Every finding on record at Autumn Leaves Nursing and Rehab Inc

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for the facility's only discontinued narcotic drug storage reviewed for reconciliation. The facility failed to ensure they had a log of the discontinued narcotic drug storage on 05/05/26. This failure could place residents at risk for missing medications and medication errors.Findings included: During an observation and interview on 05/05/26 at 01:55PM, the Acting DON took this surveyor to observe the discontinued narcotic drug storage. She unlocked the door and opened it, then unlocked the cabinet and opened it. There were several narcotic medication cards inside. This surveyor picked out 3 cards at random and checked the count sheet attached to each one, and each one had accurate counts. The acting DON said however, that she did not have a log for the medications in that cabinet. She said the previous DON was supposed to help her make a log of the discontinued narcotic drug storage. She said they last had a drug disposal with the consultant pharmacist on 03/25/26. She said she did not have access to the software the previous DON used to log the controlled medications ready for disposal. She said she did not have a log to check the medications against if they went missing. She said she was the only person with a key to the discontinued narcotic drug storage. During an interview on 05/07/26 at 09:16AM, ADON C said she did not handle the discontinued narcotic drug storage. She said the DON should have had a log of the discontinued narcotic drug storage. During an interview on 05/07/26 at 09:23AM, the Acting DON said she did not have access to the scanning system for logging drug destruction. She said after this surveyor check the discontinued narcotic drug storage the other day she went and checked all the counts and made sure they were correct. She said before the previous DON left, she checked the list then and made sure there were no discrepancies. She said that was one day in the previous week. She said there was no risk to this because she was the only one with the key to the discontinued narcotic drug storage. During an interview on 05/07/26 at 10:06AM, the Administrator said they should have a log for the drug destruction narcotics. He said someone could take one of the medications, and they would be unaware it was missing. Record review of the facility's undated policy, Discarding and Destroying Medications, reflected: .Medications are to be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled medications.6. Should the community contract with a DEA-registered collector, controlled substances may be disposed of in an authorized collection receptacle located at the community.a. If a resident is transferred to another community, or dies while he or she is in lawful possession of controlled substances, the community may dispose of the controlled substance(s) by depositing in the authorized on-site collection receptacle and recorded on the drug destruction log.b. Disposal of controlled substances should take place immediately (preferably no longer than three days) after discontinuation of use by the resident.*As in the locked box in the bottom of medication cart or [NAME] cabinet in the medications room.

Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 5 of 13 residents reviewed for care plans. (Resident #41, Resident #84, Resident #09, Resident #98, and Resident # 108)The facility failed to include in the care plan services Resident # 41 was a 2-person transfer with a Mechanical lift.The facility failed to include in the care plan services refused by Resident # 84 (left hand splints and dietary recommendations).The facility failed to develop and implement Resident #9's care plan for upper and lower extremity limited ROM.The facility failed to develop and implement Resident #98's care plan for wandering.The facility failed to develop and implement Resident #108's care plan for falls.These failures could place residents at risk of not having their individualized needs met in a timely manner and could result in a decline in physical well-being and care needs not being addressed. Findings included: 1.Record review of Resident #41's face sheet dated 05/5/2026 indicated Resident #41 was an [AGE] year-old female and admitted on [DATE] and with diagnoses including metabolic encephalopathy ( a reversible brain dysfunction caused by systemic metabolic disturbances, leading to confusion, altered consciousness, and neurological symptoms), Type II Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels in the blood), Hypertensive heart disease with heart failure (a chronic high blood pressure forces heart to work harder to pump blood through narrowed stiffened arteries, which increases cardiac workload and oxygen demand), hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood), and muscle weakness (occurs when muscles cannot generate the expected force, and it can result from temporary fatigue, nutrient deficiencies, or underlying medical conditions). Record review of Resident #41's admission MDS assessment dated [DATE] indicated Resident #41 was usually understood and usually had the ability to understand others. The MDS indicated Resident #41 had a BIMS score of 08 which indicated she was moderately cognitively impaired. Resident #41 required substantial/maximal assistance for transfers and most ADLs. The MDS indicated Resident #41 had a fall history in the last month prior to admission to facility. Record review of Resident #41's care plan initiated on 3/3/2026 indicated Resident #41 had an ADL self-care performance deficit related to generalized weakness and recent hospitalization. Interventions included: encourage resident to use call bell to call for assistance, requires 2 staff assist to move between surfaces and resident utilized a wheelchair for mobility and required 1 person assist for locomotion. During an observation and interview on 5/5/2026 at 8:36 AM, Resident #41 was observed sitting up in a wheelchair with a gait belt around her waist. Resident #41 said it was scary when the CNAs get her back in bed because they do not use the mechanical lift. She said one CNA gets behind her and grabs her from under her arms and the other CNA swings her legs back in the bed. Resident #41 denied any falls. Resident #41 said she could not bear weight. Resident #41 said 2 therapists get her up in the mornings with a gait belt. During an observation on 5/5/2026 at 3:01 PM, observed CNA M and CNA N transferring Resident #41 using the mechanical lift. CNAs properly used the mechanical lift and safely transferred from wheelchair to bed. During an interview on 5/6/2026 at 12:14 PM, PTA E said Resident #41 could stand and was a 2-person transfer. She said transfer Resident #41 by herself with a gait belt. During an interview on 5/7/2026 at 9:21 AM, CNA F said Resident #41 was a 2-person transfer. She said therapy could get her up with one person and she used the mechanical lift with her partner. CNA F said sometimes Resident #41 could not stand. CNA F said therapy was the only one that used the gait belt to assist Resident #41 back to bed. CNA F said she had not observed any CNAs using the gait belt. CNA F said she looks at the care plan if the resident needed something of which she was not sure. She said she checked the care plan daily. CNA F said if the resident were not transferred properly, her legs could give out and lose her balance causing a fall. During an interview on 5/7/2026 at 9:58 AM, RN G said Resident #41 was not weight bearing and the staff used the mechanical lift. RN G said Resident #41 was a 2-person transfer on the care plan. RN G said the mechanical lift was not documented on Resident #41's care plan. RN G said the CNAs received an ADL sheet that indicated Resident #41 was a 2-person transfer and mechanical lift. RN G said the therapist cannot transfer with one person and tell other staff to transfer with 2-person. She said therapy would need to assist Resident #41 with a mechanical lift as well. RN G said the MDS nurse was responsible for updating the care plan. RN G said a resident could fall resulting in injury if the wrong transfer technique was used. During an interview on 5/7/2026 at 10:50 AM, the MDS nurse said Resident #41 did not have a mechanical lift on her care plan. The MDS nurse said Resident #41 was care planned for 2-person assist between surfaces and wheelchair. The MDS nurse said the mechanical lift should be on the care plan. She said staff and CNAs usually tell her when a resident requires a mechanical lift. She said she was responsible for putting the mechanical lift on the care plan. MDS nurse said therapy was involved with the care plan. The MDS nurse said the therapist should also follow the care plan. She said if the resident could stand and therapy used 2-person for transfer, the resident could fall or get hurt if transfer was done improperly. During an interview on 5/7/2026 at 11:45 AM, ADON C said Resident #41 was a 2-person assist. ADON C said the CNAs can get Resident #41 up without issues. ADON C said Resident #41 was not a mechanical lift resident and she did not see any weight bearing restrictions. ADON C said if the CNAs were using the mechanical lift, it should be on the care plan. ADON C said the MDS nurse was responsible for putting mechanical lift on the care plan. ADON C said she thought therapy would need to follow the care plan. She said the therapist would need to see if Resident #41 has increased or decreased possibilities to stand. ADON C said the resident would be at risk for falls if 2 CNAs transferred her improperly. During an interview on 5/7/2026 at 12:02 PM, the DON said she expected the care plan to reflect the mechanical lift. The DON said it could be confusing to the CNAs if the care plan indicated 2-person transfer and not mechanical lift. The DON said the IDT and evaluation from therapy made the determination. The DON said the therapy must follow the care plan. The therapies plan of care could be different. She said, I would have to see what therapy notes indicated. The resident could get hurt. During an interview on 5/7/2026 at 12:19 PM, ADM said he expected the mechanical lift to be care planned. The IDT (Interdisciplinary Team) was responsible for ensuring mechanical lift was on the care plan. A resident could have an improper transfer causing a potential to have an incident 2. Record review of Resident #84's face sheet dated 5/5/2026 indicated Resident #84 was a [AGE] year-old male who was readmitted on [DATE], with diagnoses including spastic hemiplegic cerebral palsy (a type of cerebral palsy that causes muscle stiffness and weakness on one side of the body, usually due to brain damage occurring before, during or shortly after birth), hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood), acquired absence of left and right leg above the knee (a condition where an individual has lost part of leg), dysphagia (difficulty swallowing, can manifest through various symptoms), and hypertensive chronic kidney disease (a condition where high blood pressure damages the kidneys, impairing their ability to filter blood effectively and in turn, kidney damage can further elevate blood pressure). Record review of Resident #84's quarterly MDS assessment dated [DATE] indicated Resident #84 was sometimes understood and usually had the ability to understand others. The MDS indicated Resident #84 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #84 did not reject care. The MDS indicated Resident #84 had dysphagia (difficulty swallowing, can manifest through various symptoms) and had a contracture (occurs when soft tissues such as muscles, tendons, ligaments, or fascia become stiff and shortened due to scarring or fibrosis, reducing the hand's range of motion and potentially causing deformities) of left hand. The MDS indicated Resident #84 did not have a splint. During an interview on 5/7/2026 at 9:13 AM, CNA F said she has been at the facility since the end of March. CNA F says the resident will tell her what kind of care he needs. CNA F said he does not wear a splint on his left arm. CNA F said therapy puts on splints for residents. CNA F said Resident #84 was on a regular diet. He will tell you what he wants to eat. CNA F said they did not have access to the care plan because her log in was not working. She said she had notified HR and ADON C and a nurse on the floor. CNA F said she was not an agency CNA. CNA F said she thought the nurse puts together the care plan. CNA F said she and her partner document on the same sign-in sheet. CNA F said she would want to know if a resident was on a special diet if a resident refused a special diet but had rights to have the food. She said she would check with a nurse to see if a resident needed a splint. CNA F said a resident could receive care that they were not supposed to, impacting their independence. CNA F said ADON C was responsible for ensuring care plans were being followed. During an interview on 5/7/2026 at 9:42 AM, RN G reviewed Resident #84's care plan. RN G said she never looks at the care plan. RN G said Resident #84 did not have orders for splints. RN G said the care plan indicated how to care for the resident. RN G said it should be care planned if he had splints but said she looks at the orders. RN G said the care plan did not have resident refusal to wear splints. RN G said his diet was regular with thin liquids. RN G said it does not mention anything about mechanical soft diet and did not have a care plan indicating resident had signed a waiver for regular diet. RN G said she did not see a waiver. RN G said the care plan should have been updated indicating Resident was ordered a mechanical diet but Care plan showed Regular. RN G said she was unaware the resident had a waiver signed. RN G said the MDS nurse was responsible for updating the care plan. It should have been updated when the order was received. RN G said the resident could potentially get the wrong diet. It could be harmful to the resident if he did not have the waiver signed. During an interview on 5/7/2026 at 10:50 AM, the MDS Nurse said Resident #84 does not have splint on his care plan. She said if a resident had splints but refused, it should be care planned. The MDS nurse said she did not have refusal for splints on the care plan. The MDS nurse said Resident #84 was on a regular diet. The MDS nurse said the refusal for mechanical soft diet with waiver in place should be on the care plan. She said she was responsible for updating the care plan. The MDS nurse said he could choke and he does cough a lot. During an interview on 5/7/2026 at 11:38 AM, ADON C said Resident #84 does not want to wear a splint on his left hand and it should be on his care plan. ADON C said Resident #84 reviewed care plan and said he did not have hand splint refusal on his care plan. ADON C said she did not see anything about his refusals on the care plan. She said the splint refusal should have been put on the care plan since his admission. She said the MDS nurse was responsible for putting the refusals on the care plan. ADON C said she thought the NP's notes needed to be retracted to reflect the regular diet with refusal for special diet and said Resident #84 understood the risk of doing so. ADON C said the purpose of care plan was to ensure the residents' needs were met and followed, and their wishes and rights were in place. ADON C said there would be no impact on the residents. During an interview on 5/7/2026 at 11:59 AM, the DON said she expected the refusal of splints and diet to be on the care plan. She said the IDT was responsible for the care plan. She said the staff talked about the care plan in the morning care plan meetings. The DON said the staff address concerns and updates during those meetings. During an interview on 5/7/2026 at 12:19 PM, the ADM said Resident #84 wants what he wants. The ADM said refusal of care areas such as diet and splints should be care planned. He said the IDT team was responsible for putting the refusals on the care plan. The ADM said he did not know how it could negatively impact a resident but said it was the resident's rights. 3.Record review of Resident #09's undated facesheet revealed she was a [AGE] year-old female that admitted on [DATE] with the diagnoses of CVA (the medical term for a stroke), dysphagia (difficulty swallowing), and anemia. Record review of Resident #09's quarterly MDS assessment dated [DATE] revealed Resident #09 had short and long term memory impairment. She required substantial (helper does more than half the work) assistance with dressing and bed mobility and she was dependent for oral care and eating. Resident #09 had limited range of motion to upper and lower extremities on one side of her body. Record review of Resident #09's EHR on 05/07/2026 at 10:00 a.m., revealed no care plan for limited range of motion. During an observation on 05/07/2026 at 10:15 a.m., Resident #09 had hemiplegia (severe, one-sided paralysis caused by brain or spinal cord injury, affecting the face, arm, and leg on either the left or right side) on right side of her body. 4.Record review of Resident #98's undated facesheet revealed she was a [AGE] year-old female that admitted on [DATE] with the diagnoses of dementia (an umbrella term for a decline in cognitive function—including memory, language, and problem-solving—severe enough to interfere with daily life), bipolar disorder (a chronic mental health condition characterized by severe mood swings, ranging from extreme highs [mania or hypomania] to lows [depression]), and diabetes type II (a chronic metabolic disorder characterized by high blood sugar [glucose] levels, resulting from insufficient insulin production or the body's inability to use insulin effectively). Record review of Resident #98's annual MDS assessment dated [DATE] revealed Resident #98 had a BIMS score of 09, which indicated moderate cognitive impairment. She required supervision with ADLs. Resident #98 had behaviors of wandering 1 to 3 days a week and her wandering put her at risk of getting into dangerous places. Record review of Resident #98's EHR on 05/07/2026 at 10:20 a.m., revealed no care plan for wandering. 5. Record review of an undated facesheet revealed Resident #108 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (an umbrella term for a decline in cognitive function—memory, thinking, and reasoning—severe enough to interfere with daily life), history of falls, and unsteadiness on feet. Record review of a quarterly MDS dated [DATE] revealed Resident #108 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #108 had no behaviors coded. Resident #108 required substantial assistance (helper does more than half) for toileting and showers. Resident #108 required supervision for dressing and personal hygiene. The MDS revealed Resident #108 had a fall while a resident since the last MDS assessment was completed. Record review of the facility Incident and Accident Log dated 05/06/2026 revealed Resident #108 had falls on 10/11/2025 and 12/08/2025. Record review of Resident #108's EHR on 05/07/2026 at 10:30 a.m., revealed no care plan for falls on 10/11/2025 or 12/08/2025 were developed or implemented. During an interview on 05/07/2026 at 11:00 a.m., the MDS Coordinator stated it was her sole responsibility to create care plans. She stated she care planned all items that triggered as a care area that needed to be addressed on the MDS. She stated she care planned major diagnoses and medications and acute things like falls and weight loss. She stated she should have care planned Resident #09's limited range of motion to her right side because it was marked on the MDS and it was an important detail for care givers to know when caring for her. The MDS Coordinator stated Resident #98 was coded for wandering at times and that should have been care planned, as well. She stated she was unsure why Resident #108's falls from October and December were not care planned. The MDS Coordinator stated care planning was important because it was a map on how to treat each resident individually. During an interview on 5/7/2026 at 11:15 a.m., the DON said she expected the falls, wandering and limited range of motion on the care plan. She said the IDT was responsible for the care plans. She said the staff talked about the care plans in the morning care plan meetings. The DON said the staff address concerns and updates during those meetings. During an interview on 5/7/2026 at 12:00 p.m., the Administrator stated he expected all specific care areas that can affect the residents to be care planned. The Administrator stated he did not know how not having something care planned could negatively impact a resident but said it was the resident's rights. Record review of the facility's policy titled Care Plan Process undated indicated .Purpose: The facility IDT team utilizes the CMS requirements of RAI as policy for reviewing and revising care plans.Responsible Disciplines.IDT members, resident, Resident Representatives.Steps: Care Plan Completion.Care plan completion based on the CAA process is required for OBRA- required comprehensive assessment.After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors to the problems.the IDT evaluates the information gained.The care plan completion date must be either later than or the same date as the CAA completion date.The MDS completion date must be earlier than or the same sate as the care plan completion date.For Annual assessments.Review of the CAA when the MDS is complete for these assessment types should raise questions about the need to modify or continue services. A new care plan does not need to be developed after each Annual assessment.Residents' preferences and goals may change throughout their stay, therefore the IDT should have ongoing discussions with the resident and resident representative, and staff member, so that changes can be reflected in the comprehensive assessment.

Based on observations, interviews and record review, the facility failed to act upon the recommendations of the pharmacies report of irregularities for 3 of 7 residents (Resident #1, #88 and #108) reviewed for (DRR) Drug Regimen Review. 1.The facility failed to ensure a proper rationale was given for not following the pharmacy consultant's recommendation for a trial dose reduction for Resident #1's Oxcarbazepine (an anticonvulsant medication sometimes used off-label as a mood stabilizer), Trazodone (an antidepressant commonly used to treat major depressive disorder, anxiety disorders, and insomnia), and Alprazolam (a benzodiazepine used to treat anxiety disorders, panic disorders, and anxiety associated with depression). 2.The facility failed to ensure Residents #88 and #108 received gradual dose reduction attempts to determine whether the psychotropic medication could be decreased or discontinued. These failures could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy.Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female that admitted [DATE] with a readmission date of 1/23/2026. She had diagnoses that included: Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life, going beyond temporary stress), unspecified depression (significant depressive symptoms, such as persistent sadness, low energy, or hopelessness), and chronic migraine (neurological disorder defined by headaches occurring on 15 or more days per month for over 3 months). Record review of the quarterly MDS dated [DATE] indicated Resident #1 had clear speech, understood others and was understood by others. She had a BIMS score of 15 indicating she was cognitively intact. The MDS indicated she took an antianxiety, antidepressant, and an anticonvulsant currently. Record review of the undated care plan indicated Resident #1 was on an antidepressant and was to be monitored for behavior and side effects of the medication. The care plan indicated she was on an antianxiety medication related to anxiety disorder, side effects and effectiveness should be monitored. The care plan indicated Resident #1 had seizure disorder and medications should be administered per MD orders. Record review of Resident #1's physician's orders indicated: -2/2/2026 - Alprazolam oral tablet 0.5 mg, give 1 tablet by mouth at bedtime for anxiety -2/2/2026 – Oxcarbazepine oral tablet 150 mg, give 1 tablet by mouth two times a day for mood stabilizer -2/2/2026 – Trazodone HCI oral tablet 50 mg, give 1 tablet by mouth at bedtime for insomnia During an interview on 5/4/2026 at 11:29 AM, the ADM said Resident #1 had left the facility to go and eat with her family. During an interview and observation on 5/5/2026 at 8:50 AM, Resident #1 was in bed and said good morning. Said she was having a good morning so far. She had numerous personal items in her room and a trapeze bar above her bed. She said staff was nice to her and she was pleased with the facility. During an interview on 05/06/2026 at 3:21 PM, the acting DON and ADM said the reason Resident #1's medications were all dated 2/2/2026 was because a new Medical Director took over on 2/1/2026 and he would have reordered her medications. During an interview and record review on 5/06/2026 at 3:55 PM, the acting DON said Resident #1 began her began Alprazolam, Oxycarbazepine, and Trazodone on 8/8/2025. She said the orders were written again exactly the same, when the new Medical Director came to the facility on 2/1/2026, that was why those medications were dated 2/2/2026. She showed this surveyor that the original orders were dated 8/8/2025. During a record review and interview on 5/07/2026 at 8:46 AM, ADON C brought this surveyor 2 GDR's for Resident #1 dated 1/27/2026 and 2/28/2026. Both GDR's indicated Patient will not agree. ADON C said there was no documentation of discussing any of these medications with Resident #1. Record review of the GDR's for Resident #1: Consultant Pharmacist/Physician Communication dated 1/27/2026 indicated: Current Order: Oxcarbazepine 150 mg twice daily, Trazodone 50 mg at bedtime Recommendation: Oxcarbazepine 150 mg daily, Trazodone 25 mg at bedtime The NP checked disagree and indicated Patient will not agree. The NP signed the document on 2/2/2026. Record review of the GDR's for Resident #1: Consultant Pharmacist/Physician Communication dated 2/28/2026 indicated: Current Order: Alprazolam 0.5 mg at bedtime Recommendation: Alprazolam 0.5 mg at bedtime for 10 days then trial discontinue The NP checked disagree and indicated Patient will not agree. The NP signed the document on 3/3/2026. During an interview on 5/07/2026 at 9:17 AM, Resident #1 said someone talked with her about her medications, but she did not remember who or when it was. She said she did not agree or disagree to having any medication reduced or discontinued. During an interview 5/7/2026 at 9:53 AM, ADON B looked at the GDR's for Resident #1 and indicated where the NP wrote patient does not agree was not acceptable because they should have provided education to the resident on the importance of a gradual dose reduction to prevent side effects and to see if there were other options or maybe some of her medications were not needed at that dose anymore. The risk of not getting a GDR is taking medications that were not needed or were not needed at that dose. During an interview on 05/07/2026 at 10:11 AM, the NP said Resident #1 would not agree with her discontinuing or lowering the dosages of any of her medications. She said Resident #1 said it took over a year for the MD's to get her medication correct and she did not want it changed. She was with it and knew what medications she took. She said she did not document the conversation she had with Resident #1 about her medications. During an interview on 5/07/2026 at10:16 AM, ADON C said the importance of a GDR was to ensure the resident was getting the lowest possible effective dose or to see if a particular medication could be discontinued. She said the risk of a GDR not being done could be oversedation or unnecessary medications given to the resident. During an interview on 5/7/2026 at 10:26 AM, the acting DON said she would expect documentation from the NP as to why Resident #1 would not agree to a reduction in dose of her medications, or a discontinuation and when the NP spoke to her. She said the risk of not getting a GDR was taking a medication or a strength that may not be needed, and could be unnecessary medication. During an interview on 5/7/2026 at 10:38 AM, the ADM said he would expect the NP or staff to document Resident #1's refusal to have her medications changed and educate the resident regarding those medications. She could be taking medications she did not need or dosages she did not need. 2. Record review of an undated facesheet revealed Resident #88 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (a progressive, irreversible brain disorder that destroys memory, thinking skills, and eventually the ability to perform daily tasks), COPD (Chronic Obstructive Pulmonary Disease is a progressive, treatable lung disease—often caused by smoking—that makes it hard to breathe due to damaged airways and air sacs), and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #88 had a BIMS score of 05, which indicated severe cognitive impairment. Resident #88 had no behaviors or episodes of anxiety coded. Resident #88 required substantial assistance (helper does more than half) for toileting and showers. Record review of a care plan dated 02/05/2026 revealed Resident #88 was on an antianxiety medication Record review of a GDR written by Pharmacist L dated 10.31.2025 revealed Resident #88 had an 'order for lorazepam PRN. PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing NP believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document and indicate the duration of the PRN order.' During an interview on 05/06/2026 at 9:20 a.m., ADON C stated she was responsible for ensuring GDRs were completed for all residents on psychotropic medications that the pharmacist recommended monthly. She stated it was important to ensure no residents were on unnecessary medications, especially psychotropic medications because they had dangerous side effects like increased falls, decreased appetite, and sedation. She stated Resident #88 had a GDR for her prn lorazepam in October 2025 and March of 2026, but she could not find proof that the MD replied to the request to discontinue the PRN lorazepam and had no documentation of any attempts at follow up. She stated she knew it was a regulation and would ensure it was done as soon as possible. 3.Record review of an undated facesheet revealed Resident #108 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (an umbrella term for a decline in cognitive function—memory, thinking, and reasoning—severe enough to interfere with daily life), history of falls, and unsteadiness on feet. Record review of a quarterly MDS dated [DATE] revealed Resident #108 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #108 had no behaviors coded. Resident #108 required substantial assistance (helper does more than half) for toileting and showers. Resident #108 required supervision for dressing and personal hygiene. The MDS revealed Resident #108 received antipsychotic medications daily. Record review of a GDR dated 03/31/2026 revealed a pharmacist recommendation to decrease Zyprexa 5mg daily to Zyprexa 2.5mg daily to ensure lowest effective dose was being utilized. Record review of a care plan dated 08/25/2025 revealed Resident #108 was on an antipsychotic medication for a mood disorder. Record review on 05/07/2026 of the following MARs for Resident #108 revealed daily use of Zyprexa 5mg: February 2026-28 daily doses March 2026-31 daily doses April 2026-30 daily doses May 2026-7 daily doses Record review on 05/06/2026 of the behavior monitoring for the use of Zyprexa revealed the following: February 2026- 0 episodes of behaviors March 2026- 0 episodes of behaviors April 2026- 0 episodes of behaviors May 2026- 0 episodes of behaviors During an interview on 05/06/2026 at 9:20 a.m., ADON C stated she was responsible for ensuring GDRs were completed for all residents on psychotropic medications that the pharmacist recommended monthly. She stated it was important to ensure no residents were on unnecessary medications, especially psychotropic medications because they had dangerous side effects like increased falls, decreased appetite, and sedation. She stated Resident #108 came to the facility on Zyprexa and a GDR was recommended by the pharmacist, but NP J had not agreed to the reduction. She stated she was unaware of any nonpharmalogical interventions that had been tried for Resident #108. She stated Resident #108 had a brief time, maybe 2 weeks to a month, where she would swat at the staff when they tried to provide care. ADON C stated she was unaware of any other behaviors Resident #108 had. She stated Resident #108 had no behaviors that were a danger to herself or others. During an interview on 05/07/2026 at 11:00 a.m., NP J stated she felt it was necessary for Resident #108 to have Zyprexa. She stated she was admitted with an order for Zyprexa, and she had several conversations with Resident #108's family and did not feel the family would agree to decrease the Zyprexa. NP J stated she had not actually spoken to the family about the pharmacist's request to decrease the Zyprexa, but the family was particular about her medications. NP J stated Resident #108 was on Zyprexa for dementia and the behaviors of resisting care by swatting at the staff and attempting to bite them when she did not want to bathe. NP J stated she was aware of the black box warning for the elderly for antipsychotic medications. NP J stated the overuse of psychotropic medications can be considered a chemical restraint because the medications are often sedating. She stated she received the request today to discontinue the PRN lorazepam for Resident #88 and she accepted the request. Durning an interview on 05/07/2026 at 11:30 a.m., the family of Resident #108 stated they were never called or talked to about the pharmacist request for a dose reduction of Resident #108's Zyprexa. They stated it was important to them to be informed of all aspects of their mother's care. During an interview on 05/07/2026 at 1:00 p.m., the DON stated it was necessary to monitor psychotropic drug use in the elderly because the goal was for the medication to be necessary and therapeutic. The DON stated antipsychotics are not recommended for residents with dementia that do not have behaviors that are potentially dangerous to themselves or others. She stated these medications are reviewed periodically by the pharmacist and the recommendations were given to the NP to review and either agree or disagree. She stated the ultimate goal was benefit over risk with all medications, but psychotropic medications have serious side effects that had to be considered closely like increased falls and sedation that could lead to weight loss and skin impairments. During an interview on 05/07/2026 at 2:00 p.m., the Administrator stated it was his expectation that all medications would be reviewed on admission and any psychotropic medications would have appropriate diagnoses and appropriate indications for use before they are administered to the residents in this facility. He stated all pharmacy requests should be followed up on and documented. He stated the family were to be notified and documentation of the family's response. Requested policy for gradual dose reduction on 05/06/2026 and 05/07/2026. No policy was provided prior to exit.

Based on interviews, record reviews, and observation, the facility failed to consistently serve a suitable, nourishing alternative meals and snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times for 5 of 5 residents reviewed for snacks. (AR #1, AR #2, AR #3, AR #4 and AR #5) The facility failed to offer an evening nourishing snack routinely for residents on 4/5/2026 to 4/6/2026. This failure could put residents at risk of experiencing complications of diabetes such as low blood sugar, weight loss, or hunger during the night. During a confidential interview at an undisclosed date and time, AR#1 stated that the staff left snacks at the nurse station and residents must get snacks. The anonymous resident stated that not all residents were able to get out of bed to get snacks in the evening and not every resident was offered evening snacks. During a confidential interview at an undisclosed date and time, AR #2 on Hall 100 said the staff did not always ask if she wanted a snack in the evening. She said the staff placed snacks at the nurse station. She said they thought they would bring her a snack if she asked for it. During a confidential interview at an undisclosed date and time, AR #3 on hall 100 said the facility staff had not offered her snacks at bedtime. Resident said she was unsure if they put snacks out in the evenings. She said she sometimes got hungry and kept crackers in her drawer. During a confidential interview at an undisclosed date and time, AR #4 on Hall 500 stated she did not recall being offered snacks, but said she kept snacks in her room. During a confidential interview at an undisclosed date and time, AR #5 on Hall 200 said the facility staff did not offer him snacks at bedtime. Resident said he could not make his way to the nurse's station to get snacks due to being bedbound. During an interview on 5/7/2026 at 9:30 AM, CNA F said she did not work the night shift. CNA F stated residents should get snacks in the evening. CNA F said the kitchen staff would bring snack trays to the nurse station. CNA F said most of the time, she would ask the residents what they wanted off the snack trays. She said the nurses or the CNAs would pass out the snacks. CNA F said the CNAs would pass out the snacks if they were not too busy. CNA F said if a resident did not eat, they could get shaky due to low blood sugar or get dizzy resulting in a fall. During an interview and observation on 5/7/2026 at 10:11 AM, RN G said snacks were put out after every meal. RN G said the snacks were placed on a tray at the nurse's station. A snack tray was observed at the nurse's station with snacks with residents' names. RN G said residents with special requests had their name on the snacks, and some residents had orders for snacks. RN G said nurses and aides were responsible for passing out snacks. RN G said everyone was offered snacks. RN G said staff took the snacks down the hall to each resident, and if there was a snack they wanted, we would get it. RN G said if a resident was a diabetic, they could have a hypoglycemic episode. During an interview on 5/7/2026 at 11:00 AM, the Dietary Supervisor said snacks were placed at the nurse station at 10 am, 2 pm and 7 pm. She said she put names on snacks if they requested a special snack. The Dietary Supervisor said everyone in the facility was offered snacks. She said she put the snacks behind the nurse stations so the residents did not get something they should not have, such as peanuts. The Dietary Supervisor said the nurses were responsible for passing the snacks out. The Dietary Supervisor said there had been complaints from the residents not getting snacks. The Dietary Supervisor said she reported it to the ADM. She said it had been brought up in resident counsel. The Dietary Supervisor said it would get better, and the complaints would come back up. During an interview on 5/7/2026 at 11:52 AM, ADON C said the dietary staff brought snacks out to the nurse station. ADON C said there were snacks for diabetic residents and extra snacks for anyone who wanted one. ADON C said snacks should be offered down the halls. ADON C said the nurse staff were not asking residents if they wanted snacks unless they were ordered. ADON C said there were plenty of snacks to offer everyone. She said a diabetic's blood sugar could get low, or a resident with weight loss could lose more weight if a snack was not received. During an interview on 5/7/2026 at 12:11 PM, DON said snacks came from kitchen. She said everyone was responsible for offering snacks. DON said a lot of the residents had snacks in their rooms. DON said all the nurses should be offering snacks. DON said she expected the nursing staff to offer snacks at night to residents. DON said it would be the resident's right to get snacks if they wanted one. During an interview on 5/7/2026 at 12:19 PM, ADM said CNAs were responsible for offering snacks in the evening. The ADM said the snacks were available at the nurse station. The ADM said the residents could get hungry. Record review of the facility's policy titled Texture Modified Diets and Snacks dated 6/3/2025 indicated .the facility will ensure that physician orders are initiated for texture appropriate diets and snacks and provided to all residents, including available snacks. Procedures: 1. Nutrition and food service will provide bedtime snacks each night for all residents including residents with orders for a puree diet. 2. All snacks served will be appropriate for mechanical soft diets.3. Nursing will print out a diet order each morning.4. New Admissions, Readmissions diet/textures orders are reviewed in morning meeting.5. Nursing/designee the same day will enter information.6. Nursing provides the dietary manager/designee with a diet communication form.7. If communication form and Nutrition Management System consistent information.8. The Dietary manager/designee is responsible for entering additional information.9. The diet order report should be kept at the nurse's station near the snack cart for reference.The CNA staff should reference the list prior to passing foods to residents. 10. All snacks ordered at 10:00 AM and 2:00 PM will be dated and labeled with resident's name.11. The [NAME] diet manual should be used for reference.

Based on record review and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 13 residents reviewed for resident rights. (Resident #108) The facility failed to protect and promote the rights of Resident #108 by using inappropriate techniques to check the resident for the need for incontinent care. These failures could place residents at risk for decreased self-esteem, decreased privacy and decreased quality of life.The findings included: 1. Record review of an undated facesheet revealed Resident #108 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (an umbrella term for a decline in cognitive function-memory, thinking, and reasoning-severe enough to interfere with daily life), history of falls, and unsteadiness on feet. Record review of a quarterly MDS dated [DATE] revealed Resident #108 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #108 had no behaviors coded. Resident #108 required substantial assistance (helper does more than half) for toileting and showers. Resident #108 required supervision for dressing and personal hygiene. The MDS revealed Resident #108 received antipsychotic medications daily. Record review of Resident #108's care plan dated 08/25/2025 revealed Resident #108 had an ADL deficit related to dementia. Resident #108 required 1 staff assistance with ADL care. Record review on 05/05/2026 at 10:30 a.m., of a video provided by the family of Resident #108 revealed CNA K patting and squeezing Resident #108's buttock through her clothing lasting less than 30 seconds. During an interview on 05/06/2026 at 9:10 a.m., CNA K stated she did not recall patting and squeezing Resident #108's buttock at any point. She stated if she had done that it might have been to check for wetness of her clothing. CNA K stated sometimes the adulty briefs leak if they are not lined up correctly with the female anatomy. CNA K stated there were better ways to check for wetness, but she meant no harm to the resident. CNA K stated she could have assisted Resident #108 to the bathroom and checked her clothing while assisting the resident with her clothing. During an interview on 05/05/2026 at 10:30 a.m., a family member of Resident #108 stated, Resident #108 would have been furious from embarrassment if she were not stricken with dementia. [Resident #108] would not have stood for someone touching her bottom like she was a 2-year-old. The family member stated they felt it was inappropriate to treat Resident #108 like a baby. During an interview on 05/06/2026 at 10:30 a.m., the DON stated she was unaware the incident occurred. She stated it was not regular practice to check a resident for incontinence by touching them on their buttock. The DON stated it potentially could make someone feel inferior or less than the grown adult they are to be treated like a small child. The DON stated the proper way to check the resident's clothing for wetness would have been to ask the resident's permission to touch their clothing prior to and take them to the restroom where their continence status could be addressed in the appropriate environment. During an interview on 05/07/2025 at 1:00 p.m., the Administrator stated it was his expectation that all staff treat each resident with dignity and respect. He stated he did not feel CNA K was trying to be demeaning or purposely embarrass Resident #108. He stated staff education on resident rights would cover checking residents for incontinence while maintaining dignity. Review of a facility policy titled Dignity dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.When assisting with care, residents are supported in exercising their rights, For example, residents are: .e. provided with a dignified dining experience.

Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs and PRN orders for psychotropic drugs were limited to 14 days for 2 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #23, and Resident #108). 1. The facility failed to ensure Resident #23 did not have a PRN order for lorazepam 0.5 mg (a prescription medication used to treat anxiety disorders-feelings of fear, dread, and uneasiness) after 14 days without an evaluation by the physician for continued treatment with a rationale in the resident's medical record and a duration for the PRN order. 2. The facility failed to ensure psychotropic medications were not used unless necessary to treat a specific diagnosed condition by continuing an antipsychotic medication for a resident with dementia without adequate clinical justification, documented behavioral symptoms, non-pharmacological interventions, or evidence of the medication regimen was necessary to protect Resident #108 or other residents. This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #23's face sheet, dated 05/05/26, reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included hypertensive heart disease with heart failure (occurs when long-term, unmanaged high blood pressure forces the heart to work too hard, causing the muscle to thicken and eventually weaken or become too stiff to pump efficiently), and anxiety disorder (serious, treatable mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life). Record review of Resident #23's quarterly MDS assessment, dated 04/23/26, reflected she had a BIMS score of 14, which indicated intact cognition. She was able to make herself understood and she was able to understand others. Record review of Resident #23's Order Summary Report, dated 05/05/26, reflected an order for lorazepam oral tablet 0.5mg Give 1 tablet every 12 hours as needed for anxiety. The start date was 02/02/26. There was not an end date listed. During an interview on 05/07/2026 at 9:16 AM, ADON C said Resident #23 was not on hospice. She said the PRN lorazepam should have had a 14-day end date. She said there was not a risk because she would not receive too much medication and she would not receive an unnecessary medication. During an interview on 05/07/26 at 09:23AM, the Acting DON said she heard about an issue with PRN psychotropics on 05/04/26 and fixed it immediately. She said her expectation was that the policies and procedures were followed. She said there was not a risk to the resident having the PRN lorazepam without a stop date. During an interview on 05/07/26 at 10:06AM, the Administrator said Resident #23's PRN lorazepam should have had an end date. He said he did not know the risk of it not having an end date because he is not clinical. 2. Record review of an undated facesheet revealed Resident #108 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (an umbrella term for a decline in cognitive function—memory, thinking, and reasoning—severe enough to interfere with daily life), history of falls, and unsteadiness on feet. Record review of a quarterly MDS dated [DATE] revealed Resident #108 had a BIMS of 03, which indicated severe cognitive impairment. Resident #108 had no behaviors coded. Resident #108 required substantial assistance (helper does more than half) for toileting and showers. Resident #108 required supervision for dressing and personal hygiene. The MDS revealed Resident #108 received antipsychotic medications daily. Record review of a care plan dated 08/25/2025 revealed Resident #108 was on an antipsychotic medication for a mood disorder-Zyprexa 5mg by mouth at bedtime. Record review on 05/07/2026 of the following MARs for Resident #108 revealed daily use of Zyprexa 5mg: February 2026-28 daily doses March 2026-31 daily doses April 2026-30 daily doses May 2026-7 daily doses Record review on 05/06/2026 of the behavior monitoring for the use of Zyprexa revealed the following: February 2026- 0 episodes of behaviors March 2026- 0 episodes of behaviors April 2026- 0 episodes of behaviors May 2026- 0 episodes of behaviors During an interview on 05/06/2026 at 9:20 a.m., ADON C stated she was responsible for ensuring GDRs were completed for all residents on psychotropic medications that the pharmacist recommended monthly. She stated it was important to ensure no residents were on unnecessary medications, especially psychotropic medications because they had dangerous side effects like increased falls, decreased appetite, and sedation. She stated Resident #108 came to the facility on Zyprexa and a GDR was recommended by the pharmacist, but NP J had not agreed to the reduction. She stated she was unaware of any nonpharmalogical interventions that had been tried for Resident #108. She stated Resident #108 had a brief time, maybe 2 weeks to a month period, where she would swat at the staff when they tried to provide care. ADON C stated she was unaware of any other behaviors Resident #108 had. She stated Resident #108 had no behaviors that were a danger to herself or others. During an interview on 05/07/2026 at 11:00 a.m., NP J stated she felt it was necessary for Resident #108 to have Zyprexa. She stated she was admitted with an order for Zyprexa, and she had several conversations with Resident #108's family and did not feel the family would agree to decrease the Zyprexa. NP J stated Resident #108 was on Zyprexa for dementia and the behaviors of resisting care by swatting at the staff and attempting to bite them when she did not want to bathe. NP J stated she was aware of the black box warning for the elderly for antipsychotic medications. NP J stated the overuse of psychotropic medications can be considered a chemical restraint because the medications are often sedating. NP J stated there were other medications that could be tried with less serious side effects for the behaviors Resident #108 had. During an interview on 05/07/2026 at 1:00 p.m., the DON stated it was necessary to monitor psychotropic drug use in the elderly because the goal was for the medication to be necessary and therapeutic. The DON stated antipsychotics are not recommended for residents with dementia that do not have behaviors that are potentially dangerous to themselves or others. She stated the ultimate goal was benefit over risk with all medications, but psychotropic medications have serious side effects that had to be considered closely like increased falls and sedation that could lead to weight loss and skin impairments. The DON stated there were nonpharmological interventions that could have benefited Resident #108, like redirecting, getting different staff to approach, and notifying family members for them to intervene and get the care done for Resident #108. During an interview on 05/07/2026 at 2:00 p.m., the Administrator stated it was his expectation that all medications would be reviewed on admission and any psychotropic medications would have appropriate diagnoses and appropriate indications for use before they are administered to the residents in this facility. Record review of the Facility's policy, Medication and Treatment Orders, last revised July 2024, reflected: .Orders for medications and treatments should be consistent with principles of safe and effective order writing. .c. PRN medications such as psychotropic medications ordered for 14 days should have a stop date and then the need to continue be evaluated by the physician to determine a continued need for scheduling the medication ongoing.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM (Range of Motion) for 1 of 23 residents (Resident #107) reviewed for quality of care. The facility failed to ensure Resident #107 had a contracture prevention device in place for treatment of her right-hand and left-hand contractures. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. Findings include: Record review of Resident #107's undated face sheet indicated she was an [AGE] year-old female that admitted [DATE] with a readmit date of 7/13/22. She had diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis or weakness on her dominant side following a stroke, damage to the brain's left hemisphere affecting motor control, balance, and often causing speech/language deficits because the dominant hemisphere is involved), contracture of the left hand (tightening of muscles, tendons, or skin leading to rigid, still joints and a fixed, often clenched-fist position), contracture of the right hand, unspecified dementia (affects memory, thinking, and the ability to perform daily activities), and pain in right and left hand. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #107 had unclear speech, was rarely or never understood, and rarely or never understood others. She had short-term and long-term memory problems. The MDS indicated she had impairment on one side on her upper extremity, one side on her lower extremity, and required substantial/maximal assistance for eating. Record review of Resident #107's undated care plan indicated Resident #107 had an ADL self-care performance deficit related to dementia, impaired balance, limited mobility, stroke with left side hemiplegia, limited physical mobility related to neurological deficits, stroke, left hand contractures. The goal was for the resident to remain free of complications related to immobility, including contractures.The care plan indicated Resident #107 had an alteration in musculoskeletal status related to contracture of the left hand. The interventions did not include a contracture prevention device. The care plan indicated she had Carpal Tunnel Syndrome and osteoarthritis (degenerative joint disease that breaks down cartilage, bone, and tissue) with 1-2+ edema (swelling) to the right arm at times with arthritis which could cause inflammation. The interventions did not include a contracture prevention device. Resident #107 had right sided hemiplegia related to a stroke. Record review of the physician's orders dated 5/6/2026, indicated Resident #107's right- or left-hand contracture was not addressed. During an observation on 5/4/2026 at 11:04 AM, Resident #107 was lying in bed in her room. The HOB was up approximately 40 degrees. She had a feeding tube with Jevity 1.5 running at 40 ml/hr with 120 ml flush every 4 hours. The Jevity feeding and water was dated 5/4/26. Her left hand appeared contracted. She had no carrot (a cone-shaped orthosis designed to manage severe hand contractures by painlessly lifting fingers from the palm), or hand contracture splint (specialized or adjustable orthoses designed to support and stretch curled, rigid, or spastic fingers and wrists) on her left hand. Her right hand was covered with the blanket. During an interview on 5/5/2026 at 9:10 AM, the DOT said Resident #107 had therapy about a month ago. She said therapy worked with her about every 2 months. She said Resident #107 had a splint she wore on her right hand that was applied and removed by the nurses. She said she did not know where that was documented. During an interview and record review on 5/5/2026 at 9:22 AM, the DOT said Resident #107's left hand could not be splinted because it was too difficult and painful to get a splint in her hand. She said the splint for her right had been on back order, and she had not had a splint in her right hand for a couple of months. She said the right hand was splintable. She said Resident #107's left hand could have a single layer of a rag/washcloth but she had not been applying that in her left hand and did not know if the nurses were or not. She said there was no risk for not having splints in Resident #107's hands because her contractures were not any worse. She stated she knew that from working with her all the time. She said when Resident #107 was in PT, the goal was for her not to get worse. She said she screened her quarterly/every 3 months. The DOT went to look at her computer, and said the last time she saw or evaluated Resident #107 was 2/23/26 and printed and provided the evaluation. She said nursing was responsible for the splints when the resident was not in therapy, but since nursing did not ease in splints like therapy knew how, it would be the responsibility of the therapy department, and once a splint could easily go in a resident's hand, nursing could do it. She stated Therapy had modalities (help to loosen and move and make the hand more pliable) and nursing did not do that. The Therapy Screen she provided dated 2/23/26 indicated it was the quarterly screen for Resident #107. The Therapy Screen indicated under Recommendations: No recent changed and/or deficit noted. Also, Patient has no change in functional status contractures are managed by nursing staff. During an interview and record review on 5/5/26 at 11:26 AM, ADON B said she was the nurse for hall 300 today. She said Resident #107 had not had a splint or brace in either hand in months. She agreed there were no splints in either hand while this surveyor had been in the building. She said Resident #107 had a splint, before, in one of her hands, but she did not know which one and could not remember when. She got her computer and looked for a discontinued order for splints for Resident #107, and did not see any discontinued orders for splints. She showed this surveyor she went back to 2025. She said she could not tell by looking at the computer, the last time nursing applied splints on both or either of Resident #107's hands. ADON B said Resident #107 should have orders for splints/carrots/brace for her hands to prevent her contractures from getting worse. She said the risk of not having splints was that her contractures could get worse. She said normally the DOT would tell the DON when therapy was finished and let the DON know that she should get orders for the splints to be applied by nursing. She said therapy was responsible for letting the DON know. During an interview on 5/520/26 at 1:54 PM, the DOT said she did not write orders for splints or applying them. She said if a resident needed a splint after therapy had finished, she would let the DON know that therapy had ended and a particular resident needed a splint(s). She said Resident #107 had not had a splint in her left hand for years. She said she told the prior DON at the morning meeting (unknown day) that Resident #107 was about to discharge from therapy or had just discharged from therapy and she would need a splint for her right hand. She said it may have been early December but she could not remember. She said neither of them would have documented the conversation because they never did. She said Resident #107's left hand would be very painful with a splint, but she would be able to tolerate a one-layer rag/washcloth in her left hand to help with moisture, however that would not keep it from contracting more. She said her left hand had not gotten worse, but it could get worse in the future. However, if Resident #107 had no stress (causing her arm to tense up) the contracture could stay the same. She said the muscles in Resident #107's left arm were not tight. She said right now her left arm was flaccid (soft, limp, or weak/lacking in muscle tone). She said if her left hand was left alone, and untreated it may stay the same. She said she did not follow up with the prior DON to see if she had put orders in for the splint for Resident #107's right hand. She said therapy would re-evaluate and readdress Resident #107's right and left hand. During an interview on 5/5/2026 at 2:08 PM, ADON B said she was the nurse today for Resident #107's hall. She said the normal procedure for a resident having a splint or splints, after therapy discharge was for the DOT to let the DON know that therapy was about to be finished, or was finished and the DON would either put in the orders herself, or ask one of the ADON's to do it. She said this usually came up in the morning meeting. She said she was not asked to put in orders for splints for Resident #107 and did not put in any orders. She said she was not sure where the ball could have dropped. She said it could have been the communication between the DOT and the DON, or it could have been the DON forgot to do it. She said not having splints was a risk of a contracture getting worse. She said she had been at the facility since 2020 and she remembered years ago putting splints in one or both hands for Resident #107, but that was years ago. She knew Resident #107's left hand was painful. During an interview on 5/06/2026 at 8:11 AM, the acting DON said there was no documentation for the morning meetings 11/15/25 - 12/15/25 as requested by this surveyor. She said she was not here at that time, and they had no morning meeting notes. During an interview and record review on 5/6/2026 at 8:25 AM, the Medical Records staff said the DOT would go directly to her if she wanted a splint, brace, or carrot, and she would order those things. She said she ordered a left hand splint on 10/13/25 that was delivered on 10/14/25. She ordered a right hand splint on 1/19/26 that was delivered 1/20/26. She said she believed those items were for Resident #107, but she was not sure. She said the DOT asked her yesterday (5/5/26) if she had a hand splint or brace on back order and she searched and never found a splint or brace on back order. During an interview and observation on 5/6/2026 at 8:37 AM, the DOT said there was only one splint ordered for Resident #107 and it was for her right hand. She said when Medical Records ordered splints and braces she (Medical Records) did not know what resident it was for. She said yesterday, they found the splint for Resident #107's right hand in her room in a drawer. The DOT and this surveyor went to Resident #107's room. She was in a low bed with a splint on her right hand. Her left hand had no splint, brace, or carrot. It was contracted. HOB was up approximately 40 degrees, she was positioned to her right with a wedge. Her tube feed was running at 40 ml/hr with a 120 ml flush every 4 hours. Jevity 1.5 and water was dated 5/6/26. During an interview on 5/6/2026 at 9:09 AM, ADON C said normally the DOT would tell the DON in the morning meeting if a splint/brace/carrot needed to be taken up by the nursing staff, because therapy was about to finish or had finished. She said she did not remember hearing the DOT tell the DON that Resident #107's therapy was finishing. The DON had not told her to put in an order for a splint/carrot/brace for Resident #107. During an interview on 5/7/2026 at 9:53 AM, ADON B said she expected residents with contractures to work with therapy and get orders implemented so the contracture did not get worse. She said that did not happen with Resident #107. She said there was miscommunication somewhere, because the order for the right-hand splint was never done for nursing to take over. She stated there were no orders involving the left hand, per therapy, and there should have been, because Resident #107 had a contracture on her left hand too. She stated the risk of not having therapy was the contracture could get worse, resulting in decreased mobility. However, she said Resident #107 was unable to move either hand. During an interview on 5/07/2026 at 10:16 AM, ADON C said regarding Resident #107, therapy usually evaluated and ordered the splints or carrots that were needed. ADON C said in the last couple of months, she had seen nothing, no brace, splint, or carrot in either of Resident #107's hands. She said if a resident had contractures, that resident should have something in their hand, a portion of the day, whether it was a carrot, brace, or washcloth. She stated untreated contractures could cause skin issues such as pressure ulcers, yeast infections, or worsening contractures. ADON C said Resident #107 had not had an order for a brace/splint/carrot on her left hand after 12/1/2022. She said that was what she found on her computer when she checked for nursing orders. During an interview on 5/7/2026 at 10:26 AM, the acting DON said regarding Resident #107's hand contractures, she did not know her history or the severity. She said they wanted to manage contractures and make sure they did not worsen. She was not aware Resident #107 had not been treated for her hand contractures. The risk of not being treated for hand contractures was worsening of the contracture, which could be loss in range of motion and use of her hands. She said skin integrity, yeast infection, and cleanliness would also be a concern. During an interview on 5/7/2026 at 10:38 AM, the ADM said Resident #107 was not being treated for her hand contractures, but he was not aware of that. She should have had orders for treatment for both her hands. He stated he was new in the building, and did not know all the residents well yet. He said the risks of no treatment for hand contractures could be pressure sores, an infection, a worsening contracture, or her fingernails could cut into her hands. They provided the only policy they had regarding contractures. During a telephone interview on 5/07/2026 at 11:45 AM, the prior DON returned this surveyor's call. She said she did not remember the DOT telling her Resident #107 was discharging from therapy and nursing would need to take over. She said she would have remembered that, because she would have had a lot of questions regarding the contracture management. Record review of Resident #107's Occupational Therapy Evaluation and Plan of Treatment dated 5/5/2026 - 6/3/2026 indicated: 1.New Goal - Patient will exhibit a decrease in pain with movement to 6/10 in the left hand and in the right hand in order to tolerate right resting hand splint and washcloth or carrot to left hand. 2.New Goal - Patient will safely wear a resting hand splint on right hand for up to 4 hours with minimal signs and symptoms of redness, swelling, discomfort or pain. 3.New Goal - Patient will tolerate washcloth or carrot to left hand for up to 8 hours in order to decrease risk for skin breakdown. Reason for Referral: Patient is an [AGE] year-old female who presents to rehab to assess current resting hand splint and possible decrease in range of motion in bilateral hands. Patient able to tolerate gentle PROM with severe pain expressed initially but with increased time patient was able to relax hand and gain greater ROM with good skin integrity. OT to address wearing schedule with staff education. Record review of an undated Contracture Management and Prevention Policy indicated: Purpose: The Omnibus Reconciliation Act (OBRA) act of 1990 established regulations that require the long-term care facility to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Goal: To provide services to assist residents in their positioning, mobility and range of motion through focused tasks and interventions to reduce the potential for the development of contractures and if admitted with contractures to avoiding further decline in range of motion. Treatment: The individualized care plan should address the following: -Strengthening for joints that have limitations in AROM (Active Range of Motion), but not PROM (Passive Range of Motion)-Limitations in PROM that can be reversed or partially reversed.-Use of adaptive equipment to facilitate/maintain residual function-Splints and/or positioning devices necessary to maintain, reduce, or prevent decline in the affected joint(s)-Caregiver/staff education in application, care, and use of device DocumentationDocumentation should include:-The therapy evaluation documented including all items/measurements identified during the assessment.-Record and track the resident on the Contracture Management and Prevention Grid/Log-Document staff training provided on splint or positioning device (with return demonstration). Contracture Management and Prevention ProgramUpon discharge - Resident results and discharge plan should be recorded on the Contracture Management and Prevention Log with the following information documented: -Name, location of limitation, type of device and the date it was issued, last day of skilled therapy and six-month reassessment due date.-Update the Contracture Management and Prevention Log every six months upon reassessment if modifications to plan of care are indicated. MonthlyResidents identified as having contractures or limitation in range of motion that require splint or positioning device should be listed/discussed for review at the Quality Improvement/Quality Assurance Meeting.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 21 residents (Resident #29) reviewed for adequate supervision.The facility failed to securely store hydrogen peroxide and Isopropyl Alcohol 50% for Resident #29.This failure could place residents at risk for adverse reactions.Findings included:Record review of the face sheet indicated Resident #29 was [AGE] years old and was admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses including Alzheimer's Disease (a progressive, irreversible brain disorder-and the most common form of dementia-that destroys memory and thinking skills), Chronic Obtrusive Pulmonary Disease (a progressive, treatable lung disease-primarily caused by smoking-that restricts airflow, making it hard to breathe), Hypothyroidism (an underactive thyroid condition where the gland fails to produce enough hormones, slowing the body's metabolism). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and understood others. The MDS indicated a BIMS score of 15, indicating Resident #29 was cognitively intact. Record review of a care plan revised on 01/14/26 indicated Resident #29 had an activity of daily living self-care performance deficit related to Alzheimer's, Impaired balance. During an observation on 5/4/26 at 10:16 a.m. Resident #29 had a bottle of hydrogen peroxide and Isopropyl Alcohol 50% in her room. Resident #29 was not in her room at that time to be interviewed. During an attempted interview and observation on 5/5/26 at 9:00 a.m. Resident #29 was uninterested or did not want to speak about the chemicals in her room, and changed the subject to an unrelated matter. The hydrogen peroxide and Isopropyl Alcohol 50% was still in her room. During an interview on 05/07/2026 at 10:18 a.m. with the Acting DON she said that residents should not have hydrogen peroxide and Isopropyl Alcohol 50% in their rooms. She said they were prohibited items and should have been stored in a medication cart or a medication room. She said that residents could be placed at risk of harm if they misused chemicals. She said that it was everyone's responsibility to make sure these items were stored properly. During an interview on 05/07/2026 at 10:30 a.m. with the Administrator, he said that residents should not have hydrogen peroxide and Isopropyl Alcohol 50% in their rooms. He said that medications or medically related chemicals should be stored in the medication rooms or medication carts. He said it was the responsibility of everyone to ensure that chemicals were not left in residents' rooms. He said that residents could be harmed if they didn't use the chemicals in their intended manner. Review of an undated facility policy titled, Delivery, Receipt, and Storage of Medication revealed that Storage of Medication: The facility should ensure that only authorized facility staff should have access to the medication storage areas. Authorized facility staff should include nursing staff and those authorized to administer medications.

Based on observation, interviews and record review, the facility failed to ensure a resident with bowel and urinary incontinence, received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible 2 of 2 residents to reviewed for urinary and bowel incontinence (Resident #11 and Resident #41)The facility failed to ensure Resident #11 had a catheter securement device in place on 05/07/26.The facility failed to ensure CNA N and CAN M performed proper incontinent care by ensuring Resident #41 was completely clean after bowel movement and before placing a new brief on 3/5/2026.These failures could place residents at an increased risk for urinary tract infections. Findings included: 1.Record review of Resident #11's face sheet, dated 04/05/26, reflected that he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included obstructive and reflux uropathy (a blockage in the urinary tract that stops urine from flowing, causing it to back up into the kidneys) and acute cystitis (a sudden bladder inflammation, typically caused by a bacterial infection). Record review of Resident #11's quarterly MDS assessment, dated 03/31/26, reflected that he was usually able to make himself understood and he was usually able to understand others. He had a BIMS score of 08, which indicated moderate cognitive impairment. He had an indwelling catheter (a flexible tube inserted through the urethra or abdominal wall into the bladder to drain urine, held in place by a balloon). Record review of Resident #11's Order Summary Report, dated 05/05/26, reflected an order for suprapubic catheter for obstructive and reflux uropathy. The order date was 02/02/26. Further, there was an order for suprapubic catheter care every shift and as needed – check for stabilization device to be in place every shift. The start date was 02/02/26. Record review of Resident #11's care plan, included a focus, last revised 11/19/25, reflected the resident was at risk for impaired urinary elimination related to diagnosis. He was at high risk for continuous urinary tract infections. During an observation and interview on 05/06/2026 at 10:50 AM LVN P performed catheter care on Resident #11. Immediately before LVN P started the care and was washing her hands in the bathroom, Resident #11's catheter tubing had a dependent loop (a loop of the catheter tubing that hangs below the bag and fills up with urine) and that loop was beneath the opening of the catheter bag. There was yellow urine with sediment accumulating in the dependent loop. This surveyor asked LVN P about the dependent loop and she said it should not be lower than the drainage bag. LVN P removed the blanket covering Resident #11 and the catheter was not secured to his leg. There was no catheter securement device present. She performed the catheter care and placed a new securement device. She also pulled up the dependent loop higher than the drainage bag. During an interview on 05/06/26 at 11:10AM, LVN P said the aide told her earlier that day that Resident #11's catheter securement device was missing. She said she waited until the catheter care to place a new securement device and do it all at once. She said the resident should have a securement device because if he did not have one in place his catheter could be accidentally pulled on and dislodged. During an interview on 05/07/26 at 09:23AM, the acting DON said LVN P told her that she waited to replace the catheter securement device so that she could do it all at once. She said the Resident #11 messes with his catheter a good bit. She said the risk was that without the securement device the catheter could become dislodged. During an interview on 05/07/26 at 10:06AM, the Administrator said Resident #11's catheter should be secured. He said the risk was that the catheter could become dislodged and cause issues. 2. Record review of Resident #41's face sheet dated 05/5/2026 indicated Resident #41 was an [AGE] year-old female and admitted on [DATE] with diagnoses including metabolic encephalopathy ( a reversible brain dysfunction caused by systemic metabolic disturbances, leading to confusion, altered consciousness, and neurological symptoms), Type II Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels in the blood), Hypertensive heart disease with heart failure (a chronic high blood pressure forces heart to work harder to pump blood through narrowed stiffened arteries, which increases cardiac workload and oxygen demand), hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood), and muscle weakness (occurs when muscles cannot generate the expected force, and it can result from temporary fatigue, nutrient deficiencies, or underlying medical conditions). Record review of Resident #41's admission MDS assessment dated [DATE] indicated Resident #41 was usually understood and usually had the ability to understand others. The MDS indicated Resident #41 had a BIMS score of 08 which indicated she was moderately cognitively impaired. Resident #41 required substantial/maximal assistance for transfers and most ADLs. The MDS indicated Resident #41 had a fall history in the last month prior to admission to facility and was always incontinent of bowel and bladder. Record review of Resident #41's care plan initiated on 3/3/2026 indicated Resident #41 had an ADL self-care performance deficit related to generalized weakness and recent hospitalization. Interventions included: encouraged resident to use call bell to call for assistance, required 2 staff assist to move between surfaces and resident utilizes a wheelchair for mobility and requires 1 person assist for locomotion. The Care plan also indicated Resident #41 had interventions for 2-person to assist with toileting. During an observation on 05/05/2026 at 3:01 PM, Resident #41 was observed being transferred to bed to where perineal care was performed. CNA M was observed wiping from front to back using a wipe and then rolled Resident #41 over and CNA N cleansed her bottom from top of bottom downward. CNA M then used a wipe in one swipe from front to back and then folded the wipe and continued to wipe front to back using the same dirty wipe but folded. Resident #41 had feces still in the vaginal area and CNA M placed a new brief and covered up Resident #41. During an observation and interview on 5/5/2026 at 3:37 PM, LVN O and DON returned to room after requested re-assessment of incontinent care. The DON set up a tray with gloves, wipes, and trash bags. The DON washed her hands and donned (process of putting on gloves) clean gloves. DON cleansed perineal area using one swipe and disposing of used wipe, removing gloves, and using hand sanitizer between glove changes. The DON wiped the vaginal area, and feces were removed from the vaginal area. The DON said the resident may have had a bowel movement again prior to her arrival to re-assess. During an interview on 5/5/2026 at 3:48 PM, CNA M said she was to the right of Resident #41 during perineal care. CNA M said she felt she and CNA N did fine with providing perineal care on Resident #41. She said the proper way to cleanse perineal area was wiping from front to back. She said everyone was trained differently. CNA M said she could fold a wipe that was already used and use the clean side of the wipe again. CNA M said the staff could wipe from all sides of perineal area. CNA M said when they turned Resident #41, she tinkles. CNA M said it had been a while since she was trained on perineal care. She said a resident could get a bacterial infection, or a yeast infection if not cleaned properly. CNA said the skin could also breakdown. CNA M said the CNAs were responsible for ensuring the residents were clean prior to putting on a new brief. During an interview on 5/5/2026 at 3:56 PM, CNA N said she was to the left of Resident #41. CNA N said she felt Resident #41 was clean prior to her clean brief being placed. CNA N said different people do things differently. CNA N said she wiped Resident #41 from front to back. She said she wiped from the bottom upward. CNA N said she had been in-serviced on peri-care but did not state when. CNA N said they could fold the used wipe and use the clean side. CNA N said the CNAs were responsible for ensuring the residents were clean. She said a resident could get a urinary tract infection or skin could break down. During an interview on 5/7/2026 at 9:26 AM, CNA F said she would wipe front to back using wipes or if large bowel movement, she would use towels. CNA F said normally Resident #41's bowel movement would be all over her back and she would give her a sponge bath. CNA F said she turned Resident #41 to her side and wiped the same way, then applied the brief and straighten brief back up. CNA F said she wiped again from front to back to ensure she was clean. CNA F said they should not wipe downward from the top of bottom down. CNA F said it could cause feces to get in vaginal area and could cause urinary tract infection. CNA F said CNAs were responsible for ensuring the residents were clean and no feces on resident skin. During an interview on 5/7/2026 at 10:08 AM, RN G said the nurses and CNAs were responsible for ensuring a resident is clean and dry. RN G said a resident should be wiped from front to back, and wiping from front to back on the backside. She said wiping incorrectly could cause bacterial infection or a urinary tract infection. She said whoever was providing care was responsible. RN G said the staff should be making sure there is nothing in vaginal area or left behind to ensure they are clean. During an interview on 5/7/2026 at 11:49 AM, ADON C said they have done incontinence care in-services but could not recall when. ADON C said the staff should wipe Resident during incontinent care from front to back. ADON C said when the resident was turned, the staff should wipe from bottom down. ADON C said the staff could fold a wipe and use the clean side. ADON C said the staff should make sure the perineal area is clean before placing the brief. ADON C said the residents could have skin issues, and possible infection if not performed properly. She said all nursing staff were responsible for ensuring the residents were clean. During an interview on 5/7/2026 at 12:07 PM, the DON said she expected the CNAs to make sure the residents were clean before applying a clean brief. She said she expected them to use proper technique in wiping. The DON said one wipe, one swipe. The DON said she thought someone in the schools were teaching the CNAs the wrong way. The DON said she expected the CNAs to wipe female resident from front to back and perineal up when turned over to clean up bowel movements. The DON said it was all nursing responsibility to ensure the residents were clean and dry. The DON said improper perineum care could cause urinary tract infections, or skin breakdown. During an interview on 5/7/2026 at 12:19 PM, the ADM said he expected the staff to perform proper perineal care. He said if done improperly, it could cause an infection. The ADM said the nursing administration was responsible for ensuring care was provided correctly. Record review of the Facility's policy, Indwelling Urinary Catheter Care, dated January 2026, reflected: Purpose: To maintain the indwelling urinary drainage system and to help [avoid] urinary tract infections and proper securing of the catheter for safety. Guidelines for Maintaining the Urinary Drainage System:. .2. Check that the catheter remains secured with tape/stabilizer device or leg strap to reduce friction and tension/pulling and movement at the insertion site. .5. Check that urine is draining freely through the system. .7. Keep the urine-collecting bag below the level of the bladder at all times to prevent backflow of old urine into the bladder. Maintain position of urine-collecting bag according to manufacture guidelines. 8. Keep the drainage tubing and bag off the floor at all times to prevent contamination and damage. Record review of the facility's policy titled Perineal Care dated revised February 2018 indicated . the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . steps in the procedure .Place equipment on the bedside stand.wash and dry hands thoroughly.fill the wash basin on-half (1/2) full of warm water.Fold the bedspread or blanket toward the foot of the bed.Fold the sheet down to the lower part of the body.Raise the gown or lower the pajamas.Put on gloves.Ask the resident to bend their knees.For Female resident: Wet washcloth and apply soap or skin cleansing agent.Wash perineal area, wiping from front to back.Separate labia and wash area downward from front to back.Continue to wash the perineum moving from inside outward to thighs.Continue to wash the perineum moving from inside outward to the thighs.Gently dry perineum.wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.Rinse and dry thoroughly.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 1 of 13 residents reviewed for laboratory services. (Resident #108) The facility failed to obtain the following labs for Resident #108 per physician's orders:BMP- basic metabolic panel (a common blood test that measures eight key substances to evaluate kidney function, fluid/electrolyte balance, and blood sugar levels)Lipid panel (a routine blood test that measures cholesterol and triglyceride levels to evaluate cardiovascular risk, including potential heart disease and stroke risk)Liver panel (a blood test that measures enzymes, proteins, and bilirubin to assess liver health, damage, or disease)These failures could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition.Findings include: 1. Record review of an undated facesheet revealed Resident #108 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (an umbrella term for a decline in cognitive function-memory, thinking, and reasoning-severe enough to interfere with daily life), history of falls, and unsteadiness on feet. Record review of a quarterly MDS dated [DATE] revealed Resident #108 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #108 had no behaviors coded. Resident #108 required substantial assistance (helper does more than half) for toileting and showers. Resident #108 required supervision for dressing and personal hygiene. The MDS revealed Resident #108 received antipsychotic medications daily. Record review of a care plan dated 08/25/2025 revealed Resident #108 has coronary artery disease related to atherosclerosis (a disease characterized by the slow, progressive buildup of plaque-a mixture of fat, cholesterol, calcium, and other substances-within the artery walls) and hypercholesterolemia (a condition characterized by abnormally high levels of low-density lipoprotein [LDL or bad cholesterol] in the blood). Record review of physician's orders dated May 2026 revealed Resident #108 had an order dated 08/25/2025 for a BMP, Lipid, and Liver Panel every 3 months. Record review of the EHR on 05/06/2026 revealed Resident #108 had no lab results for ordered BMP, Lipid panel or liver panel. During an interview on 05/06/2026 at 9:30 a.m., ADON C stated the lab was recently integrated with the EHR system the facility used and the lab is automatically notified when the labs are due for all residents through the EHR. ADON C stated she could not find any lab results for Resident #108's BMP, Lipid or Liver panel. She stated she called the lab and they had no results for the BMP, Lipid or Liver panel for Resident #108. ADON C stated she felt like the labs were missing related to the integration of the lab system and the EHR system. She stated ordered labs not being performed could lead to the MD or NP not adjusting medications to provide the greatest benefit to the resident. ADON C stated it was her job to track the lab results and lab orders to ensure all of the labs ordered are drawn and the results get to the MD. She stated she must have overlooked Resident #108 when auditing the labs. During an interview on 05/06/2026 at 10:47 a.m., the DON said she expected labs to be obtained as ordered by the physician. The DON said all of the missing labs were likely an oversight during the integration of manual lab requisitions to automatic lab requisitions. She stated it was the responsibility of the ADONs to monitor all lab draws and reports. The DON stated not having ordered labs could lead to not having therapeutic medication dosages. She stated Resident #108 was on medications that dosages would be adjusted related to lab results. She stated the lipid panel showed how her cholesterol was, the liver panel showed how well her liver was working to break down the medications she was taking, and basic metabolic profile showed levels of important electrolytes like potassium and sodium in the blood. Record review of the facility's undated policy titled, Lab and Diagnostic Test Results- Clinical protocol, indicated. the staff will process test requisitions and arrange for tests. a nurse will try to determine whether the test was done.c. to monitor a drug level.d. report results to ordering MD

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 22 residents (Residents #13 and Resident #11) reviewed for infection control practices.1. The facility failed to properly store or dispose of a used feeding tube syringe for Resident #13.2. The facility failed to ensure Resident #11's catheter bag was not lying on the floor on 05/04/26.These failures placed residents at risk for cross contamination and infection.Findings include: 1. Record review of the face sheet indicated Resident #13 was [AGE] years old and was admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses including Autistic Disorder (a neurodevelopmental condition affecting communication, social interaction, and behavior), Intermittent Asthma (a mild form of asthma characterized by short-term symptoms occurring less than two days a week, with nighttime awakenings 3–4 times a month or fewer), and Dysphagia (difficulty swallowing). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was rarely or never understood and rarely or never understood others. The MDS indicated a BIMS score of 00 indicating Resident #13 was unable to complete a BIMS interview. Record review of a care plan revised on 01/28/26 indicated Resident #13 required tube feeding related to swallowing problems. During an observation and attempted interview on 5/4/2026 at 9:51 a.m. it was observed that Resident #13 had a feeding tube syringe lying on the resident's bedside dresser that had a dried white substance on the tip of the syringe and condensation inside the syringe. The syringe had not been stored inside a bag. Resident #13 was attempted to be interviewed but was unintelligible. During an interview on 05/07/2026 at 10:18 a.m. with the Acting Director of Nurses she said that tube feeding syringes that had been used should have been either thrown away or stored in a bag. She said that it was the responsibility of nurses to ensure that tube feeding syringes were stored or disposed of properly. She said that residents could be placed at risk of infections if proper infection prevention protocol was not followed. During an interview on 05/07/2026 at 10:30 a.m. with the Administrator he said that tube feeding syringes should be stored properly after it was used. He said that it is the responsibility of nurses to make sure that the syringes are stored and used properly. He said that residents could be placed at risk of infection if tube feeding syringes were not stored properly. Requested a facility policy from the Administrator on 05/07/2026 regarding storage of equipment regarding tube feeding syringes. An undated facility policy provided titled, Tube Feeding did not describe how to properly store or dispose of tube feeding syringes after usage. 2. Record review of Resident #11's face sheet, dated 04/05/26, reflected that he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included obstructive and reflux uropathy (a blockage in the urinary tract that stops urine from flowing, causing it to back up into the kidneys) and acute cystitis (a sudden bladder inflammation, typically caused by a bacterial infection). Record review of Resident #11's quarterly MDS assessment, dated 03/31/26, reflected that he was usually able to make himself understood and he was usually able to understand others. He had a BIMS score of 08, which indicated moderate cognitive impairment. He had an indwelling catheter (a flexible tube inserted through the urethra or abdominal wall into the bladder to drain urine, held in place by a balloon). Record review of Resident #11's Order Summary Report, dated 05/05/26, reflected and order for suprapubic catheter for Obstructive and reflux uropathy. The order date was 02/02/26. Further, there was an order for suprapubic catheter care every shift and as needed – check for stabilization device to be in place every shift. The start date was 02/02/26. Record review of Resident #11's care plan, included a focus, last revised 11/19/25, reflected, the resident was at risk for impaired urinary elimination related to diagnosis. He was at high risk for continuous urinary tract infections. During an observation on 05/04/2026 at 9:52 AM, Resident #11 was lying in bed resting. He had a urinary catheter, and the bag was on the floor. He did not respond to surveyor questions. During an observation on 05/04/2026 at 10:47 AM, Resident #11 was lying in bed. His catheter bag was still lying on the floor. During an interview on 05/07/26 at 09:16AM, the ADON said the catheter bag should have been hung on the bed frame and not on the floor. She said the risk was that Resident #11 could get an infection. During an interview on 05/07/26 at 09:23AM, the Acting DON said she found Resident #11's bag on the floor on 05/04/26 and was the person that fixed it. She said the risk to the resident was a possible infection. She said her expectation was that the policy and procedure was followed. During an interview on 05/07/26 at 10:06AM, the Administrator said Resident #11's catheter bag should have been hung on the bed. He said the risk was a possible infection. Record review of the Facility's policy, Indwelling Urinary Catheter Care, dated January 2026, reflected: Purpose: To maintain the indwelling urinary drainage system and to help [avoid] urinary tract infections and proper securing of the catheter for safety. Guidelines for Maintaining the Urinary Drainage System:. .2. Check that the catheter remains secured with tape/stabilizer device or leg strap to reduce friction and tension/pulling and movement at the insertion site. .5. Check that urine is draining freely through the system. .7. Keep the urine-collecting bag below the level of the bladder at all times to prevent backflow of old urine into the bladder. Maintain position of urine-collecting bag according to manufacture guidelines. 8. Keep the drainage tubing and bag off the floor at all times to prevent contamination and damage.

Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 2 of 9 residents reviewed for antibiotic use (Resident #16 and Resident #68). 1. The facility failed to ensure Resident #16 did not have an order for Cephalexin (an antibiotic used to treat a variety of bacterial infections) for prophylactic antibiotic use. 2. The facility failed to ensure Resident #68 did not have an order for Macrobid (an antibiotic used to treat bacterial infections) for prophylactic antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of Resident #16's face sheet, dated 05/06/26, reflected that she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included neuropathic bladder (a dysfunction where nerve damage from disease or injury disrupts signals between the brain and bladder, causing loss of bladder control) and neurocognitive disorder (a category of acquired mental health conditions characterized by a decline in cognitive functions). Record review of Resident #16's quarterly MDS assessment, dated 03/24/26, reflected that the BIMS was not conducted because she was rarely/never understood. She was also rarely/never able to understand others. Record review of Resident #16's care plan, included a focus that the resident was on prophylactic antibiotic therapy, last revised 11/24/25. Interventions included:*Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift.*Monitor/document/report PRN signs and symptoms of secondary infection related to antibiotic therapy. Record review of Resident #16's Order Summary Report, dated 05/06/26, reflected an order for cephalexin oral capsule 500mg, give 1 capsule by mouth one time a day for urinary prophylactic. The start date was 02/02/26. There was not an end date. 2. Record review of Resident #68's face sheet, dated 05/06/26, reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (an umbrella term for a decline in cognitive function severe enough to interfere with daily life) and neuromuscular dysfunction of bladder (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function). Record review of Resident #68's quarterly MDS assessment, dated 02/19/26, reflected she had a BIMS score of 02, which indicated severe cognitive impairment. She was usually able to understand others and usually able to make herself understood. Record review of Resident #68's care plan, included a focus that the resident was on antibiotic therapy related to urinary tract infection and she would be on it prophylactically, last revised 03/25/26. Interventions included:*Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift.*Monitor/document/report PRN signs and symptoms of secondary infection related to antibiotic therapy. Record review of Resident #68's Order Summary Report, dated 05/06/26, reflected an order for macrobid oral capsule 100mg give 1 capsule orally on time a day for prophylaxis. The order start date was 03/25/26. There was not an end date. During an interview on 05/07/26 at 09:16AM, ADON C said Resident #16 and Resident #68 were taking prophylactic antibiotics. She said they both had a history of recurring urinary tract infections. She said she felt like that was a proper indication for those antibiotic orders. During an interview on 05/07/26 at 09:23AM, the Acting DON said she was not a fan of starting any antibiotic without a culture. She said she was working with the nurses to empower them and have them speak with the physicians regarding prophylactic antibiotics. She said she was working on culture change in the facility. She said her expectation was that they will follow their policy. She said the risk was that it could be an unnecessary medication for an unknown organism. During an interview on 05/07/26 at 10:06AM, the Administrator said Resident #16 and Resident #68 should not have been on prophylactic antibiotics. He said the risk was that it could create a resistant or super bug bacteria. Record review of the facility's policy, Antibiotic Stewardship, last revised December 2016, reflected: .3. Appropriate indications for use of antibiotics include:a. criteria met for clinical definition of active infection or suspected sepsis; andb. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).

Based on observations, interviews, and records review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #1) reviewed for Resident Rights. The facility failed to ensure Resident #1 was treated with respect and dignity when CNAs spoke rudely and disrespectfully to him. This failure could place residents at risk of psychosocial harm, self-isolation, and diminished quality of life.Findings included: 1.Review of the admission Record for Resident #1 dated 4/22/26 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of prostate cancer, secondary bone cancer, and brain cancer. Review of the significant change MDS assessment for Resident #1 dated 3/6/26 indicated he had moderately impaired cognition with a BIMS score of 7. He required substantial/maximal assistance with all ADLs. He was always incontinent of bowel and bladder. He had moderately impaired vision. Review of the care plan for Resident #1 dated 2/11/26 indicated he had an ADL self-care performance deficit related to generalized weakness. Interventions were in place including ensuring and promoting resident self-esteem and dignity while performing ADL care and praise all efforts at self-care. During an interview and observation on 4/22/26 at 10:40 a.m., Resident #1 was lying in bed in his room, he appeared to be clean and well groomed. There were no visible marks, bruising, or skin tears on his skin. There was a mattress and a fall mat both positioned below the bed in resident's room. Resident #1 said he had multiple negative incidents with CNAs on the night shift. Resident #1 said he couldn't recall the names, but one CNA always talked bad to me. Resident said the CNA was always rude to him, telling him things like you peed all over yourself, you know better than that and you got yourself down there, you can get yourself up when the resident rolled off the bed. Resident #1 said he didn't like to complain because he feared the treatment would get worse if he complained. Resident #1 said it made him feel bad to be talked to in that manner. Resident #1 said he had complained to his family about the treatment. Resident #1 said he had not complained to the facility administration about the treatment. Record review of a grievance report dated 3/9/26 indicated RP E filed a grievance concerning CNA behavior. The grievance alleged that during her visit staff came into the room around 8:00 p.m. and did not announce their names or their purpose. CNAs told resident turn toward the wall and proceeded to talk about how he peed and messed up the covers and how he knows what he's doing when he puts himself on the floor. RP E stated in the grievance that Resident #1 told her aides frequently spoke to him like that, but he wanted to keep the peace. The grievance form identified an action taken of Resident #1 being interviewed who stated the aides cut up with him but his family member thinks everything is a big deal. Resident #1 reportedly said he didn't feel mistreated, and some aides were short with him, but most would stay and talk. Response to results of investigation indicated RP E insisted the care is not up to par and that the aides are all rude to him, but if he doesn't have a problem with it, she is satisfied During an interview on 4/22/26 at 12:45 p.m., RP E said Resident #1 frequently complained about his treatment at the facility to her. RP E said the resident frequently rolled out of the bed onto a mattress positioned on the floor. RP E said during a visit, Resident #1 was lying on the floor having rolled off his mattress. RP E said CNAs came into his room without knocking or announcing their presence. RP E said the CNAs talked to him like a drill sergeant. RP E said they came in and told him to turn toward the wall. RP E said resident was on the floor and the CNAs told him he had to get up and into the bed in order to be changed. RP E said CNAs made comments that Resident #1 knew what he was doing putting himself down there. RP E said their tone throughout was rude and disrespectful. RP E said she filed a grievance at the facility, but it didn't do anything. RP E said Resident #1 continued to complain about the treatment specifically the night shift. RP E said she was looking into taking Resident #1 out of the facility. RP E was able identify the CNA as CNA C. During an interview on 4/22/26 at 1:05 p.m., CNA A said Resident #1 complained to her previously that CNA staff on night shift were rude to him. CNA A said she didn't report the complaint to the ADM because there was no current ADM at the facility at the time of the incident which was approximately 2 months ago. CNA A said she did report the incident to a charge nurse who was no longer employed at the facility and had been gone approximately 2 months. During an interview on 4/22/26 at 2:15 p.m., CNA C said she worked the nightshift at the facility. CNA C said she had not witnessed anyone being rude or rough with Resident #1. CNA C said Resident #1 had behaviors which included rolling out of bed and pulling out his penis and urinating on the bed/mattress. CNA said she could not change resident when he was on the mattress on the floor due to her own injuries. CNA C said she had never spoken to Resident #1 rudely or disrespectfully. CNA C said she had not witnessed any staff members talking rudely or disrespectfully to Resident #1. Resident #1 said these behaviors were care-planned for the resident. CNA C said she always went into the room to provide care with another CNA as required. During an interview on 4/22/26 at 2:25 p.m., CNA D said she worked the nightshift at the facility and worked with CNA C. CNA D said she had not witnessed staff members being rude or disrespectful to Resident #1. CNA D said she had never spoken to Resident #1 in a rude or disrespectful manner. CNA D said CNAs were required to provide care of staff members at all times for Resident #1. During an anonymous interview on 4/21/26 at 2:40 p.m. , a resident at the facility who resided on the same hall as Resident #1, said that CNAs on the night shift had been rude and disrespectful towards them, but the resident said they did not want to discuss the matter or call names at that time. During an interview on 4/22/26 at 2:55 p.m., RP F said Resident #1 had complained frequently about staff being rude and/or rough with him. RP F said she had reported the concerns to the facility ADM and was told they should get a camera for Resident #1's room. RP F said that wasn't an acceptable response to her concerns. During an interview on 4/23/26 at 10:19 a.m., RP G said Resident #1 frequently complained about his treatment at the facility. RP G said Resident #1 said the staff talk bad to him. RP E said she had witnessed staff members talking roughly to the resident, telling him he knew what he was doing when he rolled out of bed or urinated in the bed. RP G was unable to specifically identify a staff member. During an interview on 4/23/26 at 12:05 p.m., the DON said she had not been notified of any previous instances of staff being rude with Resident #1. The DON said if Resident #1 reported the allegation to CNA A, the report did not make it to administration. The DON said if she had received the report, she would have thoroughly investigated the incident and reported it to the state if applicable. The DON said it was her expectation that each resident was treated with dignity and respect. During an interview on 4/23/26 at 12:15 p.m., the ADM said it was never reported to administration that Resident #1 had complained about the nightshift CNAs to facility staff. The ADM said it was not appropriate to speak to residents in a disrespectful or scolding manner such as telling them you know better than that following incontinent episodes or rolling out of bed. The ADM said they had responded to the grievance by assigning staff members to care for resident at a time. The ADM said he had discussed the concerns with this resident's family and had offered them the option of putting a camera in the room. The ADM said the family had not opted todo that. The ADM said going forward he planned to in-service staff on customer service and speaking to residents with respect. Review of the facility's policy titled Statement of Resident Rights indicated You have the right to.be treated with courtesy, consideration, and respect.

Based on interviews, observations and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan was implemented on 1/7/2026 and 1/10/2026 by having two people provide incontinent care to Resident #1.This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs.Findings included: Record review of Resident #1's Face Sheet, dated 1/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (her right side was weak and paralyzed), and contracture of the left hand (fingers and wrist stuck in a fixed position). Record review of Resident #1's MDS assessment dated [DATE] indicated that Resident #1 did not speak and required substantial assistance for all functional needs including toileting, hygiene, transfer and dressing. Record review of Resident #1's Care Plan dated 11/25/2025 indicated that Resident #1 was bedfast and required two staff to assist with all personal care needs including bathing, toileting, bed mobility, dressing, eating and transfer. Record review of Resident #1's Progress Note dated 11/25/2025 indicated that Resident #1 required two people to assist her with toileting. Record review on 1/15/26 at 12:30 p.m. of Resident #1's ADL Sheet that was not dated but was located in the binder at the nurse's station at the time of this review indicated that Resident #1 was to have two people in the room any time that care was provided. Observation on 1/15/26 at 5:15pm of video of Resident #1's bedroom recorded on 1/7/2026 at 2:31 p.m. showed CNA B completing incontinent care on Resident #1. Resident #1's bed was raised and pulled away from the wall while CNA B repositioned Resident #1 in bed. CNA B adjusted a fabric incontinent pad under Resident #1 while she was rolled on her right side, rolled Resident #1 from her right side onto her back, placed a pillow under her legs, and placed a wedge pillow by her right side. The only other individual observed in the recording present in Resident #1's room was Resident #1's visitor who was positioned in a chair against the opposite wall from Resident #1's bed. The visitor is not assisting with care and is observed watching and then operating her phone. Observation on 1/16/26 at 7:30am of video of Resident #1's bedroom recorded on 1/10/2026 at 3:49 p.m. showed CNA C performing incontinent care on Resident #1. Resident #1's bed was raised and against the wall. CNA C unfastened Resident #1's incontinent brief and placed it between Resident #1's legs. CNA C placed her hands behind Resident #1's knees and pulled her towards her to push the incontinent brief under her. CNA C rolled Resident #1 on her right side towards the wall and held her in that position with her right hand while she completed incontinent care on Resident #1. There were no other staff observed in the video present in Resident #1's room assisting with care. Record review of Grievance/Concern Report dated 1/15/2026 reflected a statement recorded by the DON which includes information that CNA B had conducted incontinent care by herself on 1/7/2026 as the family member of Resident #1 was yelling at her to change her and threatened to call State on her if she did not change Resident #1. This document also indicated that an in-service was conducted on this date regarding safety of the residents. Record review of an undated statement given by CNA B reflected it included a hand-written statement signed by CNA B that on 1/7/2026 she went to change Resident #1 and when she went to get help to change the resident the family member began yelling at her, recording with her cell phone and questioning her with attitude. Record review of in-service entitled Safety and dated 1/15/2026 reflected It is vital that you keep yourself and residents safe during ADLs. If a family member is yelling or demanding you perform ADLs on a resident that are unsafe for you or the resident, step out of the room and call for help. You may respectfully decline to perform unsafe actions. Get another staff member or member of nurse management to help you. Report any incident of a family member pressuring you to perform unsafe actions to the DON. This document was signed by CNA B and was ongoing at the time of the review. During an interview on 1/15/2026 at 3:48 p.m. LVN A stated that the CNAs use the ADL binder and POC, a section in PCC, which is the electronic medical record, to ascertain the information regarding the resident needs or requirements for tasks such as how many staff need to assist with the task. She stated that it would not be appropriate to complete a two-person task by yourself as the directive is in the care plan for a reason and it is typically for resident safety. She stated that the nurses are always willing to assist the CNAs when they need help. During an interview on 1/15/2026 at 3:55 p.m. the DON stated that Resident #1's care plan reflects that two staff are to be in the room when any tasks are being completed for Resident #1. She stated that this was changed after Resident #1 fell out of bed when being changed by one CNA several months back. She stated that regardless of the reason it is in the care plan that it should be followed by staff and that she would implement an in-service on this issue to ensure that staff understand. During an interview on 1/16/2026 at 8:30 a.m. the DON reviewed video footage of Resident #1's bedroom on 1/7/2026 and 1/10/2026 which showed two incidents of a single staff checking and changing Resident #1 alone. She stated that the staff in the video on 1/7/2026 was CNA B and the staff on 1/10/2026 was CNA C. The DON stated that CNA B and CNA C should not have changed Resident #1 by themselves and should have asked for help. She stated that she began the in-service to correct this issue yesterday on 1/15/2026 and was under the impression that it was one staff who had done this as CNA B had stated that she had done this on 1/7/26 when the family member of Resident #1 was in the room and began yelling at her to change Resident #1 after CNA B told her that she would go and get help. DON stated that the risk involved in changing any resident that requires more assistance would be injury to the resident or staff during the task and that nurses should always be willing to assist if the CNAs are busy with other tasks. During an interview on 1/16/2026 at 11:13 a.m. CNA B stated that she has been a CNA at the facility for almost two years. She stated that on 1/7/26 she changed Resident #1 by herself because the family member of Resident #1 was in the room and asked her to be changed. CNA B stated that she informed the family member that she would go and get help, and the family member yelled at her and told her to change her immediately. CNA B stated that to avoid any further conflict, she went ahead and changed Resident #1 without assistance. CNA B stated that the DON has since talked to her about it and informed her that she needs to step out and ask for help when the family yells at her and let the administration know so that they can intervene. CNA B stated that she was trying to get Resident #1 changed so that there would be no question that she did the check and change as directed and to keep the family happy. CNA B stated that she understands that she should have waited for help as this places the resident and her at risk of avoidable injury and that she would do so moving forward. During an interview on 1/16/2026 at 11:24 a.m. CNA C stated that on 1/10/2026 she changed Resident #1 with her being the only staff in the room as she had asked for help but everyone was busy at the time. CNA C stated that often Resident #1 is dry and clean when she checks and changes but due to the family concerns about Resident #1 being changed, she will often go ahead and change her. CNA C stated that she knew that the ADL sheet indicated that two staff are required for changing Resident #1 but she felt as though she could do it safely and not have to keep Resident #1 waiting and ensure that the family saw that staff were checking on their relative. Record review of the undated facility policy entitled Routine Resident Care indicated that residents should receive the necessary assistance to maintain good grooming and personal.hygiene.care is taken to maintain resident safety at all times.11. Staff members should follow the resident plan of care and update with identified resident changes.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards. CNA A and CNA B failed to lock Resident #1's bed wheels before they raised Resident #1's bed, before they performed peri-care (removal of soiled brief, the cleaning of the genital/ anal areas and placement of a clean brief which required turning Resident #1 side to side in the bed) and pulling Resident #1 up in the bed on 10/23/25. This failure could place residents at risk of significant injury.Findings included: Record review of Resident #1's face sheet, dated 10/23/25, indicated she was 81- years- old female who was re-admitted to the facility on [DATE]. Resident #1 had with diagnoses which included hemiplegia (paralysis) and hemiparesis (weakness) following stroke affecting the right dominant side of the body, generalized muscle weakness, generalized osteoarthritis (cartilage that lines the joints is worn down and bones rub against each other. It causes joint pain, stiffness, swelling and reduced range of motion) dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) aphasia (disorder that can impact speech, as well as the way a person understands both spoken and written language). Record review of Resident #1's MDS, dated [DATE], indicated Resident #1 had no speech, rarely/never made herself understood and rarely/never understood others. Resident #1 had short-term as well as long-term memory problems and had severely impaired cognitive skills for daily decision making. Resident #1 was completely dependent on staff for toileting and required substantial/maximal assistance with eating, oral hygiene, showering, dressing the upper and lower body, putting on/ taking foot wear and personal hygiene. Resident #1 was completely dependent on staff for chair/bed-to-chair transfers and toilet transfers. Resident #1 required substantial/maximal assistance for all other transfers, except sit to stand transfer and walking 10 feet which were not performed due to medical condition or safety concerns. Resident #1 was incontinent of bowel and bladder. Record review of Resident #1's care plan, revised on 8/18/25, indicated Resident #1 was at risk for falls. The care plan interventions included follow facility fall protocol. During an observation on 10/23/25 at 11:35 AM, CNA A and CNA B provided Resident #1 with incontinent care and repositioned her in bed. CNA A and CNA B unlocked the bed wheels and moved Resident #1's right side away from the wall. CNA B stood on the right side of the bed and CNA A stood on the left side of the bed. CNA B and CNA A raised Resident #1's bed and performed incontinent care, turning Resident #1 to the right and left of the bed while the wheels of the bed were not locked. CNA B and CNA A then lifted (using the draw sheet) Resident #1 higher in the bed. The wheels remained unlocked and the bed moved gently as they (CNA A and CNA B) moved Resident #1. During an interview on 10/23/25 at 11:50 AM, CNA B was asked if she should have done anything differently during incontinent care and repositioning of Resident #1. CNA B looked at the bed wheels of Resident #1's bed and said we forgot to lock the bed. CNA B said the bed wheels should have been locked before the bed was raised, before the incontinent care (which required turning Resident #1 side to side) and before raising her up in the bed. CNA B said not ensuring the bed wheels were locked placed Resident #1 at risk of falling out of bed and also placed the staff at risk of injury. During an interview on 10/23/25 at 11:53 AM, CNA A was asked if she should have done anything differently during the incontinent care and repositioning of Resident #1. CNA A looked at the bed wheels of Resident #1's bed and said she forgot to lock the bed. CNA A said before turning Resident #1 side to side, in the bed and before raising Resident #1 up in the bed she (CNA A) should have ensured the bed wheels were locked. CNA A said not ensuring the bed wheels were locked could have caused the bed to slide during the repositioning and could have resulted in Resident #1 falling out of the bed. During an interview on 10/23/25 at 12:39 PM, the DON said CNA A and CNA B should have double checked to ensure the bed wheels were locked before moving and repositioning Resident #1. The DON said staff had to lock the bed before providing care to any resident while they were in bed and before repositioning any resident in the bed. The DON said the CNAs body weight or the resident's body weight shifting while the bed was not locked could result in a resident falling out of the bed or staff falling themselves. During an interview on 10/23/25 at 1:20 PM, LVN D said CNA A and CNA B should have ensured the bed wheels were locked before moving the resident in bed. LVN D said not ensuring the bed wheels were locked before moving Resident #1 could have caused her to fall out of the bed and also put the CNAs at risk of injury. During an interview on 10/23/25 at 1:30 PM, the Administrator said he expected staff to ensure bed wheels were locked before repositioning or turning a resident. The Administrator failing to do so could result in serious injury to the resident. Record review of the facility's, undated, policy procedure titled, Routine Resident Care, stated .Care is taken to maintain resident safety at all times.(10) Staff members should observe the following safety precautions with all residents: a. Equipment with wheels (beds, wheelchairs, and other equipment) should be in the locked position when not moving.

Based on interviews and records review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #1) reviewed for Dialysis. The facility failed to ensure the appropriate dialysis port care was provided to Resident #1 on 8/5/25, 8/7/25, 8/9/25, 8/16/25, 8/19/25, and 9/6/25 when the facility failed to remove the dialysis port (access point for dialysis) dressing as ordered by the dialysis center. This failure could place residents at risk of infection, hospitalization, and diminished quality of life.Findings include: Record review of Resident #1's admission Record dated 10/13/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included end stage renal disease (kidney failure), type 2 diabetes, and schizophrenia (mental condition characterized by hallucinations, delusions, and/or disorganized thinking). Record review of Resident #1's quarterly MDS, dated [DATE], indicated she had intact cognition with a BIMS of 15. She required Hemodialysis. Record review of Resident #1's care plan, dated 7/9/25, indicated she needed dialysis related to renal failure. Appropriate interventions were in place which included monitoring the dialysis access site for signs of infection, encouraging the resident to go to scheduled dialysis appointments, and monitoring for signs of renal insufficiency. There were no interventions in the care plan regarding removing or changing the soiled port-access dressings. Record review of a Dialysis Communication Record, dated 7/26/25, indicated Special Instructions/Comments/Concerns: Please remove dressings 2-4 [hours] after dialysis. Record review of a Dialysis Communication Record, dated 8/5/25, indicated Special Instructions/Comments/Concerns: Please Remove dialysis bandages by your p.m. med time to prevent access from clotting Record review of a Dialysis Communication Record, dated 8/7/25, indicated Special Instructions/Comments/Concerns: Please Remove patients dressing post dialysis treatment. Remove at least before next treatment. Record review of a Dialysis Communication Record, dated 9/6/25, indicated Special Instructions/Comments/Concerns: Bandages need to be removed after 4 hours Record review of Resident #1's dialysis center patient note, dated 8/5/25 at 11:43 a.m., by PCT F, indicated .Patient's bandages from previous treatment were not removed by the staff at her nursing facility. They have been told to remove them before the patient goes to bed in the past but continue not to do so. A note has been sent with Dialysis Communication Record and the charge nurse was notified. Record review of Resident #1's dialysis center patient note, dated 8/7/25 at 1:11 p.m., by PCT G, indicated .Patient's bandages from previous treatment were not removed by the staff at her nursing facility. They have been told to remove them before the patient goes to bed in the past but continue not to do so. A note has been sent with Dialysis Communication Record and the charge nurse was notified. Record review of Resident #1's dialysis center patient note, dated 8/9/25 at 12:00 p.m., by RN A, indicated .Access extremity remains swollen and patient reports bleeding at access site yesterday and pressure dressings are in place causing further damage to patient's access. SNF has been notified countless times. Skin tears and signs of erosion present on access. Record review of Resident #1's dialysis center patient note, dated 8/16/25 at 11:10 a.m., by PCT G, indicated .Patient's bandages from previous treatment were not removed by the staff at her nursing facility. They were covered with an additional dressing but not removed. They have been told to remove them before the patient goes to bed in the past but continue not to do so. A note has been sent with the Dialysis Communication Record and the charge nurse was notified. Access extremity remains swollen and patient reports pain in access and pressure dressings remain in place causing further damage to patient's access. Record review of Resident #1's dialysis center patient note, dated 8/19/25 at 11:43 a.m by PCT G, indicated .When patient arrived to treatment today the patient's bandages from previous treatment were still present and not removed by the staff at her nursing facility. The facility has been told to remove them before the patient goes to bed in the past but continues not to do so. A note has been sent with the Dialysis Communication Record and the charge nurse was notified. During an interview on 10/13/25 at 9:50 a.m., the ADM said it was the responsibility of the charge nurse on the unit to provide care related to the dialysis access ports. The ADM said the charge nurse was expected to complete a checklist form prior to the resident leaving for dialysis and again upon returning which required assessing the dialysis port. During an interview on 10/13/25 at 9:55 a.m., the ADON said it was the unit nurse's responsibility for conducting daily assessments of the dialysis ports and to prepare a resident for transport to dialysis. The ADON said the unit nurse was expected to complete a computerized resident assessment and fill out a physical assessment sheet that the resident took to dialysis with them. The ADON said when a resident returned from dialysis it was the unit nurse's responsibility to look at the dialysis assessment sheet for any information/education sent back from the dialysis center and complete another assessment of the resident's access port. During an interview on 10/13/25 at 11:00 a.m., LVN B said the procedure for getting a resident ready for dialysis included assessing the port for function and signs of infection, filling out a computer-based assessment, and filling out a dialysis transfer form which went with the resident. The LVN said when a resident returned from dialysis the dressing should be removed to inspect the port. LVN B said she did not know Resident #1 and no residents on her assigned hallway received dialysis treatments.During an interview on 10/13/25 at 11:10 a.m., LVN C said the charge nurse was responsible for assessing the resident dialysis access port, checking for medication orders, and filling out a dialysis transfer form. LVN C said when a resident returned from dialysis the dressing should be removed and the port left open to the air. LVN C said she did not know Resident #1 and no residents on her assigned hallway received dialysis treatments. During an interview on 10/13/25 at 11:15 a.m., LVN D said she knew Resident #1 and performed her weekly skin assessments to monitor for any signs of infection around the dialysis access port. LVN D said she did not recall seeing a dressing in place which covered the port when conducting skin assessments on Resident #1. LVN D said it was the unit nurse's responsibility to assess the resident's dialysis access ports before and after dialysis treatments. During an interview on 10/13/25 at 11:35 a.m., LVN E said the charge nurse was expected to complete a dialysis port site assessment on residents before they went to dialysis. LVN E said the inspection included assessing the port for function, checking blood pressure, and vital signs. LVN E said she was unsure if a dialysis port site should be covered by a dressing or not. LVN E said she did not know Resident #1 and no residents on her assigned hallway received dialysis treatments. During an interview on 10/13/25 at 12:00 p.m., RN A said she worked at the dialysis center where Resident #1 received treatments. RN A said she provided education to the facility multiple times regarding removing the dialysis dressing within 2-4 hours after dialysis. RN A said she told the facility staff that leaving the dressings on the access site could cause clotting problems. RN A said she noted multiple occurrences of the same dressing that was applied at the dialysis center still in place when Resident #1 returned for her next appointment. Attempted telephone interviews with Resident #1 on 10/13/25 at 10:30 a.m. and 1:45 p.m., the telephone number indicated the number was disconnected or no longer in service. During an interview on 10/13/25 at 3:35 p.m., the RP said she frequently visited Resident #1 in the facility. The RP said she usually noticed a dressing in place on the resident's access port, she said the facility began removing the dressing when the resident started having increased swelling in her arm. The RP said Resident #1 discharged home with home health and her phone was broken. Record review of the facility's, undated, policy titled Hemodialysis - Care of Resident, indicated .Provide routine AV Shunt (a medical device created by surgically connecting an artery to a vein) Care and Monitoring per physician orders.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision and assistance on 3/25/25 when a mechanical lift (specialized device designed to safely transfer individuals with limited mobility) sling broke while CNA A was conducting a mechanical lift transfer without the required two (2) staff members, causing Resident #1 to fall from the mechanical lift sling and sustain a minor injury, a hematoma (collection of blood) on the back of her head. An Immediate Jeopardy (IJ) situation was determined to have begun on 3/25/2025 and ended on 3/27/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place all residents who require mechanical lift assistance at risk for serious injury and accidents. Findings include: Record review of Resident #1's admission record, dated 6/23/25, indicated she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia (decline in cognitive function) and Alzheimer's Disease (progressive decline in cognitive function). Record review of Resident #1's annual MDS, dated [DATE], indicated a BIMS was not conducted due to resident being rarely or never understood. She required maximal or total assistance with all ADLs. She was always incontinent of bowel and bladder. Record review of Resident #1's comprehensive care plan, dated 1/29/25, indicated she had an ADL self-care performance deficit related to diagnoses of Alzheimer's disease, impaired balance, and limited mobility. Appropriate interventions were in place including requiring two staff members when moving Resident #1 using a mechanical lift. Record review of a progress note, dated 3/25/25 at 10:38 a.m. by the DON, indicated she was called to Resident #1's room by CNA A. Resident #1 was noted sitting on the floor, on her buttocks. The mechanical lift was in Resident #1's room, the sling was noted to be split down the middle. The same progress noted indicated .resident able to move upper and lower extremities large hematoma noted to the back of her head 911 . Record review of incident report for a Fall on 3/25/25 by the DON indicated Resident #1 fell on 3/25/25 at approximately 10:18 a.m. during a mechanical transfer when the sling straps snapped. Resident #1 was taken to the ER and returned to the facility with no acute injuries. Record review of a CT of Resident #1's cervical spine indicated she had a left occipital scalp hematoma (collection of blood at the back of the head). No acute intracranial injury (brain bleeding) was noted. During an observation on 6/23/25 at 10:30 a.m., Resident #1 was in her room lying on the bed, covered up with a blanket. She appeared clean and well-groomed with no offensive odors; she had no visible skin tears, marks, or bruising. Resident #1 did not respond to interview questions and was not interviewed due to her cognition. During an interview with on 6/23/35 at 11:10 a.m., CNA B said she received recent in-service training regarding mechanical lift transfers. She verbalized that two staff are always required and the sling must be inspected for proper fit and wear and tear. She said she had no concerns about staffing, and she was always able to find another staff member to assist when using a mechanical lift. During an attempted telephone interview on 6/23/25 at 2:29 p.m. with CNA A, the number dialed went directly to voice mail. A recorded message indicated the correct number had been dialed; a voice message was left stating the purpose of call and requesting a return call. During an observation of a mechanical lift transfer on 6/23/25 at 3:17 p.m., CNA B and CNA C conducted a mechanical transfer by transferring Resident #2 to her bed from her wheelchair. CNA B and CNA C completed the Hoyer transfer in accordance with the facility's mechanical transfer checklist and no deficient practice was noted. During an interview with CNA C at 3:29 p.m., CNA C said before transferring a resident she made sure the mechanical lift sling was not ripped or torn and was the right size for the resident. She said mechanical lifts always require two (2) staff members. She said she never had problems getting assistance from other CNAs or nurses to conduct a mechanical lift transfer. During an interview on 6/23/25 at 4:05 p.m. Laundry Aid E said she was trained on washing, drying, and inspecting mechanical slings as part of new-hire training. She said she attended an in-service in March of 2025 as well. Laundry Aid E said she inspects all slings daily for damage and signs the laundry checklist indicating there was no damage. She said she washed slings alone, without bleach, and hung them on a designated drying rack to air dry. She said if she identified any damaged slings, she would report it immediately to the housekeeping supervisor and administration. During an interview on 6/24/25 at 9:40 a.m., the Housekeeping Director said he was responsible for training laundry aids. He said all laundry aids were trained to wash mechanical slings by themselves, with no bleach, and to hang them to air dry. He said slings were to never be put into a dryer or washed with bleach. He said laundry aids were expected to inspect slings for any tears or damage and to report any damage immediately to administration. He said laundry aids were responsible for completing a daily checklist which includes inspection of slings for damage. He said he monitors staff compliance with policy by routinely checking on laundry aides throughout the shift. He said following the incident with Resident #1 he in-serviced all laundry staff on proper cleaning, drying, and inspection of mechanical slings. During an interview on 6/24/25 at 10:00 a.m., Laundry Aid F said she received new hire training presented by Housekeeping Director and an in-service was conducted in March of 2025 covering how to wash, dry, and inspect mechanical slings. She said she inspects every sling daily that comes into the laundry. She said slings are to be washed by themselves without bleach and hung up to dry. She said she completed a daily laundry checklist, which includes instructions for inspecting slings. She said slings are inspected for any sign of damage which would be reported to the housekeeping director. During an interview on 6/24/25 at 10:30 a.m., RN G said she was a charge nurse at the facility and her duties included monitoring CNAs to ensure compliance with care plan and facility policy. She said she monitors compliance by frequently rounding, observing, and assisting CNAs with resident care. She said all nursing staff were expected to get a second staff member to assist with mechanical transfers. She said staff are also expected to inspect slings for wear and tear prior to use and report any concerns to nursing or administration. She said no CNA had expressed concerns about staff availability to assist with transfers because nurses always assist if another CNA was not available. During an interview on 6/24/25 at 10:45 a.m., the Rehab Director said she was responsible for training direct care staff regarding mechanical lift transfers and safety. She said all new employees attended an in-service, watched a demonstrational video of a mechanical transfer, and completed a hands-on competency to verify mechanical lift competency. She said following the incident with Resident #1 falling from a mechanical lift, PT worked with nursing administration to conduct competency evaluations of all direct care staff regarding mechanical lift transfers. She said the facility also implemented on-going weekly monitoring which was being conducted by nursing administration. During a second attempted telephone interview on 6/24/25 at 11:00 a.m. with CNA A, the number dialed went directly to voice mail. A recorded message indicated the correct number had been dialed; a voice message was left stating the purpose of call and requesting a return call. Record review of a statement dated 3/25/25 from CNA A indicated .1, (CNA A) was doing patient care for (Resident #1) and made sure the lift pad was under her and completely secured. As I was transferring (Resident #1) .the lift pad snapped and broke, and (Resident #1) fell on the floor and also hit her head . During an interview on 6/24/25 at 3:20 p.m., the DON said she first learned of Resident #1 falling from a mechanical lift on 3/25/25 soon after it occurred. She said she was called to Resident #1's room and observed resident sitting on the floor. She said the mechanical lift was in resident's room and the sling appeared to be split down the middle but had no other visible wear/tear. The DON said Resident #1 had bruising on the back of her head and was sent to the ER for evaluation. She said Resident #1 returned the same day after a CT showed no other injury. The DON said CNA A was immediately suspended for conducting a mechanical lift transfer without additional staff assistance and she was terminated by phone two (2) days later, on 3/27/25. The DON said following the incident the mechanical lift sling wear and tear checklist was audited, all slings were inspected, all direct care were given in-services on mechanical lift safety which included instruction, watching a mechanical lift safety video, and demonstrating proficiency through a mechanical lift competency check-off, and all laundry staff were in-serviced on how to wash and dry mechanical lift slings. She said the facility also implemented monitoring by randomly checking slings for wear and tear and observing mechanical lift transfers. The DON said the Therapy department was responsible for training new employees in mechanical lift safety and assisted nursing with auditing all direct care staff for mechanical lift transfer competency. She said all direct care staff must demonstrate mechanical lift competency and are expected to never conduct a mechanical lift transfer without at least two (2) staff members present. She said direct care staff was responsible for checking slings for damage before using them. The DON said the director of housekeeping was responsible for training all laundry staff, and laundry staff are expected to wash and dry mechanical lift slings per manufacturers specification (machine wash and hung to air dry) and to inspect slings for wear and tear. The DON said the facility follows the manufacturer guidelines for mechanical lift use and maintenance, the facility does not have additional policies. Record review of mechanical lift undated manufacturer's safety guide indicated .Most lifts require two or more caregivers to safely operate lift and handle patient .Examine sling and attachment areas for tears, holes and frayed seams . The same safety guide also included instructions for sling care which indicated .remove metal or plastic reinforcements if required .Do Not Bleach .Air Dry Only . Record review of laundry training checklist titled Laundry staff Duties indicated .Slings are to be washed on F3 (no bleach) by themselves and then hung to dry. Never wash with bleach. Never put in the dryer. Any tears or damage must be reported to maintenance director asap . Record review of checklist titled Laundry Cleaning List dated for March 2025 indicated all appropriate checks were conducted related to sling wear and tear. The same checklist also indicated .SLINGS TO BE WASHED ON F3 THEN AIR DRY REPORT ANY SIGNS OF RIPS, BURNS, OR LOOSE STITCHING . Record review of competency assessment for Lifting Machine, Using a Mechanical indicated At least two (2) Staff (CNA/Nurse) are needed to safely move a resident with a mechanical lift .BEFORE USING THE LIFT .Checks - Body of sling has no rips, tears, fraying, loose threads in the material or trim/[NAME] . It was determined these failures placed residents in an IJ situation on 3/25/25 to 3/27/25. The facility corrected the noncompliance on 3/27/25 by the following: Observations of mechanical lift slings at various times on multiple shifts during the investigation revealed 10 of 10 sampled mechanical lift slings to be free of wear and tear and loose stitching. Observation of 1 of 1 facility laundry room at various times on multiple shifts revealed that washed mechanical lift slings were hung on a separate rack to air dry and laundry staff were completing required laundry check sheet, including inspection of slings. During additional staff interviews at various times and of varying disciplines throughout the investigation indicated all direct care staff 4 CNAs (CNA J, CNA L, CNA M, CNA N), 3 LVNs (LVN H, LVN K, LVN P) and 1 RN (RN G) said they had received in-service training following Resident #1's fall, which included watching a safety video, verbal instruction and demonstration, and were required to complete a mechanical lift competency evaluation. All staff verbalized to inspect the mechanical lift sling before every use to identify rips, tears, or other damages. All staff verbalized two staff members are required during all mechanical lift transfers. Record review of a Corrective Action Notice dated 3/27/25 at 2:39 p.m. indicated .On 3.25.25 (CNA A) was conducting a mechanical lift transfer by herself. During the transfer the straps on the sling ripped apart and the patient fell .Upon completion of investigation it was determined that (CNA A) violated company policies and safety rules of a proper mechanical lift transfer . The same corrective action note indicated CNA A was terminated on 3/27/25 by phone. Record review of document titled TRANSFER LIFTS (Hoyer (mechanical lift), Sit to Stands) SLING WEAR/TEAR CHECKS indicated all slings were checked for damage on 3/25/25, 4/3/25, and 5/16/25. Record review of an undated in-service titled Please sign to acknowledge you have watched the mechanical lift training video indicated training was attended by all direct-care staff. Record review of an in-service dated 3/25/25 titled Hoyer transfer safety indicated training was attended by all nursing and CNA staff. Record review of an in-service dated 3/25/25 titled Hoyer slings indicated all laundry staff attended training which covered cleaning and inspecting slings for ware. Record review of an in-service dated 3/27/25 titled Do not attempt to move a resident after a fall indicated all CNAs attended training. Record review of a facility monitoring tool beginning 3/25/25 and continuing for the next 90 days indicated the facility implemented random mechanical lift competency evaluations for direct care staff and random mechanical lift sling checks to be completed by administration 3 times weekly for the next 90 days. Record review of competency assessments for Lifting Machine, Using a Mechanical revealed 76 competency assessments were completed starting 3/26/25 through 5/14/25.

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 19 (Resident #64, Resident #74 and Resident #76) residents reviewed for call lights. The facility failed to ensure call lights were within reach while Resident #64, Resident #74 and Resident #76 were in bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Record review of Resident 64's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #64 had diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body, affecting muscles and motor function), acquired absence of left leg above the knee, and depression. Record review of Resident #64's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #64 was totally dependent on staff for most ADLs. The MDS indicated Resident #64 was totally dependent for chair/bed-to-chair transfers. The MDS indicated Resident #64 was always incontinent of bowel and bladder. Record review of Resident #64's Care Plan last revised 02/10/25 reflected the resident had an ADL self-care performance deficit with an intervention to encourage the resident to use bell to call for assistance. During an observation and interview on 03/17/25 at 9:48 a.m., Resident #64 said he did not have a call button. He said he had to holler when he did not have his call bell. Resident #64's call light draped over the foot of the bed. He said he was unable reach it. He said, once it is down there it is gone. 2. Record review of Resident #74's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #74 had diagnoses which included anxiety, depression, stroke and hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body, affecting muscles and motor function). Record review of Resident #74's a quarterly MDS assessment dated [DATE], indicated he had a BIMs score of 11, which indicated he had moderate cognitive impairment. Resident #74 required substantial/maximal assistance for with ADLs. The MDS indicated Resident #74 was always incontinent of bladder and bowel. The MDS indicated Resident #74 required substantial/maximal assistance with chair/bed-to-chair transfers. Record review of Resident #74's Care Plan last revised 02/21/25 reflected the resident had an ADL self-care performance deficit with an intervention to encourage the resident to use bell to call for assistance. The care plan indicated Resident #74 was at risk for falls. During an observation and interview on 03/17/25 at 10:32 a.m., Resident #74's call light was draped over head of bed. He said he could not reach the call light. He said, I have to holler nurse, but they don't like that. During an observation on 03/18/25 at 8:24 a.m., Resident #74 was asleep in the bed. The call light was on the floor under the edge of the head of the bed. 3. Record review of Resident #76's face sheet dated 03/18/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #76 had diagnoses which included morbid obesity, diabetes, stroke and hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body, affecting muscles and motor function). Record review of Resident #76's quarterly MDS assessment dated [DATE], indicated he had a BIMs score of 10, which indicated he had moderate cognitive impairment. Resident #76 required substantial/maximal for most ADLs including chair/bed-to-chair transfers. The MDS indicated Resident #76 was always incontinent of bladder and bowel. Record review of Resident #76's Care Plan last updated 01/29/25 reflected Resident #76 had an ADL self-care performance deficit with an intervention to encourage the resident to use bell to call for assistance. The care plan reflected Resident #76 was at risk for falls. During an observation and interview on 03/17/25 at 10:12 a.m., Resident #76's call light was on floor under the side of the bed. She said she could reach the call light. She said sometimes she had to holler and sometimes she tried to sit up to get it. During an observation and interview on 03/19/25 at 8:15 a.m., Resident #76 was in bed eating breakfast. Her call light was draped over the foot of her bed. She said she could not reach the call light if she needed it. During an interview on 03/19/25 at 10:03 a.m., CNA B said call lights should been to where residents could always reach them. She said all care givers were responsible for making sure residents have their call lights. She said not having a call light could lead to a fall risk or the resident might have an emergency. During an interview on 03/19/25 at 10:23 a.m., LVN M said everybody was responsible for making sure residents had their call lights. She said ultimately the CNAs provided care and they should be checking to make sure residents had call lights. She said a resident not having a call light did not have any way to call staff for help. She said it could cause them to try to get up and cause them to fall. During an interview on 03/19/25 at 12:56 p.m., the DON said CNAs and floor staff were responsible for making sure resident could reach their call lights. She then said everyone was responsible for keeping call lights in reach of residents. She said she would have expected for the residents to have had their call lights. She said a resident not having a call light might need something and not be able to get to staff. During an interview on 03/19/25 at 1:23 p.m., the Administrator said he just had in-serviced staff on call lights about making sure the call lights were visible and within reach . He said the call lights should be attached to the pillow or clothes so the residents could respond in a time of need. He said he would have expected each of the resident to have had their call light within reach. Record review of an In-Service Training Report for RNs, LVNs, and CNA dated 02/25/25 at 4:15 p.m. reflected, Please make sure (when you are doing rounds) that CALL LIGHTS are easily in reach and are clipped onto linens/night clothes/etc. Too many families (and) residents are complaining that the CALL LIGHT is not reachable. If you need clips - Let someone know . The In-Service was signed by 34 staff members. Record review of an Answering the Call Light facility policy dated 03/2021 indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Record review of an undated Certified Nurse Aide Standards of Clinical Practice facility policy indicated, .The CNA answer call lights promptly and assists residents as required and checks for call light in reach prior to leaving the room .

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 5 of 11 residents (Resident #42, Resident #246, Resident #16, Resident #9, and Resident #33) reviewed for respiratory care and services. The facility failed to properly store Resident #246's Nasal Cannula. The facility failed to change the dirty filters for Resident #16. The facility failed to ensure Resident #42's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to ensure Resident #9's oxygen concentrator filter was without white fuzzy particles. The facility failed to ensure Resident #33's oxygen concentrator filter was without white fuzzy particles. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #246's face sheet dated 3/17/2022 indicated the resident was a [AGE] year- old female who admitted to the facility on [DATE] with diagnoses of Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Cerebral Infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), and Muscle Weakness (decreased ability of muscles to contract and generate force). Record review of Resident #246's MDS assessment, dated 3/11/2025, indicated the resident had a BIMS score 12 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #246 was dependent with all activities of daily living (ADL). The MDS indicated Resident #246 was on oxygen. Record review of Resident #246's Care Plan indicated the resident had a problem initiated on 3/4/2024. The resident has oxygen therapy regarding their diagnosis of Chronic Obtrusive Pulmonary Disease . During an interview and observation on 3/17/24 at 10:29 a.m., Resident #246's nasal cannula was laying in the trashcan. Resident #246 said that she did not place her nasal cannula in the trashcan and that a nurse that was in there who just made her bed must have placed it in the trashcan while she was making her bed. She said that she would never place her cannula in the trashcan because it would go into her nose when she got into bed again. During an interview on 3/19/25 at 10:44 a.m., CNA C said that residents nasal canula should be stored in a bag when it was not in use. She said that if a resident's cannula was lying in a trashcan, it could place the resident at risk of infection. She said it was the responsibility of CNAs and nurses to ensure that cannula is stored properly . 2. Record review of Resident #16's face sheet dated 2/04/2022 indicated the resident was a 67-year- old female who admitted to the facility on [DATE] with diagnoses of Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), and Heart Failure (a condition in which the heart cannot pump enough blood to meet the body's needs). Record review of Resident #16's MDS assessment, dated 3/6/2025, indicated the resident had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS indicated Resident #16 was on oxygen. Record review of Resident #16's Care Plan indicated the resident had a problem initiated on 4/11/2024. The resident has oxygen therapy regarding their diagnosis of Chronic Obtrusive Pulmonary Disease. During an interview and observation on 3/17/25 at 10:44 a.m., Resident #16's oxygen concentrator was covered in a thin layer of dust. The external filter had a thick layer of dust that when touched became airborne. Resident #16 was asked about her filter but she did not give a valid response to the question asked. 3. Record review of Resident #42's face sheet dated 3/18/2025 indicated the resident was a 81-year- old male who admitted to the facility on [DATE] with diagnoses of acute gastritis with bleeding ( an inflammation of the lining of the stomach), gastrointestinal hemorrhage (a sign of bleeding in the digestive tract), Hypertensive heart disease with heart failure (a condition caused by prolong high blood pressure which can lead to heart failure) and urinary calculus (harden deposits of minerals that form in the kidney and cause pain as they pass through the urinary tract). Record review of Resident #42's MDS assessment, dated 3/7/2025, indicated the resident had a BIMS score 9 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #42 was dependent with all activities of daily living (ADL). The MDS indicated Resident #42 was on oxygen. Record review of Resident #42's Care Plan created on 2/21/2025 indicated the resident had little to no activity involvement due to disinterest, immobility and physical limitations. The care plan revised on 3/18/2025 indicated the resident wanted his RP to manage talking with physicians, staff members and nurses about care. Interventions included to administer medications as ordered and monitor and document effects and effectiveness. The care plan did not indicate Resident #42 was on oxygen. Record review of Resident #42's MAR dated 3/1/2025-3/31/2025 indicated the resident was on 2 liters via nasal cannula continuously every shift starting on 3/16/2025. The Physician's order was initiated on 3/16/2025 indicated Resident #42 was prescribed 2 liters via nasal cannula continuously every shift. During an interview and observation on 3/17/2025 at 11:14 AM, Resident #42 said he was not feeling well, and RP was at bedside. The RP said the resident recently returned from the hospital. The RP was concerned Resident #42 was sleeping too much. Observed Resident #42's oxygen setting on 5 liters of oxygen. During an interview and observation on 3/17/2025 at 3:43 PM, Resident #42 continued to have oxygen setting on 5 liters. The RP said she had not adjusted the oxygen settings. During an interview on 3/17/2025 at 3:45 PM, LVN T said the resident was supposed to be on 2 liters of oxygen and returned to his room and corrected the setting. She said she was not sure why the resident was on 5 liters. She said she tries to check the setting as she reviews the residents MAR and makes her rounds. She said she had just recently disconnected resident from the oxygen tank to the concentrator. During an interview on 3/19/2025 at 8:56 AM, LVN M said the nursing staff changed the oxygen tubing and dated weekly. LVN said the nurses were responsible for ensuring the settings were correct and educating the resident and family on proper placement, keeping the tubing above the level of the water, not dropping the tubing on the floor and monitoring areas behind the ears for sores. LVN said the staff educate the resident and family on not adjusting the oxygen settings and follow the physician orders. LVN said we educate residents with respiratory issues such as COPD (a group of lung diseases that block airflow and make it difficult to breathe) that increasing the oxygen setting could cause other risk such as increasing CO2 retention and causing an exacerbation of their Chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). LVN said it was the responsibility of the nurses to ensure the oxygen was on the correct settings every shift. During an interview on 3/19/2025 at 11:30 AM, LVN N said the nursing staff should be checking the oxygen settings every shift. LVN N said if she observed a resident on 5 liters and the order was for 2 liters, she would make the adjustment to correct. She said she had never had any issues with residents on oxygen. LVN N said the nurses were responsible for ensuring the orders were followed and the family or resident should not be adjusting their own oxygen. During an interview on 3/19/2025 at 12:00 PM, the RP said she had never touched the oxygen concentrator or adjusted the oxygen settings. She said she saw when LVN M returned to the room and adjusted the setting. During an interview on 3/19/2025 at 1:14 PM, ADON H said the nurses should be checking to make sure how many liters of oxygen were ordered and checking the resident's oxygen saturations. She said if a resident's oxygen were set too low, it could cause complications and she was not sure what would happen if the setting were too high. ADON H said every shift, the nurses check to ensure the oxygen was on the correct liters ordered. ADON H said the staff made Angel rounds and assigned to a hall and they checked to make sure the tubing was changed, and the oxygen were on the correct settings. ADON H said she did not know why Resident #42's oxygen was set on 5 liters. She said when she made rounds, Resident #42 was on his oxygen tank and not the concentrator. 4. Record review of Resident #9's face sheet dated 3/18/25 indicated Resident #9 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses including cerebral palsy (is a group of conditions that affect movement and posture) and hypertensive heart disease with heart failure (is a condition where chronic high blood pressure (hypertension) damages the heart muscle, leading to heart failure). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and had the ability to understand others. Resident #9 had a BIMS score of 15 which indicated intact cognition. Resident #9 MDS assessment did not indicated oxygen therapy. Record review of Resident #9's care plan dated 3/3/35 indicated Resident #9 was on oxygen therapy related to ineffective gas exchange. Intervention included oxygen settings per medical doctor orders. Record review of Resident #9's consolidated physician orders dated 3/18/25 indicated: *Check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. *Oxygen at 2-4 liters via nasal cannula as needed every 12 hours if saturation less than 88%. Start date 10/13/24. Record review of Resident #9's MAR dated 3/1/25-3/31/25 indicated check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. The MAR indicated administration on 3/16/25 (LVN E). During an observation on 3/17/25 at 11:41 a.m., Resident #9 was lying in her bed with a nasal cannula connected to an oxygen concentrator. Resident #9's oxygen concentrator filter had a thick, moderate amount of white, fuzzy particles. Resident #9 said staff changed her nasal cannula tubing once a week. She said she did not know about the oxygen filter. During an observation on 3/18/25 at 8:47 a.m., Resident #9 was lying in her bed with a nasal cannula connected to an oxygen concentrator. Resident #9's oxygen concentrator filter had a thick, moderate amount of white, fuzzy particles. 5. Record review of Resident #33's face sheet dated 3/18/25 indicated Resident #33 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #33 had diagnoses including acute respiratory failure (is a life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels (hypoxemia) and/or high carbon dioxide levels (hypercapnia)) and chronic obstructive pulmonary disease (is an ongoing lung condition caused by damage to the lungs). Record review of Resident #33's quarterly MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. Resident #33 had a BIMS score of 9 which indicated moderate cognitive impairment. Resident #33 had oxygen therapy within the last 14 days. Record review of Resident #33's care plan dated 02/24/25 indicated Resident #33 had oxygen therapy related to history of respiratory failure and chronic obstructive pulmonary disease. Intervention included oxygen settings per medical doctor orders. Record review of Resident #33's consolidated physician order dated 3/18/25 indicated: *Oxygen at 2 liters via nasal cannula continuous every shift. Start date of 12/27/24. *Check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. Record review of Resident #33's MAR dated 3/1/25-3/31/25 indicated check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. The MAR indicated administration on 3/16/25 (LVN E). During an observation on 03/17/25 at 9:41 a.m., Resident #33 was lying in bed with a nasal cannula connected to an oxygen concentrator. Resident #33's oxygen concentrator filter had a small amount of white, fuzzy particles. During an observation on 3/18/25 at 8:19 a.m., Resident #33 was lying in bed with a nasal cannula connected to an oxygen concentrator. Resident #33's oxygen concentrator filter had a small amount of white, fuzzy particles. On 3/19/25 at 12:15 p.m., call placed to LVN E and was unable to leave a message. During an interview on 3/19/25 at 12:51 p.m., LVN K said the nurses who worked on Sunday nights were responsible for cleaning oxygen filters. She said the facility also had staff assigned to complete angel rounds in the resident's room. She said angel rounds were done every morning. She said during angel rounds the assigned staff looked at the oxygen setups and other things. She said Resident #33's oxygen filter did not look as if it was cleaned last Sunday night. She said it was important for a resident's oxygen filter not to have white fuzzy particles because it was respiratory equipment. She said an unclean oxygen filter could cause a bunch of problems. She said an unclean filter could cause sickness and affect the resident's overall health. During an interview on 3/19/25 at 1:23 p.m., the Director of Nurses said that it is the responsibility of nurses to ensure that nasal cannula is stored properly when not in use. She said that cannula should not be left hanging in a trashcan. She said that resident filters are replaced by nursing staff, and they are kept clean by nursing staff. She said there was a risk of a respiratory infection if cannula is not stored properly, and concentrators are not kept clean. During an interview on 3/19/25 at 1:40 p.m., the Administrator said that nasal cannula should be stored properly and not left in a trashcan. He said that their concentrators should be cleaned, and filters changed. He said residents could be placed at risk of a respiratory infection if proper protocol was not followed. During an interview on 3/19/2025 at 2:05 PM, the DON said the nurses were responsible for ensuring orders were followed. She said the oxygen should be care planned. The DON said she spoke with the RP and she reported she turned up the oxygen concentrator. The DON said Resident #42 could have had respiratory issues. During an interview on 3/19/2025 at 2:21 PM, the ADM said he expected the nurses to check the orders and oxygen daily. The ADM said he expected the family and resident to be educated on oxygen care. The ADM said too much oxygen could cause light headedness or dizziness. The ADM said the nurses were responsible for checking the oxygen settings and orders. During an interview on 3/19/25 at 3:15 p.m., the DON said the nurses were responsible for the external oxygen filters and maintenance was responsible for the internal. She said oxygen filters were supposed to be cleaned weekly. She said the oxygen filters on concentrators were supposed to draw in the particles, in the resident's environment. She said if the oxygen filter had white fuzzy particles, then it was doing its job. She said it was important the oxygen filter to be clean to maintain airflow to the resident. She said if the resident's oxygen filter was not cleaned weekly, it could decrease the air flow. During an interview on 3/19/25 at 3:23 p.m., the Administrator with the VP of Operations present said he had been employed at the facility for thirteen months. The VP of Operations said the external filter on the oxygen concentrator was assigned to the nursing staff. The VP of Operations said the facility had daily angel rounds who also were supposed to check the oxygen filters. The VP of Operations said the internal filters were assigned to the Maintenance staff. The VP of Operations said he was not sure how often the internal filters were cleaned by Maintenance. The VP of Operations said he believed Maintenance were supposed to clean the internal filters monthly. The Administrator said the external filters should be cleaned as needed. The Administrator said oxygen filters should be cleaned because it affected the resident's breathing. The Administrator said he was responsible to ensure the nursing staff, assigned angel round employees, and maintenance staff cleaned the resident's oxygen concentrator filters. Review of a facility policy titled Oxygen undated indicated Purpose .A resident will receive oxygen therapy when ordered by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration. Responsible Disciplines .Licensed Nursing, Attending physician, FNP .Procedure .1. Assess the resident's room to determine if the environment is safe for oxygen administration. 2. Post an oxygen precaution No smoking sign on the resident's door.3. Obtain physician orders for oxygen administration .Orders should include following .oxygen source .method of delivery .flow rate .oxygen saturation monitoring parameters .4. Assess the resident's condition .5. Monitor the resident's response to oxygen .Check pulse oximetry 6. Monitor for signs of hypoxemia .a. level of consciousness .pulse oximetry .vital signs .skin and mucous membrane .breathing patterns .dyspnea .cyanosis, cool .7. Observe the resident's skin .Documentation: Place documentation in the resident's EMR Administration Record (TAR) .date and time of oxygen administration .type of delivery///oxygen flow rate .residents vital signs, skin 49019 44933

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms and to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 19 residents (Resident #50 and Resident #47) reviewed for medications storage and pharmacy services. 1. The facility failed to remove expired over the counter medications from the Medication Storage room. 2. The facility failed to ensure narcotic counts were accurate for Resident # 50's Belsomra 10 mg (medication used for insomnia) for medication cart on Hall 100 at shift change on [DATE]. 3. The facility failed to ensure Resident #47 Midodrine (is used to treat low blood pressure (hypotension)) had hold blood pressure (is the force exerted by blood against the walls of your arteries as it circulates through your body) parameters orders. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications and inaccurate drug administration. Findings included: Record review of Resident # 50's Face sheet dated [DATE] indicated the resident was a 68-year- old male who readmitted to the facility on [DATE] with diagnoses of Hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side (a complete paralysis or weakness affecting one side of the body after a stroke due to the damage to the brains motor pathway), recurrent depression (a pattern of repeated episodes of major depressive disorder), Hypertensive heart disease with heart failure (prolonged high blood pressure that causes the heart to work harder, leading to weakened heart muscle and reduced pumping ability), and convulsions (a rapid, involuntary muscle contraction that causes uncontrollable shaking and limb movement). Record review of Resident #50's MDS assessment, dated [DATE], indicated the resident had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #50 required supervision with personal hygiene and ADL's. Record review of Resident #50's Care Plan created on [DATE] indicated the resident was taking an antidepressant medication for depression. Interventions included monitoring, documenting, and reporting adverse reactions to antidepressant therapy such as changes in behavior, mood, cognition, hallucinations, social isolation, withdrawal, decline in ADL ability, continence, constipation, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors and insomnia. Record review of Resident # 50's MAR dated [DATE]-[DATE] indicated he was ordered Belsomra 10 mg (a medication used to treat insomnia) was started on [DATE]. During medication cart review on [DATE] at 10:00 AM, Resident # 50 had documented on the narcotic sheet to have 3 tablets remaining. LVN O pulled Belsomra 10 mg packet out for a narcotic count and Resident #50 had 4 tablets of medication left. LVN O said she did the counts that morning and did not identify the off count. She said the medication must have been signed out and not given. She said she did not know why the counts were off and she did not work last night. During an interview on [DATE] at 10:03 AM, the DON said she was going to check the EMR, and she requested LVN O to notify the Physician. During an interview on [DATE] at 12:00PM, the DON said she had investigated the narcotic counts, and it was determined the night shift nurse failed to administer the medication on [DATE]. The DON notified Resident #50 of the medication error, notified the Physician, and completed an incident report. The DON provided documentation that she would begin monitoring narcotic counts beginning on [DATE], 3 times weekly for 90 days. The DON completed an in-service with the 3 nurses responsible for medication counts on the Rights of Medication Administration and controlled substances and narcotic counts. The nurse who was responsible for administering the medication indicated on the in-service he may have forgotten to pop the pill out but signed it out in the narcotic book and electronic medical record. During an observation on [DATE] at 3:10 PM, this surveyor reviewed the storage room and found the following medications: Lorazepam 2 mg/ml 3 vials with dated expirations (2 vials) expired on [DATE] and (1 Vial) expired on [DATE] for Resident # 52. The medication was in the refrigerator under double lock and key. Potassium 99 mg tablets 2-bottles had expired [DATE]. The DON said she was responsible for removing the expired Lorazepam vials from the refrigerator. She said Resident #52 was on the medication for seizures and he was currently well controlled with oral medications. The DON said she was going to notify the Physician. The DON said she had just returned from vacation and had not removed the medication. The DON said central supply was responsible for stocking and removing expired over the counter medications. Review of an in-service dated [DATE] subject Handoff/Narcotic Counts indicated the DON discussed proper hand off of medication cart keys and narcotic counts at shift change. The DON indicated 2 nurses are to count narcotics and compare them to the narcotic book. She noted keys should not change hands until the counts were confirmed to be accurate. The DON indicated for any discrepancies, the DON and MD must be notified so an investigation could be completed. 44933 Record review of Resident #47's face sheet dated [DATE] indicated Resident #47 was a [AGE] year-old female admitted on [DATE]. Resident #47 had diagnosis including hypotension. Record review of Resident #47's admission MDS assessment dated [DATE] indicated Resident #47 was understood and had the ability to understand others. Resident #47 had a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #47's care plan dated [DATE] did not reflect the diagnoses of hypotension and use of Midodrine. Record review of Resident #47's consolidated physician order dated [DATE] indicated Midodrine HCl Oral Tablet 5mg, give 1 tablet by mouth three times a day related to Hypotension. One tab in morning, one tab at noon, and one tab in the evening. Started on [DATE]. Resident #47's consolidated physician order did not reflect hold blood pressure parameters. Record review of Resident #47's MAR dated [DATE]-[DATE] indicated Midodrine HCl Oral Tablet 5mg, give 1 tablet by mouth three times a day related to Hypotension. One tab in morning, one tab at noon, and one tab in the evening. Started on [DATE]. Resident #47 received 30 of 52 doses. Resident #47 had 13 doses held for parameters not me. Resident #47's MAR did not reflect hold blood pressure parameters. During an interview on [DATE] at 12:51 p.m., LVN K said the nurse who put the order in should get the hold parameters. She said the ADONs were supposed to monitor medication orders. She said without hold parameters if a resident's blood pressure was low it could bottom out. She said if the resident's blood pressure was high it could increase the blood pressure. She said if a resident was administered a blood pressure medication and the hold parameters were not followed, it could cause the need for more medication or being sent out to the hospital. LVN K reviewed Resident #47's Midodrine order and said it did not have blood pressure hold parameters. During an interview on [DATE] at 2:15 p.m., the DON said the admit nurse or whoever received the physician order should have also obtained hold parameters. She said Resident #47's Midodrine order should also have hold parameters orders. She said it depended on the physician, what hold parameters were ordered to follow. She said if resident received a medication for hypotension but was not hypotensive, they could become hypertensive (is a condition where the force of blood against artery walls is consistently too high). She said nursing management, through chart audits, should ensure the nursing staff obtained hold blood pressure parameters. During an interview on [DATE] at 3:23 p.m., the Administrator, with the VP of Operations present, said the physicians decide the hold parameters for the resident's medications. He said the nurses should contact the physician for hold parameters orders. He said if a resident received a medication to increase their blood pressure but it was not needed, they could experience increased blood pressure. He said with the increased blood pressure they could have a stroke or heart attack. He said the DON should ensure the nursing staff obtained hold blood pressure parameters. Review of a facility policy titled Storage of Medications Revised on [DATE] indicated .all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs and biologicals used in the community are stored in a locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2.are stored in the packaging, containers, or other dispensing systems in which they were received .3.nursing staff is responsible for maintaining medication storage and preparation .4.discontinue, outdated or deteriorated drugs . Record review of a facility's Administering Medications policy revised ,d+[DATE] indicated .medications are administered in a safe and time manner, and as prescribed .the director of nursing services supervises and directs all personnel who administer medications and/or have related functions .the following information is checked/verified for each resident prior to administering medication .vital signs .

Based on interview, and record review, the facility transportation staff failed to ensure resident received adequate supervision and assistance devices to prevent accident for 1 (Resident #1) of 1 resident reviewed for accidents. The facility failed to secure Resident #1 in wheelchair while being transported in the facility van from dialysis. This failure could place residents in the facility who required assistive safety devices when traveling in the facility van at risk for accidents. Finding included: Record review of a facility investigation report dated 03/13/2023 indicated that Resident #1 wheelchair tipped backward, resident sustained superficial hematoma back of head, small skin tear to right elbow, and a small skin tear to back of right hand. Record review of Resident#1 face sheet revealed is [AGE] year-old, primary language English, date of birth 10/06/1942. admitted [DATE] and was discharged on [DATE] to home with home health service. admitted from an Acute care hospital: Diagnoses: Acute respiratory failure with hypoxia, pneumonia, unspecified organism, chronic obstructive pulmonary disease with acute exacerbation, other chronic pancreatitis, benign prostatic hyperplasia without lower urinary tract symptoms, , peripheral vascular disease (unspecified), type two diabetes mellitus with diabetic neuropathy (unspecified), hyperlipidemic (unspecified), dependence on renal dialysis, end stage renal disease, anemia in other chronic diseases classified elsewhere, essential ( primary ) hypertension, arthropathy (unspecified), muscle weakness ( generalized), sarcopenia, difficulty in walking, unspecified lack of coordination, acquired absence of right leg below knee, acquired absence of left below knee. Review of Resident #1's Plan of care indicated resident/resident representative has been informed of medical condition and plan of care: Admit to Skilled services, continue skilled services times five weeks' time thirty days for therapeutic exercise, therapeutic activities, neuro muscular re-education, safety, and Activities of daily living (ADL) training with use of modalities per protocol for pain and strengthening. 02/08/2023: Continue skilled physical therapy for five weeks' time thirty days for balance activities, gait/transfer training, and pain management. 01/06/2023: Dialysis-monitor AV Shunt/Fistula to (left inner forearm) for thrill and bruit every shift, notify MD (medical doctor), NP (nurse practitioner) for any unusual/ unexpected findings. Record reviewed of incident report dated 3/13/2023 at 4:37pm reflected: SN (Skilled Nurse) was notified by transportation driver that resident #1 received some injuries from a fall in the transportation van. Resident#1 assessed, 1.5cm x1.5cm skin tear to top of right hand between the 1st and 2nd proximal knuckles, 1.5cm x 1.5cm skin tear to top of right elbow with bruising around area and a raised area to the back of resident's head with some dry blood noted. Both skin tears cleansed, and Triple Antibiotic Ointment (TAO) applied along with steri-strips in place. Pressure applied to raised area to head. SN offered sending resident to hospital, resident refused and states I am fine, it's nothing big. Review of Medication order review dated 03/13/2023 reflected at 7:44pm Orders Administration Note: Acetaminophen-Codeine Tablet 300-30 milligram. Give 1 tablet by mouth every 6 hours as needed for Pain, may give 2nd tab if 1st tab is ineffective** no more than 3 grams of Acetaminophen in a 24-hour period. In an interview with LVN A on 6/6/2023 at 2:30 pm states Resident #1, was discharged on [DATE] to home with home health service and (van driver) no longer work with at the facility. During an interview on 06/06/2023 at 2:45pm: Director of Nursing (DON) verified Resident#1 was discharged on [DATE], and Facility Reported Incident occurred on 3/13/2023. Primary Care Physician (PCP), and spouse representative notified. Report review indicated on investigation summary Van Driver stated, she did not properly and safely secure resident prior to the transport. DON states (van driver) and staff, was in-serviced regarding Abuse/Neglect. Post incident (3/13/2023), DON states provider action: Transport driver, suspended times three days, given a written Corrective Active notice pending investigation, removed from transportation position, 3/16/2023 removed from suspension, she re-assigned to a Certified Nurse Aide(CNA), position, which was excepted by staff, but never pick-up any additional shifts. Record Review on 06/06/2023, Educational In-Service Regarding Transport Safety given on 3/13/23: Ensure resident is properly and comfortable seated. Lap belts and shoulder belts are tightened and securely fasted. Chairs are securely fastened with all straps; front and rear clamps are locked and in placed as chair is secured to the van floor. Chair brakes are locked. If a sling is used ensure it is snuggly draped over transport chair with non-skid mat in place. Monitor residents during transport. If a resident refused to all required safety. If a resident refuses to all required safety devices in place, do not transport, immediately report the concern to Administrator and or DON. Record Review of Investigation report dated 03/13/2023 revealed Transportation driver was returning Resident #1 from dialysis via transport van. While pulling into facility driveway incline, resident #1 wheelchair tipped backwards, Resident #1 sustained small superficial hematoma to back of head as well as small skin tear to right elbow and a small skin tear to back of right hand. Resident refused to be sent to emergency room . During an In a phone interview with Resident #1 06/08/2023 at 3:30pm, Resident#1 said, we usually use a Lap Belt but, was not use this time., my wheelchair (w/c) went backwards and flipped upside down, I tried to use my hands to catch myself, but I couldn't. Review of an undated policy and procedure for Facility Transportation indicated: Purpose, to indicate who is eligible to drive the facility owned van and for what reason the van may be utilized. Eligible Drivers: Only the employee of the facility, who have been approved by the central office and whose name appears on the driving list shall be authorized to drive the facility van on [NAME] fide facility business. Resident needs to be met while out of the facility prior to being transported by facility personnel. Transportation Aide Responsibility to report all accidents and incidents while on a trip to the DON and Administrator. Review of the facility Abuse/ Neglect Policy dated 2023 reflected: POLICY STATEMENT; It is the responsibility of our facility employees/associates, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to facility management.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards for 1 of 4 residents reviewed for accidents. (Resident #26) The facility did not repair Resident #26's raised threshold between the bathroom and bedroom area after a CNA pulled the resident in her shower chair through the doorway, causing it to catch on the raised threshold. The shower chair tipped over, causing Resident #26 to fall out, and sustained a right ankle fracture. This failure could place residents at further risk of falling or other accidents. Findings included: 1. Physician orders [REDACTED].#26 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #26's cognition was intact. Resident #26 had clear speech, could be understood and could understand with no behaviors. Resident #26 received assistance by 1 person with locomotion on the unit and with transfers. The resident was noted to have required limited assistance of 1 person with personal hygiene and total dependence of one person with bathing. A care plan dated 09/05/19 indicated Resident #26 had a fractured right ankle due to a fall at the facility. The Incident Report dated 09/05/19 indicated the incident occurred on 09/04/19 at 9:10 p.m. It was documented CNA G was assisting Resident #26 over the threshold between the resident's bathroom into room area when the shower chair caught on the threshold and tipped over. An x-ray was obtained at the local hospital and it was indicated the resident received a fracture to the right ankle area. During an interview on 10/14/19 at 3:31 p.m., Resident #26 said she had never fallen at the facility until 09/04/19 when she and the shower chair tipped over as staff assisted her from her shower/bathroom into her room. She said CNA G was pulling the shower chair over the hump of the threshold when the chair and she tipped over. Resident #26 said her ankle became entangled in the shower chair and her right ankle was fractured. During an interview on 10/16/19 at 3:06 p.m., the DON said the incident in which Resident #26 and the shower chair tipped over occurred in the doorway of the resident's bathroom and bedroom. The DON said the wheel of the shower chair caught on the rubber covered bump of the doorway's threshold. The DON said she thought at one point the facility discussed trying to make the threshold area more even but that this had not been done. She said the CNAs who had been working with Resident #26 at the time of the incident had been in-serviced regarding being more careful. During an observation and interview on 10/16/19 at 3:13 p.m., the rubber threshold cover between Resident #26's room and bathroom was not completely secured. The rubber cover to the threshold was able to be moved. The DON said the threshold cover would need to be secured. The tile in the bathroom was higher than the flooring in the bed room, causing a hump in the door way. During an interview on 10/16/19 at 3:35 p.m., CNA G said on the day of the incident, she was standing in front of Resident #26 attempting to pull the shower chair Resident #26 was sitting in over the threshold of between the bathroom and bedroom. The CNA said she hit the lip in the doorway and the shower chair containing Resident #26 tipped over. CNA G said she received an in-service from ADON H about being more observant and careful and hitting the threshold at a different angle with the shower chair over the uneven threshold. The CNA said she was not used to working on Hall 400 where the incident occurred. She reported that the bathrooms on her normal hall were different and easier to get through. During an interview on 10/16/19 at 2:35 p.m., ADON H said she had assisted a resident with a shower in the past and had almost tipped the resident out of a similar shower chair going over one of the uneven thresholds. She said had been able to use her leg to stabilize the resident and the shower chair. ADON H said there had been no other accidents of this nature to her knowledge. She said CNA G had been in-serviced. During an interview on 10/17/19 at 12:11 p.m., the administrator said the staff involved in the incident with Resident #26 had been in-serviced about being careful. He said the rubber covered uneven threshold was in good shape. The administrator said the facility would have maintenance to go look at the threshold and have it assessed to see if the threshold could be made to have a lower profile to assist with the transition between the private bathroom and room area. During an interview on 10/17/19 at 1:30 p.m., the Human Resource manager said the facility had been without a maintenance man since 06/14/19. During an interview on 10/17/19 at 2:20 p.m., the facility was asked for additional information at exit regarding this deficiency, no additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was received for 1 of 5 residents reviewed for accidents. (Resident # 1) CNA A did not provide Resident #1 two person assistance with a bed bath. CNA A pulled the sheets from under Resident #1 while attempting to change the bed and the resident slid out of bed. Resident #1 fell and sustained a closed [MEDICAL CONDITION] humerus. (long bone in arm) This failure could place residents who required 2- person assist with transfers at risk of injury. Findings included: A face sheet undated indicated Resident #1 was a [AGE] year-old female, admitted [DATE] with [DIAGNOSES REDACTED]. A nursing progress note dated 04/24/19 at 6:29 a.m., indicated nurse was notified by CNA A that Resident #1 slid out of bed. Upon entering noted resident was lying in floor. Resident #1 voiced no complaints of pain or discomfort during assessment. Hoyer lift used with 3 staff assist to lift resident from floor back into bed. Resident #1 did not remember falling. The nursing notes for Resident #1 dated 4/25-27/19 did not indicate any injuries related to her fall on 4/24/19. A nursing progress note dated 04/29/2019 at 4:40 p.m., upon assessment Resident #1's thighs (predominantly the left) shows signs of third spacing, with various scattered areas of ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) to both thighs (red/pink in color and irregularly shaped). The resident stated, oh my legs when re-positioned but continued to decline PRN (as needed) Tylenol when offered. There was no complaint of shoulder pain. The need for hospice services was discussed with family. The family requested an x ray because of the previous fall. A nursing progress note dated 04/29/2019 at 9:27 p.m., indicated x rays showed a fracture to Resident #1's humeral head (shoulder joint) fracture with greater tuberosity fracture of right shoulder. Resident #1's physician ordered her to be sent to the hospital for further evaluation. A nursing progress note dated 04/30/2019 at 12:43 a.m., indicated Resident #1 returned from the hospital with her right arm placed in sling at hospital. No new orders were received. A hospital discharge summary dated 04/29/19 indicated Resident # 1 had a closed [MEDICAL CONDITION]. The report indicated the fracture would be treated with immobilization. A MDS dated [DATE] indicated Resident #1 was total dependent with all ADLs and required two person assist with bathing, toileting, dressing, transfers, and bed mobility. The most recent MDS dated [DATE] indicated Resident #1 had severely impaired cognition. She was total dependent and required 2- person assistance with all activities of daily living. A care plan dated 05/01/19 with start date of 04/03/19 indicated Resident #1 had severe [MEDICAL CONDITION] and was at risk for fracture. She required extensive assistance with all activities of daily living. An updated care plan dated 05/03/19 indicated Resident #1 had a fracture and wore a sling to her arm. During an observation on 05/05/19 at 12:26 p.m., Resident #1 was lying in bed with a sling on her right shoulder. Resident #1 did not respond to any questions. During an interview on 05/07/19 at 10:00 a.m., the DON said CNA A said she knew Resident #1 was a 2- person assistance but, felt she could do it by herself. During a phone interview on 05/13/19 at 2:59 p.m., CNA A said she was pulling the clean sheets under Resident #1 when Resident #1 let go of the grab bar and slid off the bed. CNA A said she thought she could provide Resident #1 her bed bath without assistance. CNA A said, my mistake. CNA A said she knew Resident #1 was a 2- person assist because it was indicated on the ADL care sheet. A safe lifting and movement of residents, policy with a revision date of (MONTH) (YEAR) indicated .In order to protect the safety and well-being of staff and resident, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent an accident for 1 of 3 residents reviewed for accidents. (Resident #2) The facility did not prevent Resident #2 from sustaining a knee fracture. Resident #2 complained of knee pain after being transferred by a Hoyer lift and a week later she was diagnosed with [REDACTED]. This failure contributed to Resident #2's knee fracture. This failure could place 20 residents who required a Hoyer lift for transfers at risk of injury. Findings included: The Physician order [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The report indicated Resident #1 had an order for [REDACTED]. The report indicated Resident #2's pain level was to be assessed daily and offer an as needed pain medication if pain was greater than a 2 on a scale of 0-10. An MDS dated [DATE] indicated Resident # 2's cognition was intact with adequate hearing, clear speech, and clear comprehension. Resident #2 required extensive assistance of two persons for transfer and ADLs. Resident #2 complained of pain frequently and described pain as a 6 on a scale of 0-10 with 0 being no pain and 10 being the worst. A care plan with problem start date of 01/25/17 indicated Resident #2 required the use of a Hoyer lift due to inability to ambulate and or/paralysis. The Lifting Machine, Using a Portable policy and procedure revised October 2010 indicated two nursing assistants would be required to perform the procedure if the resident was unable to participate in the lifting procedures. A progress note recorded as a late entry on 1/30/17 dated 01/21/16 at 5:17 p.m., completed by LVN D indicated a staff member wanted someone to look at Resident #2's leg. The note indicated the resident said I was transferring her yesterday and she complained of pain. The late entry documented no bruising, redness, warmth, swelling noted, no complaint of pain at this time. During an interview on 02/12/17 at 2:34 p.m. CNA C said she could not remember who assisted her with the transfer of Resident # 2 from her wheelchair to the bed on 1/20/17. CNA C said as she was lifting Resident #2 with the Hoyer lift the resident said her leg hurt and she just lowered Resident #2 onto the bed. CNA C said she reported the incident to LVN D on 1/21/17. CNA C said it was normal procedure to write up an incident report, but she did not do one and did not know why. A witness statement dated 1/27/17 completed by CNA E indicated Resident #2 said a CNA used a Hoyer lift to put her in and her leg snapped and she asked for a pain pill. A witness statement dated 1/27/17 completed by LVN F indicated Resident #2 said she had been having pain to the right knee for one week. The note indicated the LVN assessed the right knee and no bruising, warmth, displacement or redness was noted. A witness statement dated 1/27/17 completed by LVN G indicated Resident #2 told her on 1/21/17 when CNA B transferred her using the Hoyer lift her right leg got caught between the Hoyer lift and the wheelchair and she heard her knee snap. The statement indicated the resident said she spoke with LVN D who would get her something for pain. A witness statement dated 1/27/17 completed by LVN H indicated Resident #2 said when CNA B transferred her using the Hoyer lift her right leg got caught between the Hoyer lift and the wheelchair and she heard her knee snap. The medications administration history dated 1/20/17 through 01/31/17 indicated Resident #2 received tramadol 50 mg on 1/24/17 for pain level 5 out of 10 and1/27/16 for pain level 6 out of 10 prior to medication and her pain level was 2 out of 10 after medication. The medications administration history for January 2017 indicated Resident #2 had a leg immobilizer on the right leg at all times with an initial start date of 1/29/17 and discontinued on 2/2/17. A progress note dated 01/27/17 at 5:06 p.m., indicated Resident # 2 complained of pain to the right knee and said she had been having pain/discomfort to the right knee for one week. An x-ray was ordered and the physician notified. A radiology report dated 01/27/17 indicated 2 views of the right knee with findings of mildly displaced acute fracture through the distal femoral metaphysis (fractured knee). A progress note dated 01/27/17 at 9:42 p.m., indicated x-rays results received with impression of acute mildly displaced fracture of the distal femoral metaphysis (fractured knee). Resident #2 said that last weekend on Saturday her right left got hung on the Hoyer lift when she was being transferred. A nursing trauma flow sheet from the emergency room dated 1/27/17 at 11:45 p.m. indicated Resident #2 had marked swelling in both feet. Her right leg was shortened and rotated outward. The flow sheet indicated the resident received morphine (pain medication) 4 mg intravenous for pain at a level of 8 out of 10. An emergency department physician note dated 1/27/17 indicated Resident #2 reported her right knee got caught and was hurt when being transferred. The note indicated the resident reported her knee hurt all week. The note indicated the resident had swelling and tenderness to the right knee. A Provider Investigation Report dated 1/28/17 indicated Resident #2 had an injury of unknown source on an undetermined date. The report indicated Resident #2 reported her right leg may have been injured during a transfer by a Hoyer lift. A progress note dated 1/29/17 at 12:05 p.m., indicated Resident #2 was transported back into the facility. Right leg supported during transfer. New order to Right leg non-weight bearing up as tolerated and to wear immobilizer at all times. A progress noted completed by the psychologist dated 1/30/17 indicated Resident #2 said her knee was hurt by accident during a Hoyer lift transfer on 1/21/17. The note indicated Resident #2 said at the time of the incident she was not aware her knee was injured much less broken. The note indicated the resident said her knee began to hurt the next day and her knee hurt more each passing day when she was moved. The note indicated she mentioned it to the staff. The note indicated the resident felt staff did not take her complaints seriously until the X-ray was ordered. During an interview on 2/13/17 at 10:00 a.m., Resident #2 said her heel got caught on the handle of the Hoyer lift while being transferred by CNA C and one other CNA. Resident #2 said no one looked at her knee until a week later and it started to swell. During an interview on 2/13/17 at 11:00 a.m., Resident #2 said when she told staff her knee hurt they did not do anything. She said she guessed they thought I was a crybaby. She said her knee hurt when she was moved. During an interview on 02/16/17 at 11:55 a.m., the DON stated the facility could not determine the exact time or place that the fracture to Resident # 2's knee occurred. During an interview on 02/22/17 at 1:53 p.m., the administrator said 20 residents required a Hoyer lift for transfers.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent an accident for 1 of 8 residents reviewed for accidents. (Resident #20) Resident #20 received a burn to her right outer thigh from a rice sock that was used as a heating pad. The facility did not supervise the use of the rice sock. This failure contributed to Resident #20 receiving a second degree burn to her outer thigh. This failure could place 37 residents who received rehabilitative services at risk for injury. Findings included: Physician orders [REDACTED].#20 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #20 ' s cognition was moderately intact and did not exhibit any signs or symptoms of delirium, psychosis, or behaviors. A short term care plan dated 10/19/15 indicated Resident #20 received a burn from the rice filled sock the resident was applying to her neck and shoulder area for pain. The area was assessed and described to be a denuded blister to Resident #20's anterior (outer) right thigh, measuring 15.0 cm x 6.0 cm x<0.1 cm. There were 2 intact blisters to the distal portion of the denuded blister, measuring 0.7 cm x 2.0 cm and 0.5 cm x 1.0 cm. Resident #20 was documented to have reported she did not know what occurred she woke up on Saturday morning and the blisters were just there. A care plan dated 10/20/15 indicated Resident #20's daughter reported bringing a rice filled sock from home on Saturday (10/17/15), heating it in the microwave to heat it, wrapped the rice filled sock in a towel for the resident to use for pain relief to her neck and shoulder area. The care plan indicated the resident's daughter reported she thought Resident #20 could have gone to sleep and the rice filled sock rolled under her. During an interview on 11/05/15 at 10:52 a.m., CNA G said after lunch on 10/18/15 she observed Resident #20 at the microwave located at the end of Hall 500 trying to heat up the rice filled sock. She said the resident asked her to heat the rice filled sock. CNA G said she turned the microwave on for 30 seconds for Resident #20. She indicated the resident wanted her to keep re-heating the sock to get it hotter, but she refused. CNA G said she removed the rice filled sock from the microwave to check if it was too hot and Resident #20 became angry because CNA G would not heat the sock anymore. She said Resident #20 grabbed the sock from her and returned to her room. CNA G said she informed LVN J Resident #20 was heating up the rice filled sock. The CNA said LVN J said she was aware the resident had a sock, she (LVN) would watch Resident #20 and would send a message on through the shifts. CNA G said she was not aware the resident should not have the sock. During an interview on 11/05/15 at 9:49 a.m., CNA G said she was providing care for Resident #20 when she noticed a large blister on the resident's outer right thigh area, on 10/19/15. She said she was told by CNA L the night staff was aware of the burn because the night shift CNA notified her of the burn. CNA G said she notified LVN J regarding the blister/burn. CNA G said she informed the treatment nurse about the burn. During an interview on 11/05/15 at 3:45 p.m., LVN J said she found out about the incident in which Resident #20 burned herself the day after the injury was found. The nurse said she did not re-call anyone telling her about the rice filled sock prior to the incident. LVN J said if she had known about the rice filled sock she would have removed it from the resident. During an interview on 11/05/15 at 11:25 a.m., COTA K said during therapy the therapist used hot packs on Resident #20's shoulder for pain. He indicated on 10/16/15 Resident #20 asked how she could continue to use heat once she went home. COTA K said he mentioned a rice sock to the resident. He said no information was provided about when or how to use a rice sock and Resident #20 took it upon herself to have her daughter bring one up to the facility. COTA K said the therapy department found out about the incident on Monday (10/19/15) upon returning to work after the weekend. COTA K said himself, a PTA, and a nurse met with Resident #20 on 10/19/15 and told the resident she was not to use the rice sock at the facility. They told her when she returned home she could talk to the home health agency about how to use heat in general. He said Resident #20 said she knew not to use it, but was talked into it by someone she would not identify. COTA K said the mentioning of the rice sock was a spur of the moment, brief mention and it was never thought anyone would bring a rice sock to the facility to use. During an interview on 11/05/15 at 3:09 p.m., LVN A said CNA G notified her of the area on Resident #20's right thigh area on 10/19/15. The LVN said she checked the area and notified the treatment nurse. LVN A said Resident #20 indicated she did not know what occurred initially to her. She indicated she started the incident report. LVN A said after the treatment nurse completed her assessment of the blister/burned area she reported contacting Resident #20's daughter who reported she had brought a sock of rice to the facility for her mother to use on her neck. The LVN said the treatment nurse brought the rice filled sock to the nurses' station. LVN A denied being aware the resident had the sock until the treatment nurse presented it at the nurses' station. She said Resident #20 was very alert and oriented and when she took the sock of rice to the resident's room at first Resident #20 would not look at her but then finally admitted to using the rice sock. LVN A said the sock had dark spots and the rice was burned. During an interview on 11/05/15 at 3:40 p.m., LVN H said she worked the 6 p.m. to 6 a.m. shift and that she was told by the evening CNA Resident #20 had a blister to her leg after they had put the resident to bed. The LVN said she could not remember who the staff was or the exact time it was reported. She said she did measure the area, the blister was still intact, and she left the area open to the air. LVN H said she did not report the incident. She said she meant to put the information on the 24 hour report to tell the on-coming shift but she did not. LVN H said things had been busy and she forgot. The nurse said she was aware Resident #20's daughter brought the rice filled sock to the facility, but was not aware how long the resident had the sock. The LVN said she was aware of the sock since Friday (10/16/15). She indicated she and her CNAs did not know how to use the rice sock, so they did not ever apply it on the resident. LVN H said the way the resident sounded she used the rice filled sock at home. She said she was a brand new nurse and had not been aware there was a procedure to address the rice filled sock, did not know a physician's orders [REDACTED]. During an interview on 11/05/15 at 10:44 a.m., the DON said CNA G should not have heated the rice filled sock. She said Resident #20's daughter indicated she heated the sock. During an interview on 11/05/15 at 11:00 a.m., the DON said the staff should have removed the sock from Resident #20 upon becoming aware the resident had the rice sock. The DON said an in-service was conducted regarding being aware of what the residents have in their possession. The Provider Investigation Report dated 10/19/15 indicated the facility conducted an in-service for all nursing staff regarding the procedures for items or medications residents may have in their possession or rooms. The in-service explained residents should not have heating items in their rooms and staff nor residents should heat up or apply any devices or items on the residents without a physician's order [REDACTED]. It was indicated only a nurse should apply heating items and only with a physician's order [REDACTED]. Also, if a resident inquired about home use the staff are to encourage the resident to ask their home health agency upon discharge. The 672 dated 11/03/15 indicated 37 residents received rehabilitative services.

Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedure to prohibit neglect to ensure the code status was promptly determined and lifesaving interventions were immediately initiated for 1 of 12 residents reviewed for neglect. (Resident #1) Resident #1, a full code (requested life saving measures), was found in his wheelchair unresponsive, cold, and without a pulse. Life-saving measures were not initiated for more than 10 minutes because the staff (CNA A, LVN A, and RN B) did not know the resident's code status. A family member (CNA D) arrived and told them Resident #1 was a full code. This failure contributed to Resident #1 not receiving lifesaving interventions immediately upon being found unresponsive. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 45 residents that were full code at risk for not receiving lifesaving interventions immediate. Findings included: Physician orders [REDACTED]. A physician assessment dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had adequate hearing and vision, clear speech, usually made himself understood, and understood others. His mental status score was 11 which indicated he could repeat 3 words, but could not state the year, month, or day of the week. No behaviors of [MEDICAL CONDITION] were noted. He required extensive assistance with 2+ persons for bed mobility, transfers, and dressing. He required total assistance with toilet use, personal hygiene, and bathing. He used a wheelchair for mobility. He was incontinent of bowel and bladder. He had complained of difficulty swallowing. A green sheet of paper at the front of Resident #1's clinical record read "full code." During an interview on [DATE] at 5:30 p.m. the corporate nurse said that the purpose of the green and red sheets in the front of the charts was so the staff can hold them up and other staff could see the resident's code status from a distance. During an interview on [DATE] at 3:10 p.m., CNA F said around 5:00 p.m. on [DATE], she found Resident #1 slumped over in his wheelchair. She said she grabbed his hand to try to wake him up and he was "ice" cold. She said she went across the hall and got LVN A. She said LVN A assessed the resident and left the room. CNA F said she did not know why the LVN left. CNA F said about 5 minutes later, Resident #1's niece (CNA D) came into the room and said, "What are they doing? Why aren't they doing CPR? Why isn't anyone calling 911? He is a full code." CNA F said LVN A, LVN E, and RN B entered the room with the emergency crash cart (a cart containing equipment for initiating emergency resuscitation). CNA G and RN B began CPR when the crash cart arrived. CNA F said she left the room and waited for the paramedics to arrive. Nursing notes for Resident #1 included the following documentation: *[DATE] at 4:40 p.m., CNA F notified LVN A to come check on Resident #1and stated Resident #1 was sliding out of the wheelchair. On arrival to the room the resident was sliding to right and had no response. The nurse checked his carotid pulse and auscultate (listened) for lung and heart sounds and nothing was heard. The nurse notified the house supervisor and grabbed the crash cart. CPR was started and M.D. notified and the ambulance was called. *[DATE] at 4:45 p.m. RN B was requested to come to Resident #1's room by LVN A. When the nurse arrived in the room, Resident #1 was lying on his back in bed, with the bed in the lowest position. Resident #1's pupils were fixed and dilated, no carotid or radial pulses noted. No rise and fall of chest. Resident #1 was moved to the floor beside bed so that he was on hard surface. Crash cart obtained and CPR was started immediately with compressions to the chest and breaths of oxygen via ambu bag were administered until 5:10 p.m. when paramedics arrived and took care of Resident #1. Family arrived at approximately 5:15 p.m. and Resident #1 left with paramedics at 5:25 p.m. DON and ADON notified by phone *[DATE] at 5:31 p.m., the hospital called and stated Resident #1 died of [MEDICAL CONDITION]. During an interview and observation on [DATE] at 10:30 a.m., the administrator and DON said according to the surveillance video from [DATE] that Resident #1 was first found at 4:54:00 p.m. by CNA F. They said LVN A obtained a stethoscope at 4:58:36 p.m. and LVN C called 911 after the sitter ran to the nursing station at 5:04:14 p.m. LVN E and RN B went into the resident's room with the crash cart after more than 10 minutes at 5:04:40 p.m. During an interview on [DATE] at 2:10 p.m., LVN C said between 4:30 - 4:45 p.m. a lady came to the nursing station and said to call 911 because Resident #1 had breathing problems. He said he called 911, got the Medication Administration Record, [REDACTED]. LVN C did not take document of code status to the room. During an interview on [DATE] at 2:25 p.m., LVN E said CNA F came to get her. She said she went to Resident #1's room and checked his carotid pulse. The resident had no pulse and was cyanotic. She left LVN A in the room and returned to the nursing desk. She said she then accompanied RN B to Resident #1's room with the crash cart. During a telephone interview on [DATE] at 5:10 p.m., LVN A said at the time of the incident on [DATE], he did not know Resident #1's code status, so he did not start lifesaving interventions. He said when someone told him that the resident was a full code they started CPR. During a telephone interview on [DATE] at 9:15 a.m., RN B, the charge nurse, said she went into the resident ' s room after she was notified by LVN A that the resident was not breathing and did not have a pulse. RN B said she asked about Resident #1's code status and someone told her that the resident was a full code. She said prior to that, she did not know Resident #1's code status. She said the crash cart was not in the resident ' s room and no one had initiated CPR upon her entrance into the resident's room. She said they placed the resident on the floor and began CPR while LVN A and LVN E set up the crash cart. The emergency room physician notes dated [DATE] indicated CPR was taken over by emergency medical services for Resident #1 at 5:38 p.m. and stopped at 5:55 p.m. During a telephone interview on [DATE] at 9:00 a.m., the emergency room director of the local hospital said Resident #1 died of [MEDICAL CONDITION] according to the emergency room physician notes. During an interview on [DATE] at 5:00 p.m., the DON said if a resident was full code then staff should start CPR immediately even if there was no hope for resuscitation. During an interview on [DATE] at 5:02 p.m., the administrator said that the CNAs were not expected to know the code status of the residents and if something happened they were to notify the nurses. The facility abuse policy dated [DATE] indicated that neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Emergency and First Aid policy dated [DATE] indicated if the victim was unresponsive to call a "code" designate someone to call 911 and initiate CPR. According to the National Institute of Health Medline Plus, <http://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm>, accessed [DATE], " Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 - 6 minutes later. " According to the American Heart Association, <http://www.heart.org/HEARTORG/Conditions/More/CardiacArrest/Symptoms-Emergency-Treatment-of-Cardiac-Arrest_UCM_ 1_Article.jsp>, accessed [DATE], " If two people are available to help, one should begin CPR immediately while the other calls [DATE] and finds an AED (automatic external defibrillator). " Immediate Jeopardy On [DATE] at 1:15 p.m. the administrator was informed of Immediate Jeopardy (IJ) for failing to immediately determine the code status and initiate lifesaving procedures for Resident #1. A plan of removal was accepted on [DATE] at 4:11 p.m. and included: " 1. In-services will be conducted will be conducted with all staff, prior to their next shift, and will include instructions for residents found in distress or unresponsive to include: a. If someone is found unresponsive, do not leave the resident, yell for help. b. A nurse will assess the resident. c. If no pulse, determine code status. d. The nurse is to delegate someone to verify code status IMMEDIATELY. e. This person is to go to the chart IMMEDIATELY and bring it back to the code site. f. If the resident is a full code, these things must begin immediately: Start chest compressions while waiting for crash cart as per American Heart Association Guidelines. Crash cart should be obtained immediately. 911 must be called stat. g. CPR must continue until EMS arrives. If the staff needs to switch out during compressions, this should be done with minimal delay. h. During a code, there should be a sense of urgency. The first few minutes are critical. 2. Resident charts will be updated with color coded "code status" sheets. Green sheet means full code. Red means DNR. DO NOT PLACE ANY PAPERS IN FRONT OF THE CODE STATUS SHEET FOR ANY REASON; this should be the first page of every chart. 3. Resident rooms will be coded with their code status by color coding the name plate with red or green according to their code status. This will be updated by the social worker with current status and will be resident specific. It will be changed each time a resident is admitted , discharged , transferred to a room, or any change in code status. Code status will be determined upon admission as soon as the physician verifies the orders and the charts will be identified appropriately. All current residents will have their code status on their name plate by 7:00 pm on [DATE]. " The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 3 LVNs were interviewed and correctly stated the actions detailed in the new policy. 3 CNAs were interviewed and correctly stated the actions detailed in the new policy. The ADON was interviewed and correctly stated the actions detailed in the new policy. DON was interviewed and correctly stated the actions detailed in the new policy. Social worker was interviewed and correctly stated the actions detailed in the new policy. Housekeeping staff was interviewed and correctly stated the actions detailed in the new policy. The administrator was interviewed and correctly stated the actions detailed in the new policy. On [DATE] at 5:45 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. During a telephone interview on [DATE] at 3:10 p.m. the DON indicated 45 residents were designated as a full code.

Based on observation, interview, and record review, the facility failed to implement their written abuse policy and procedure to prohibit neglect to ensure the code status was promptly determined and lifesaving interventions were immediately initiated for 1 of 12 residents reviewed for neglect. (Resident #1) Resident #1, a full code (requested life saving measures), was found in his wheelchair unresponsive, cold, and without a pulse. Life-saving measures were not initiated for more than 10 minutes because the staff (CNA A, LVN A, and RN B) did not know the resident's code status. A family member (CNA D) arrived and told them Resident #1 was a full code. This failure contributed to Resident #1 not receiving lifesaving interventions immediately upon being found unresponsive. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 45 residents that were full code at risk for not receiving lifesaving interventions immediate. Findings included: The facility abuse policy dated [DATE] indicated that neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Emergency and First Aid policy dated [DATE] indicated if the victim was unresponsive to call a "code" designate someone to call 911 and initiate CPR. Physician orders [REDACTED]. A physician assessment dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had adequate hearing and vision, clear speech, usually made himself understood, and understood others. His mental status score was 11 which indicated he could repeat 3 words, but could not state the year, month, or day of the week. No behaviors of [MEDICAL CONDITION] were noted. He required extensive assistance with 2+ persons for bed mobility, transfers, and dressing. He required total assistance with toilet use, personal hygiene, and bathing. He used a wheelchair for mobility. He was incontinent of bowel and bladder. He had complained of difficulty swallowing. A green sheet of paper at the front of Resident #1's clinical record read "full code." During an interview on [DATE] at 5:30 p.m. the corporate nurse said that the purpose of the green and red sheets in the front of the charts was so the staff can hold them up and other staff could see the resident's code status from a distance. During an interview on [DATE] at 3:10 p.m., CNA F said around 5:00 p.m. on [DATE], she found Resident #1 slumped over in his wheelchair. She said she grabbed his hand to try to wake him up and he was "ice" cold. She said she went across the hall and got LVN A. She said LVN A assessed the resident and left the room. CNA F said she did not know why the LVN left. CNA F said about 5 minutes later, Resident #1's niece (CNA D) came into the room and said, "What are they doing? Why aren't they doing CPR? Why isn't anyone calling 911? He is a full code." CNA F said LVN A, LVN E, and RN B entered the room with the emergency crash cart (a cart containing equipment for initiating emergency resuscitation). CNA G and RN B began CPR when the crash cart arrived. CNA F said she left the room and waited for the paramedics to arrive. Nursing notes for Resident #1 included the following documentation: *[DATE] at 4:40 p.m., CNA F notified LVN A to come check on Resident #1and stated Resident #1 was sliding out of the wheelchair. On arrival to the room the resident was sliding to right and had no response. The nurse checked his carotid pulse and auscultate (listened) for lung and heart sounds and nothing was heard. The nurse notified the house supervisor and grabbed the crash cart. CPR was started and M.D. notified and the ambulance was called. *[DATE] at 4:45 p.m. RN B was requested to come to Resident #1's room by LVN A. When the nurse arrived in the room, Resident #1 was lying on his back in bed, with the bed in the lowest position. Resident #1's pupils were fixed and dilated, no carotid or radial pulses noted. No rise and fall of chest. Resident #1 was moved to the floor beside bed so that he was on hard surface. Crash cart obtained and CPR was started immediately with compressions to the chest and breaths of oxygen via ambu bag were administered until 5:10 p.m. when paramedics arrived and took care of Resident #1. Family arrived at approximately 5:15 p.m. and Resident #1 left with paramedics at 5:25 p.m. DON and ADON notified by phone *[DATE] at 5:31 p.m., the hospital called and stated Resident #1 died of [MEDICAL CONDITION]. During an interview and observation on [DATE] at 10:30 a.m., the administrator and DON said according to the surveillance video from [DATE] that Resident #1 was first found at 4:54:00 p.m. by CNA F. They said LVN A obtained a stethoscope at 4:58:36 p.m. and LVN C called 911 after the sitter ran to the nursing station at 5:04:14 p.m. LVN E and RN B went into the resident's room with the crash cart after more than 10 minutes at 5:04:40 p.m. During an interview on [DATE] at 2:10 p.m., LVN C said between 4:30 - 4:45 p.m. a lady came to the nursing station and said to call 911 because Resident #1 had breathing problems. He said he called 911, got the Medication Administration Record, [REDACTED]. LVN C did not take document of code status to the room. During an interview on [DATE] at 2:25 p.m., LVN E said CNA F came to get her. She said she went to Resident #1's room and checked his carotid pulse. The resident had no pulse and was cyanotic. She left LVN A in the room and returned to the nursing desk. She said she then accompanied RN B to Resident #1's room with the crash cart. During a telephone interview on [DATE] at 5:10 p.m., LVN A said at the time of the incident on [DATE], he did not know Resident #1's code status, so he did not start lifesaving interventions. He said when someone told him that the resident was a full code they started CPR. During a telephone interview on [DATE] at 9:15 a.m., RN B, the charge nurse, said she went into the resident ' s room after she was notified by LVN A that the resident was not breathing and did not have a pulse. RN B said she asked about Resident #1's code status and someone told her that the resident was a full code. She said prior to that, she did not know Resident #1's code status. She said the crash cart was not in the resident ' s room and no one had initiated CPR upon her entrance into the resident's room. She said they placed the resident on the floor and began CPR while LVN A and LVN E set up the crash cart. The emergency room physician notes dated [DATE] indicated CPR was taken over by emergency medical services for Resident #1 at 5:38 p.m. and stopped at 5:55 p.m. During a telephone interview on [DATE] at 9:00 a.m., the emergency room director of the local hospital said Resident #1 died of [MEDICAL CONDITION] according to the emergency room physician notes. During an interview on [DATE] at 5:00 p.m., the DON said if a resident was full code then staff should start CPR immediately even if there was no hope for resuscitation. During an interview on [DATE] at 5:02 p.m., the administrator said that the CNAs were not expected to know the code status of the residents and if something happened they were to notify the nurses. According to the National Institute of Health Medline Plus, <http://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm>, accessed [DATE], " Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 - 6 minutes later. " According to the American Heart Association, <http://www.heart.org/HEARTORG/Conditions/More/CardiacArrest/Symptoms-Emergency-Treatment-of-Cardiac-Arrest_UCM_ 1_Article.jsp>, accessed [DATE], " If two people are available to help, one should begin CPR immediately while the other calls [DATE] and finds an AED (automatic external defibrillator). " Immediate Jeopardy On [DATE] at 1:15 p.m. the administrator was informed of Immediate Jeopardy (IJ) for failing to immediately determine the code status and initiate lifesaving procedures for Resident #1. A plan of removal was accepted on [DATE] at 4:11 p.m. and included: " 1. In-services will be conducted will be conducted with all staff, prior to their next shift, and will include instructions for residents found in distress or unresponsive to include: a. If someone is found unresponsive, do not leave the resident, yell for help. b. A nurse will assess the resident. c. If no pulse, determine code status. d. The nurse is to delegate someone to verify code status IMMEDIATELY. e. This person is to go to the chart IMMEDIATELY and bring it back to the code site. f. If the resident is a full code, these things must begin immediately: Start chest compressions while waiting for crash cart as per American Heart Association Guidelines. Crash cart should be obtained immediately. 911 must be called stat. g. CPR must continue until EMS arrives. If the staff needs to switch out during compressions, this should be done with minimal delay. h. During a code, there should be a sense of urgency. The first few minutes are critical. 2. Resident charts will be updated with color coded "code status" sheets. Green sheet means full code. Red means DNR. DO NOT PLACE ANY PAPERS IN FRONT OF THE CODE STATUS SHEET FOR ANY REASON; this should be the first page of every chart. 3. Resident rooms will be coded with their code status by color coding the name plate with red or green according to their code status. This will be updated by the social worker with current status and will be resident specific. It will be changed each time a resident is admitted , discharged , transferred to a room, or any change in code status. Code status will be determined upon admission as soon as the physician verifies the orders and the charts will be identified appropriately. All current residents will have their code status on their name plate by 7:00 pm on [DATE]. " The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 3 LVNs were interviewed and correctly stated the actions detailed in the new policy. 3 CNAs were interviewed and correctly stated the actions detailed in the new policy. The ADON was interviewed and correctly stated the actions detailed in the new policy. DON was interviewed and correctly stated the actions detailed in the new policy. Social worker was interviewed and correctly stated the actions detailed in the new policy. Housekeeping staff was interviewed and correctly stated the actions detailed in the new policy. The administrator was interviewed and correctly stated the actions detailed in the new policy. On [DATE] at 5:45 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. During a telephone interview on [DATE] at 3:10 p.m. the DON indicated 45 residents were designated as a full code.

Based on observation, interview, and record review, the facility failed to provide care and services according to the comprehensive assessment to ensure the code status was promptly determined and lifesaving interventions were immediately initiated for 1 of 12 residents reviewed for neglect. (Resident #1) Resident #1, a full code (requested life saving measures), was found in his wheelchair unresponsive, cold, and without a pulse. Life-saving measures were not initiated for more than 10 minutes because the staff (CNA A, LVN A, and RN B) did not know the resident's code status. A family member (CNA D) arrived and told them Resident #1 was a full code. This failure contributed to Resident #1 not receiving lifesaving interventions immediately upon being found unresponsive. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 45 residents that were full code at risk for not receiving lifesaving interventions immediate. Findings included: Physician orders [REDACTED]. A physician assessment dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had adequate hearing and vision, clear speech, usually made himself understood, and understood others. His mental status score was 11 which indicated he could repeat 3 words, but could not state the year, month, or day of the week. No behaviors of [MEDICAL CONDITION] were noted. He required extensive assistance with 2+ persons for bed mobility, transfers, and dressing. He required total assistance with toilet use, personal hygiene, and bathing. He used a wheelchair for mobility. He was incontinent of bowel and bladder. He had complained of difficulty swallowing. A green sheet of paper at the front of Resident #1's clinical record read "full code." During an interview on [DATE] at 5:30 p.m. the corporate nurse said that the purpose of the green and red sheets in the front of the charts was so the staff can hold them up and other staff could see the resident's code status from a distance. During an interview on [DATE] at 3:10 p.m., CNA F said around 5:00 p.m. on [DATE], she found Resident #1 slumped over in his wheelchair. She said she grabbed his hand to try to wake him up and he was "ice" cold. She said she went across the hall and got LVN A. She said LVN A assessed the resident and left the room. CNA F said she did not know why the LVN left. CNA F said about 5 minutes later, Resident #1's niece (CNA D) came into the room and said, "What are they doing? Why aren't they doing CPR? Why isn't anyone calling 911? He is a full code." CNA F said LVN A, LVN E, and RN B entered the room with the emergency crash cart (a cart containing equipment for initiating emergency resuscitation). CNA G and RN B began CPR when the crash cart arrived. CNA F said she left the room and waited for the paramedics to arrive. Nursing notes for Resident #1 included the following documentation: *[DATE] at 4:40 p.m., CNA F notified LVN A to come check on Resident #1and stated Resident #1 was sliding out of the wheelchair. On arrival to the room the resident was sliding to right and had no response. The nurse checked his carotid pulse and auscultate (listened) for lung and heart sounds and nothing was heard. The nurse notified the house supervisor and grabbed the crash cart. CPR was started and M.D. notified and the ambulance was called. *[DATE] at 4:45 p.m. RN B was requested to come to Resident #1's room by LVN A. When the nurse arrived in the room, Resident #1 was lying on his back in bed, with the bed in the lowest position. Resident #1's pupils were fixed and dilated, no carotid or radial pulses noted. No rise and fall of chest. Resident #1 was moved to the floor beside bed so that he was on hard surface. Crash cart obtained and CPR was started immediately with compressions to the chest and breaths of oxygen via ambu bag were administered until 5:10 p.m. when paramedics arrived and took care of Resident #1. Family arrived at approximately 5:15 p.m. and Resident #1 left with paramedics at 5:25 p.m. DON and ADON notified by phone *[DATE] at 5:31 p.m., the hospital called and stated Resident #1 died of [MEDICAL CONDITION]. During an interview and observation on [DATE] at 10:30 a.m., the administrator and DON said according to the surveillance video from [DATE] that Resident #1 was first found at 4:54:00 p.m. by CNA F. They said LVN A obtained a stethoscope at 4:58:36 p.m. and LVN C called 911 after the sitter ran to the nursing station at 5:04:14 p.m. LVN E and RN B went into the resident's room with the crash cart after more than 10 minutes at 5:04:40 p.m. During an interview on [DATE] at 2:10 p.m., LVN C said between 4:30 - 4:45 p.m. a lady came to the nursing station and said to call 911 because Resident #1 had breathing problems. He said he called 911, got the Medication Administration Record, [REDACTED]. LVN C did not take document of code status to the room. During an interview on [DATE] at 2:25 p.m., LVN E said CNA F came to get her. She said she went to Resident #1's room and checked his carotid pulse. The resident had no pulse and was cyanotic. She left LVN A in the room and returned to the nursing desk. She said she then accompanied RN B to Resident #1's room with the crash cart. During a telephone interview on [DATE] at 5:10 p.m., LVN A said at the time of the incident on [DATE], he did not know Resident #1's code status, so he did not start lifesaving interventions. He said when someone told him that the resident was a full code they started CPR. During a telephone interview on [DATE] at 9:15 a.m., RN B, the charge nurse, said she went into the resident ' s room after she was notified by LVN A that the resident was not breathing and did not have a pulse. RN B said she asked about Resident #1's code status and someone told her that the resident was a full code. She said prior to that, she did not know Resident #1's code status. She said the crash cart was not in the resident ' s room and no one had initiated CPR upon her entrance into the resident's room. She said they placed the resident on the floor and began CPR while LVN A and LVN E set up the crash cart. The emergency room physician notes dated [DATE] indicated CPR was taken over by emergency medical services for Resident #1 at 5:38 p.m. and stopped at 5:55 p.m. During a telephone interview on [DATE] at 9:00 a.m., the emergency room director of the local hospital said Resident #1 died of [MEDICAL CONDITION] according to the emergency room physician notes. During an interview on [DATE] at 5:00 p.m., the DON said if a resident was full code then staff should start CPR immediately even if there was no hope for resuscitation. During an interview on [DATE] at 5:02 p.m., the administrator said that the CNAs were not expected to know the code status of the residents and if something happened they were to notify the nurses. The Emergency and First Aid policy dated [DATE] indicated if the victim was unresponsive to call a "code" designate someone to call 911 and initiate CPR. According to the National Institute of Health Medline Plus, <http://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm>, accessed [DATE], " Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 - 6 minutes later. " According to the American Heart Association, <http://www.heart.org/HEARTORG/Conditions/More/CardiacArrest/Symptoms-Emergency-Treatment-of-Cardiac-Arrest_UCM_ 1_Article.jsp>, accessed [DATE], " If two people are available to help, one should begin CPR immediately while the other calls [DATE] and finds an AED (automatic external defibrillator). " Immediate Jeopardy On [DATE] at 1:15 p.m. the administrator was informed of Immediate Jeopardy (IJ) for failing to immediately determine the code status and initiate lifesaving procedures for Resident #1. A plan of removal was accepted on [DATE] at 4:11 p.m. and included: " 1. In-services will be conducted will be conducted with all staff, prior to their next shift, and will include instructions for residents found in distress or unresponsive to include: a. If someone is found unresponsive, do not leave the resident, yell for help. b. A nurse will assess the resident. c. If no pulse, determine code status. d. The nurse is to delegate someone to verify code status IMMEDIATELY. e. This person is to go to the chart IMMEDIATELY and bring it back to the code site. f. If the resident is a full code, these things must begin immediately: Start chest compressions while waiting for crash cart as per American Heart Association Guidelines. Crash cart should be obtained immediately. 911 must be called stat. g. CPR must continue until EMS arrives. If the staff needs to switch out during compressions, this should be done with minimal delay. h. During a code, there should be a sense of urgency. The first few minutes are critical. 2. Resident charts will be updated with color coded "code status" sheets. Green sheet means full code. Red means DNR. DO NOT PLACE ANY PAPERS IN FRONT OF THE CODE STATUS SHEET FOR ANY REASON; this should be the first page of every chart. 3. Resident rooms will be coded with their code status by color coding the name plate with red or green according to their code status. This will be updated by the social worker with current status and will be resident specific. It will be changed each time a resident is admitted , discharged , transferred to a room, or any change in code status. Code status will be determined upon admission as soon as the physician verifies the orders and the charts will be identified appropriately. All current residents will have their code status on their name plate by 7:00 pm on [DATE]. " The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 3 LVNs were interviewed and correctly stated the actions detailed in the new policy. 3 CNAs were interviewed and correctly stated the actions detailed in the new policy. The ADON was interviewed and correctly stated the actions detailed in the new policy. DON was interviewed and correctly stated the actions detailed in the new policy. Social worker was interviewed and correctly stated the actions detailed in the new policy. Housekeeping staff was interviewed and correctly stated the actions detailed in the new policy. The administrator was interviewed and correctly stated the actions detailed in the new policy. On [DATE] at 5:45 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. During a telephone interview on [DATE] at 3:10 p.m. the DON indicated 45 residents were designated as a full code.

Based on observation, interview, and record review, the facility failed to develop and implement their abuse prohibition policy and procedure to prohibit mistreatment, neglect, and abuse for 1 of 3 residents reviewed for neglect. (Resident #1) Resident #1, a cognitively impaired female, had a history of [REDACTED]. She left the facility with a male visitor and was gone for about 6 hours before the staff realized she was missing. When she was found in the home of the male visitor, she had been sexually assaulted. An Immediate Jeopardy situation was identified on 7/12/12. The Immediate Jeopardy was removed on 7/19/12. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #1 being sexually assaulted and could place her at risk for abuse and/or serious injury in the future. Findings included: Physician orders [REDACTED]. She was administered psychoactive medications [MEDICATION NAME] and [MEDICATION NAME] for a [MEDICAL CONDITION]. A quarterly psychosocial assessment dated [DATE] listed her [DIAGNOSES REDACTED]. An emergency psychological evaluation dated 3/13/12 was conducted that was necessitated by a "groping" incident with a male resident in the facility lobby, and the resident's recent sexual acting out with peers. This evaluation indicated that Resident #1 conceptualized the male resident as her "boyfriend." The psychologist documented her actions were of a pre-adolescent nature with disregard to her surroundings or being observed by others. He also indicated Resident #1 was rather primitive with cognition /social awareness, but could follow directives. It was recommended that the facility "increase supervision" of Resident #1 and educate her to "better social propriety if feeling need for affection." A social worker's note dated 5/4/12 indicated Resident #1's responsible party was notified that the resident had "found her a boyfriend, (the son of another resident) and that he was found in her room with his shirt up." The social worker documented that Resident #1's responsible party felt the resident had instigated the contact. The responsible party was quoted as saying, "This is what she wants, she has never been sexually active, she just likes the attention from men. She wants a boyfriend. He needs to understand she is not mentally all there." The most recent MDS assessment dated [DATE] indicated Resident #1 usually understood others and could sometimes make herself understood. Resident #1 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive deficits. She required supervision with her ADLs. Resident #1 ambulated with a walker. There was no documentation of any sexual acting out behaviors. A nursing care plan dated 5/24/12 had no indication that Resident #1 had sexual acting out behaviors or required additional monitoring when in the presence of a male. During an interview on 7/18/12 at 10:10 a.m. the DON said on 7/12/12 Resident #1 left the facility with a male visitor without the staff ' s knowledge. She said Resident #1 was gone for 6 hours before the staff realized she was missing. The staff reported that Resident #1 was last seen Thursday, 7/12/12 around 5:30 p.m. in the dining room with a male visitor. The DON said the camera in the lobby recorded Resident #1 and the male visitor leaving the facility out the front door on 7/12/12 at 6:29 p.m. The DON said the male visitor's truck was recorded pulling out of the parking lot at 6:40 p.m. She said the staff did not know Resident #1 was not in the facility until she could not be located after midnight rounds. During an interview on 7/18/12 at 3:35 p.m. Resident #1 communicated with gestures and verbally that she thought she and her male visitor were leaving the facility to get a "coke and ice cream." She said she told the visitor more than once to turn around and take her back home. Resident #1 said he took her to his house. She pinched her nose and said his house smelled bad. She said he put her on a bed and gestured to her buttocks and said he hurt her there. She put her right index finger in and out of a circle, made by placing the tips of her thumb and forefinger of her left hand together, and said that was what he did "back there." She then put the middle finger of her right hand in her mouth and said he put his "thing" in her mouth. Resident #1 crossed her arms over her chest and said he held her very tight on the bed and would not let her go. During a telephone interview on 7/18/12 at 3:55 p.m. Resident #1's sister, who was her responsible party, said her mother had been granted legal guardianship of Resident #1 in 1965 due to the resident's cognitive deficits. The sister said she assumed responsibility for Resident #1's health and welfare following her mother's death in Dec. 1997. Resident #1's responsible party said she had told facility staff her sister could only leave the facility with a family member and had to be signed out upon leaving. During an interview on 7/18/12 at 10:25 a.m. the social worker said the male visitor came to the facility daily at 5:30 a.m. and would stay most all day. The social worker said the visitor would sometimes sit with his mother but the majority of the time he was with Resident #1. The social worker recounted the "groping" incident of March 2012 between Resident #1 and another male resident that resulted in the male resident being discharged . He said following this incident there had been no initiation of a plan to monitor or increase supervision of Resident #1 when she was with a male visitor. The social worker said staff had been instructed not to allow the male visitor in Resident #1's room. There had been no education of Resident #1 regarding "social propriety when she felt the need for affection," as recommended by the psychologist who evaluated her following the "groping" incident. During an observation and interview on 7/18/12 at 11:55 ADON D said they had been instructed not to allow the male visitor in Resident #1's room. She said he had been found in the room once and another time he had walked down the hall to the room and motioned for Resident #1 to come out. It was noted Resident #1's room was almost to the end of a long hall from the nursing station. There was an exit door in an alcove across from Resident #1's room that did not lock. ADON D said she came to the facility at 1:00 a.m. on 7/13/12 when staff discovered Resident #1 was not in the facility. She said she and LVN F drove to the male visitor's home and CNA G followed in her car. ADON D said when they arrived the visitor answered his door and told them Resident #1 was inside. They told him he had to bring her outside and he closed the door and was gone for "some time." She said after they knocked several more times he returned to the door and let them in and told them Resident #1 was in the bedroom. She said the house "smelled really bad" and they found the resident trying to dress herself. They assisted her to dress, notified the DON, and called the police. ADON D said when the police arrived; they determined that although the individuals were "mentally impaired," their being together appeared to be consensual. ADON D said they left and took Resident #1 to the emergency room where they were told an examination could not be performed because they had no proof of anyone having medical power of attorney. Nursing notes dated 7/12/12 (sic) (written 7/13/12) indicated the following: -12:30 a.m. Upon making rounds staff were unable to find Resident #1. -1:00 a.m. Contacted sister of a frequent visitor to the facility to obtain a phone number or address. The address was obtained and the sister said he did not have a phone. -1:20 a.m. The ADON and charge nurse went to the visitor's address. The visitor answered the door unclothed. Resident #1 was found inside the house. The DON was notified and the police were called. -1:50 a.m. The police arrived. The responsible party was notified. -2:15 a.m. Resident #1 was taken to the emergency room (ER). -3:00 a.m. Resident #1's responsible party arrived at the ER and was told they could not perform an examination because there was no proof of her power of attorney to give them permission. -3:20 a.m. Resident #1 was returned to the facility and assisted to her room, a shower was given, and she was assisted to bed. -7:30 a.m. A safety arm band was applied to Resident #1. -11:30 a.m. Resident #1 complained of pain in her vaginal, pelvic, and breast area. The DON and Resident #1's physician were notified. -2:00 p.m. Resident #1 returned from the physician's office with orders for [MEDICATION NAME] 500 mg, three times daily for 10 days, [MEDICATION NAME] mg, twice daily for 10 days. Nursing notes dated 7/14/12 indicated: -2:10 a.m. Labia noted to be grossly swollen with brown purulent drainage. Complained of vaginal pain and was medicated with [MEDICATION NAME] 5/500 mg. -untimed entry Labia swollen, brown purulent drainage noted. -11:30 p.m. The resident was at the nursing station complaining of pain to groin and vaginal area. She was medicated with [MEDICATION NAME] 1 tab as ordered PRN. The resident stated she did not feel well and was going back to bed. Nursing notes dated 7/15/12 indicated: -1:45 a.m. Labia remains swollen, tender to touch with brown purulent drainage with slight foul odor noted. The resident states she hurts "down there." During an interview on 7/18/12 at 12:40 p.m. CNA G said she had been asked to look for Resident #1 after 12:30 a.m. on 7/12/12. CNA G said she had driven her car to the male visitor's home because she knew the area. She said when they entered the house she found Resident #1 in the bedroom attempting to put on her dress and she assisted her. CNA G said Resident #1 told her, "My boyfriend put three fingers in me between my legs and sucked on my breasts." CNA G said she worked the 10 p.m.-6 a.m. shift and would see the male visitor in the facility every morning before she left work. During an interview on 7/18/12 at 1:15 p.m., CNA A said she worked the 2-10 p.m. shift and was assigned to Resident #1's hall. She said she last saw Resident #1 on 7/12/12 at 5:30 p.m. in the dining room with her male visitor. CNA A said Resident #1 "does for herself" and she would sometimes see her, but might not see her every evening. CNA A said if Resident #1 needed anything she would use her call light, so she assumed she was in her room. CNA A said staff had been instructed that the male visitor was not to go into Resident #1's room, but no other monitoring instructions were given. During an interview on 7/18/12 at 1:45 p.m., CNA B said she worked the 10 p.m.-6 a.m. shift and was assigned to Resident #1's hall. CNA B said she did not see Resident #1 on her shift unless she needed something. CNA B said on 7/12/12 she became aware that Resident #1 was not in the facility when the charge nurse was making rounds at midnight and the resident was not in her room. She said when they brought Resident #1 back to the facility she gave her a bath. CNA B said Resident #1 told her that her "boyfriend" picked her up and they had sex and he hurt her. CNA B said staff had been instructed that the male visitor was not to go into Resident #1's room, but no other monitoring instructions were given. During an interview on 7/18/12 at 3:20 p.m., LVN C said she worked the 2-10 shift on Resident #1's hall. She said she last saw Resident #1 on 7/12/12 around 6 p.m. in the dining room with her male visitor. LVN C said she would normally be told if a resident could not leave with someone. LVN C said she had seen Resident #1 being sexually inappropriate with a former male resident. She said the male resident was "feeling" Resident #1 between the legs. LVN C said after the male resident was discharged , the resident became attached to a male visitor who would visit his mother who was also a resident. LVN C said she had seen Resident #1 and the male visitor in the family room kissing and told them, "Don't do that." She said they were to ensure that the male visitor did not go to Resident #1's room, but other than that there had been no instruction to increase monitoring of their whereabouts. During an interview on 7/18/12 at 2:00 p.m. Resident #1's physician said he did not do a rape exam of the resident when she was brought to his office the morning of 7/13/12. He said he examined her vaginal area and it was red and she had a purulent discharge. He said he prescribed two broad spectrum antibiotics, [MEDICATION NAME] to prevent disease. During an interview on 7/18/12 at 4:00 p.m. ADON E said the facility did not have a system to identify for staff who a resident could leave with. She said the family would "just tell them" and they "knew." She said there was no formal documentation that would inform a new staff member of who a resident could or could not leave the facility with. During an interview on 7/18/12 at 5:15 p.m. the administrator said his abuse prohibition policy would have been better if it had contained information on missing residents. The facility's undated Abuse/Neglect Prohibition Policy indicated; "The facility will prohibit neglect, mental or physical abuse...Abuse means the willful infliction of injury ...with resulting physical harm, pain or mental anguish. Sexual abuse includes, but is not limited to, rape, sexual harassment, sexual coercion or sexual assault. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Immediate Jeopardy The administrator and DON were notified on 7/19/12 at 10:10 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/19/12 at 1:15 p.m. and included: " -Resident #1 was assessed and a wanderguard had been placed on resident. Staff are monitoring her location every 2 hours unless more frequent required. -A care plan was developed for Resident #1 to address sexual acting out behaviors. Any resident with wandering or sexual acting out behaviors will be documented on every 2 hours to ensure they are in the building and safe. -A new monitoring system to include how staff are made aware of the need to initiate the monitoring system -All wandering residents will be assessed for possible sexually inappropriate behavior. -All staff will be in-serviced on monitoring of residents with sexual acting out behaviors -All staff were in-serviced on the proper procedure to follow with a missing resident. " The surveyors confirmed the Plan Of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews were performed with 11 staff that represented the 3 shifts related to the new monitoring system. All staff reported they knew how information related to the need for increased monitoring of residents with specific behaviors would be communicated to them. They also reported the proper procedure to follow if a resident is determined to be missing. On 7/19/12 at 3:15 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm with due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list received from the DON dated 7/19/12 indicated there was 1 resident with inappropriate acting out sexual behaviors.