mg Delayed Release (DR) tablet orally daily, Depakote 250 mg DR orally daily, and Pantoprazole 20 mg DR orally 2 times a day.Observation on 1/21/26 at 9:33 AM with LPN #1 during medication administration identified Resident #20's medications were in a plastic cup and upon administration, Resident #20 was asked if s/he would like her/his medications crushed, s/he replied yes. LPN #1 donned gloves, placed the 3 morning medications in an envelope, crushed the contents, and then placed them in applesauce and administered the medications to Resident #20. During a subsequent review of the physician's orders and interview with RN #4 on 1/21/26 at 2:00 PM indicated that delayed release medications (Aspirin DR, Depakote DR and Pantoprazole DR) should not be crushed.Review of the facility policy for Medication Administration and General Guidelines directed that if it is safe to do so, medication tablets may be crushed or capsules emptied out when the resident has difficulty swallowing; long-acting medications or enteric coated dosage forms should generally not be crushed.According to the US Food and Drug Administration, long-acting medications, extended release, delayed release, enteric coated medications should not be split, chewed or crushed.

Based on observations, review of the clinical record, facility policy, and interviews during a review of medication storage for 1 of 3 medication carts, for the only sampled resident (Resident #85) reviewed, the facility failed to ensure expired medications were disposed of properly and not administered after the expiration date. The findings include:Resident #85's diagnosis included osteomyelitis and type II diabetes mellitus.A physician's order dated 12/19/25 directed Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro), inject per a sliding scale, subcutaneously, 3 times a day for diabetes mellitus.Observation on 1/22/26 at 10:34 AM, of the medication cart located at the nurse's station, identified Resident #85's Lispro insulin flex pen was dated 12/19/25. Interview with LPN #4 identified that the resident's insulin was used as needed for coverage and hasn't been administered lately.Review of the January Medication Administration Record (MAR) identified that Lispro insulin was administered per the sliding scale on 1/17/26, 1/18/26, 1/19/26 and 1/20/26 at 4:30 PM and 1/19/26 at 11:30 AM for coverage of blood glucose results over 251 milligrams, 4 days after the discard date of 1/17/26.Subsequent interview with the ADNS at on 1/22/26 at 10:37 AM, identified that the resident received insulin coverage on 1/20/26 at 4:30 PM therefore, the flex pen was expired and should have been discarded after 28 days (1/16/26) per facility expectations.Review of the facility policy for Expiration of Insulin Vials directed Humalog (Lispro) insulin should be discarded when un/opened in 28 days.

Based on observations, interviews, and record review for 1 of 2 sampled residents (Resident #1) reviewed for accommodation of needs, and for 1 of 4 sampled residents, (Resident #5) reviewed skin conditions, the facility failed to follow physician's orders for air mattresses and additionally, for Resident #5, failed to follow a physician's order for heel offloading (elevation.) The findings include:1. Resident #1's diagnoses included dorsalgia (back pain), malignant neoplasm of skin, and unspecified severe protein calorie malnutrition. The physician's order dated 12/23/25 directed for skin prevention protocol: pressure relieving mattress to be in place every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, was dependent on staff for dressing and toileting with substantial/maximal assistance needed for transfers. Additionally, Resident #1 had a pressure ulcer/injury, was at risk for developing pressure ulcers, and had a pressure reducing device for his/her bed. The Resident Care Plan dated 12/29/25 identified Resident #1 was at risk for alteration in skin integrity relating to a stage 3 pressure ulcer to the coccyx present on admission which resolved on 12/23/25. Interventions included an anti-pressure low air loss mattress to be in place, gentle handling during transfers and to inspect skin when providing care for signs and symptoms of skin breakdown. Review of the admission Braden Scale Assessment (risk for developing pressure ulcers) dated 12/29/25 identified Resident #1 had a Braden scale score of 16 indicating he/she was at high risk for pressure ulcer development. The physician's order dated 1/5/26 directed for a low air loss mattress, check function and setting every shift (weight 95 pounds). A review of the Medication Administration Record from 1/5/26 through 1/27/26 identified nurse initials reflecting every day, evening, and night shift checked function of the pressure relieving mattress and set to 95 pounds. Interview and observation of Resident #1 in bed on 1/21/26 at 11:08 AM identified he/she was having difficulty sleeping because the bed was broken for a week now, the mattress was sunken down to the point that he/she could feel the metal, and although he/she had informed the NA, nothing has been done. Observation of the pressure relieving mattress identified the appearance of being sunken in and the pressure was set at 325 pounds. Interview with Nurse Aid (NA) #1 on 1/21/26 at 12:49 PM identified she was Resident #1's regular NA, and that morning he/she complained about the bed and having backache due the mattress being improperly inflated. Additionally, NA #1 identified it was facility policy to notify maintenance of malfunctioning equipment by putting the issue in the maintenance book; however, she was unable to identify why she had not made anyone aware of Resident #1's report of the pressure relieving mattress malfunctioning. Interview, observation, and clinical record review with Licensed Practical Nurse (LPN) #1 on 1/21/26 at 12:52 AM identified it was the policy for the charge nurse to check the function and setting of the pressure alternating mattresses every shift, and if there were any issues with a mattress it should be reported to maintenance immediately. Observation of Resident #1's pressure relieving mattress with LPN #1 identified Resident #1 in bed with the mattress set to 325 pounds. LPN #1 stated she could not identify if that was the appropriate setting, but when she peeked in the room earlier it did not appear to be sinking as it was currently. Resident #1's clinical record review with LPN #1 identified that per the physician's order the pressure relieving mattress should be set to 95 pounds, however she could not identify why it was set to 325 pounds or why she signed off on the function and setting of the mattress when it was not set per physician's order and not functioning as intended. Interview with Resident #1 on 1/21/26 at 12:53 PM identified he/she felt the bone in my butt and I've been complaining with no results. I told the guys that were in here earlier, but no one listens to me. Interview with the Maintenance Director on 1/21/26 at 1:07 PM identified it was facility policy for staff to use the maintenance book or call the Maintenance Department if there was an issue with broken or malfunctioning equipment that needed to be addressed immediately. The Maintenance Director further identified that although staff did not alert him to an issue with Resident #1's bed, when he was in the room at 11:00 AM Resident #1 complained of his/her bed being too soft so he doubled the setting from 125 pounds to 325 pounds. Additionally, the Maintenances Director identified that it was the departments practice to increase the setting on a mattress when there was a complaint of a malfunctioning pressure reducing bed. Observation of Resident #1's pressure reducing mattress with the Maintenance Director identified Resident #1 in bed, with the bed set to 325 pounds and an exclamation mark alert lit up in red on the display. The Maintenance Director unplugged and re-plugged in the bed stating it did not appear the pressure relieving mattress was working since it was still soft. He indicated that he would alert the Nursing Department of the issue immediately. Subsequent to surveyor inquiry review of a nurses note dated 1/21/26 at 2:00 PM, identified that due to decreased comfort and decreased mattress inflation, Resident #1 was provided with a new mattress. Observation on 1/22/26 at 9:16 AM and 1/27/26 at 10:21 AM identified Resident #1 in bed with the pressure relieving mattress set to 160 pounds. Interview and record review with Infection Prevention Registered Nurse (RN) #4 on 1/27/26 at 1:25 PM identified that it was facility policy to provide residents with pressure relieving mattresses if they had a wound or for comfort, with physician's orders dictating the appropriate weight setting for residents with wounds. A review of Resident #1's electronic health record with RN #4 identified that per the physician's order, he/she had a pressure relieving mattress that should be monitored for function and set to 95 pounds. Additionally, RN #4 identified the expectation was only nurses (not maintenance staff) changed the setting to reflect physician's orders and any pressure alternating mattress troubleshooting should be performed with residents out of bed. 2. Resident #5's diagnoses included chronic obstructive pulmonary disease, type 2 diabetes, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment and was dependent on staff for showering/bathing, personal hygiene, sit to lying in bed, lying to sitting on the side of the bed, and transfers. The Resident Care Plan (RCP) dated 12/29/25 identified Resident #5 was at risk for alteration in skin integrity related to decreased mobility. Interventions included inspecting skin when providing care and an anti-pressure mattress in bed. Physician's orders in effect from 1/21/26 through 1/27/26 directed to ensure Resident #5 's heels were off loaded (not touching the mattress) while in bed, placement of a Low Air Loss (LAL) mattress and to check function and setting every shift set to 207 pounds. Observation on 1/21/26 at 9:55 AM and 1/27/26 at 10:13 AM identified Resident #15 lying in bed with the head of the bed elevated, no LAL mattress was present, and his/her heels were not offloaded. Interview and observation with the Licensed Practical Nurse (LPN) #9 on 1/27/26 at 10:15 AM identified that that it was the facility's policy to provide and set a LAL mattress per the physician orders and to check daily to see if the LAL mattress was functioning properly. LPN #9 indicated that residents with physician orders of offloading heels while in bed should have either heel boots on or pillows under the ankles to relieve pressure from the heels off the mattress. LPN #9 indicated that Resident #5 had current physician orders for offloading heels while in bed and an LAL mattress to be set at 207 lbs. LPN #9 observed that Resident #5 was lying in bed without his/her heels offloaded and that there was no LAL mattress present per the physician orders. LPN #9 could not identify why Resident #5's heels were not offloaded, or why a LAL mattress was not present but indicated they should have been per the physician orders. Interview and observation with the Assistant Director of Nurses (ADNS) on 1/22/26 at 9:41 PM identified that it was the facility's policy to provide and set a LAL mattress per the physician orders. The ADNS indicated that if a resident had orders for offloading heels, their heels should have a pillow under them or some sort of barrier to relieve pressure and that it was the responsibility of the unit nurse to carry out the physician orders as directed. The ADNS identified that Resident #5 had current physician orders for offloading heels while in bed and an LAL mattress to be set at 207 lbs. The ADNS identified that Resident #5 was lying in bed without the benefit of his/her heels being offloaded and that there was no LAL mattress present per physician order. The ADNS indicated that she did not know why the physician orders were not being followed but believed that it was because the resident had a wound that healed. Additionally, the ADNS identified that per the current physician order, Resident #5 should have had a LAL mattress present, and his/her heels should have been offloaded.

Based on review of the clinical record, facility policy, and interviews for 2 of 3 sampled residents (Resident #9 and Resident #19) reviewed for hospitalizations, the facility failed to provide a written notice of the right to hold a bed upon discharge from the facility for a medical leave. The findings include:1. Resident #9's diagnoses included extremity amputations, diabetes with underlying diabetic neuropathy (nerve damage), and altered mental status. The annual Minimum Data Set assessment dated [DATE] identified Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment and required supervision with toileting and transfers, substantial maximal assistance with lower body dressing, and was independent with eating, hygiene, upper body dressing, and bed mobility. The Resident Care Plan dated 12/2/25 identified Resident #9 was re- hospitalized due to precarious medical condition, at risk for re-hospitalization. Interventions included activity as tolerated, body audit, Braden scale and medication review upon re admission, notify physician for any changes in status. A nurse's note dated 1/16/25 at 6:31 PM identified at 7:27 PM Resident #9 was having increased confusion with a blood pressure of 136/97, pulse 76, temperature 98.1, and a weight of 229 pounds. No changes in respiratory, cardiovascular or neurological status. No changes in abdominal, gastrointestinal or urinary systems, were observed. Resident #9 was post a fall day 1 and displaying increased confusion and trouble word finding and was unable to complete a sentence when assessed. The Advanced Practice Nurse Practitioner (APRN) was notified. A new order to send Resident #9 to the emergency room for evaluation was obtained and Resident #9 was transported by ambulance to the hospital at 6:00 PM. A review of social services notes from 11/2025 through 1/2026 failed to identify the responsible party/conservator was notified of the bed hold policy upon Resident #9 being sent to the hospital. The medical record failed to contain documentation that Resident #9 or the responsible party was notified of the right to hold the bed during a medical leave of absence. 2. Resident #19's diagnosis included severe protein calorie malnutrition, viral intestinal infection and hyperosmolality (concentrated blood due to dehydration or high sodium levels) and hypernatremia (high sodium levels in the blood.) The significant change Minimum Data Set assessment dated [DATE] identified Resident #19 had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and required substantial maximal assistance with hygiene and was totally dependent on staff for eating, bed mobility, toileting, dressing, and transfers. The Resident Care Plan dated 12/9/25 identified Resident #19 had a positive level of care with Ascend due to a psychiatric diagnosis. Interventions included a guardian/conservator for decisions regarding health and safety, a minimum of a yearly comprehensive psychiatric evaluation to clarify the current psychiatric diagnosis and appropriate treatments. A Situation Background Assessment and Recommendation form dated 1/3/26 at 10:11 AM identified Resident #19 reported vomiting coffee ground emesis, that was unwitnessed. The resident's mental status was noted with increased confusion or disorientation, and Resident #19 had nausea and vomiting this morning. A report from the night Registered Nurse (RN) supervisor, identified Resident #19 had vomited coffee ground emesis this morning. Upon palpation of the resident's abdomen, he/she complained of tenderness. The RN supervisor notified the APRN on 1/3/26 at 9:16 AM and an order was received to send Resident #19 to the emergency room for further evaluation. A review of social services notes from 11/2025 through 1/2026 failed to identify the responsible party/conservator was notified of the bed hold policy upon Resident #19 being sent to the hospital. The medical record failed to contain documentation that Resident #19 or the responsible party was notified of the right to hold the bed during a medical leave of absence. Interview with Social Worker # 1 and Social Worker # 2 on 1/29/26 at 11:25 AM indicated that they do not issue the bed hold policy form to residents that go out to the hospital. Business office or Admissions staff was responsible to issue bed hold forms. Interview and clinical record review with Regional Business Office Manager on 1/29/26 at 11:30 AM identified the medical record failed to reflect documentation a bed hold policy form was delivered to Resident #9 and Resident #19 or the responsible party at the time of the hospitalization. The Regional Business Office Manager could not explain why a form was not issued and indicated that a bed hold policy form should have been sent with the resident or the responsible party contacted and documented in the clinical record of the right to hold the bed during hospitalization. Review of the bed hold policy dated 10/1/19 directed, in part, it is the policy of Apple Rehab to notify all residents of their rights to reserve their bed upon discharge to the hospital. The notice regarding reservation of the Residents' bed if the resident is hospitalized is given to each resident upon admission and this states the facility's policy regarding payment for days absent from the facility. The notice regarding reservation of the resident's bed will also be given by the social worker or the facility's designee to each resident/responsible party upon discharge to the hospital. The resident bed hold documentation form will be completed by social services or admissions for each hospitalization and maintained in the resident's financial folder. It should also be scanned into the Point Click Care (PCC) miscellaneous tab.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of four (4) residents (Residents #1, 2, 3 and 4) reviewed for resident-to-resident abuse, the facility failed to ensure the residents were monitored for injuries, mood and behaviors after resident-to-resident abuse incidents. The findings include: 1. Resident #1's diagnoses included vascular dementia, anxiety disorder, history of a traumatic brain injury and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severely impaired cognition and was independent with bed mobility, transfers and ambulation. The MDS identified Resident #1 exhibited no behaviors. The Resident Care Plan (RCP) dated 10/21/24 identified Resident #1 was involved in a resident-to-resident altercation on 10/21/24 and he/she hit another resident in the face. Interventions included completing a Registered Nurse (RN) assessment, administering medications per physician's orders, offering psychiatric support and services, social services to follow-up and offer support, monitoring Resident #1 for signs of mental distress, increased anxiety, change in mood state and reporting to the provider, and if signs of increased agitation, anxiety and/or mood changes were identified, provide Resident #1 with emotional support. Review of the facility Reportable Event (RE) dated 10/21/24 identified that at 2:30 PM Resident #1 was agitated with Resident #2 yelling in the hallway and Resident #1 subsequently went out into the hallway and struck Resident #2 on the left side of the face with a closed fist. The RE identified both Resident #1 and Resident #2 were separated, the Advanced Practice Registered Nurse (APRN) was notified, the responsible party was notified and the psychiatric APRN was in-house and met with Resident #1 and ordered Trazodone 25 milligrams (mg) every six (6) hours as needed for anxiety for fourteen (14) days. The intervention included emotional support to be provided by social services, psychiatric support and services and identified that the facility would monitor Resident #1 for mood and behaviors and redirect Resident #1 as needed. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 10/21/24 identified she evaluated Resident #1 following an altercation with another resident. The note reported Resident #1 denied worsening mood concerns but directed to monitor for emergence. The note identified Resident #1 denied worsening anxiety but indicated Resident #1 presented mildly anxious secondary to the interaction, would order trazodone as needed, directed to monitor for changes in cognition, provide support/reassurance as needed and redirect Resident #1 as tolerated. Review of physician's orders for October 2024 failed to identify an order for monitoring of the resident's behaviors or mood. Review of the October 2024 Medication Administration Record (MAR) failed to identify mood or behavior monitoring for Resident #1. Review of nurses notes from 10/21/24 through 10/24/24 failed to identify any documentation of Resident #1's mood or behavior on the 3:00 PM to 11:00 PM shift on 10/21/24, the 11:00 PM to 7:00 AM shift on 10/21/24, the 3:00 PM to 11:00 PM shift on 10/22/24, the 11:00 PM to 7:00 AM shift on 10/22/24 or the 11:00 PM to 7:00 AM shift on 10/23/24 following the resident-to-resident incident. 2. Resident #2's diagnoses included vascular dementia with mood disturbances, generalized anxiety disorder, other specified depressive episodes and chronic myeloid leukemia (an uncommon slowly progressing blood-cell cancer that begins in the bone marrow). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of six (6) indicative of severely impaired cognition and required supervision assistance for ambulation and substantial assistance for transfers. The Resident Care Plan (RCP) dated 10/21/24 identified Resident #2 was involved in a resident-to-resident altercation on 10/21/24 when he/she was hit in the face by another resident. Interventions included completing a Registered Nurse (RN) assessment, a body audit/skin check as needed, offering psychiatric support and services, social services to follow-up and offer support, monitoring Resident #2 for signs of mental distress, increased anxiety and change in mood state, and reporting to the provider and if signs of increased agitation, anxiety or if making inappropriate statements to staff/residents was identified, provide Resident #2 with emotional support. Review of the facility Reportable Event (RE) dated 10/21/24 identified that at 2:30 PM Resident #2, who was yelling in the hallway, was struck by Resident #1, on the left side of the face, with a closed fist. The RE identified that both Resident #1 and Resident #2 were separated, the APRN was notified, the responsible party was notified and the psych APRN was in-house and met with the resident and ordered Trazodone 25 milligrams (mg) every six (6) hours as needed for anxiety for fourteen (14) days. The intervention included emotional support to be provided by social services, psychiatric support and services and identified that the facility would monitor Resident #2 for mood and behaviors and Resident #2's skin would be monitored for any discoloration at the site of the impact. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 10/21/24 identified she evaluated Resident #2 following an altercation with another resident, Resident #2 denied any anxiety or distress and stated he/she felt safe in the facility following the incident. The note identified that due to intermittent behavioral disturbance and anxiety, trazodone would be ordered as needed, directed to provide support/reassurance as needed and redirect Resident #2 as tolerated. Review of physician's orders for October 2024 failed to identify orders for monitoring Resident #2's mood or monitoring Resident #2's skin for any discoloration at the site of the impact. Review of the October 2024 Medication Administration Record (MAR) failed to identify monitoring of Resident #2's mood or monitoring of Resident #2's skin for any discoloration at the site of the impact. Review of nurses notes from 10/21/24 through 10/24/24 failed to identify any documentation of Resident #2's mood or documentation of Resident #2's skin on the 11:00 PM to 7:00 AM shift on 10/22/24 or the 11:00 PM to 7:00 AM shift on 10/23/24 following the resident-to-resident incident. 3. Resident #3's diagnoses included vascular dementia, anxiety, restlessness and agitation and atrial fibrillation (an irregular and often very rapid heart rhythm). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of four (4) indicative of severely impaired cognition and required supervision assistance for bed mobility and ambulation and substantial assistance for transfers. The MDS identified Resident #3 exhibited no behaviors. The Resident Care Plan (RCP) dated 10/26/24 identified Resident #3 was involved in a resident-to-resident altercation on 10/26/24 when he/she hit another resident in the face. Interventions included completing a Registered Nurse (RN) assessment, offering psychiatric support and services, social services to follow-up and offer support, monitoring Resident #3 for signs of mental distress, increased anxiety and change in mood state and report to the provider and if signs of increased agitation, anxiety and/or mood changes were identified, provide Resident #3 with emotional support. Review of the facility Reportable Event (RE) dated 10/26/24 identified that at 4:30 PM Resident #3 allegedly stated there was a fire in the room, that Resident #4 (roommate) needed to get out of the way, and then Resident #3 slapped Resident #4 in the face, which was unwitnessed and reported by Resident #4. The RE identified that both Resident #3 and Resident #4 were separated, the Advanced Practice Registered Nurse (APRN) was notified and recommended Resident #3 be evaluated by psychiatric services and the responsible party was notified of the event. The interventions included a room change for Resident #3, emotional support to be provided by social services, psychiatric support and services and identified that the facility would monitor Resident #3 for mood and behaviors. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 10/28/24 identified she evaluated Resident #3 following an altercation with another resident. The note reported Resident #3 had no memory of the incident but was noted to have an increase in anxiety and intermittent episodes of impulsivity and was reporting poor sleep. The APRN identified she was going to trial Remeron 7.5 milligrams (mg) daily at bedtime for anxiety/sleep/poor intake, directed to provide Resident #3 with support and reassurance, and redirect as needed. Review of physician's orders for October 2024 failed to identify an order for monitoring Resident #3's behaviors or mood. Review of the October 2024 Medication Administration Record (MAR) failed to identify mood or behavior monitoring for Resident #3. Review of nurses notes from 10/26/24 through 10/29/24 failed to identify any documentation on Resident #3's mood or behavior on the 11:00 PM to 7:00 AM shift on 10/26/24, the 7:00 AM to 3:00 PM shift on 10/27/25, the 3:00 PM to 11:00 PM shift on 10/27/24, the 11:00 PM to 7:00 AM shift on 10/27/24, the 11:00 PM to 7:00 AM shift on 10/28/24, the 7:00 AM to 3:00 PM shift on 10/29/24 or the 3:00 PM to 11:00 PM shift on 10/29/24 following the resident-to-resident incident. 4. Resident #4's diagnoses included anxiety disorder, mild cognitive impairment and other specified depressive episodes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required supervision assistance for transfers and substantial assistance for ambulation. The Resident Care Plan (RCP) dated 10/26/24 identified Resident #4 was involved in a resident-to-resident altercation on 10/26/24 when he/she was hit in the face by another resident. Interventions included completing a Registered Nurse (RN) assessment, a body audit/skin check as needed, offering psychiatric support and services and social services to follow-up and offer support. Review of the facility Reportable Event (RE) dated 10/26/24 identified that at 4:30 PM Resident #4 came out of his/her room and reported to staff that Resident #3 stated there was a fire in their room and that Resident #4 (roommate) needed to get out of the way and then Resident #3 slapped him/her (Resident #4) in the face, which was unwitnessed. The RE identified that both Resident #3 and #4 were separated, the Advanced Practice Registered Nurse (APRN) was notified and recommended Resident #4 was evaluated by psychiatric services and the responsible party was notified of the event. The interventions included emotional support to be provided by social services, psychiatric support and services and identified that the facility would monitor Resident #4 for mood and behaviors and Resident #4's skin would be monitored for any discoloration at the site of the impact. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 10/29/24 identified she evaluated Resident #4 following an altercation with another resident, Resident #4 denied anxiety or distress and stated he/she felt safe in the facility following the incident. The note identified that no medication changes were indicated and directed to monitor for the emergence of anxiety. Review of physician's orders for October 2024 failed to identify orders for monitoring of Resident #4's mood and behaviors or monitoring of Resident #4's skin for any discoloration at the site of the impact. Review of the October 2024 Medication Administration Record (MAR) failed to identify monitoring of Resident #4's mood or behaviors, or monitoring of Resident #4's skin for any discoloration at the site of the impact. Review of nurses notes from 10/26/24 through 10/29/24 failed to identify any documentation on Resident #4's mood or behaviors or documentation on Resident #4's skin on the 11:00 PM to 7:00 AM shift on 10/26/24 or the 11:00 PM to 7:00 AM shift on 10/27/24 following the resident-to-resident incident. Interview with the DNS on 4/30/25 at 1:28 PM identified that for all resident-to-resident incidents, nursing staff should monitor, assess and document mood, behavior, resident's skin and any subsequent injuries for all residents involved, every shift, for 72 hours. She reported she was unaware monitoring and documentation was not completed consistently for Residents #1, #2, #3 and #4 and indicated she did education with the 11:00 PM to 7:00 AM shift nurses a few weeks prior, after identifying documentation was not being completed consistently, but further identified she did not document the education or complete audits. Review of the Resident-to-Resident Abuse policy dated (undated) directed, in part, identified that abuse of any kind between residents, including physical will not be tolerated. All residents have the right to feel safe, respected and free from harm while residing in the facility. Staff will observe interactions and intervene as necessary. The safety and well-being of residents will be prioritized. Allegations will be reviewed promptly and appropriate action taken, which may include medications, separation of residents, increased supervision, behavioral interventions or referrals for outside support. Affected residents may be offered access to clinical, medical, or supportive services including counseling as needed. Staff will monitor future interactions to help prevent recurrence.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation when a staff member obtained the resident's phone, gained account access, and transferred money. The findings include: Resident #1's diagnoses included acute respiratory failure with hypercapnia (when the body can't remove excess carbon dioxide from the bloodstream causing it to build up) and cognitive communication deficit. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented with good memory recall and required a two (2) person assist for transfers and ambulation and was independent with bed mobility and positioning. The baseline Resident Care Plan (RCP) dated 2/14/25 identified Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included utilizing a walker when ambulating. Review of the Resident Personal Possessions form dated 2/14/25 identified Resident #1 brought an iPhone and an iPad to the facility on admission. A nurse's note dated 2/16/25 at 4:08 AM identified Resident #1 was complaining of shortness of breath with noted oxygen levels between 71-72 percent (low oxygen level/body is not getting enough oxygen). The note identified that Emergency Medical Services (EMS) was called, and Resident #1 was transferred to the hospital Emergency Department (ED) for evaluation. Review of the facility Accident and Incident (A & I) report dated 3/19/25 identified the facility was notified by Resident #1's family member (Person #1) of unauthorized financial transactions made from Resident #1's personal cell phone to a PayPal account associated with a facility staff member's (NA #1) address and telephone number. Review of the facility Summary Report dated 3/21/25 identified that on 2/16/25, Resident #1 was transferred to the hospital for an acute change in condition and his/her belongings, including his/her cell phone remained at the facility following the transfer. The report identified that the resident did not return to the facility, subsequently passing away in the hospital, and on 3/14/25, Person #1 came to the facility to retrieve Resident #1's belongings and reported Resident #1's cell phone to be missing. On 3/19/25, Person #1 contacted the facility and reported that he/she identified multiple unauthorized financial transactions originating from Resident #1's PayPal account. Person #1 identified there was a bank login alert on 3/17/25 which prompted him/her to access Resident #1's email where a series of PayPal withdrawals were discovered, dating from 2/19/25 through 3/17/25, totaling approximately $1735.00. Person #1 identified that the PayPal account in question was linked to an email and phone number which the facility verified matched a facility staff member (NA #1). The report identified that upon notification, the facility immediately initiated an internal investigation, the police were notified and the employee in question was suspended pending the outcome of the investigation. Interview with the DNS on 4/11/25 at 10:48 AM identified that following Person #1's report on 3/19/25 of unauthorized transactions on Resident #1's account associated/linked with NA #1's account, NA #1 was suspended pending an investigation. She identified that the facility had since been unable to contact NA #1, and reported he will no longer be employed by the facility. Review of NA #1's timecard identified that he worked the 11:00 PM to 7:00 AM shift on 2/14/25, 2/21/25, 2/22/25, 2/23/25, 2/27/25, 2/28/25, 3/4/25, 3/5/25, 3/7/25, 3/13/25 and 3/15/25. The timecard identified that he worked 7:09 AM to 11:04 PM on 2/17/25, 3:04 PM to 11:05 PM on 2/18/25, 7:08 AM to 3:20 PM on 2/19/25, 7:14 AM to 11:03 PM on 3/3/25, 3:02 PM to 11:00 PM on 3/17/25 and 3:10 PM to 10:59 PM on 3/18/25. Interview with Person #1 on 4/11/25 at 10:55 AM identified that he/she was Resident #1's financial Power of Attorney (POA) and reported Resident #1's personal bank account security reset was linked to his/her (Person #1's) phone. Person #1 indicated that on 3/17/25, he/she received a text with a code to sign into Resident #1's bank account. Person #1 identified when he/she (Person #1) signed into the account there was only about $500 left in the account, and the balance was usually between $2,000 and $6,000 depending on the time of the month. Person #1 identified he/she noticed numerous withdrawals from Resident #1's personal PayPal account. Person #1 identified that he/she was unable to gain access to Resident #1's PayPal account, so accessed Resident #1's email where he/she observed numerous emails associated with PayPal transactions that were made. She identified that fraudulent charges included: $108 on 2/19/25, $100 on 2/24/25, $377 on 3/6/25, $550 on 3/12/25, $550 on 3/17/25 and $50 on 3/17/25. Person #1 then withdrew all remaining funds from the bank account after filing a police report on 3/18/25. Person #1 reported that although not all the transfers were identified in Resident #1's email, he/she was able to locate an email showing a transfer of $200 was sent to NA #1 from Resident #1 on 3/15/25 and another email with a transfer of $200 was sent to Person #2 with NA #1's phone number on 3/17/25. Person #1 identified that he/she was unsure who Person #2 was but that there was a NA with Person #2's last name who worked at the facility. Person #1 indicated he/she never reported Person #2 to the facility. Additionally, Person #1 identified that a letter was received and identified a PayPal credit card was requested in Resident #1's name but was denied because Resident #1's identity was not confirmed. Further, an email was received on 3/17/25 stating that the PayPal account billing address for Resident #1 was changed to NA #1's address. Review of the facility schedule dated 2/15/25 identified NA #3 was scheduled to work the 11:00 PM to 7:00 AM shift on 2/15/25 at the facility. Interview with the DNS on 4/11/25 at 11:25 AM identified that NA #3 was terminated prior to the misappropriation allegation on 3/19/25 for attendance issues. She indicated there were no reports made to her of a connection between NA #3 and the allegation. Review of NA #3's personnel file identified his address matched that of NA #1. Review of NA #3's timecard identified he worked the 3:00 PM to 11:00 PM shift on 2/17/25, 2/19/25, 2/20/25, 2/22/25, 2/23/25, 2/24/25, 2/26/25, 2/27/25, 3/3/25, 3/5/25, 3/6/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25 and 3/17/25. He worked the 11:00 PM to 7:00 AM shift on 3/15/25. Interview with NA #3 on 4/11/25 at 12:15 PM identified that he did not have recent contact with NA #1 and reported that he never stole from a resident or been involved with misappropriation of resident property or money. He identified that the phone number associated with Person #2's name was NA #1's phone number. Interview with Administrator #2 (previous Administrator) on 4/11/25 at 1:44 PM identified she was unaware NA #3 was involved in the allegation. Administrator #2 indicated that other staff, residents and their representatives were not interviewed to ensure other residents were not affected but stated those interviews should have been conducted. Administrator #2 identified that the misappropriation of Resident #1's money should not have occurred. Although attempted, an interview with NA #1 was not obtained. Review of the Abuse policy (undated) directed, in part, that abuse or mistreatment of any kind towards a resident is strictly prohibited. Any allegation of abuse by a staff member, visitor, family member, or resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated, and appropriate action will be taken. Misappropriation of resident property is defined as the deliberate misuse, exploitation, or theft of a resident's belongings or money without consent. Any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the Director of Nursing (DNS) and the Administrator. An A & I report will be completed for each resident involved. Nursing staff will document a description of the incident in the resident's record. The DNS or designee will notify the resident's family, physician, Department of Public Health and local police as needed. The Administrator/DNS or designee will initiate an investigation and submit an online report to the Facility Licensing and Investigation Section (FLIS) within two (2) hours of notification. The accused individual will be immediately suspended pending the outcome of the investigation. The investigation will include: Interviews with all witnesses, including the accused, interviews with any individuals with relevant information, signed and dated statements from all involved parties and review of the accused staff member's employment record.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to fully investigate an allegation of misappropriation of money to include obtaining statements from the accused, other staff, other residents and/or resident representatives to ensure all residents were free from misappropriation in accordance with facility policy. The findings include: Resident #1's diagnoses included acute respiratory failure with hypercapnia (when the body can't remove excess carbon dioxide from the bloodstream causing it to build up) and cognitive communication deficit. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented with good memory recall and required a two (2) person assist for transfers and ambulation and was independent with bed mobility and positioning. The baseline Resident Care Plan (RCP) dated 2/14/25 identified Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included utilizing a walker when ambulating. Review of the Resident Personal Possessions form dated 2/14/25 identified Resident #1 brought an iPhone and an iPad to the facility on admission. A nurse's note dated 2/16/25 at 4:08 AM identified Resident #1 was complaining of shortness of breath with noted oxygen levels between 71-72 percent (low oxygen level/body is not getting enough oxygen). The note identified that Emergency Medical Services (EMS) was called, and Resident #1 was transferred to the hospital Emergency Department (ED) for evaluation. Review of the facility Accident and Incident (A & I) report dated 3/19/25 identified the facility was notified by Resident #1's family member (Person #1) of unauthorized financial transactions made from Resident #1's personal cell phone to a PayPal account associated with a facility staff member's (NA #1) address and telephone number. Review of the facility Summary Report dated 3/21/25 identified that on 2/16/25, Resident #1 was transferred to the hospital for an acute change in condition and his/her belongings, including his/her cell phone remained at the facility following the transfer. The report identified that the resident did not return to the facility, subsequently passing away in the hospital, and on 3/14/25, Person #1 came to the facility to retrieve Resident #1 ' s belongings and reported Resident #1's cell phone to be missing. On 3/19/25, Person #1 contacted the facility and reported that he/she identified multiple unauthorized financial transactions originating from Resident #1 ' s PayPal account. Person #1 identified there was a bank login alert on 3/17/25 which prompted him/her to access Resident #1's email where a series of PayPal withdrawals were discovered, dating from 2/19/25 through 3/17/25, totaling approximately $1735.00. Person #1 identified that the PayPal account in question was linked to an email and phone number which the facility verified matched a facility staff member (NA #1). The report identified that upon notification, the facility immediately initiated an internal investigation, the police were notified and the employee in question was suspended pending the outcome of the investigation. Interview with the DNS on 4/11/25 at 10:48 AM identified that following Person #1's report on 3/19/25 of unauthorized transactions on Resident #1's account associated/linked with NA #1 ' s account, NA #1 was suspended pending an investigation. She identified that the facility had since been unable to contact NA #1 and reported he will no longer be employed by the facility. Review of NA #1's timecard identified that he worked the 11:00 PM to 7:00 AM shift on 2/14/25, 2/21/25, 2/22/25, 2/23/25, 2/27/25, 2/28/25, 3/4/25, 3/5/25, 3/7/25, 3/13/25 and 3/15/25. The timecard identified that he worked 7:09 AM to 11:04 PM on 2/17/25, 3:04 PM to 11:05 PM on 2/18/25, 7:08 AM to 3:20 PM on 2/19/25, 7:14 AM to 11:03 PM on 3/3/25, 3:02 PM to 11:00 PM on 3/17/25 and 3:10 PM to 10:59 PM on 3/18/25. Interview with Social Worker #1 (Director of Social Services) and Social Worker #2 on 4/11/25 at 10:34 AM identified they were not involved in the investigation regarding NA #1 and that Resident #1 was no longer in the facility when the allegations were made. They indicated they were made aware of the allegations but were not provided a timeline or instructed to assist in the investigation or conduct interviews. They identified they had no reports of expensive missing items between February and March 2025, only reports of missing clothing. Interview with Person #1 on 4/11/25 at 10:55 AM identified that he/she was Resident #1's financial Power of Attorney (POA) and reported Resident #1's personal bank account security reset was linked to his/her (Person #1's) phone. Person #1 indicated that on 3/17/25, he/she received a text with a code to sign into Resident #1's bank account. Person #1 identified when he/she (Person #1) signed into the account there was only about $500 left in the account, and the balance was usually between $2,000 and $6,000 depending on the time of the month. Person #1 identified he/she noticed numerous withdrawals from Resident #1 ' s personal PayPal account. Person #1 identified that he/she was unable to gain access to Resident #1's PayPal account, so accessed Resident #1 ' s email where he/she observed numerous emails associated with PayPal transactions that were made. She identified that fraudulent charges included: $108 on 2/19/25, $100 on 2/24/25, $377 on 3/6/25, $550 on 3/12/25, $550 on 3/17/25 and $50 on 3/17/25. Person #1 then withdrew all remaining funds from the bank account after filing a police report on 3/18/25. Person #1 reported that although not all the transfers were identified in Resident #1's email, he/she was able to locate an email showing a transfer of $200 was sent to NA #1 from Resident #1 on 3/15/25 and another email with a transfer of $200 was sent to Person #2 with NA #1's phone number on 3/17/25. Person #1 identified that he/she was unsure who Person #2 was but that there was a NA with Person #2's last name who worked at the facility. Person #1 indicated he/she never reported Person #2 to the facility. Additionally, Person #1 identified that a letter was received and identified a PayPal credit card was requested in Resident #1's name but was denied because Resident #1's identity was not confirmed. Further, an email was received on 3/17/25 stating that the PayPal account billing address for Resident #1 was changed to NA #1's address. Review of the facility schedule dated 2/15/25 identified NA #3 was scheduled to work the 11:00 PM to 7:00 AM shift on 2/15/25. Interview with the DNS on 4/11/25 at 11:25 AM identified that NA #3 was terminated prior to the misappropriation allegation on 3/19/25 for attendance issues. She indicated there were no reports made to her of a connection between NA #3 and the allegation. Review of NA #3's personnel file identified his address matched that of NA #1. Review of NA #3's timecard identified he worked the 3:00 PM to 11:00 PM shift on 2/17/25, 2/19/25, 2/20/25, 2/22/25, 2/23/25, 2/24/25, 2/26/25, 2/27/25, 3/3/25, 3/5/25, 3/6/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25 and 3/17/25. He worked the 11:00 PM to 7:00 AM shift on 3/15/25. Interview with NA #3 on 4/11/25 at 12:15 PM identified that he did not have recent contact with NA #1 and reported that he never stole from a resident or been involved with misappropriation of resident property or money. He identified that the phone number associated with Person #2's name was NA #1's phone number. Interview with Administrator #2 (previous Administrator) on 4/11/25 at 1:44 PM identified she was unaware NA #3 was involved in the allegation. Administrator #2 indicated that other staff, residents and their representatives were not interviewed to ensure other residents were not affected but stated those interviews should have been conducted. Administrator #2 identified that the misappropriation of Resident #1's money should not have occurred. Interview with the DNS on 4/11/25 at 2:51 PM identified that a full investigation regarding the 3/19/25 allegation of misappropriation should have been completed to include interviews with other staff, residents and their representatives. The DNS indicated interviews were not conducted because the allegation was made a month after the alleged misappropriation and the residents and their families on Resident #1's unit were involved and vocal, and she assumed they would report anything missing. Although attempted, an interview with NA #1 was not obtained. Review of the Abuse policy (undated) directed, in part, that abuse or mistreatment of any kind towards a resident is strictly prohibited. Any allegation of abuse by a staff member, visitor, family member, or resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated, and appropriate action will be taken. Misappropriation of resident property is defined as the deliberate misuse, exploitation, or theft of a resident's belongings or money without consent. Any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the Director of Nursing (DNS) and the Administrator. An A & I report will be completed for each resident involved. Nursing staff will document a description of the incident in the resident's record. The DNS or designee will notify the resident's family, physician, Department of Public Health and local police as needed. The Administrator/DNS or designee will initiate an investigation and submit an online report to the Facility Licensing and Investigation Section (FLIS) within two (2) hours of notification. The accused individual will be immediately suspended pending the outcome of the investigation. The investigation will include: Interviews with all witnesses, including the accused, interviews with any individuals with relevant information, signed and dated statements from all involved parties and review of the accused staff member's employment record.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for personal care and assistance, the facility failed to ensure documentation was complete in the clinical record. The findings include: Resident #2's diagnoses included type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels), congestive heart failure (when the heart cannot pump blood efficiently enough to give your body a normal supply), obesity and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition and required setup assistance with eating, substantial assistance with toileting hygiene, showering/bathing self, personal hygiene, bed mobility and transfers. Additionally, it identified that Resident #1 had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and was occasionally incontinent of bowel. The Resident Care Plan (RCP) dated 3/25/25 identified Resident #2 required assistance with Activities of Daily Living (ADLs) due to a history of falls, Acute Kidney Injury (AKI) and chronic first thoracic (T1) fracture (topmost vertebrae in the thoracic spine). Interventions included to offer assistance as needed with washing, bathing, dressing, toileting and oral hygiene, offer comfort bath/bed bath if the resident refuses a bath/shower, offer the resident assistance with tasks that they are unable to complete and provide assistance as ordered with transfers, ambulation and toileting. Review of the March 2025 Documentation Survey Report (Nurse Aide Documentation) for Resident #2 failed to identify documentation every shift on: a. Bladder elimination on 3/3/25, 3/4/25, 3/8/25 through 3/14/25, 3/17/25, 3/19/25 and 3/23/25 through 3/26/25. b. Bowel elimination on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/17/25, 3/19/25 and 3/23/25 through 3/26/25; c. Eating on 3/4/25, 3/5/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25; d. Personal hygiene on 3/4/25, 3/5/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25. e. Showering/bathing self on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25. f. Toileting hygiene on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25 g. Amount eaten on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25. h. Bowel and Bladder diary on 3/4/25 through 3/6/25, 3/8/25 through 3/10/25 and 3/12/25 through 3/14/25. i. Fluid intake on 3/19/25 and 3/23/25 through 3/26/25. j. Output on 3/19/25 and 3/23/25 through 3/26/25. A nurse's note dated 3/29/25 at 4:01 PM identified that Resident #2 was unable to hold the phone per his/her baseline. The note reported that a blood pressure was obtained and was high, blood sugar was normal, skin was pale and cool to touch and the resident was unable to respond verbally to staff regarding how he/she felt. The APRN was notified, and an order was obtained to transfer the resident to the Emergency Department for evaluation. Review of facility census identified that Resident #2 did not return to the facility. Interview with the DNS on 4/11/25 at 1:25 PM identified that it is expected that the Nurse Aides (NA's) are documenting on every resident, every shift, or as directed in the electronic medical record. She identified that NA compliance with consistent documentation was a work in progress and she is continuing to educate staff as she identifies missing documentation. Review of the CNA Flow Sheets (Resident Care Record) policy dated 05/2023 directed, in part, that the resident flow sheet will be completed nearest to the end of the shift as possible by the Certified Nursing Assistant (CNA) assigned to the resident. The following guide must be followed: Each resident in the facility will have a new flow sheet initiated by the CNA in Point Click Care (electronic health record), the flow sheet will have the resident's name, month, year and date, the CNA will document the care provided to the resident for that shift by completing the entire flow sheet, all the approved coding and abbreviations shall be used and upon completion each CNA must initial in the appropriate box. The flow sheet is a part of the resident's medical record in Point Click Care. The CNA flow sheet will be used to assist in developing an individualized plan of care for the resident.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure Resident #1 was not verbally abused by staff. The findings include: Resident #1's diagnoses included schizoaffective disorder, cognitive communication deficit, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, had not exhibited behavioral symptoms, and was dependent on staff for toileting. The Resident Care Plan dated 2/20/25 identified Resident #1 required assistance with incontinent care. Interventions directed to assist the resident with incontinent care timely and assist the resident in and out of bed during the day. The Facility Reported Incident form dated 3/2/25 identified at 3:40 PM Resident #1 reported having an interaction with an 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/2/25 that upset him/her. Resident #1 requested that NA #1 no longer provides care for him/her. The nurse's note dated 3/3/25 at 2:02 PM identified the Social Worker and the Assistant Director of Nursing provided support to Resident #1 following a concern of staff to resident interaction. The note identified Resident #1 expressed concern regarding a nurse aide being argumentative on the prior overnight shift. Resident #1 reported staff had been supportive, he/she feels comfortable and safe at the time. The summary report dated 3/4/25 indicated on the 11PM- 7AM shift, 3/1/25 into 3/2/25, Resident #1 reported he/she had an interaction with NA #1 that he/she found upsetting and Resident #1 expressed concern about the way the situation was handled by NA #1. The report indicated the interaction did not reflect a level of professionalism and resident care that the facility expected from the team. NA #1 was suspended pending the investigation and then terminated. Interview with the Assistant Director of Nursing (ADON) on 3/26/25 at 11:25 AM identified on 3/2/25 the 3PM-11PM Nursing Supervisor called her at approximately 3:00 PM to report that the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, told her she was made aware by a 3PM-11PM nurse aide, NA #2, that Resident #1 had an audio recording of an interaction that occurred between Resident #1 and NA #1 on 3/2/25 at approximately 2:00 AM. The ADON indicated she met with Resident #1 and listened to the recording which was very disturbing. The ADON explained when NA #1 entered Resident #1's room to provide care, Resident #1 inquired why it took so long for NA #1 to come back into his/her room to change him/her at which time the two (2) began to argue and NA #1 became extremely argumentative, and her voice escalated. The ADON identified the recording revealed Resident #1 had asked NA #1 to leave the room several times and NA #1 was heard refusing to leave the room, Resident #1 requested to see a supervisor several times and at one (1) point NA #1 said no, and Resident #1 was heard telling NA #1 to stop touching him/her several times. The ADON identified NA #1 should have left the room when Resident #1 requested she leave the room. The ADON explained Resident #1's roommate told her NA #1 was very rude, and he/she was scared the nurse aide was going to hit Resident #1, so she turned his/her light on. Interview with Resident #1 on 3/26/25 at 12:45 PM identified although he/she could not recall the exact date of the altercation with NA #1, he/she was able to recall the details as written in his/her original statement. Resident #1 stated he/she recalled pressing the call bell at approximately 1:00 AM requesting assistance to be changed and NA #1 came into his/her room and said she would be back as soon as she could, however an hour passed, so Resident #1 explained he/she called again. Resident #1 indicated when NA #1 entered the room, he/she began to question her about the delay and NA #1 became belligerent and argumentative. Resident #1 stated he/she played the audio recording and the contents of the conversation match what was reported to the ADON. Resident #1 identified NA #1 could be heard yelling at, arguing with, and refusing to stop care and get the supervisor as he/she requested. Resident #1 identified he/she and his/her roommate were fearful of NA #1. In a written statement obtained by the facility of an interview on 3/3/25 with NA #1, NA #1 identified when she went into Resident #1's room the second time she told the resident that he/she was not the only resident there. NA #1 explained Resident #1 started going off on her and she said if you're going to go off, were going to go off together. In the statement NA #1 acknowledged it was not okay to raise her voice, and she should have excused herself and gotten a nurse to intervene. The facility Abuse Policy identified abuse or mistreatment of any kind toward a resident is strictly prohibited. Review of facility documentation identified that a Plan of Correction was initiated immediately: Staff training on Abuse and Neglect including Timely Reporting. Random audits on abuse and neglect, customer service, resident to staff interactions, care, and customer service will be conducted and will continue for a period of thirty (30) days or until substantial compliance is met. Audits to be reviewed at the monthly QAPI meetings. The Administrator or designee are responsible for the plan. Compliance as of 3/7/25. The plan of correction was reviewed on 3/26/25 and the facility met all components for past non-compliance.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to report the allegation of verbal abuse to the Administrator and/or designee within two (2) hours after the event was reported by the resident to facility staff. The findings include: Resident #1's diagnoses included schizoaffective disorder, cognitive communication deficit, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, had not exhibited behavioral symptoms, and was dependent on staff for toileting. The Facility Reported Incident form dated 3/2/25 identified at 3:40 PM Resident #1 reported having an interaction with an 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/2/25 that upset him/her. Resident #1 requested that NA #1 no longer provides care for him/her. The nurse's note dated 3/3/25 at 2:02 PM identified the Social Worker and the Assistant Director of Nursing provided support to Resident #1 following a concern of staff to resident interaction. The note identified Resident #1 expressed concern regarding a nurse aide being argumentative on the prior overnight shift. Resident #1 reported staff had been supportive, he/she feels comfortable and safe at the time. The summary report dated 3/4/25 indicated on the 11PM- 7AM shift, 3/1/25 into 3/2/25, Resident #1 reported he/she had an interaction with NA #1 that he/she found upsetting and Resident #1 expressed concern about the way the situation was handled by NA #1. The report indicated the interaction did not reflect a level of professionalism and resident care that the facility expected from the team. NA #1 was suspended pending the investigation and then terminated. In a written statement dated 3/4/25 the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #2, identified on 3/2/25 sometime after 1:00 AM, NA #1 informed her that she was upset with Resident #1 because Resident #1 was rude and disrespectful, and Resident #1 requested to speak with the Nursing Supervisor. LPN #2 indicated she spoke with Resident #1 who appeared very upset and Resident #1 informed her of the altercation with NA #1. LPN #2 explained Resident #1 played the recorded audio for her. LPN #2 identified she provided care to Resident #1 the remainder of the shift and although she told NA #1 she was no longer to provide care to Resident #1, LPN #2 allowed NA #1 to provide care for others on her assignment. LPN #2 indicated she did not report the allegation to the Nursing Supervisor. Interview with the Assistant Director of Nursing (ADON) on 3/26/25 at 11:25 AM identified on 3/2/25 the 3PM-11PM Nursing Supervisor called her at approximately 3:00 PM to report that the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, told her she was made aware by a 3PM-11PM nurse aide, NA #2, that Resident #1 had an audio recording of an interaction that occurred between Resident #1 and NA #1 on 3/2/25 at approximately 2:00 AM. The ADON indicated she met with Resident #1 and listened to the recording which was very disturbing. The ADON indicated Resident #1 identified the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #2 had come into her room, listened to the recording of the incident that occurred and provided care to him/her. The ADON identified she spoke with LPN #2 and LPN #2 confirmed she was aware of the altercation, and she did not allow NA #1 to provide further services to Resident #1 that night. The ADON identified LPN #2 stated she did not report the incident to anyone because Resident #1 did not want it reported and LPN #2 allowed NA #1 to continue working the shift with other residents. The ADON identified LPN #2 should have informed the Nursing Supervisor and NA #1 should have been sent home immediately pending an investigation. The facility Abuse Policy identified abuse or mistreatment of any kind toward a resident must be reported to a supervisor immediately and the accused individual will be immediately suspended pending the outcome of the investigation. Review of facility documentation identified that a Plan of Correction was initiated immediately: Staff training on Abuse and Neglect including Timely Reporting. Random audits on abuse and neglect, customer service, resident to staff interactions, care, and customer service will be conducted and will continue for a period of thirty (30) days or until substantial compliance is met. Audits to be reviewed at the monthly QAPI meetings. The Administrator or designee are responsible for the plan. Compliance as of 3/7/25. The plan of correction was reviewed on 3/26/25 and the facility met all components for past non-compliance.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for Leave of Absence (LOA), the facility failed to ensure a resident who is dependent on staff for transfers, Activities of Daily Living (ADLs) and severely impaired cognition was accompanied to a medical appointment out in the community, resulting in the resident being dropped off at the wrong location, then dropped off by an unknown person to the emergency department. The findings include: Resident #1 had diagnoses that included mild cognitive impairment, seizures, diabetes mellitus, peripheral vascular disease, and bipolar disorder. The clinical record failed to identify an LOA order. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) indicative of severely impaired cognition, has impaired vision, dependent with ADLs and transfers. The care plan dated 10/8/24 identified Resident #1 needs assistance with ADLs due to cognitive deficit with interventions that direct to assure Resident #1 is accompanied to medical appointments as deemed necessary per facility policy. The nurse's note dated 11/12/24 at 2:32 P.M. written by LPN #3 identified Resident #1's daughter called, and she scheduled a vascular appointment for Resident #1, the family member will meet Resident #1 at the appointment. A nurse's note dated 11/20/24 (Late entry) at 9:42 A.M. written by the Assistant Director of Nursing (ADNS) identified that Resident #1 was scheduled for a vascular appointment. The appointment was changed to another location and the facility was not made aware. The ADNS indicated she called the transportation company who agreed to go back to transport Resident #1 to the other address. The ADNS indicated she spoke with Resident #1's family member who was on her way to meet Resident #1 at the original location and Resident #1's daughter acknowledged she was not made that the location of Resident #1's appointment had been changed. The ADNS identified she provided Resident #1's family member with the address of the new location of the appointment and she would to go meet Resident #1 at the appointment. A nurse's note dated 11/20/24 (Late entry) at 3:37 P.M. written by the ADNS identified she was alerted by RN #2 (supervisor) that Resident #1's family member called the facility looking to see if Resident #1 made it back because Resident #1 never came to the appointment. The ADNS identified another family member called the facility and stated that Resident #1 was dropped off at the wrong location and Resident #1 was transported to the emergency room by an unknown person. The ADNS identified Resident #1 returned to the facility via car Resident #1 was transported by a family member. Review of the emergency department observation note dated 11/20/24 at 2:00 P.M. identified Resident #1 was dropped off at the door in a wheelchair with no family or staff. Resident #1 is unable to provide history due to cognitive impairment. Resident #1 does have paperwork that has h/her medical history, medication, and name of the facility h/she is from. Collateral information obtained from the facility Resident #1 was supposed to go to a vascular appointment today with an aide, instead, Resident #1 reportedly was dropped at the wrong address and then from there dropped off at the emergency department. Resident #1 discharged from the emergency department back to the facility accompanied by a family member. Interview with the ADNS on 12/13/24 at 11:40 A.M. identified on 11/20/24 Resident #1 was picked up at the facility by the transportation company, and sent out unaccompanied for h/her appointment, and dropped off at the appointment. The ADNS indicated she received a call from the MD office reporting that Resident #1 had not arrived for h/her appointment. The ADNS identified that the MD office informed her the location of Resident #1's appointment had changed. The ADNS indicated prior to 11/20/24 that the MD office had not communicated that the location of Resident #1's appointment had been changed. The ADNS indicated she contacted the transportation company who agreed they would have the driver return to the original MD address and transport Resident #1 to the appointment at the new location of the MD appointment. The ADNS indicated she contacted Resident #1's family would meet Resident #1 at the new location. Interview with RN #2 on 12/13/24 at 3:25 P.M. identified on 11/20/24 she tried to contact Resident #1's family prior to the resident leaving, but was unable to reach her. RN #2 identified a nurse aide was not assigned to accompany Resident #1 to h/her appointment. RN #2 indicated she spoke with Resident #1 and Resident #1 indicated h/her daughter would be meeting Resident #1 at the appointment. RN #2 identified when a resident is going out to a medical appointment if is is noted that the resident's family will accompany the resident the family needs to be present in the facility prior to the resident leaving the facility. RN #2 indicated it was a miscommunication and Resident #1 should not have been sent out to h/her appointment unaccompanied. Interview with the DNS on 12/13/24 at 1:00 P.M. identified when a resident is going out to a medical appointment with family the family must be physically present in the facility prior to the resident leaving the building or a nurse aide must accompany the resident. The DNS identified on 11/20/24 when Resident #1's daughter was not present in the facility to accompany The DNS identified on 11/20/24 Resident #1 should not have left the facility with the transportation company alone to go to h/her medical appointment. The DNS identified on 11/20/24 RN #2 was provided with employee coaching because RN #2 sent Resident #1 who requires assistance, is cognitively impaired, and wheelchair bound out to h/her appointment unaccompanied. The DNS identified supervisors are responsible for assuring the resident's family is present at the time of pick up or a nurse aide is assigned to accompany the resident to the appointment. The DNS stated that it is unclear how the resident ended up at the emergency department. Interview with the MD #1 (Medical Director) on 12/13/24 at 2:25 P.M. identified his expectation is when a resident is going out for an appointment a family member, or a staff member must accompany the resident. MD #1 identified on 11/20/24 Resident #1 should not have been sent out alone to h/her appointment and Resident #1 should have been accompanied by a staff member. Review of the undated facility MD appointment/Offsite/Transportation policy identified the purpose of the policy is to ensure the safety of residents going to offsite M.D. appointments and assist with transportation to and from any appointments. In instances where the resident requires supervision on medical appointments, the resident's family/responsible party may be contacted to attend the appointment. If the family is unable to attend and the facility is unable to provide a staff member to accompany the resident, the appointment may have to be rescheduled.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: Resident #1 was admitted with diagnoses that included stroke with resultant left sided hemiplegia (inability to move the left side of the body), anxiety and depression. An admission MDS assessment dated [DATE] identified that Resident #1 was alert and oriented, and was independent for transfers and mobility with a wheelchair. The RCP dated 6/11/2024 identified Resident #1 was in the facility for short term rehabilitation and needed orientation to facility and new surroundings. The RCP directed to check in to see if there was anything to assist adjustment to new environment and to be aware of mood and behaviors. A facility incident report dated 8/19/2024 accident and investigation report dated 8/19/2024 at 11:00 AM identified an allegation of staff-to-resident abuse without injury; NA #1 was involved in an interaction with Resident #1 in which inappropriate language was used. NA #1 was suspended pending investigation. Psych and social services saw Resident #1 immediately after the incident for emotional support. A facility summary dated 8/24/2024 identified Resident #1 stated that he/she and NA #1 were involved in an interaction where inappropriate language was used by the NA, and that NA #1 hit him/her on the right shoulder. The investigation confirmed yelling and cursing, but failed to confirm any foul language was directed towards Resident #1 by NA #1. The summary indicated a review of video footage failed to show any direct verbal or physical abuse to the resident and the allegation of abuse was unsubstantiated. Interview and facility documentation review with RN #1 identified she was the day shift supervisor 8/19/2024, and she was asked to speak with NA #1 because NA #1 was late to work and after NA #1 had punched in, she went on a break in the room behind the nursing station. RN #1 entered the back room and told NA #1 that she needed to start her assignment and that NA #1 should not take a break after punching in about an hour and half late. NA #1 immediately got upset and responded to her by yelling you can't tell me what to f--- to do. RN #1 replied to NA #1 that she was the supervisor, and it was within her role to tell NA #1 that she needed to start her assignment. RN #1 stated that NA #1 then stood up and got close to RN #1's face and was saying in a loud voice that she didn't care about this f---ing job and that RN #1 could not tell her what the f---- to do and RN #1 should not be talking to NA #1 that way. RN #1 walked to her office (located on the same unit) and NA#1 followed her while speaking to her in a loud voice. RN #1 told NA #1 that her behavior was unprofessional and unacceptable, and to punch out and go home. At this time, RN #1 identified Resident #1 had wheeled him/herself outside of her office and began to tell NA #1 to calm down. NA #1 appeared to be headed to the punch clock and leaned close to Resident #1's face and told Resident #1 to get the f---- out of her way, leave her the f--- alone and to mind his/her own f---ing business. Resident #1 responded that NA #1 was scaring the other residents. RN #1 again directed NA #1 again to clock out and go home, and NA #1 left the unit. RN #1 then reported the incident and observed NA #1 leave the facility. Interview with NA #2 on 9/4/2024 at 11:30PM identified that on 8/19/2024 she observed Resident #1 in the hallway in his/her wheelchair. Resident #1 was wheeling him/herself down the hall towards NA #1 who was standing in the hallway near the supervisor's office. NA #2 stated she heard NA #1 say to Resident #1 back the f---k away from me. She indicated she then observed NA #1 lean slightly forward so NA #1 was closer to Resident #1's face and she heard NA #1 repeat the same comment again directly to Resident #1 and heard NA #1 say Don't you f---ng touch me and NA #1 pushed Resident #1's hand away from her. Interview with NA #4 on 9/4/2024 at 11:45 AM identified on 8/19/2024 she heard yelling when she was in a resident room and when she stepped into the hallway, she observed NA #1 follow RN #1 to her office, cursing at her and yelling at RN #1. NA #4 then observed Resident #1 had stopped his/her wheelchair and put the brakes on to stand and talk to NA #1. LPN #1 was behind Resident #1 and was telling him/her to sit down and NA #4 observed NA#1 say in a loud voice to Resident #1 not to f---ing touch her. Interview with NA #3 on 9/4/2024 at 11:52 AM identified she witnessed RN #1 talk to NA #1 in the room behind the nursing station when she heard loud voices and observed RN #1 walk toward her office. NA #1 followed RN #1 to her office saying loudly that she didn't care if she came in at noon, the supervisor could not tell her what to f---ing do. She observed Resident #1 in the hallway near NA #1 tell NA #1 to calm down and heard NA #1 began to curse and speak in a loud voice at Resident #1 using the f word. Interview with the DON on 9/4/2024 at 1:30 PM identified that if a staff member swears at a resident, it could be abuse depending upon the context of the conversation the foul language was used in. The DON stated although staff are educated not to use foul language within hearing distance of the residents, use of foul language would be considered disrespectful and not abuse as long as the resident was not upset Interview failed to identify why the interaction witnessed by several staff was not substantiated. Interview with the Administrator on 9/4/2024 at 1:35 PM identified the facility investigation conclude the foul language used in front of residents was not directed at Resident #1, and therefore was not abuse. The Administrator further identified the video reviewed during the investigation did not have any recorded audio. The Administrator stated NA #1's employment was terminated due to attendance issues and did not return to work at the facility after the incident. Interview failed to identify why the interaction witnessed by several staff was not substantiated. The facility Abuse/Residents Policy directed in part, purpose was to ensure each resident is treated with kindness, compassion and in a dignified manner. Abuse or mistreatment of any kind towards a resident is strictly prohibited. Verbal abuse is defined as the use of oral, written or gestured language that will fully included disparaging and derogatory terms to residents or families or within their hearing distance, regardless of their age, ability to comprehend, or disability. The facility Resident's [NAME] of Rights Policy dated 11/18 identified that residents have the righty to be treated with consideration, respect and full recognition of their dignity and individuality.

Based on record review and interviews for one (1) of three (3) residents, (Resident #1), reviewed for elopement, the facility failed to provide the necessary supervision to a resident who had cognitive impairment, and was at risk for elopement and as a result, the resident eloped from the building unsupervised and wandered off facility property. This failure resulted in a finding of Immediate Jeopardy. The finding included: Resident #1 was admitted to the facility with diagnoses that included dementia, adjustment disorder and delusional disorders. Resident #1 had a power of attorney for care appointed on 5/13/2009. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition and was independent with ambulation utilizing an assistive device. The care plan dated 2/27/24 identified Resident #1 was at risk for elopement from the building due to an attempt to go out the front door in August 2023, with interventions that included to a wander guard device (a device worn by a resident that alerts staff that the resident is near an exit door) in accordance with physicians orders, offer to escort Resident #1 to another area of the building if heading towards or lingering near an exit door, offer to engage Resident #1 in an activity he/she enjoys and a wander guard per physician's orders. A physician's order dated 4/1/24 directed placement of a wander guard to the resident's right ankle and under the seat of his/her rolling walker, and to check placement every shift and check function every night shift. A nurse's note dated 5/19/24 at 6:51 PM written by Licensed Practical Nurse (LPN)#1 identified at approximately 6:15 PM, the writer was notified that Resident #1 was observed walking next to the police station. Resident #1 was last observed at approximately 5:40 PM ambulating on the unit. A nurse's note dated 5/19/24 at 7:55 PM written by Registered Nurse (RN) #1 identified Resident #1 was found outside walking towards the police station. Resident #1 was wearing his/her wanderguard on his/her right ankle, the wanderguard was tested and functional, and although the alarm sounded as the resident exited, the front door lock did not engage. Review of the audit forms for facility doors (tests if wanderguard is functioning and that the door is secure) for the month of May 2024 identified that the doors were not checked on the weekends, including 5/19/24 (the day of the elopement). Review of the facility camera footage dated 5/19/24 identified at 5:48 PM Nurse Aide (NA) #1 was observed exiting the facility through the lobby doors, into the parking lot. At 5:50 PM Resident #1 was observed leaving the facility through the lobby doors unattended. After NA #1 exited the lobby doors he appeared to scan the parking lot before heading to a car and staying in the vicinity of that car. At 5:54 PM, NA #1 was observed entering the facility lobby doors alone. At 5:57 PM RN #1 was observed exiting the facility lobby doors and at 6:00 PM (10 minutes after the resident eloped from the facility alone), Resident #1 was observed entering the facility lobby doors with RN #1. Observation of the front door identified the presence of a wanderguard alarm that required code entry to silence the alarm. Interview with LPN #2 on 5/22/24 at 11:59 AM identified she was on a leave of absence from the facility at the time of the elopement. On 5/19/24 around dinner time she was driving by the facility and observed Resident #1 walking out of the parking lot towards the police station. She pulled into the facility parking lot, called the facility to let them know the resident was out of the building, and by the time she reached Resident #1, the resident was in the police station parking lot, off the facility premises. Interview with LPN #1 on 5/22/24 at 12:04 PM identified she was Resident #1's nurse on 5/19/24 from 7:00 AM to 11:00 PM. LPN #1 identified around 5:40 PM Resident #1 wanted to go downstairs to read in the library (resident resided on the second floor), which was a normal request for the resident, she disarmed the wanderguard alarm on the nursing unit by punching in the code and Resident #1 was allowed to exit the nursing unit to go down to the first-floor library via the elevator. LPN #1 further stated after the resident left the unit, she did not hear any alarms sound. Interview with LPN #3 on 5/23/24 at 1:24 PM identified she was working on the first floor on 5/19/24 and heard the wanderguard alarm going off for approximately five (5) minutes, however, did not respond because the wanderguard alarm upstairs sounds frequently and assumed that was why it was sounding. LPN #3 further stated she thought that NA #2 had responded to the alarm. Interview with NA #1 on 5/24/24 at 10:18 AM identified he was working on the first floor on 5/19/24 and heard the wanderguard alarm sounding, he checked the panel at the front door and identified the alarm was triggered in the lobby, and the Rosewood unit (upstairs) and Ashwood unit (upstairs). NA #1 went outside, looked at the cars in the parking lot and then went to his car, however he did not search anywhere else. He then came inside, (the alarm still sounding) and went to the bathroom for approximately three (3) minutes (prior to informing staff he was unable to locate a resident outside). Subsequently he went to inform the supervisor about the wanderguard alarm and the door being open and the supervisor had already received a call that the resident was found outside at the police station (the alarm had been sounding for 9 minutes at this point, with only NA #1 responded). NA #1 identified that although he knows to look at the alarm panel for the location of the alarm, he was not aware that the panel could identify which resident had triggered the wanderguard alarm, and that he was supposed to get the wanderguard book and search to locate for the residents that are in the book when the alarm is triggered. Interview with RN #1 on 5/22/24 at 12:43 PM identified she was the nursing supervisor on 5/19/24 when the resident eloped from the facility. RN #1 stated that she did not hear the wanderguard alarm sounding from her office on the first floor. RN #1 identified when Resident #1 was brought back into the facility she tested the front doors with three different wanderguard devices and the door alarmed, however, the door lock did not engage. RN #1 identified the DNS was notified and was told the team would take care the door issue in the morning, as the front doors lock automatically at 6:30 PM which would prevent any residents from attempting to leave the facility. Interview with the Director of Maintenance (DM) on 5/22/24 at 10:40 AM identified he was not notified of any issues with the front lobby doors on 5/19/24 as he would expect, if he had been notified, he would have come in and checked the doors immediately. He identified he tested the lobby doors on 5/20/24 at 9:20 AM and identified the front door lock was engaging and the alarm sounded when approached with a wanderguard. The DM stated on 5/19/24 there could have been debris between the door and frame causing the lock not to engage. He further identified the doors are to be checked daily for function, however, no one was checking the doors on the weekends. Interview with the Administrator on 5/22/24 at 12:00 PM identified there was no receptionist in the lobby at the time of the incident because reception works from 8:00 AM - 5:00 PM on the weekends. The Administrator was unable to identify why staff did not follow the elopement protocol including verifying which resident was missing and a thorough search was not conducted. Subsequent to Resident #1's elopement staff were educated on the elopement drill protocol which includes checking the elopement book to account for all residents at risk, checking the serial number on the alarm panel to indicate which resident had set off the alarm, and to search the parking lot. Interview with LPN #4 on 5/23/24 at 11:35 AM, who was working on the first floor unit during the 7:00 AM - 3:00 PM shift identified she was not able to locate an elopement book on the first floor unit and was unaware there should be an elopement book on the unit. She identified after the elopement occurred on 5/19/24 she was educated that the pin pad on the front door displayed a code when a resident exits that matches their wanderguard number, however, LPN #4 was not educated about the wanderguard book. Interview with LPN #5 on 5/23/24 at 11:40 AM, who was working on the first floor during the 7:00 AM - 3:00 PM shift identified she was not able to locate an elopement book on the first floor unit and was unaware there should be an elopement book on the unit. She identified after the elopement occurred on 5/19/24 she was educated that the pin pad on the front door displayed a code when a resident exits that matches their wanderguard number, however, LPN #5 stated that she did not receive education about the wanderguard book. Interview with NA #3 on 5/23/24 at 11:45 AM, who was working on the first floor during the 7:00 AM - 3:00 PM shift identified the procedure for an active elopement is that she would tell the nurse and supervisor and it would be their responsibility. She further identified she had never seen an elopement book before and was unable to locate an elopement book on the first floor unit. She identified after the elopement occurred on 5/19/24 she was educated that the pin pad on the front door displayed a code when a resident exits that matches their wanderguard number, however there was no education about the wanderguard book. Review of the door checks policy directed that facility doors are checked for proper functioning on a routine basis, ensuring the safety of residents and staff. The policy directed the maintenance supervisor or designee is responsible for checking and documenting the proper functioning of the exterior doors, stairwell doors, and doors equipped with wander guard devices on a routine basis and as needed. Review of the staff role during an elopement drill procedure directed when a wander guard door alarm is activated you must locate the elopement book which can be found on each unit, supervisor's desk, and reception desk. Each resident who has a wanderguard will have a corresponding number associated with the device. When the front door is approached, the wander guard will alarm, the corresponding number assigned to that wanderguard will show on the screen to identify which resident has triggered the wanderguard alarm. Staff must also verify that all residents in the elopement book are accounted for and there are no missing residents. If no residents are known to be missing, staff should reset the alarm.

Based on review of the clinical record, facility documentation, facility policy, and interviews for three (3) of four (4) residents (Resident #1, Resident #3, and Resident #4) reviewed for elopement risk, the facility failed to complete the elopement risk assessment in a timely manner in accordance with facility policy. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, adjustment disorder and delusional disorders. An elopement risk evaluation dated 8/24/23 identified Resident #1 was at risk for elopement (8 months since the last assessment was completed). A physician's order dated 1/20/24 directed wander guard to left ankle and under seat of rolling walker, check placement every shift and check function every night shift. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition and was independent with ambulation with a device. The care plan dated 2/27/24 identified Resident #1 was at risk for elopement from the building due to an attempt to go out the front door in August 2023 with interventions that included to discuss with Resident #1's family the risk of wandering and elopement and ensure they are aware of all steps to maintain safety, offer to escort Resident #1 to another area of the building if seen heading towards or lingering near an exit door, offer to engage Resident #1 in an activity he/she enjoys and wander guard per physician's orders. 2. Resident #3 was admitted to the facility with diagnoses that included dementia, generalized anxiety disorder and insomnia. A physician's order dated 1/29/24 directed wander guard to left underside of wheelchair, check placement every shift and check function every night shift. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition and required assistance with activities of daily living. The care plan dated 5/7/24 identified that Resident #3 was at risk for elopement from the building with interventions that included to apply wander guard, discuss with Resident #3's family the risks of wandering and elopement and ensure that they are aware of the steps taken to maintain safety, if you see Resident #3 heading towards or lingering near an exit door offer to escort to another area of the building and offer to engage Resident #3 in an activity he/she would enjoy. An elopement risk evaluation dated 5/20/24 identified Resident #3 was at risk for elopement from the building. Resident #3's medical record failed to identify an elopement risk assessment(s) was completed between 8/30/23 - 5/20/24 (8 months). 3. Resident #4 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease, and generalized anxiety disorder. A physician's order dated 1/29/24 directed wander guard to left ankle, check placement every shift and check function every night shift. Expiration dated 6/2026. The annual MDS dated [DATE] identified Resident #4 had severely impaired cognition. The care plan dated 3/22/24 identified Resident #4 wandered and could be confused and forgetful. Resident #4 was at risk for elopement from the building with interventions that included to apply wander guard, discuss with Resident #3's family the risks of wandering and elopement and ensure that they are aware of the steps taken to maintain safety, if you see Resident #4 heading towards or lingering near an exit door offer to escort to another area of the building and offer to engage Resident #3 in an activity, he/she would enjoy. An elopement risk evaluation dated 5/20/24 identified Resident #4 was at risk for elopement. Resident #3's medical record failed to identify an elopement risk assessment(s) was completed between 9/12/23 - 5/20/24 (8 months). Interview with the Administrator on 5/31/24 at 2:00 PM identified she was under the impression that elopement risk assessments were completely annually. She could not speak to why the policy directed elopement risk assessments to be completed quarterly. Review of the elopement risk policy directed the purpose of the policy is to identify all residents at risk of elopement and to institute interventions for those residents identified to be at risk. The policy further directed all residents are evaluated for risk of elopement of admission, readmission, quarterly, and with a change in condition, utilizing the elopement risk evaluation.

Based on review of the clinical records, review of facility documentation, and interviews for 1 of 5 residents (Resident #31) reviewed for staff to resident abuse, the facility failed to ensure Resident #31 was free from abuse and for 3 of 5 residents (Resident #62, Resident #74 and Resident #76) reviewed for resident to resident abuse, the facility failed to ensure adequate supervision was provided for a resident with intrusive behaviors which resulted in physical abuse. The findings include: 1. Resident #31 was admitted to the facility with diagnoses which included dementia, traumatic brain injury, and dysphasia. A physician's order dated 12/16/22 directed when out of bed Resident #31 was to sit in an adaptive tilt in space wheelchair with specialty cushion with bilateral elevating leg rests and a head support via standing mechanical lift with assist of 2. Reposition every 2 hours and sit upright for meals. The annual MDS assessment dated [DATE] identified Resident #31 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with toileting and eating and required total assistance with personal hygiene, dressing, bed mobility and transfers. Additionally, Resident #31 had no behaviors of physical or verbal directed towards others. The care plan dated 1/31/23 identified an alleged staff to resident altercation. Interventions included to report incident to family and physician, watch for any signs of distress, and investigate per facility policy. The reportable event dated 1/31/23 at 12:45 PM alleged LPN #8 forced crushed medications into Resident #31's mouth while holding the resident's left wrist down which resulted in the resident sustaining a cut on the lip. Additionally, LPN #8 allegedly spoke to the resident in Spanish using profanity. The APRN was notified on 1/31/23 at 1:00 PM however the police were not notified. The time clock punch detail for LPN #8 identified that he clocked in on 1/31/23 at 7:17 AM until 3:15 PM (2.5 hours after incident). A written statement by RN #4 on 1/31/23 identifed an incident occurred at 12:45 PM where she was notified by the DNS that the charge nurse (LPN #8) was holding residents' arm down and forcefully spooning medication into resident's mouth and he/she was bleeding. This writer assessed resident for injuries in the mouth area and gums. No injury or bleeding observed. Resident #31 was sitting in wheelchair and sleeping. A written statement by the prior DNS #2 on 1/31/23 at 1:15 PM indicated NA #1 and NA #3 went to her office and reported they witnessed LPN #8 hold down Resident #31's arm and shove medication on a spoon into the resident's mouth. Additionally, they reported the residents' lip was bleeding. NA #1 and #3 reported that LPN #8 whispered to Resident #31 in Spanish using profanity. The nurse's note written by RN #4 on 1/31/23 at 3:00 PM indicated this writer was informed by staff members an incident occurred at 12:45 PM they allegedly witnessed charge nurse treating a resident poorly. This writer updated DNS, and investigation was initiated. RN#4 performed a head-to-toe assessment on the resident, no injuries observed. Call made to update APRN with no new orders at this time. A reportable event completed by DNS #2 on 1/31/23 at 3:42 PM indicated she was reporting an alleged staff to resident abuse and she was first aware of incident on 1/31/23 at 1:00 PM. DNS #2 indicated that it was reported that an LPN held a combative resident's left wrist and aggressively administered medications and whispered to Resident #31 in Spanish using profanity. It was reported that resident could have sustained a cut on his/her lip from the encounter. Resident #31 does not recall the incident. APRN aware and LPN sent home until further investigation. A written statement by LPN #8 on 1/31/23 indicated at approximately 1:00 PM NA # 1 informed this nurse that Resident #31 needed medication because he/she was yelling and disruptive to other residents. LPN #8 indicated he went to medicate Resident #31 with his/her 2:00 PM dose of Trazodone and the resident was very combative. LPN #8 indicates he held up his hand against resident because Resident #31 was swinging his/her arms at LPN #8's face level. LPN #8 indicated there was a nursing assistant present that was assisting with the administration of the medication. LPN #8 indicated the nursing assistant told Resident #31 in Spanish who she was, and Resident #31 calmed down and took the medication. LPN #8 felt that he was being targeted by the nursing assistants because he had told one nursing assistant to take his gloves off in the hallway. LPN #8 indicated at no time was he unprofessional to the staff or residents. Interview with LPN #7 on 3/13/24 at 9:30 AM indicated that she remembers that she was sitting at the nurses station and heard Resident #31 talking loud which is Resident #31's baseline and when she stood up and she witnessed LPN #8 talking mean to Resident #31 and being very aggressive trying to place a spoon with medications in Resident #31's mouth. LPN #7 indicated she went over to Resident #31 right away, but LPN #8 was done and had started walking away. LPN #7 indicated that LPN #8 held Resident #31's left arm down forcefully with LPN #8's right hand. LPN #7 indicated that LPN #8 was forcing the medications with his left hand on a spoon. LPN #7 indicated that Resident #31 never cries but on this day Resident #31 was crying during and after the incident. LPN #7 indicated she saw a crack/broken skin on Resident #31's bottom lip, but it was not bleeding. LPN #7 indicated she then reported it to RN #4. LPN #7 indicated that RN #4 did not take the allegation seriously and LPN #8 worked until the end of the shift. Interview with NA#2 on 3/13/24 at 10:37 AM identified she was standing by nurses' station in the community room, and she could see Resident #31 sitting in his/her wheelchair at a table in community room. NA #2 indicated she saw LPN #8 forcefully slam Resident #31's left arm down onto the armrest of the wheelchair and shovel the medicine in Resident #31's mouth while Resident #31 was resisting the medication by turning his/her head side to side. NA #2 indicated that Resident #31 was saying no, no, no and shaking his/her head side to side. NA #2 indicated at no time did Resident #31 raise his/her arms. LPN #8 was very aggressive with Resident #31 by shoving the spoon with medicine in his/her mouth. NA #2 indicated NA #3 was present and spoke Spanish and understood what LPN #8 had said to Resident #31. NA #2 indicated whatever LPN #8 said to Resident #31 at the end really agitated Resident #31. NA #2 indicated that NA #1 was present. NA #2 indicated she saw blood on Resident #31's had blood in his/her mouth from the cut on his/her lower lip from the spoon. NA #2 indicated she became upset when she saw the blood in the residents mouth. NA #2 indicated that Resident #31's hands were shaking on the wheelchair arm rest at the table after incident and Resident #31 was crying like a child in trouble and was asking for his/her mother. NA #2 stated she never had observed Resident cry like that before. NA #2 indicated she reported it immediately to RN #4, but RN #4 really wasn't listening and brushing NA #2 off. NA #2 indicated she later went to the prior Administrator #2 and reported the incident because nothing was getting done. NA #2 indicated that Administrator #2 had her write a statement and she informed the Administrator #2 that there were other people standing there that witnessed the incident. NA #2 indicated that LPN #8 did not get sent home after the incident it wasn't until after she had reported it to Administrator #2 that a short time after that LPN #8 was sent home but it was at the end of the shift. Interview with SW #1 on 3/14/24 at 10:14 AM indicated that she recalled the incident from 1/31/23 and Resident #31 was limited verbally and unable to state what happened. SW #1 indicated that Resident #31's baseline is to shout as his/her normal tone of voice and could say yes and no, simple words, and calls out for his/her mother. SW #1 indicated that Resident #31 could shake his/her head but doesn't have good motor skills. SW #1 indicated that Resident #31 hands and arms shake sometimes. SW #1 indicated there was nursing staff that witnessed the incident, but she did not see the incident occur. SW #1 indicated she had just met with the resident, and he/she did not recall the incident the next day. Review of the facility Abuse Policy identified to ensure each resident is treated with kindness, compassion, and in a dignified manner. Additionally, to ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws. Abuse or mistreatment of any kind towards a resident is strictly prohibited. Allegations of abuse, by any individual towards a resident must be reported immediately to a facility supervisor. Abuse shall be defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Pre-hire screening of licensed staff and reference checks for all potential employees including previous employers. Investigation indicated that anyone who witnesses or has knowledge of abuse or mistreatment must report it immediately to the supervisor, DNS, and Administrator. The DNS or designee shall notify the resident representative, physician, DPH, and local police. The individual accused will be immediately suspended without pay pending the investigation. In conducting the investigation, the Administrator, DNS, or designee will interview all witnesses including the person accused of abuse, interview anyone with knowledge useful to the investigation. Documenting the conclusion of the investigation and actions taken on the internal investigation form. Follow up with the DPH reporting the conclusion and/or action taken and submission to FLIS within 5 days after the alleged incident. Review of the facility Resident [NAME] of Rights identified residents have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality. 2. Resident #62 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebrovascular disease affecting the left side, diabetes, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #62 had severely impaired cognition, identified no behaviors, and required total dependence for transfers with a mechanical lift with assistance of 2, and utilized a wheelchair for mobility. The November 2023 care plan identified Resident #62 was on psychotropic medications. Interventions included to administer medications as ordered, and adjust medication as needed. Offer support and reassurance if anxious. Review of the reportable event form dated 12/29/23 at 1:50 PM identified a resident to resident abuse without injury. Resident #62 attempted to redirect Resident #74 by self-propelling his/her wheelchair into Resident #74 to prompt Resident #74 to leave the room. Resident #62 made contact with Resident #74 lower extremities with his/her wheelchair. Resident #74 bent down to touch his/her leg and Resident #62 struck Resident #74 on the back. Resident #74 stood up and struck Resident #62 in the face. No injuries were noted. Both residents were immediately separated and Resident #74 was placed on 1:1 monitoring. A stop sign was placed across Resident #62's room door following the incident. A statement by RN #9 (Regional Clinician) dated 12/29/23 identified a resident to resident altercation reported by LPN #7. Resident #74 is eyes on supervision due to wandering and aggression. The staff reported Resident #74 has exhibited increase anxiousness due to not seeing his/her daughter in a few days. Resident #74 went into Resident #62's room and NA#9 witnessed Resident #62 running his/her wheelchair into Resident #74 leg. Resident #74 bent down to touch his/her leg and Resident #62 hit him/her on the back. As Resident #74 was standing up he/she struck Resident #62 in the face. RN #9 indicated Resident #62 has a small scratch on the inner right eye lid and Resident #74 was noted to be limping. 3. Resident #74 was admitted to the facility on [DATE] with diagnoses which included vascular dementia with behavioral disturbance, vascular dementia with mood disturbance, psychotic disturbance, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #74 had severely impaired cognition, exhibited wandering behavior, and was independent with bed mobility and transfer. The care plan dated 10/23/23 identified Resident #74 tends to wander around the unit looking for his/her sister, granddaughter, daughter, and keys at times. Interventions included to offer emotional support as needed. The care plan dated 10/23/23 identified Resident #74 was at risk for an alteration in mood and behaviors as evidence by wandering in and out of rooms at times. Interventions included one on one for mood/behaviors as ordered, psychiatric followed up as ordered and wanderguard bracelet. The nurse's note dated 12/1/23 - 12/28/23 failed to reflect consistent and complete documentation of Resident #74 behaviors. The nurse's note dated 12/29/23 at 6:58 AM identified Resident #74 was alert and confused. Resident #74 complained of pain in the left leg Resident #74 was restless during the shift, wandering into many resident rooms and had to be redirected multiple times. Review of clinical record for the month of December 2023 failed to reflect consistent documentation of Resident #74 behavior monitoring with the use of Trazodone medication for dementia behavior, sundowning, decreased sleep, increased yelling, and wandering at hours of sleep. The nurse's note dated 12/29/23 at 2:06 PM identified Resident #74 was observed urinating and defecating on the floor on the unit. Resident #74 was wandering on the unit and was noted walking into Resident #62's room. An altercation transpired between the two residents and Resident #74 punched Resident #62 in the face. The supervisor, APRN, and the resident representative were notified. Resident #74 was placed on on one to one for the remainder of the shift. A statement by NA #9 dated 12/29/23 identified Resident #74 had refused care today. Resident #74 was very restless and he/she has been up all night. Resident #74 has been going into other resident rooms and going through their belongings and many residents were yelling at Resident #74. NA #9 indicated she saw Resident #74 going into Resident #62's room. NA #9 indicated she saw Resident #62 propelled his/her wheelchair into Resident #74's leg when he/she was entering his/her room. NA #9 indicated Resident #74 bent over to touch his/her leg and Resident #62 hit him/her on the back. NA #9 indicated Resident #74 then struck Resident #62 in the face. A statement by RN #9 (Regional Clinician) dated 12/29/23 identified a resident to resident altercation was reported by LPN #7. Resident #74 is on eyes on supervision due to wandering and aggression. The staff reported that Resident #74 has exhibited increase anxiousness due to not seeing his/her daughter in a few days. Resident #74 normally wanders. Resident #74 went into Resident #62's room. It was witnessed by NA #9 Resident #62 ran his/her wheelchair into Resident #74 leg, and Resident #74 bent down to touch his/her leg and Resident #62 hit his/her on the back. As Resident #74 was standing up he/she struck Resident #62 in the face. RN #9 indicated Resident #62 has a small scratch on the inner right eye lid. Resident #74 was noted to be limping, resident was seen by the physician assistant with orders to obtained an X-ray of the left ankle. The psych APRN note dated 12/29/23 identified Resident #74 had an altercation with another resident. Resident #74 was alert and oriented. Resident #74 doesn't remember the incident and stated he/she would not hurt anyone. Resident #74 is not considered a danger to self or others. Discontinue one to one. Trazodone 25 mg every 8 hours as needed for 14 days for anxiety.(Trazadone is an antidepressant medication that may take two weeks for symptoms to improve) The revised care plan dated 12/29/23 identified Resident #74 was at risk for an alteration in mood and behaviors as evidence by wandering in and out of rooms at times. On 12/29/23 Resident #74 wandered into another resident's room. Interventions included adjusting medications as ordered. X-ray as ordered. Redirect when entering another resident's room. A physician's order dated 1/1/24 directed to administer Trazodone HCl (antidepressant medication) 50 mg in the afternoon for dementia behavior and sundowning. Trazodone HCl 100 mg at bedtime for decreased sleep, increased yelling, wandering at hours of sleep. Trazodone HCl 25 mg every 8 hours as needed for anxiety for 14 days. Review of the MAR dated 1/1/24 - 1/10/24 identified Trazodone HCl 25 mg every 8 hours as needed for anxiety for 14 days. The documentation identified the medication was only administered once between 1/1/24 - 1/10/24. Resident #74 received the medication on 1/2/24 at 6:50 PM with effect. Review of clinical record for 1/1/24 - 1/10/24 failed to reflect consistent documentation of Resident #74 behavior monitoring with the use of Trazodone medication for dementia behavior, sundowning, decreased sleep, increased yelling, wandering at hours of sleep, and anxiety. Review of the summary report dated 1/4/24 at 3:13 PM identified both residents experience cognitive impairment. Resident #62 was aphasic and not able to respond verbally to questions and has a history of being aggressive toward others. Resident #74 has a baseline tendency to wander. On 12/29/23 the day of the altercation Resident #74 was upset that his/her daughter had not visited in 2 days and was up late the evening before (12/28/23), and early the day of and was wandering into resident rooms more than normal. When Resident #74 entered Resident #62's room that day, Resident #62 responded by hitting him/her with the wheelchair and in response Resident #74 punched Resident #62 in the face. Neither resident sustained any injuries. Resident #62 was placed at the nurse's station for direct observation and Resident #74 was placed on 1:1 monitoring pending evaluation of both resident by psychiatry. Both residents were evaluated by psychiatry and determined not to be a risk of injury to self or others. Interventions were put into place for both residents to prevent further altercations. A stop sign was placed on the door of Resident #62's room as a deterrent for Resident #74 to keep out of his/her room. Resident #74 will be redirected by staff when he/she wanders to prevent him/her from entering Resident #62's room. The 1:1 observation was discontinued once both residents were cleared by psychiatry. The summary report failed to reflect documentation of Resident #62 had sustained a scratch below the right eyebrow. Review of the facility abuse/resident policy identified to ensure each resident is treated with kindness, compassion and in a dignified manner. To ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 4. Resident #76 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, anxiety disorder, and osteoarthritis. The quarterly MDS assessment dated [DATE] identified Resident #76 moderately impaired cognition, identified no behaviors, and required substantial/maximal assistance with personal hygiene. A physician's order dated 1/1/24 directed to administer Paroxetine HCl (antidepressant) 20 mg one time a day related to anxiety disorder. The nurse's note dated 1/10/24 at 5:26 AM by RN #8 (1/9/24 on 11:00 PM - 7:00 AM nursing supervisor) identified she was notified by the license nurse that Resident #76 was involved in an incident with another resident. RN #8 spoke with Resident #76 who stated that he/she was sound asleep and was startled awake by Resident #74 standing over him/her looking for something. Resident #76 indicated he/she waved his/her hands telling Resident #74 to go back to his/her room, but the resident was insisting Resident #76 had the keys. Resident #76 indicated Resident #74 was swinging his/her arms and hit Resident #76 on the hand and hip (pointing to right hip). Resident #76 had no complaint of pain, no bruising, abrasions, or skin tear noted. Vital signs 97.9 - 65 - 19 - 122/60 - 93% on room air. The police were notified and interviewed Resident #76. The DNS was notified and will contact the Administrator. The APRN was notified. Message left for psych APRN. Resident representative was updated on overnight incident. A statement by NA #7 dated 1/10/24 identified she noticed Resident #76 saying something in a loud voice. NA #7 indicated when she arrived at Resident #76 room, she saw Resident #74 was in the room speaking in a loud angry voice to Resident #76 to give him/her the keys. Resident #76 stated she did not have the keys and Resident #74 was to go back into his/her room. NA #7 indicated she was redirecting Resident #74 out of the room and explaining to him/her that it was 3:00 AM and Resident #76 was trying to go to sleep. NA #7 indicated Resident #74 was very agitated and not happy. NA #7 indicated Resident #74 pushed Resident #76 hands and telling him/her to give the keys. NA #7 indicated she got in between the residents and spoke to Resident #74 and redirect him/her back to his/her room. NA #7 indicated she made sure Resident #74 was calm and then she notified the nurse. The APRN note dated 1/10/24 at 12:23 PM identified Resident #76 was seen after being involved with another resident, Resident #76 was hit on hand and hip. Skin is clear and intact, denies any pain. Resident #76 claimed he/she understands his/her aggressor and is not upset about it, alert and oriented. The social service note dated 1/10/24 at 2:14 PM identified follow up regarding altercation. Resident #76 alert and oriented, able to recall details of the event. Resident #76 is very compassionate, verbalized understanding resident who entered the room has impairment it just disrupted his/her sleep. Resident #76 expressed he/she feels very safe at the facility and is empathetic to the situation with no further concerns. Review of the summary report by the DNS dated 1/14/24 at 1:26 PM identified on 1/10/24 Resident #74 wandered and startled Resident #76 who was sleeping in his/her room. On this occasion Resident #74 was having delusions that he/she was looking for his/her keys and believed that Resident #76 had them despite Resident #76 stating a number of times that he/she did not have the keys. Resident #74 then struck Resident #76. Resident #76 stated it felt more like a love tap and no injuries occurred to both residents. Resident #74 is experiencing delusions that are new and required psych evaluation of these behaviors and review of current medications. Upon completion of this investigation medications were adjusted and a new medication for delusions and agitation was added. Resident #74 was placed on 1:1 observation. Resident #74 was seen by the psych APRN and was deemed not to be a risk of injury to self or others and the 1:1 observation was discontinued. Resident #74 was placed on every one hour behavioral observations were implemented requiring staff to document what he/she was doing and interventions that were implemented. On 1/11/24 Resident #74 medications were adjusted Trazodone dosing was changed, and Seroquel was added to address the delusions and agitation. During the 48-hours observation period Resident #74 was noted to be either sitting in his/her room, sleeping or in the common room socializing and eating with other residents. Resident #74 behaviors were currently being observed every hour for the next 48-hours to assure the medications started are working to address the behaviors. Interview with the DNS on 3/14/24 at 10:35AM indicated Resident #74 was placed on 1:1 monitor with every resident to resident altercation. The DNS indicated Resident #74 was evaluated by the psych APRN who discontinued the 1:1 monitoring after each evaluation, reviewed and adjusted the medications, and the care plans have been revised. The DNS indicated with the 1/10/24 resident to resident altercation the psych APRN has added a new antipsychotic medication. The DNS failed to provide evidence that additional supervision was provided and/or additional interventions were implemented for Resident #74 following the discontinuation of 1:1 monitoring while the effectiveness of the new medication was being evaluated beyond a 48 hour time period. Review of the facility Abuse/Resident policy identified to ensure each resident is treated with kindness, compassion and in a dignified manner. To ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for two of three residents (Resident #2 and #3) reviewed for abuse, the facility failed to ensure residents with a history of verbal altercations were free from mistreatment. The findings include: a. Resident #2's diagnoses included Diabetes Mellitus, spinal stenosis, asthma, abnormality of gait and mobility, and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented, required extensive assistance of one staff for transfers and ambulation, and used a walker and a wheelchair. The Resident Care Plan (RCP) dated 3/2/2023 identified Resident #2 was moved to a new room. Interventions directed to encourage to get to know roommate, introduce to new roommate, orient to new environment and provide opportunities to express concerns and issues resident may have while adjusting to new environment and roommate. Review of Resident #2's clinical record identified a Social Services (SS) note dated 3/21/2023 at 2:09 PM identified Resident #2 was being seen in follow up regarding recent room change. The note further identified Resident #2 indicated there were occasional disagreements with his/her roommate. Social Service (SS) note dated 3/23/2023 at 11:07 AM identified a one-to-one (1:1) visit was provided after staff reported a conflict between Resident #2 and #3; both residents indicated they had not spoken to each other and continued to notify staff with disagreements. A nursing note dated 3/25/2023 at 9:14 PM identified Resident #2 continued to argue with Resident #3 regarding if lights should be on/off and if the door should be open/closed. Staff attempted to defuse the situation multiple times throughout the shift, and SS was notified. A nursing note dated 3/26/2023 at 3:47 PM identified Resident #2 was arguing with Resident #3 all day, yelling, and swearing, making derogatory comments and LPN #1 attempted to intervene and both residents requested to see SS about a potential room change. A SS note dated 3/29/2023 at 4:11 PM identified Resident #2 was taken to see and meet potential roommate in available room and Resident #2 declined the room change as he/she did not feel it would be a good fit with the potential new roommate. b. Resident #3's diagnoses included muscle weakness, adjustment disorder, and vascular dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was alert and oriented, walked and transferred independently, and used a cane and walker. The RCP dated 2/27/2023 identified psychotropic drug use due to mood fluctuations. Interventions directed to be aware of mood state/behavior, and medications as ordered, adjust as ordered. A SS note dated 3/23/2023 at 11:12 AM identified a 1:1 visit provided after staff reported a conflict between Resident #3 and his/her roommate (Resident #2). The note further identified both residents expressed that they go to staff with all concerns and do not speak to each other. The note further identified SW #2 discussed with Resident #3 the need for patience and flexibility as Resident #3 had not shared a room for a great length of time and would need to gradually relearn how to do so. Nursing note dated 3/26/2023 at 3:52 PM identified Resident #3 was alert and oriented, and arguing with roommate during the shift. The note indicated Resident #3 was yelling, swearing and making derogatory comments, and requested to speak with SS regarding a room change. 1. The facility reportable event form dated 4/20/2023 at 8:30 PM identified Resident #2 and Resident #3 were roommates, had a history of verbal arguments in the past and had a physical altercation over a television volume. Resident #2 complained the television volume was too loud and the residents got into a verbal altercation which progressed to a physical altercation with both residents using their canes toward the other. Both residents were transferred to the hospital for evaluation after the incident. Resident #2 was diagnosed with a hematoma on the forehead, and Resident #3 with a diagnosis of a fractured left arm. Both residents were placed on one-to-one (1:1) monitoring and Resident #2 was moved to another room upon return from the hospital. Review of Resident #2's clinical record identified as Resident #2 was exiting his/her room on 4/20/2023, Resident #2 got into a physical altercation with Resident #3 (roommate). Nursing note dated 4/20/2023 at 9:58 PM and Resident #2 sustained a fall after an altercation with Resident #3. The note further identified Resident #2 and #3 were arguing and then Resident #3 hit Resident #2 with a cane. Resident #2 stated when he/she was hit with the cane, it caused Resident #2 to lose his/her balance and fall to the ground, landing on his/her buttocks. Observations identified purple discoloration and swelling to the left elbow with a large, raised area on the forehead and a 2 centimeter (cm) by 1 cm abrasion on the center of the forehead. Review of Resident #2's hospital discharge summary identified x-ray results, elbow no fracture, and CT scan of the head indicated a hematoma (blood under the skin) in the midline frontal region without fracture and no intracranial hemorrhage. Review of Resident #3's clinical record identified on 4/20/2023 Resident #3 was in a physical altercation with his/her roommate (Resident #2). A nurse's note dated 4/20/2023 at 11:38 PM identified Resident #3 was hit in the arm with a cane by Resident #2 with a purple discoloration observed to the left forearm. Resident #3 complained of a pain (level of 7 out of 10) and indicated it felt like his/her arm was broken. Review of Resident #3's hospital discharge summary dated 4/21/2023 identified an obliquely oriented and mildly displaced fracture of the distal ulnar diaphysis (near the wrist). A nurse's note dated 4/21/23 at 7:27 AM identified Resident #3 returned from the ED and had a mildly displaced wrist fracture with soft case in place and to follow up with orthopedics. Additional review of Resident #2 and Resident #3's clinical records failed to identify interventions were utilized to prevent escalating behaviors between the residents after behaviors were identified between the roommates on 3/21, 3/23, 3/25 and 3/26/2023, to prevent the incident on 4/20/2023. Interview with LPN #1 on 5/8/2023 at 1:26 PM identified after 3/26/2023 there were multiple incidents of verbal altercations between Resident #2 and Resident #3 prior to 4/20/2023, and she notified the RN supervisor and the Social Worker of the incidents. Interview and medical record review with SW #1 and SW #2 on 5/9/2023 at 10:36 AM identified when Resident #2 was moved into Resident #3's room initially, SS provided follow up visits for three (3) days. SW #1 and SW #2 identified Resident #3 had not had a roommate since December 2022 (four months). After the third day staff notified them Resident #2 and #3 were having disagreements. Although SW #1 and #2 indicated they provided follow-up visits to the residents for support, encouragement and to offer room changes (both refused), they were unable to describe what measures were put into place to prevent escalating behaviors or an altercation between the roommates. Interview and chart review with the DNS and the Corporate Clinical Specialist (CCS) on 5/10/2023 at 11:32 AM identified Resident #2 and Resident #3 had individual SW visits after each verbal altercation on 3/21, 3/23, 3/25 and 3/26/2023. The DNS and CCS identified both Resident #2 and Resident #3 were both offered room changes after each occurrence, and both refused. The DNS and CCS identified Resident #3 had had a history of issues with roommates in the past; Resident #3 did not want a roommate and had not had a roommate since 12/2022 because of issues with roommates. Interview identified, although Residents #2 and #3 were seen by SS after each verbal altercation (on 3/21, 3/23, 3/25 and 3/26/2023), the DNS and CCS were unable to describe interventions that were utilized to prevent escalating behaviors between the residents to prevent a physical altercation. Interview identified although the facility capacity was 120 and the census on 3/26/2023 was 109 (11 empty beds) and one of the residents should have had a room change, the DNS and CCS were unable to explain why a room change was not provided prior to 4/20/2023. Further, the interview failed to identify any additional interventions put into place when a room change did not occur. Interview with the Administrator on 5/10/2023 at 1:28 PM identified both Resident #2 and #3 refused a room change previously, and although Resident #3 had issues with previous roommates, the Administrator was unable to provide documentation of any additional interventions to prevent escalating behaviors/physical altercation between the roommates. Review of the facility Residents [NAME] of Rights, dated July 2021, directed each resident has the right to be free from verbal, physical, or mental abuse. Review of the facility policy Abuse/Resident, dated January 11, 2023, directed in part, abuse or mistreatment of any king toward a resident is strictly prohibited. The policy defined abuse as the willful infliction of injury, with resulting physical harm, pain or mental anguish. The policy further for prevention, the facility should identify, correct and intervene in situations in which abuse is likely to occur including assessment, care planning and monitoring of residents with needs and behaviors, which might lead to conflict or abuse.

Based on a review of clinical records, facility documentation, interviews, and policies for one of three residents reviewed for abuse (Resident #3), the facility failed to ensure that the resident was free from abuse. The finding includes: R#3's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified that R#3 was severely cognitively impaired and required extensive physical assistance with activity of daily living tasks (ADL). The resident's care plan dated 12/30/17 identified that R#3 demonstrated behaviors which included refusal of care and combative with staff. Interventions included provide 1:1 observation as ordered/needed, attempt to redirect as needed, provide a calming environment when resident is upset, provide resident with medications as prescribed, adjust medication as ordered by MD/APRN, encourage family's input to help determine the best approaches, if staff unable to redirect, call daughter as needed. Review of a Reportable Event Form dated 3/4/18 identified that at approximately 6:30 AM, a NA reported that the resident was observed in the wheelchair with a sheet tied around his/her waist. The NA responsible for tying the sheet was taken off the schedule pending investigation. A review of the facility's investigation identified that on 3/4/18 during the 11 PM to 7 AM shift, R#3 was very agitated, staff attempted to re-direct R#3 and provide increased safety by seating R#3 in a wheelchair initially with a seatbelt in place and later with a bedsheet around the resident's waist. The facility substantiated abuse and NA #3 was subsequently terminated for failure to adhere to facility policy/procedure. Review of a nursing note dated 3/4/18 at 10:49 AM, authored by RN #1 (11PM-7AM supervisor), identified that at approximately 6:30 AM, while doing medication pass, NA #3 called her to inform her that R #3 was tied in the wheelchair around his/her waist with a sheet, the dayshift NA untied the sheet and took the resident to his/her room to perform morning care. RN #1 assessed the resident to have no injuries. All appropriate parties were notified including the resident's daughter who was understandably upset and had requested a meeting with administration. Review of the Physician Assistant's note dated 3/5/18 at 12:41 PM identified that she was requested to perform a body audit to assess for potential injury related to an incident on 3/4/18 where the resident was noted to have a sheet tied around the abdomen. No injury related to the incident was identified. Review of NA#2's statement dated 3/4/18 and interview on 11/15/18 at 11AM indicated that on 3/4/18 at 6:30AM, upon the start of her shift, s/he observed R#3 in a wheelchair, on the unit in the common area, with a sheet tied around his/her waist and around the wheelchair. The resident was trying to slide out of it trying to remove the sheet and it was tied in the back. NA #2 untied the sheet and took him/her to the room to provide care. Review of LPN #3's (7AM-3PM shift) statement dated 3/4/18 identified that she was notified by a NA that the resident was tied in a wheelchair by a sheet when she came in at 6:30 AM. LPN #3 documented R #3 told her that two girls tried to hurt him/her, that s/he fought back and that s/he doesn't want them here anymore. Review of NA #3's (11PM-7AM shift) statement dated 3/5/18 identified that she, another NA, and the nurse assisted the resident in a wheelchair for safety, clipped the seatbelt in place, then went to start morning rounds. At approximately 6:30 AM, she was questioned by the daytime NA why the resident was tied to the chair to which she replied, I don't know, last she knew there was a seatbelt in place. NA #3 further noted that she went downstairs to report this to the supervisor. Review of NA#4's (11PM-7AM shift) statement dated 3/5/18 identified the resident was aggressive and refused most care during the 11-7 shift. NA #4 stated NA #3 asked the nursing supervisor for a wheelchair due to aggression and she held the wheelchair while NA #3 and the nurse assisted the resident to the chair. NA #3 applied the seatbelt and identified that the resident would have fallen without the seatbelt in place. NA #4 further stated that she observed the sheet tied around the resident, however, did not know who applied the sheet. Review of RN #2's statement dated 3/5/18 (7AM-3PM nursing supervisor) identified that when she called NA #4 to tell her she was off the schedule, NA #4 reported that NA #3 had tied the sheet around the resident. Subsequently, NA #3 was notified that she was off the schedule pending an investigation. The statement further noted that the resident's daughter was informed that R #3 alleged s/he was hurt last night by two girls and wanted to speak with administration. RN #2 subsequently notified the Administrator of the allegation. Interview with Person #2 on 11/15/18 at 11:10AM indicated that R#3 was fearful of the staff after the incident. Review of LPN #2's (11 PM-7AM assigned nurse) statement dated 3/4/18, 3/5/18, and 3/8/18 and interview with LPN# 2 on 11/15/18 at 2:10PM identified that the resident was yelling, hitting out and throwing the phone, she assisted the resident to a wheelchair with NA #3 then resumed her medication pass. LPN #2 indicated that she did not observe the NA's clip the seatbelt and/or apply the sheet around the resident. Interview with DNS #1 on 11/15/18 at 2:00 PM stated the seatbelt was being utilized as a restraint on 3/4/18 and that the facility does not utilize restraints. Interview with Administrator on 11/15/18 at 3 PM indicated that R#3 should never have been restrained to the chair. The Administrator indicated that the facility staff was re-educated on the facility' policy and the staff involved in the incident are no longer employed at the facility. Attempts to interview NA#3 on 11/15/18 at 1:10 PM, DNS #2 on 11/15/18 at 2:15 PM, and NA#4 on 11/15/18 at 1:35 PM were unsuccessful. A review of the Resident Abuse policy defined abuse in part, as unreasonable confinement, and the residents have the right to be free from abuse.

Based on a review of clinical records, facility documentation, interviews, and policy review, for one of three residents reviewed for accidents (Resident #1), the facility failed to ensure the resident was transferred in accordance with the plan of care. The finding include: Resident #1's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #1 was unable to identify the correct day or month, had a BIMS score of 10 (moderate cognitive impairment), and required extensive assist of two for transfers. The Resident Care Plan (RCP) dated 1/15/18 identified R #1 required assistance with ADLs. Interventions directed to transfer with two staff assistance. Review of the nurse aide care card directed in part, to provide assist of two for transfers. Review of facility incident report dated 4/8/18 at 7:30 AM identified R #1 required two assist for transfers, and when NA #1 transferred R #1 without additional staff, R #1 sustained a six (6) by five (5) cm laceration to the right leg. Documentation further identified staff education was completed. The nurse's note dated 4/8/18 at 2:45 PM identified at approximately 8:30 AM, R #1 had a laceration on the right calf, R #1 stated he/she bumped his/her leg on the wheelchair, the resident was transferred to the hospital for treatment and returned at approximately 1:30 PM. Review of the hospital record dated 4/8/18 at 12:28 PM identified R #1's laceration was closed in a layered fashion with absorbable sutures. Nurse's note dated 4/8/18 at 9:40 PM identified R #1 was readmitted with seven (7) stitches to the right lower leg. Interview, clinical record review, and facility documentation review with NA #1 on 4/8/18 at 11:46 AM identified when she attempted to transfer R #1 alone, R #1 sustained a skin tear. NA #1 further stated that she did not check R #1's NA care card prior to attempting the transfer, and was not aware R #1 required two staff for transfers. NA #1 stated she should have checked the care card prior to providing care. Interview, clinical record review, and facility documentation review with the DON and ADON on 11/16/18 at 12:34 PM identified resident transfer status is on the NA care card and in the care plan. Interview further identified that although R #1 required assist of two for transfers, NA #1 attempted to transfer R #1 without assistance and R #1 sustained the skin tear. The DON stated two staff should have completed the transfer. Interview with the DON identified there was no transfer facility policy for surveyor review, however the expectation was that two staff should have completed the transfer.

Based on clinical record review, facility documentation and interviews for two of three sampled resident's (Resident#63 and Resident#135) reviewed for accidents, the facility failed to conduct an assessment and training to ensure equipment and/or was adequate supervision was provided to prevent an accident which resulted in an injury prior to a leave a absence and/or implemented interventions to prevent an accident. The findings include: 1. Resident #63's [DIAGNOSES REDACTED].The admission MDS assessment dated [DATE] identified intact cognition, non-ambulatory and required extensive assistance of 2 staff members for bed mobility and transfers. A physician's orders [REDACTED].The care plan dated 8/18/17 identified assistance was required for activities of daily living with interventions which included: assist of 2 staff members with a stand pivot transfer using a gait belt due to recent hospitalization following syncopal episode and a fall at home. Review of the Reportable Event dated 9/23/17 identified at 3:00 PM, Resident #63 was attempting to get into the family car and was unable to complete the transfer and sat onto the curb in front of the building. An X ray of the right ankle was obtained on 9/23/17 due to complaints of pain which identified a bimalleolar fracture and dislocation. Resident #63 was transferred to the emergency roiagnom on [DATE] and admitted to the acute care hospital for pain management and conservative treatment of [REDACTED].Review of the Release of Responsibility For Leave of Absence Log identified Person #1 signed Resident #63 out on 9/23/17 at 3:02 PM and that there were no other LOA's prior to this date since admission on 8/8/17. Interview with PT#1 on 10/12/17 at 2:15 PM identified at the time of the fall on 9/23/17, Resident#63 was receiving physical therapy five times a week for therapeutic exercise, neuro-muscle re-education, gait training, therapeutic activity and was a stand pivot transfer with an assist of 2 and a gait belt. PT#1 identified s/he was not aware the resident was going on a LOA with the family and transfer training/car transfers training was not done with the family prior to the LOA. PT#1 identified car transfer training and/or education was not conducted with the family because it was not safe and Resident #63, although making progress, was not physically ready for car transfers. Interview with the DNS on 10/12/17 at 2:50 PM identified s/he was unsure if Resident #63's LOA with family on 9/23/17 at 3:00 PM was planned but that s/he did have an LOA order from the attending physician in place at that time. The DNS failed to provide evidence that transfer training was conducted with the family prior to the LOA. The DNS further identified transfer training with the family was not considered until after the fall which resulted in an injury. Interview with Person #1 on 10/13/17 at 2:20 PM identified s/he asked the nurse on 9/22/17, a day prior to the planned LOA, if it was acceptable for Resident #63 to go out with him/her on 9/23/17 and was given the approval. Further interview identified on 9/23/17, LPN#2 changed Resident #63's oxygen over to the portable tank and handed Person #1 the LOA sign out book. Person #1 further identified staff did not assist Resident #63 into the vehicle and Resident #63 did not have a gait belt or a walker provided to him/her to assist with the transfer from the W/C into the car. Person #1 identified that s/he would not have attempted the car transfer if s/he did not think it was safe, indicating that s/he assumed it was or the facility would not have allowed him/her to go on the LOA. 2. Resident #135's [DIAGNOSES REDACTED]. The 14 day MDS assessment dated [DATE] identified intact cognition and required extensive assistance with walking in corridor and locomotion on the unit. The care plan dated 5/4/17 identified assistance with ADLS with interventions which included may ambulate independently with rolling walker and offer assistance as needed.The accident and investigation dated 6/2/17 identified while Resident #135 was in a standing position, LPN#3 was adjusting the dressing on the right leg when the resident shifted his/her weight to the left leg and the knee gave out resulting in a fall. The resident was transferred to the emergency room for an evaluation due to complaints of knee and shoulder pain. Resident #135 returned to the facility on [DATE] with a possible acute left tibial plateau fracture. The CT scan report dated 6/6/17 identified no acute tibial plateau fracture. A written statement provided by LPN#3 dated 6/2/17 identified the resident asked her to re-tape his/her leg dressing which was becoming unraveled. She further identified that she suggested the resident should go back to his/her room but the resident refused. In her written statement LPN#3 denied touching the resident at the time of fall. Attempts to contact LPN#3 were unsuccessful. Interview with the DNS on 10/13/17 at 1:00 PM identified that although LPN #3 denied changing the lower extremity dressing, the facility investigation identified LPN # 3 was observed adjusting Resident #135's dressing in the hallway by facility staff. The DNS further identified it was the responsibility of LPN#3 to ensure Resident #135 was in a safe position prior to adjusting the dressing on the lower extremity.LPN#3 should have provided the resident a seat to prevent the resident from losing his/her balance while adjusting the bandage.

Based on clinical record reviews and interviews for three of six sampled residents reviewed for pressure sores (R #3, 48, 99), the facility failed to conduct weekly skin audits, and/or failed to develop and/or initiate a comprehensive care plan to ensure repositioning and the prevention of pressure sores, and/or failed to review and revise the care plan when interventions failed to prevent a pressure sore and/or the pressure sore got bigger, and/or failed to conduct and document thorough assessments of pressure sores at least weekly, and/or failed to conduct nutritional assessments for residents with pressure sores. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified the skin was intact with redness to the bilateral buttocks. The interim/admission care plan initiated on 7/25/15 failed to identify a risk for pressure ulcer development and/or interventions to prevent the development of pressure ulcers. The admission MDS assessment dated [DATE] identfied the resident without cognitive impairment, no mood or behaviors exhibited, required extensive assistance of two for bed mobility, transfers, toilet use and personal hygiene, was always incontinent of bowel, at risk for developing pressure ulcers, and currently with no pressure ulcers. The care plan dated 8/12/15 identified a risk for alteration in skin integrity related to decreased mobility from new paralysis. Interventions included elevate my legs as possible when in bed or up in chair, offer to assist with turning and repositioning approximately every two hours and/or as needed, and pressure ulcer wound care as per facility policy, measure,describe, note any worsening of area and notify the MD. The physician orders [REDACTED]. The clinical record failed to reflect documentation of an assessment of the new open area when identified on 8/6/15 and/or failed to reflect a comprehensive care plan was developed with interventions implemented for the prevention of pressure ulcer development. The physician orders [REDACTED]. The physician orders [REDACTED]. Review of the APRN progress notes dated 8/17/15 identified a stage two pressure ulcer on the right sacrum measuring 2 CM x 3 CM with 100% nongranulating tissue, peri wound excoriated, a new partial thickness wound on the right lower buttocks measuring 2 CM x 2.1 CM x 0.5 CM with 100% [MEDICATION NAME] tissue. A new partial thickness wound on the left buttocks measuring 4.5 CM x 3.5 CM x 0.5 Cm with 100% [MEDICATION NAME] tissue. APRN progress note dated 8/25/15 identified an unstageable pressure ulcer on the right sacrum measuring 2 CM x 2 CM with 80% slough,scant serosanguineous drainage, the right ischium with an unstageable pressure ulcer measuring 1.5 CM x 1.2 CM with 100% slough. The right upper sacrum with an unstageable area measuring .80 CM x 1.4 CM with 100% slough. The left sacrum with unstageable area measuring 4.5 CM x 1.5 CM with 80 % slough. Review of the weekly body audit sheets dated 7/25/15 through 9/17/15 identified four out of seven weekly body audits were not competed in accordance with facility policy and procedure. Interview with R #3 on 8/16/15 at 11:15 AM identified staff utilize a mechanical lift to transfer him/her out of bed daily, once he/she is gotten out of bed he/she stays out of the bed all day most times till after dinner. Additionally although he/she stayed out of bed most days, the staff did not provide repositioning and/or incontinent care until he/she is returned back to bed. Interview and review of the clinical record with LPN #3 on 9/16/15 at 11:30 AM identified R #3 was frequently non compliant with repositioning and/or returning back to bed in the afternoon. The clinical record failed to reflect R #3's non compliance with repositioning and/or incontinent care. LPN #3 indicated due to R #3's [DIAGNOSES REDACTED]. Additionally when R #3 was identified with a new open area on 8/15/15 the nurse who identified the area should have completed an assessment and documented an assessment of the area including location, size, measurements, drainage, odor, or pain in the clinical record. 2. Resident #48's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident was cognitively impaired, required extensive assist with transfer, and did not walk. A resident care plan dated 7/7/15 identified a risk for impaired skin integrity due to immobility and incontinence. Interventions included off load heels while in bed and turn and position every 2 hours. An additional problem dated 8/28/15 indicated the resident had a stage 2 pressure ulcer on the left medial halllux. The revised intervention included no shoes, use slipper socks only. A skin/wound tracking record dated 8/28/15 indicated the resident had 2.5 cm x 2.0 cm x 0.1 cm stage 2 pressure ulcer on the left medial hallux. A subsequent skin/wound tracking record dated 9/8/15 indicated the stage 2 pressure ulcer on the left medial hallux measured 2.0 cm x 1.3 cm x 0.1 cm. A physician's orders [REDACTED]. A wound assessment dated [DATE] indicated the pressure ulcer on the left medial hallux was unstageable and measured 0.7 cm x 0.6 cm. An observation on 9/17/15 at 12:15 PM noted R # 48 with sneakers on both feet. An interview with LPN # 2 at that time indicated the resident was not to have shoes on and would have them removed. An interview on 9/17/15 at 12:20 PM with NA # 1 indicated he/she had gotten R # 48 out of bed at 8:30 AM and put his/her shoes on at that time. He/she was aware the resident was not to wear shoes, but forgot. At that time with LPN # 2 the resident's left foot was observed. The open area on the left medial hallux was unstageable with a reddened periwound. The resident called out in pain when the nurse attempted to measure the wound. The wound was not able to measured at that time. An interview on 9/17/15 at 12:45 PM with LPN # 3 indicated when he/she saw the resident's left medial hallux on 9/14/15 the periwound was within normal limits and not reddened. 3. Resident #99's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identfied that the resident was without cognitive impairment, did not resist/refuse care, was dependent on 2 staff for bed mobility, dependent on 1 staff for all other ADL's, was frequently incontinent of bowel and bladder, and was at risk for but had no pressure sores. Laboratory tests on 6/10/15 noted the resident's [MEDICATION NAME] was low at 2.9 (normal 3.6-5.1) and total protein was low at 5.6 (normal 6.1-8.1). No new orders were written. Wound assessment records identified that on 6/19/15 the resident developed a 0.3 x 0.3 x 0.2 stage 2 pressure ulcer to the left sacrum. Treatment orders were obtained at that time but no changes were made to the care plan. Dietitian notes dated 6/26/15 identified that the resident had experienced a 4% weight loss (from 207 lbs to 198 lbs). The note failed to mention the presence of a pressure sore and/or assess for the resident's increased protein needs related to the pressure sore. No recommendations were made. On 7/6/15, the wound assessments documented that the wound had increased in size. No changes were made to the plan of care regarding the increase in size of the pressure sore. Interview and clinical record review with LPN #3 on 09/17/2015 2:01:25 PM failed to provide documentation that the care plan was reviewed and revised when the resident developed a pressure sore and/or that resident was re-assessed by the dietitian for nutritional needs related to pressure sore development and/or that the wound was thoroughly assessed at least weekly, and/or that weekly skin audits had been conducted as ordered. Interview with the dietitian on 09/17/2015 at 1:41:38 PM noted that s/he had not been notified of the presence of a pressure sore and would have ordered a protein supplement if s/he had been made aware.

Based on clinical record review, facility documentation and interviews for one of three sampled residents (Resident # 2) who required a heated compress treatment, the facility failed to ensure that the temperature of the compress was safe prior to the application and/or for one of three sampled residents (Resident #1) who were reviewed for consulting physician appointments, the facility failed to provide the resident with supervision while outside the facility. The findings include: Based on 1. Resident #2's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified that Resident #2 had no cognitive and/or memory deficits, required total one to two person assistance with activities of daily living, and had bilateral lower extremity functional limitations in range of motion. A physician's orders [REDACTED]. The resident care plan revision dated 3/21/14 identified a recent hospitalization related to the deep vein thrombosis. Interventions directed weekly body audits, to monitor for pain and notify the physician of any changes. The nurse's note dated 3/24/14 at 7:00 AM identified a large blister on the left leg was noted. Upon assessment the area measured 7 centimeters (cm) by 7 cm and the resident complained of a "stinging feeling". The Reportable Event Form dated 3/24/14 identified Resident #2 stated that the prior evening someone placed a hot pack on the left upper posterior calf. The resident sustained [REDACTED]. The investigation identified that Licensed Practical Nurse (LPN) #3 indicated she had placed a wet towel in the microwave to warm and applied the towel to Resident #2's left leg without checking the temperature first. Subsequent to the incident the physician was notified and directed to cleanse the left calf blister with Normal Saline followed by medihoney and ABD pad change daily times fourteen days then re-evaluate. Review of LPN #3's written statement dated 3/24/14 identified that she heated the wet towel up in the microwave, wrapped the towel around the leg with two other towels for approximately ten minutes and that the resident had no complaints of pain at that time. Review of the skin and wound tracking record dated 3/24/14 identified a 7 cm by 7 cm burn to the left upper posterior leg and a second area, a fluid filled blister that measured 2 cm by 2 cm burn on the left upper posterior calf. The tracking record identified that on 4/7/14 the area measured 7 cm by 9 cm with 100% necrotic tissue and the second area was 1 cm by 2 cm with 100% slough. On 5/1/14 the upper posterior site was debrided by the Advanced Practice Registered Nurse (APRN). Interview with Registered Nurse (RN) #2 on 7/10/14 at 1:20 PM stated that she was made aware that Resident #2 had a blister by the nurse aide who was providing care. Upon assessment RN #2 indicated that the area was large and the surrounding skin was red, the physician was notified and a treatment order obtained. Interview with RN #3, who was the Director of Nurses (DON) at time of the incident, on 7/10/14 at 12:50 PM identified that she spoke with LPN #3. RN #3 stated that LPN #3 was told by another nurse to heat a wet towel in the microwave. RN #3 indicated that the LPN did not reference the policy and procedure manual regarding warm compresses and that all staff were provided education after the incident. Interview with the Acting DON on 7/9/14 2:00 PM identified that the facility did not have a policy regarding warm compresses until after the incident with Resident #2, however there was a policy for the application of a hydrocollator pad. Subsequent to the incident LPN #3 was suspended and placed on 90 days probation. 2. Resident #1's [DIAGNOSES REDACTED]. The Resident Demographic information identified that Resident #2 was conserved. The admission Minimum Data Set assessment dated [DATE] identified Resident had moderate impaired cognition, short and long term memory impairment, had difficulty focusing attention and disorganized thinking, required extensive one person assistance with bed mobility, had an infection of the foot and a surgical wound. The resident care plan dated 2/17/14 identified alteration in skin integrity related to a recent amputation of left second toe. Interventions, in part, directed to follow up with surgeon as ordered and/or as needed. Review of facility documentation from 1/28/14 through 4/17/14 identified although Resident #1 was scheduled twelve times for follow up appointments with the podiatrist, the resident only went seven times, four appointments were canceled and rescheduled due to inclement weather and the other was canceled when an angiograph was performed. Interview with MD #2 on 7/10/14 at 11:35 AM stated that at each time, except for one, Resident #1 was alone. MD #2 indicated that the facility was notified to have someone accompany the resident to the appointment. MD #2 identified that the resident required a person with him/her due to the resident's medical issues and there was only one appointment when a staff member was present. Interview with LPN #1 on 7/8/14 at 1:10 PM identified that she scheduled appointments for the residents, would notify and/or leave a message for the family of the appointments and let the scheduler know to book the transportation. LPN #2 stated that she did not ask Resident #2's responsible party if they would be accompanying the resident to the appointments. LPN #2 indicted that if a resident was cognitively impaired and/or required a wheelchair she would let the scheduler know so a staff member or family member could accompany the resident. LPN #2 stated that she did not inform the scheduler to send anyone with Resident #1. Interview with RN #1 and the Administrator on 7/8/14 at 1:30 PM identified that nursing would complete a form to determine if the resident needed to be accompanied to an outside appointment. RN #1 stated that Resident #1 was not an elopement and/or fall risk so no staff accompanied him/her. Review of facility the policy and procedure for Physician Appointments Offsite directed the facility will provide supervision to residents for offsite medical appointments, unless the physician's office states it was not necessary.

Based on clinical record reviews and interviews for one of three sampled residents (Resident #1) reviewed for vascular wounds, the facility failed to ensure that interventions were implemented to promote healing, prevent infection and/or prevent new sores from developing. The findings include: Resident #1 was admitted to the facility on [DATE] status [REDACTED]. [DIAGNOSES REDACTED]. The physician's admission order dated 1/28/14 directed to elevate the left foot on two pillows. The admission Minimum Data Set assessment dated [DATE] identified that Resident #1 had moderate impaired cognition, short and long term memory impairment, had difficulty focusing attention and disorganized thinking, required extensive one person assistance with bed mobility, had an infection of the foot and a surgical wound. The resident care plan dated 2/17/14 identified the resident was at risk for an alteration in skin integrity related to recent amputation of the left second toe. Interventions directed to elevate the foot on two pillows, follow up with the surgeon as ordered and/or as needed, inspect the skin daily when providing care, surgical wound care as ordered, monitor for signs and/or symptoms of infection and notify the physician with any change. Review of the treatment kardexes from the time of admission (1/28/14) through discharge (4/17/14) identified for January 2014 the left foot was elevated from 1/28/14 through 1/31/14. The facility was unable to locate the February 2014 kardexes. Although the March 2014 and April 2014 treatment kardexes directed to elevate the left foot on two pillows, the kardexes lacked signatures that the intervention was implemented. Review of the nurse's notes from 1/28/14 through 4/17/14 identified only two times when the foot was elevated 2/5/14 during the 11 PM-7 AM shift and 2/12/14 at 11:00 AM. Although the individualized resident assignment card directed to elevate the left foot on two pillows, the nurse aide flow sheets lacked documentation that the intervention was implemented. The podiatrist's (MD #2) consultant report dated 3/3/14 identified a multi-podus boot was dispensed to the resident. Review of the physician's orders [REDACTED]. Further review of the APRN progress note dated 3/24/14 identified multipodus boot in place. Although the Individualized Resident Assignment directed the application of the multi-podus boot to Resident #1's left foot, the nurse aide flow sheets failed to reflect documentation that the boot was utilized. Review of treatment kardexes from 3/3/14 through 4/17/14 failed to reflect documentation that a multi-podus boot the left foot was ordered by the podiatrist. Review of the discharge summary dated 4/17/14 identified Resident #1 was to wear the multi-podus boot at bedtime. The skin/wound tracking record dated 2/18/14 identified a reddened vascular area to the left lateral foot measuring 10.0 centimeters (cm) by 1 cm, the Advanced Practice Registered Nurse (APRN) was notified and a treatment, skin prep daily was put into place. Review of the weekly tracking record identified that on 3/25/14 the left lateral foot was noted to be a 1.5 cm by 1 cm scabbed area, the APRN was made aware and the current treatment of [REDACTED]. The weekly skin tracking record identified that on 4/15/14 the left lateral foot was assessed to be 9.0 cm by 3.0 cm with 100% eschar and [DIAGNOSES REDACTED]. The APRN was made aware and the treatment, skin prep, was continued. The clinical record lacked documentation that the Podiatrist was made aware of the change. Interview with LPN #1 on 7/8/14 at 1:10pm stated she could not recall if the residents foot was elevated and/or if the multibodus boot was on. Interview with Registered Nurse (RN) #1 on 7/8/14 at 1:30 PM stated that when a resident goes out to a specialist for a consult upon return the physician and/or Advanced Practice Registered Nurse (APRN) are notified and the physician orders [REDACTED].#1 and interview identified that although the podiatrist ordered the multi-podus boot on 3/3/14 the order was not written until 3/20/14 after the resident was seen again by the podiatrist. Upon further review, the clinical record failed to identify the multi-podus boot had been applied as ordered and/or the resident's foot was elevated. RN #1 identified that the order should have been transcribed on to the treatment kardex and signed for every shift. Interview with MD #2 on 7/10/14 at 11:35 AM identified that had the facility elevated the resident's foot and applied the multi-podus boot, these interventions would have prevented the redness and scabbed area and the development of the eschar to the foot. Review of the clinical record and interview with the DNS on 7/24/14 at 11:15am identified Resident #1 was seen on 1/30/14 by the attending physician and a history and physical were completed. Further review of the clinical record identified all subsequent visits (1/31/14, 3/20/14 and 4/24/14) were conducted by the APRN.

Based on clinical record review, and interviews for one of three sampled residents reviewed for dehydration (R#178), the facility failed to ensure that resident's who fail to consume the necessary fluid intake, are assessed for signs of dehydration and/or interventions put in place to prevent dehydration, and/or that the physician/APRN are immediately notified of poor fluid intake and abnormal laboratory reports. The findings include: Resident #178's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident cognitively impaired, required extensive assistance from staff for all ADL's and mobility, and was dehydrated. The care plan dated 11/7/13 identified the potential for dehydration. Interventions included to check labs per MD order, be aware of poor skin turgor, dry mucous membranes, decreased urine output, or change in mental status, offer and encourage fluids between meals, and document I&O every shift. The dietitian's initial assessment recommended daily fluid intakes of between 2050-2460 cc per 24 hours. Review of the resident's November 2013 intake and output records noted the following: 12th 1480 13th 1380 14th 1320 15th 1320 16th 1570 17th 1690 18th 1320 19th 1500 20th 1715 21st 1350 22nd 1440 23rd 1500 24th 1560 25th 1220 The resident's lab work noted on 11/1/13 a BUN of 13 (normal 7-25) and a creatinine of 1.17 (normal 0.6-0.88). On 11/20/13, the BUN had risen to 27 with the creatinine at 2.08. Labs done on 11/22/13 noted a BUN of 21 and creatinine of 1.82. The MD progress note dated 11/7/13 indicated that the resident had signs of [MEDICAL CONDITION] due to use of [MEDICATION NAME] and [MEDICATION NAME] intravenously. "hydrate as needed". On 11/18/13, the physician directed a psychiatric evaluation for depression and anorexia. On 11/25/13, the APRN progress note indicated the resident had an increased creatinine and appeared to have dehydration based on labs (11/22/13 lab results). 3 liters of IV fluids were ordered for hydration. Interview and clinical record review with the DNS on 1/9/14 at 11 AM failed to provide documentation that the resident was assessed for signs and symptoms of dehydration, and/or that the care plan was reviewed and revised and interventions initiated to prevent dehydration, and/or that the physician and/or APRN were made aware of the low fluid intakes, when the resident was noted to fail to meet the estimated fluid needs every day for 14 days resulting in a [DIAGNOSES REDACTED].

Based on clinical record reviews and interviews for one of three sampled residents reviewed for hydration (R#178), the facility failed to review and revise the care plan to prevent dehydration. The findings include: Resident #178's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident cognitively impaired, required extensive assistance from staff for all ADL's and mobility, and was dehydrated. The care plan dated 11/7/13 identified the potential for dehydration. Interventions included to check labs per MD order, be aware of poor skin turgor, dry mucous membranes, decreased urine output, or change in mental status, offer and encourage fluids between meals, and document I&O every shift. The dietitian's initial assessment recommended daily fluid intakes of between 2050-2460 cc per 24 hours. Review of the resident's November 2013 intake and output records noted the following: 12th 1480 13th 1380 14th 1320 15th 1320 16th 1570 17th 1690 18th 1320 19th 1500 20th 1715 21st 1350 22nd 1440 23rd 1500 24th 1560 25th 1220 The resident's lab work noted on 11/1/13 a BUN of 13 (normal 7-25) and a creatinine of 1.17 (normal 0.6-0.88). On 11/20/13, the BUN had risen to 27 with the creatinine at 2.08. Labs done on 11/22/13 noted a BUN of 21 and creatinine of 1.82. The MD progress note dated 11/7/13 indicated that the resident had signs of [MEDICAL CONDITION] due to use of [MEDICATION NAME] and [MEDICATION NAME] intravenously. "hydrate as needed". On 11/18/13, the physician directed a psychiatric evaluation for depression and anorexia. On 11/25/13, the APRN progress note indicated the resident had an increased creatinine and appeared to have dehydration based on labs (11/22/13 lab results). 3 liters of IV fluids were ordered for hydration. Interview and clinical record review with the DNS on 1/9/14 at 11 AM failed to provide documentation that the resident was assessed for signs and symptoms of dehydration, and/or that the care plan was reviewed and revised and interventions initiated to prevent dehydration, and/or that the physician and/or APRN were made aware of the low fluid intakes, when the resident was noted to fail to meet the estimated fluid needs every day for 14 days resulting in a [DIAGNOSES REDACTED].

Based on clinical record review, interview and observation for one (R#1) of three residents reviewed for smoking, the facility failed to implement measures to prevent an accident involving smoking which resulted in a finding of Immediate Jeopardy. The findings include: R#1's [DIAGNOSES REDACTED]. R#1 was transported to dialysis treatments at another facility 3 times per week. Review of physician orders [REDACTED]. The clinical record identified that R#1 used the oxygen daily. The admission nursing assessment dated [DATE] identified R#1 as alert, oriented and cooperative. The resident education assessment dated [DATE] identified R#1 with no cognitive loss and was able to participate in teaching. A smoking assessment was completed on admission and identified that R#1 agreed not to smoke. The interim care plan dated 10/15/12 identified that the facility's no smoking policy was reviewed with R#1 with an intervention to use a nicotine patch (which R#1 periodically refused). A nursing note dated 10/16/12 at 6:30 AM identified that RN #2 witnessed R#1 with an unlit cigar and/or cigarette in his/her mouth (in the building) and reeducated the resident on the no smoking policy. However, R#1 was not asked to relinquish the smoking material and there was no update to the plan of care to address the possession of smoking materials. Interviews with RN#2 on 11/8/12 at 11:30 AM and with the van driver on 11/8/12 at 3:20 PM, and review of nurse's notes dated 10/18/12 at 6:00 AM, identified that the van driver reported to RN #2 that he/she had to wait on multiple occasions for R#1 to finish his/her cigarette (with the oxygen on) before being transported to the dialysis facility. RN #2 documented the van drivers observations on the 11-7 supervisor's report and also reported the incident to the day supervisor. Interview with the day supervisor on 11/8/12 at 1:00 PM identified that R#1's smoking was discussed during morning report. However, no action was taken and no new interventions were implemented. Review of R#1's care plan dated 10/25/12 identified that a cigarette butt was found in the resident's drawer. Although R#1 denied smoking, the care plan was updated to include the installation of a smoke detector in the resident's bathroom. However, the clinical record lacked evidence that staff searched for additional smoking materials. Interview with RN #4 on 11/14/12 at 12:30 PM identified that he/she noted that on 10/28/12, R#1 had what appeared to be a dirty face and was instructed to wash his/her face. Nursing notes dated 10/30/12 at 3:30 PM identified that early that morning, R#1 was observed with scabbed areas on the upper lip and around the nares. R#1 denied that the scabbed areas were related to smoking and stated that the areas were irritated by him/her rubbing the area with paper towels. R#1 was seen by an Advanced Practice Nurse Practitioner on 10/30/12, who identified that R#1 had sustained second degree burns above the lip and nares. Review of a psychiatric evaluation dated 10/30/12 and interview with R#1 on 11/8/12 at 4:00 PM identified that R#1 stated that he/she had caught self on fire while smoking outside while using oxygen. However, social service progress notes dated 10/31/12 identified that R#1 stated that he/she incurred the burns while smoking with the oxygen on and that he/she "wished it had occurred outside because the wind would have blown the oxygen mask away" from him/her. In addition, R#1 identified that it was possible that the injury occurred on 10/28/12, not 10/30/12. Interview on 11/8/12 at 2:30 PM with R#1 identified that on admission to the facility he/she brought four to five cigarettes and a couple of lighters. Interview with the Assistant Director of Nursing on 11/13/12 at 10:20 AM identified that it was the nurses responsibility to complete a smoking assessment and determine if a resident had smoking materials. Review of the clinical record lacked evidence that R#1 (a known smoker) was checked for smoking materials on admission. Interview with RN#1 on 11/13/12 at 12:40 PM identified that he/she did not recall admitting R#1 and could not recall if he/she inquired about smoking materials. Interview with NA #1 on 11/13/12 at 12:30 PM identified that he/she completed R#1's inventory list of belongings on admission, but did not inquire about smoking materials. Interview and review of the clinical record with the Administrator on 11/13/12 at 12:15 PM identified that between 10/14/12 and 10/30/12, the facility failed to establish if R#1 had smoking materials, where R#1 obtained smoking materials, and failed to implement measures/interventions when R#1 was observed smoking while using oxygen. Review of facility policies identified that smoking was strictly prohibited in all areas of the facility and any smoking materials would be stored in a secure location.

Based on clinical record review and staff interviews for one of three residents in the survey sample reviewed for accidents (R # 66), the facility failed to transfer a resident safely and in accordance with the assessment and plan of care, resulting in a fracture. The findings include: Resident #66's [DIAGNOSES REDACTED]. The MDS dated [DATE] noted the resident was cognitively intact and required the extensive assistance of two persons for transfers. A care plan dated 2/1/12 noted problems with mobility, transfers and ambulation. Interventions included transfer with assist of one with a slide board. A subsequent note on the care plan dated 2/3/12 indicted the resident had right lower leg weakness for 2 years-continue slide board. The nurse aide assignment noted that R#66 was a fall risk. Staff were directed to transfer with the assistance of 2 staff. A physician's orders [REDACTED]. A subsequent physician order [REDACTED]. A nurse's note dated 2/19/12 during the 7 AM - 3 PM shift noted that R #66' right leg gave out during a transfer in the bathroom. The nurse aide was able to assist the resident into the wheelchair, preventing a fall. The resident complained of some discomfort in the right leg. No evidence of injury at this time. A nurse's note dated 2/19/12 at 5:30 PM indicated that R #66's right shin area was swollen and discolored. The APRN was notified and an x-ray of the right lower leg was ordered. A radiology report dated 2/19/12 noted a right tibia fracture. An interview on 3/1/12 at 11:10 AM with OT #1 indicated at the time R # 66 fractured the right tibia, the resident had not been cleared to be toileted. She indicated the physician order [REDACTED]. OT #1 further indicated that the resident was not cleared for toilet transfer because he/she could not stand long enough for clothing adjustment. An interview on 3/1/12 at 1:30 PM with the DNS indicated she was not aware the resident could not be toileted. She further indicated that although she thought the resident could be toileted, she would have expected the staff to use a 2 person assist as directed in the 1/19/12 physician order. An interview on 3/2/12 at 12:45 PM with NA # 4 indicated she transferred R #66 to the toilet on 2/19/12 without the assistance of another nurse aide. She noted the resident's right leg gave out and using the incontinent brief she guided the resident into the wheelchair. She indicated the resident immediately complained of right leg pain and she notified the nurse. Nurse aide # 4 indicated from the resident's admission (1/18/12) up until and including 2/19/12 she transferred the resident by herself in and out of bed and to and from the toilet without the assistance of a slide board and never had a problem.