Every finding on record at Apple Rehab Uncasville

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 28 residents (Resident #13, 9 and 63) reviewed for advance directives, the facility failed to ensure there was an accurate physician's order according to th4e residents wishes for code status. The findings include: Resident #13's diagnoses included Parkinson's, degenerative disorder of the nervous system, severe protein malnutrition. The quarterly MDS assessment dated [DATE] identified Resident #13 was moderately cognitively impaired and was dependent with toileting hygiene, dressing, personal hygiene substantial maximal assistance with bed mobility. The care plan dated [DATE] identified interventions that included advance directives per physician's orders. Review of a Medical Intervention Consent Form dated [DATE] signed by Resident #13's responsible party, a staff member, and the provider on [DATE]. The form identified in the event of cardiopulmonary arrest, Resident #13 choices included the provision of Cardiopulmonary Resuscitation (CPR), Intravenous fluids (IV), hospitalization and Tube Feeding/TPN. A review of the physician's orders for the period of [DATE] to [DATE] identified orders dated [DATE] that directed Do Not Resuscitate (DNR), and Do Not Intubate (DNI). A physician's order for CPR was not written until [DATE], subsequent to surveyor inquiry. Interview on [DATE] at 1:45 PM with the Charge Nurse (LPN #4) identified that if Resident #13 had a life-threatening emergency i.e. cardiopulmonary arrest, she would check the resident's code status in the front of the chart. LPN #4 identified the code status is found also in the banner section of the resident's electronic medical record. LPN #4 further noted that they were taught in an emergency to go to the resident's physical chart in the front to locate the advance directive consent form for the elected code status. LPN #4 identified that code status consents are obtained on admission by the charge nurse or the nursing supervisor from the resident or the resident's responsible party. After which the Code Status form is signed by the physician or APRN, and the nursing supervisor would then obtain the physician's order. After reviewing the Medical Intervention Consent form, and the banner in the computer with LPN #4, she noted that the Medical Intervention Consent form did not match the code status on the banner of the resident's electronic records. LPN #4 identified that they should match and she will have to notify the nursing supervisor to address this issue. LPN #4 identified that if a resident had two Medical Intervention Consent forms in the chart that she would use the most recent one as the elected code status. Interview on [DATE] at 1:55 PM with the DNS in the presence of the nursing supervisor (RN #1) identified the Medical Intervention Consent should match the banner, which is derived from the physician's order. The DNS identified that the 11:00 PM to 7:00 AM shift is responsible for completing a 24-hour chart check, which includes checking all new orders to ensure they were transcribed accurately. The DNS further noted that if there was a new advance directive/code status physician's order, she expects the 11:00 PM to 7:00 AM nurse to check the physician's order against the Medial Intervention Consent form. The DNS further identified if there are two signed Medial Intervention Consent form in the resident's record, the nurses are expected to use the most recent date. Review of the Advance Directives clinical policy identified the facility provides the resident or the representative, upon admission, notice of the policy of advance directives and the resident's rights regarding refusal or treatment. The policy further identifies licensed nursing staff and/or resident's attending physician will review advance directives with the capable resident or the appropriate substitute decision maker(s). The plan of care related to advance directives and withholding/withdrawing life sustaining treatment will be documented on resident's advance directive consent form and physician's orders. The form will be signed and dated by the person who reviewed the advance directive with the resident or decision maker(s), the person who consented to the advance directives. The physician's order will be obtained related to the resident's advance directives and refusal of treatment. The policy further adds if the resident or substitute decision maker(s) does not execute an advance directive, the resident will be a full code until a decision is made by the resident or substitute decision maker(s). Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for three of twenty-eight sampled residents (Resident #9, and Resident #63) reviewed for advance directives, the facility failed to ensure there was an accurate physician's order indicating the resident's wishes related to cardiopulmonary code status. The findings include: 2. Resident #9's diagnoses included depression, pneumonia, type 2 diabetes mellitus and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #9 was cognitively intact. The care plan dated [DATE] identified Resident #9 an intervention that included advance directives per physician's orders. A Medical Intervention Consent Form dated [DATE] was signed by Resident #9, two nurses, and by the provider. The form identified in the event of cardiopulmonary arrest, Resident #9's choices included Do Not Resituate (DNR), and Do Not intubate (DNI). Further, the form identified staff will administer Intravenous fluids (IV) and send the resident to the hospital if necessary. A review of the physician's orders for the period of February 2025, and [DATE] through [DATE], failed to reflect a physician's order for DNR, DNI and no artificial nutrition according to the resident's wishes. Interview on [DATE] at 1:45 PM with the Charge Nurse (LPN #4) identified that if Resident #9 had a life-threatening emergency she would check the resident's code status in the front of the chart. LPN #4 identified the code status is found also in the banner section of the resident's electronic medical record. LPN #4 further noted that they were taught in an emergency to go to the resident's physical chart in the front to locate the advance directive consent form for the elected code status. LPN #4 identified that code status consents are obtained on admission by the charge nurse or the nursing supervisor from the resident or the resident's responsible party. After which the Code Status form is signed by the physician or APRN and the nursing supervisor would then obtain the physician's order. After reviewing the Medical Intervention Consent form, and the banner in the computer with LPN #4, she noted that the Medical Intervention Consent form did not match the code status on the banner of the resident's electronic records. LPN #4 identified that they should match and she will have to notify the nursing supervisor to address this issue. 3. Resident #63's diagnoses included schizoaffective disorder-bipolar type, delusional disorders and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #63 had moderately impaired cognition. The care plan dated [DATE] identified interventions that included advance directives per physician's orders. A Medical Intervention Consent Form dated [DATE] was signed by Resident #63's responsible party, one nurses and the provider. The form identified in the event of cardiopulmonary arrest, Resident #9's choices included Do Not Resituate (DNR), Do Not intubate (DNI) and do not administer artificial means of nutrition. A review of the physician's orders [DATE] through [DATE] failed to identify a physician's order for DNR/DNI, or no administration of artificial nutrition. Interview on [DATE] at 1:45 PM with the Charge Nurse (LPN #4) identified that if Resident #63 had a life-threatening emergency she would check the resident's code status in the front of the chart. LPN #4 identified the code status is found also in the banner section of the resident's electronic medical record. LPN #4 further noted that they were taught in an emergency to go to the resident's physical chart in the front to locate the advance directive consent form for the elected code status. LPN #4 identified that code status consents are obtained on admission by the charge nurse or the nursing supervisor from the resident or the resident's responsible party. After which the Code Status form is signed by the physician or APRN and the nursing supervisor would then obtain the physician's order. After reviewing the Medical Intervention Consent form, and the banner in the computer with LPN #4, she noted that the Medical Intervention Consent form did not match the code status on the banner of the resident's electronic records. LPN #4 identified that they should match and she will have to notify the nursing supervisor to address this issue. LPN #4 identified that if a resident had two Medical Intervention Consent forms in the chart that she would use the most recent one as the elected code status. Subsequent to surveyor's inquiry, a new Medical Intervention Consent Form for Resident #63 was completed on [DATE] by the resident's representative, which was signed by the provider and a facility staff indicating DNR/DNI, no artificial means of nutrition, to administer IV fluids and for hospitalization. Interview on [DATE] at 1:55 PM with the DNS in the presence of the nursing supervisor (RN #1) identified the Medical Intervention Consent should match the banner, which is derived from the physician's order. The DNS identified that the 11:00 PM to 7:00 AM nursing shift is responsible for completing a 24-hour chart checks, which includes checking all new orders to ensure they were transcribed accurately. The DNS further noted that if there was a new advance directive/code status physician's order, she expects the 11:00 PM to 7:00 AM nurse to check the physician's order against the Medial Intervention Consent form. The DNS further identified if there are two signed Medial Intervention Consent form in the resident's record, the nurses are expected to use the most recent date. Review of the Advance Directives clinical policy identified the facility provides the resident or the representative, upon admission, notice of the policy of advance directives and the resident's rights regarding refusal or treatment. The policy further identifies licensed nursing staff and/or resident's attending physician will review advance directives with the capable resident or the appropriate substitute decision maker(s). The plan of care related to advance directives and withholding/withdrawing life sustaining treatment will be documented on resident's advance directive consent form and physician's orders. The form will be signed and dated by the person who reviewed the advance directive with the resident or decision maker(s), the person who consented to the advance directives. The physician's order will be obtained related to the resident's advance directives and refusal of treatment. The policy further adds if the resident or substitute decision maker(s) does not execute an advance directive, the resident will be a full code until a decision is made by the resident or substitute decision maker(s).

Based on observation, review of the clinical record, facility policy and interviews for two of three sampled residents (Resident #58 and 63) who resided on the lower-level secured unit, the care plan failed to reflect the resident placement on a secured unit. The findings include: 1. Resident #58 was admitted to the facility in June of 2024 and had diagnoses that included paranoid schizophrenia, dementia, and type 2 diabetes mellitus.Review of the clinical record identified a Consent to Voluntarily Reside on a Secure Unit dated 5/19/25 obtained from Resident #58's responsible party. Review of the clinical record identified a Cognitive Impairment Program Unit Resident Review completed on 10/2/25 indicating Resident #58 met criteria to be placed on the secured unit. The quarterly MDS assessment dated [DATE] identified Resident #58 had moderately impaired cognition, had behaviors of hallucinations, delusions and rejection of care. The assessment further identified Resident #58 requires supervision or touching assistance with personal hygiene, dressing, and independent with bed mobility and ambulation. The care plan dated from May 2025 through 11/3/25 identified Resident #58 had schizophrenia disorder and was at risk for changes in mood state and behaviors with interventions that included to watch for and report new onset or increase in symptoms such as delusions, hallucinations, impaired communication, speech, bizarre or unusual behavior, periods of manic mood, medication as ordered and to watch for adverse effects associated with psychotropic drug use. However, the care plan failed to identify placement of the resident on the facility's secured unit. A review of the physician's orders, including discontinued orders for the period of October 2025 to December 9, 2025 failed to include an order that directed placement of the resident on a secured unit. Observation on 12/8/25 identified that the facility had a secured unit located on the lower level of the building which required a code to enter and exit the unit. The code was required to be entered into a keypad located on the wall outside and inside of the egress door to enter and exit the unit. Interview and record review on 12/16/25 at 9:47AM with the DNS identified residents residing on the secured unit as of May 2025 should have consent, a resident review assessment quarterly and a care plan that includes placement on a secured unit. The DNS reviewed the resident's care plan, and physician orders which failed to identify the resident's placement on a secured unit. The DNS identified the resident's placement on a secured unit should have been included in during the last care plan review in October 2025. The DNS added that it was recently added by the MDS Coordinator on 12/15/25 after the surveyor's inquiry. Interview with the MDS Coordinator (RN #2) on 12/15/25 at 12:44 PM identified she was responsible for reviewing and revising the residents care when the MDS assessment is due to be completed. RN #2 identified she would review and ensure the resident's diagnoses and care plan match the individual, including placement on the secured unit. Review of the Nursing Home Residents Who Reside on a Secured Unit policy identifies care plan development upon the admission phase, an individualized care plan will be created to address the residents' specific needs in a secure environment and should include individualized targeted preferences if available. The policy further identified that the care plan will be reviewed frequently, and updated as needed for the first 60 days of the program/unit launch as well as within 90 days of there is a significant change in the resident's condition and quarterly cadence ongoing. Review of the Care Planning policy and procedure identifies the care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status. 2. Resident #63's was admitted to the facility in October of 2024 and had diagnoses that included schizoaffective disorder-bipolar type, delusional disorders and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #63 had moderately impaired cognition, had no behaviors, and was independent with personal hygiene, toileting hygiene and ambulation. Review of the clinical record identified a Consent to Voluntarily Reside on a Secure Unit dated 10/1/25 obtained from Resident #63's responsible party. Review of the clinical record identified a Cognitive Impairment Program Unit Resident Review completed on 10/1/25 indicating Resident #68 met criteria to be placed on the secured unit. A review of the physician's orders, including discontinued for the period of October 2025 to December 9, 2025 failed to include an order that directed placement of the resident on a secured unit. The care plan dated 10/21/25 identified Resident #68 was at risk for an alteration in mood and behaviors as evidence by a schizoaffective disorder bipolar type with intervention that included attempt to keep schedule routine and predictable when possible, be aware of changes in mood/behavior and notify provider and if resident is abusive to towards staff, leave resident in a safely alone and return at a later time. However, the care plan failed to identify placement of the resident on the facility's secured unit. Interview and record review on 12/15/25 at 12:17 PM with the DNS identified Resident #68 was admitted to the secured unit on 10/1/25. The DNS indicated the clinical record should include a consent, a resident review assessment done quarterly and a care plan that identifies placement of the resident on a secured unit. The DNS reviewed the resident's care plan, last revised in 10/2025, the physician orders, social service notes, psychiatric notes, and physician notes which failed to identify placement of the resident on a secured unit. The DNS identified nursing was responsible for reviewing and revising the care plan. She further identified it was missed when the care plan was last reviewed in October of 2025. Interview with the MDS Coordinator (RN #2) on 12/15/25 at 12:44 PM identified she was responsible for reviewing and revising the residents care when the MDS assessment is due to be completed. RN #2 identified she would review and ensure the resident's diagnoses and care plan match the individual, including the residents placement on the secured unit. Review of the Nursing Home Residents Who Reside on a Secured Unit policy identifies care plan development upon the admission phase, an individualized care plan will be created to address the residents' specific needs in a secure environment and should include individualized targeted preferences if available. The policy further identified that the care plan will be reviewed frequently, and update as needed for the first 60 days of the program/unit launch as well as within 90 days of there is a significant change in the resident's condition and quarterly cadence ongoing. Review of the Care Planning policy and procedure identifies the care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #120) reviewed for dignity, the facility failed to provide care in a dignified manner when the resident needed to use the bathroom and the nurse aide told the resident to urinate in the diaper. The findings include:Resident #120's diagnoses included bradycardia (slow heart rate), pacemaker placement and high blood pressure. A physician's order dated 6/17/25 directed: may transfer the resident with assist of one with a rolling walker.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #120 was cognitively intact, required the assistance of one with a walker for toileting and transfers.The investigation (accident and incident report) dated 6/25/25, identified NA #2 instructed Resident #120 to urinate in the diaper, if the resident couldn't wait for assistance.A facility One to One Inservice Record indicated NA #2 was in-serviced regarding using the phrase diaper as not appropriate for the age group served and the phrase to be used was brief or incontinent care products. If unable to assist the resident immediately, simply state they would return as soon as they could. Do not encourage urinating in brief. The care plan dated 7/25/25 identified Resident #120 was incontinent of bowel and bladder and at risk for bladder infections and skin breakdown. Interventions included encourage and provide assistance with toileting and incontinent care. Provide briefs for dignity and monitor for any urinary retention and skin breakdown.Interview on 12/9/25 at 2:16 PM with Person #1 identified Resident #120 needed to use the bathroom and was instructed by staff to pee or poop in the diaper if the resident was unable to wait until the aide came back. Resident #120 had to sit in poop all night before the staff came back to provide care.Interview on 12/10/25 at 3:33 PM with the DNS identified the NA could have let the bell ring until the NA was able to assist the resident or the NA could have answered the call light and told the resident he/she would come back after helping another resident. The NA should not have told the resident to urinate in the brief and should not have used the word diaper.Although attempted, an interview with NA #2 on 12/16/25 at 11:26 AM was not obtained.The Resident Rights policy directed that the resident has the right to be treated with respect and full recognition of his/her dignity and individuality. The resident has the right to receive quality care and services with reasonable accommodation of their individual needs and preferences.

Based on review of the clinical record, facility policy and staff interview for 1 of 3 residents (Resident #119), reviewed for closed record, the facility failed to ensure a physician was involved in a resident's discharge. The findings include: Resident #119 was admitted with diagnosis that included third-degree burns, cocaine dependence, and alcohol dependence. A hospital Discharge summary dated [DATE] identified Resident #119 had a past medical history of anxiety, bipolar disorder, and substance abuse. The hospital discharge summary indicated Resident #119 had burn wounds to both hands and was provided with wound care and occupational therapy. The hospital occupational therapy evaluation indicated Resident #119 demonstrated impaired range of motion and strength in both hands and demonstrated difficulty completing bimanual tasks required for grooming. Additionally, the hospital discharge summary indicated that due to housing insecurity and a need for further occupational therapy related to dominant hand burns, Resident #119 was discharged to a short-term rehabilitation facility.A nursing admission assessment dated [DATE] identified Resident #119 was cognitively intact, independent with transfers, and slightly limited in mobility. A physician's order dated 11/13/2025 directed to monitor left and right hand burns every shift, provide wound care to the hands with soap and water, apply bacitracin to open areas, apply a petroleum dressing covered with a dry dressing and obtain physical therapy/occupational therapy evaluation. The nursing supervisor's note (RN #3) dated 11/14/2025 (the day after Resident #119's admission) indicated Resident #119 requested to be discharged that day and that the resident would stay with a family member. The note identified that the resident was educated on wound care but failed to identify if a medical provider was notified of the resident's request for discharge or if the resident was medically cleared for discharge. A social work note dated 11/14/2025 identified Resident #119 made an appointment at a community clinic and requested to be discharged to a family member's home. The social work note further indicated that phone calls were made to the community clinic and to the resident's family member, and that Resident #119 was given all discharge paperwork. The social work note failed to identify if a medical provider was notified of the resident's request for discharge or if the resident was cleared for discharge. A review of the medical record failed to identify a physician's note or evaluation for 11/13/2025 or 11/14/2025 and failed to identify an order for discharge. A review of the facility Discharge summary dated [DATE] identified an electronic signature by Social Worker #1, but the areas designated for signatures by the physician, DNS, and Administrator were left blank.On 12/16/2025 at 11:27 AM, an interview with Social Worker #1 indicated that for discharges, the APRN would medically clear a resident if the APRN is present at the facility, and if the APRN or physician is not at the facility, then the facility would call to obtain an order. Social Worker #1 indicated that she did not know if Resident #119 had been medically cleared or evaluated by a medical provider; Social Worker #1 indicated that the nursing supervisor would be the one to know. On 12/16/2025 at 12:27 PM, an interview with RN #3 indicated that Resident #119 requested to be discharged because the facility was not what they expected but offered no specific reason for wanting to leave. RN #3 indicated that for discharging a resident, the facility usually obtains a discharge order, or the nurse takes a verbal order, and that a medical provider would usually medically clear a resident for discharge by performing a medical evaluation and evaluating nursing and therapy needs. RN #3 indicated she spoke to APRN #1 but could not recall if the resident was evaluated or cleared for discharge. RN #3 could not identify why the medical record failed to have a discharge order or indicate if a provider was notified of the resident's request for discharge. On 12/16/2025 at 12:37 PM, an interview with APRN #1 indicated that she did not recall if she received a call from the facility on 11/14/2025 regarding Resident #119's request for discharge. Additionally, APRN #1 indicated she did not work on 11/14/2025 and that there would have been an on-call provider. APRN #1 indicated that when residents are being discharged , there is usually a discharge order placed and was unsure if staff could discharge a resident without an order. APRN #1 indicated that provider evaluations prior to discharge are done on a case-by-case basis because residents are different and not every resident is unsafe to go home. On 12/16/2025 at 1:00 PM, an interview with the DNS and ADNS identified that there was no medical provider in the building on Fridays and that they use an on-call service. The ADNS indicated she was working on 11/14/2025 and believed that RN #3 had communicated with a provider but could not recall which provider. The DNS indicated that staff usually obtain an order to discharge a resident and that the discharge would have been discussed with the medical provider. The DNS and ADNS could not identify why neither an order nor a note was documented identifying which provider was involved in the discharge process for Resident #119. A review of the facility policy for Discharge Planning/Community identified that pre-determined discharge goals are set by the interdisciplinary team and the resident upon admission. The interdisciplinary team is encouraged to determine the resident's needs for discharge for the appropriate referrals to be made in the community. The policy further identified that a physician's order was recommended to be obtained by nursing, indicating discharge home with medication and/or services needed. In addition, the facility policy indicated that the discharge summary should be signed by the physician, social worker, administrator, and director of nursing prior to discharge.

Based on observation, review of facility documentation, facility policy and interviews for 1 of 2 medication rooms, the facility failed to discard expired controlled medications from the emergency narcotic box in a timely manner. The findings include:During a review of the upper-level medication storage room, an observation on 12/9/2025 at 12:23 PM identified Ambien (a sedative medication) 5 milligram, 5 tablets with an expiration date of 9/2025 in the emergency controlled narcotic box.Interview with RN #1 on 12/9/2025 at 12:23 PM identified that the supervisors count the controlled narcotics in the emergency controlled narcotic box with every change of shift, but they were never trained to review the expiration dates of the medications contained in the emergency controlled narcotic box.Interview with the Director of Nursing (DNS) on 12/9/2025 at 12:27 PM identified that the pharmacy and the DNS were responsible for checking the expiration dates of the medications contained in the emergency controlled narcotic box. The expired Ambien failed to be identified until 12/9/2025 because the DNS assumed the pharmacy representative identified expired medications when the pharmacy representative conducted their audit. A pharmacy representative was in the facility last week and 12/8/2025 at 4:00AM auditing but may have been unable to check the emergency controlled narcotic box. A new pharmacy began service at the facility in September 2025. Subsequent to surveyor inquiry, the DNS removed the expired Ambien tablets and proof of use record, from the emergency controlled narcotic box and placed them, doubled locked in her office drawer for destruction.A review of the Medication Administration policy identified, in part, medication storage and handling: All medication should be stored in a secure, locked area accessible only to authorized personnel. Narcotics and controlled substances must be double locked and counted per facility protocol. Additionally, for quality assurance, regular audits are conducted of medication administration records and practices and reviewed and updated medications administration procedures as needed based on audit findings and regulatory changes. The Policy failed to direct protocols on checking for expired medications

Based on review of clinical record, facility policy, facility documentation, and interviews for one of five sampled residents (Resident #13) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was assessed/ offered to the resident upon admission. The findings include: Resident #13 was admitted to the facility in December 2024 and had diagnoses of Parkinson's disease with dyskinesia, aphasia, severe protein-calorie malnutrition, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition. The assessment further identified Resident #13 did not receive the pneumococcal vaccine. Review of the clinical records for Resident #13 immunization consents and records failed to identify a consent/declination was obtained or a record of a documented vaccine was found in the resident record. Review of Resident #13 immunization consents and records with the Infection Preventionist (IP) (RN #3), the DNS and Regional DNS (RN #4) on 12/10/25 at 12:30 PM failed to identify that the pneumococcal vaccine was offered to the resident, or the resident had received the vaccine prior to admission. Interview on 12/10/25 at 12:30 PM with RN #3, the DNS in the presence of RN #4 identified it was the responsibility of the IP nurse on admission to review the resident's vaccination history and review the information with the provider to select the appropriate vaccine to offer the resident. RN #3 further noted that once the appropriate vaccine is identified, consent is then obtained from the resident, the order is written, as the facility has standing orders for vaccine, then the vaccine is administered to the resident. RN #3 identified she was not working as the IP at the time when Resident #13 was admitted to the facility as she has only been in the role of the IP nurse since the last week of August. Interview on 12/15/25 at 10:32 AM with the DNS identified they were unable to locate any consent for the pneumococcal vaccine or proof of vaccine from the previous facility. The DNS further identified the resident should have been offered the vaccine on admission as he/she was due for the vaccine at the time of admission. Subsequent to surveyor's inquiry Resident #13 was offered the pneumococcal vaccine on 12/11/25. Review of the Pneumococcal policy identified residents, or their responsible party will be offered the pneumococcal vaccine according to their specific eligibility that aligns with the current Center for Disease Control (CDC) Adult Immunization Schedule upon admission. The policy further identified the facility should obtain historical pneumococcal vaccine history and collaborate with the MD to determine appropriate vaccine need.

Based on review of the clinical record, facility policy/procedures and interviews for 2 of 7 residents (Resident #7, and 63) reviewed for Preadmission Screening and Resident Review (PASARR), and for 2 residents (Resident #46 and 72) reviewed for hospice, the facility failed to ensure the MDS was accurately coded. The findings included: 1. Resident #7's diagnoses included bipolar disorder, other depressive episodes, and major depressive disorder. Review of a PASARR level II completed on 8/14/24 identified Resident #7 was had a positive level II screening approved without specialized services. The annual MDS dated [DATE] identified Resident #7 was moderately cognitively impaired. The assessment failed to identify the resident was currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition (A1500). The care plan dated 12/8/25 identified Resident #7 had a positive PASARR level II due to psychiatric diagnoses with interventions that included a behaviorally based treatment plan, a minimum yearly comprehensive psychiatric evaluation, case management services to explore supportive community living. Interview on 12/16/25 at 9:45AM with Social Worker #2 identified she coded the Annual MDS on 11/28/25 for Section A1500 as no regarding a positive Level II PASARR assessment for Resident #7. To complete the coding typically she would look back on the last MDS to see what they were coded and utilize that or look at their current diagnoses to see if they have mental health diagnoses and how severe they were. Social Worker #2 identified that upon review of the resident record she did see that a positive level II was completed for Resident #7 and therefore should have coded the resident as yes for A1500 in the MDS. Review of the MDS policy directed MDS assessments will be completed by facility staff trained in the MDS process. Facility administration will determine who completes each section of the MDS process. The resident care coordinator may complete any section of the MDS when another discipline is unable to do so. 2. Resident #63's diagnoses included schizoaffective disorder, bipolar type, delusional disorders, major depressive disorder. Review of a Level II PASARR completed on 10/4/24 identified a positive Level II approval without specialized services. The annual MDS dated [DATE] identified Resident #63 as cognitively intact. The assessment failed to identify the resident was currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition (A1500). The care plan dated 11/19/25 identified Resident #63 has a had a positive level II PASARR due to psychiatric diagnoses with interventions that included a behaviorally based treatment plan, a minimum yearly comprehensive psychiatric evaluation, and case management services to explore supportive community living. Interview on 12/16/25 at 10:27AM with MDS Coordinator identified Resident #63 had a positive Level II PASARR and should have been coded as yes on the annual MDS section A1500. The MDS Coordinator identified she gains her information for coding by looking into the documents section of resident chart or the care plan. She was the one who coded this specific MDS for section A1500 and identified that it was an error that she coded it incorrectly. Review of the MDS policy directed MDS assessments will be completed by facility staff trained in the MDS process. Facility administration will determine who completes each section of the MDS process. The resident care coordinator may complete any section of the MDS when another discipline is unable to do so. 3. Resident #46's diagnoses included dementia and anxiety. The physician's order dated 1/30/25 directed hospice care. The nurse's note dated 1/30/25 at 8:27 PM identified Resident #46 was admitted to the facility with medical diagnosis of dementia and hospice care. The Resident Care Plan (RCP) dated 2/3/25 identified Resident #46 was receiving hospice services. The care plan interventions included to provide one to one visits with the resident to assess comfort level, anticipate needs, to make self-available to the resident and family as needed, and facilitate communication with family, interdisciplinary team and hospice staff. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had severe cognitive impairment and was dependent for dressing, personal hygiene, and transfers, and was non-ambulatory. The MDS failed to identify the resident was receiving hospice. 4. Resident #72's diagnoses included non-Hodgkin lymphoma, type 2 diabetes, malignant neoplasm of the brain, and heart failure. The Resident Care Plan (RCP) dated 5/28/25 identified Resident #72 requested a hospice referral. The care plan interventions included social worker will make referral to hospice per resident choice, provide support to the family, visit with resident regularly to assess for comfort, psychosocial well-being and direct need to appropriate disciplines. The physician's order dated 6/3/25 directed hospice care. The social worker progress note dated 6/4/25 at 3:06 PM identified Resident #76 was admitted for hospice care. The family member was involved in the hospice services and process. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #76 with intact cognition but failed to identify the resident was receiving hospice care. Interview with RN #2 (MDS Coordinator) on 12/16/25 at 10:30 AM identified that she was responsible for coding section O of the MDS. She identified that the resident admitted for hospice would have a significant change MDS assessment and the assessment would include, in section O, that the resident was receiving hospice services. She identified that Resident #46 and 72 were receiving hospice services and section O of the MDS should reflect that both residents were receiving hospice services. RN #2 indicated she follows the Resident Assessment Instrument (RAI) manual instructions to accurately code the MDS and indicated it was an error that she failed to mark both residents for hospice services. The RAI manual 3.0, section O for special treatments, procedures, and program identified that any special treatments, procedures, and programs that the resident received or performed during the specified time period should be marked yes, including hospice services.

Based on review of the clinical record, facility policy, and interviews for 3 of 28 residents (Resident #58, 25 and 32) reviewed for advance directives, the facility failed to ensure a signed copy of the Medical Intervention Consent Form, which identified the residents' wishes for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) was included in the clinical record. The findings include: 1. Resident #58's diagnoses included paranoid schizophrenia, dementia, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #58 had moderately impaired cognition. The care plan dated [DATE] identified Resident #58 interventions including advance directives per physician's orders. A review of the clinical record, both the physical chart and the electronic medical record failed to identify a Medical Intervention Consent Form completed by the resident/resident representative. A review of the physician order for the period of [DATE] to [DATE], and for the period of [DATE] to [DATE], directed a code status of Full Code/Cardiopulmonary Resuscitation (CPR) with an order origination dated [DATE]. Interview and clinical record review on [DATE] at 2:16 PM with the Charge Nurses (LPN #2) identified that if Resident #58 had a life-threatening emergency she would check in the electronic medical record on the banner section which displays the resident's code status. LPN #2 reviewed the physical paper records and identified that there was not a copy of the Medical Intervention Consent form under the Advance Directive tab and in the chart. If the resident did not have a Medical Intervention Consent form in the chart and the code status was not in the banner the resident would become a full code, and they would start CPR. LPN #2 further identified that she did not know where the information of the code status came from, but the information would be provided on admission. Interview on [DATE] at 2:35 PM with the DNS identified that each resident should have advance directive consent form (Medical Intervention Consent) in the chart. She further identified that if the resident does not have an advance directive consent form completed then their code status would become a full code. The DNS identified that the supervisor's, the DNS or ADNS would reach out to resident representatives/POA, conservator when necessary to obtain consent regarding advance directive, and a copy should be placed in the chart. Interview with Person #2 on [DATE] at 2:58PM identified he/she was provided with information and paperwork to sign when Resident #58's was admitted to the facility. Person #2 identified he/she was unsure if there was any advance directive consent form amongst the paperwork given. However, he/she indicated that the facility had discussed what to do in an event of an emergency situation where he/she had elected a full code. Subsequent to surveyor's inquiry, a new Medical Intervention Consent Form for Resident #58 was reviewed with the resident representative on [DATE] and signed by the representative on [DATE] with an election of a full code for the resident's code status. Review of the Advance Directive procedure identified if a decision is made regarding advance directives, the advance directive consent form will be signed and dated by the resident or substitute decision maker(s), the physician and the person who explained the advance directive. The procedure further identifies the advance directive form will be kept in the resident's medical record. Review of the medical records policy directed medical records will be retained for a minimum of 7 years from the date of the resident's discharge or last encounter, whichever is later. 2. Resident #25's diagnoses included dementia, acute and chronic respiratory failure with hypoxia, mitral and tricuspid valve insufficiency. The care plan dated [DATE] identified Resident #25 was at risk for cardiac issues related to cardiovascular disease with interventions that directed to watch for chest pain or discomfort, follow up with cardiologist, check oxygen saturations as ordered. The admission MDS dated [DATE] identified Resident #25 was severely cognitively impaired. Review of physician's orders [DATE] through 12/2025 directed full code status (full code directs the medical team to take all possible measures to save the resident's life in the event of a medical emergency). Review of physician's orders dated [DATE] through 12/2025 directed to administer CPR in the event of cardiopulmonary arrest. Record review on [DATE] at 10:30AM failed to include a Medical Intervention Consent Form. Interview and clinical record review with the Charge Nurses (LPN #2) on [DATE] at 2:16 PM identified in an emergency, she would check in the electronic medical record system on the banner section on the top of the page which displays the resident's code status. LPN #2 reviewed the physical paper records and identified no Medical Intervention Consent Form in the clinical record and indicated in the absence of a Medical Intervention Consent Form in the chart the resident would be a full code, and they would start CPR. LPN #2 further identified that she did not know where the information of the code status came from, but the information would be provided on admission. Interview on [DATE] at 2:35 PM with the DNS identified that each resident should have advance directive consent form (Medical Intervention Consent) in the chart. She further identified that if the resident does not have an advance directive consent form completed then their code status would become a full code. The DNS identified that a copy of the Medical Intervention Consent Form should be placed in the chart. Review of the medical records policy directed medical records will be retained for a minimum of 7 years from the date of the resident's discharge or last encounter, whichever is later. Review of the advance directive procedure directed if a decision is made regarding advance directives, the advance directive consent form will be signed and dated by the resident or substitute decision maker(s), the physician and the person who explained the advance directive. The procedure further identifies the advance directive form will be kept in the resident's medical record. 3. Resident #32's diagnoses included dementia, non-traumatic intracerebral hemorrhage, and adult failure to thrive. The baseline care plan dated [DATE] identified Resident #32 was a full code status. The admission MDS assessment dated [DATE] identified Resident #32 was moderately cognitively impaired. A review of the clinical record failed to identify a Code Status form signed by the resident or the resident representative. Review of physician's orders dated [DATE] through 12/2025 directed to administer CPR in the event of cardiopulmonary arrest. Interview and clinical record review with the Charge Nurses (LPN #2) on [DATE] at 2:16 PM identified in an emergency, she would check in the electronic medical record system on the banner section on the top of the page which displays the resident's code status. LPN #2 reviewed the physical paper records and identified no Medical Intervention Consent Form in the clinical record and indicated in the absence of a Medical Intervention Consent Form in the chart the resident would be a full code, and they would start CPR. LPN #2 further identified that she did not know where the information of the code status came from, but the information would be provided on admission. Interview on [DATE] at 2:35 PM with the DNS identified that each resident should have advance directive consent form (Medical Intervention Consent) in the chart. She further identified that if the resident does not have an advance directive consent form completed then their code status would become a full code. The DNS identified that a copy of the Medical Intervention Consent Form should be placed in the chart. Review of the medical records policy directed medical records will be retained for a minimum of 7 years from the date of the resident's discharge or last encounter, whichever is later. Review of the advance directive procedure directed if a decision is made regarding advance directives, the advance directive consent form will be signed and dated by the resident or substitute decision maker(s), the physician and the person who explained the advance directive. The procedure further identifies the advance directive form will be kept in the resident's medical record.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of four (4) residents (Resident #1 and #2) reviewed for medication administration, the facility failed to ensure licensed nursing staff observed the residents consume prescribed medications prepared by the licensed nursing staff prior to exiting the room. The findings include: 1. Resident #2 's diagnoses included adult failure to thrive, anemia (when the blood doesn't have enough healthy red blood cells and hemoglobin to carry oxygen all throughout the body) and atrial fibrillation (irregular heartbeat). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 14), required setup assistance for eating and supervision assistance for bed mobility and transfers. The Resident Care Plan (RCP) dated 3/13/25 identified Resident #2 was at risk for pain and discomfort which may impact mobility, mood, behaviors, sleep, Activities of Daily Living functioning and relationships with others. Interventions included watching for nonverbal signs and symptoms of pain and administering medications as ordered. On 6/3/25 at 9:24 AM, LPN #1 was observed preparing prescribed medications for Resident #2, entering Resident #2's room and setting the medication cup on the bedside table as she conversed with Resident #2. LPN #1 was observed applying Lidocaine patches to Resident #2's shoulders and lower back and then exited the room prior to observing Resident #2 consume the medications in the medication cup. Interview and observation with LPN #1 on 6/3/25 at 9:35 identified medications should not be left at the bedside of residents who are not authorized to self-administer medication(s). This surveyor asked LPN #1 if she had ever left medications at the bedside of any other residents and she self-identified that she left medications at the bedside during the 7:00 AM to 3:00 PM shift on 5/11/25 for another resident The medications prepared by LPN #1 for Resident #2 on 6/3/25 at 9:24 AM included: -Three (3) lidocaine patches- one (1) to be applied to each shoulder and one (1) to be applied to the lower back -Psyllium oral powder 25 percent (%) give 15 cubic centimeter (cc) mixed in 8 ounces (oz) of water -One (1) furosemide 40 milligram (mg) tablet -Two (2) potassium chloride Extended Release (ER) 10 milliequivalent (mEq) tablets -One (1) Preservision AREDS 2 plus multivitamin oral capsule -One (1) sertraline 50 mg tablet -Two (2) Tylenol extra strength 500 mg tablets -One (1) calcium carbonate-vitamin d-mineral 600-400 mg-unit tablet Review of the clinical record failed to identify that Resident #2 was assessed to self-administer oral medications. The DNS was made aware of the above incident on 6/3/25 at 9:47 AM. 2. Resident #1 's diagnoses included anxiety disorder, chronic pain and neoplasm of uncertain behavior of the parathyroid gland (a tumor in the parathyroid gland isn't definitively identified as benign or malignant). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required setup assistance for eating and was independent with bed mobility and transfers. The Resident Care Plan (RCP) dated 4/3/25 identified Resident #1 had a history of depression and anxiety and took medications to help alleviate the symptoms. The RCP identified Resident #1 had an adrenal mass causing chronic pain. Interventions included providing good pain management and administering medications as ordered. Review of the facility grievance dated 5/27/25 identified, in part, that medications were left at the bedside on 4/30/25 and 5/11/25 and although the complainant could not definitively remember who the nurse was, they thought it was LPN #1. Review of the clinical record failed to identify that Resident #1 was assessed to self-administer oral medications. Review of the facility schedule failed to identify that LPN #1 worked on 4/30/25 but did identify she worked on 5/11/25. Interview with LPN #1 on 6/3/25 at 9:35 AM identified she left Resident #1's morning medications at the bedside during the 7:00 AM to 3:00 PM shift on 5/11/25. She identified that Resident #1's family members were visiting so she left the medications on the bedside table and thought the family would ensure Resident #1 took the medications. She further identified that the family approached her and were upset that she did not administer Resident #1's medications or ensure that he/she had taken the medications. LPN #1 reported that she subsequently administered the medications to Resident #1. She identified that the DNS approached her after the incident and verbally educated her on medication administration. Interview with the DNS on 6/3/25 at 9:47 AM identified that LPN #2 was the licensed nurse who left Resident #1's medications at the bedside on 4/30/25. She identified that when she asked LPN #2 about the incident, LPN #2 stated, Resident #1 always tells me to leave medications at the bedside, so I did. The DNS identified that licensed nurses should never leave medications at a resident's bedside and they should ensure residents take their medications prior to leaving the room. The DNS identified that both LPN #1 and LPN #2 had been educated on medication administration and that medication administration education was also a part of nursing orientation. She identified that she provided verbal medication administration education to LPN #1 and LPN #2 following the incidents and no disciplinary action was amdinstered. Review of the facility schedule dated 4/30/25 identified that LPN #2 worked the 7:00 AM to 3:00 PM shift on Resident #1's unit. Interview with LPN #2 on 6/3/25 at 10:23 AM identified she was assigned to provide care for Resident #1 on 4/30/25 during the 7:00 AM to 3:00 PM shift. She identified that she floats units and did not often work on that unit. LPN #2 identified that previously, Resident #1 would not take his/her medications in front of her so she would leave his/her medications at the bedside and then circle back to ensure he/she had taken them. She reported that since she had not worked on that unit in a while, she was unaware Resident #1 was allowing staff to administer the medications, therefore, she left the medications at the bedside, as she previously had. She identified that when she went to check on Resident #1, his/her family had arrived to visit and asked why his/her medications were at the bedside, so she administered them at that time. LPN #2 identified that the family reported the incident to the DNS and the DNS provided verbal medication administration education. LPN #2 identified that she should not have left the medications at the bedside but instead should have reapproached Resident #1 if he/she refused to take the medications with her present. Review of Inservice Education titled Med Pass and dated 8/28/24 identified that it is not acceptable to leave medications at the bedside for a resident to self-administer for their convenience or preference. It is unacceptable to leave any medications at the bedside, as it is a safety risk to other residents who may inadvertently gain access to medications not meant for them. If a resident tells a nurse that they are not ready to take their medications at the time they are offered, the only two (2) options are: keeping the medications locked in the medication cart and offering them again at a later time or documenting them as refused, as residents have the right to refuse medications. This education was signed by LPN #2 on 10/4/24. Review of the Nurse Orientation checklist for LPN #1 dated 9/20/24 included education on medication passes and medication administration. Subsequent to surveyor interview on 6/3/25, copy of a disciplinary action for LPN #1 dated 6/3/25 was provided identifying that medications were not administered to a resident per policy and were left at the bedside. Review of the Medication Administration policy (undated) directed, in part, that nursing staff is to administer the medications as per the prescribed route and observe the resident for any adverse reactions or side effects.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to follow physician's orders to have two-half siderails and padded siderails on the bed . The findings include: Resident #1's diagnoses included Alzheimer's disease with late onset (a type of dementia that affects memory, thinking and behavior), dementia with behavioral disturbances, age-related cataract (clouding of the normally clear lens of the eye that can cause blurry vision), bilateral sensorineural hearing loss (permanent hearing loss caused by damage to the inner ear or the nerve from the ear to the brain) and difficulty in walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted identifying long and short-term memory problems and was able to recall staff names and faces only indicative of moderately impaired cognition and required staff supervision for bed mobility, transfers and ambulation. Additionally, it identified that Resident #1 had not had any recent falls. A physician's order dated 11/28/23 directed for Resident #1 to have siderails, two-half up for mobility and safe transfers out of bed and for staff to check every shift. A physician's order dated 1/24/25 directed for Resident #1 to be on seizure precautions including a low bed with fall mats and padded side rails every shift. The Resident Care Plan (RCP) updated on 1/22/25 (originally dated 10/30/19) identified that Resident #1 is at risk for falls due to psychotropic medication, chronic pain, poor safety awareness, impaired vision, hard of hearing and seizure precautions with interventions that included checking on the resident as needed, as he/she often does not use the call bell to summon assistance, ensuring the bed is in the lowest position when care is not being provided, keeping frequently needed items within reach and encouraging the resident to request help with picking up items, fall mat to be placed on the window side of the bed when the resident is in bed and seizure precautions including a low bed with fall mats and padded rails. Observations and interview with the DNS on 2/10/25 at 10:24 AM, identified the bed in Resident #1's room as a low bed without any side rails attached to the frame of the bed and no side rail padding was observed in the room. Two (2) black floor mats were observed, one in place on the floor to the left side of the bed (window side) and the other was noted to be propped up against the back wall next to the right side of the headboard. She reported that when the bed was switched out for a low bed on 1/24/25, it must not have been communicated to maintenance staff to put side rails on the low bed and although both the side rails and side rail padding was a physician's order, she was unsure why nursing staff had not noticed that they were not in place to the bed. Further, she identified that Resident #1 had not had a fall since 1/18/25. Review of the January 2025 Treatment Administration Record (TAR) identified that since 1/24/25, nursing staff signed off that they checked that the two-half side rails to Resident #1's bed were in place 23 out of 23 (100 %) shifts. Review of the January 2025 Treatment Administration Record (TAR) identified that nursing staff signed off that seizure precautions including a low bed with fall mats and padded side rails were in place 23 out of 23 (100 %) shifts. Review of the February 2025 Treatment Administration Record (TAR) identified that nursing staff signed off that they checked that the two-half side rails to Resident #1's bed were in place 28 out of 28 (100 %) shifts, which included the 7:00 AM to 3:00 PM shift on 2/10/25. Review of the February 2025 Treatment Administration Record (TAR) identified that nursing staff signed off that seizure precautions including a low bed with fall mats and padded side rails were in place 28 out of 28 (100 %) shifts, which included the 7:00 AM to 3:00 PM shift on 2/10/25. Interview with RN #2 on 2/10/25 at 11:54 AM identified that she worked the 3:00 PM to 11:00 PM shift on 1/25/25, 1/30/25, 2/3/25, 2/5/25, 2/7/25 and 2/9/25 and although she signed off on the TAR that both the two-half side rails were in place, as well as seizure precautions including a low bed with fall mats and padded side rails were in place, she was not aware that the two-half side rails nor the side rail padding had not been in place since 1/24/25 when the bed was switched out to a low bed, stating she should have checked prior to signing off the orders but that she didn't and was unsure why. Interview with LPN #2 (7:00 AM to 3:00 PM nurse on 2/10/25) on 2/10/25 at 2:13 PM identified that although she signed off the orders on the TAR for 2/10/25 that both of the two-half side rails were in place to Resident #1's bed, as well as seizure precautions including a low bed with fall mats and padded side rails were in place, she stated she was busy and did not actually check to ensure that the two-half side rails nor the side rail padding was in place. She reported that after signing off the orders in the TAR she realized the resident didn't have the side rails on the bed when she heard staff talking on the unit. Further interview with the DNS on 2/10/25 at 2:25 PM identified that when Resident #1's bed was changed to a low bed, she was responsible for communicating to maintenance that the new bed required side rails to be put on, but stated she was unsure if that happened, reporting that subsequent to surveyor inquiry, she spoke with maintenance and the side rails and padding were now in place to Resident #1's bed. She identified that she expects all nursing staff to be reading and following physician's orders at all times, as well as verifying that the interventions are in place as ordered and stated she was unsure why staff had been signing off the orders for the side rails and side rail padding when they weren't in place to Resident #1's bed. Although requested, a facility policy for following physicians' orders was not provided.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for nursing documentation, the facility failed to ensure a complete and accurate medical record for a resident when staff documented that side rail and side rail padding interventions were in place that were identified to not be in place per physician's orders. The findings include: Resident #1's diagnoses included Alzheimer's disease with late onset (a type of dementia that affects memory, thinking and behavior), dementia with behavioral disturbances, age-related cataract (clouding of the normally clear lens of the eye that can cause blurry vision), bilateral sensorineural hearing loss (permanent hearing loss caused by damage to the inner ear or the nerve from the ear to the brain) and difficulty in walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status conducted identifying long and short-term memory problems and was able to recall staff names and faces only indicative of moderately impaired cognition and required staff supervision for bed mobility, transfers and ambulation. Additionally, it identified that Resident #1 had not had any recent falls. A physician's order dated 11/28/23 directed for Resident #1 to have siderails, two-half up for mobility and safe transfers out of bed and for staff to check every shift. A physician's order dated 1/24/25 directed for Resident #1 to be on seizure precautions including a low bed with fall mats and padded side rails every shift. The Resident Care Plan (RCP) updated on 1/22/25 (originally dated 10/30/19) identified that Resident #1 is at risk for falls due to psychotropic medication, chronic pain, poor safety awareness, impaired vision, hard of hearing and seizure precautions. Interventions included checking on the resident as needed, as he/she often does not use the call bell to summon assistance, ensuring the bed is in the lowest position when care is not being provided, keeping frequently needed items within reach and encouraging the resident to request help with picking up items, fall mat to be placed on the window side of the bed when the resident is in bed and seizure precautions including a low bed with fall mats and padded rails. Observations and interview with the DNS on 2/10/25 at 10:24 AM, identified the bed in Resident #1's room as a low bed without any side rails attached to the frame of the bed and no side rail padding was observed in the room. Two (2) black floor mats were observed, one in place on the floor to the left side of the bed (window side) and the other was noted to be propped up against the back wall next to the right side of the headboard. She reported that when the bed was switched out for a low bed on 1/24/25, it must not have been communicated to maintenance staff to put side rails on the low bed and although both the side rails and side rail padding was a physician's order, she was unsure why nursing staff had not noticed that they were not in place to the bed. Review of the January 2025 Treatment Administration Record (TAR) identified that since 1/24/25, nursing staff signed off that they checked that the two-half side rails to Resident #1's bed were in place 23 out of 23 (100 %) shifts. Review of the January 2025 Treatment Administration Record (TAR) identified that nursing staff signed off that seizure precautions including a low bed with fall mats and padded side rails were in place 23 out of 23 (100 %) shifts. Review of the February 2025 Treatment Administration Record (TAR) identified that nursing staff signed off that they checked that the two-half side rails to Resident #1's bed were in place 28 out of 28 (100 %) shifts, which included the 7:00 AM to 3:00 PM shift on 2/10/25. Review of the February 2025 Treatment Administration Record (TAR) identified that nursing staff signed off that seizure precautions including a low bed with fall mats and padded side rails were in place 28 out of 28 (100 %) shifts, which included the 7:00 AM to 3:00 PM shift on 2/10/25. Interview with RN #2 on 2/10/25 at 11:54 AM identified that she worked the 3:00 PM to 11:00 PM shift on 1/25/25, 1/30/25, 2/3/25, 2/5/25, 2/7/25 and 2/9/25 and although she signed off on the TAR that both the two-half side rails were in place, as well as seizure precautions including a low bed with fall mats and padded side rails were in place, she was not aware that the two-half side rails nor the side rail padding had not been in place since 1/24/25 when the bed was switched out to a low bed, stating she should have checked prior to signing off the orders but that she didn't and was unsure why. She reported that documentation in the clinical record should always be complete and accurate. Interview with LPN #2 (7:00 AM to 3:00 PM nurse on 2/10/25) on 2/10/25 at 2:13 PM identified that although she signed off the orders on the TAR for 2/10/25 that both of the two-half side rails were in place to Resident #1's bed, as well as seizure precautions including a low bed with fall mats and padded side rails were in place, she stated she was busy and did not actually check to ensure that the two-half side rails nor the side rail padding was in place. She reported that after signing off the orders in the TAR she realized the resident didn't have the side rails on the bed when she heard staff talking on the unit. She reported that documentation in the clinical record should always be complete and accurate and that her documentation on 2/10/24 was not accurate. Further interview with the DNS on 2/10/25 at 2:25 PM identified that when Resident #1's bed was changed to a low bed, she was responsible for communicating to maintenance that the new bed required side rails to be put on, but stated she was unsure if that happened, reporting that subsequent to surveyor inquiry, she spoke with maintenance and the side rails and padding were now in place to Resident #1's bed. She identified that she expects all nursing staff to be reading and following physician's orders at all times, as well as verifying that the interventions are in place as ordered and documenting accurately in the clinical record, stating she was unsure why staff had been signing off the orders for the side rails and side rail padding when they weren't in place to Resident #1's bed but they shouldn't have been. Review of the Nursing Documentation policy (undated) directed, in part, that all entries must be factual, complete, and reflect the resident's current condition and care provided.

Based on clinical record reviews, review of facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #4) who were reviewed for an omission of medications, the facility failed to ensure medications were administered in accordance with the physician's order. The findings include: Resident #4's diagnoses included cerebral vascular infarction (a stroke), congestive heart failure, hypertension, and depression. The annual Minimum Data Set assessment dated [DATE] identified Resident #4 had memory recall deficits, rarely or never made decisions regarding tasks of daily life, was dependent on staff for activities of daily living, and had a feeding tube, gastrostomy tube (G-tube), for nutritional approaches. The Resident Care Plan dated 12/21/24 identified cardiovascular disease, at risk for a heart attack, chest pain, or stroke and depression. Interventions directed to administer medications as prescribed. Physician orders dated 1/2/25 directed to administer a medication to treat high blood pressure, Losartan Potassium, give 0.5 milligrams (mg) daily, and a medication to treat depression, Escitalopram (Lexapro), a 10 mg tablet and 5 mg tablet to equal 15 mg total daily via the G-tube. The Medication Error Report dated 1/6/25 identified on 1/5/25 at 9:00 AM the Losartan and Lexapro were omitted, and the responsible party and physician had been notified. In an interview with the Director of Nurses (DON) on 1/22/25 at 11:00 AM identified she was notified by one (1) of the nurses that another nurse may not be administering the correct dose of medication to Resident #4. The DON stated an investigation was conducted and identified the wrong dose of Losartan and Lexapro had been administered by a charge nurse, Licensed Practical Nurse (LPN) #1. The DON stated she contacted LPN #1 to discuss the incident, LPN #1 denied the allegation, and subsequently resigned from employment on 1/6/25. Although attempted, an interview with LPN #1 was unsuccessful.

Based on observations, review of facility documentation, and interviews for 7 out of a census of 111 residents who were sampled for identification bracelets, the facility failed to ensure the residents wore an identification bracelet or other form of visible identification. The findings include: Observations of the memory care unit on 1/22/25 at 12:30 PM identified three (3) of five (5) residents sitting in wheelchairs in the dining room with no visible form of identification on. Observations of the upper and lower resident units, recreation area, common areas and rehab area identified multiple residents had no identification bracelets or visible form of identification. Interview with two (2) residents stated they have not been provided with identification name bands. Interview with the Director of Nurses (DON) on 1/22/25 at 1:20 PM identified she was aware a week ago residents were missing name bands, and she thought the issue had been resolved. The DON stated the expectation was that each resident had an identification name band. The DON identified the name bands were a means of resident identification for all nurses to perform medication administration. The DON indicated instructions were given to the charge nurses on the units to audit the residents for name bands and to ensure each resident had a visible form of identification. Subsequently, an audit was conducted, and several other residents were found to have no visible form of identification, identification name bands were placed on the residents, and though requested the actual number of residents without name bands was not provided. Review of the Policy Identification of the Resident identified all residents shall be provided with a means of identification. An identification bracelet shall be placed on the wrist of each resident at the time of admission.

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 misappropriation of a resident's personal property, the facility failed to ensure a resident's medication was not removed from the facility by a licensed nurse. The findings include: Resident #1's diagnoses included cellulitis of the right and left lower limbs, anxiety, peripheral neuropathy, type 2 diabetes mellitus, and end stage renal disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life. The Resident Care Plan dated 3/28/24 identified Resident #1 took medications to help manage pain from the bilateral leg wounds. Interventions directed to administer medications as ordered, activity as tolerated, monitor pain level with pain scale, and monitor for adverse effects of the medications. A physician's order dated 3/10/24 directed to administer the muscle relaxer Cyclobenzaprine HCI 5 milligrams (mg) one (1) tablet every eight (8) hours around the clock for muscle spasms. A physician's order dated 5/16/24 directed to discontinue the every eight (8) hour scheduled Cyclobenzaprine and administer Cyclobenzaprine HCI 5 mg every eight (8) hours as needed for muscle spasms. A physician's order dated 6/9/24 directed to administer Cyclobenzaprine HCI 5 mg one (1) tablet every eight (8) hours as needed for muscle spasms and Oxycodone 10 mg take half (0.5) tablet for moderate pain and one (1) tablet for severe pain every six (6) hours as needed. The pain assessment dated [DATE] at 2:00 PM identified Resident #1 had almost constant severe pain in the right lower leg and right ankle arterial wounds. Review of the April, May, and June 2024 pain scales identified most of the time Resident #1 got fair to good relief with the pain medication and muscle relaxer. Review of the pharmacy shipment summaries identified the dates and quantities of the Cyclobenzaprine 5 mg delivered to the facility on: 3/10/24 total of thirty (30) tablets; 4/15/24 total of thirty (30) tablets; 4/23/24 total of ninety (90) tablets; 5/21/24 total of thirty (30) tablets; and 6/10/24 total of thirty (30) tablets. Review of the March, April, May, and June 2024 Medication Administration Records identified Resident #1 received the Cyclobenzaprine as ordered. The facility discharge paperwork dated 6/28/24 identified Resident #1 was discharged home. In an interview with the Director of Nursing (DON) on 9/16/24 at 11:45 AM identified on 9/12/24 she was contacted by the police department and informed one (1) of the facility's Registered Nurse was found in possession of a medication package that was Resident #1's Cyclobenzaprine 5 mg tablets that had a fill date of 4/23/24. The DON identified this was against the facility's policy and the licensed staff member should not have been in possession of a resident's medications. Review of the facility Abuse Policy directed abuse or mistreatment of any kind toward a resident is strictly prohibited and would be thoroughly investigated. The policy further identified misappropriation of resident property in part is the deliberate misplacement or use oof a resident's belongings without the resident's consent.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #236) reviewed for pain, the facility failed to administer pain medication for a resident whose pain level was assessed at a severe level of pain. The findings include: Resident #236's diagnoses included cellulitis of left leg, cellulitis of right leg, Type 2 diabetes mellitus with diabetic chronic kidney disease. The care plan dated 3/9/24 identified Resident #236 was at risk for pain/discomfort and noted that pain may impact mobility, mood (anxiety, depression), behaviors, sleep, ADL functioning, and relationships with others. Care plan interventions directed medication(s) as ordered, skilled assessment of pain symptoms: location, type, duration, frequency, intensity, factors that exacerbate and relieve pain. Admission physician's orders dated 3/9/24 directed to assess pain every shift using the pain of scale 010 0: no pain 1-2: mild pain 3-4: minimal pain 5-6: moderate pain 7-8: strong pain 9-10: severe pain, and administer Oxycodone HCl oral tablet 15 mg, give 1 tablet by mouth every 3 hours as needed for severe pain. The admission history and physical progress note dated 3/10/24 authored by MD#1 identified Resident #236 was admitted to the facility on [DATE] status post peritoneal dialysis catheter placement, lower extremity cellulitis with chronic wounds with a plan to continue Oxycodone (narcotic) and return to the pain clinic when stable where previously on Suboxone (opioid). Observation on 3/10/24 at 11:30 AM identified Resident #236 lying in bed crying, interview with Resident #236 at the time of the observation identified he/she had been administered a dose of Oxycodone early that morning. He/she further identified that he/she had been admitted to the facility around 9 or 9:30 PM on 3/9/24. In addition, Resident #236 identified he/she was in severe pain at the present time and noted that the nurse was aware that he/she was experiencing severe pain. Interview with LPN #1 on 3/10/24 at 11:40 AM identified she was aware that Resident #236 was in pain, and noted she was waiting for the resident's pain medication to be delivered from the pharmacy. The nurse's note dated 3/10/24 at 3:12 PM written by LPN #1 identified Resident #236 was in a lot of pain and non-compliant with care. When attempts made to re-approach, resident identified that she needed Oxycodone and a Nicotine patch. The note further identified that when the resident was administered Tylenol, the cup was crumpled and thrown to the floor. Further review of the nurse's note failed to identify the resident was administered Oxycodone by LPN #1 at any time during the shift. The Nurse Practitioner's (#1) progress note dated 3/11/24 identified Resident #236 had undergone multiple vascular procedures in the most recent hospital stay including lower extremity angioplasties with stent placements and peritoneal dialysis catheter placement on 3/1/24. The note further identified that the resident's hospital stay was complicated by uncontrolled pain which required intravenous (IV) opioids. A second interview with LPN #1 on 3/12/24 at 11:24 AM identified she entered Resident #236's room around 10:00 AM to administer morning medications, and Resident #236 complained of pain and rated it as a level 10 on the pain scale. She noted that she did not administer Oxycodone for the resident's complaint of severe pain because the medication had not been delivered by the pharmacy. She further identified that she did not think to check the automated medication dispensing system because she thought that it contained back up medications for residents that already had their medications in house. Additionally, LPN#1 identified that medication was retrieved from the automated medication dispensing system for Resident #236 because the therapist went into the room to see the resident and identified that the medication could be obtained from the automated medication dispensing system. She further noted that she and the Therapist went to the Nursing Supervisor, who was able to obtain the Oxycodone HCL 15mg dose from the automated medication dispensing system, but LPN #1 could not recall administering the medication to the resident, and identified that her shift ended shortly after 3:00 PM Review of the medication administration record (MAR) for 3/10/24 identified Resident #236 had been administered Oxycodone HCL 15mg at 5:25 AM and then at approximately 5:00 PM but failed to reflect documentation that Oxycodone HCl was administered between 7:00 AM and 3:00 PM (1st shift). Further review of the MAR identified Resident #236's pain level was assessed at a level 10 (severe) on the 1st shift. Interview with the Nursing Supervisor (RN#5) on 3/12/24 at 11:48 AM with LPN #1 present, identified she was notified by the MDS Coordinator (RN #3) on 3/10/24 in the afternoon that Resident #236 was in pain and needed to be medicated with medication from the automated medication dispensing system (emergency medication storage). RN#5 further noted that she obtained the medication from the automated medication dispensing system and handed it to LPN #1. Review of the automated medication dispensing system's detail report with the DNS on 3/12/24 at 11:58 AM identified RN #5 retrieved Oxycodone 10mg at 2:08 PM and Oxycodone 5mg at 2:09 PM on 3/10/24 from the automated medication dispensing system (emergency medication supply). Interview with the MDS Coordinator (RN #3) on 3/12/24 at 12:12 PM identified that she went to Resident #236's room to convey the date of the care plan meeting, and while in the room she identified the resident was in severe pain and notified LPN #1. RN #3 further noted that LPN#1 told her that the resident did not have any available Oxycodone because the resident's medications had not yet been delivered by the pharmacy. RN #3 noted that she told LPN #1 that she could obtain the Oxycodone from the automated medication dispensing system and went with LPN #1 to speak with RN #5. Further, RN #3 identified that she accompanied RN #5 to the automated medication dispensing system to obtain the medication and then watched RN #5 hand the medication to LPN #1. RN #3 further identified that the medication should have been documented in the electronic MAR, which would indicate the time the medication was administered. After reviewing the MAR for 3/10/24, RN #3 identified that she did not see documentation to indicate the resident was medicated with Oxycodone on first shift. A third interview with LPN #1 on 3/12/24 at 12:20 PM identified she could not locate documentation of the administration of Oxycodone on 3/10/24, however she indicated that it was a crazy day, and she may have forgotten to document. LPN#1 indicated that she may have thought she did not have to document administration due to the fact the medication was not from her cart and that it was obtained from the automated medication dispensing system and indicated that she thought the administration may have been documented already through the automated medication dispensing system. LPN#1 indicated she did not notify the Nursing Supervisor when the medication was unavailable and the resident's pain level was at a level 10. A second interview with Resident #236 on 3/12/24 at 2:45 PM identified that on 3/10/24 she was in pain all day and she needed a Nicotine patch that he/she had his/her significant other on standby waiting for him/her to say the word for him/her to come pick him/her up. Resident #236 further noted that she was not medicated for pain until sometime on the second shift and identified that they wanted to change the dressings on his/her legs immediately after administering the medication but he/she told the nurse that he/she needed to wait until the pain medication kicked in first. He/she did not know the exact time he/she was medicated but referred to a text message that had been sent to his/her significant other at 5:02 PM that identified that they'd just given him/her medication. Resident #236 indicated that it was around that time that he/she had finally received the medication. Further, he/she noted that she had not received pain medication on the first shift on 3/10/24. Interview with MD #1 on 3/14/24 at 11:45 AM identified she saw Resident #236 on 3/10/24 around 8:00 AM and the resident did not complain of pain at that time. and noted was not notified the resident was in pain on 3/10/24 following her visit to the facility. MD #1 further identified that she would expect to be notified if a resident is in pain and a pain medication is unavailable or ineffective at controlling the pain. Interview with the Staff Development nurse (RN #6) on 3/12/24 at 2:40 PM identified training materials regarding medication administration are done via video as well as verbal information about various topics. She further identified LPN #1 was walked through the automated medication dispensing system area during the orientation tour and also received 120 hours of mentoring for orientation. Review of the Receipt of Interim/Stat/Emergency delivered medications policy identified that the facility should not borrow medication from another resident. The facility should immediately notify the pharmacy when the facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery and if a necessary medication is not contained within a facility's interim/stat/emergency supply, and the facility determines that an interim/stat/emergency supply is necessary, the facility should make arrangements with the pharmacy to obtain the medication. Based on review of the facility's policy, interviews and record review, the facility failed to comply with their policy for obtaining a necessary medication in a timely manner. The facility failed to ensure that a resident who was assessed to be in severe pain and had pain medication ordered for severe pain that could be administered every three hours was medicated as ordered. The resident waited for a period of approximately 9 to be medicated for complaints of severe pain.

Based on review of facility documentation, review of facility policies, and interviews, the facility failed to review the infection prevention control program policies and procedures at least annually, failed to provide documentation that the Infection Control Surveillance and Safety rounds were conducted on a quarterly basis, and failed to provide documentation that monthly infection reports or analysis of infection trends within the facility were completed, along with quarterly reports in 2022 and 2023 . The findings include: 1. Review of the facility's Infection Control Program Policies and Procedure manual for the past two years with the DNS (former IP and currently oversees the IP program) on 3/12/24 at 12:19 PM identified that the policies and procedures manual was reviewed on 7/18/23, and 1/1/24, but failed to provide any documentation that the Infection Control Program Policies and Procedure manual was reviewed in 2022. Interview with the DNS on 3/12/24 at 12:19 PM identified that the policy and procedures manual should be reviewed annually, and it's the responsibility of the then IP nurse to ensure that it was completed. The DNS further added that she was not working at the facility during the time for the annual review was due, as she started working as the IP in July of 2023 until December of 2023. Review of the Infection Prevention and Control Program policy directed that an annual review to be conducted of the Infection Prevention and Control Program and to update the program as necessary to include updates as national standards changes. 2. Review of the Infection Control Surveillance and Safety rounds documentation for the past two years with the DNS (former IP and currently oversees the IP program) on 3/12/24 at 12:19 PM identified that the quarterly infection control surveillance and safety rounds were not completed for the months of April 2022, July 2022, October of 2022, January 2023, and April 2023. Interview with the DNS on 3/12/24 at 12:19 PM identified that she was unable to locate the quarterly infection control surveillance and safety rounds forms for the months of April 2022, July 2022, October of 2022, January 2023, and April 2023. The DNS further added that she started working at the facility in July of 2023 and it would have been the responsibility of the previous IP nurse to ensure that the infection control surveillance and safety rounds were completed. Review of the Infection Control Surveillance and Safety Rounds policy identified that Surveillance rounds are conducted on a quarterly basis by the Infection Preventionist. The policy further identified that rounds will be documented on the surveillance rounds form and maintained by the Infection Preventionist. 3. Review of the infection control program for the past two years with the DNS (former IP and currently oversees the IP program) on 3/12/24 at 12:19 PM failed to identify that monthly infection reports or analysis of infection trends were completed for the year of 2022, and during the period of January 2023 to June 2023, along with the quarterly reports for January of 2022, April 2022, July 2022, October 2022, January 2023, April 2023, and July 2023. Review of the Medical Staff Meeting agendas for all the quarters in 2022 and 2023, the documentation provided failed to identify any topics related to infection control. Interview with the DNS on 3/12/24 at 12:19 PM identified she was not working at the facility during the time frame and was unable to locate the reports. The DNS indicated that she would continue to search for the reports prior to her started date in July of 2023. The DNS further added that she was unable to locate the quarterly infection control reports in the Medical Staff Meeting binder, only the ones she completed. Interview with the DNS on 3/14/24 at 11:00 AM identified that she was able to locate the infection control individual reports for residents for the year 2022 but was able to find the monthly report/analysis that consisted of the rate of healthcare/facility acquired infections and community acquired infections within the facility. Review of the Monthly Infection Report policy identified that the monthly infection report is completed in the first week of each month for the month prior to compute rates of nosocomial (Healthcare/Facility) and community acquired infections and resolution rates. The policy further identified that the records would be maintained for a period of no less than three years. Review of the Surveillance Data Collection policy identified that an infection surveillance data collection form would be completed for each resident with an infection. The policy further identified that the data collected would be analyzed monthly for treads and incorporated into the quarterly infection control report. Review of the Quarterly Infection Report policy identified that the Infection Control Nurse (Infection Preventionist) completes the quarterly report quarterly and presented data collected to the infection control committee for review/recommendation.

Based on review of facility documentation, review of facility policy and interviews, the facility failed to ensure that a review of the antibiotic stewardship program including antibiotic usage, and audit tool results were presented at the quarterly medical staff meetings. The findings include: Review of the antibiotic stewardship program for the past two years with the DNS former IP and currently oversees the IP program) on 3/12/24 at 12:19 PM failed to identify any documentation related to monthly review of the antibiotic stewardship program for the period of January 2023 to June 2023. The facility also failed to provide documentation that a quarterly review of antibiotic usage for 2022 and 2023 was presented at the quarterly medical staff meeting. A review of the Review of the Medical Staff Meeting agendas for all the quarters in 2022 and 2023, the documentation provided by the facility failed to identify any topics related to infection control and antibiotic usage/antibiotic stewardship program within the facility that was presented at the Medical Staff Meeting by the Infection Preventionist. Interview with the DNS on 3/14/24 at 11:00 AM identified that she was not working at the facility during the time frame and was only able to locate the monthly Antibiotic Tracking tool for 2022. The DNS further added that she reviewed the Medical Staff Meeting binder and was unable to locate any reports that included the antibiotic stewardship program that was presented at the quarterly medical staff meeting that was held in 2022, 2023, and was only able to locate the reports that she completed for the last quarters in 2023. The DNS further added that started the role of the facility's Infection Preventionist (IP) in July of 2023 to December of 2023, and it would have been the responsibility of the previous IP to complete and present the reports at the quarterly medial staff meeting. Review of the Antibiotic Stewardship policy identified that all infections will be tracked by the IP or designee and reviewed for trends. The policy further directed that the facility would review the antibiotic usage and present findings quarterly at the medical staff meeting. Review of the Infection Prevention and Control Program Manual Surveillance policy identified that data analysis is completed by the IP from both process and outcomes of surveillance activities, which this data is recorded at least quarterly.

Based on facility documentation, review of facility policy, and interviews the facility failed to have a consistent designated Infection Preventionist (IP) with the required specialized training in infection control, that was responsible for the facility's Infection Control Program in 2022 and 2023. The findings include: Interview with the DNS on 3/12/24 at 12:19 PM identified that she was the Infection Preventionist at the facility starting in July of 2023 until December of 2023. The DNS further added that her role was changed to DNS on December 22, 2023, and that she currently oversees the program until the newly hired nurse for the Infection Preventionist position completes the required specialize training. Interview with Human Resources on 3/13/24 at 10:19AM identified and provided a total of 3 nurses who worked in the position of an IP prior to the DNS in the years of 2022 and 2023. Human Resources identified RN #8 with a date of hire of 5/16/23 and termed on 5/26/23, RN #9 with a date of hire of 12/6/21 and termed on 4/25/2022, and RN #10 with a date of hire of 7/19/22 and termed on 8/14/22. Human Resources identified that RN #12 worked mainly as the wound nurse for the facility from 12/7/22 to 6/28/23 but did not work in the month of March 2023 based on her employee punch history. Interview with the Cooperate Nurse RN #11 on 3/13/24 at 12:50 PM identified that they had staff filling in the role as the IP such as RN #12 who was in the role as the IP for the facility, but there was a gap in the facility in the years 2022 and 2023 with having a designated IP. A request was made on 3/14/23 at 10:00 AM to Human Resources for any certification or specialized training related to infection control for all the individuals hired for the IP role. Although requested, Human Resources failed to provide a copy of the employees who were hired as IP in the years of 2022 to 2023. Review of the facility's Infection Prevention and Control Program identified that the facility would designate one or more individual (s) as the infection control preventionist and had completed specialized training in infection prevention and control.

Based on observations, review of facility documentation review of facility policy and interviews for one sampled resident (Resident #286) who had an indwelling urethral catheter, the facility failed to develop a comprehensive care plan to address the specific type of catheter, how often the catheter should be changed, the size of the balloon to be used with the catheter, and the general care of the catheter as it relates to the resident. The findings included: Resident #286 was admitted to the facility on [DATE]. Resident diagnoses included Type II diabetes mellitus with diabetic polyneuropathy, above the knee right side amputation, neuromuscular dysfunction of the bladder, and renal dialysis. The quarterly Minimum data set (MDS) assessment dated [DATE] identified Resident #286 had intact cognitive status, had an indwelling Foley catheter, and was dependent on staff for mobility, transfers, and personal care. The care plan dated 3/6/2024 identified Resident #286 required staff assistance with activities of daily living, wore glasses, was morbidly obese, and utilized a wheelchair for mobility. The care plan further identified the resident had an indwelling urinary catheter in place but further review of the care plan failed to include the size of the indwelling catheter, instructions on how often the catheter should be changed and/or irrigated, or instructions on when the bag itself should be switched to a leg bag. Review of the monthly physician's orders for March/2024 failed to identify orders that addressed the use of the indwelling urethral catheter and/or the care of the catheter. Interview with the DNS on 3/14/2024 at 2:34 PM identified that the expectation for care planning would be to provide specific details to direct use and care of the indwelling Foley catheter. She further noted that orders and care planning can come from hospital discharge recommendations but should be specific to the resident's needs and noted that the initial care plan is completed by the admission nurse or the MDS coordinator on admission. Interview with the MDS coordinator on 3/14/2024 at 11:55 AM identified the care plans are reviewed at the resident's quarterly meetings. The admission nurse would be responsible for the initial care plan, depending on when the resident was admitted . Review of the facility Care Planning Policy dated 10/30/2020 identified the facility will develop a comprehensive and individualized plan of care will be developed for each resident to guide caregivers to assist residents to achieve or maintain their highest practical level of well-being. The care plan will include reasonable and measurable goals and interventions to achieve these goals and discipline responsible for carrying out the interventions.

Based on observation, clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #236) with a recent history of smoking, the facility failed to administer a nicotine patch for a newly admitted resident. The findings include: Resident #236 diagnoses included cellulitis of left leg, cellulitis of right leg, Type 2 diabetes mellitus with diabetic chronic kidney disease, and tobacco use. The admission Minimum Data Set assessment dated [DATE] identified Resident #236 had intact cognition, required extensive assistance with bed mobility, and was independent to eat. The Resident Care Plan dated 3/11/24 identified prior to admission Resident #236 was actively smoking in the community. Interventions directed to offer to obtain a MD order for nicotine patch, nicotine gym or nicotine lozenges. A physician's order dated 3/9/24 directed to apply NicoDerm CQ 24hr 21mg 1 patch transdermal one time a day for and remove per schedule. Interview with Resident #236 on 3/10/24 at 11:30 AM identified he/she was not given a nicotine patch because they did not have any available. He/She was a pack and a half a day smoker prior to admission and needed a nicotine patch to help curb his/her cravings. Progress Note from LPN #1 on 3/10/24 at 3:12 PM identified Resident #236 was non-compliant with care and was in a lot of pain. When trying to re-approach stated I need oxy and patch when Tylenol was given it was taken by mouth the cup was crumpled and thrown to the floor. Interview with LPN #1 on 3/12/24 at 11:24 AM identified she did not pass the Nicoderm patch on Sunday 3/10/24 due to the fact there were none in stock. Interview with RN#2 on 3/13/24 10:07AM identified she was responsible for the admission of Resident #236 on 3/9/24. She identified she did not administer a nicotine patch as she did not have any on hand. She looked on all of the carts and in the back stock room and none were available. RN#2 identified the weekends are difficult when you are out of a supply like this because the deliveries come in on Mondays. Interview with DON on 3/13/24 at 9:30 AM identified there were two boxes of 14mg Nicotine patches and two boxes of 7 mg Nicotine patches that were ordered on 3/8/24 and arrived in the facility on 3/11/24. Review of medication cart identified that no patches were available on Saturday, Sunday, and part of Monday in the facility. At least one box of each should always be kept on hand and orders are put in on Fridays by the nurse scheduler and received on Mondays. The DON identified if medication is not available it should be ordered stat from the pharmacy which should be delivered in 4 hours, however pharmacy does not usually deliver NicoDerm Patches as a stat medication. No documentation was received that this medication was in fact ordered stat on 3/9/24. Review of purchase order #OGV195240 created on 3/4/24 delivery date 3/11/24 identified two boxes of 14 mg Nicotine Patch was ordered and two boxes of 7mg Nicotine Patch was ordered. Interview with Resident #236 on 3/12/24 at 2:50 PM identified his/her significant other brought 21mg Nicotine patches to the facility Monday 3/11/24 afternoon prior to going to work, and that was the first time one was applied. Documentation of a patch applied by the facility in March 2024 Medication administration record did not occur until 3/12/24 at 8:21 PM. Review of the Omnicare policy 5.2 Receipt of Interim/Stat/Emergency delivered policy revised 1/1/22 directed facility should immediately notify Pharmacy when Facility receives from a Physician/Prescriber a medication order that may require an interim/stat/emergency delivery. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency supply is necessary, Facility should arrange with Pharmacy.

Based on a review of clinical records, facility documentation, observations, interviews, and policy reviews, the facility failed to ensure adequsate staffing levels to protect the residents' right to be free from neglect for thirty (31) residents who required assistance with turning, repositioning, transfers and incontinent care, (Resident #1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). The findings include: a. Resident #1 had diagnoses that included mild cognitive impairment and brain cancer. A quarterly Minimum Data Set assessment (MDS) dated [DATE] identified that the resident had severe cognitive impairment, required total dependence with Activities of Daily Living (ADSL's), including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/10/23 identified that the resident needed staff assistance with ADL's with an intervention to receive incontinent care per facility policy. A physician's order dated 9/23/21 directed Hoyer lift assist of two staff for transfers. b. Resident #2 had diagnoses that included dementia and schizocarp disorder. A care plan dated 3/8/23 identified that the resident had a total self-care deficit related to a progressive neurological disorder with interventions that included to provide AM/PM care as per facility protocol. It further identified the resident was at risk for skin breakdown with interventions that included incontinent care per facility policy. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including eating and bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. c. Resident #3 had diagnoses that included dementia, a pressure ulcer on the coccyx and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/12/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. d. Resident #4 had diagnoses that included psychotic disturbance and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 6/12/23 identified that the resident was incontinent of bowel and bladder with interventions that included to check the resident for incontinence per his/her needs and provide him/her with care if he/she was incontinent. e. Resident #5 had diagnoses that included dementia and dysphasia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 5/1/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 7/18/22 directed a Hoyer lift transfer with assist of two. f. Resident #6 had diagnoses that included Alzheimer's dementia and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, was totally dependent with ADL's, including bed mobility, was at risk for pressure ulcers, was always incontinent of bowel and was frequently incontinent of bladder. A care plan dated 7/6/23 identified that the resident was incontinent of bowel with the inability to identify urges with interventions that included to check for incontinence at typical defecation times. A physician's order dated 4/29/22 directed Hoyer lift to custom wheelchair. g. Resident #7 had diagnoses that included Alzheimer's dementia and major depressive disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 12/5/22 directed a Hoyer lift with assist of two. h. Resident #8 had diagnoses that included dementia, psychotic disturbance, and dysphagia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, required extensive assistance with bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing. i. Resident #9 had diagnoses that included dementia, dysphagia, and a pressure ulcer of the sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/27/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. j. Resident #10 had diagnoses that included Alzheimer's disease and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/29/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 9/23/21 directed mechanical lift with assist of two for transfers. k. Resident #11 had diagnoses that included dementia, major depressive disorder, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder. A care plan dated 6/14/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 9/24/21 directed a stand mechanical lift with assist of two for transfers. l. Resident #12 had diagnoses that included dementia, stroke, and failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. m. Resident #13 had diagnoses that included Alzheimer's dementia, severe protein-calorie malnutrition, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 5/9/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician order dated 7/25/23 directed an assist of two for transfers. n. Resident #14 had diagnoses that included neurocognitive disorder with Lewy bodies, dysphagia, and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/14/23 identified that the resident was incontinent of bowel and bladder related to diminished sensation with interventions that included to check the resident for incontinence per his/her needs, provide incontinence care when the resident has been incontinent and provide the resident with assistance with toileting. A physician order dated 9/28/21 directed assist of two via hydraulic lift to wheelchair. o. Resident #15 had diagnoses that included Alzheimer's dementia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included incontinent care per policy and assist the resident as needed to meet toileting needs. p. Resident #16 had diagnoses that included macular degeneration and mild cognitive impairment. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 7/19/23 identified that the resident was incontinent of bladder with interventions that included to check the resident for dryness frequently during waking hours and use incontinent garments to contain urine. It further identified the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 7/30/22 directed assist of two for transfers. q. Resident #17 had diagnoses that included Alzheimer's dementia, pressure ulcer of sacral region and severe protein-calorie malnutrition. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident had a pressure injury to coccyx with interventions that included incontinence care per policy and to turn and reposition per nursing standards of care and policy. r. Resident #18 had diagnoses that included dementia, expressive language disorder and adult failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified the resident was dependent on staff for all ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician's order dated 1/28/22 directed to transfer the resident with the mechanical lift. s. Resident #19 had diagnoses that included metabolic encephalopathy, Alzheimer's dementia, and palliative care. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's and eating, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and always incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 1/30/23 directed assist of two for bed to chair transfers. t. Resident #20 had diagnoses of Alzheimer's dementia, expressive language disorder and syncope. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. u. Resident #21 had diagnoses of dementia, cerebral infarction, and dysphagia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 4/19/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. v. Resident #22 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. w. Resident #23 had diagnoses that included frontotemporal neurocognitive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/29/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 2/22/23 directed to transfer the resident with a mechanical lift with assist of two. x. Resident #24 had diagnoses that included epilepsy and schizophrenia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 6/29/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times, and further identified the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. y. Resident #25 had diagnoses that included dementia, adult failure to thrive, dysphagia and pressure ulcer of sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times. The care plan further identified that the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. A physician's order dated 12/10/21 directed a Hoyer lift for transfers. z. Resident #26 had diagnoses that included dementia and muscle weakness. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. aa. Resident #27 had diagnoses that included Alzheimer's dementia and severe protein-calorie malnutrition. A care plan dated 2/24/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy, and to turn and reposition per standards of nursing practice. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and always incontinent of bowel. bb. Resident #28 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. cc. Resident #29 had diagnoses that included dementia and bipolar disorder. A MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder and bowel. A care plan dated 5/2/23 identified that the resident needed staff assistance with ADLs with interventions including incontinence care per policy. dd. Resident #30 had diagnoses that included Alzheimer's dementia and weakness. An admission MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and bowel. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. ee. Resident #31 had diagnoses that included epilepsy, cognitive communication deficit and encephalopathy. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 5/31/23 directed Sara lift with assist of two for transfers. Review of the facility assessment dated [DATE] identified that the average census in the building is 85 to 95 residents and the staffing plan identified that there will be seven (7) NAs on the 3:00 PM to 11:00 PM shift, a ratio of one (1) NA to 12 residents. Review of clinical records and facility documentation identified on 6/13/23 thirty-one (31) residents were at risk for pressure ulcers, twenty-nine (29) residents had severly impaired conginition, two (2) residents had moderately impaired cognition, thirteen (13) residents required Hoyer lifts or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist and twenty-nine (29) residents were incontinent of bowel and/or bladder and required incontinent care and turning and repositioning. Review of clinical records and facility documentation on 7/10/23 identified that thirty-one (31) residents were at risk for pressure ulcers, thirteen (13) residents required Hoyer lift assistance for transfers and/or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist, and thirty (30) residents were incontinent of bowel and/or bladder. Review of the facility schedule of Tuesday 6/13/23 identified the facility census was 92. The staffing for the 3:00 PM to 11:00 PM shift included one (1) NA (NA #1) and one (1) licensed staff (LPN #1) on the lower unit and one (1) NA (NA #2) and one (1) registered nurse (RN #1) on the upper unit. NA #1 was the only NA on the lower unit, responsible for forty-six (46) residents and NA #2 was the only NA on the upper unit, responsible for 46 residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 6/13/23 the facility had 64 NA hours and were required to have 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 80 NA hours for 6/13/23). Review of the facility schedule of Monday 7/10/23 identified the facility census was 88. The staffing for the 3:00 PM to 11:00 PM shift included two (1) NA (NA #1) and one (1) licensed staff on the lower unit for forty-six (46) residents and one (2) NA's (NA #3), two (2) NA students and (2) licensed staff on the upper unit for forty-one (41) residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 7/10/23 the facility had 58 NA hours and required 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 86 NA hours for 7/10/23). Interview with NA #1 on 7/27/23 at 10:15 AM identified she was the only NA who worked from 3:00 PM to 11:00 PM on the lower level on 6/13/23 (responsible for 46 residents). She identified Resident's #4, #11, #15 and #29 did not receive any care, except for being served meals during the entire 3:00 PM to 11:00 PM shift (bathing, incontinent care and turning and repositioning). NA#1 further identified that she barely had time to look at resident #4, #11, #15, and #29. She identified Resident's #1, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #31 had one incontinent change and one reposition and Resident #2 had two incontinent changes and two repositions because he/she was known to void large amounts when incontinent. She identified that she was aware that these residents required incontinent care and repositioning every two (2) hours, however, she could not accomplish this task by herself, additionally, the incontinent care she was able to give was not thorough. She identified she did not give any residents showers during her shift. She further identified that she Hoyered residents without a second staff member, although she was aware two (2) staff were required per policy, she did not have a second NA on the floor to assist. (NA#1 could not identify the number of residents she Hoyered without assistance of another staff member, as she could not remember) She identified for the residents who were totally dependent for eating (10 residents), she fed one at a time in their rooms (either in their bed if they were in bed or in their chair) because it would have been impossible to get all the resident's out of their room by herself. Furthermore, she had no help on the floor from any staff on 6/13/23. She identified she did not tell the charge nurse or DNS that she was the only NA on 6/13/23 because she would expect them to know because they create the staffing schedules. Further interview with NA #1 on 7/27/23 at 10:35 AM identified she had also worked from 3:00 PM - 11:00 PM on the lower level on 7/10/23, along with NA #3. She identified the floor was split between her and NA #3 and she cared for the Residents in rooms 100 - 113 and 130-134 (a total of twenty (25) residents). She identified Residents' #1, #3, #5, #6, #7, #8, 10, #12 and #30, had incontinent care and repositioning twice during that shift. Residents' #9, #11 #28 had incontinent care once during the shift. Residents' # 9 and #11 had one incontinent change because they were in their wheelchairs, and she changed them when they were placed into bed for the night (around 9:00 PM). She identified she did not give any residents showers during her shift as even with two NA's, it is impossible to provide showers. NA #2 identified that although she was aware to give incontinent care every (2) hours this could not be accomplished while caring for 25 residents. Interview with NA #2 on 7/27/23 at 2:40 PM identified she worked from 3:00 PM - 11:00 PM on 6/13/23 on the upper level. She identified sometimes she works as the only NA but the nurse on the floor would help, and they would work as a team. She further identified that she did not have time to assist NA#1 on the lower level and further identified that management does not usually help when needed on the floor because they leave by 5:00 PM. Interview with LPN #1 on 8/7/23 at 12:37 PM identified she was the nurse who worked 3:00 PM - 11:00 PM on 6/13/23 on the lower level. She identified it was just her and NA #1 who were on the floor. She identified she helped feed at dinner time and put 3 or 4 residents to bed after dinner. She identified she did not provide any showers incontinent care or turn and reposition residents. She identified she had to tend to two medication carts. She further identified NA #1 did not tell her there was care that she did not get done. Interview with Person #1 (facilities previous scheduler) on 8/7/23 at 1:21 PM identified her last day was 6/14/23. She identified if the schedule was not meeting the minimum requirements, she would tell HR #1, who trained Person #1. She identified they would have a daily meeting at 1:00 PM to discuss the schedule. She further identified she could not recall the schedule on 6/13/23. Interview with the DNS on 7/27/23 at 1:00 PM identified he was not aware of the schedule on 6/13/23. He identified it could not be accurate and the scheduler confirmed it was. He further identified he was not aware that residents did not receive appropriate care and had he known, he would have checked on the residents. He identified on 7/10/23, NA #3 was moved from the upper-level unit to the lower-level unit to help NA #1. He further identified he does not notify corporate of staffing issues, as he was not told to do so. The DNS stated that residents who are scheduled for shower, should receive showers on their scheduled day, residents who are incontinent and require repositioning should be given incontinent care and repositioned every 2 hours, and there should be two (2) staff assists with Hoyer lift transfers. Interview with the Administrator on 7/20/23 at 11:30 AM identified their goal for staffing NA's is 12 NAs on 7:00 AM - 3:00 PM shift and 9 NAs on 3:00 PM - 11:00 PM shift and if the census is greater than 90 then 11 NAs on 3:00 PM - 11:00 PM shift. She identified they are currently staffing with the staff they have available. She identified the hardest shift to find new staff for is the 3:00 PM - 11:00 PM shift. She identified there are currently five (5) NA students who will be independent upon completion of the class in August. She identified when there are call outs, all staff are reached out to, and the rehab staff is asked to assist on the floor. The facility is active in job fairs and provides bonus'. The administrator further identified that one or two NAs on a unit is not acceptable. After surveyor inquiry, the facility has begun an investigation of neglect regarding the care concerns identified on 6/13/23. The facility submitted a report for Residents' #4, #11, #15 and #29 to the reportable event website on 7/27/23 for investigation of neglect. Although attempted, an interview with RN #1 (RN for 3:00 PM - 11:00 PM on 6/13/23) was not obtained. The facility administrator identified that there was no staffing policy, the facility follows the state public health code. Review of the Administrator job description identified an essential job function to ensure all written policies, procedures and manuals are maintained, updated, and followed. Review of the incontinent care policy directed that incontinent care is performed by nursing staff on all residents following an episode of incontinence, every two hours and as needed. Review of the bathing/shower policy directed that each resident will be offered a full bath/shower at least weekly. Review of the positioning policy directed residents who are unable to turn themselves will be repositioned at least every two hours and/or as needed. Review of the abuse policy identified that neglect means a deprivation of an individual, including a caretaker, of good and services that are necessary to attain or maintain physical mental or psychological well-being.

Based on a review of clinical records, facility documentation, observations, interviews, and policy reviews, for thirty (31) residents who required assistance with turning, repositioning, transfers and incontinent care, (Resident #1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 31), the facility failed to ensure adequate staffing levels to meet the needs of the residents. The findings include: a. Resident #1 had diagnoses that included mild cognitive impairment and brain cancer. A quarterly Minimum Data Set assessment (MDS) dated [DATE] identified that the resident had severe cognitive impairment, required total dependence with Activities of Daily Living (ADSL's), including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/10/23 identified that the resident needed staff assistance with ADL's with an intervention to receive incontinent care per facility policy. A physician's order dated 9/23/21 directed Hoyer lift assist of two staff for transfers. b. Resident #2 had diagnoses that included dementia and schizocarp disorder. A care plan dated 3/8/23 identified that the resident had a total self-care deficit related to a progressive neurological disorder with interventions that included to provide AM/PM care as per facility protocol. It further identified the resident was at risk for skin breakdown with interventions that included incontinent care per facility policy. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including eating and bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. c. Resident #3 had diagnoses that included dementia, a pressure ulcer on the coccyx and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/12/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. d. Resident #4 had diagnoses that included psychotic disturbance and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 6/12/23 identified that the resident was incontinent of bowel and bladder with interventions that included to check the resident for incontinence per his/her needs and provide him/her with care if he/she was incontinent. e. Resident #5 had diagnoses that included dementia and dysphasia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 5/1/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 7/18/22 directed a Hoyer lift transfer with assist of two. f. Resident #6 had diagnoses that included Alzheimer's dementia and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, was totally dependent with ADL's, including bed mobility, was at risk for pressure ulcers, was always incontinent of bowel and was frequently incontinent of bladder. A care plan dated 7/6/23 identified that the resident was incontinent of bowel with the inability to identify urges with interventions that included to check for incontinence at typical defecation times. A physician's order dated 4/29/22 directed Hoyer lift to custom wheelchair. g. Resident #7 had diagnoses that included Alzheimer's dementia and major depressive disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 12/5/22 directed a Hoyer lift with assist of two. h. Resident #8 had diagnoses that included dementia, psychotic disturbance, and dysphagia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, required extensive assistance with bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing. i. Resident #9 had diagnoses that included dementia, dysphagia, and a pressure ulcer of the sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/27/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. j. Resident #10 had diagnoses that included Alzheimer's disease and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/29/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 9/23/21 directed mechanical lift with assist of two for transfers. k. Resident #11 had diagnoses that included dementia, major depressive disorder, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder. A care plan dated 6/14/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 9/24/21 directed a stand mechanical lift with assist of two for transfers. l. Resident #12 had diagnoses that included dementia, stroke, and failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. m. Resident #13 had diagnoses that included Alzheimer's dementia, severe protein-calorie malnutrition, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 5/9/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician order dated 7/25/23 directed an assist of two for transfers. n. Resident #14 had diagnoses that included neurocognitive disorder with Lewy bodies, dysphagia, and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/14/23 identified that the resident was incontinent of bowel and bladder related to diminished sensation with interventions that included to check the resident for incontinence per his/her needs, provide incontinence care when the resident has been incontinent and provide the resident with assistance with toileting. A physician order dated 9/28/21 directed assist of two via hydraulic lift to wheelchair. o. Resident #15 had diagnoses that included Alzheimer's dementia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included incontinent care per policy and assist the resident as needed to meet toileting needs. p. Resident #16 had diagnoses that included macular degeneration and mild cognitive impairment. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 7/19/23 identified that the resident was incontinent of bladder with interventions that included to check the resident for dryness frequently during waking hours and use incontinent garments to contain urine. It further identified the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 7/30/22 directed assist of two for transfers. q. Resident #17 had diagnoses that included Alzheimer's dementia, pressure ulcer of sacral region and severe protein-calorie malnutrition. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident had a pressure injury to coccyx with interventions that included incontinence care per policy and to turn and reposition per nursing standards of care and policy. r. Resident #18 had diagnoses that included dementia, expressive language disorder and adult failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified the resident was dependent on staff for all ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician's order dated 1/28/22 directed to transfer the resident with the mechanical lift. s. Resident #19 had diagnoses that included metabolic encephalopathy, Alzheimer's dementia, and palliative care. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's and eating, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and always incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 1/30/23 directed assist of two for bed to chair transfers. t. Resident #20 had diagnoses of Alzheimer's dementia, expressive language disorder and syncope. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. u. Resident #21 had diagnoses of dementia, cerebral infarction, and dysphagia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 4/19/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. v. Resident #22 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. w. Resident #23 had diagnoses that included frontotemporal neurocognitive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/29/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 2/22/23 directed to transfer the resident with a mechanical lift with assist of two. x. Resident #24 had diagnoses that included epilepsy and schizophrenia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 6/29/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times, and further identified the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. y. Resident #25 had diagnoses that included dementia, adult failure to thrive, dysphagia and pressure ulcer of sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times. The care plan further identified that the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. A physician's order dated 12/10/21 directed a Hoyer lift for transfers. z. Resident #26 had diagnoses that included dementia and muscle weakness. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. aa. Resident #27 had diagnoses that included Alzheimer's dementia and severe protein-calorie malnutrition. A care plan dated 2/24/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy, and to turn and reposition per standards of nursing practice. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and always incontinent of bowel. bb. Resident #28 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. cc. Resident #29 had diagnoses that included dementia and bipolar disorder. A MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder and bowel. A care plan dated 5/2/23 identified that the resident needed staff assistance with ADLs with interventions including incontinence care per policy. dd. Resident #30 had diagnoses that included Alzheimer's dementia and weakness. An admission MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and bowel. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. ee. Resident #31 had diagnoses that included epilepsy, cognitive communication deficit and encephalopathy. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 5/31/23 directed Sara lift with assist of two for transfers. Review of the facility assessment dated [DATE] identified that the average census in the building is 85 to 95 residents and the staffing plan identified that there will be seven (7) NAs on the 3:00 PM to 11:00 PM shift, a ratio of one (1) NA to 12 residents. Review of clinical records and facility documentation identified on 6/13/23 thirty-one (31) residents were at risk for pressure ulcers, twenty-nine (29) residents had severly impaired conginition, two (2) residents had moderately impaired cognition, thirteen (13) residents required Hoyer lifts or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist and twenty-nine (29) residents were incontinent of bowel and/or bladder and required incontinent care and turning and repositioning. Review of clinical records and facility documentation on 7/10/23 identified that thirty-one (31) residents were at risk for pressure ulcers, thirteen (13) residents required Hoyer lift assistance for transfers and/or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist, and thirty (30) residents were incontinent of bowel and/or bladder. Review of the facility schedule of Tuesday 6/13/23 identified the facility census was 92. The staffing for the 3:00 PM to 11:00 PM shift included one (1) NA (NA #1) and one (1) licensed staff (LPN #1) on the lower unit and one (1) NA (NA #2) and one (1) registered nurse (RN #1) on the upper unit. NA #1 was the only NA on the lower unit, responsible for forty-six (46) residents and NA #2 was the only NA on the upper unit, responsible for 46 residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 6/13/23 the facility had 64 NA hours and were required to have 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 80 NA hours for 6/13/23). Review of the facility schedule of Monday 7/10/23 identified the facility census was 88. The staffing for the 3:00 PM to 11:00 PM shift included two (1) NA (NA #1) and one (1) licensed staff on the lower unit for forty-six (46) residents and one (2) NA's (NA #3), two (2) NA students and (2) licensed staff on the upper unit for forty-one (41) residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 7/10/23 the facility had 58 NA hours and required 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 86 NA hours for 7/10/23). Interview with NA #1 on 7/27/23 at 10:15 AM identified she was the only NA who worked from 3:00 PM to 11:00 PM on the lower level on 6/13/23 (responsible for 46 residents). She identified Resident's #4, #11, #15 and #29 did not receive any care, except for being served meals during the entire 3:00 PM to 11:00 PM shift (bathing, incontinent care and turning and repositioning). NA#1 further identified that she barely had time to look at resident #4, #11, #15, and #29. She identified Resident's #1, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #31 had one incontinent change and one reposition and Resident #2 had two incontinent changes and two repositions because he/she was known to void large amounts when incontinent. She identified that she was aware that these residents required incontinent care and repositioning every two (2) hours, however, she could not accomplish this task by herself, additionally, the incontinent care she was able to give was not thorough. She identified she did not give any residents showers during her shift. She further identified that she Hoyered residents without a second staff member, although she was aware two (2) staff were required per policy, she did not have a second NA on the floor to assist. (NA#1 could not identify the number of residents she Hoyered without assistance of another staff member, as she could not remember) She identified for the residents who were totally dependent for eating (10 residents), she fed one at a time in their rooms (either in their bed if they were in bed or in their chair) because it would have been impossible to get all the resident's out of their room by herself. Furthermore, she had no help on the floor from any staff on 6/13/23. She identified she did not tell the charge nurse or DNS that she was the only NA on 6/13/23 because she would expect them to know because they create the staffing schedules. Further interview with NA #1 on 7/27/23 at 10:35 AM identified she had also worked from 3:00 PM - 11:00 PM on the lower level on 7/10/23, along with NA #3. She identified the floor was split between her and NA #3 and she cared for the Residents in rooms 100 - 113 and 130-134 (a total of twenty (25) residents). She identified Residents' #1, #3, #5, #6, #7, #8, 10, #12 and #30, had incontinent care and repositioning twice during that shift. Residents' #9, #11 #28 had incontinent care once during the shift. Residents' # 9 and #11 had one incontinent change because they were in their wheelchairs, and she changed them when they were placed into bed for the night (around 9:00 PM). She identified she did not give any residents showers during her shift as even with two NA's, it is impossible to provide showers. NA #2 identified that although she was aware to give incontinent care every (2) hours this could not be accomplished while caring for 25 residents. Interview with NA #2 on 7/27/23 at 2:40 PM identified she worked from 3:00 PM - 11:00 PM on 6/13/23 on the upper level. She identified sometimes she works as the only NA but the nurse on the floor would help, and they would work as a team. She further identified that she did not have time to assist NA#1 on the lower level and further identified that management does not usually help when needed on the floor because they leave by 5:00 PM. Interview with LPN #1 on 8/7/23 at 12:37 PM identified she was the nurse who worked 3:00 PM - 11:00 PM on 6/13/23 on the lower level. She identified it was just her and NA #1 who were on the floor. She identified she helped feed at dinner time and put 3 or 4 residents to bed after dinner. She identified she did not provide any showers incontinent care or turn and reposition residents. She identified she had to tend to two medication carts. She further identified NA #1 did not tell her there was care that she did not get done. Interview with Person #1 (facilities previous scheduler) on 8/7/23 at 1:21 PM identified her last day was 6/14/23. She identified if the schedule was not meeting the minimum requirements, she would tell HR #1, who trained Person #1. She identified they would have a daily meeting at 1:00 PM to discuss the schedule. She further identified she could not recall the schedule on 6/13/23. Interview with the DNS on 7/27/23 at 1:00 PM identified he was not aware of the schedule on 6/13/23. He identified it could not be accurate and the scheduler confirmed it was. He further identified he was not aware that residents did not receive appropriate care and had he known, he would have checked on the residents. He identified on 7/10/23, NA #3 was moved from the upper-level unit to the lower-level unit to help NA #1. He further identified he does not notify corporate of staffing issues, as he was not told to do so. The DNS stated that residents who are scheduled for shower, should receive showers on their scheduled day, residents who are incontinent and require repositioning should be given incontinent care and repositioned every 2 hours, and there should be two (2) staff assists with Hoyer lift transfers. Interview with the Administrator on 7/20/23 at 11:30 AM identified their goal for staffing NA's is 12 NAs on 7:00 AM - 3:00 PM shift and 9 NAs on 3:00 PM - 11:00 PM shift and if the census is greater than 90 then 11 NAs on 3:00 PM - 11:00 PM shift. She identified they are currently staffing with the staff they have available. She identified the hardest shift to find new staff for is the 3:00 PM - 11:00 PM shift. She identified there are currently five (5) NA students who will be independent upon completion of the class in August. She identified when there are call outs, all staff are reached out to, and the rehab staff is asked to assist on the floor. The facility is active in job fairs and provides bonus'. The administrator further identified that one or two NAs on a unit is not acceptable. After surveyor inquiry, the facility has begun an investigation of neglect regarding the care concerns identified on 6/13/23. The facility submitted a report for Residents' #4, #11, #15 and #29 to the reportable event website on 7/27/23 for investigation of neglect. Although attempted, an interview with RN #1 (RN for 3:00 PM - 11:00 PM on 6/13/23) was not obtained. The facility administrator identified that there was no staffing policy, the facility follows the state public health code. Review of the Administrator job description identified an essential job function to ensure all written policies, procedures and manuals are maintained, updated, and followed. Review of the incontinent care policy directed that incontinent care is performed by nursing staff on all residents following an episode of incontinence, every two hours and as needed. Review of the bathing/shower policy directed that each resident will be offered a full bath/shower at least weekly. Review of the positioning policy directed residents who are unable to turn themselves will be repositioned at least every two hours and/or as needed. Review of the abuse policy identified that neglect means a deprivation of an individual, including a caretaker, of good and services that are necessary to attain or maintain physical mental or psychological well-being.

Based on observation, review of clinical records, facility documentation, facility policies, and interviews for one (1) of four (4) residents, (Resident #1), reviewed for resident-to-resident abuse, the facility failed to ensure that a resident who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in a finding of Immediate Jeopardy on 9/2/22. The facility further failed ensure residents were free from neglect by failing to provide incontinent care to 36 residents on the secured dementia unit in accordance with facility policy. The findings include: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severely impaired cognition, inattention, and disorganized thinking, wandering that occurred daily, was independently ambulatory, and required assistance with activities of daily living. The care plan dated 5/1/21 identified that Resident #1 frequently wandered and could be forgetful and confused with interventions that included a wander guard, and if seen by facility exit doors to re-direct. Review of the facility census identified that the resident resided on the secured dementia unit. Review of nurse's notes during the period of 5/1/21 through 6/23/21 identified that on several occasions the resident was pacing the hallways and entering other resident rooms. a. Review of a reportable event report dated 6/24/21 identified that Resident #1 had wandered into Resident # 3's room and was bitten on the left hand by Resident #3. A nurse's note dated 6/24/21 at 3:30 PM identified that Resident #1's left had was noted with an open bite mark, the APRN was notified, and Resident #1 was started on [MEDICATION(S)] (an antibiotic) prophylactically and was sent to the emergency department for a [CONDITION(S)] shot and a [CONDITION(S)] series. The intervention for the altercation was to place a stop sign on Resident #3's door to prevent Resident #1 from entering. Review of Resident #1's plan of care lacked interventions to address Resident #1's wandering into other's rooms. Review of nurse's notes during the period of 8/1/21 through 9/30/21 identified that on multiple occasions, Resident #1 was wandering the hallways and entering other resident's rooms. b. Review of the reportable event report dated 10/1/21 identified Resident #1 had a resident-to-resident physical altercation due to Resident #1 invading another resident's personal space, and Resident #1 was pushed to the ground by Resident #4, no injuries were identified. The intervention for the altercation on 10/1/21 was to place a stop sign on the doorway of Resident #4's room to prevent Resident #1 from entering. A care plan intervention was added to Resident #1's care plan that directed to keep Resident #1 out of other residents' rooms, however, the care plan lacked direction on how this intervention would be accomplished. c. A reportable event dated 6/13/22 at 11:00 PM identified that Resident #1 had an unwitnessed fall while in another resident's room, the circumstances of the fall were unknown as the resident was unable to state what had happened due to cognitive impairment. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's plan of care failed to reflect any interventions to address the fall or wandering into other's rooms. d. A quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition, disorganized thinking, inattention, poor decision-making skills, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A psychiatric progress note dated 7/1/22 identified Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's intrusiveness had resulted in a resident-to-resident altercation in October of 2021. The note directed to continue to manage Resident #1 on secured dementia unit for patient safety, provide appropriate re-direction to minimize intrusiveness into peer's space, and to minimize the risk of peer-to-peer altercations. The care plan dated 7/2/22 identified Resident #1 had frequently wandered, could be forgetful and confused, with a goal to keep the resident in common areas or in his room. Interventions included to assist the resident in meeting this goal included keeping the resident from entering others rooms. The facility failed to develop specific interventions to effectively monitor the resident to address wandering behaviors. e. A nurse's note dated 7/24/22 at 2:04 PM identified Resident #1 was noted pacing, beginning to move furniture, picking up chairs, carrying them in the hallway, was in and out of other resident rooms and was difficult to redirect. Review of the facility census on 8/8/22 identified that there were 86 residents in the facility. Review of the staffing for 8/8/22 for the 3:00 PM to 11:00 PM shift identified two (2) licensed staff and four (4) Nurse Aides, the staffing on 8/8/22 failed to meet the minimum requirements of the state agency for NA by 8 hours. Review of the reportable event report and facility investigation dated 8/8/22 at 8:00 PM identified that Resident #1 entered Resident #2's room and started to touch Resident #2's belongings. At that time Resident #2 cornered Resident #1 behind the door, repeatedly punched Resident #1 in the head and face, Resident #2 was heard yelling and the nurse entered the room and separated the residents. A nurse's note dated 8/8/22 at 11:50 PM identified Resident #1 wandered into Resident #2's room resulting in a physical altercation between the two residents. Staff removed Resident #1 from the room and Resident #1 was noted with a laceration to his/her her left eyebrow and skin tear to his/her right arm and was sent to the emergency room (ER). On 8/8/22, a stop sign and a motion detector were placed on Resident #2's doorway to deter Resident #1 from entering Resident #2's room, however, there were no interventions added to Resident #1's plan of care to address wandering into other resident's rooms. The hospital discharge summary dated 8/8/22 identified Resident #1 had a 2 centimeter (cm) jagged laceration to his/her left eye that required repair with sutures. Interview with LPN #2 on 8/15/22 at 1:45 PM identified on 8/8/22 around 8:00 PM she was at the nursing desk when she heard a commotion that led her to Resident #2's room. Resident #1 was standing in front of the closet with his/her elbow up to defend him/herself and Resident #2 was in front of him/her punching Resident #1 in the head. LPN #1 got between the two residents and separated them, Resident #1 was brought into the hall and assessed by RN #1. LPN #1 further identified Resident #1 has a history of wandering around the unit and needs re-direction. Interview with NA #1 on 8/15/22 at 2:09 PM identified on 8/8/22 around 8:00 PM she heard LPN #2 yell for help. When she got to Resident #2's room, Resident #1 was already in the hallway with RN #1. She observed Resident #1 was bleeding from his/her eyebrow, mouth, and arm. NA #1 identified that Resident #1 has a history of wandering and walking into other resident's rooms and needed to be re-directed frequently. NA #1 further identified that it was difficult to supervise/re-direct Resident #1 because although she was working with NA#3 on 8/8/22, NA#3 was an orientee and it was her first shift on the dementia unit, and due to her orientee status she did not have her own assignment. NA#1 identified that she was the only NA assigned to care for the 46 residents who resided on the dementia unit. Interview with RN#1 on 8/16/22 at 11:15 AM identified on 8/8/22 around 8:00 PM she heard LPN #2 yelling for help. She responded to see Resident #1 in the hallway with a laceration to his/her right eyebrow and a skin tear to the left elbow, she assessed the injuries and sent the resident to the hospital. She further identified Resident #1 has a history of wandering and does not know what he/she is doing, and with the limited staff on the unit on 8/8/22 it would have been difficult to supervise/re-direct Resident #1. Interview with the facility scheduler on 8/22/22 at 1:00 PM identified that the facility staffing is according to census and the census was 86 on 8/8/22 which would require at least 6 NA, which would mean there would be three (3) NA assigned to the secured dementia unit. The scheduler identified that NA#3 would not have taken an assignment because of her orientation status. The scheduler further identified that although she cannot recall this specific day, if there are not enough staffing in the building to meet the public health code she informs the Administrator and DON. Interview with the Administrator on 9/2/22 at 11:34 AM identified that she would expect to be notified if the staffing does not meet the requirements of the Public Health Code, however she did not recall being notified on 8/8/22. Multiple attempts to interview NA#3 were unsuccessful, and further attempts to interview the DON were also unsuccessful (the DON is no longer employed at the facility). Interview with the Corporate Registered Nurse (CRN) on 9/2/22 at 1:46 PM identified that according to the reportable events Resident #1 has a history of wandering into other rooms with altercations, and after review of the plan of care, the intervention that directed to keep the resident from entering other rooms was unclear and did not identify how this would be done. The CRN further identified that the resident should have had interventions put into place after each altercation to prevent re-occurrence. Further Interview with the CRN on 9/2/22 at 11:00 AM identified that NA#3, although her first day on the dementia unit should have taken an assignment which would have brought the number of NA's to two (2) for 46 residents (23 residents each). The facility abuse policy identified that all residents will be free from abuse. The facility failed to ensure that Resident #1 was free from abuse resulting in a finding of Immediate Jeopardy. On 9/2/22 at 3:00 PM, the Department requested an immediate action plan to address the noncompliance. The facility submitted the following plan: Resident #1 was placed on every thirty (30) minute checks to ensure staff are aware of h/her location, education to staff on the abuse policy, care plan interventions, one-to-one observation, and the need to send residents to the ED if inpatient psychiatric care is not available. The facility will also be conducting audits to ensure close observation is being completed, and review of all resident to resident altercations to ensure interventions are in place. 2. Review of the facility census on 8/8/22 identified that there were 86 residents in the facility. Review of the staffing for 8/8/22 for the 3:00 PM to 11:00 PM shift identified two (4) licensed staff and four (4) Nurse Aides, the staffing on 8/8/22 for the 3:00 PM to 11:00 PM shift failed to meet the minimum requirements of the state agency for NA by 8 hours. There were 2 NA on the secured dementia unit for a total of 46 residents. Review of the resident census and conditions report dated 9/1/22 identified that the secured dementia unit had 36 residents that were occasionally or frequently incontinent of bladder, and 25 of those residents were occasionally or frequently incontinent of bowel. The report further identified that 20 residents were dependent for bathing and nine were dependent for dressing. Interview with NA #1 on 8/15/22 at 2:09 PM identified on 8/8/22 identified that she was the only NA on the unit with an orientee and a hospitality aid. NA #1 stated that she was the only staff on the unit able to do personal care because it was the orientee's (NA#3) first day on the unit, and the Hospitality Aide is not allowed to do personal care. NA#1 identified that she did her best that night, however, although she knew that incontinent residents should be checked for incontinence and changed as necessary every 2 hours, she was only able to give incontinent care once to each of the incontinent residents for the whole shift. Additionally, she identified that she did not have time to wash the residents or change the residents into their night clothes before bed. NA #1 stated that she was responsible for 46 residents that evening and that the supervisor and nurse were already aware, but they had their own jobs to do. NA #1 stated that she could not identify who she had given care to, and who she hadn't because the night was so busy, however she was sure that the incontinent residents only got care one time on her shift, instead of 3-4 times which is the facility policy (every 2 hours). NA#1 further identified that she did not report to the charge nurse or supervisor that she was unable to provide care to the incontinent residents as per facility policy. Interview with RN#1 on 8/16/22 at 11:15 AM identified that on 8/8/22 there were limited staff on the dementia unit, the facility had called everyone available to come in however, they were unable to obtain any more staff for the shift, the DON was aware of the staffing issue. Interview with the facility scheduler on 8/22/22 at 1:00 PM identified that the facility staffing is according to census and the census was 86 on 8/8/22 which would require at least 6 NA, which would mean there would be three (3) NA assigned to the secured dementia unit. The scheduler identified that NA#3 would not have taken an assignment because of her orientation status, leaving the unit with only one NA for 46 residents. The scheduler further identified that although she cannot recall this specific day, if there are not enough staffing in the building to meet the public health code, she informs the Administrator and DON. Attempts to interview NA#3 were unsuccessful. Interview with the DON on 8/15/22 at 2:00 PM identified that she was aware that the staffing on 8/8/22 did not meet the requirements of the state agency, and had called corporate and was told to do a hiring event. Interview with the Administrator on 9/2/22 at 11:34 AM identified that she would expect to be notified if the staffing does not meet the requirements of the state agency, however she did not recall being notified on 8/8/22. Interview with the Corporate Registered Nurse (CRN) on 9/2/22 at 1:46 PM identified that NA#3, although her first day on the dementia unit should have taken an assignment which would have brought the number of NA to two (2) for 46 residents (23 residents each). Review of the facility policy for incontinent care identified that incontinent residents will be checked for incontinence every two hours and changed accordingly. The facility identified that they do not have a staffing policy and follow the requirements of the state agency for staffing.

Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for resident-to-resident abuse (Resident #1), the facility failed to supervise a resident who had a history of wandering and on multiple occasions, was assaulted by other residents for wandering in their rooms and further failed to provide adequate supervision for two (2) residents, (Resident #2 and Resident #6), who were assessed as a danger to others. The lack of supervision resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1 had diagnoses that included dementia with behavioral disturbance, anxiety disorder and [CONDITION(S)]. A quarterly Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, inattention, and disorganized thinking, wandering that occurred daily, was independently ambulatory, and required assistance with activities of daily living. The care plan dated 5/1/21 identified that Resident #1 frequently wandered and could be forgetful and confused with interventions that included a wander guard, and if seen by facility exit doors to re-direct. Review of the facility census identified that the resident resided on the secured dementia unit. Review of nurse's notes during the period of 5/1/21 through 6/23/21 identified that on several occasions the resident was pacing the hallways and entering other resident rooms. a. Review of a reportable event report dated 6/24/21 identified that Resident #1 had wandered into Resident # 3's room and was bitten on the left hand by Resident #3. A nurse's note dated 6/24/12 at 3:30 PM identified that Resident #1's left had was noted with an open bite mark, the APRN was notified, and Resident #1 was started on [MEDICATION(S)] (an antibiotic) prophylactically and was sent to the emergency department for a [CONDITION(S)] shot and a [CONDITION(S)] series. The intervention for the altercation was to place a stop sign on Resident #3's door to prevent Resident #1 from entering. Review of Resident #1's plan of care lacked interventions to address Resident #1's wandering into other's rooms. b. Review of nurse's notes during the period of 8/1/21 through 9/30/21 identified that on multiple occasions, Resident #1 was wandering the hallways and entering other resident's rooms. Review of the reportable event report dated 10/1/21 identified Resident #1 had a resident-to-resident physical altercation due to Resident #1 invading another resident's personal space, and Resident #1 was pushed to the ground by Resident #4, no injuries were identified. The intervention for the altercation on 10/1/21 was to place a stop sign on the doorway of Resident #4's room to prevent Resident #1 from entering. A care plan intervention was added to Resident #1's care plan that directed to keep Resident #1 out of other residents' rooms, however, the care plan lacked direction on how this intervention would be accomplished. c. A reportable event dated 6/13/22 at 11:00 PM identified that Resident #1 had an unwitnessed fall while in another resident's room, the circumstances of the fall were unknown as the resident was unable to state what had happened due to cognitive impairment. The resident sustained skin tears to the right and left arm and treatments were initiated. Review of Resident #1's plan of care failed to reflect any interventions to address the fall or wandering into other's rooms. d. A quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, disorganized thinking, inattention, poor decision-making skills, had a history of falls, wandered daily, and required supervision with ambulation. A psychiatric progress note dated 7/1/22 identified Resident #1 had a history of wandering, intrusive behavior that included wandering into peer's personal space and baseline confusion. Resident #1's intrusiveness had resulted in a resident-to-resident altercation in October of 2021. The note directed to continue to manage Resident #1 on secured dementia unit for patient safety, provide appropriate re-direction to minimize intrusiveness into peer's space, and to minimize the risk of peer-to-peer altercations. The care plan dated 7/2/22 identified Resident #1 had frequently wandered, could be forgetful and confused, with a goal to keep the resident in common areas or in his room. Interventions to assist the resident in meeting this goal included keeping the resident from entering others rooms. The facility failed to develop specific interventions to effectively monitor the resident to address wandering behaviors. e. A nurse's note dated 7/24/22 at 2:04 PM identified Resident #1 was noted pacing, beginning to move furniture, picking up chairs, carrying them in the hallway, was in and out of other resident rooms and was difficult to redirect. Review of the facility census on 8/8/22 identified that there were 86 residents in the facility. Review of the staffing for 8/8/22 for the 3:00 PM to 11:00 PM shift identified two (4) licensed staff and four (4) Nurse Aides, the staffing on 8/8/22 failed to meet the minimum requirements of the state agency for NA by 8 hours. Review of the reportable event report and facility investigation dated 8/8/22 identified that Resident #1 entered Resident #2's room and started to touch Resident #2's belongings, at that time Resident #2 cornered Resident #1 behind the door, repeatedly punched Resident #1 in the head and face, Resident #2 was heard yelling and the nurse entered the room and separated the residents. A nurse's note dated 8/8/22 at 11:50 PM identified Resident #1 wandered into Resident #2's room resulting in a physical altercation between the two residents. Staff removed Resident #1 from the room and Resident #1 was noted with a laceration to his/her her left eyebrow and skin tear to h/her right arm and was sent to the emergency room (ER). On 8/8/22 A stop sign and a motion detector were placed on Resident #2's doorway to deter Resident #1 from entering Resident #2's room, however, there were no interventions added to Resident #1's plan of care to address wandering into other resident's rooms. The hospital discharge summary dated 8/8/22 identified Resident #1 had a 2 centimeter (cm) jagged laceration to his/her left eye that required repair with sutures. Interview with LPN #2 on 8/15/22 at 1:45 PM identified on 8/8/22 around 8:00 PM she was at the nursing desk when she heard a commotion that led her to Resident #2's room. Resident #1 was standing in front of the closet with his/her elbow up to defend him/herself and Resident #2 was in front of him/her punching Resident #1 in the head. LPN #1 got between the two residents and separated them, Resident #1 was brought into the hall and assessed by RN #1. LPN #1 further identified Resident #1 has a history of wandering around the unit and needs re-direction. Interview with NA #1 on 8/15/22 at 2:09 PM identified on 8/8/22 around 8:00 PM she heard LPN #2 yell for help. When she got to Resident #2's room, Resident #1 was already in the hallway with RN #1. She observed Resident #1 was bleeding from his/her eyebrow, mouth, and arm. NA #1 identified that Resident #1 has a history of wandering and walking into other resident's rooms and needed to be re-directed frequently. NA #1 further identified that it was difficult to supervise/re-direct Resident #1 because although she was working with NA#3 on 8/8/22, NA#3 was an orientee and it was her first shift on the dementia unit, and due to her orientee status she did not have her own assignment. NA#1 identified that she was the only NA able to care for the 46 residents who resided on the dementia unit. Interview with RN#1 on 8/16/22 at 11:15 AM identified on 8/8/22 around 8:00 PM she heard LPN #2 yelling for help. She responded to see Resident #1 in the hallway with a laceration to his/her right eyebrow and a skin tear to the left elbow, she assessed the injuries and sent the resident to the hospital. She further identified Resident #1 has a history of wandering and does not know what he/she is doing, and with the limited staff on the unit on 8/8/22 it would have been difficult to supervise/re-direct Resident #1. Interview with the facility scheduler on 8/22/22 at 1:00 PM identified that the facility staffing is according to census and the census was 86 on 8/8/22 which would require at least 6 NA, which would mean there would be three (3) NA assigned to the secured dementia unit. The scheduler identified that NA#3 would not have taken an assignment because of her orientation status. The scheduler further identified that although she cannot recall this specific day, if there are not enough staffing in the building to meet the public health code she informs the Administrator and DON. Interview with the Administrator on 9/2/22 at 11:34 AM identified that she would expect to be notified if the staffing does not meet the requirements of the Public Health Code, however she did not recall being notified on 8/8/22. Multiple attempts to interview NA#3 were unsuccessful, and further attempts to interview the DON were also unsuccessful (the DON is no longer employed at the facility). Interview with the Corporate Registered Nurse (CRN) on 9/2/22 at 1:46 PM identified that according to the reportable events Resident #1 has a history of wandering into other rooms with altercations, and after review of the plan of care, the intervention that directed to keep the resident from entering other rooms was unclear and did not identify how this would be done. The CRN further identified that the resident should have had interventions put into place after each altercation to prevent re-occurrence. Further Interview with the CRN on 9/2/22 at 11:00 AM identified that NA#3, although her first day on the dementia unit should have taken an assignment which would have brought the number of NA to two (2) for 46 residents (23 residents each). f. On 9/2/22 from 9:45 AM until 10:45 AM, Resident #1 was observed to walk by Resident #2's room a total of five times. Observation of Resident #2's room at 10:45 AM with Registered Nurse #1 identified that there was no stop sign on the door in accordance with the plan dated 8/9/22 and the motion detecting mechanism was facing the wall and was unable to detect a person walking into the room rendering this intervention ineffective. Interview with NA#1 on 9/2/22 at 10:52 AM identified that Resident #2 frequently removed the stop sign and disabled the motion detector, and she had told multiple nurses about the non-compliance. Interview with the CRN on 9/2/22 at 2:02 PM identified that if the resident was non-compliant with the motion detector and stop sign the facility should have attempted other interventions and she was unable to identify any further interventions. 2. Resident #2 had a diagnosis of dementia, adjustment disorder, and anxiety. A quarterly MDS dated [DATE] identified that the resident was cognitively intact, was independently ambulatory, and required assistance with ADL's. A care plan dated 6/11/22 identified that the resident could be physically and verbally abusive towards staff members or residents with interventions that included psychiatric consults as needed, and approach slowly and scheduled activities as tolerated. A reportable event dated 8/8/22 at 8:00 PM identified that Resident #2 was involved with an altercation with another resident (Resident #1). Resident #2 assaulted Resident #1 when Resident #1 entered his/her room. Resident #2 was sent to the ED for evaluation. Review of the hospital record dated 8/8/22 identified that the resident was evaluated by psychiatric services and was not a homicide risk and had no psychotic symptoms and would be returning the to the skilled nursing facility that evening. A nurse's note dated 8/9/22 at 4:02 AM identified that the resident arrived back from the hospital and was cleared by a psychiatric clinician at the hospital. An updated plan of care for Resident #2 on 8/8/22 identified that there will be a stop sign placed on the door of Resident #2 to prevent residents from entering his/her room and a motion detector to alert staff that if a resident is entering Resident #2's room. A nurse's note dated 8/17/22 identified that Resident #2 came out of h/her room after being seen by the psychiatrist and stated, there h/she is (referring to Resident #1). Resident #2 was notes to continue to watch Resident #1 until Resident #1 left the facility for an appointment. A psychiatric note written by Advanced Practice Registered Nurse (APRN) #1 dated 8/17/22 identified that Resident #2 struck another resident multiple times after the other resident entered his/her room on 8/8/22. The note further identified that Resident #2 had a history of impulsive behavior and irritability, was sent to the hospital after the incident on 8/8/22 and was cleared by psychiatry, however felt the resident was a danger to others due to impulsive and unpredictable behavior and at this time the resident required a higher level of care. Review of APRN #1's order dated 8/17/22 directed to provide one to one observation. Resident #2's record identified multiple nurse's notes during the period of 8/17/22 and 9/2/22 that identified one-to-one observation could not be done related to having limited staff. Interview with APRN #1 on 9/2/22 at 12:36 PM identified that she had seen Resident #2 on 8/17/22 and noted that Resident #2 was staring at Resident #1 and pointed at Resident #1 stating, that's him/her. APRN #1 felt there could be a repeat incident between the two residents, stated Resident #2 was a danger to others so she ordered one-to-one observation, called her company who makes the arrangements for placement in a higher level of care, then left the facility. APRN #1 stated she was not aware the transfer to a higher level of care did not occur or that staff were unable to monitor Resident #2 as directed. Review of the clinical record failed to identify that Resident #2 was transferred to a higher level of care or placed on one-to-one observation in accordance with the order. 3. Resident #6 had diagnoses that included Alzheimer's dementia. An annual MDS dated [DATE] identified that the resident has severely impaired cognition, inattention, disorganized thinking was independent with ADL's and ambulation. A care plan dated 8/2/22 identified that Resident #6 can be physically and verbally aggressive toward other residents with interventions that included to approach slowly, recreational activities as needed, allow adequate time for responses, and psychiatric follow up as needed. Review of a reportable event report dated 8/7/22 identified that Resident #6 slapped Resident #7 on the arm. A nurse's note dated 8/7/22 at 2:47 PM identified that during mealtime the resident was notably agitated and yelled at staff and then went into his/her room and slammed the door. The resident then yelled at another resident, called him/her a name, and then slapped the other resident on the right arm. The residents were immediately separated, and Resident #6 was sent to the ED and returned to the facility at 11:00 PM. The hospital discharge summary dated 8/7/22 at 9:02 PM identified that the resident was not suicidal or homicidal. Review of the nurse's notes between 8/7/22 through 8/17/22 identified that the resident was verbally aggressive with other residents. A nurse's note on 8/17/22 identified that Resident #6 was observed with increased delusions, had verbally aggressive behaviors and kicked a staff member. A psychiatric progress note written by APRN #1 on 8/17/22 identified that Resident #6 was frequently irritable, verbally aggressive, and recently slapped another resident. APRN #1 identified that Resident #6 was a danger to others given unpredictable aggressive and impulsive behaviors and directed one-to-one observation and a transfer to a higher level of care was recommended. APRN #1 wrote an order dated 8/17/22 that directed to place the resident on one-to-one observation. Review of the clinical record from 8/17/22 through 9/2/22 failed to identify that one-to-one observation was completed, with several entries that identified the facility did not have the staffing to complete one-to-one observation. The clinical record further identified that the resident was not transferred out of the facility. Interview with APRN #1 on 9/2/22 at 2:35 PM identified that she had seen the resident on 8/17/22 and the resident was still aggressive, and felt the resident was [NAME] up, and was a danger to others so she recommended that the resident be placed on one-to-one observation until he/she could be transferred. APRN #1 called the psychiatric company and told the representative that Resident #6 needed placement in an inpatient facility. APRN #1 identified that she was not aware that the one-to-one observation was not completed or that the resident had not been transferred to an inpatient psychiatric facility. She further identified that the facility contacted her on 9/2/22 to assess Resident #6, and she felt like the resident was no longer a danger to others. Interview with the Psychiatric Company Representative on 9/2/22 at 1:11 PM identified that she was notified by APRN #1 on 8/17/22 that Resident #2 and #6 needed placement in an inpatient psychiatric facility because they were a danger to others. The representative stated that she called 2 different inpatient facilities and no beds were available, so she called the Director of Nurses (DON) and informed her that Resident #2 and Resident #6 could not be transferred to a psychiatric inpatient facility. The company representative identified that there was no request for a psychiatrist to complete a Physician's Emergency Certificate (PEC) because there were no beds available for Resident #2 and #6. Multiple attempts to contact the DON were unsuccessful. Interview with the CRN on 9/2/22 at 2:17 PM identified that she was unaware that Resident #2 and #6 had been deemed a danger to others on 8/17/22 until surveyor inquiry on 9/2/22. The CRN identified that she had reviewed the clinical record of Resident #2 and #6 and could not find any documentation that the one-to-one observation had been completed from 8/17/22 through 9/2/22. The CRN further identified the DON should have immediately placed the resident on one-to-one observation, and if the resident could not be placed at a psychiatric facility, the residents should have been sent to the hospital for evaluation. The CRN further identified that if the facility could not complete the one-to-one observation due to staffing issues the DON should have been notified, however was not made aware. Review of facility policy identified that one to one observation is constant visual supervision and monitoring of a resident, and the staff member will remain with the resident. If the resident is deemed a danger to others, one to one observation will be put into place until the resident can be sent to the hospital for evaluation. Review of facility policy identified that one to one observation is constant visual supervision and monitoring of a resident, and the staff member will remain with the resident. If the resident is deemed a danger to others, one to one observation will be put into place until the resident can be sent to the hospital for evaluation. Review of facility documentation identified that on 9/9/22 APRN #1 was educated that if she deems a resident a danger to self or others that she ensures that interventions are in place (such as increased supervision) and to send the resident to an acute care setting if an admission to an in-patient psychiatric facility is not possible. The facility failed to supervise a resident who had a history of wandering and on multiple occasions, was assaulted by other residents for wandering in their rooms, and further failed to provide adequate supervision for two (2) residents, resulting in a finding of Immediate Jeopardy. On 9/2/22 at 3:00 PM, the Department requested an immediate action plan to address the noncompliance. The facility submitted the following plan: Resident #1 was placed on every thirty (30) minute checks to ensure staff are aware of h/her location, education to staff on the abuse policy, care plan interventions, one-to-one observation, and the need to send residents to the ED if inpatient psychiatric care is not available. The facility will also be conducting audits to ensure close observation is being completed, and review of all resident to resident altercations to ensure interventions are in place.

Based on observation, review of the clinical records, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #1 and Resident #2), reviewed for elopement risk, the facility failed to adequately supervise, assess for elopement risk, maintain a secured environment to prevent elopement, and monitor the wander guard for placement and function in accordance with facility policy. As a result, Resident #1 eloped from the secured unit and courtyard and was located approximately one mile away from the facility on the highway. This resulted in a finding of Immediate Jeopardy on 5/26/22, and for one (1) of three (3) residents reviewed for supervision at mealtime (Resident #4), the facility failed to ensure that adequate supervision was provided. Although the facility submitted an action plan to correct the Immediate Jeopardy, during the onsite visit on 6/3/22, Resident #1 was observed to have access to knives, therefore the IJ was determined to not be corrected despite the plan of care. During an on-site visit on 6/7/22 the action plan was verified as implemented and the Immediate Jeopardy was removed as of 6/7/22. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included [CONDITION(S)] and dementia. Resident #1 resided in the facility's secured dementia unit. The admission elopement risk assessment dated [DATE] identified Resident #1 was not at risk for elopement. A Physician note dated 3/8/22 identified Resident #1 had [CONDITION(S)] with underlying dementia and was appointed a conservator as Resident #1 was deemed to lack decisional capacity. The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was independent with transfers and walking, and had a history of wandering that occurred 1-3 days. A psychiatry progress note dated 3/23/22 identified Resident #1 was confused and exit seeking. The elopement risk assessment dated [DATE] identified Resident #1 was at risk for elopement. A care plan dated 3/28/22 identified Resident #1 had chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgement, decision making and thought process related to delusional dementia. Interventions included to give instructions one at a time, gently redirect when inappropriate actions/behaviors are exhibited, introduce yourself and provide reality orientation. a. A nursing note dated 4/11/22 at 1:01 PM identified Resident #1 was observed by a staff member on the lower-level unit (off the locked unit). Resident #1 was redirected and able to get back to the unit safely. Resident #1 was placed on 15-minute checks, wander guard was applied, and the resident was referred to psychiatry for further evaluation. The care plan was updated on 4/11/22 to include that Resident #1 frequently wandered, was at risk for an elopement, was confused and forgetful with interventions that included to apply a wander guard, check the placement each shift, check the function each day, and offer to escort Resident #1 if observed heading towards or lingering near an exit door. Physician's order dated 4/11/22 directed wander guard to left wrist and check placement and functioning every shift. Interview with the Director of Nursing Services (DON) on 5/24/22 at 1:33 PM identified that the resident was able to exit through the secured door of the dementia unit and believed it may have been a family member that allowed the resident off the unit. The DNS stated a wander guard should have been implemented on 3/28/22 when the resident was identified as an elopement risk. Interview with the Director of Maintenance (DM) on 5/23/22 at 2:18 PM identified he found Resident #1 in the stairwell outside of the secured dementia unit on 4/11/22. He identified the locked dementia unit is wander guard equipped and the door would lock if a resident who is wearing a wander guard approaches the door. The Elopement Risk policy identified a care plan will be developed and interventions implemented if the resident is identified to be an elopement risk per the elopement risk evaluation. The policy further identified an activated elopement bracelet (wander guard) will be placed on the resident's wrist or ankle and documented in the treatment administration record (TAR). b. A nursing note written by the DNS dated 5/11/22 at 11:25 AM identified the charge nurse was notified that Resident #1 was no-where to be found on the unit and Resident #1's window in his/her room was open. The note further identified that Resident #1 eloped from the building at an unknown time and at approximately 11:35 AM. a Dr. Hunt (a code used to search for a missing resident) was called overhead. Staff conducted a thorough search inside and outside of the facility, however the resident was not located. The search of Resident #1's room (ground level) identified that the window was found to be open, and screen appeared to have been cut. Maintenance was notified and Resident #1's window was immediately repaired. Review of the reportable event report and facility investigation dated 5/11/22 identified that Resident #1 eloped and was located in an adjacent town about a mile away from a homeless shelter by state police at 12:27 PM, and subsequently transported to emergency room for evaluation. The reportable event summary identified Resident #1 was last seen around 9:30 AM and had eloped sometime between 9:30 AM and 9:45 AM. Resident #1 was observed by a passing motorist in the breakdown lane of a highway at 10:15 AM, a police officer responded to the motorists 911 call and the resident was evaluated by EMS. Resident #1 did not have an ID bracelet on therefore the resident was transported to the homeless shelter by the Police Officer. Resident #1 was observed 1 mile away from the homeless shelter at 12:27 PM and was transported to the ED for evaluation. All windows in resident care areas were assessed, secured measures were placed to prevent inappropriate opening of all windows and the courtyard gate was secured. Resident #1 arrived back to the facility around 7:00 PM with no noted injuries and placed on 1:1 observation and a wander guard was placed on his/her left wrist. Interview with Nurse Aide (NA) #1 on 5/24/22 at 1:05 PM identified that subsequent to the elopement Housekeeper #1 had informed her that earlier that day when Housekeeper #1 was making her rounds, she had noticed Resident #1's screen was broken but did not tell anyone because maintenance was going in and out of the rooms. Housekeeper #1 stated to NA#1 that she had noticed the cut in the screen approximately 45 minutes prior to the facility identifying that the resident was missing. Several attempts were made to interview Housekeeper #1 but were unsuccessful. Interview with the Recreation Director on 5/24/22 at 1:00 PM identified she was bringing a resident back to their room around 11:30 AM and noticed Resident #1's window folded open, and screen ripped. She reported it to the nurse who assessed the screen and window and proceeded to call a Dr. Hunt. Interview with the DNS on 5/24/22 at 10:30 AM identified that on 5/11/22 a landscaping company was at the facility and she noted at approximately 11:35 AM the courtyard gate was open. She identified the courtyard gate has a pin pad code to exit the courtyard and a button that did not require a pin code to enter the courtyard, and the landscapers were able to enter the courtyard independently without facility staff assistance. When the courtyard gait was assessed subsequent to the elopement, it failed to lock once shut. The DNS identified that the day of the elopement the resident opened the window, and cut the screen (with a knife), and left the courtyard area through the open gait, went through the woods and up onto the highway, where a passerby called the police. Interview with Director of Maintenance on 5/23/22 at 2:18 PM identified that the courtyard gate had not been checked for function and security because the courtyard had not been in use due to the pandemic. The DM identified that the courtyard gait was immediately repaired to lock once closed. The facility failed to ensure that the cut screen was immediately reported in a timely manner and that the gait to the courtyard was checked for function (locking capability) on a regular basis. Following the elopement, Resident #1 was immediately placed on one to one observation, a wander guard was reapplied to the resident, all windows in resident care areas were assessed and secured, the outside courtyard gait was secured appropriately, and the resident will not be allowed a knife at meal time, and all elopement assessments and care plans were reviewed to ensure proper interventions were in place. c. Review of physician's orders dated 5/11/22 directed to provide one to one supervision for Resident #1. Review of the one to one resident locator flowsheet documentation from 5/11/22 to 5/18/22 identified the following: i. No documentation of one to one observation for 5/12/22 - 5/14/22 ii. 5/15/22 there was no documentation for one to one observation for 11:30-11:45 PM, 12:15 AM, 12:45 AM, 1:15 AM, 1:45 AM. 2:15 AM, 2:45 AM, 3:15 AM, and 3:45 AM through 6:45 AM iii. 5/16/22 there was no documentation for 1:1 observation for 7:00 AM - 10:45 PM. d. Review of physician's orders dated 5/18/22 directed to discontinue one to one supervision and start every fifteen (15) minute checks. Review of the every fifteen (15) minute check observations identified the following: i. 5/18/22 there was no documentation for 15-minute observations from 3:15 PM - 6:45 AM ii. 5/19/22 there was no documentation for 15-minute observations for the entire day iii. 5/20/22 there was no documentation for 15-minute observations for 3:15 PM - 6:45 AM iv. 5/21/22 there was no documentation for 15-minute observations for 3:15 PM - 6:45 AM v. 5/22/22 there was no documentation for 15-minute observations for 3:15 PM - 6:45 AM vi. 5/24/22 there was no documentation for 15-minute observations for 11:00 AM - 6:45 AM Interview with the DNS on 5/23/22 at 10:00 AM identified one to one observation was discontinued on 5/18/22 and the resident was started on 15-minute checks. The DNS stated these were the only resident locator flowsheets she could find and although she believes staff conducted the observations, if the observations were not documented they weren't done. The close observation policy identified that the resident locator form must be completed with the location of the resident, and the initials of the person completing the checks. The facility failed to ensure that close observations were completed in accordance to facility policy subsequent to an elopement. e. A care plan dated 5/12/22 identified that the resident eloped from the facility on 5/11/22 through the window, with interventions that included not providing a knife at mealtime, staff will cut food as needed and return to the cart after use. On 5/24/22 at 12:30 PM, Resident #1 was observed in his/her room with the lunch tray. A knife was observed wrapped in a napkin on the windowsill. Interview with the DNS on 5/24/22 at 12:35 PM identified the dietary aid handed out Resident #1's lunch plate, not the silverware and thought Resident #1 may have gotten the knife from the utility cart where silverware is stored. She further identified Resident #1's meal ticket lacked the information not to provide knives at mealtime, and she would immediately be updating Resident #1's meal ticket with dietary to reflect no knifes with meals. Interview with the Dietary Director on 5/24/22 at 12:57 PM identified an in-service was held after Resident #1's elopement on 5/11/22 for no knives and that the DNS would have the documentation for that in-service. He further identified Resident #1's meal ticket was updated on 5/24/22 to reflect no he/she should not be provided with knives. A subsequent interview with the DNS on 5/24/22 at 3:15 PM identified that staff were not educated on Resident #1's plan of care for no knives and that the Nurse Aide's should be managing the resident's silverware, not the dietary department. She further identified an in-service will be held on 5/24/22 for all staff so that Resident #1 would not receive knives and only the NA's would manage the silverware. On 5/26/22, IJ was identified for failure to maintain a secured environment resulting in the resident eloping from the locked unit on two occasions. On 5/26/22, the Department requested an action plan to address resident's at risk for elopement and to ensure a safe environment. The plan included that the windows on the dementia unit were secured so they are unable to be opened, the courtyard gait was repaired and secured and will be checked for function weekly, the staff was educated on the elopement policies and reporting irregularities in the environment immediately, windows and doors will be checked daily by maintenance and housekeeping to ensure that they are secure, all residents were checked to ensure name bracelets were in place, and Resident #1 will not have access to knives. Families were educated on not allowing others off the locked unit. Licensed staff will be educated on completing elopement assessments on admission and once a change in condition is identified, and to place an intervention into place to address the elopement risk. The DNS will conduct audits of the last 3 months admissions to ensure the elopement assessments are complete and appropriate interventions are in place, weekly audits will be performed to ensure that wander guard orders are in place and being documented on the TAR and weekly audits to ensure that Resident #1 is not provided with a knife. The facility identified that substantial compliance would be reached by 5/27/22. f. Observation of Resident #1 on 6/3/22 with the DNS at 8:40 AM identified Resident #1 was cutting his/her pancakes with a knife. The DNS then asked permission to look in Resident #1's drawers and found a second knife. The DNS identified that she was not sure how the resident obtained the knife; however, h/she does ambulate independently around the unit and does have access to the meal carts and could have obtained a knife that way. The state agency requested an action plan to address Resident #1 having a knife, the facility's action plan will include room checks after mealtime to ensure no knives are available to the resident. 2. Resident #2 was admitted to the facility on [DATE] with a diagnosis of a urinary tract infection and essential tremors. A minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severely impaired cognition, was independently ambulatory with a walker, and required extensive assistance with Activities of Daily Living ADL's. A nurse's note dated 5/10/22 at 4:37 PM identified that the resident was found in the facilities parking lot and was moved to the secured dementia care unit related to the resident being a high elopement risk. A reportable event report dated 5/10/22 at 3:30 PM identified that the resident was found on the ground in the parking lot by a member of the housekeeping staff. The resident was brought back into the facility and placed on the secured dementia unit with a wander guard. An elopement assessment was completed on 5/11/22 (the day after the elopement, and three days after admission) and the resident was assessed as an elopement risk and a wander guard was applied. a. Review of the clinical record failed to identify that the resident had an elopement risk assessment completed upon admission on 5/8/22. Interview with the receptionist on 5/25/22 at 2:00 PM identified that on 5/10/22 she had seen the resident go out the front door, however, she thought the resident was a visitor because the resident was a new admission, and she was not familiar with the resident. Interview with the Director of Nurses on 5/25/22 at 12:07 PM identified that the elopement assessment should be done upon admission, and given the resident's cognitive status and independent ambulatory status, s/he would have been an elopement risk upon admission and should have been given a wander guard, which would have prevented the resident from exiting the building. Review of the elopement risk assessment policy identified that residents will be evaluated upon admission for elopement risk, and if the resident is at risk for elopement a wander guard bracelet will be applied to the resident. b. Review of the reportable event report dated 5/10/22 identified that after the elopement the wander guard was applied to the resident on 5/10/22. Review of the clinical record from 5/10/22 until 5/23/22 failed to identify that the wander guard was on the Treatment Administration Record (TAR) and was being checked every shift for placement and daily for function. A physician's order dated 5/23/22 directed to check the placement of the wander guard on the left lower extremity every shift and function every shift. Review of the May 2022 TAR failed to identify that the wander guard was being checked for placement and function until 5/23/22 (13 days after it was applied). Interview with the DNS on 5/25/22 at 12:43 PM identified that although the wander guard was applied to the resident on 5/10/22, the physician's order was not written, and although the wander guard should be signed off every shift for placement and once a day for function, she could not identify why it had not been done. The elopement risk policy identified that the placement of the wander guard will be verified every shift and the function will be tested on ce a day and documented on the TAR. The facility failed to monitor a wander guard for a resident who has a history of elopement in accordance with facility policy. During an onsite visit on 6/7/22, the action plan was verified as implemented and the Immediate Jeopardy was removed as of 6/7/22. 3) Resident #4 had a diagnosis of dysphagia. A quarterly Minimum Data Set, dated dated dated [DATE] identified that the resident had significant cognitive impairment, required total care for Activities of Daily Living, required extensive assistance with eating, and received a mechanically altered diet. A care plan dated 3/10/22 identified that the resident was at risk for aspiration due to dysphagia with interventions that included to assist with meals as needed, follow up with Speech Language Pathology (SLP) as needed, and to monitor for signs and symptoms of aspiration. Review of a Fiberoptic Endoscopic Evaluation of Swallowing (FEES) identified that the resident identified that the resident requires a dysphagia level 3 texture, required one to one supervision at meal time with cueing to alternate liquids and solids and take small bites. Review of a Speech Therapy treatment encounter note dated 5/31/22 identified that staff was educated on the importance to adhere to safe swallowing strategies and the staff's role in reducing the risk of aspiration. A physician's order dated 6/1/22 directed to provide the resident with a dysphagia level 3 texture and to assist and cue as needed. Review of an undated Nurse Aide care card identified that the resident required set-up and assist at meal time. Review of a diet slip for lunch time on 6/3/22 identified that the resident required supervision at meal time. Observation of the breakfast meal on 6/3/22 at 9:19 AM identified Resident #4 was seated in h/her wheelchair across from the nurse's station, there were no staff at the nurse's station or in the immediate area. The resident was eating breakfast that consisted of pancakes, syrup, and scrambled eggs. Resident #4 was noted to start coughing excessively, the surveyor summoned Licensed Practical Nurse (LPN) #4 a from down the hall and she provided assistance to the resident. A nursing progress note dated 6/3/22 at 1:05 PM identified that the resident was noted with increased coughing at breakfast, although the resident does tend to cough at mealtime. Nurse Aides (NA) and nursing staff were educated regarding the importance of supervision at meal time in accordance with the plan of care. Interview with the Speech Therapist (ST) on 6/6/22 at 10:01 AM identified that the diet that Resident #4 was provided on 6/3/22 at breakfast was appropriate. The ST stated he was currently treating Resident #4 for dysphagia, and the resident required supervision at meal time to remind the resident to slow down and to alternate liquids and solids. Interview with NA on 6/3/22 at 10:01 AM identified that she was Resident #4's NA and although she knew the resident should have supervision at meal time, there were only two nurse Aides on the floor and she had four (4) residents to feed, so she could not supervise Resident #4. Interview with Licensed Practical Nurse (LPN) #4 on 6/3/22 at 10:15 AM identified that she was the charge nurse for Resident #4, and she could not supervise Resident #4 during mealtime because she was doing the medication pass. Interview with the Director of Nurses on 6/3/22 at 11:05 AM identified that the resident should have supervision with meals, and she was not notified that the staff could not supervise Resident #4. The DNS stated that she would have assigned someone to supervise the resident if she was aware.

Based on observations, clinical record review, facility documentation and staff interviews for one of three sampled residents (Resident #3) reviewed for quality of care, the facility failed to ensure a comprehensive nursing assessment was promptly conducted when a change of condition was reported. The findings include: A review of Resident #3's clinical record on 2/4/21 identified that the resident was admitted to the facility in February 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/7/19 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #3 was cognitively impaired and totally dependent on staff for transfers. On 12/14/20 Resident #3's clinical record identified that the resident had tested positive for COVID-19. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/8/21 the physician further directed that a chest x-ray be performed, and Resident #3 was subsequently diagnosed with pneumonia. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #3 daily in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of nursing progress notes for the period from 1/16/21 at 11:28 AM through 1/25/21 at 10:06 PM indicated that Resident #3's condition was stable. The next nurse's note which was dated 2/2/21 at 1:31 PM as a late entry for 1/26/21 at 5:25 AM identified that on 1/26/21 at approximately 2:00 AM Licensed Practical Nurse (LPN) #2 called Registered Nurse (RN) #5 to report a change in Resident #3's respiratory status. The note failed to identify that a nursing assessment was conducted by a registered nurse after the change in Resident #3's condition was reported and indicated that RN #5 placed the resident's name on a list for follow up later in the day with the physician/ advanced practice registered nurse (MD/APRN). The late entry progress note identified that on 1/26/21 at 5:20 AM RN #5 found the resident without signs of a heartbeat or breathing, and the resident's death was subsequently pronounced. Further review of the clinical record failed to identify that a registered nurse had conducted a nursing assessment at any time during the three-hour period from 2:00 AM to 5:20 AM on 1/26/21 after LPN #2 informed RN #5 of a change in Resident #3's condition and respiratory status at approximately 2:00 AM on 1/26/21. Interview with LPN #2 on 2/5/21 at 7:40 AM indicated s/he checked Resident #3's vital signs at the beginning of the 11:00 PM to 7:00 AM shift on the night of 1/25/21 to 1/26/21 and found the resident's oxygen saturation level to be ninety-five (95) percent with supplemental oxygen at the rate of two (2) liters per minute via nasal cannula. LPN #2 stated that at approximately 2:00 AM on 1/26/21 NA #4 informed him/her that Resident #3 did not look right. LPN #2 further indicated Resident #3 had audible expiratory wheezes, and s/he immediately called RN #5 to report a change in Resident #3's respiratory status. Interview with RN # 5 on 2/5/21 at 9:55 AM identified that s/he received a call from LPN #2 on 1/26/21 at approximately 2:00 AM as well as a second call at approximately 4:00 AM. RN #5 stated that since LPN #2 indicated the resident's vital signs were stable, s/he did not consider the situation urgent and was not aware that death was imminent. RN #5 further indicated that during facility rounds on 1/26/2021 at 5:00 AM, s/he asked LPN #2 to accompany him/her while Resident #3 was assessed. RN #5 stated that s/he found Resident #3 with skin that was waxy, and the resident was without signs of breathing or a pulse. Interview with NA #4 on 2/5/21 at 3:25 PM identified s/he notified LPN #2 of the change in Resident #3's condition during rounds on 1/26/2021 at approximately 2:00 AM and again at 4:00 AM. NA #4 indicated that while making rounds at approximately 5:00 AM, s/he observed that the resident's color was pale and waxy and immediately walked to the hallway to seek nursing assistance. NA #4 stated that when s/he reached the hallway, LPN #2 and RN #5 were nearby and entered Resident #3's room NA #4 further identified that after the resident's death was pronounced, s/he and another nurse aide provided Resident #3 with post-mortem care. Review of the Job Description for a Registered Nurse identified that nursing care responsibilities included assessment and documentation of the resident's condition through observation and reporting of the condition and symptoms to the appropriate medical personnel. The facility failed to ensure a comprehensive nursing assessment was promptly completed when a change in condition was reported, failed to ensure that the changes observed were reported to a Physician/ Advanced Practice Registered Nurse or that the events which occurred were promptly documented in the clinical record.

Based on a clinical record review, staff interviews, and a review of the facility policies one of three sampled residents (Resident #2), who required total staff assistance with bed mobility, the facility failed to assess Resident #2's risk factors for the development of a pressure ulcer, and/or failed to conduct a comprehensive initial wound assessment, and/or failed to implement interventions to prevent pressure ulcers in accordance with the facilities policies and procedures. The findings include: Resident #2's [DIAGNOSES REDACTED]. The braden scale dated 9/6/19 identified Resident #2 was at low risk for the development of pressure ulcers. The Resident Care Plan dated 5/27/20 identified Resident #2 was at risk for skin breakdown related to impaired mobility and incontinence. Interventions included a pressure redistributing mattress (standard mattress). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified long and short term memory problems, severe cognitive impairment for daily decision making, total assistance of 2 staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and had a pressure reducing device for the chair and the bed. A physician's orders [REDACTED]. The nurse's note dated 7/24/20 at 9:08 PM identified breakdown to the left foot, heel and malleolus absent measurements or a comprehensive assessment of the wounds. A physician's orders [REDACTED]. An individualized resident assignment dated 7/24/20 identified Resident #2 had an open area to left foot, heel and malleolus and directed frequent turns, and to float the residents heel as much as possible. A nurse's note dated 7/25/20 at 2:47 PM identified Resident #2 was alert, skin prep was applied to left heel and lateral ankle wounds. The skin was intact with redness and a deep purple center to the left lateral ankle was noted. The resident's heels were red. Shoes were kept off, and heels were elevated. The nurse's note dated 7/30/20 at 12:33 PM identified Resident #2 had new red blanchable area to right heel, and treatment was in place. A physician's orders [REDACTED]. Additional orders included an air mattress to the bed, off loading boots at all times, and check skin integrity every shift. The wound tracking progress note dated 7/31/20 at 2:34 PM identified a new right heel stage 2 pressure ulcer that measured 2.0 centimeter (cm) by 3.5 cm, a left lateral ankle pressure area deep tissue injury (DTI) and left lateral foot pressure area DTI that measured 1.1 cm by 1.5 cm. The nurse's note dated 7/31/20 at 2:44 PM identified Resident #2 was seen by wound physician via face time with a registered nurse and a nurses aide present. The wound care specialist progress note dated 7/31/20 identified Resident #2 was seen as a consultation and evaluation for Resident #2's wounds. The right heel stage 2 pressure injury measured 2.0 cm by 3.5 cm, there was no drainage, granulation, slough, eschar or [MEDICATION NAME] present. The right heel stage 2 pressure ulcer presented as a collapsed intact blister. The left lateral ankle was an acute DTI, persistent non-blanchable deep red, maroon or purple discoloration measuring 1.1 cm by 1.5 cm. A physician's orders [REDACTED]. The right heel stage 2 pressure ulcer was to be cleansed with normal saline, pat dry, apply skin prep once daily for 14 days, the left lateral ankle deep tissue injury was to be cleansed with normal saline, pat dry, apply skin prep once daily for 14 days, and the left heel redness was to be cleansed with normal saline, pat dry, apply skin prep once daily for 14 days. The wound care specialist progress note dated 8/14/20 identified a right heel stage 2 pressure injury measuring 2.5 cm by 3.0 cm by 0.1 cm, there was a moderate amount of serous drainage without an odor, the wound bed had 1 to 25% [MEDICATION NAME] present, no granulation, no slough, no eschar. The left lateral ankle was an acute deep tissue injury (DTI), persistent, non-blanchable deep red, maroon or purple discoloration that had received an outcome of resolved. The left lateral foot DTI, was non-blanchable and deep red, maroon or purple discoloration measuring 1.0 cm by 1.0 cm. and the wound was improving. Interview with NA #1 on 8/18/20 at 4:30 PM identified Resident #2 was able to move his/her feet in the past, however since his/her fall on 7/8/20 Resident #2 did not move by him/herself anymore. NA #1indicated if the staff did not move the residents legs, he/she was not able to move it by him/herself. Interview with PT #1 on 8/18/20 at 4:55 PM identified Resident #2 cannot move his/her lower extremities significantly while in bed and needed assistance from staff to re-position in bed. PT #1 indicated Resident #1 had some movement to his/her lower extremities, however was not cognizant enough to change his/her position. Interview with NA #2 on 8/19/20 at 1:50 PM identified Resident #2 was able to move his/her legs minimally while in bed before the fall on 7/8/20. After the fall in July of 2020 Resident #2 was not able to move his/her legs unless the staff moved them for him/her. NA #2 indicated subsequent to the identification of the wounds Resident #2 had boots while in bed, however prior to that she would put a pillow under his/her legs while in bed. Interview with NA #3 on 8/19/20 at 2:08 PM identified when she walked by Resident #2's room or would feed Resident #2, she did not see his/her legs elevated off the bed. NA #3 indicated she did not see Resident #2's legs offloaded prior to the development of the wounds. NA #3 identified the lack of staffing caused the resident to stay in bed. Interview with RN #1 (Infection Preventionist) on 8/18/20 at 3:25 PM identified Resident #2 could move his/her upper and lower extremities while in bed, however for major body changes he/she needed assistance. RN #1 indicated interventions that were in place to prevent pressure sore development included, a standard pressure relieving mattress, body audits, encouragement of good nutrition and hydration, dietary consultation and the application of a moisturizing lotion however, the facility failed to conduct quarterly braden assessments in January of 2020, May of 2020, and on July 8th of 2020 when the resident had a change in condition to determine the residents skin integrity risk, so that appropriate interventions could be implemented to prevent the development of pressure ulcers. Furthermore, RN #1 indicated she was not trained to conduct wound assessments and waited for the wound care physician (seven days after the wound appeared) for a comprehensive assessment of the wounds with subsequent treatment modalities. Interview with the Director of Nursing (DON) and RN #2 on 8/20/20 at 1:35 PM identified the last braden scale assessment was completed on 9/6/19, and was overdue by seven months. The braden scale should have been completed quarterly, and when the resident experienced a change in condition to determine if he/she was at risk for pressure ulcer development, and was not. The DON also indicated when the resident required staff assistance for bed mobility, the expectation was to communicate the change in condition, conduct a braden skin assessment and develop individualized interventions to prevent pressure ulcer development. Further interview and review of the clinical record with the DON and RN #2 failed to identify Resident #2 was turned and repositioned every two hours. Moreover, the DON indicated the wounds should have be measured and assessed when they were first identified on 7/24/20 in accordance with the facility policy and were not. The facilities wound and skin care protocol directed that all residents would be assessed by the nurse for the risk of skin breakdown, utilizing the braden scale upon admission, readmission, every week for the first 4 weeks, upon a significant change in condition, and quarterly thereafter. The facilities policy further directed that a complete wound assessment would be conducted weekly and documented utilizing the wound tracking record. The interdisciplinary plan of care protocol would address resident problems, goals and interventions directed toward the prevention and/or treatment of [REDACTED]. The care plan would address preventative and treatment interventions for the impairment of skin integrity and pressure ulcers.

Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for 1 of 3 sampled residents (Resident #2) reviewed for accidents, the facility failed to ensure two staff were utilized during a transfer that resulted in an injury. The findings include: Resident #2's diagnoses include dementia without behavioral disturbance, [CONDITION(S)] and hypertension. The individualized resident assignment form dated 7/9/19 identified a risk for falls with interventions which included to utilize the assistance of two staff with all transfers with a [NAME] lift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired, did not ambulate, required extensive assistance of two staff with transfers, bed mobility and toilet use. A physician's order dated 9/3/19 directed to provide the assistance of two staff with transfers via [NAME] lift (sit to stand lift). A Reportable Event (RE) form dated 9/14/19 identified that during a transfer at 3:30 PM, Resident #2 sustained a laceration to the right leg. The report further identified that the resident was assessed by the RN supervisor who applied pressure to the wound and the resident was transferred to the emergency department for an evaluation. A review of the emergency department record identified that the resident was treated on 9/14/19 at 4:03 AM. The documentation identified that the resident's chief complaint was a right lower leg laceration and noted that the resident complained of pain to the lower leg. The documentation further noted that the resident was on a blood thinner for [CONDITION(S)] and the laceration measured 8 centimeters (cm) in length. The documentation further identified that sutures were used to close the laceration. The reportable event summary report dated 09/19/19 identified on 9/14/19 at 3:30 AM, the resident was requesting to go to the bathroom. NA #1 responded to the resident and assisted the resident from the bed to the wheelchair and during the transfer Resident #2 sustained a laceration to the right leg. The summary further identified that the resident was sent to the emergency department and returned from the emergency department with sutures to the wound and the resident's wheelchair was evaluated by physical therapy and padding was applied to the wheelchair. A nurse's note dated 9/14/19 identified that Resident #2 returned to the facility around 9:00 AM with a dressing to the right leg that was noted as intact and clean with no signs or symptoms of bleeding and no complaints of pain. A nurse's note dated 9/19/19 at 3:48 PM identified that the right leg had 9 sutures. Review of facility documentation identified a written statement by NA #1 dated 9/16/19, that noted that she was covering the unit and was the only nurse aide on the unit at the time. She further identified that she was not familiar with Resident #2's plan of care. NA #1's written statement further identified that LPN#1 approached her and informed her that Resident #2 was yelling and instructed NA #1 to get the resident up. The statement further identified that NA#1 went into Resident #2's room and the resident indicated that he/she needed to use the bathroom. NA#1 identified that she called out for help and no one came to assist her. The resident indicated that he/she could not wait any longer and NA#1 noted that she transferred the resident from the bed to the wheelchair without the benefit of using the [NAME] lift or having the assistance of a second staff person. NA #1's statement further identified that once the resident was transferred into the wheelchair, she noticed blood on the floor and a cut on the resident's right leg. LPN#1 and the nursing supervisor were notified immediately. Attempts to interview NA #1 and the nursing supervisor were unsuccessful. Interview with LPN#1 on 1/22/20 at 1:25 PM indicated that NA#1 went into the resident's room on 9/14/19 at 3:30AM because the resident was yelling. She indicated that NA#1 did not call for help at any time prior to the transfer. She indicated that NA#1 transferred the resident alone and did not follow the resident's care card. She further indicated that the [NAME] lift was not used to transfer the resident. Observation with the Director of Nursing (DNS) on 1/23/20 at 11:00 AM of Resident #2, identified the resident seated in a standard wheelchair during a recreational activity. The wheelchair did not have the leg rests in place and Velcro padding was noted around the metal hinges where the leg rests would attach to the wheelchair. The Velcro padding was removed and there were no sharp edges observed. Interview with the Director of Nursing (DNS) on 1/23/20 at 11:00 AM identified that she thought NA #1 was rushing because Resident #2 is impulsive and attempts to get up on his/her own. She identified that she felt that NA #1 transferred her alone because she did not want the resident to fall. She further identified that Resident #2 required the use of the [NAME] lift and the assistance of two staff for transfers. The DNS identified that NA #1's rushing and lack of utilization of the [NAME] lift caused the resident to sustain the laceration to the left lower leg during the transfer. She further identified that she felt that the resident had injured her leg on the wheelchair and that was the reason she had physical therapy evaluate the chair and apply the Velcro padding to the hinges. Review of the facility's mechanical lift policy directed that two staff members are to perform this procedure to lift and transfer a resident safely. Further review of the facility's fall policy directed that residents who are at risk for falls shall have a care plan that addresses interdisciplinary measures to prevent falls and any environmental/equipment recommendations to prevent injuries. The facility failed to ensure two staff were utilized during a transfer that resulted in an injury which required the resident to be transported to the hospital where he/she received 9 sutures for his/her injury.

Based on clinical record review, facility documentation, policy review, and interviews for one of three residents reviewed for mistreatment, (Resident #1), the facility failed to ensure that the resident's rights were considered when the resident requested that care be stopped. The findings include: Resident #1 had [DIAGNOSES REDACTED]. Review of a care plan dated 8/26/19 identified that the resident was incontinent and required the assistance of staff for incontinence management with interventions to provide assistance with toileting, to check for incontinence and provide incontinent care as needed. A 5 day minimum (MDS) data set [DATE] identified that the resident had moderately impaired cognition, had no mood indicators, required extensive assistance with activities of daily living and was occasionally incontinent of bowel and bladder. Review of a behavioral health progress note written by Psychologist #1 dated 10/10/19 identified that the resident was oriented to person, place, time and situation and had appropriate thought content. Review of a reportable event and investigation dated 10/10/19 identified that Resident #1 reported that a staff member touched him/her inappropriately during personal care. The investigation identified that the resident alleged that the NA had inserted her finger into his/her rectum, and when asked to stop, the NA continued. Review of the investigation identified a statement obtained from Resident #1 on 10/10/19 that identified that the NA had inserted his/her finger up his/her rectum, he/she told the NA to get her finger out of his/her rectum, but the NA continued to cleaned the resident up and left the room. Interview with Resident #1 on 11/7/19 at 9:30 AM identified through tears, that about 3 weeks ago Nurse Aide (NA) #1 stuck her finger up my butt and twisted it around. Resident #1 stated that he/she was turned on his/her side while care was being provided and said to the NA what the hell are you doing, get your finger out of my rectum and told NA #1 to stop, but NA#1 continued with the circular motion in the rectum, despite his/her request for the NA to stop. Resident #1 stated that he/she was unable to physically stop NA #1 because of paralysis on his/her left side. Resident #1 stated that the NA did not respond to the request to stop. Resident #1 stated that he/she felt violated and was upset and cried for days after the incident. Interview with NA #1 on 11/7/19 at 10:55 AM identified that Resident #1 was ringing for assistance, and needed the bed pan. She stated that hospitality Aide (HA) #1 was in the room at the time, emptying the trash and removing the soiled linen. NA #1 stated that while removing the resident's brief, she noted that it was wet, so she cleaned him/her. NA#1 stated that at no time did she insert her finger into Resident #1's rectum, and further identified that the resident never complained of pain and/or asked her to stop care. Interview with Hospitality Aide #1 on 11/7/19 identified that he was in the room while the NA was providing care, and NA #1 appeared to be cleaning the resident's backside when the resident started to cry and stated don't do that, it hurts. He stated that the NA responded, I'm not hurting you, I'm cleaning you, and continued to provide care, although the resident requested that she stop. Interview with Psychologist #1 on 11/6/19 at 11:15 AM identified that she had weekly visits with Resident #1, and although the minimum (MDS) data set [DATE] identified moderate cognitive impairment, the resident's cognitive status had improved, and at the time of the incident she considered the resident to be cognitively intact. She stated that although she had complaints about care in the past, she had never exhibited any type of accusatory behaviors. She further identified that she had visited the resident on 10/10/19 subsequent to the incident and the resident was very upset, distressed, and tearful about the incident. Interview with the Director of Nurses (DON) on 11/7/19 at 2:00 PM identified that the facility did not substantiate that NA#1 had inserted his/her finger into Resident #1's rectum because HA #1 did not hear the resident say get your finger out of my rectum, but the facility was able to substantiate that Resident #1 had asked NA#1 to stop care, and NA #1 continued with care despite the residents request to stop. The DON stated that NA#1 was terminated. Review of the resident's rights policy identified that the resident has the right to refuse, and to be treated with consideration, respect, and with full recognition of the resident's dignity and individuality.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for 1 of 2 sampled residents reviewed for falls (Resident #107), the facility failed to ensure two staff were utilized during a transfer that resulted in an injury, and/or for 1 resident reviewed for smoking (Resident #53), the facility failed to properly complete a quarterly and/or yearly smoking assessment per facility policy and/or for 1 of 1 sampled resident with behaviors of opening the medication cart (Resident #409), the facility failed to ensure medication was secured. The findings include: 1. Resident #107's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #107 was without cognitive impairment and required the extensive assistance of two staff with transfers. a. The Resident Care Plan (RCP) dated 10/15/18 identified a risk for falls with interventions that included to utilize the assistance of two staff with all transfers. A physician's orders [REDACTED]. The Reportable Event (RE) form dated 12/27/18 at 9:45 PM identified Resident #107 was lying on the floor at the bedside and was assessed prior to being assisted off the floor with assist of two staff and a gait belt. The fall scene investigation (FSI) dated 12/27/18 identified that the root cause of Resident #107's fall was that Resident #107 required the assistance of two staff, only one staff transferred the resident, and that the facility had failed to update the Nurse Aide (NA) care card to reflect the need for two staff for transfers. A new intervention to update the NA care card was implemented. The nurse's note dated 12/27/18 at 10:58 PM identified that Resident #107 was lying on the floor at the bedside. The NA stated he/she helped the resident to the floor during the transfer. The resident stated I bumped my head on the bed but not hard, denies pain of discomfort with range of motion. b. A physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #107 was cognitively intact and required extensive assistance of two for bed mobility, transfers, dressing, toilet use and personal hygiene. The Resident Care Plan (RCP) dated 4/8/19 identified a risk for falls with interventions that included to provide the assistance of two staff with transfers. A Reportable Event form dated 4/12/19 at 9:00 PM identified that Resident #107 lost his/her balance during a transfer from the wheelchair to the bed using a pivot disc. The facility investigation dated 4/12/19 identified that Resident #107 was not assisted with two staff. Additionally, disciplinary action was issued to the Nurse Aide (NA). The care plan was updated on 4/12/19 to include that staff was reminded of the need for the assistance of two staff with transfers for Resident #107. The nurse's note dated 4/12/19 at 9:56 PM identified the resident was being transferred from the wheelchair to the bed with the assistance of one staff and a pivot board when the resident fell to the floor landing on his/her buttocks. The NA and Resident #107 both lost their balance. There were no marks present, Resident #107 denied pain and range of motion was at baseline. c. The Resident Care Plan (RCP) dated 7/1/19 identified a risk for falls with interventions that included to provide the assistance of two staff with transfers and remind the staff of the need for the assistance of two staff with transfers. A physician's orders [REDACTED]. The Reportable Event form dated 7/2/19 at 7:15 AM identified that NA #4 transferred Resident #107 from the bed to the wheelchair, the resident became weak, and was assisted to the floor. Facility investigation identified that Resident #107 was alert and oriented and that NA #4 was not using a gait belt, was not using an orbit turner, and was transferring Resident #107 independently, without the assistance of a second NA. Additionally, NA #4 did not transfer Resident #107 per the care plan, per the care card and/or per the physician's orders [REDACTED].>The nurse's note dated 7/2/19 at 11:19 AM identified the resident had a witnessed fall during a transfer. Resident #107 reported pain with the movement of his/her left upper extremity. Resident #107 was lowered to the floor during transfer from the bed to the chair. Resident #107 complained of left shoulder pain radiating down the left arm at an intensity pain level of 10 where 10/10 was the worst pain and he/she was moaning and grimacing. Resident #107 was transferred to the Emergency Department for evaluation. Nurse's notes dated 7/2/19 at 5:07 PM identified Resident #107 returned from the hospital with the left arm in a sling and a [DIAGNOSES REDACTED]. Interview with Resident #107 on 7/22/19 at 10:58 AM identified that about a month ago there were supposed to be two staff helping with his/her transfer, there was only one and the chair went back. He/she wasn't sure if the brake was off but the wheelchair rolled back. Additionally, Resident #107 stated that when he/she was on the floor, the Supervisor came over, went in back of him/her, grabbed his/her arm and pulled. That was when Resident #107 identified that he/she heard a snap and said my arm, my arm. Resident #107 identified that the Supervisor was trying to lift him/her up. Resident #107 identified that he/she could not see the Supervisor and was not sure who the staff member was. Interview and review of facility documentation with Registered Nurse (RN) #2 on 7/24/19 at 1:08 PM identified that he/she had worked the prior 11:00 PM to 7:00 AM shift on 7/2/19 and was giving report to the on-coming 7:00 AM to 3:00 PM shift Licensed Practical Nurse (LPN) #7, when NA #4 reported that Resident #107 was on the floor. On arrival, Resident #107 was noted to be on the door side of the bed, facing the headboard wall, leaning back at a 45 degree angle, holding onto the left side rail with his/her right arm across his/her body with the left side of his/her body pressed against the bed frame and mattress. RN #2 identified that Resident #107 initially denied pain. RN #2 identified that he/she was kneeling behind Resident #107 and was trying to slip his/her hand under the resident's armpit edging him/her away from the bed. RN #2 identified that he/she could not lay Resident #107 down because he/she would have hit his/her head, could have moved the bed, but wanted to support Resident #107. RN #2 identified that he/she was not sure if the resident broke his/her arm on the fall and/or if when the pressure was relieved the bone displaced. Interview and review of facility documentation with LPN #7 on 7/24/19 at 2:34 PM identified that after being told Resident #107 was on the floor, he/she and RN #2 went to assess the resident. LPN #7 identified that he/she had been looking at Resident #107's legs when he/she had heard a pop noise. LPN #7 identified that Resident #107 was uncomfortable prior to the pop noise. Interview and review of facility documentation with NA #4 on 7/25/19 at 11:20 AM identified that there was supposed to be five NA's on the upper level but there were only four at the time Resident #107 fell . He/she was the only NA assigned to the entire hall of 32 residents on the 7:00 AM to 3:00 PM shift and had transferred Resident #107 alone without the benefit of the orbit turner. Additionally, NA #4 identified when Resident #107 was placed in the wheelchair, the wheelchair slipped out and he/she had lowered Resident #107 to the floor. NA #4 identified that he/she had not looked at the care card, was not aware that Resident #107 required the assistance of two NA's to transfer, had not used a gait belt and was not aware that Resident #107 required the orbit turner to transfer from the bed to the wheelchair. NA #4 identified that he/she could not recall what position Resident #107 was in when he/she returned from reporting the fall to the nurses but identified that Resident #107 was on his/her back with a pillow under his/her head when both RN #2 and LPN #7 attempted to pull Resident #107 up from his/her arms. NA #4 identified that was when a pop noise was heard. On demonstration with the surveyor, NA #4 identified that he/she had swung Resident #107's legs over so that his/her feet and part of the calves were off the bed. NA #4 then demonstrated that he/she had hooked his/her left arm under Resident #107's left arm (the affected side) and pulled Resident #107 to a sitting position on the bed. NA #4 identified that he/she then swung Resident #107, still holding the left affected arm and the back of the resident's clothing into the wheelchair. NA #4 was unsure if the wheelchair brake gave way or if he/she had hit the brake with his/her leg when the chair started to roll away. While trying to boost Resident #107 back in the chair, NA #4 identified that he/she lowered the resident to the floor. Interview and review of facility documentation with the DNS on 7/25/19 at 9:21 AM identified that the facility determined Resident #107 was difficult to move because of his/her position close to the bed. RN #2 was closest to the bed on the resident's affected left and weakened side, and because he/she was so close to the bed and leaning at a 45 degree angle, RN #2 felt the need to move the resident to get to a safer position. When RN #2 gently moved Resident #107, a pop was heard RN #2 and just let him/her go and called 911. Interview and review of facility documentation with MD #1 on 7/25/19 at 10:00 AM identified that per the X-ray report Resident #107 had a displaced [MEDICATION NAME] humeral neck fracture. The shaft fragment was anteriorly located relative to the humeral head. Humeral head remains located relative to the glenoid. The details of the resident's fall as discussed with the DNS were reviewed; the resident was transferred using the assistance of one NA landing on the left side with the resident's body against the bed and when a range of motion was performed by the RN#2 a pop was heard. MD #1 identified that pops and cracks that are heard, are usually the result of tendons and the noise may have been from an air bubble in the joint fluid. MD #1 identified that the fracture, most likely, resulted from the fall. Review of facility Gait Belt Policy identified the use of gait belts is mandatory for transferring or ambulating a resident. 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53's cognition could not be determined, was always continent of bowel and bladder and was independent with activities of daily living. The Resident Care Plan dated 6/17/19 identified a problem with smoking with interventions to complete a quarterly smoking assessment, do not allow smoking materials on person, and escort Resident #53 out to the smoking area. Resident #53 individualized resident assignment identified Resident liked to smoke, must go with staff and wear an apron, staff must light cigarette for resident and should stay with resident and bring lighter back to nurse. A Smoking assessment dated [DATE] identified was a current smoker, resident did not have a potential to violate the smoking policy, and could not demonstrate the ability to light and smoke a cigarette, but did have safe technique for putting out lighter, hold a cigarette, and verbalize understanding of smoking in designated areas Observations on 7/23/19 at 9:45 AM identified Resident #53 was brought to the designated smoking area, wore an apron, and was supervised smoking per the 12/4/18 smoking assessment. Interview and review of the smoking assessments with the DNS on 7/25/19 at 1:12pm failed to identify that a quarterly smoking assessment had been completed since 12/4/18. Additionally, the DNS identified that it is the nurses responsibility to complete the smoking assessment and that the MDS coordinator may also complete the assessment. DNS further identified that he/she does not know the reason a quarterly smoking assessment was not completed per policy. Review of facility smoking policy identified a smoking assessment was to be completed annually, quarterly, and with a significant change in condition. 3. Resident #409's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #409 was severely cognitively impaired, had delusions and physical/verbal behaviors directed to others and walked unassisted with supervision in the corridor. A nurse's note dated 6/19/19 at 12:40 PM identified Resident #409 attempted to remove anything appealing to him/her from the nurse's cart and was continually in search of vanilla milkshakes. A nurse's note dated 6/20/19 at 10:31 PM identified Resident #409 attempted to snatch medication off the nurse's medication cart. The Resident Care Plan (RCP) dated 7/21/19 identified Resident #409 likes to try to open medication cart. Interventions included to modify the enviornment to prevent situations that trigger inappropriate behaviors, to provide consistent caregivers, and to gently redirect Resident #409 when inappropriate behaviors are exhibited. Observation on 7/22/19 at 10:45 AM on the Gardenview unit identified Registered Nurse (RN) #4 at a medication cart preparing medications for administration while Licensed Practical Nurse (LPN) #4 prepared transfer paperwork for another resident (Resident #46). RN #4 left the medication cart unattended, approached the nurse's station and reviewed Resident #46's paperwork with LPN #4. Additionally, Resident #409 was heard approaching the unattended medication cart, make the statement this is a milkshake, I can take it. Resident #409 was then observed to pick up a cup from the unattended medication cart (the cup contained a white liquid), walk away from the medication cart towards the dining room carrying the cup of white liquid. Further observation identified a medication cup that contained 2 pills was on top of the unattended medication with an unidentified resident seated alongside the medication cart. This surveyor immediately notified RN #4 who was reviewing paperwork facing away from the medication cart that Resident #409 had taken a cup with white liquid from. RN #4 identified that he/she was not concerned with Resident #409 taking a cup with white liquid because it was milkshake and did not contain medication (although there was a cup with 2 pills located on top of the medication cart when Resident #409 was at the unattended cart). Interview on 7/22/19 at that time with RN #4 identified he/she had left the medication cart unattended because he/she was helping LPN #4 with paperwork. A review of the medication administration policy identified facility staff should not leave medications unattended.

Based on clinical record review, review of facility documentation, and interviews for three of six sampled residents reviewed for accidents (Resident #55, #86, and #419) the facility failed to obtain a physician's orders [REDACTED]. potential hazards was locked. The findings include: 1. Resident #55's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #55 had no memory or cognitive deficits, required extensive two (2) person assistance with moving to and from a lying position and turning side to side while in bed, personal hygiene, required one (1) person assistance with dressing, had limitations in range of motion in both upper and lower extremities, had the presence of pain frequently and received a scheduled and as needed medication for pain, the resident's skin was intact with no open areas, and the resident received physical and occupational therapies. The Resident Care Plan, which was originally created on 2/12/16, identified an alteration in comfort related to acerbation of the multiple scleroses and [MEDICAL CONDITION] diagnoses. Interventions directed to administer the [MEDICATION NAME] as ordered and assess the effectiveness of the medication, administer the as needed medication for break-through pain and investigate other therapeutic modalities as ordered to decrease pain sensations such as E-Stim, massage, ice packs, and/or heat. The occupation therapy treatment note dated 4/7/18 identified Resident #55 had received passive range of motion to the upper extremities followed by an application of moist heat. The nurse's note dated 4/7/18 at 10:48 PM identified Resident #55 was noted to have a 8 centimeter (cm) by 6 cm fluid filled blister on the top of the right shoulder with a 15.5 cm by 9 cm rash on the right shoulder and a 6.5 cm by 6 cm red rash on the left shoulder. The note indicated both areas were blotchy and blanchable, the Nursing Supervisor was notified and [MEDICATION NAME] was given at 10:45 PM. The Nursing Supervisor's assessment identified a 5 cm by 7 cm intact clear fluid filled blister with redness on the right shoulder, a 6 cm by 9 cm red area on the left shoulder and the resident denied pain or discomfort. The note identified Resident #55 was unaware of any specific incident which may have caused the areas but questioned the possibility of the areas being from a moist heat pack applied by physical therapy. The nurse's note dated 4/9/18 at 11:42 AM identified Resident #55 had multiple areas of large fluid filled blisters on both the right and left shoulder, the surrounding skin was red and the areas were now oozing serous fluid. The note indicated the resident had poor sensation in the shoulders due to multiple scleroses and the Wound Nurse assessed the areas. The Reportable Event Form dated 4/7/18 at 11:30 PM identified Resident #55 was noted to have a 8 centimeter (cm) by 6 cm fluid filled blister on the top of the right shoulder with a 15.5 cm by 9 cm rash on the right shoulder and a 6.5 cm by 6 cm red rash on the left shoulder and an investigation was initiated to determine the cause of the blisters. The investigation identified moist heat packs had been applied to Resident #55's shoulders with the use of [MEDICATION NAME] packs and the resident was identified at risk for skin injury related to sensory impairment and two central nervous system disorders. In a statement written the Occupational Therapist (OT) #1, who applied the moist heat to the resident's shoulders, identified that during the treatment the [MEDICATION NAME] pack placed on the resident's shoulders was covered with a [MEDICATION NAME] cover and a large towel folded in three layers on top of the resident's shirt for a total of 3 towel layers between the [MEDICATION NAME] pad and the resident. The therapist indicated the resident's skin was checked during the treatment process and the resident had no complaints of discomfort at the time of the treatment. The wound consult progress note dated 4/10/18 identified an acute second degree burn to the right shoulder that measured 8 cm by 16 cm and an acute second degree burn to the left shoulder that measured 3.5 cm by 1.8 cm and both serous blisters were intact. The plan directed to cleanse the wounds, apply Xeroform, then a clean dry dressing and to change daily and as needed. A recommendation was to discontinue all heating elements. Interview and review of the clinical record and facility documentation with the Director of Rehab on 5/23/18 at 11:00 AM identified Resident #55 did not have a physician's orders [REDACTED]. Review of the facility's policy failed to direct staff to obtain physician's orders [REDACTED]. [REDACTED]. Upon further review, the policy identified the appropriate towel layering between the [MEDICATION NAME] cover and the resident should be six (6) to eight (8) towel layers. The Director of Rehab indicated a resident with significant risks, eight (8) layers should be used. 2. Resident #86 ' s [DIAGNOSES REDACTED]. a. The annual MDS assessment dated [DATE] identified Resident #86 as severely cognitively impaired and required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. The Resident Care Plan (RCP) dated 10/23/17 identified a fall risk, fell from wheelchair. Interventions included to provide a self release seat belt for positioning. Interview with the DNS on 5/23/18 at 12:53 PM identified that although a new intervention was identified on the interdisciplinary fall assessment for the use of a self release seat belt, the facility never assessed the resident for the use of a seat belt and/or implemented a self release seat belt use. b. The quarterly MDS assessment dated [DATE] identified Resident #86 as severely cognitively impaired and required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. The Resident Care Plan (RCP) dated 5/16/18 identified a fall risk. Interventions included to provide perimeter mattress, encourage to common areas when out of bed, and dycem to wheelchair. Interview and observation of Resident #86 on 5/22/18 at 12:30 PM with PT #1 and PTA #1 identified that the resident was leaning to the left and that a bolster might assist the resident to maintain a more upright position. PT #1 and PTA #1 then stood the resident and it was noted that the resident did not have dycem in the Broda chair per the fall care plan. Interview and review of facility documentation with the DNS on 5/22/18 at 3:00 PM identified the resident should have had a dycem in his/her Broda chair according to the care plan. 3. Resident #419's [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified Resident #419 had poor decision making skills regarding tasks of daily life, required extensive two (2) person assistance with turning side to side while in bed and transfers in and/or out of the bed and chair, was non-ambulatory, received a scheduled pain medication, had a chronic disease that may result in life expectancy of less than six (6) months and no recent history of falls. The Resident Care Plan dated 6/26/17 identified the resident was at risk for falls related to weakness, and impaired cognition and mobility. Interventions directed to check on the resident every two (2) hours when not in plain sight, an alarm when in the wheelchair, and to ensure the bed was in the lowest position when not delivering care. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) identified the use of floor mats at the bedside, while in bed. The Reportable Event Form identified on 8/8/17 at 8:45 PM Resident #419 was found on the floor at the bedside. An assessment identified a bruise on the right knee and a one centimeter skin tear on the right elbow. The investigation of the incident identified Resident #419 rolled out of the bed, the resident's bed was not in the lowest position at the time and the TAR for that day failed to reflect documentation the floor mats were in place at the time of the fall. The Reportable Event Form identified on 8/10/17 at 2:20 AM a second incident the resident was found on the floor, at the bedside and no injuries were noted. The investigation of the incident identified Resident #419 was restless and confused and the TAR for that day failed to reflect documentation the floor mats were in place at the time of the fall. Interview and review of the clinical record and facility documentation with the Director of Nursing (DON) on 5/23/18 at 10:00 AM identified the resident required the use of floor mats and the bed in the lowest position to prevent an injury when the resident had a fall from the bed. 4. Observation and interview with RN#4 on 5/20/18 at 9:20 AM identified an unlocked treatment cart on the second floor. The top drawer of the cart contained 7 razors, a pair of bandage scissors, and multiple topical medications including [MEDICATION NAME], and [MEDICATION NAME]. Interview with RN#4 identified he/she was assigned to that treatment cart and it should be locked, but he/she did not know it was unlocked because he/she had not used it yet.

Based on observations, clinical record reviews, review of facility documentation, review of facility policy, and interviews for two of four sampled residents reviewed for accidents, (R#114 and R#140), the facility failed to provide the appropriate level of supervision on a locked dementia unit to prevent incidents/accidents. The findings include: 1. Resident #114's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident # 114 had long and short term memory impairment, exhibited behavioral symptoms one to three days per week such as hitting or scratching self, pacing, and rummaging, and required supervision with transfers, locomotion and ambulation. The Resident Behavioral Care Plan (RCP) dated 3/28/17 identified hoarding and rummaging behaviors due to cognitive impairment. Interventions included to be aware of hoarding/rummaging triggers, offer distraction and redirect from rummaging behavior as tolerated. Review of the 1/24/17 Resident Council Minutes identified that the Resident's would like the nurses not to leave the pills without telling them they are there. a. A review of the Reportable Event dated 3/16/17 at 10:30 AM identified that an empty bottle of Robitussin DM (cough syrup) was found in the resident's possession. The disposition identified that Poison Control recommended to have the resident observed at the Emergency Department for an adverse reaction. Review of the Nurse's note dated 3/16/16 at 11:16 PM identified that the resident had admitted to taking half the bottle of Robitussin. A physician's orders [REDACTED]. An On the Job training provided to staff after the incident included to always close the lid on the trash can on the medication cart and dispose of empty medication bottles in the trash in the medication room. b. A review of the Reportable Event dated 5/9/17 at 6 AM identified that the NA found an empty bottle of Tussin (cough syrup) and half a bottle of liquid iron supplement in the resident's night stand drawer. An investigation identified that the bottles were open. Review of the Nurse's note dated 5/9/17 at 7 AM identified an empty bottle of Tussin and half full bottle of liquid iron supplement found in the resident's side table drawer this morning. Emergency Medical Services was notified and resident sent to the Emergency Department. A review of the facility documentation and interview with the DNS on 5/9/17 at 10:30 AM identified that he/she was not here for the 3/16/17 incident but that the investigation was not thorough. For the incident that occurred on 5/9/17 he/she was not sure how the resident obtained the bottles of medication but that the investigation identified all staff stated the medications were locked up and that all bottles of medication were thrown away appropriately. The DNS identified that no increased supervision was given to the resident following the first incident. The DNS identified that the medications were both brands ordered by, and used by the facility. Interview with RN#3 on 5/11/17 at 12:50 PM identified that he/she was notified that the resident was in possession of two bottles of medication, s/he assessed the resident, called Poison Control and was told to send the resident to the Emergency Department. Re-interview with the DNS on 5/11/17 at 1:15 PM identified that although the resident is on a locked dementia unit, there is no program or criteria for admission to the locked dementia unit. It was the DNS understanding that the only criteria required was a [DIAGNOSES REDACTED]. 2. Resident #140's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified that the resident had moderate cognitive impairment with short and long term memory problems, required extensive assistance with transfers and toileting, and limited assistance with bed mobility and ambulation. The assessment further identified that the resident had fallen in the past month and sustained a fracture as a result of falling prior to admission to the facility. A fall risk assessment dated [DATE] identified the resident was at risk of falling with a score of 17 (A score of 16 or more indicates a risk of falling). The care plan dated 9/13/16 identified the resident was at risk for falling due to weakness, impaired mobility, pain and being in a new environment. The interventions included; keep frequently needed items in reach when in the bed, keep call light in reach, keep pathway to the bathroom clear at all times, refer to therapy as needed for changes in mobility and remind and encourage resident as needed to use call light to summon assistance. physician's orders [REDACTED]. physician's orders [REDACTED]. Review of Reportable Event forms and investigations and the clinical record identified that the resident sustained [REDACTED]. A review of the falls identified the following: 1. On 11/8/16 at 4:30 PM, the resident was found on the floor in his/her room and the alarm did not sound due to the string to the alarm being too long. 2. On 11/11/16 at 2:00 PM, the resident fell from his/her wheelchair in the corridor near the nurses' station. The investigation determined that the resident had removed his/her alarm. 3. On 11/14/16 at 12:30 PM, the resident fell in his/her room (the resident's spouse was present). The investigation noted that the resident's spouse removes the alarm, at times. 4. On 11/18/16 at 10:30 AM, the resident was found on the floor in his/her room. The investigation noted that the resident had a seatbelt alarm and that it was sounding. 5. On 11/21/16 at 9:20 AM, the resident was found sitting on the floor at his/her bedside and his/her spouse was with the resident. The investigation noted that the resident had a seatbelt alarm and that the alarm was sounding. 6. On 11/29/16 at 7:40 AM, the resident was found sitting on the floor. The investigation noted that the resident was being pushed in the wheelchair, became agitated and slid out of the wheelchair. 7. On 12/04/16 at 4:45 AM, the resident had a witnessed fall during care. 8. On 12/21/16 at 2:30 PM, the resident was found on the floor of his/her bathroom. The investigation noted that the alarm was sounding. 9. On 01/06/17 at 1:05 PM, the resident was found lying on the floor in a common area and sustained a 1 cm bruise to the left eyebrow. The investigation noted that the alarm did not sound and that the resident had removed the alarm. 10. On 02/06/17 at 6:00 PM, the resident's spouse reported that the resident had fallen and the resident sustained [REDACTED]. The investigation identified that the resident's spouse was provided education related to removing the resident's alarm and transferring the resident. 11. On 02/08/17 at 5:20 AM, the resident was found on the floor of his/her room bleeding from the face and nose with decreased range of motion to the right wrist. The resident was sent to the hospital emergency room where it was determined that he had acute on chronic bilateral subdural hematomas that had to be drained. The investigation identified that the resident had a clip alarm and that it had not sounded because the resident had disconnected it. 12. On 03/06/17 at 8:00 PM, the resident slid to the floor from the Broda chair, which the documentation notes was witnessed by the charge nurse. The investigation identified that the tab alarm did not sound because the resident had unclipped the alarm. 13. On 03/11/17 at 12:00 PM the resident was found sitting on the floor in his/her room. The investigation noted that the alarm was sounding. 14. On 4/27/17 at 7:40 AM the resident was found sitting on the floor at the bedside. The resident was subsequently sent to the hospital emergency department where it was determined that he/she sustained a rib fracture. The investigation noted that the resident had removed his/her shirt with the alarm attached, therefore the alarm did not sound. A review of the resident's care plan identified that although, interventions were added to the care plan following each fall, the care plan failed to address the resident's behavior of removing the alarms/clothing and it failed to identify interventions that addressed the level of supervision the resident required and/or how to provide the necessary supervision and/or how to engage the resident. Observations of the resident on 5/10/17 at 7:00 AM and on 5/11/17 at 11:00 AM noted the resident lying on the bed in his/her room alone with an alarm in place. Review of the resident's fall history and plan of care with the ADNS on 05/11/17 at 12:32 PM identified that the nurses on the unit were responsible for revising the care plan after a fall. She further noted that they had a fall committee and were working on a root cause analysis for falls on an individual basis. Review of the facility documentation with the ADNS failed to identify that a root cause analysis had been completed following the resident's falls and/or how the resident was to be monitored and/or engaged to reduce the risk of falls and injuries. S/he further noted that the resident had alarms since admission to the facility and noted that the alarms had recently been discontinued. A review of the fall protocol identified that each time a resident experienced a fall, an interdisciplinary fall assessment tool will be completed tin order to identify the potential causes of the fall. The care plan will be revised with any interim interventions to minimize the risk of injury.

Based on review of the clinical records, facility documentation and interviews for one of four sampled residents (Residents #122) reviewed for accidents, the facility failed to provide the necessary supervision to prevent an accident and/or failed to ensure the environment was free of accident /hazards. The findings include: 1. Resident #122's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified intact cognition, total assistance of one person for bathing, a history of falls in the last month and a height of 5 feet 2 inches. The resident care plan dated 01/13/16 identified a risk for falls related to weakness, impaired mobility, pain and osteoporosis that increases my risk for injury with a fall. Interventions that included applying alarms on the bed and wheelchair. The Accident and Incident report and investigation dated 01/13/16 at 8:30 PM noted that during a shower the resident slid to the floor from the shower chair. Left lower extremity pain was identified and the resident was transferred to the hospital for an evaluation. The resident was identified with a left hip fracture which required surgical repair. The investigation further identified that NA # 6, who was assigned to care for the resident on 01/13/16 was in the process of washing the resident's bottom when the resident leaned forward and fell to the floor. NA #6 in a statement at the time attributed the fall to the cushion in the shower chair that became slippery during the bath. Interview with NA #6 on 06/15/16 at 4:00 PM identified before providing the shower on 01/13/16 the resident requested to use a specific shower chair. NA #6 indicated he/she was unfamiliar with the shower chair the resident wanted to use because he/she had never used that specific shower chair before. NA #6 noted the shower chair did not have a seatbelt and had a thicker cushion than the shower chairs he/she usually used. NA #6 noted that while in the process of giving the shower the resident leaned forward and although NA #6 asked the resident to sit back in the chair, the resident started to slide of the shower chair. NA #6 indicated other shower chairs in the facility had seatbelts. Interview with COTA #1 on 06/16/16 at 10:30 AM noted the therapy department does not typically assess residents for use of shower chairs. COTA #1 indicated that if an assessment was done, the assessment would include seat height and whether or not the resident required trunk support. Observation of the shower chair with the ADNS on 06/16/16 at 2:15 PM identified the chair was significantly higher than the other shower chairs in the facility. The ADNS who identified her height was 5 feet 3 ½ inches tall, could not place her feet on the floor once seated in the shower chair, she could only point her toes and touch the floor with her toes and noted that the resident would not have had the ability to point her toes in attempt to support her weight once she was leaned forward. Observation at the time of other shower chairs located in the bath core noted that there were at least 3 other types of shower chairs but all the other chairs contained a seatbelt and an area where the feet could be supported. Interview with the ADNS at the time noted that they allow the nurse aides to decide what shower chair to utilize when giving showers. 2. Resident # 159 ' s [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified severely impaired cognition, and he/she required extensive assistance with all ADL ' s.The physician order [REDACTED].Observation on 6/13/2016 at 9:50AM identified Resident #159, in the resident dining room on the lower level, sleeping in his chair. A Catapres 0.3mg/day transdermal patch was observed on the table within the resident ' s reach. Interview with RN #1 at 9:50AM indicated that he/she did not know who the medication belonged to or why it was left there. Upon surveyor inquiry RN#1 removed the medication and secured it out of the residents reach. Interview with LPN#1 on 6/13/2016 at 9:53AM indicated that she was called away from Resident #159 to respond to an emergency approximately one hour ago, she left the medication on the table, and forgot to return to administer the medication. Upon surveyor inquiry, LPN #1 administered the medication patch as directed by the physicians order. 3a. Observation on 6/13/16 at 9:30 AM of the soiled utility room on the Skyview Unit identified one bottle each of the following solutions stored on the counter: Liquid Enzyme II Clean Assist, Clorox Bleach Germicidal Cleaner and 3M Quat Disinfectant. Each bottle was open and partially full. Interview and observation with RN #5 on 6/13/16 at 9:30 AM identified Liquid Enzyme II Clean Assist, Clorox Bleach Germicidal Cleaner and 3M Quat Disinfectant should not be stored on the counter in the soiled utility room and should be stored in a locked location. During the interview Housekeeper #1 entered the room and identified these products were used to clean wheelchairs. RN #5 informed Housekeeper #1 that these products cannot be stored on the counter in an unlocked room and needed to be stored in a locked location. Subsequent to surveyor inquiry the Liquid Enzyme II Clean Assist, Clorox Bleach Germicidal Cleaner and 3M Quat disinfectant were removed from the unlocked soiled utility room. The facility was unable to provide a policy that addressed the storage of potentially hazardous cleaning solutions. b. Observation on 6/13/16 at 11:25 AM identified the water temperature in the bathroom of room 214 to be 128.8 degrees. Observation with the Director of Maintenance on 6/13/16 at 11:35 AM identified a water temperature in the bathroom of room 201 to be 127.9. Interview with the Director of Maintenance on 6/13/16 at 11:35 AM identified the facility strives to maintain the water temperature between 110-120 degrees and he was not aware of any issues related to excessivley hot water. Further observation of water temperature readings on 6/13/16 identified a water temperature of 125.7 degrees in the bathroom of room 218 at 11:45 AM and a water temperature of 125.4 degrees in the bathroom of room 217 at 12:00 PM. Observation on 6/14/16 at 11:30 AM identified a water temperature in the bathroom of room 218 to be 121.9 degrees and on 6/14/16 at 11:45 AM a water temperature of 121.6 degrees in bathroom of room 214.The Director of Maintenance identified he made some adjustments to the hot water tank and he was continuing to monitor the hot water temperatures to get them consistently below 120 degrees. Interview with the Director of Maintenance on 6/15/16 at 10:30 AM identified when he started in this position six months ago the practice was to take water temperatures daily at various times of the day with the laser gun so he continued the practice. A review of the water temperature monitoring logs from February 2016 to June 2016 identified daily water temperatures were monitoredand were within normal limits. Subsequent to surveyor inquiry, the hot water tanks were serviced on 6/14/16 and adjustments were made to the hot water tank and a plan was put in place to replace the hot water controls. Observation on 6/15/16 at 12:00 PM identified the water temperature in the bathroom of room 214 to be 112 degrees. Review of facility policy identified water temperature readings are to be between 105-120 degrees and that water temperatures readings should be taken daily with a reliable pocket thermometer

Based on review of clinical record, review of facility documentation, and interviews for one of three sampled residents (R# 113), the facility failed to ensure the resident was free from abuse. The findings include: Resident #113's [DIAGNOSES REDACTED]. An annual MDS dated [DATE] identified the resident had moderate cognitive impairment and required extensive assistance with ADL's including bathing. The RCP's dated 3/26/15 and 7/1/15 identified a self care deficit, cognitive loss and fluctuations in mood related to anxiety and depression. Interventions directed the staff to approach the resident in a warm positive manner, provide hands on assist during weekly showers for safety, speak with the resident during care, and use a gentle touch. Nurse's notes dated 7/8/15 identified the APRN was updated on a recent abuse allegation. A facility investigation dated 7/8/15 identified that the facility had received notification on 7/7/15 that NA instructor #1 and student NA #1 had observed NA #4, a facility NA, providing the resident a shower on 6/30/15 during the 3:00 PM to 11:00 PM in an inappropriate manner. NA#4 was observed pulling off the resident's shoe veryroughly causing the resident to call out in pain. The NA did not respond to the resident's pain. They also reported that NA #4 failed to use the shower chair's safety strap and was reminded by the instructor to do so. NA #4 was observed to turn on the shower and without checking the water temperature or having the resident check it, the NA sprayed the water on the resident. The resident yelled out too hot. NA#4 was then witnessed to use excessive force while cleaning the resident's peri-area without visual or verbal regard to the resident's protests of pain. When the resident verbally complained, NA #4 admonished the resident for complaining. Additionally the resident was left naked after the shower without a towel or bath blanket for cover. The instructor and NA student reported that when the resident was transferred off the shower chair, a large amount of blood was noted on the chair. Although the incident occurred on 6/30/15, the NA instructor and student failed to report the incident to the facility immediately as directed by facility policy A statement written by NA#4 noted that when the resident was transferred to bed, a small scratch was noted and although the NA identified she/he reported the scratch to the supervisor, there was no documentation of the wound and/or treatment orders in the clinical record. A Social Service note dated 7/8/15 identified the resident was crying and was upset with the roommate but lacked documentation of an alleged abuse or an assessment of the resident's well being related to the incident the week prior. A Physician orders [REDACTED]. A Behavior Health Progress note dated 7/9/15 identified the resident had been exhibiting a fluctuation in mood and resistance to care and and will continue to monitor. The RCP was updated on 7/8/15 and identified the resident reported a NA was rough with handling her/him and directed the staff to monitor for signs of mental distress. Interview on 8/19/15 at 8:45 AM with the ADNS identified although there were two witnesses to the incident, the allegation of abuse was unsubstantiated because the resident was unable to recall the incident 7 days after in occurred. Interview and review of the clinical record with the DNS on 8/19/15 at 10:45 AM identified that although the facility did not substantiate the allegation of abuse the NA received a disciplinary action that included a suspension with a 90 day probation. Review of the the NA Student program catalog with the DNS on 8/20/15 at 10:00 AM identified that although the NA instructors provided the students with education on the facility's Abuse Prevention Policy on 6/22/15, the NA and instructor that witnessed the incident on 6/30/15 failed to immediately report it to the facility until 7/7/15, 7 days later. Subsequent to the incident, all NA instructors were provided with education regarding the timely reporting of resident mistreatment. Interview with NA#4 and review of his/her written statement of the incident on 8/20/15 at 2:30 PM identified that there were two NA students and an instructor present during the resident's shower. She/he denied that s/he treated the resident in an inappropriate manner stating, that's how everyone does it. Additionally the NA stated that the resident 's scratch was approximately 1 inch long and was located on the residents upper thigh near the residents buttocks. Attempts to interview the instructor and the NA student were unsuccessful.

Based on clinical record review, facility documentation, interview and review of facility policy for one of three residents, Resident #9, in the survey sample reviewed for hydration, the facility failed to ensure adequate fluids were provided to prevent dehydration. The findings include: Resident #9's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified Resident #9 was severely cognitively impaired and required set up help/supervision with meals. The care plan dated 4/22/15 identified the resident was at nutritional risk. Interventions included to consult with the dietician as needed, document percent of meal consumed, I&O at least quarterly, and to offer fluids with med pass with each meal and as needed. The interim care plan dated 6/17/15 identified the resident was receiving IV therapy for dehydration. Interventions included to monitor vitals each shift and as needed and keep on intake and output throughout therapy. Interview and review of facility documentation on 8/19/15 at 3:35 PM with the DNS identified laboratory work dated 6/17/15 which identified a BUN of 62 (normal 7-18), creatinine of 2.4 (normal 0.6-1.3), GFR of 20 (normal >60) that was signed by the physician on 6/17/15. physician's orders [REDACTED]. Review of labwork dated 6/18/15 identified a BUN of 51, creatinine of 2.1, and GFR of 24 which was signed by the physician on 6/18/15. Review of physician's orders [REDACTED]. The APRN note dated 6/22/15 identified he/she was asked to see the resident to follow up on an increased BUN and creatinine after intravenous re-hydration. Dietician notes dated 3/11/15 identified an estimated fluid need of 1300 milliliters and on 8/6/15 identified an estimated fluid need of 1550 milliliters. There were no assessments documented when the resident was dehydrated in June. Facility intake records noted the following: 6/8/15 - 480 milliliters (ml) 6/9/15 - none recorded 6/10/15 - none recorded 6/11/15 - 720 ml 6/12/15 - 960 ml 6/13/15 - none recorded 6/14/15 - 720 ml 6/15/15 - 620 ml 6/16/15: 600 ml 6/17/15: 240 ml A hydration assessment dated [DATE] identified that the resident was hydrated. No further hydration assessments were noted until 6/17/15 when the assessment noted that the resident had no signs or symptoms of dehydration. The DNS on 8/19/15 at 3:35 PM identified that the facility policy is to notify the physician only when signs of dehydration occur or when the resident has no fluid intake for a day. The DNS identified that the NAs' input the fluid intake into the computer, the charge nurse runs the report and if fluid needs are not met for three days, a hydration assessment is triggered. The DNS was unable to identify why a hydration assessment was not completed prior to 6/12/15 and/or from 6/12-17/15, and/or why the dietician did not have a note in the clinical record , and/or provide documentation of interventions initiated to prevent the dehydration when the resident was noted with repeatedly poor fluid intakes. Interview and review of the clinical record with the APRN on 8/20/15 at 10:30 AM identified that he/she had been made aware of the results of Resident #9's hydration assessment on 6/6/15 as he/she had signed it, however could not be sure if he/she had been notified regarding the resident's poor intake and hydration assessment dated [DATE] since he/she had not signed the assessment off (as per facility practice) and no nurse's note was written. Additionally, he/she identified that neither him/herself nor the physician saw Resident #9 between 6/8/15 and 6/16/15 and that he/she had not been notified of the resident's poor fluid intakes from 6/8/15 through 6/16/15. The APRN identified that he/she would have expected to have been notified of Resident #9's poor intake amounts.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) reviewed for hydration, the facility failed to monitor and/or assess the resident to ensure the resident consumed a sufficient amount of fluids to maintain proper hydration. The findings include: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Nutritional assessment dated [DATE] identified the estimated fluid needs for Resident #1 was 1820 cubic centimeters (cc) per day and a goal was adequate hydration. The laboratory report dated 3/11/15 identified the Blood Urea Nitrogen (BUN) level was 17 (normal range 7-18mg/dl), the creatinine was 1.0 (0.6-1.3mg/dl) and Sodium level was 144 (136-145mmol/L). The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairments, required cues and supervision with decision making skills, required limited assistance with eating, received a mechanically altered therapeutic diet and was always incontinent of bladder. The resident care plan dated 3/27/15 identified the resident was at risk for dehydration related to diarrhea and vomiting. Interventions directed to encourage the resident to drink, offer small fluids frequently, monitor for symptoms of dehydration (increased confusion, decreased urine output. dry mucous membranes, poor skin turgor), monitor labs as ordered, and to monitor the intake and output. Physician orders [REDACTED]. Review of the nurse's notes from 3/27/15 through 3/29/15 identified the resident experienced loose stools and was on a clear liquid diet. The facility policy and procedure for Intake & Output (I&O) identified that I&O is to be instituted on admission for seventy-two hours, quarterly for all residents, and with a change of condition which may alter hydration status a minimum of three days or until condition stabilizes. The policy identified if the resident was not meeting the fluid needs the Hydration Assessment was to be completed and the physician and/or Advanced Practice Registered Nurse (APRN) notified. Review of the I&O sheets from 3/27/15 through 4/10/15 identified that eleven out of seventeen days failed to reflect documentation that the I&O was monitored, and the six days the I&O was monitored, Resident #1 did not meet the estimated fluid needs, the fluid intake ranged from 230cc-1370cc per day and/or that the physician had not been notified. Review of the clinical record identified that hydration assessments for Resident #1 were blank. Review of the nurse's notes from 4/4/15 through 4/11/15 identified that Resident #1 was fatigued, had increased confusion, weakness, increased lethargy and fluids were encouraged. The nurse's notes and the I&O record failed to reflect the amount of fluids Resident #1 had consumed from 4/4/15 through 4/10/15. The nurse's note dated 4/11/15 at 1:45 PM identified the physician was notified that Resident #1's temperature was 100.9 degrees Fahrenheit and directed to obtain blood work and chest x-ray. The laboratory results dated [DATE] identified the BUN was 64, creatinine 2.2 and the Sodium 161. The nurse's notes dated 4/11/15 at 9:30 PM identified the physician was made aware of the resident's poor intake, increased lethargy and confusion and the blood work results. A physician's orders [REDACTED]. The nurse's note dated 4/12/15 at 8:15 AM identified Resident #1's face was flushed, tremors of the upper and lower extremities, temperature was 99.5, and there had been no improvement during the night. Subsequent to physician notification Resident #1 was transferred to the hospital and was admitted with [DIAGNOSES REDACTED]. The emergency department note dated 4/12/15 identified that the oral mucosa was dry, the Sodium level was 160, BUN 58 and creatinine 2.0. Resident #1 was hospitalized from [DATE] through 4/17/15. Interview and review of the clinical record with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/10/15 at 3:00 PM identified that the clinical record failed to reflect documentation that hydration assessments were conducted when Resident #1 did not meet the daily fluid needs and/or that the I&O was monitored every shift as directed in the plan of care. The DON identified that per the facility's policy when a resident fails to meet fluid requirements, the resident would be kept on I&O, a hydration assessment completed and the physician notified for direction.

Based on clinical record review, and interviews for 1 of 6 sampled residents reviewed for pressure sores (R#161, the facility failed to review and revise the care plan when the resident developed a pressure sore and/or when the wound declined and/or when the wound became infected. The findings include: Resident #161 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden Scale for pressure sore risk dated 6/30/13 identified that the resident was at high risk for development of pressure sores. The 14 day MDS dated [DATE] identified that the resident was severely cognitively impaired, required the assistance of 2 staff for transfers and bed mobility, was incontinent of bowel and bladder, was at risk for pressure sores and had no pressure sores present at that time. The interim care plan dated 6/30/13 failed to identify pressure sore risk and/or risk interventions were not checked. The care plan dated 7/12/13 identified the risk for skin breakdown related to immobility. Interventions included to assist resident with repositioning, conduct body audits on shower days, consult dietitian, provide pressure re-distribution cushion and mattress, apply barrier ointment, and to use tilt in space feature on w/c to offset weight pressure in one area. The nursing readmission assessment dated [DATE] identified the presence of a small reddened area on the sacrum with EPC cream applied. No measurements or other assessments were noted. On 7/13/13, physician orders [REDACTED]. Nurse's notes and wound records lacked any assessment of the area until 7/17/13 when the sacral pressure sore was described as a stage IV with necrotic tissue present. An air mattress was ordered at that time. On 7/18/13, physician orders [REDACTED]. On 8/9/13, the resident was sent for a wound consult. From the physician's office the resident was sent to the hospital for "emergency surgery because of significant soft tissue infection". The resident remained hospitalized until 8/24/13 for treatment of [REDACTED]. Interview and clinical record review with the DNS and ICN on 12/5/13 at 11 AM failed to provide documentation that the care plan reflected the presence of the reddened area on admission and/or that the care plan was revised when the resident was found to have a stage IV pressure sore.

Based on clinical record reviews, observations, review of facility policies, and interviews for 3 of 6 sampled residents reviewed for pressure sores (R#161, R # 80 and #43 ), the facility failed to ensure that resident's with potential skin issues were assessed by licensed staff at least weekly, and/or failed to ensure that when wounds developed, they were appropriately assessed, and/or failed to prevent the pressure sore from infection, and/or failed to review and revise the care plan when the resident developed the wound and/or when the wound continued to decline, and/or failed to ensure that the resident was appropriately positioned off the area at least every 2 hours. The findings include: 1. Resident #161 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden Scale for pressure sore risk dated 6/30/13 identified that the resident was at high risk for development of pressure sores. The 14 day MDS dated [DATE] identified that the resident was severely cognitively impaired, required the assistance of 2 staff for transfers and bed mobility, was incontinent of bowel and bladder, was at risk for pressure sores and had no pressure sores present at that time. The interim care plan dated 6/30/13 failed to identify pressure sore risk and/or risk interventions were not checked. The care plan dated 7/12/13 identified the risk for skin breakdown related to immobility. Interventions included to assist resident with repositioning, conduct body audits on shower days, consult dietitian, provide pressure re-distribution cushion and mattress, apply barrier ointment, and to use tilt in space feature on w/c to offset weight pressure in one area. The nursing readmission assessment dated [DATE] identified the presence of a small reddened area on the sacrum with EPC cream applied. No measurements or other assessments were noted. On 7/13/13, physician orders directed application of Allevyn to sacrum / buttock wounds. Nurse's notes and wound records lacked any assessment of the area until 7/17/13 when the sacral pressure sore was described as a stage IV with necrotic tissue present. An air mattress was ordered at that time. On 7/18/13, physician orders directed the resident get out of bed from 11:30 AM-2:30 PM, and 4:30 pm to 7:30 pm (3 hours sitting each time). On 8/9/13, the resident was sent for a wound consult. From the physician's office the resident was sent to the hospital for "emergency surgery because of significant soft tissue infection". The resident remained hospitalized until 8/24/13 for treatment of [REDACTED]. Interview and clinical record review with the DNS and ICN on 12/5/13 at 11 AM failed to provide documentation that the reddened sacrum was assessed from re-admission on 6/30/13 through 7/17/13, when the pressure ulcer was first assessed and found to be a stage IV pressure sore. Further review failed to provide documentation that positioning on the sacral area was limited to hours or less in accordance with professional standards of pressure sore prevention and treatment to encourage healing, and/or that appropriate treatments were administered by licensed staff and/or that the pressure sore was assessed and treated to prevent infection of the wound requiring surgical intervention. Interview further noted that the nurse aides apply the EPC cream and not licensed staff. 2. Resident # 80 was admitted to the facility on [DATE] with dementia, failure to thrive, hypertension, anxiety, [MEDICAL CONDITION], and depression. An admission MDS assessment dated [DATE] identified the resident had severe cognitive impairment, required limited assistance with bed mobility, extensive assist with transfers, did not walk, had no pressure ulcers, and was at risk for developing a pressure ulcer. A resident care plan dated 10/7/13 identified the risk for skin breakdown related to impaired mobility and incontinence. Interventions included protective ointment to the perineal area after incontinence and use of a pressure redistributing cushion in the wheelchair. A Physician history and physical exam dated 9/22/13 identified the resident had bilateral lower extremity [MEDICAL CONDITION]. A subsequent APRN note dated 10/26/13 identified the resident had +3 non [MEDICAL CONDITION] to the left leg and +2-3 [MEDICAL CONDITION] to the right leg. Review of weekly body audits noted the 9/23/13 and 9/30/13 body audits were blank. The weekly body audit dated 10/11/13 indicated no new bruises from admission noted. No further weekly body audits were noted to be completed for October 2013. A wound tracking record dated 10/30/13 noted the presence of a new unstageable pressure ulcer on the left heel. The area measured 2.5 cm x 4.5 cm and was noted to be dark in color. Off-loading heels was noted at that time. A subsequent assessment dated [DATE] noted the unstageable pressure ulcer on the left heel measured 2.5 cm x 4.0 cm with dry eschar. An observation on 12/09/13 at 12 noon with LPN #1 noted the skin on the left heel was black. An interview on 12/5/13 at 12:40 PM with RN # 2 (wound nurse) indicated a preventative skin care program for resident heels would include off-loading (pressure from) the heels. He/she indicated the admission nurse would assess the resident for risk and if the resident had certain indicators, for example boggy heels, the resident's heels would be off-loaded. At that time RN # 2 was unable to provide any preventative interventions that were put in place on admission for R # 80 to prevent skin breakdown to his/her heels. RN#2 further indicated the body audits that were incomplete and/or missing should have been completed per facility policy of once a week. 3. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] identified that both heels were intact and no pressure areas were noted. An admission MDS assessment dated [DATE] identified the resident had severely impaired cognition, required limited assistance of two for bed mobility, and extensive assistance of two for transfers, had an unstageable/deep tissue injury/pressure ulcer, and utilized pressure relieving devices on the bed and chair. An admission care plan dated 11/2/13 failed to reflect a risk for pressure ulcers. A revised care plan dated 11/13/13 identified a risk for skin breakdown related to impaired mobility, incontinence, and the presence of a stage two pressure ulcer on the left heel. Interventions included to conduct weekly body audits, utilize a pressure redistributing mattress and a redistributing cushion in the wheel chair. The care plan failed to identify interventions for off loading pressure to the heels. Admission physician's orders dated 11/2/13 directed body audits every week by the licensed nurse on shower day, document on the body audit form. The Physician's orders dated 11/9/13 directed to apply Allevyn Gentle Border dressing to the left heel. Physician orders dated 11/11/13 directed no shoes to left foot, off load heels at all times, discontinue the current treatment to the left heel and initiate [MEDICATION NAME] to wound bed and cover with Allevyn gentle border. Nursing notes dated 11/6/13 identified the left heel was red and boggy with pain noted, updated wound nurse. Nurse ' s notes dated 11/6/13 at 10:00 pm identified the left heel red and boggy with pain. Nurse ' s notes dated 11/9/13 at 1:00 PM identified a new wound was found on the left heel, dressing applied, note for wound nurse on file. The clinical record failed to reflect any interventions were implemented for the off loading of pressure to the lower extremities when the left heel was identified a being boggy on 11/6/13. Weekly body audit dated 11/6/13 identified the left heel was boggy. On 11/13/13 the weekly body audit was noted as blank. The next weekly body audit completed was dated 11/27/13 (14 days later) and noted the dressing to left heel was clean, dry, and intact. The clinical record failed to reflect weekly body audits were conducted per physician's orders and/or facility policy. The Advanced Practice Registered Nurse (APRN) wound noted dated 11/12/13 identified a stage two pressure ulcer measuring 2.0 cm x 2.0 cm x < 0.1 cm, with scant serous drainage. Recommendations for prevention included repositioning and heels on pillows. The Skin/Wound assessment record dated 11/9/13 identified the left heel had an open area measuring 2 cm x 2 cm with sanginous drainage noted. No new interventions were implemented. On 11/11/13 the skin/wound assessment record identified the left heel measured 2 cm x 2 cm < 0.1 cm with slight serous sanginous drainage, and the periphery was noted to be macerated. Interventions noted were to off load heels, Alleyvn dressing to the heel and no shoes. Review of the facility policy and procedure for Wound Prevention/Interventions identified interventions are directed toward minimizing and/or eliminating any negative effects of the causal/contributing factors such as pressure, moisture, friction/shear, and poor nutrition for all residents admitted to this facility. Pressure intervention suggestions include pressure redistribution mattresses are available for all beds, turn and/or reposition as needed per individualized resident assessment, use pillows to elevate heels while in bed or other pressure reducing devices for feet in bed or chair. Interview and review of the clinical record with RN #1 on 12/9/13 at 12:30 PM identified all residents on admission are assessed for a risk of skin breakdown utilizing the Braden Scale, when a resident is identified as being at risk for skin breakdown the resident care plan should reflect appropriate interventions implemented to prevent further breakdown and/or assist in the healing of the area. RN #1 indicated R #43 ' s plan of care should have identified interventions for the off loading of pressure to the lower extremities from admission. The clinical record failed to reflect any interventions were implemented for the off loading of pressure to the heels on admission and/or when the area was noted to be boggy.

Based on clinical record reviews, review of facility policies, and interviews for one resident who had a documented allergy to medication, (R#170), the facility failed to address the resident's allergy to a medication that was prescribed and/or failed to implement interventions to monitor for signs and symptoms of an allergic reaction, and/or for the only sampled resident with a fecal impaction (R#153), the facility failed to ensure that physician orders [REDACTED].#18), the facility failed to ensure that physician orders [REDACTED]. The findings include: 1. Resident #153 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 10/20/12 indicated that the resident's last bowel movement (BM) was on 10/17/12. The resident had received milk of magnesia on 10/19/12 at 10:21 PM at the hospital. The nursing admission assessment identified constipation as an issue and that the last BM was 10/10/12. The bowel data assessment dated [DATE] identified the resident was unable to move bowels without interventions. The care plan/intervention portion of the assessment was blank. The admission care plan failed to identify the resident's history/problem related to constipation. The admission history and physical dated 10/21/12 indicated that the resident had constipation with the plan to monitor bowel movements. On 10/23/12 at 3 PM, nurse's notes indicated that the resident was not moving bowels enough and would receive MOM on the evening shift. No documentation of administration or results were noted in nursing notes. The next note written was on 10/24/12 for "3-6 PM" which indicated that the resident had complained of abdominal pain and was unable to have a BM. The resident had hypoactive bowel sounds, and a distended and firm abdomen. An enema was administered at 4 PM with no results and at 6 PM the physician was notified and directed the resident be sent to the ED. Emergency department records dated 10/24/12 indicated that the resident had not had a bowel movement for one week and that copious amounts of hard stool were manually removed. Interview and clinical record review on 1/10/13 at 10:38 AM failed to provide documentation that the resident was provided with the constipation medications as ordered by the physician and/or that the resident was assessed for constipation. Although the medication administration kardex indicated that the resident received MOM on 10/21 and 10/24/12, no results, follow up and/or assessments were documented. 2. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 4/2/12 directed administration of [MEDICATION NAME] 40 mg daily with the last dose administered by the hospital at 10:10 AM on 4/2/12. Admission physician orders [REDACTED]. On 4/ 5/12, physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 4/8/12 the resident was hospitalized with altered mental status and the [MEDICATION NAME] was restarted. Interview with RN#1 on 1/8/13 at 10:30 AM noted that the medication was omitted and that the nurse was provided education regarding double checking physician orders [REDACTED]. 3. Resident #170's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had moderately impaired cognition, required limited assistance with mobility and had no pain symptoms during the assessment period. Physician orders [REDACTED]. Review of a care plan dated 3/29/12 identified that the resident had allergies [REDACTED]. A nurse's note dated 4/8/12 identified that the resident sustained [REDACTED]. The resident was evaluated at the Emergency Department at 7:30 AM and returned to the facility on [DATE] at 2:20 PM. A physician order [REDACTED]. Review of the resident's clinical record for the period of 4/8/12 through 4/11/12 failed to identify that the resident's allergy to opioids was addressed and/or failed to implement a care plan to address the resident's pain management and/or signs and symptoms of allergic reaction. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses' notes for the period of 4/9/12 through 4/11/12 at 12:00 PM identified that the resident had increased lethargy and poor oral food/fluid intake. On 4/11/12 the resident's 6:00 PM medications were held related to the resident's lethargy and inability to swallow. A physician order [REDACTED]. Nurses' notes for the period of 4/12/12 through 4/13/12 identified that the resident continued with fatigue, lethargy and poor intake. On 4/13/12 at 3:15 PM, the resident was found on the floor at his/her bedside. The resident sustained [REDACTED]. The resident required five sutures to a laceration on his/her forehead. The resident returned to the facility at 9:00 PM. Interview with RN #5 on 1/10/13 at 10:55 AM identified that on 4/8/12 she transcribed a physician's orders [REDACTED]. Subsequent to surveyor inquiry, the Acting Director of Nurses provided a statement, dated 1/11/13, that identified that on 4/8/12, RN#5 verified the physician's orders [REDACTED].#5 had informed R#170's physician that the resident had received OxyIR at the hospital without an allergic reaction. The ADNS was unable to provide clinical record documentation of the physician's notification and/or documentation that the resident's plan of care addressed signs and symptoms of allergic reaction. Although the facility had information that the resident was allergic to opioid medications, the facility failed to plan care to monitor the resident for reaction to this medication. Review of the facility's Medication Monitoring policy identified in part, that the facility employs a system to ensure that medication usage is evaluated on an ongoing basis and when the resident receives a new medication, the medication order is evaluated to determine if the resident has a condition, history or sensitivity that would preclude the use of the medication. The policy further identified that the clinical rationale for using the medication outside the stated guidelines is documented in the resident's active record. Additionally, the facility's policy regarding allergies [REDACTED].

Based on clinical record reviews, review of facility investigations, and staff interviews for 2 of 3 sampled residents who sustained injuries with falls (R#168, 170), the facility failed to ensure the resident was transferred according to the plan of care and/ or that assistive devices were in place to prevent injuries from falls. The findings include: 1. Resident # 168's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident was cognitively impaired and required extensive assistance of one staff member for bed mobility, dressing and personal hygiene, and extensive assistance of 2 staff members for transfers. A fall risk assessment dated [DATE] identified the resident was at risk for falls. A care plan dated 12/6/12 identified the risk for falls with interventions that included to utilize a tab alarm and transfer with the assistance of two staff. Physician orders [REDACTED]. Nurse's notes dated 12/7/12 at 12:30 AM noted the resident was found lying on the floor and sustained a 1/2 inch laceration over the right eye. Bleeding was noted from a mouth laceration on the inside of the upper lip. The resident was transferred to the hospital for evaluation and returned to the facility on [DATE] at 3:15 AM. On 1/10/12 at 12:20 PM, interview with NA#1 noted she took care of the resident on 12/7/12 when the resident fell . She further noted that she transferred the resident alone from the toilet to the wheelchair, began to transfer the resident alone back to bed from the wheelchair, realized the oxygen tubing would not reach, placed her hand over the resident's chest, pulled the oxygen tubing out from under the resident and the resident fell forward to the floor. NA#1 further identified that she transferred the resident alone because she observed staff transferring the resident with one staff member the night before and was unaware the resident required a 2 person transfer. She further noted that she did not review the resident's care card prior to caring for the resident. Subsequent to the resident falling, NA#1 was inserviced on reviewing a resident's care card prior to providing care. 2. Resident #170's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified that the resident had moderately impaired cognition, required limited assistance with bed mobility, transfers and ambulation, was independent with locomotion in a wheelchair in the room and had experienced falls with no injuries. A care plan dated 3/29/12 identified that the resident was susceptible to skeletal injury related to osteoporosis and risk for falls related to inability to ambulate and a history of noncompliance with transfer assistance. Interventions included to protect the resident from falls, assist with transfers, check on resident every two hours when in plain sight, ensure that bed is in lowest position, ensure to engage sensor alarm at all times and utilize a tab alarm in and out of bed. A fall assessment dated [DATE] identified that at 7:00 AM, R#170 was found on the floor in the bathroom. An assessment identified that the resident was responsive, with no obvious deformities of bone or soft tissue however the resident complained of right upper thigh pain. The resident was transferred to the Emergency Department for evaluation at 7:35 AM. Review of hospital records dated 4/8/12 identified that the resident sustained [REDACTED]. Interview with RN #2 on 1/9/13 at 2:00 PM identified that when she found the resident on the bathroom floor on 4/8/12 at 7:00 AM, there was no alarm sounding and she did not recall checking the resident's bed to ascertain if a sensor alarm was on the bed. Interview with the Acting Director of Nurses and review of the facility's fall investigation dated 4/8/12, identified that the resident had a history of [REDACTED]. The ADNS identified the resident must have remove his/her tab alarm and transferred self from the bed to the wheelchair, as no staff person had transferred the resident. The ADNS identified that no alarm was sounding when the resident was found and staff were unable to identify if the resident's sensor alarm was on the bed.

Based on review of clinical records, facility investigations, facility policies and procedures and interviews for two of four sampled residents reviewed for bruises and/or other injuries of unknown source, Resident (R) R #1 and R #4, the facility failed to ensure that the residents received adequate supervision and assistance devices to prevent accidents. The findings include: 1. R #1's [DIAGNOSES REDACTED]. Review of a Rehabilitation Discharge Summary dated 07/08/10 and a corresponding Functional Maintenance Program identified that the safest transfer was a Hoyer/mechanical lift, however, R #1 often refused this. R #1 also tended to refuse the sliding board as well as the stand-pivot transfer with a camboot even though he/she was at risk for further fractures. Instruction to the staff included offer the Hoyer lift first, offer the sliding board second, and, if R #1 refused both, may stand-pivot-transfer with camboot. Review of legal documents dated 05/05/2011 identified that the resident's son, Conservator #1, was legally appointed as conservator of person and estate. An annual Minimum Data Set (MDS) assessment dated [DATE] identified impaired cognition with moderately decision-making, no mood indicators, delusions, rejection of care 1 to 3 days per week, total assistance of 2 staff for bathing and bed mobility; total assistance of 1 staff for toilet use; extensive assistance of 2 staff for transfer, extensive assistance of 1 staff for wheelchair locomotion, dressing, personal hygiene, and independence with eating with set-up; not steady and only able to stabilize with human assistance when moving from a seated to standing position and during a surface to surface transfer; functional limitations in range of motion (ROM) of both lower extremities; scheduled and as needed pain management regime; no falls; at risk for developing pressure ulcers, daily insulin injections, and antipsychotic and antianxiety medications. Resident Care Plans (RCP) reviewed with the MDS, identified the problems of Fall Risk and Osteoporosis with interventions that included, in part, provide with assist of 2 for all transfers, and dependent mechanical lift for all transfers. physician's orders [REDACTED]. Review of a nursing note dated 04/18/12 identified that R #1's left knee was noted to be increasingly swollen and twice the size of the right knee with no pain. Advanced Practice Registered Nurse (APRN) #1 assessed the resident on 04/19/12 and ordered an x-ray. At 9:00 PM on 04/19/12, the x-ray report identified a comminuted fracture through the distal femur with some impaction and posterior rotation of distal fragments, joint effusion, marked osteopenia, and tricompartmental degenerative changes. Additionally, the note identified that no recent injury was noted. A facility investigation dated 04/19/12 and documented by the Director of Nursing (DNS), identified that on 04/20/12 at 4:00 PM the resident complained of pain in the left knee and swelling was noted with no open areas, additionally documented was no injury, positive circulation-motion-sensation (CMS), and positive pedal pulses. Interview with the DNS on 08/07/12 at 10:00 AM identified that because there was no report of a fall or injury he/she concluded that the fracture was related to the [DIAGNOSES REDACTED]. Interview with NA #5 on 08/07/12 at 3:00 PM identified that he/she had cared for R #1 on the 7:00 AM to 3:00 PM shift regularly since the resident's initial admission and that R #1 had consistently refused the use of a mechanical lift. Prior to the identification of the fracture in April of 2012, R #1 was a 2 person lift, then became a 1 person stand-pivot transfer. Interview with NA #4 on 08/08/12 at 1:45 PM identified that he/she had cared for R #1 for the last 3 years and had been instructed to offer the mechanical lift first, followed by the slide board, followed by a stand-pivot-transfer with the use of a camboot. NA #4 identified that he/she was the only staff member who could convince the resident to use the camboot for transfer. Prior to the resident's fracture in April of 2012, following the refusals, 2 staff would transfer the resident by applying a gaitbelt under the breast area and, facing the resident, each staff member would put one arm under the resident's armpit, and, with the other hand, grab the gaitbelt behind the resident and lift the resident from a sitting to a standing position. R #1's feet would then slide across the floor during the pivot. Interview with NA #2 on 08/08/12 at 3:50 PM identified that, prior to the fracture, he/she transferred R #1 with assist of 2 staff, a gaitbelt, and a stand-pivot transfer where the feet would slide over the floor during the pivot. NA #2 described the transfer as "easy". Interview with Physician #2 (the consulting orthopedic surgeon) on 08/14/12 at 1:45 PM identified that, based on review of the x-rays, R #1 had sustained a supracondylar fracture of the left femur which was slightly impacted. The resident had a history of [REDACTED]. Physician #2 identified that this type of fracture would require minimal injury and/or trauma and could occur with weight bearing. 2. R #4's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified impaired hearing, vision, speech, and cognition with severely impaired decision-making; total assistance of 2 staff for transfer; total assistance of 2 staff for bed mobility, locomotion in wheelchair, eating, toilet use, and personal hygiene; functional limitation in ROM on one upper extremity, always incontinent of bowel and bladder, scheduled pain medication regime, no falls, risk for pressure ulcers. RCPs reviewed with the MDS identified the problems of Seizure Disorder, Fall Risk secondary to dementia, impaired mobility, and dystonic movements secondary to MS, and Risk for skin breakdown, bruises, and skin tears due to dyskinesia and risk of injury due to osteoporosis and dyskinesia with interventions that included, in part, small grab bars at upper ends of bed, bed in low position, mats on both sides of the bed, seat belt in custom wheelchair (CWC), report any issues or injuries due to CWC, remove seatbelt and laptray for repositioning, notify nurse for bruising, skin tears, cuts, and abrasions and position chair away from objects when out of bed. Review of a nursing note dated 03/19/12 at 11:50 AM identified that R #4's sister reported a black/blue bruise on the resident's fifth finger. The resident was observed to have spastic movements of the left hand that resulted in the finger coming in contact with various parts of the wheelchair including the laptray. The resident complained of pain in the left hand and right shoulder. A nursing note dated 03/23/12 on the 3:00 PM to 11:00 PM shift identified that the left fifth finger was bruised with a superficial abrasion on the dorsal aspect. An order was obtained to obtain an x-ray in the morning. X-rays of the left fingers obtained on 03/24/12 and 03/25/12 identified a distal subarticular 5th middle phalanx avulsion fracture. Review of a facility investigation dated 03/23/12 identified that at 4:30 PM R #4 was noted to have a bruise of the entire left fifth finger with a superficial abrasion noted at the nail bed. Pain was elicited with passive range of motion. Cause of injury was unknown. The investigation consisted of 5 interviews of Nurse Aides (NA) that worked on the 3:00 PM to 11:00 PM shift on 03/23/12. 3 of the 5 NA's had not had any contact with the resident that day. A summary of the event dated 03/27/12 sent to the State Regulating Agency concluded that the resident had a lot of spastic movements due to the disease process. Interview with NA #6 on 08/13/12 at 3:35 PM identified that R #6's arms frequently dangled off the laptray. The resident tried to assist the staff during care and needed to be cued to keep his/her arms folded out of the way during the mechanical lift transfer and during application of the laptray to the CWC.

Based on observation, interview, clinical record review and review of facility documentation for one ( R #88) of 3 residents reviewed for pressure ulcers, the facility failed to implement appropriate treatment to a stage II pressure ulcer. The findings include: Resident #88's [DIAGNOSES REDACTED]. The resident was readmitted to the facility after extensive abdominal surgery on 9/16/11 with intact buttock skin. An assessment dated [DATE] identified intact cognition, required extensive assistance with most ADL's, had no urine output in the previous 7 days and was occasionally incontinent of bowel. The care plan dated 9/25/11 identified an alteration in skin integrity. Interventions included to notify nurse with any signs/symptoms of skin breakdown. Physician orders [REDACTED]. Review of the wound tracking sheet dated 10/31/11 identified an "excoriation" measuring 1.5 cm by 1.0 cm that was red with no drainage. The wound was assessed weekly, the EPC treatment continued, and on 11/28/11, the wound had deteriorated and Alleyvn was ordered to cover the wound. On 12/5/11, the wound was smaller and an order obtained to change back to EPC cream instead of Allevyn. Observation on 12/14/11 with RN #1 and LPN #1 at 9:45 am identified the left buttock open area was a stage II pressure ulcer measuring 2.0 cm x 1.5cm >0.1, with a partial thickness loss, the wound bed was pink/red and surrounding edges slightly macerated. At that time LPN #1 re- evaluated the current treatment (EPC). Interview and review of facility documentation with RN #3 on 12/15/11 at 11 am noted EPC cream was not an appropriate treatment for [REDACTED]. Review of the manufacturer's website identified EPC was to be applied after each incontinent episode, but was not appropriate for a pressure ulcer.

Based on clinical record reviews, review of facility documentation/investigations, and interviews for 3 of 6 sampled residents with a history of falls/injuries (R# 88, 95, 124), the facility failed to ensure that staff followed the plan of care and/or physician orders, and/or safety principals while transferring and/or caring for residents to prevent injuries and/or falls. The findings include: 1. Resident #124's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified that the resident was cognitively intact, required extensive assistance for transfers, and was totally dependent for personal hygiene. The care plan dated 4/5/11 identified that the resident required assistance of two staff for transfers. Nurse's notes dated 5/1/11 identified that the RN was called to the room where the resident was found seated in the wheelchair with profuse bleeding from the left lower leg. The resident was transferred to the hospital and required seven staples to close the laceration. Interview with NA #5 on 12/6/11 at 2:45 PM noted that the resident was standing at the sink in the bathroom, stepped back and hit his/her leg on the wheelchair sustaining an injury to the leg. The NA further noted that although the resident required the assistance of two staff members for transfer, the bathroom was "too small" to accommodate two staff. The facility failed to ensure that the resident was provided adequate assistance to prevent an injury in accordance with the plan of care. 2. Resident #88's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified that the resident was cognitively intact and required limited assistance with transfers. The care plan dated 4/18/11 indicated that the resident was at risk for falls. Interventions included to assist with all transfers and "may use the sara-lift with me for days I am feeling weak (i.e. after dialysis)". Physician orders [REDACTED]. A nursing note dated 5/21/11 identified that during the 5:00 PM medication pass, the RN heard a loud cry from the resident's room. Upon entering the room the resident was found on the floor. Review of facility documentation/investigation dated 5/21/11 identified that upon return from hemodialysis, the assigned NA assisted the resident to the bathroom without the benefit of the SARA lift. The resident lost his/her balance and landed on the floor. The resident was transferred to the hospital and admitted with a right ankle fracture that required surgical repair. Attempts to contact the assigned NA were unsuccessful. 3. Resident #95's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was without cognitive impairment, and required extensive assistance with ADL's including transfers and ambulation. The RCP dated 11/22/11 identified the resident was at risk for falls related to weakness, impaired mobility, and poor safety awareness. Nurse's Notes dated 12/3/11 identified that at 8:30 AM the physician was notified of a fall. Review of an Interdisciplinary Fall assessment dated [DATE] identified that while the resident was attempting to get out of the bed, the bed was not locked and rolled. Subsequently the resident slid to the floor. Interview, review of the clinical record and facility documentation on 12/15/11 at 11:00 AM with RN #3 identified that the facility conducted an inservice on 12/8/11 on the importance of ensuring beds remain locked.