Every finding on record at Bella Vita Health and Rehabilitation Center

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of residents (#21; #27; 39) to be free from abuse by other resident(s) (#22; #28; 110). The deficient practice could result in resident injury.Findings Include:-Regarding Resident #21 and Resident #22:-Resident #21 was admitted on [DATE], with a diagnoses that included non-Alzheimer's dementia, anxiety disorder, depression (other than bipolar), and post-traumatic stress disorder (PTSD).An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. A review of the care plan, initiated on January 2, 2024, identified a focused area regarding an alleged incident involving Resident #21 and Resident #22. Goal included to will maintain the current level of cognitive function through the review date. Interventions included for the date of January 2, 2024 to monitor/observe resident for changes in mood/behavior patterns of aggressive behavior towards other residents and/or staff, fear of other residents and/or staff, and notify the provider if present.A nursing note dated January 2, 2024, at 5:58 PM revealed that at approximately 11:40 AM Resident #21 came to the nurse's station and informed nurse that he pushed his roommate, Resident #22, down because Resident #22 had punched him in the right side of his neck. The note revealed that the resident #22 was noted to be in a seated position on the floor, in the doorway of the bathroom. The note further included that Resident #21 stated that resident #22 was coming out of the bathroom, and accused him of urinating on the bathroom floor then took his right arm and punched him in the right side of the neck. In return, Resident #21 explained that he pushed resident #22 down, then left to tell the nurse. A skin assessment completed on January 2, 2024, revealed that Resident #21 had a red area on the right side of the neck.A review of the Psychiatric note dated January 4, 2024, revealed that Resident #21 had a psychiatry follow-up and consult before the scheduled appointment due to a resident-to-resident altercation. Resident #21 reported that he was struck by another resident two days ago. -Resident #22 was admitted on [DATE], with a diagnoses that included hemiplegia, depression, aphasia, cerebral infarction, and mood disorder.Review of the care plan, a focus area was initiated on January 2, 2024, regarding Resident #22 and an alleged incident with another resident. Goal included to maintain the current level of cognitive function through the review date. Interventions included for the date of January 2, 2024 to monitor/observe resident for changes in mood/behavior patterns, aggressive behaviors towards other residents and/or staff, fear of other residents and/or staff, and notify the provider if present.A change of condition note dated January 2, 2024, at 11:25 revealed a change of condition for a change in mood that showed no noted issues with mood. A skin assessment dated [DATE], revealed that resident #22 has a scraped right elbow. A social service note dated January 3, 2024, at 12:30 revealed social worker met with resident #22 at the bedside to follow up after the resident-to-resident altercation. A review of the Psychiatric note dated January 4, 2024, at 10:33 revealed that there was a follow-up regarding to resident-to-resident altercation, where residents struck each other. A facility investigation dated January 02, 2024, revealed that Resident #21 pushed down Resident #22 because Resident #22 had punched him in the right side of his neck. Resident #22 was noted to be in a seated position on the floor in the doorway to the bathroom when the nurse arrived. Resident #22 explained that Resident #21 pushed him into the ground after he hit Resident #21 in the neck. Resident #21 explained that Resident #22 was accusing him of urinating on the floor in the bathroom, and Resident #22 took his right arm and punched him in the right side of his neck. In return, Resident #21 pushed down Resident #22.A quarterly MDS assessment dated [DATE], revealed no BIMS score. However, it was indicated that Resident #22 had modified independence for daily decision making.An interview was conducted on November 17, 2025, at 10:55 AM with Resident #21's Wife, who stated that one of the residents attacked her husband, got him bruised up and resident #22 was moved to a different room. She stated that her husband might have attacked another resident. -Regarding Resident #27 and Resident #28:-Resident #27 was admitted on [DATE], and re-entered the facility on February 24, 2023, with a diagnosis that included seizure disorder or epilepsy, traumatic brain injury (TBI), anxiety disorder, and depression.A Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating resident #27 was cognitively intact. A review of the care plan focus initiated on August 30, 2023, for Resident #27, indicated that Resident #27 had an incident with another resident. Goal included to maintain the current level of cognitive function through the review date. Interventions included to monitor/observe resident for changes in mood/behavior patterns, aggressive behaviors towards other residents and/or staff, fear of other residents and/or staff, and notify provider if present. A nursing progress note dated August 30, 2023, at 10:28 AM revealed that at approximately 0900, Resident #27 notified the nurse that Resident #27 roommate, Resident #28, placed his left arm over his shoulder and across his chest and pulled him back, and also grabbed his right arm and placed it partially behind his back. A skin assessment dated [DATE], revealed that Resident #27's skin was warm, dry, and intact. A review of the Psychiatric note dated August 31, 2023, at 08:35 AM revealed that there was a follow-up regarding a recent altercation with another resident, where Resident #27 reported that he was arguing with his roommate yesterday, and his roommate proceeded to grab the patient by the neck.-Resident #28 was admitted on [DATE] with diagnosis included acute slipped upper femoral epiphysis, left hip, displaced intertrochanteric fracture of right femur, sequela, difficulty in walking, cognitive social or emotional deficit following cerebral infarction, dysphagia, and oropharyngeal phase.An admission MDS dated [DATE], revealed a BIMS score of 12, indicating moderately impaired cognition.A care plan focus initiated on August 14, 2023, for Resident #28, who is at risk for impaired thought processes related to the new environment. Goal included to maintain current level of cognitive function through the review date. Interventions included to identify self at each interaction, face when speaking and make eye contact, reduce any distractions- turn off TV, radio, close doors etc., use simple, directive sentences, provide with necessary cues- stop and return if agitated, monitor/document /report to MD any changes in cognitive function, specifically changes in: decision-making ability, memory, recall, and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, and social services to provide psychosocial support as needed. A nursing progress dated August 30, 2023, at 10:27 AM revealed that, at approximately 0900, an alleged incident had occurred between roommates. Resident #28 explained that he was sleeping in bed and got startled to see someone at the bed messing with his cell phone on his entry table. He asked his roommate, Resident #27, what he was doing and got no response, then Resident #28 got up from the bed, and went behind resident #27, and placed his left arm over his shoulder and across his chest, and pulled him back, and also grabbed his right arm and placed it partially behind his back. A skin assessment completed on August 30, 2023 revealed that Resident #28's skin was warm, dry, intact.A review of the Psychiatric note dated August 31, 2023, at 08:35 AM revealed that there was a follow-up regarding a recent altercation with another resident, where Resident #27 reported that he was arguing with resident #28 and resident #28 proceeded to grab the patient by the neck.An interview was conducted on November 19, 2025 at 10:59 AM, with the Director of Nursing (DON/staff #4), who stated that the expectation for staff members when they are notified about an unwitnessed abuse is to report to the manager immediately or the DON. She stated that Resident #27 and Resident #28 were in the behavioral unit, that Resident #28 informed the Nurse that he had pushed Resident #27 down to the floor because he had hit him in the neck. She confirmed that this incident happened, and it was reported as a residents-to-resident altercation. DON stated that there was altercation between resident #27 and #28 and the incident happened. -Regarding Resident #39 and Resident #110:-Resident #39 was admitted initially on August 26, 2017, and readmitted on [DATE], with diagnoses that include metabolic encephalopathy, acute and chronic respiratory failure with hypercapnia, diabetes, chronic pulmonary edema, cirrhosis of the liver, and obesity.Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief interview for mental status (BIMS) summary score of 15, indicating that the resident was cognitively intact. A review of the resident's current care plan initiated on November 12, 2023, revealed that the resident was at risk for impaired thought processes. A progress note dated March 21, 2024, 12:45, revealed that a registered nurse (RN) was requested by a certified nursing assistant (CNA) due to a resident becoming aggressive with staff. When the RN arrived, Resident #39 was telling Resident #110 to treat the staff better. Resident #110 was threatened by Resident #39, and both residents began yelling at one another aggressively. The staff intervened, but Resident #110 had struck Resident #39 with his closed right fist and made contact with Resident #39's neck and shoulder. The note included that before Resident #39 could strike back, the nursing staff separated the two residents. A skin assessment was done and a small reddened area was noted to Resident # 39's left side of his neck. The local authorities were called in addition to the provider, Director of Nursing (DON), ombudsman, and administrator.-Resident #110 was admitted on [DATE], with diagnoses that included wound infection, malnutrition, anxiety, depression, cellulitis of left and right lower limbs, encounter for change or removal of nonsurgical wound dressing, unspecified open wound right lower leg subsequent encounter, other stimulant abuse uncomplicated, muscle weakness, unspecified abnormalities of gait and mobility.Review of the resident's admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief interview for mental status (BIMS) summary score of 13, indicating that the resident was cognitively intact. Further review of the resident's MDS revealed the resident had physical and verbal behavioral symptoms directed towards others.A progress note dated March 21, 2024, revealed that a registered nurse (RN staff #221 ) was requested by a certified nursing assistant (CNA staff #201 ) due to a resident becoming aggressive with staff. When the RN arrived, Resident #39 was telling Resident #110 to treat the staff better. Resident #110 then threatened Resident #39, and both residents began yelling at one another aggressively. The staff intervened, but Resident #110 had struck Resident #39 with his closed right fist and made contact with Resident #39's neck and shoulder. Before Resident #39 could strike back, the nursing staff separated the two residents. Resident #110 refused to allow the nurse to assess him and denied any pain or injury. The local authorities were called in addition to the provider, Director of Nursing (DON), ombudsman, and administrator.An interview was conducted with a CNA (staff #201) on November 11, 2025. The CNA stated that abuse is neglect, and when residents' needs are not being met. The CNA stated that an example of physical abuse would be residents' altercating and contact is made. Staff #201 confirmed that a resident hitting another resident in the neck is a form of physical abuse. The CNA stated that if she were a witness to an incident, she would intervene to separate the residents, then she would make a report immediately to her supervisor and/or the administrator.An interview was conducted with a licensed practical nurse (LPN/Staff #215) on November 19, 2025, at 12:51 p.m., who stated that abuse is any occurrence that can be harmful to another person, whether that be actual harm or the potential for harm. The LPN stated that the facility provides annual training on abuse in addition to educational spotlights to ensure staff are up to date on regulations. Staff #215 was asked to look at the progress note for Resident #39 from March 21, 2024, and confirmed that Resident #110 caused harm to Resident #39 with physical contact and verbally. She stated that this is further confirmed as Resident #39 had a red mark at the base of his neck. The LPN stated that this incident would absolutely be considered abuse. She further stated that she would tell any manager, but the administrator must be notified, and if there is any injury, it needs to be reported within the two-hour window. The LPN stated that risks that can arise would be that further abuse could continue to occur, and the outcomes can become worse. An interview was conducted with a DON (Staff #4) on November 19, 2025, at 1:01, who stated that her expectation is that staff need to report any allegations of abuse immediately. She further stated that it must be reported to anyone in management, and both the administrator and she will start the investigation and ensure everyone's safety. The DON stated that staff are trained on abuse annually, and in addition to that, at the monthly meetings. Staff #4 was asked to pull up Resident #39's clinical health record and read the progress note from March 21, 2024. The DON stated that the way she read it was that the alleged perpetrator (Resident #110) did hit Resident #39. Staff #4 stated that she would not consider this incident abuse; instead, it was a disagreement between two adults, and it escalated. She further stated that Resident #39 was protecting staff and confirmed the incident happened. The DON stated that risks could lead to more harm occurring. A Policy entitled Abuse: Prevention of and Prohibition Against revealed that it is the policy of this facility that each resident has the right to be free from abuse.The deficient practice corrected with POC on 12/23/2025 with compliance date of 12/26/2025. Interviews with random staff members verified consistent knowledge.

Based on clinical record reviews, staff and resident interviews, review of facility documentation, and policy and procedures, the facility failed to ensure one (#1) out of three sampled residents was free from a significant medication error. The deficient practice could result in resident discomfort or jeopardize the resident's health and safety. Findings Include:Resident #1 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included anterior dislocation of left humerus,(primary) hypertension, cirrhosis of liver, chronic viral hepatitis C, iron deficiency anemia, schizophrenia, gastro-esophageal reflux disease, anxiety disorder, Waldenstrom macroglobulinemia, aphasia, hearing loss, and depression. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 was cognitively intact. Further review of the Section of Active Diagnosis revealed no evidence of active diagnosis for diabetes and no evidence of Resident #1 taking any insulin injections.A review of Resident #1's list of physicians' orders summary for June and July 2026 revealed no evidence of orders for insulin. Review of the care plan dated June 2026 through July 2026 for Resident #1 revealed no focused care area for Diabetes Mellitus. Vital signs record following blood sugar reading on July 1, 2026;at 5:45 PM: 96.0 milligrams per deciliter (mg/dL); at 6:00 PM: 51.0 mg/dL; at 6:20 PM:79.0 mg/dL; at 6:40 PM:97.0 mg/dL.A nursing progress note was entered into the clinical record for Resident #1 on July 1, 2026, at 7:19 PM, this revealed that at approximately 5:45 PM, the Registered Nurse (RN/Staff #3) inadvertently administered insulin to the wrong resident. The note identified that the error was immediately recognized, and the provider was notified without delay. The note further revealed that new orders were received by the doctor to monitor the resident's blood glucose every 15 minutes and once every hour and that Resident #1 was informed of the medication error and verbalized understanding. The note documented that the resident was placed on change of condition (COC) monitoring and that a call was placed to Resident #1's daughter to notify her of the incident; a voicemail message was left to return the call. Additionally the note documented that Resident #1 would be monitored closely for any signs or symptoms of hypoglycemia. All provider orders would be followed. Another nursing note dated July 1, 2026, at 7:24 PM revealed that Resident #1 was sent to the hospital per the provider's orders. Review of the RN (Staff#3) counseling and disciplinary action documentation revealed that a written warning was given to Staff #3 for administering insulin to the wrong resident on July 1, 2026, at 5:45 PM, which resulted in a medication error because she did not follow the rights of medication administration. Staff #3 received immediate one-on-one coaching with the Assisted Director of Nursing (ADON) regarding the medication error and the importance of adhering to the rights of medication administration using two resident identifiers, verification of the medication administration record (MAR), and following the medication administration process without deviation. Review of the facility internal medication error report completed on July 02, 2026, at 2:13 PM revealed that on July 1, 2026, Staff #3 administered 18 units of insulin (Glargine) to the wrong resident, which was Resident #1. An interview was conducted on July 09, 2026, at 11:26 AM with Resident #1, who stated that on July 1, 2026, the nurse came to her with her medication with a large needle in her hand ; she stated to the nurse multiple times she was not diabetic and not to insert the needle in her and she stated the the nurse still gave her the injection. Resident #1 stated that after the nurse inserted the needle, she found out she was not diabetic; then the nurses rushed to her and did everything to bring back her blood sugar, but it was not going up. Resident #1 further stated that she was transferred to the hospital, and the doctor told her that she was in a danger zone. Resident #1 also stated that ever since then, she has been having headaches and has lost her appetite. An interview was conducted on July 9, 2026, at 1:39 p.m. with Staff #3, Registered Nurse (RN). Staff #3 stated that the five rights of medication administration are the correct resident, correct medication, correct dose, correct route, and correct time. Staff #3 stated that when administering medications, she first washes her hands, reviews the medication in the electronic medical record, applies the five rights of medication administration, verifies the medication three times, then proceeds to confirm the resident's identity using the room number and identification information before administering the medication. She stated that she identifies whether a resident is diabetic by reviewing the resident's medical record. She further stated that insulin should never be administered to a resident who is not diabetic because it places the resident at risk for hypoglycemia and constitutes a significant medication error.Staff #3 stated that on July 1, 2026, she was assigned to pass medications at the facility. She stated that she mistakenly administered 18 units of insulin intended for another resident to Resident #1. She stated that she does not recall the name or room number of the resident for whom the insulin was intended.Staff #3 explained that on July 1, 2026, a Certified Nursing Assistant (CNA) provided her with the blood glucose reading of 250 mg/dL for the resident who was prescribed the insulin. She went to that resident's room; however, the resident was not there. After waiting approximately 10 minutes, she began searching for the resident because the insulin administration was becoming overdue. She stated that she found another resident who resembled the profile photo of the intended resident. She approached Resident #1 and asked if the resident's name matched the name of the resident for whom the insulin was prescribed. Resident #1 responded, Yes, and Staff #3 administered the 18 units of insulin.Staff #3 stated that after the injection, Resident #1 repeatedly asked why insulin had been administered because she was not diabetic. Staff #3 stated that she immediately reviewed the medical record, recognized that she had administered the insulin to the wrong resident, and promptly notified the physician and the Assistant Director of Nursing (ADON). She stated that she followed the physician's orders, and Resident #1's blood glucose remained stable following the insulin administration. Staff #3 acknowledged that the incident constituted a significant medication error and stated that the potential risk to Resident #1 was hypoglycemia.An interview was conducted on July 10, 2026, at 10:03 AM with RN (Staff #4), who stated that the five rights of administering medication include the right resident, right medication, right route, right time, and right dose. She stated that she will administer medication to the resident by first reviewing the MAR to see what medication it is and if it is available, then pulling the medication, double-checking the dosage on the MAR, and checking the resident's wristband to ensure it is the right resident, introducing herself and telling the resident about the medication and get their consent if it is ok administer, double check the route, administer the medication, if the medication is to take orally and stand there until it is taken, then recheck the resident in 15 minutes if the resident is ok ensure there is no adverse side effects and recheck the resident 15-20 minutes. She stated that when administering insulin, she usually checks the MAR, checks if the medication is available match medication with the MAR, then enters the resident room, looks over the wristband to ensure they are diabetic or not diabetic make it is the right resident, then explains to the resident about the insulin and checks the blood sugar. Then, according to order, she will insert the units, ask the resident where they want the injection to be inserted, then clean the site properly with alcohol wipes, make sure they are in a comfortable position, then administer the insulin. She further stated that insulin is not administered to any resident who is not diabetic because this could pose a risk of the resident having low blood sugar and count as a significant medication error. She stated that if there is a significant medication error, it should be immediately reported to the Director of Nursing (DON), ADON, and the doctor. Further, she stated that it would be a medical emergency for the resident. She stated that she has not worked with Resident #1. An interview was conducted on July 10, 2026, at 10:30 AM with the DON (staff #5), who stated that the five rights to administer medication are right resident, right dose, right route, right medication, and right time. She stated that her expectation of staff members for medication administration is to follow physician orders and follow the rights of medication administration. She stated that her expectation of staff members when it comes to administering insulin to residents who are diabetic is that the staff need to go through the verification of the order and follow the medication administration. She stated staff should not administer insulin to residents who are not diabetic. She further stated that if medication is administered to the wrong resident, it would be considered a significant medication error because the order was not for the resident. She stated that it could risk the resident to be hypoglycemic. She stated that Resident #1 was administered insulin, and she was not diabetic, so proactive action was taken for her to be sent to the hospital. She stated that her blood sugar was stable and that she did not have any negative outcome because they found the error immediately. She stated that when she was in the hospital, she received Dextrose 5% in Water (D5) medication that stabilizes the sugar while the insulin is flushed out of her system. A policy titled Medication Errors and Adverse Reactions was revised in May 2026, revealing that adverse drug reaction errors and adverse drug reactions are reported to the resident's attending physicians.A policy titled Physicians Orders, revised February 2026, revealed that no drugs or biologicals shall be administered except upon the orders of a person lawfully authorized to prescribe and treat human illness. A policy titled Administration of Drugs, reviewed in June 2025 and revised in June 2023, revealed that this facility's policy is that medications shall be administered as prescribed by the attending physician. Identification of the resident must be made before administering medication to the resident; medication should be administered in accordance with the written orders of the attending physician, and the seven rights of medication administration are as follows to ensure safety and accuracy of administration.

Based on staff and residents interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#2) right to be free from verbal abuse from a staff member for one of eleven sampled residents. The deficient practice could result in psychosocial harm to the resident.-Findings include:-Regarding Resident #2:Resident #2 was admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, anxiety disorder, depression, type 2 diabetes mellitus, chronic kidney disease, and epilepsy.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating intact cognition. Additionally, Section C-Cognitive patterns revealed Resident #2 had no inattention, disorganized thinking, or altered level of consciousness. Section E-Behavior revealed the resident had no hallucinations or delusions. Also, the assessment revealed the resident had exhibited physical and verbal behavioral symptoms toward others between 1 and 3 days.A care plan focus initiated October 8, 2025, revealed Resident #2 demonstrated verbal behaviors due to ineffective coping skills, with interventions that included to analyze key times, places, circumstances, triggers, and what de-escalates the behavior and to document, to assess and anticipate the resident's needs, to assess the resident's coping skills and support system, to document observed behavior and attempted interventions, to give as many choices as possible about care and activities, to provide positive feedback for good behaviors, and for psychiatric consult as indicated.A Psychiatric Note dated June 22, 2026, revealed the visit was a follow-up psychiatric evaluation and that the resident had a history of impulsivity, yelling, and aggression; however, the note included that the resident did not appear to be having increased behavioral disturbance since the last visit.The care plan was reviewed and revealed no evidence that Resident #2 had an actual fall on June 28, 2026, or that the resident had behaviors of intentionally placing himself on the floor.A Change in Condition Note dated June 28, 2026, at 3:57 a.m., revealed Resident #2 had no behaviors of verbal aggression that shift, and was compliant with medications and care.A Behavior Note dated June 28, 2026, at 8:11 a.m. revealed that Resident #2 refused personal care and assistance before breakfast. The note included that Resident #2 was yelling out when staff were passing trays, and that he was informed that staff would assist him. The note revealed that Resident #2 came out of his room with no pants on and was then redirected to his room. Additionally, the note revealed Resident #2 started cursing at staff, threatened to hit staff, and was making false accusations. The note included that the Assistant Director of Nursing (ADON), the provider, and the resident's family were notified.The clinical record was reviewed and revealed no evidence of Resident #2 having a fall or intentionally placing himself on the floor on June 28, 2026.A physician order dated June 29, 2026, included for change of condition monitoring for mood behavior pattern and fear of other patients and staff.A Change in Condition Note dated June 29, 2026, revealed that Resident #2 was on change of condition monitoring for mood behavior pattern and fear of other patients and staff, and that an episode of Resident #2 yelling was observed. The note included that the resident was not observed to be afraid of other patients and staff.- Regarding Resident #35:Resident #35 (who was a resident on the same unit as Resident #2) admitted to the facility on [DATE], with diagnoses of incomplete paraplegia, bipolar disorder, schizophrenia, anxiety disorder, and type 2 diabetes mellitus.A quarterly MDS assessment dated [DATE], revealed Resident #35 had a BIMS assessment score of 15, indicating cognitively intact. The documentation included that Resident #35 had no inattention, disorganized thinking, altered level of consciousness, hallucinations, or delusions. Additionally, the assessment revealed the resident had no episodes of physical or verbal behavioral symptoms.-Regarding Resident #40:Resident #40 (who was a resident on the same unit as Resident #2) admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, schizophrenia, type 2 diabetes mellitus, acquired absence of right leg below the knee, and epilepsy.A quarterly MDS assessment dated [DATE], revealed Resident #40 had a BIMS assessment score of 13, indicating intact cognition. Additionally, the documentation revealed that Resident #40 had no inattention, disorganized thinking, altered level of consciousness, hallucinations, or delusions, and no episodes of physical or verbal behavioral symptoms.-Regarding Resident #30:Resident #30 (who was also a resident on the same unit as Resident #2) admitted to the facility on [DATE], with diagnoses of parkinsonism, unspecified psychosis, schizophrenia, bipolar disorder, muscle weakness, and other abnormalities of gait and mobility.An admission MDS assessment dated [DATE], revealed Resident #30 had a BIMS assessment score of 14, indicating intact cognition. The assessment also revealed that Resident #30 had no inattention, disorganized thinking, altered level of consciousness, hallucinations, or delusions, and no episodes of physical or verbal behavioral symptoms.An interview was conducted on July 2, 2026, at 9:13 a.m., with a certified nursing assistant (CNA / Staff #74), who stated that there was one nurse on the unit whom she observed to be verbally aggressive with residents, and that Staff #74 did not want to state who that staff was.A telephonic interview was conducted with Resident #2's family member / emergency contact on July 2, 2026, at 9:28 a.m. who stated that Resident #2 had informed her that there was one nurse at the facility with whom Resident #2 did not get along with, and that she had heard Resident #2 and the nurse had verbal exchanges back and forth, and that Resident #2 got along with all the other staff members. The family member stated that she believed it was a personality clash between Resident #2 and the nurse. Additionally, the family member stated that Resident #2 was cognizant and aware, and would be able to remember and verbalize if an abusive situation occurred.A telephonic interview was conducted with a licensed practical nurse (LPN / Staff #66) on July 2, 2026, at 12:15 p.m., who stated that Resident #2 often had behaviors of yelling, cursing, and attempting to stand up and hit staff, and that staff would respond by attempting to redirect the resident. Staff #66 stated that around breakfast time on June 28, 2026, that Resident #2 had come out of his room with his brief halfway on, and was yelling and cursing, and Staff #66 stated that she redirected the resident back to his room. At one point during the interview, Staff #66 referred to Resident #2 as a grown a** man. Additionally, Staff #66 stated that she did not go into the resident's room and was never alone with Resident #2 anytime during her shift June 28, 2026.An interview was conducted with Resident #2 on July 2, 2026, at 1:09 p.m., who stated that sometime between several days ago to less than a week ago, Staff #66 was his nurse, and that she had bullied him, and yelled and cursed at him. Resident #2 stated that Staff #66 had gotten him alone in his room, and she threw him down on the floor, and that he did not believe there were any witnesses that saw the nurse throw him on the floor. Resident #2 stated that he did not have any issues with any other staff member. Resident #2 stated the mistreatment he had received from Staff #66 had left him feeling scared.An interview was conducted with Resident #35 on July 2, 2026, at 1:15 p.m., who stated that every staff member treats him really well, except Staff #66. Resident #35 stated that he had been cursed at before by Staff #66, who had told him to shut the f**k up. Resident #35 stated that several days ago, he had witnessed Staff #66 verbally assault Resident #2, and then drag Resident #2 to his room by his wheelchair, and that Resident #35 did not see anything after that.A telephonic interview was conducted with a CNA (Staff #8) on July 2, 2026, at 1:31 p.m., who stated that on June 28, 2026, at breakfast time, Staff #8 had observed Resident #2 come out of his room, and then the nurse (Staff #66) was yelling and cursing at Resident #2, and specifically said I don't play that sh*t ni**er, and pushed Resident #2 in his wheelchair very aggressively back into his room. The CNA stated she did not see what happened next inside the Resident #2's room, but then the nurse (Staff #66), who had been in the room alone with the resident, then left the resident's room. Staff #8 stated that directly after that, Staff #8 entered Resident #2's room, and observed Resident #2 sitting on the floor crying, and then Staff #8 helped him get up off of the floor. Staff #8 stated that she did not believe that Resident #2 had placed himself on the floor.A telephonic interview was conducted with a CNA (Staff #29) on July 2, 2026, at 1:48 p.m. who stated that during breakfast time on June 28, 2026, Resident #2 had come out of his room and his pants were down, and the nurse (Staff #66) had told him to go back into his room. Staff #29 stated that she observed the nurse go over to the resident, and then Staff #29 stated she did not pay attention to what happened next because she was busy passing coffee. Staff #29 stated that then she overheard Resident #2 scream get your hands off of me. Staff #29 stated that right after that, she walked past Resident #2's room, and saw that Staff #66 had left the resident's room and Resident #2 was sitting on the floor in his room. Staff #29 stated that Resident #2 was not able to get himself off of the floor, and that another CNA entered the resident's room and helped the resident get off of the floor.An interview was conducted with Resident #40 on July 2, 2026, at 2:13 p.m. who stated that on June 28, 2026, he had observed Resident #2 come out of his room to ask for cigarettes and to smoke, and that there was a verbal exchange between Resident #2 and Staff #66. Resident #40 stated he heard Resident #2 call Staff #66 a bi**h and that Staff #66 said something disrespectful back to Resident #2 and then took the resident back into his room. Resident #40 stated he did not want to repeat what the nurse had said, but that it was disrespectful and not something you would say to a family member. An interview was conducted on July 2, 2026, at 2:34 p.m. with Resident #30, who stated that approximately 4-5 days ago, he had witnessed Staff #66 say something rude to Resident #2, but could not recall exactly what was said.An interview was conducted on July 2, 2026, at 3:05 p.m. with the ADON (Assistant Director of Nursing/ Staff #41), who stated that there were different types of abuse, such as verbal or physical, and that if an allegation of abuse were to occur, that staff were expected to follow the chain of command and report the incident right away to their supervisor. The ADON stated that facility staff were expected to never use foul language toward residents, and if that did occur, then staff would report it right away as an allegation of verbal abuse. The ADON stated that a risk to a resident if staff were to use foul language or verbally abuse a resident would be that the resident could become sad or get their feelings hurt. The ADON stated that on June 28, 2026, she was working on a medication cart in another unit, and that the nurse (Staff #66) had come to her unit and informed her that Resident #2 was acting up and was agitated. The ADON stated she went to Resident #2's unit and attempted to calm the resident. The ADON stated that she went with Resident #2 outside on the patio to sit with him while he smoked a cigarette and that helped to calm the resident.An interview was conducted with the Director of Nursing (DON / Staff #90) on July 2, 2026, at 3:35 p.m., who stated that the facility staff identify and report any allegation of abuse immediately. The DON stated that it is not her job to determine if abuse occurred, and that all allegations are reported to the abuse coordinator / administrator immediately, and that an investigation takes place, and that after the investigation, that it is a collaborative team effort to determine if abuse occurred or not. The DON stated that a risk to a resident if a staff member abused a resident would be a potential injury to the resident. The DON stated that on June 29, 2026, an Adult Protective Services (APS) investigator entered the facility and informed facility staff that there was an allegation of physical and verbal abuse from a staff member toward Resident #2, and the staff member had been identified as Staff #66. The DON stated that she had suspended Staff #66, and the completion of the investigation was pending. Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised April 2026, revealed that it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Additionally, the policy revealed that abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on clinical record review, hospital discharge documentation review, staff interviews, and review of facility policies and procedures, the facility failed to ensure physician-ordered services were provided in accordance with professional standards of practice for one (#16) of three sampled residents by failing to implement and coordinate physician-directed oncology follow-up appointments identified on the hospital discharge plan. The deficient practice had the potential to result in delayed evaluation, diagnosis, monitoring, and treatment of the resident's medical condition.Findings include:Hospital discharge documentation dated May 3, 2026, revealed Resident #16 had a scheduled oncology laboratory appointment on May 5, 2026, at 9:30 a.m. and a scheduled oncology follow-up appointment with his oncologist on May 8, 2026, at 9:00 a.m.Resident #16 was admitted to the facility on [DATE], with diagnoses that included acute on chronic systolic congestive heart failure, chronic obstructive pulmonary disease (COPD), and monoclonal gammopathy.Review of Resident #16's physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed no physician orders, appointment documentation, transportation arrangements, or other evidence indicating that the oncology laboratory appointment scheduled for May 5, 2026, or the oncology appointment scheduled for May 8, 2026, had been entered into the facility's clinical record, communicated to staff, or implemented following admission to the facility.Review of Progress Notes for Resident #16 revealed no documentation indicating the resident attended either appointment, was transported to or from either appointment, refused either appointment, or that either appointment was cancelled or rescheduled. Census records indicated Resident #16 remained in the facility until discharge on [DATE].On June 2, 2026, at 3:15 p.m., an interview was conducted with Admissions Licensed Practical Nurse (LPN/Staff #88). Staff #88 stated that when a newly admitted resident arrives from the hospital, the facility receives discharge orders that include medications, treatments, and follow-up appointments. Staff #88 stated those orders are entered into the facility's electronic health record system. Staff #88 further stated that when follow-up medical appointments are identified, transportation services are arranged to ensure the resident is transported to and from the appointment. Upon review of Resident #16's clinical record, Staff #88 confirmed that no orders for the laboratory appointment scheduled for May 5, 2026, or the oncology appointment scheduled for May 8, 2026, had been entered into the clinical record. Staff #88 further confirmed there was no documentation indicating the appointments had been completed, cancelled, or rescheduled.On June 3, 2026, at 9:00 a.m., an interview was conducted with the Director of Nursing (DON/Staff #33). Staff #33 stated it was her expectation that hospital discharge orders are transcribed into the clinical record for each newly admitted resident and that follow-up medical appointments are discussed with the resident or resident representative and coordinated by the facility. Upon review of Resident #16's clinical record, Staff #33 confirmed the resident did not attend the laboratory appointment scheduled for May 5, 2026, or the oncology appointment scheduled for May 8, 2026. Staff #33 stated this did not meet her expectations and placed the resident at risk for not receiving follow-up evaluation and treatment from his oncology provider.The facility policy titled Documentation and Charting, reviewed July 2023, revealed it is the policy of the facility to provide a complete account of the resident's care, treatment, response to care, and progress toward care goals.The facility policy titled Resident Rights, reviewed June 2025, revealed residents have the right to contact with providers of their choice and to be fully informed in advance about their care and treatment.

Based on closed record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure that the receiving facility was provided the required documentation pertaining to one resident's (#911) transfer/discharge. The deficient practice could lead to the receiving facility not having the appropriate information regarding the resident's medical status and cause a delay in treatment/care.Findings include: Resident #911 (alleged victim) was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, borderline personality disorder, anxiety disorder, age-related cognitive decline, and depression. Review of a care plan initiated on October 26, 2024 revealed that the resident is on anticoagulant therapy. Interventions indicated to monitor/document/report to MD (Medical Doctor) PRN (Pro Re Nata = as needed) signs/symptoms of anticoagulant complications such as bruising, and to monitor/document location, size and treatment of skin injury. A care plan pertaining to resident's impaired thought process/dementia, and cognitive-loss initiated October 26, 2024 revealed an intervention which directed psychosocial support as needed. Review of a care plan initiated on November 5, 2024 revealed that the resident wanders on the unit. Interventions indicated for resident to be in secured unit and to provide structured activities. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has both short-term and long-term memory problems. Per the MDS the resident was severely impaired regarding cognitive skills for daily decision making. The assessment noted that the resident was negative for indicators of psychosis. However, the resident exhibited physical behavioral symptoms toward others and verbal behavior symptoms directed towards others 1-3 days during the assessment period. Additionally, the resident exhibited other behavioral symptoms not directed toward others 1-3 days during the assessment period. The assessment also noted that the resident wandered 1-3 days during the assessment period. The MDS documented that the resident has had a fall since admission/reentry. According to the assessment the resident has had one fall with no injury since admission/reentry and one fall with injury since admission/reentry. A Nursing note dated November 3, 2025 documented that resident #911's family member approached staff about a bruise on the resident's back of the head. The staff informed the family member that she would follow-up with the ADON (Assistant Director of Nursing). However, the family member called 911 to transfer the resident to the ER (Emergency Room) for evaluation. Per the note, once the paramedics arrived, they only requested a facesheet for the resident. The note indicated that the staff member called the hospital to give report to ER Nurse. Review of the SNF/NF to Hospital Transfer Form dated November 3, 2025 documented that it indicated that the primary reason for transfer was not for diagnostic testing. The form did not contain information regarding the resident's relevant diagnosis, vital signs, or pain level. The form noted that the name of the hospital that the resident was transferred to. The form also indicated that at 7:30 p.m., a report was called in and noted the name of the nurse that the report was relayed to. However, the Document Checklist section of the form was left blank indicating that none of the documents were provided or accompanied the resident during transfer. An interview was conducted with the Assistant Director of Nursing (DON/staff #15) was conducted on December 29, 2025 at 2:40 p.m. Staff #15 stated that it was resident #911's family that first noticed the resident's injuries and called 911 to transfer the resident to the hospital. During an interview with the Executive Director (ED/staff #25) conducted on December 29, 2025 at 4:57 p.m., staff #25 stated that he was not familiar with required documents/information that needs to go with the resident during a hospital transfer. An interview with the Director of Nursing (DON/staff #50) on December 29, 2025 at 5:15 p.m. Staff #50 stated when a resident is transferred to a hospital, her expectation is that the information regarding the resident's name, age, allergy to medications, and synopsis of the reason for transfer is provided to the receiving facility. The DON said that in the case of resident #911, fire (paramedics) only wanted the face sheet and would not tell the facility where the resident was going. Staff #50 noted that a report was called into the hospital and was documented on the nurse's note. However, since the report was called in it does not say exactly what information was provided. Furthermore, there is no actual documentation of what was provided to the hospital. The DON said that the importance of providing the required documents during transfer for the resident can receive continuity of care when the hospital assumes care. Staff #50 stated that the impact of not having the required document is that the hospital would not be able to get ahold of the family to provide information or not know how to treat the resident. Review of the facility's policy titled Discharge or Transfer reviewed July 2025 stated that it is the facility's policy to provide the resident with a safe, organized structured transfer or discharge to the hospital. The policy directed that for transfer/discharge during an emergency, the transfer/discharge form will be completed and the following copies will be attached:Face SheetAdvance DirectivesCurrent physician's orders, H & P (History & Physical), copies of pertinent labs/x-rays

Based on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that one resident's (#911) injury of unknown origin was reported to the state agency. The deficient practice could result in injury of unknown origin not being reviewed for potential abuse.Findings include: Resident #911 (alleged victim) was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, borderline personality disorder, anxiety disorder, age-related cognitive decline, and depression. Review of a care plan initiated on October 26, 2024 revealed that the resident is on anticoagulant therapy. Interventions indicated to monitor/document/report to MD (Medical Doctor) PRN (Pro Re Nata = as needed) signs/symptoms of anticoagulant complications such as bruising, and to monitor/document location, size and treatment of skin injury. A care plan pertaining to resident's impaired thought process/dementia, and cognitive-loss initiated October 26, 2024 revealed an intervention which directed psychosocial support as needed. Review of a care plan initiated on November 5, 2024 revealed that the resident wanders on the unit. Interventions indicated for resident to be in secured unit and to provide structured activities. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has both short-term and long-term memory problems. Per the MDS the resident was severely impaired regarding cognitive skills for daily decision making. The assessment noted that the resident was negative for indicators of psychosis. However, the resident exhibited physical behavioral symptoms toward others and verbal behavior symptoms directed towards others 1-3 days during the assessment period. Additionally, the resident exhibited other behavioral symptoms not directed toward others 1-3 days during the assessment period. The assessment also noted that the resident wandered 1-3 days during the assessment period. The MDS documented that the resident has had a fall since admission/reentry. According to the assessment the resident has had one fall with no injury since admission/reentry and one fall with injury since admission/reentry. A Skin Evaluation dated October 27, 2025 documented that the resident had no new skin issues noted. However, a Skin Evaluation with an effective date of November 1, 2025 documented that the resident had abrasion to back of head with a lump size of golf ball, lip redness to left sclera. A care plan initiated on November 1, 2025 documented that the resident had actual impairment to skin integrity related to abrasion to back of head, bottom lip, and redness to left sclera. Interventions included monitor/document location, size, and treatment of skin injury. A late entry Nursing note dated November 1, 2025 documented that resident woke up with an abrasion on her lip. Per the note the abrasion was cleaned up. Additionally, the note indicated that the family and ADON (Assistant Director of Nursing) were notified and resident will be monitored. Review of the facility's self-reports in the last 90-days revealed that the facility has had no self-reports during that time frame. Review of the facility's Incident Report log for the last 90-days did not reveal an incident involving resident #911 matching the documented injury. However, review of the facility's internal Incident Report dated November 1, 2025 documented that resident #911 had an unwitnessed incident. The incident described that the resident was observed wandering the unit when she approached a nurse and was noted with an abrasion to the bottom lip, left eye redness, and bump the size of a golf-ball with discoloration. The report indicated the location of the injuries for the abrasion and hematoma as the top of the scalp. Additionally, the report indicated that the resident is unable to describe what happened due to end stage dementia. According to the report, the ADON and the physician were notified of the incident on November 1, 2025. However, the report did not indicate that the stage agency was notified. A Nursing note dated November 3, 2025 documented that at approximately 7:00 p.m., the resident's family member approached staff about a bruise on the back of the resident's head. The staff informed the family member that she would follow up with the ADON (Assistant Director of Nursing), but the family member called 911 to have the resident transferred to the ER (Emergency Room) to be evaluated. However, review of the Stage Agency database revealed no evidence that the facility submitted a self-report regarding an injury of unknown origin pertaining to resident #911. An interview with a Certified Nursing Assistant (CNA/staff #5) was conducted on December 29, 2025 at 12:55 p.m. According to the CNA anything that is outside of the resident's baseline is reported immediately to the nurse. Specifically, injury of unknown origin is reported to the nurse right away. Per staff #5, it is important that injury of unknown origin is reported so that the facility can follow its protocols and try to figure out what happened and if something happened that caused the injury. The CNA stated that the impact of not reporting an injury of unknown origin is that problems can go undetected and can cause more problems along that way that can affect the resident's health. During an interview with a Licensed Practical Nurse (LPN/staff #10) conducted on December 29, 2025 at 1:14 p.m., staff #10 stated that her expectation is that when an injury of unknown origin is discovered, that it is reported to a nurse so that the provider, the ADON, and POA (Power of Attorney) can be contacted and the facility protocol can be implemented. Per the LPN, it is important for injury of unknown origin to be reported so that residents can be kept safe especially when the resident is unable to voice what is going on. Staff are pretty much the residents' advocate when they cannot speak for themselves. Additionally, staff #10 explained that there is a small window in which to determine the cause of an injury of unknown origin. According to the LPN, the potential impact of not reporting an injury of unknown origin is that it can affect the resident psychologically if the issue is not addressed, especially if the situation is a potential harm that needs to be taken care of immediately. Overall, it is the responsibility of the facility to take care of the residents. An interview with the Assistant Director of Nursing (ADON/staff #15) was conducted on December 29, 2025 at 2:40 p.m. Staff #15 stated that her expectation is that staff reports injury of unknown origin immediately so that the facility can investigate what happened and determine what happened. The ADON said that it is important for injury of unknown origin to be reported because it can potentially be a form of neglect or abuse. Staff #15 noted that there should be no reason to not know what happened since staff should be paying attention to what is happening to keep residents safe. Per the ADON the potential impact of not reporting injury of unknown origin is that it can be something serious that could be misdiagnosed or not treated. During an interview with the Social Services (SS) Manager (staff #20) conducted on December 29, 2025 at approximately 3:00 p.m., staff #20 stated that about a month ago he received a call from resident #911's granddaughter regarding a concern that the resident had a bump on the head. Per the SS Manager, he informed the ADON about the injury and he believed the information was relayed to the DON (Director of Nursing). However, he is unsure if the injury of unknown origin was reported to outside agencies. Staff #20 stated that it is important to report injury of unknown origin because it can potentially be abuse since the facility does not know what happened. In the case or resident #911, the injury of unknown origin should have been considered potential abuse since they did not know where the injury came from. The SS Manager said that it is important to report and investigate injury of unknown origin so that appropriate actions can be taken and state agencies can look into it as well. Staff #20 stated that the impact of not reporting injury of unknown origin is that depending on the injury, it can relate to potential health problems which can impact the resident, alter mental status of an already frail population, and if the situation goes uninvestigated the resident can be placed in a vulnerable situation. An interview with the Executive Director (ED/staff #25) was conducted on December 29, 2025 at 4:57 p.m. Staff #25 stated that injuries of unknown origin are injuries in which you do not know how it occurred. Per the ED, his expectation is that nursing completes an assessment and depending on the injury send the resident out, and notify the physician, POA (Power of Attorney), and investigate how the injury happened. If the resident was sent out then he expects for the incident to be looked into upon the resident's return. Staff #25 stated that it is important to investigate an injury of unknown origin to know how it happened, understand how it happened, and if something happened deal with it. The ED indicated that the impact of not addressing an injury of unknown origin is that it is not good for both the resident and the facility. During an interview with the Director of Nursing (DON/staff #50) conducted on December 29, 2025 at 5:15 p.m., staff #50 stated that an injury of unknown origin is when you are not able to find out how the injury happened. The DON stated that her expectation is that when an injury of unknown origin is found, that one of the leadership team (ADON/DON/designee) is notified. According to staff #50 in the case or resident #911 they were not aware of the bump on the resident's head but knew of the other injuries. She noted that they do not know what happened but knew that resident #911 was known to rest her head on the headboard or footboard. The DON noted that the facility was not given the time to look into what occurred since the family called 911. Staff #50 said that the resident had not had a witnessed fall. An incident report dated November 1, 2025 was reviewed with the DON. She conceded that the report did make it appear that the injuries were known as of that day. However, she noted that the date could have been a documentation error. Staff #50 said that based on their policy, resident #911's injury did not meet the definition of injury of unknown origin. The DON explained that this was because although the resident cannot verbalize how the injury occurred there was documentation that she rests her head on headboard/floorboard and bites her lip. When asked to provide the documentation, she referred to a clinical record document dated November 14, 2025 which was after the alleged incident. Staff #50 admitted that the incident was not reported to any outside agency because when the facility looked into it, the resident was known to rest her head on the headboard and therefore took steps to ensure that resident #911 was safe. Per the DON, it is important that injury of unknown origin is reported for the protection of the resident. Staff #50 said that the impact of not reporting is that you cannot find out what happened which in itself could be an impact. Review of the facility policy titled Abuse: Prevention of and Prohibition Against revised April 2025 defined injuries of unknown source as a term used to classify an injury when all of the following are met:The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury, or the number of injuries observed at one particular point in time or the incidence over time.The policy noted that since some cases of abuse are not directly observed, possible indicators of abuse can include bruises, skin tears, and injuries of unknown source. Furthermore, the policy noted that allegations of abuse, neglect, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes. A facility policy titled Freedom from Abuse, Neglect, Exploitation revised April 2025 directed that the facility to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately but not later than two hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Additionally, the policy noted that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the State Survey Agency. Furthermore, the policy stated that the results of investigations are reported within five working days of the incident to the State Survey Agency.

Based on observation, interviews, facility documentation, policy review, and the State Agency complaint tracking system, the facility failed to ensure that one resident (#1) was not neglected by failing to assess and meet their basic needs to prevent the development of a Stage 3 pressure ulcer and Deep Tissue Injury (DTI). The deficient practice could result in the residents' development of pressure ulcers and deep tissue injuries.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that included hypertension, Diabetes Mellitus (DM) Type 2, Schizophrenia, Non-Alzheimer's Dementia, and Cerebrovascular Accident (CVA) with a left-sided weakness.On May 9, 2025, a Braden Scale for Predicting Pressure Sore Risk assessment was completed, and the resident's score was 10.0, high risk.A review of a document, Skin Evaluation-PRN/Weekly, dated May 10, 2025, revealed an initial admission skin evaluation by a wound nurse. The skin evaluation revealed the resident's bilateral feet were dry and flaky; toenails were elongated and thick, with the left great toenail having dark discoloration; right groin with multiple dry, dark brown colored thick nodules; left hand with slight purple discoloration; and a bruising sacrum, pink and blanchable.Another Braden Scale for Predicting Pressure Sore Risk assessment was completed on May 10, 2025, and the resident's score was 13.0, moderate risk.A review of a document, Skin Check - Shower Sheets, dated May 10, 2025, revealed the Resident had a full assist shower, and there were no bruises, skin tear, red areas, open areas, rashes, or unusual marks noted.A review of the Nutrition-admission Evaluation assessment dated [DATE], revealed the resident had an order for regular mechanical soft diet, thin fluid consistency, no supplement ordered; resident's weight on May 10, 2025 using a wheelchair scale was 195.8 pounds; have upper and lower dentition; feeds self; skin status was intact; had a Body Mass Index (BMI) of 28.1, overweight; and the resident was at risk of malnutrition per the Minimum Nutrition Assessment (MNA) due to decreased mobility from CVA, Schizophrenia, diabetes, and dysphagia.A review of the resident's care plans dated May 13, 2025, revealed the following focus:-The resident has a pressure ulcer or potential for pressure ulcer development related to neurocognitive, CVA, bipolar, and diabetes mellitus. The interventions included administering medications and treatments as ordered; monitoring for effectiveness; daily body checks; notifying the nurse immediately of any new areas of skin breakdown noted during bath or daily care; and using pressure-relieving/reducing device, float heels as the resident allows and as tolerated; and-The resident has Diabetes Mellitus. The goal was to have no complications related to diabetes. And, the interventions included checking the body for breaks in skin and treating promptly as ordered by the doctor; checking skin when assisting with ADLs; inspecting feet daily for open areas, sores, pressure areas, blisters, edema or redness, and report any of the above to the nurse; monitor, document, report to the medical doctor as needed for signs and symptoms of infection to any open areas, redness, pain, heat, swelling or pus formation; and refer to podiatrist or foot care nurse to monitor, document foot care needs and to cut long nails.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0.0; did not exhibit behavioral symptoms; did not exhibit rejection of care or wandering behavior; the resident was assessed as having impairment on both upper and lower extremities, had functional limitation in range of motion that interfered with daily function or placed the resident at risk of injury; the resident was mostly dependent for oral, personal, shower/bathe, lower and upper body dressing, and toileting hygiene; the resident was dependent on staff to assist with rolling left and right while in bed; the resident was dependent on staff for chair/bed-to-chair transfer; and the resident was always incontinent of urine and bowel. In addition, the MDS revealed that the resident did not have unhealed pressure ulcers/injuries, but was at risk of developing pressure ulcers/injuries, and the resident does not have a condition or chronic disease that may result in a life expectancy of less than six months.Additional review of the document Skin Check - Shower Sheets dated May 16, 2025, revealed that the Resident had a full assist shower and no bruises, skin tear, red areas, open areas, rashes, or unusual marks were noted.Another review of the care plan dated May 17, 2025, revealed the resident has bowel and bladder incontinence related to impaired mobility. The interventions included checking as required for incontinence; washing, rinsing, and drying the perineum; and changing clothes as needed after incontinence episodes.A review of a document, Skin Evaluation-PRN/Weekly, dated May 17, 2025 and May 23, 2025, revealed there was no new skin issue noted.Another review of the document Skin Check - Shower Sheets dated May 24, 2025, revealed that the Resident had a shower, and no bruises, skin tear, red areas, open areas, or rashes. The comment section of the form revealed skin good.On May 24, 2025, another Braden Scale for Predicting Pressure Sore Risk assessment was completed, and the resident's score was 13.0, moderate risk.A review of a document, Weekly Skin Evaluation, dated May 28, 2025, revealed that the resident had a bed bath and there were no bruises, skin tear, red areas, open areas, or rashes. The comment section of the form revealed no new skin issues.Another review of a document, Skin Evaluation-PRN/Weekly, dated May 30, 2025, revealed a documentation that the resident's skin was clean, dry and intact, and no new skin issue was observed.Additional review of the document Skin Check-Shower Sheet dated May 31, 2025, revealed the Resident had total assistance for shower, nails were trimmed, and there were no bruises, skin tear, red areas, open areas, rashes, or unusual marks noted.A review of the Medication Administration Record (MAR) and Treatment Medication Record (TAR) for May 2025 revealed the following transcribed orders:-May 9, 2025 an order for Eucerin Advanced Repair External Cream (Emollient) apply to the affected area topically every 8 hours for dry/ rough skin;-May 9, 2025 an order for Blood sugar less than 100, hold medication, and notify the provider as needed.-May 9, 2025, an order for Weekly Skin Evaluation: initial on TAR and fill out the Weekly Skin Evaluation form every night shift every seven days;-May 9, 2025, an order to apply house barrier cream topically to buttocks/peri area every shift;-May 9, 2025, an order to encourage the Resident to offload heels while in bed as tolerated every shift;-May 10, 2025, an order for Low Air Loss Mattress (LALM): check proper placement and function every shift; and-May 31, 2025, an order for a wheelchair cushion: check proper placement and function every shift.A review of a document, Skin Assessment - Shower, for June 4 and June 7, 2025, revealed the Resident had a shower, no bruises, no skin tear, no red areas, no open areas, nor rashes, fingernails and toenails were clean, and the condition of the feet was good and clean.A review of the resident's weight revealed that on June 5, 2025, he weighed 180.0 pounds compared to his previous weight on May 31, 2025, of 196.0 pounds, a weight loss of 16.0 pounds.A review of the document Nutrition Interdisciplinary Team Update with an effective date of June 5, 2025, revealed the resident's most recent weight was 180.0 pounds on June 5, 2025. The progress/status note revealed that the resident had a BMI of 28.8, overweight. The Interdisciplinary Team (IDT) comments revealed current weight shows an 8% weight loss in one week and in one month, and questionable weights with good intake recorded. The IDT recommendation was to add House Supplement 4 ounces by mouth at bedtime and weigh weekly, and monitor.Additional review of the Resident's shower document, Skin Check - Shower Sheet, dated June 11, 2025, revealed that the Resident had no bruises, skin tear, red areas, open areas, rashes, or unusual marks. The form revealed a written comment, no new skin issues. And, in the POC Task documentation on June 11, 2025, the resident received a full body bath on the day shift and a shower on the night shift.A review of the nursing progress note dated June 17, 2025 at 1:47 PM, revealed the resident was very sleepy and unable to keep his eyes open. The staff attempted to wake him up at the table and cued him to eat, but he fell back to sleep. The resident was usually alert and active. The provider was notified, and the staff received an order for lab work. The staff notified the pain management provider and received an order to hold the gabapentin and baclofen medications. The staff also notified the resident's family member.A review of the behavior progress note dated June 17, 2025 at 11:37 PM, revealed the resident was compliant with medication and care, and no behavior issues were noted.A review of the Medication Administration Record (MAR) revealed that the medications gabapentin and baclofen were held on June 17, 2025.Another review of the shower document Skin Check-Shower Sheet dated June 18, 2025, revealed the Resident had a shower and there were no bruises, skin tear, red areas, open areas, rashes, or unusual marks noted.A review of the MAR revealed that the medications gabapentin and baclofen were held on June 18 through June 19, 2025.A review of the document Skin Evaluation - PRN / Weekly dated June 20, 2025 at 10:07 PM revealed no new skin issue noted.A review of the nursing progress note dated June 21, 2025 at 1:31 AM, revealed the resident was compliant with meds and care, with no target behavior noted. An eMAR-Medication Administration progress note at 3:47 AM revealed that the resident had not had a bowel movement for three days, and Milk of Magnesia 30 ml (milliliter) by mouth was administered for bowel care.A review of the nursing progress note dated June 21, 2025 at 7:18 AM, by LPN/Staff #20 revealed that the resident was drowsy/sleepy, was able to wake up for care, meals, and vital signs, but went back to sleep. The resident had not voided since yesterday evening. He was given fluids. He was assessed, and there was no abdominal distention nor complaint of pain. The staff notified the provider and the assistant director of nursing (ADON). The provider ordered to hold the Gabapentin.However, a review of the document POC Task Documentation Survey Report for June 2025 revealed the resident was incontinent of bladder every shift.Another review of the shower document, Skin Check-Shower Sheet, dated June 21, 2025, revealed that the Resident had a full shower; nails were not trimmed; there were no bruises or rashes; however, there were skin tear, red areas, and open areas noted. The body diagram on the form revealed four circles placed on the following areas: two out of the four circles were placed on the middle of the butt area, the third circle was placed on the left medial lower leg, and the fourth circle was placed on the right heel. The form revealed that a nurse was informed of the findings.A review of a physician progress note dated June 21, 2025 at 11:52 AM, revealed a late entry note; staff reported the resident had wounds all over his body. A wound provider will be notified. The progress note revealed a physical exam, general exam, of the resident being awake and alert, no acute distress, generalized weakness noted, moves extremities equally, and cooperative and calm.Another review of a nursing progress note dated June 21, 2025 at 4:12 PM, revealed that Staff #20 was notified by the aide to assess the resident's skin. Staff #20 assessed the resident's skin and found red spots on his left gluteal area, a skin tear in between the gluteus below the sacrum, a skin tear on the left side of the lower leg, and redness, blister-like on the right heel. Staff #20 notified the provider, ADON, wound nurse, and the resident's family.A review of the document Skin Ulcer Non-Pressure Weekly dated June 21, 2025, revealed a left medial lower leg full thickness wound with an onset date of June 21, 2025; described as diabetic; had pink tissue mixed with scant slough; and scant serosanguineous exudate. The wound measured 3.0 cm in length by 3.0 cm in width; the wound edges were defined, and the surrounding tissue had normal skin. The intervention initiated included silver alginate treatment. According to the facility document form, Skin Ulcer Non-Pressure Weekly, diabetic (neuropathic) wounds are caused by loss of sensation and feeling in the lower extremities.A review of a document Skin Evaluation-PRN/Weekly dated June 21, 2025, revealed a wound nurse skin evaluation documentation that identified a deep tissue injury (DTI) to the rear area of the left iliac crest, a DTI to the right heel, a pressure injury to the left buttock, a diabetic ulcer to the left medial lower extremity, and a Moisture Associated Skin Damage (MASD) to the buttocks.According to the facility's document, Skin Evaluation - PRN / Weekly, the following are definitions of ulcers and wounds:-Suspected Deep Tissue Injury (SDTI) is defined as a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warm, or cooler as compared to adjacent tissue; and-Stage 3 is defined as a full thickness tissue loss. The subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present, but it does not obscure the depth of tissue loss. May include undermining and tunneling.According to the National Institutes of Health, Moisture Associated Skin Damage (MASD) occurs with exposure to various sources of moisture (bodily secretions or effluents) such as urine or fecal matter, perspiration, wound exudate, mucus, digestive secretions, respiratory secretions, or saliva.A review of a document, Skin Pressure Ulcer Weekly, dated June 21, 2025, revealed an initial evaluation of the pressure ulcer for the following sites:-Regarding left buttock Stage 3:The left buttock Stage 3 pressure ulcer was not present on admission; the onset date was June 21, 2025, and was described as terminal: red beefy tissue wound bed, edges were undefined, with scant serous exudate, had erythema to the surrounding tissue; and measuring in centimeters (cm), 5.0 cm in length by 4.0 cm in width. The interventions initiated include Triad paste for the floor nurse to apply, Low Air Loss Mattress (LALM), and WCC (Wheel Chair Cushion).-Regarding rear left iliac crest suspected deep tissue injury (SDTI): The rear left iliac crest SDTI was not present on admission; the onset date was June 21, 2025, and was described as terminal: dark pink slow blanchable, intact tissue; measuring 10.0 cm in length by 5.0 cm in width, depth unable to determine (UTD); wound bed was pink; wound edges undefined; and the surrounding tissue was described as erythema. The intervention initiated included skin prep for the floor nurse to apply, LALM, and WCC.-Regarding the right heel SDTI:The right heel SDTI was not present on admission; the onset date was June 21, 2025, and was described as terminal: pink/purple non-blanchable intact tissue with a small fluid-filled collection, measuring 6.0 cm in length by 6.0 cm in width, the depth was UTD (unable to determine), wound bed was pink, wound edges undefined, and surrounding tissue was described as erythema. The intervention initiated included a skin prep for the floor nurse to apply and LALM.A review of the Treatment Medication Record (TAR) for June 2025 revealed the following transcribed orders:-May 9, 2025, an order for Weekly Skin Evaluation: Initial on TAR and fill out the Weekly Skin Evaluation form every night shift every 7 days;-May 9, 2025, an order to apply house barrier cream topically to buttocks/peri area every shift;-May 9, 2025, an order to encourage the Resident to offload heels while in bed as tolerated every shift;-May 10, 2025, an order for Low Air Loss Mattress: check proper placement and function every shift;-May 31, 2025, an order for a wheelchair cushion: check proper placement and function every shift; and-June 20, 2025, an order for Weekly Skin Evaluation: Initial on TAR and fill out the Weekly Skin Evaluation form every night shift, every Saturday.Despite having a care plan with an intervention that included daily body checks and notifying the nurse immediately of any new areas of skin breakdown noted during bath or daily care; and an order for the application of the house barrier cream topically to buttocks/peri area every shift from June 1 through June 20, 2025, the resident was assessed to have a Stage 3 pressure ulcer to his left buttock, and a moisture associated skin damage (MASD) to the buttocks on June 21, 2025.Despite having a care plan with an intervention that included daily body checks and notifying the nurse immediately of any new areas of skin breakdown noted during bath or daily care, and the encouragement for the resident to offload heels while in bed as tolerated, the resident was assessed to have a right heel suspected deep tissue injury (SDTI) on June 21, 2025.Despite having a care plan with an intervention that included daily body checks and notifying the nurse immediately of any new areas of skin breakdown noted during bath or daily care, and an order for Weekly Skin Evaluation, the resident was observed to have skin damage and multiple wounds on June 21, 2025, to the following body sites:-Stage 3 pressure ulcer to the left buttocks;-MASD to the buttocks; -right heel SDTI;-left iliac crest (rear) SDTI; and-left medial lower leg full thickness wound.A review of the eMAR-Medication Administration progress note dated June 22, 2025 at 12:58 PM, revealed a change of condition for pressure wounds in different areas of the resident's body. The areas affected included the resident's left lower back, buttocks, left medial lower leg, and right heel.Another review of the TAR from June 21, 2025, revealed the following additional transcribed orders:-June 21, 2025 an order for Buttocks: cleanse with warm soapy water, pat dry, apply Triad Paste. Notify provider and wound team of any concerns every shift;-June 21, 2025 an order for left lower back: apply skin prep to dry, clean area. Notify provider and wound team of any concerns every shift;-June 21, 2025 an order for Right heel: apply skin prep to dry clean skin. Notify provider and wound team of any concerns every shift; and-June 23, 2025 an order for Right foot: monitor foam boot, proper placement and function. Notify provider and wound team of any concerns every shift.Despite the resident having a right heel DTI initially noted on June 21, 2025, the TAR revealed the order for the Right foot: monitor foam boot, proper placement, and function was administered with a start date of June 23, 2025, on the night shift.A review of the nursing progress note dated June 24, 2025 at 10:13 AM, revealed the Resident was very sleepy and unable to keep his eyes open. This was not the resident's baseline. The provider was notified. The staff received an order for STAT labs and urinalysis with culture and sensitivity to rule out infection. The resident's family was notified. The resident's family voiced their concerns regarding brushing the resident's teeth, cutting off the resident's mustache due to the food getting stuck in it, and concern about the resident's wounds.Additional review of the TAR for June 2025 revealed an order was transcribed on June 24, 2025, for the resident's left medial lower leg wound: cleans with wound cleanser, pat dry, apply silver alginate, cover with island dressing every day shift every Tuesday, Thursday, and Saturday. Despite the wound initially identified and documented on the Skin Ulcer Non-Pressure Weekly form on June 21, 2025, as a full thickness wound, the TAR revealed a blank box on June 24, 2025, which does not indicate whether the resident received his left medial lower leg wound care that day.A review of a document, Nutrition Interdisciplinary Team Update, with an effective date of June 24, 2025, revealed a nutrition update. The document revealed the resident's most recent weight of 180.0 pounds, which was taken on June 5, 2025. The IDT comments revealed that there was no new weight; wounds were considered to be terminal per the wound nurses; the family does not want hospice for the resident; the resident had a diagnosis of dementia that affects nutrient absorption, therefore, the development of wounds and weight loss was unavoidable. The IDT recommendation included increasing the House Supplement 4 ounces to three times a day, adding multivitamins with minerals, and Prostat 30 milliliter (mL) by mouth every day, and monitoring. Despite a recommendation from the last Nutrition IDT Update on June 5, 2025, to monitor the resident's weight weekly due to an eight percent weight loss in one week and in one month, there were no documented weekly weights after June 5, 2025.A review of the nursing progress note dated June 26, 2025 at 3:13 PM revealed the Resident was on change of condition monitoring for altered mental status. The resident was sleepy and wouldn't wake up for his breakfast or lunch.A review of the nurse practitioner (NP) progress note dated June 26, 2025 at 3:45 PM, revealed the NP saw and examined the resident, resident speaks limited English. The staff reported the resident appeared lethargic and was tired on June 17, 2025. The medication, Gabapentin 300 mg, was placed on hold due to potential side effects.On June 26, 2025, Resident#1 was sent out to the hospital because of continued lethargy.A review of the document, IDT Review-Unavoidable Pressure Injury(s) & Skin Integrity Risk, dated June 26, 2025, revealed the resident's pressure ulcer were unavoidable because the resident has impaired mobility and had the following clinical conditions: bowel incontinence; continuous urinary incontinence; malnutrition or failure to thrive: poor skin turgor and weight loss of more than 10% during the last month; and diabetes mellitus. The form included other clinical conditions/issues/risk factors such as muscle weakness, hemiplegia and hemiparesis affecting the non-dominant side, the resident does not eat unless encouraged to eat, the resident refused to get out of bed and will lie in bed all day, and the resident lost 20.0 pounds in about a week. The form included interventions to address the risk factors and clinical conditions, such as the resident already on an offloading device, LALM, foam boots, and the resident was encouraged to eat and drink fluids.However, a review of the TAR for May 2025 and June 2025 revealed that there were transcribed orders to encourage the resident to offload heels while in bed as tolerated every shift on May 9, 2025, and a transcribed order for LALM ordered on May 10, 2025, but, the TAR did not have a transcribed order for foam boots until June 23, 2025 for the right foot: monitor foam boot, proper placement and function, notify provider and wound team of any concerns. Additionally, a review of the POC Task documentation for May 2025 revealed that the resident's percent amount eaten was between 76% to 100% most of the time, and in June 2025, the resident's percent amount eaten from June 1 through June 13, 2025 was mostly 76% to 100% and from June 14 through June 20, 205 was mostly 51% to 75%. And, a review of the resident's weight summary for May and June 2025, revealed the following documented weights:-May 10, 2025 weight was 195.8 pounds;-May 17, 2025 weight was 196.0 pounds;-May 24, 2025 weight was 195.4 pounds;-May 31, 2025 weight was 196.0 pounds; and-June 5, 2025 weight was 180.0 pounds. There were no other documented weights in June 2025.On June 27, 2025 at 3:57 AM, a nursing progress note revealed the resident returned to the facility from the hospital.Another review of a progress note, nurse practitioner/physician assistant note, dated June 27, 2025 at 9:23 AM revealed a late entry note; the resident was evaluated from the emergency room on June 26, 2025 per family request related to increased lethargy. The progress note revealed a plan for the resident's care: for his type 2 diabetes, to increase and continue Lantus; for failure to thrive, to hold Risperdal, baclofen, and gabapentin, start Remeron for appetite, encourage intake by mouth; and the resident was okayed for hospice evaluation by his public fiduciary.On July 2, 2025, a behavior progress note revealed the resident was alert, and his family visited him.A review of the psychiatric progress note dated July 3, 2025, revealed the resident was doing a lot better over the past several days with a significant improvement in his episodes of anorexia and hypersomnolence.A review of the Skin Pressure Ulcer Weekly assessment for July 2025 revealed the following follow-up assessment:-Right heel described as terminal: pink/purple non-blanchable intact tissue with a small fluid filled collection, SDTI, measuring 6.0 cm length by 8.0 cm width, depth undetermined (UTD), no odor, no exudate, wound bed black/brown eschar, wound edges undefined, surrounding tissue with erythema;-Left buttock described as terminal: wound now extending to sacrococcygeal area, red beefy tissue mixed with pink tissue with scant exudate; erythema to the surrounding tissue; Stage 3, measuring 7.0 cm length by 5.0 cm width, scant serous exudate, no odor, pink wound bed, undefined edges; and the treatment included Triad paste for floor nurse to apply, LALM, and WCC; and- Left iliac crest (rear) described as a terminal wound: pink non-blanchable tissue, SDTI, measuring 8.0 cm length by 4.0 cm width, no odor, no exudate, pink wound bed, undefined edges, surrounding tissue normal for skin.A review of Skin Pressure Ulcer Non-Pressure Weekly assessment for July 2025 revealed the following follow-up assessment:-A full thickness wound on the left medial heel was identified on July 5, 2025. The wound was described as diabetic, pink/purple intact tissue with a small fluid filled collection, blanchable, erythema to the surrounding skin, measuring 3.0 cm length by 3.0 cm width, depth undetermined, no odor, no exudate, and undefined edges. The treatment initiated was skin prep, foam boots, and LALM; and- left medial lower leg wound, with an onset date of June 21, 2025, diabetic, pink tissue mixed with scant slough, scant serous exudate, measures 3.0 cm length by 3.0 cm width, full thickness, no odor, wound bed pink, defined edges, surrounding tissue scar.A review of a nursing progress note dated July 10, 2025 at 12:53 AM revealed the resident had a sacral and left lower leg wound monitored by the wound team. The wound dressings from both wound sites were redressed after the resident's shower. During the skin assessment, the resident's both heels have closed pressure ulcers with underlying tissue discolorations. The ADON was notified.On July 12, 2025, the left iliac crest (rear) wound, described as a terminal wound, was closed/resolved.A review of a surgical note document revealed the resident had his first visit on July 14, 2025, for a wound consultation to evaluate and treat his wounds located at the sacrococcyx, left medial heel, right medial heel, and left medial lower leg. The document included the resident's past medical history of CVA/stroke, hypertension, diabetes type 2, hyperlipidemia, dementia, muscle weakness, psychosis, bipolar disorder, anxiety, schizophrenia, and left hemiplegia after stroke. The resident had significant contractures of the bilateral legs and right hand, was bedbound, rapid decline in skin breakdown, and failure to thrive. The risk factors included poor nutritional intake, dementia, terminal illness, depression, diabetes, and limited mobility, including significant contractures of the bilateral lower extremities, failure to thrive, incontinence, multiple psychiatric disorders, and a 24-pound weight loss over two months. All these factors put the resident at the highest risk for further unavoidable skin breakdown and delayed wound healing. Regarding the resident's wounds:-Regarding the sacrococcyx wound, a terminal skin failure, with no signs of infection. The document revealed that the reason a debridement procedure was not performed was that the resident was unable to consent. The sacrococcyx wound was described with moderate serous exudate, 80% slough, 0% granulation, 20 % necrotic tissue, 0% hypergranulation tissue, 0% eschar, 0% epithelial tissue, 0% dermal. The wound progress was unable to be determined by the provider, as this was the resident's first visit;-Regarding the left medial heel wound, diabetic, no signs of infection, no procedure performed, dressing treatment used was betadine, has moderate serous exudate, no odor, draining fluid filled blister, fragile layer of epithelium still intact, 0% slough, 0% granulation, % necrotic tissue, 0% hypergranulation tissue, 0% eschar, 100% epithelial tissue, and 0% dermal. The wound progress was unable to be determined by the provider, as this was the resident's first visit;-Regarding the right medial heel, diabetic, no signs of infection, no procedure performed, dressing treatment used was betadine, has moderate serous exudate, no odor, draining fluid filled blister, with some discoloration underneath a fragile layer of the epithelium that was still intact. The wound progress was unable to be determined by the provider, as this was the resident's first visit; and-Regarding the left medial lower leg wound, diabetic, no infection, dressing treatment used was honey alginate, mild serosanguinous exudate, no odor, two open wounds with intervening epithelium. The wound progress was unable to be determined by the provider, as this was the resident's first visit.The July 14, 2025, surgical note included an assessment and plan of the wounds. The assessment and plan revealed the wounds were stable and required continued topical wound dressing therapy; to obtain consent from family in case the resident has some improvement overall and would benefit from further debridement; offload; turn per facility protocol; LALM; foam boots; and a follow-up interval of every week. On the July 21, 2025 visit, the surgical note document revealed that the sacrococcyx wound, the left and right medial heel wounds, and the left medial lower leg wound, and all the wounds had all decreased in size. A review of the psychiatric progress note dated July 28, 2025 at 8:28 AM revealed a late entry note; the resident had not had any evidence of increased depression, no psychotic symptoms or major behavioral disturbances, maintaining a fair oral intake, and no evidence of worsening anorexia, and had been cooperative with his cares.A review of the nursing progress note dated August 11, 2025 at 12:56 PM revealed the resident was very lethargic, not opening eyes or responding to voice or touch in the morning, and was unable to answer any questions for the MDS quarterly. The floor nurse and the ADON were aware of the resident's decline in health.A review of the Nutrition-Quarterly Evaluation assessment dated [DATE], revealed the resident had an order for regular mechanical soft diet, thin fluid consistency; resident's weight on August 11, 2025 using a wheelchair scale was 195.7 pounds, significant weight gain noted for August; have upper and lower dentition; total assist for dining; pressure and non-pressure wounds skin status; had a Body Mass Index (BMI) of 28.1, overweight; at risk of malnutrition per the Minimum Nutrition Assessment (MNA) due to decreased mobility and impaired cognition; has healing pressure and non-pressure wounds; meal intake of mechanical soft food and House supplement 4 ounces by mouth three times a day, meeting needs; and intake of Prostat 1 ounce at bedtime, exceeding needs.Review of Skin Wound progress note dated August 14, 2025 at 3:54 PM revealed the provider, ADON, and floor nurse were notified of a new foul odor from the resident's buttock wound. A wound culture and an infectious disease consult were ordered. A wound culture specimen was obtained and placed in the refrigerator. The staff was unable to reach the resident's guardian for a debridement consent.Review of eMAR-Medic

Based on clinical record review, staff and resident/resident representative interviews, the facility failed to ensure that the resident and resident ' s representatives were a part of the discharge/transfer process for 4 of 5 sampled residents (#21, #32, #16 and #14). Findings include: -Regarding Resident #21 Resident #21 was originally admitted on [DATE] with diagnoses that included cerebral palsy, functional quadriplegia, tourettes and dysphagia. Review of the resident ' s care plan dated February 19, 2017 indicated that the resident did not have an active discharge plan and wished to remain in the facility for long term care (LTC). There were no additions or corrections made to the care plan until the cancellation due to the resident ' s discharge date d March 3, 2025. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 28, 2025 indicating that the resident ' s niece/representative was notified. There were no prior indications of discharge planning. Review of resident #21 ' s most recent Discharge Minimum Data Set (MDS) dated [DATE] identified that the resident was discharged on March 3, 2025 to another skilled nursing facility. Further review of the resident ' s MDS identified a Brief Interview for Mental Status (BIMS) summary score of 00 indicating severe cognitive impairment. A progress note dated March 3, 2025 at 15:57 p.m. revealed a discharge note, that the resident was admitted to the facility for custodial/long-term care services. The note identified that the reason for discharge was due to ' being discharged to another facility. ' An interview was conducted on March 19, 2025 at 11:54 a.m. with the resident ' s representative. The representative stated that Resident #21 could not consent on her own for a transfer. She further stated that the facility contacted her after the transfer was complete but did not mention the transfer at all before. -Regarding Resident #14 Resident # 14 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia and congestive heart failure. Review of the resident ' s care plan dated September 19, 2022 indicated that the resident wished to remain in the facility for LTC. There were no additions or corrections made to the care plan until the cancellation of the care plan due to resident ' s discharge date d February 14, 2025. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 5, 2025 indicating that the resident ' s Daughter/representative and LTC case manager (CM) were notified. There were no prior indications of discharge planning in the clinical record. Review of resident #14 ' s most recent Discharge Minimum Data Set (MDS) dated [DATE] identified that the resident was discharged on February 13, 2025 to another skilled nursing facility. Further review of the resident ' s MDS identified a Brief Interview for Mental Status (BIMS) summary score of 15 indicating no cognitive impairment. A progress note dated February 12, 2025 at 15:12 p.m. revealed the reason for discharge was due to ' being discharged to another facility. ' An interview was conducted on March 19, 2025 at 10:04 a.m. with the resident ' s representative who was also her power of attorney (POA). The representative stated that the receiving facility notified her the day before that the resident would be transferred. She further stated that she reached out to the prior facility ' s social worker and was told that the facility had already contacted her regarding the transfer, but she stated that she had not talked to anyone. She revealed that her mother did not want to transfer but the facility did not give her an option and transferred her. The POA stated that she did not receive any formal paperwork or notice nor did she give verbal consent; and that the facility just picked the new facility and sent her. An interview was conducted with the resident ' s insurance case manager on March 19, 2025 at 10:21 a.m. who stated that she was not made aware of the transfer until they were completed. -Regarding Resident #16 Resident #16 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, hypertensive chronic kidney disease, diabetes and dementia. Review of the resident ' s care plan dated January 16, 2017 indicated that the resident wanted to discharge home with family in Alabama and noted that this was an unrealistic goal stating she will remain in the facility for LTC. There were no additions or corrections made to the care plan until the cancellation of the care plan due to resident ' s discharge date d February 18, 2025. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 14, 2025 indicating that the resident ' s sister/representative was notified. There were no prior indications of discharge planning in the clinical record. Review of resident #16 ' s most recent Discharge Minimum Data Set (MDS) dated [DATE] identified that the resident had a planned discharge on [DATE] to another skilled nursing facility. Further review of the resident ' s MDS identified a Brief Interview for Mental Status (BIMS) summary score of 15 indicating she was cognitively intact. A progress note dated February 17, 2025 at 17:00 p.m. revealed a discharge note that identified that the reason for discharge was ' being discharged to a skilled nursing facility. ' Another progress note dated February 17, 2025 at 17:00 p.m. revealed the resident was discharged from the facility to the receiving facility. An interview was conducted on March 19, 2025 at 1:49 p.m. with the resident ' s representative. The representative stated that she had not talked with her sister in 2 months and that the resident suffered from short term memory loss and would forget to call. She further stated that the facility did not reach out to her to notify her of the transfer and she was completely unaware that they even initiated the transfer. -Regarding Resident #32 Resident #32 was originally admitted on [DATE] with diagnoses that included end stage renal disease, chronic hypertensive kidney disease and type 2 diabetes. Review of the resident ' s care plan dated October 17, 2017 indicated that the resident wanted to remain in the facility for LTC. There were no additions or corrections made to the care plan until the cancellation of the care plan due to resident ' s discharge date d February 21, 2025. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 14, 2025 indicating that the resident ' s son/representative was notified. There were no prior indications of discharge planning in the clinical record. Review of resident #32 ' s most recent Discharge Minimum Data Set (MDS) dated [DATE] identified that the resident had a planned discharge on [DATE] to another skilled nursing facility. Further review of the resident ' s MDS identified a Brief Interview for Mental Status (BIMS) summary score of 15 indicating the resident was cognitively intact. A progress note dated February 19, 2025 at 18:07 p.m. revealed a discharge note that identified that the reason for discharge was due to ' being discharged to a skilled nursing facility. ' Another progress note dated February 17, 2025 at 17:00 p.m. revealed the resident was discharged from the facility to the other. An interview was conducted on March 19, 2025 at 11:37 a.m. with Resident #32. The resident stated that he did not have a plan for discharge and he had wanted to remain in the facility. He further stated that the facility told him he was going to transfer due to renovations.The resident then stated that he was transferred to the new facility. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #31) on March 19, 2025 at 12:29 p.m. The LPN demonstrated an ongoing discharge and stated that the process is case management/ the social worker will have all the paperwork ready. The paperwork will identify where the resident is going and around what time, she stated that she will then go over all the information with the resident and the patient will sign on the face sheet. Staff #31 stated the discharge process starts with case management and social services; she mainly works on the actual discharge and assessments. An interview was conducted with the Social Services Manager (SSM/Staff #19) on March 19, 2025 at 12:39 p.m. He stated that he does not handle skilled nursing discharges, just long term care. The SSM stated that he initiates the discharge planning process when delivering the 30 day notice. He further stated that if they have a POA or family he will talk with them before the resident. Staff #19 stated that the process is different with LTC since residents are there long term but if needed he will tell them that their needs cannot be met at the facility and provide them with a list of other facilities in the area. The SSM stated that there will be a packet sent out with the resident to the receiving facility. Staff #19 stated that the process for discharge begins with a notice for transfer/discharge. In addition he stated that notifications are usually delivered 30 days before discharge. He then stated there should be consent whether from the resident or the representative to initiate the transfer and if that is not possible he will get verbal consent and sign off. An interview was conducted with the MRD (Staff #56) on March 19, 2025 at 12:53 p.m. with an additional corporation resource (Staff #72) present. When asked if she was able to retrieve the notices pertaining to the specific residents the MRD stated that she does not have access to them and was confused by what was being asked of her. The corporate resource then attempted to look into the requested transfer notices and accepted a formal request for those discharge records, he also stated that 30 day notices are not applicable in all cases of transfers/discharges. An interview was conducted with the administrator (Staff #7) on March 19, 2025 at 2:13 p.m. The administrator stated that with LTC residents the facility would try to talk with the family right away regarding the discharge. The residents might be in the facility for varied reasons. He further stated that many of the residents chose to be discharged /transferred themselves. Staff #7 stated that a lot of the long term residents want to transfer to be close to family so the facility tries to work and send referrals out to get things done. He also stated the facility tries to give a 30 day notice if the transfer/discharge is planned. The administrator stated that the facility had started renovations in January of 2025 and that it was communicated to the residents that the facility was not kicking anyone out. Staff #7 further restated that residents who left self-elected to leave the facility and go to another facility. The administrator stated the process is that the facility will notify and communicate with case managers, the ombudsman and family to ensure the residents are properly placed. Review of a facility policy obtained on March 19, 2025, Issued May of 2007 and reviewed in July 2024 titled, Nursing Administration Section: Continuum of Care Subject: Discharge or Transfer states, A transfer and or discharge shall be considered for the following reasons as regulated by Federal, State and other Regulatory Agencies. 2. Transfer/discharge: Other Healthcare Facility B. Keep Resident/Family involved with all discharge planning.

Based on clinical record review, staff and resident/resident representative interviews, the facility failed to ensure that residents and/or the resident's representative (RR) were notified in writing of transfer to another facility for 2 of 5 sampled residents (#21, and #14). Failure of notification had the potential to affect the resident and their RR by not having clear knowledge of where and why the resident was transferred. Findings include: -Regarding Resident #21 Resident #21 was originally admitted on [DATE] with diagnoses that included cerebral palsy, functional quadriplegia, tourettes and dysphagia. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 28, 2025 indicating that the resident ' s niece/representative was notified. There were no prior indications of discharge planning. Review of the resident ' s care plan dated February 19, 2017 indicated that the resident did not have an active discharge plan and wished to remain in the facility for long term care (LTC). There were no additions or corrections made to the care plan until the resident ' s discharge - dated March 3, 2025. Review of resident #21 ' s most recent Discharge Minimum Data Set (MDS) dated [DATE] identified that the resident was discharged on March 3, 2025 to another skilled nursing facility. Further review of the resident ' s MDS identified a Brief Interview for Mental Status (BIMS) summary score of 00 indicating severe cognitive impairment. A progress note dated March 3, 2025 at 15:57 p.m. revealed a discharge note, that the resident was admitted to the facility for custodial/long-term care services. The note identified that the reason for discharge was due to, being discharged to another facility. An interview was conducted on March 19, 2025 at 11:54 a.m. with the resident ' s representative. The representative stated that Resident #21 could not consent on her own for a transfer. She further stated that the facility contacted her after the transfer was complete; and that, the reason for the transfer was because the facility would be undergoing construction; and that, the resident would not be able to return due to the long term care unit being changed to a memory care unit. The resident ' s representative also stated that the receiving facility now calls constantly due to the resident ' s behaviors which she does not understand why it was not communicated. -Regarding Resident #14 Resident # 14 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia and congestive heart failure. Review of the resident ' s care plan dated September 19, 2022 indicated that the resident wished to remain in the facility for LTC. There were no additions or corrections made until the resident ' s discharge - dated February 14, 2025. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 5, 2025 indicating that the resident ' s Daughter/representative and LTC case manager (CM) were notified. The document identified that the reason for discharge was that the resident ' s needs could no longer be met in the facility. Review of resident #14 ' s most recent Discharge Minimum Data Set (MDS) dated [DATE] identified that the resident was discharged on February 13, 2025 to another skilled nursing facility. Further review of the resident ' s MDS identified a Brief Interview for Mental Status (BIMS) summary score of 15 indicating no cognitive impairment. A progress note dated February 12, 2025 at 15:12 p.m. revealed a discharge note the reason for discharge was due to being discharged to another facility. An interview was conducted on March 19, 2025 at 10:04 a.m. with the resident ' s representative who was also her power of attorney (POA). The representative stated that the receiving facility notified her the day before that the resident would be transferred. She further stated that she reached out to the prior facility ' s social worker and was told that the facility had already contacted her regarding the transfer, but she knows that she had not talked to anyone. The resident ' s POA stated that she was told the transfer was due to renovations. She revealed that her mother did not want to move but the facility did not give her an option and simply transferred her. The POA stated that she did not receive any formal paperwork or notice nor did she give verbal consent; and that the facility just picked the place and sent her. An interview was conducted with the resident ' s insurance case manager on March 19, 2025 at 10:21 a.m. who stated that the social service director called to tell her that some residents would be moved out due to renovations that were being done. She stated that she was not made aware of these transfers until they were completed. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #31) on March 19, 2025 at 12:29 p.m. The LPN demonstrated an ongoing discharge and stated that the process is case management/ the social worker will have all the paperwork ready. The paperwork will identify where the resident is going and around what time, she stated that she will then go over all the information with the resident and the patient will sign on the face sheet. The LPN stated that she will then check medications and ensure that correct medications are being sent with the resident or that the medications are discharged if appropriate. Staff #31 stated that prescriptions are also sent with the resident. She further stated that she will check the inventory sheet to ensure that residents are sent out with everything, as well as doing appropriate assessments like skin checks. The LPN stated that everything is scanned into the system and sent directly to the medical records supervisor. Staff #31 stated the discharge process starts with case management and social services; she mainly works on the actual discharge and assessments. The LPN stated that she ' s aware that there are renovations to turn the back half of the 400s unit into a walking dementia unit. She stated that a lot of residents were being transferred out and gave an estimate of 10 that she knew of, but was not sure of how far in advance residents and/or their representatives were notified. An interview was conducted with the Social Services Manager (SSM/Staff #19) on March 19, 2025 at 12:39 p.m. who stated that he does not handle skilled nursing discharges, just long-term care. The SSM stated that he initiates the discharge planning process when delivering the 30 day notice. He further stated that if they have a POA or family he will talk with them before the resident. Staff #19 stated that the process is different with LTC since residents are there long-term but if needed he will tell them that their needs cannot be met at the facility and provide them with a list of other facilities in the area. The SSM stated that there will be a packet sent out with the resident to the receiving facility. He stated that the 400s hall is currently being renovated and the 500s hall should be next. Staff #19 stated that the discharge process begins with a notice for transfer/discharge. Additionally, he stated that notifications are usually delivered 30 days before discharge. He then stated there should be consent whether from the resident or the representative to initiate the transfer and if that is not possible he will get verbal consent and sign off. When asked about the specific residents records the SSM stated he did not have access to them and stated that the Medical Records Director (MRD) would be able to provide them. An interview was conducted with the MRD (Staff #56) on March 19, 2025 at 12:53 p.m. with an additional corporation resource (Staff #72) present. When asked if she was able to retrieve the notices pertaining to the specific residents the MRD stated that she does not have access to them and was confused by what was being asked of her. The corporate resource then attempted to look into the requested transfer notices and accepted a formal request for those discharge records. An interview was conducted with the administrator (Staff #7) on March 19, 2025 at 2:13 p.m. The administrator stated that with LTC residents the facility would try to talk with the family right away regarding the discharge. The residents might be in the facility for varied reasons. He further stated that many of the residents chose to be discharged /transferred themselves. Staff #7 stated that a lot of the long term residents want to transfer to be close to family so the facility tries to work and send referrals out to get things done. He also stated the facility tries to give a 30 day notice if the transfer/discharge is planned. The administrator stated that the facility had started renovations in January of 2025 and that it was communicated to the residents that the facility was not kicking anyone out. Staff #7 further restated that residents who left self-elected to leave the facility and go to another facility. The administrator stated the process is that the facility will notify and communicate with case managers, the ombudsman and family to ensure the residents are properly placed. Review of a facility policy obtained on March 19, 2025 and reviewed in July 2024 titled, Nursing Administration Section: Continuum of Care Subject: Discharge or Transfer states, A transfer and or discharge shall be considered for the following reasons as regulated by Federal, State and other Regulatory Agencies. 2. Transfer/discharge: Other Healthcare Facility B. Keep Resident/Family involved with all discharge planning.

Based on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#320) was provided assistance with showering and dressing. This deficient practice could result in residents not being provided appropriate hygiene care and services. Findings include: Resident #320 was admitted to the facility on [DATE] with diagnoses that included muscle weakness (generalized), hemiplegia and hemiparesis, and type 2 diabetes mellitus. Review of the care plan dated October 24, 2024 revealed the resident had activities of daily living (ADL) performance deficit related to general weakness, impaired mobility, history of multiple strokes, hypertension, and atrial fibrillation with pacemaker. Review of the Certified Nursing Assistant (CNA) bathing task log revealed no evidence that the resident had received a shower from admission on October 23, 2024 to October 30, 2024. The task log revealed one entry of a refusal of a shower on October 28, 2024. Review of the shower sheets for resident #320 revealed the refusal on October 28, 2024 and signed by the CNA and charge nurse assigned on that date. The resident did not sign this sheet. No other shower sheets were provided or available. Interview was conducted with resident #320 on October 28, 2024 at 12:09 PM, who stated that no one has offered him a shower since admitting to the facility; and that, he would be interested in having one. At the time of the interview, the resident was laying in bed. He was dressed in a black t-shirt with yellow print, and there were dried skin flakes covering the shirt. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident required partial/moderate assistance with activities such as bathing and dressing. Further interview was conducted with resident #320 on October 30, 2024 at 10:22AM. The resident is observed in bed, wearing the same shirt from previous interview 2 days prior. Dried skin is still noted over the shirt. In this interview, the resident reports that he still has not been given a shower. He reports that a few days prior, a female staff member stated they would come back to give him a shower, but she never returned. The resident could not recall exactly when this happened or who the staff was. He reports no one has offered a shower since. The resident also reports he has not refused any showers and would love to receive one. Interview was conducted on October 30, 2024 at 1:19PM with a Licensed Practical Nurse (LPN/Staff #83) who stated that residents get showers at least twice a week, and any refusals should be documented by both the CNAs and nurses. Interview was conducted on October 30, 2024 at 01:33PM with the CNA (staff #203) who signed the refusal shower sheet on October 28, 2024. The CNA reports that residents receive showers twice a week or as requested. The CNA reports that she offered resident #320 a shower on October 28, 2024, but he reported feeling sick and did not want one. She states she returned later and offered again. She could not recall what times she offered, but reports that is was before and after breakfast. When asked if she assisted the resident to get dressed, the CNA reports that therapy often helps with that. The CNA was also informed at this time by the surveyor that resident #320 reported he would like a shower. Additional interview was conducted with Resident #320 on October 31, 2024 at 08:40AM, who reports that he still was not offered a shower. He further explains that he does not know what dates he is supposed to receive a shower, and thinks the staff may be too busy to assist him. The resident was observed to still be in the same clothing, a black t-shirt with yellow print. The resident reports that no one has offered to assist him to change clothing. He reports that he can sometimes manage on his own, but has a hard time due to a history of multiple strokes. The resident also explains that he has new shirts in his drawer, but no one had come to change him into a new shirt. He could not recall how long he had the same shirt on, but confirms his shirt had not been changed this week. Interview was conducted on October 31, 2024 at 8:46AM with an LPN (staff #314), who confirmed that resident #320's scheduled shower dates are Mondays and Thursdays. Upon looking at the electronic health record (EHR) and the resident's admitted , the LPN states that the resident should have been offered at least two showers by this point. The LPN instructs to check the EHR for charting of showers. Interview was conducted on October 31, 2024 at 10:53AM with the Director of Nursing (DON/Staff #42) and the Assistant Director of Nursing (ADON/Staff #34). In this interview, the DON confirms that residents should be offered a shower twice a week, according to their shower schedule and preferences. The DON and ADON both explain that these showers are expected to be charted in the EHR. The DON further explains that each refusal or offering of a shower is not necessarily expected to be charted. When asked about dressing residents, the DON states that the staff encourage residents to get dressed, but it is their right to refuse. When asked if this should be documented, the DON and ADON both report that it does not have to be documented that a staff offers to dress the resident or if the resident refuses. When asked how they can ensure their staff are offering to assist residents with dressing, the DON reports that you can tell through the staff rounding. Review of the facility policy titled, ADLs- hygiene, grooming, toileting, bathing, oral care, dressing, grooming, mobility, transfers, ambulation, etc. indicates that if a resident is unable to carry out ADLS independently, including dressing and grooming, the services will be provided by staff. This policy also indicates that bathing will be offered twice a week and as requested by the resident. The policy states that ADL care, including dressing, personal hygiene and grooming, will be documented in the medical record.

Based on observation, clinical record review, interviews, and policy review, the facility failed to ensure that a blood pressure medication was administered within ordered parameters for one resident (# 60). Findings Include: Resident # 60 was readmitted to the facility on [DATE] with diagnoses that included dependence on hemodialysis, hypotension, hypothyroidism, muscle weakness, and unspecified issues of the musculoskeletal system. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The care plan for hypotension-initiated January 3, 2024, revealed for staff to monitor, and record vital signs, and to report any significant abnormalities to the physician (MD). A medication order for Midodrine HCL 5 mg was initiated on January 30, 2024 for three tablets to be administered with meals for hypotension (low blood pressure), but to hold the dose if the systolic blood pressure was greater than 130. The MAR revealed that the Midodrine 5mg tablet was administered outside of parameters with systolic blood pressures (BP) greater (>) than 130, 4 times in June 2024, 5 times in July 2024, 1 time in August 2024 and 2 times in October 2024. The clinical record failed to reflect any documentation supporting the reason for administration of Midodrine 5 mg to be given outside of parameter. The clinical record failed to reflect documentation that the provider was notified when Midodrine 5mg was given outside of parameter. In an interview with the Assistant Director of Nursing (ADON/Staff # 34) on 10/31/24 at 8:43 a.m. the ADON was able to identify occurrences of when the Midodrine administered above a systolic of 130, but was unable to locate any order to support this medication to be given out of parameter. The ADON was also unable produce any documentation that the physician was contacted. The ADON stated that blood pressure medications should be given within parameter, especially this one because high blood pressure can also cause the resident issues, and any concerns about the blood pressure or parameters should be directed to the DON and provider. In an interview with the Director of Nursing (DON/Staff # 42) on October 31, 2024 at approximately 1:30, the DON was also unable to produce documentation to support the blood pressure medication was to be given out of parameter. She voiced that this practice was not per facility protocol and further reinforced the importance of the administering nurse's duty of ensuring medications are given correctly. A policy titled Documentation and Charting advises the facility is to provide a complete account of the resident's care, treatment, response to care, and progress of the resident's care. A policy titled Medication Administration-Oral revealed that if there is any question in regard to dosage, the person in doubt should not give the drug until clarification has been obtained.

Based on observations, staff and resident interviews, clinical record and policy review the facility failed to ensure enhanced barrier precaution orders were implemented for two residents (#157 and #60); proper infection control practices were implemented during the laundry process; and that, infection prevention and personal protective equipment were utilized as ordered for one resident during medication administration. The deficient practice could result in a spread of preventable illness to residents and staff. Findings Include: -Regarding Resident #157 Resident #157 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left side, morbid obesity, and dysphagia. Review of the Nurse Practitioner (NP) progress noted dated October 11, 2024 revealed that the NP was aware that the resident had a gastrojejunostomy (GJ tube), and therefore instructed the staff to provide GJ tube site care. Review of the physician order dated October 11, 2024 revealed instructions for staff to monitor the resident's percutaneous endoscopic gastromy (PEG) tube site, including cleansing and covering the site with a dressing every shift. Review of the Treatment Administration Record (TAR) for October 2024 revealed that staff were instructed to monitor the PEG tube site, including cleansing and covering the site with a dressing every shift. This was charted as completed twice a day since admission. Further review of physician orders revealed no evidence of an order for Enhanced Barrier Precautions (EBP). Review of the care plan revealed no evidence of enhanced barrier precautions being utilized, and no mention of the resident having a feeding tube in place. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Observation of Resident #157's room on October 28, 2024 at 8:32AM revealed no evidence of EBP signage in or outside of the resident's room. Observation revealed the resident was laying in bed at this time with shirt slightly exposing their stomach, and a feeding tube was noted in place. Observation of resident #157's room on October 30, 2024 at 11:52AM revealed two staff members in the resident's room at this time. Both staff members did not wear gowns. The two staff were assisting the resident to re-position in bed, as they were touching the resident's bedding under the resident. Interview was conducted on October 30, 2024 at 11:58 AM with Resident #157 and their mother. At this time, still no EBP signage in or outside of the resident's room. Resident #157 lifted their shirt, exposing the feeding tube and explained that the staff assist with cleaning the feeding tube by wiping it with gauze and applying a dressing onto it. An interview was conducted on October 31, 2024 at 07:12 AM with the Infection Preventionist/ Licensed Practical Nurse (IP/LPN/Staff #89) who stated that she expects staff to follow CDC guidelines regarding EBP usage. She further explained that EBP should be implemented if a resident has anything coming out of their body such as devices, foley catheters, or PICCs (peripherally inserted central catheter). When asked if resident #157 should be on EBP, she stated that she was not sure since his feeding tube has not been accessed at the facility. -Regarding Laundry Practice An interview was conducted on October 30, 2024 at 11:20 AM with the Director of House Keeping and Laundry (Staff #60), who stated that during washing process in the laundry, everything is treated as infected, so a gown should be worn every time. She also stated that the certified nursing assistants should strip the beds and place the dirty linens in a sealed bag, which is collected for cleaning. Observation of the laundry process was conducted on October 30, 2024 at 11:26 AM with Staff #60. During this observation, the staff member washed their hands and then wore gloves but no gown. The staff member opened the cart with the soiled linens revealing some items in the soiled cart were bagged and others were not. Some of the bags were sealed and others were not. Staff #60 then moved each item from the soiled linen cart into the washing machine. Sealed bag was placed into the washing machine and then opened inside the machine to remove the items. Staff #60 completed this process wearing gloves but no gown was worn. Interview was conducted on October 31, 2024 at 07:12AM with the Infection Preventionist (IP/Staff #89), who stated that housekeeping is instructed to treat every room as infectious. She elaborated that soiled linens should be bagged in the room, and PPE should be properly donned and doffed when handling dirty linen. Further observation of the laundry process was conducted on October 31, 2024 beginning at 7:26 AM with staff #60 and staff #126. During this observation, the two staff were observed holding linen against their body when transferring the items from the clean linen bin onto the folding table as well as during the folding process -- without use of gloves or gowns. At 7:27AM, Staff #126 was observed folding a blanket over the clean linen bin, holding the blanket against her chest, and then placed it on the folding table. At 7:29 AM, Staff #126 was observed folding a fitted sheet from the clean linen bin, then holding the sheet against her chest as they folded the sheet and placed it onto the folding table. At 7:31AM, Staff #126 again was observed to pull a fitted sheet from the clean linen bin, held the sheet against her waist when folding, and then placed it on the folding table. At 7:33AM, Staff #60 was observed pulling dry linen from the dryer, and held some of the clean linen against her chest as they placed it into the clean bin. This process was conducted without the use of a gown or gloves. An interview was conducted on October 31, 2024 at approximately 07:50AM with the Director of Housekeeping and Laundry (Staff #60), who stated that staff are not supposed to touch clean linen to their clothing during folding. Instead, the folding table should be used to fold items. Staff #60 also identified that touching clean laundry to staff clothing could result in contamination to the clean laundry. At 08:07AM on October 31, 2024, again staff were observed transferring dirty linen from the soiled linen cart to the washing machine. Prior to handling the dirty linen, staff #126 donned a gown and tied it at the waist, but did not tie the gown at her neck. The soiled linen cart was observed at this time to have un-bagged dirty linen sitting on top of bagged laundry within the cart. The staff proceeded to don gloves and removed the laundry from the top of the linen cart. While removing the dirty linen from the cart, the staff member's gown fell down from her shoulder to the top of her chest, with the inside of the gown turned out. The staff then pulled up the gown, touching the inside of the gown while readjusting gown. The gown continued to fall down again 2 more times, once at 08:10 AM and again at 08:11AM. Both times, the staff member touched the inside of the gown with her gloved hand to pull the gown up to their shoulders. An interview was conducted on October 31, 2024 at 08:11AM with Staff #126, who stated that when handling the laundry, staff are supposed to tie the gown at the neck and waist. She stated there was not any risk associated with her gown falling down from her shoulders, because the dirty linen would not touch her clothing. She further stated that gowns were used to protect their clothing from touching the dirty linen. 51006 -Regarding medication administration A medication administration observation was conducted on October 30, 2024 at 7:19 AM of a Licensed Practical Nurse (LPN/Staff #83). The following medications were administered: -Acetaminophen Tablet 650 MG -Lidocaine External Patch 4 % (Lidocaine) -Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) The medications were administered to one resident with Enhanced Barrier Precautions (EBP) signage in front of the resident's door. Staff #83 was observed without utilizing EBP prior to administering Lidocaine External Patch 4 % (Lidocaine) onto the resident's right chest and Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) into the resident's lower left quadrant In an interview conducted with Staff #83 on October 30, 2024 at 7:23 AM, staff #83 stated that the facilities' expectations regarding EBP signage in regards to medication administration is that any direct contact requires full personal protection equipment (PPE), including a gown, gloves, and hand sanitizer before and after touching the resident. Staff #83 stated that EBP was not utilized while the medication administration was observed. In an interview conducted with an Licensed Practical Nurse (LPN/ Staff #101) on October 30, 2024 at 8:13 AM, staff #101 stated that the facilities' expectations, regarding EBP signage, during medication administration is that any direct contact requires full personal protection equipment (PPE), including a gown, gloves, and hand sanitizer before and after touching the resident. Staff #101 also stated that medications that require full PPE are patches, injections and topicals; and that, oral medications do not require full PPE. In an interview conducted with an LPN (Staff #29) on October 30, 2024 at 8:38 AM, staff #29 stated that the facilities' expectations regarding EBP signage in regards to medication administration is that any direct contact requires full personal protection equipment (PPE). During an interview conducted with the Director of Nursing (DON/Staff #42) on October 30, 2024 at 1:02PM, Staff #42 stated that the facilities' expectations regarding EBP signage, during medication administration is that any direct contact requires full personal protection equipment (PPE), including a gown, gloves, and hand sanitizer before and after touching the resident. Staff #42 also stated that the medications that require full PPE are for patches, injections and topicals; and that, oral medications do not require full PPE. Staff #42 also stated that not utilzing PPE during admnistration of patches, injections, and topicals when a resident has an EBP signage in front of their door is not the facilities best practice. 51103 Regarding Resident # 60 Resident # 60 was admitted to the facility on [DATE], with diagnoses that include; end-stage renal disease (ESRD), dependence on renal dialysis, anxiety, tobacco use, and anemia. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also identified the resident as hemodialysis dependent. Review of the care plan for hemodialysis initiated on January 11, 2024 included the intervention for the use of enhanced barrier precautions (EBP) with the resident. An order dated May 17, 2024 provides instruction for the care of the resident's fistula (left upper arm hemodialysis access). An order dated October 28, 2024 was written to begin Enhanced Barrier Precautions (EBP) due to the resident's fistula. Review of resident's record did not indicate resident had order for EBP prior to October 28, 2024 and after resident's admission. An interview was conducted on October 30, 2024 at 8:15 am with the resident. Resident stated everything is going good at dialysis, and that she handles her fistula herself at the nursing home. She states four hours after treatment she knows it's safe to remove her bandages. She further elaborated that if she has any issues with the access, she is to notify staff for assistance. An interview was conducted on October 30, 2024 at approximately 1:30 p.m. with the Director of Nursing (DON/Staff # 42). The surveyor reviewed with DON the order entry for EBP that was activated on October 28, 2024 at 6:30 p.m. The DON stated that whenever a resident is indicated to be on EBP, orders and implementation of those orders are expected to begin immediately. A policy titled Dialysis (Renal), Pre and Post Care indicates the dialysis access should be assessed upon return to the facility for patency, and any unusual redness or swelling. Review of facility policy titled, Infection Prevention and Control Program (revised 06/23) revealed that policies, procedures and aseptic practices are following by personnel in performing procedures, linen handling, and disinfection of equipment. This policy also revealed that the spread of infections is accomplished by use of Standard Precautions and/or other transmission-based precautions. However, review of this policy revealed no descriptive CDC guidance or application of CDC recommendations. Review of the EBP signage provided by the facility revealed that providers and staff must wear gloves and gown for high-contact resident care activities including: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care. Review of the guidelines published June 2021 from the Centers for Disease Control and Prevention (CDC) revealed that EBP may be applied to residents with wounds or indwelling devices, regardless of MDRO (multidrug-resistant organism) colonization status. Review of facility policy titled, Linen Handling, states that all soiled linen shall be treated as possibly infectious and handled as such. The policy states that clean linens should be carried and held away from the body, and gowns and gloves should be worn when sorting or washing linen. Review of facility policy titled, Infection Prevention and Control Program, revealed that policies, procedures and aseptic practices are following by personnel in performing procedures, linen handling, and disinfection of equipment.

Based on interview, record review, and facility policy review, the facility failed to notify the Ombudsman of transfer/discharge for one resident (#163). Failure to notify Ombudsman of transfers/discharges may result in residents being discharged against their will. Findings include: Resident # 163 was admitted on [DATE] with a diagnoses including acute kidney failure, Gastro-Esophageal reflex, and multiple fractures of the ribs. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. Admission transfer/discharge reports dated July 2024 revealed no evidence that resident (#163) had been listed as discharged . A Care plan dated July 29, 2024 revealed a focus that the resident is to return or be discharged to an alternative placement. A progress note dated July 30, 2024 revealed that the resident was transferred to a rehabilitation facility via stretcher. A physician's order dated July 30, 204 revealed an order to discharge to a rehabilitation facility. An email sent to the Ombudsman on August 7, 2024 by the Medical Records Supervisor ( Staff # 208) revealed no evidence that the resident was discharged in July 2024. Review of the facility Record Hospital Transfer and Admission / Discharge revealed no evidence of Resident ( #163) discharge. An interview was conducted on October 30, 2024 at 11:53 AM with Social Services Supervisor (Staff # 230), who stated that the resident had requested to be transferred to another facility. She also stated that the Ombudsman should be notified when residents transfer / discharge from the facility on a monthly basis. She reviewed the email she sent to the Ombudsman with the residents that discharged /transferred during July 2024, and stated that resident #163 was not on the list. An interview was conducted on October 30,2024 at 12:33 PM with the Medical Records Supervisor (Staff #208), who stated that the discharge paperwork would be sent to her, and scanned into the clinical records. She also stated that she would send a list of discharged or transferred residents to the Ombudsman once a month. She reviewed the clinical Record and stated there was no evidence that the Ombudsman had been notified of the resident's discharge. She further stated that Resident (#163) was not on that list of discharged / transferred residents for July 2024 that she sent to the Ombudsman. An interview was conducted on October 30,2024 at 2:26PM with the Assistant Director of Nursing (ADON/ Staff # 34) who reviewed the July Hospital Transfers and Admission Discharge report and stated that Resident (#163) was not included on the list of transfers or discharges. An interview was conducted on October 31, 2024 at 8:56 AM with the Case Manger ( Staff #301), who stated that it is mandatory to notify the Ombudsman when residents are discharged from the facility . She further stated the risk could be that the Ombudsman would not be aware that a resident was discharged . An interview was conducted on October 31, 2024 at 11:34 AM with the Director of Nursing (DON/ Staff # 42) who stated that the Ombudsman would be notified of when a resident transfers or discharges from the facility. She also stated that the Ombudsman was not notified of the resident's discharge in July. A facility Policy titled, Admission, Transfer and Discharge, revealed that when the facility transfers/discharges a resident, the facility will ensure that the transfer / discharge is documented in the Resident medical record and appropriate information is communicated to the receiving health care institution is provided. Review of facility policy titled, Change of Condition Reporting, reviewed on June, 2023 indicated, for acute medical change that the resident representative will be notified that there has been a change in the resident's condition and what steps are being taken. Review of State Operations Manual (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) revealed, S483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observations, staff and resident/resident representative interviews, clinical record and policy review the facility failed to ensure that two resident 's (#214 and #525) were free from abuse. The deficient practice may result in physical and/or psychosocial harm to the residents. Findings include: Resident #214 was admitted on [DATE] and discharged on [DATE] with diagnosis including unilateral primary osteoarthritis of left hip, other intervertebral disc disorders of lumbar region, pain in left hip, and muscle weakness. Review of the incident report dated January 15, 2024 revealed Resident #214 had a Brief Interview for Mental Status (BIMS) summary score of 14 indicating no cognitive impairment. The care-plan initiated on January 18, 2024 revealed that Resident #214 was at risk for impaired thought process related to new environment. The goal was that resident will maintain current level of cognitive function through the review date. Interventions included - monitor/observe resident for changes in mood/behavior patterns, fear of other residents and/or staff. Review of progress note dated January 18, 2024 showed that resident #214 was seated in her wheelchair in front of station 300 drinking her tea. Resident #214 was approached by another resident who yelled in her face. The unit secretary immediately came from behind the desk and removed resident #214 and called for assistance. Further around 4:10 pm, resident #214 informed the unit secretary that prior to her coming that the other resident had walked past her in front of the desk and took his right fist and struck her in the right shoulder and mid-back area as she was passing him in her wheelchair. Resident #214 didn't tell anyone of this alleged incident prior to telling the unit secretary. Resident #214 had a PRN skin evaluation completed and noted no marks or bruising to her right shoulder or mid-back area. Resident #214 denied pain or discomfort and feels safe in the facility. She declined notification to her family and explained that she would call her family. Provider, Ombudsman, Glendale Police, APS, and DHS were notified of the alleged incident. Resident #525 was admitted on [DATE] and discharged on [DATE] with diagnoses which included non-displaced zone II fracture of sacrum, acute pain due to trauma, muscle weakness and other stimulant abuse. Review of the incident report dated January 15, 2024 revealed Resident #214 had a Brief Interview for Mental Status (BIMS) summary score of 15 indicating no cognitive impairment. Review of progress note dated January 18, 2024 showed that resident #525 approached another resident and started yelling in her face. The unit secretary immediately separated both residents. Resident #525 continued to walk towards both the unit secretary and the other resident yelling and showed signs of aggression and then he walked outside to the patio. Around 4:10 pm, the other resident had informed the unit secretary that prior to her coming, resident #525 walked past her and took his right fist and struck her in her right shoulder and mid back area as she was passing him in her wheelchair. Both assistant directors of nursing went to speak with resident #525 and he continued to yell and requested to leave facility against medical advice (AMA). Resident #525 was removed by police and detained due to alleged incident and outstanding warrants. A facility reported incident and 5-day report was made on January 18, 2024. This report included Resident #214 notified unit secretary (staff #321) that resident #525 took his right fist and struck her in her shoulder and mid back area as she was passing him in her wheelchair. Resident #214 did not tell anyone prior to telling staff #321. An interview was conducted with several certified nursing assistants (CNAs) and licensed practical nurse (LPNs) who did not witness any aggressive behaviors between resident #214 and resident #525 in past. An interview was conducted licensed practical nurse (LPN/Staff #314) on October 30, 2024 at 8:54 a.m. who stated that the altercation had happened between resident #214 and #525. Staff #314 recalled that resident #525 had raised his fist and hit resident #214 but not sure how hard. Moreover, Staff #314 stated that assistance director of nursing and director of nursing approached resident #525 and separated him from the other residents. Full skin assessments were done on resident #214 and no injury were found. An interview was conducted with certified nursing assistant (CNA/Staff #203) on October 30, 2024 at 9:32 a.m. who stated that process after an altercation is reporting it to floor nurse, call for help, and separate residents immediately. If a resident hits another resident then we do skin assessment for any marks, injury, bruise or open areas. An interview was conducted with administration/executive director (Staff # 72) on October 30, 2024 at 9:48 a.m. who stated that any altercation or abuse that happens is reported to adult protected service (APS), state, police, family, power of attorney (POA) and ombudsmen within 2 hours. He further stated that we substantiate if it happens or people witness that it happens then we separate them first, make sure they are safe, not injured. Regarding resident #214 and #525, he stated that he saw in camera recorder that residents were in hall 300, resident #214 said something to resident #525, he gone away and then he came back and pushed resident #214 with palm on right shoulder and both of them were on wheelchair. Review of facility policy regarding Abuse: Prevention of and Prohibition Against revised on August, 2024 revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by establishing a safe environment.

Based on record review, staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#11) was free from abuse from a staff member. This deficient practice could result in the physical and/or mental harm of a resident. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included Bipolar disorder, Anxiety disorder, and Schizophrenia. A 5-day MDS (Minimum Data Set) dated September 10, 2024 was reviewed. A BIMS (Brief Interview for Mental Status) assessment was completed and indicated BIMS score was 13 which indicated Resident #11 was cognitively intact; and that, the resident had experienced hallucinations, and physical and verbal behaviors directed at others. Moreover, this assessment revealed that this resident was independent for bathing. A care plan dated September 10, 2024 revealed that this resident had potential for a psychosocial well-being problem related to a staff to resident altercation. A Psychiatric Note dated September 10, 2024 revealed that this resident had multiple suicide attempts in the past and had feelings of anger, frustration, and some depression due to her current situation. Patient stated had been feeling intermittently anxious and restless. This note revealed that the resident had chronic auditory and visual hallucinations as well as episodes of severe paranoia and admits to having daily command hallucinations that included self-harm; and that, while in the facility -- tried to stab herself with a handle of a hairbrush, but it didn't work. This document included, assessed patient a likelihood rating of self-harm or harming others which patient verbalized a 10. Document revealed staff reported the resident had intermittent episodes of hallucinations since arriving to the facility, appeared to react to internal stimuli at times and that the day of the note the resident has been getting more aggressive and agitated. A nursing noted dated September 1, 2024 included that the provider had ordered staff to send resident to ER and that resident #11 was sent to the hospital for suicidal ideation and physical aggression. A self-reported document provided by the Director of Nursing (DON/staff #71) revealed, At approx. 10:30 am on 9/10/2024 (staff #57) was showering (resident #11). During the shower (resident #11) began yelling and screaming and striking out. The nurse (staff# 92) came in the shower room to inform the patient that she was being sent out for SI (suicidal ideation) and that once her shower is completed, she would need to come in the common area until transportation arrives. The patient's behaviors began to escalate when the CNA provided her with clean clothes to wear. The CNA called the nurse(staff #91) to the shower room to inform that the patient refused to put on clean clothes and wanted her dirty clothes back. When the nurse provided patient with education regarding the importance of having clean clothes, the patient became immediately aggressive towards the nurse (staff #91). (Resident #11) began spitting at the nurse in her face, cursing at the nurse, kicking, punched the nurse in the chest twice and the patient then grabbed the nurse's arm and began to dig her nails into her right arm. The patient was yellingand cursing when two other certified nursing assistants (CNAs) came into the shower room. They were alerted due to the level of yelling from the patient CNAs (#54 and #22). The patient was seated on the chair in the shower room and (staff #22) approached the patient and as she approached the patient grabbed her left hand and placed it in her mouth and then continued to bite the CNAs left index finger. The CNA continued to ask the patient to release her bite and the patient continued to bite harder. The staff were unable to get her to release the bite and redirect her. (Staff #22) then took her right closed hand and struck the patient in the right side of her face twice. Once the CNA struck the patient her bite was released. The nurse intervened immediately and removed the patient. (Staff #22) left the unit. Manager was informed immediately and CNA was suspended and escorted from the facility. The patient denied pain or discomfort. PRN skin assessment was completed and noted no bruising or discoloration to face. Provider and all parties notified. A Counseling or Disciplinary Note for CNA (staff #22) dated September 10, 2024 revealed that action was taken to suspend staff pending investigation and subject to discharge. An interview was conducted on September 16, 2024 at 10:42 A.M. with a Certified Nursing Assistant (CNA/staff #54) who stated that the resident kept to herself and was only up for meals. She stated that one of the CNAs was giving her a shower that day, and that she heard someone screaming in the shower. The CNA stated that she went into the shower, and the resident was screaming and spitting at the nurse, the CNA giving shower on left was telling her to calm and trying to calm her and the other was grabbing her wrist, to stop her from digging her nails into the CNA on her left. Staff #54 stated that the resident bit her finger, and as soon as she bit her finger, that the CNA punched her with her right hand because she was holding with the left. The CNA stated that she observed that the resident's forehead was red. The CNA stated that later she gave the resident a cup of water and the resident said she was fine. The CNA stated that the CNA who hit the resident was #22 and the nurse was #92. An interview conducted on September 16, 2024 at 10:53 with a Licensed Practical Nurse (LPN/staff #92), who stated that resident #11 was upset and started screaming after the nurse mentioned having to be there monitoring since she had told the provider that she had a plan to commit suicide. This nurse stated that the CNA had called her, and that the resident said she wanted them out; and that, when they stayed -- she started screaming and punching. This nurse also stated that the resident was digging her nails into a CNA and bit her on the finger. She said that the staff had calmed the resident down; and that, the resident was sitting on a shower bench; and that, CNA #22 punched her; and that, she had no idea why the CNA did it because it was after the bite; and that, the resident had already calmed down and was sitting on the bench. This nurse stated that the CNA punched her twice with a closed hand. An interview was conducted pm September 16, 2024 at 12:38 P.M. with a CNA (staff #57) who stated that she had only worked with the resident a day and a half and that the resident had no outbursts at that time. This CNA stated that the resident asked if she could get a shower. This CNA stated that the resident was told that she needed to sit in the area for her safety; and that, after the resident finished showering attempted to give her clean clothes, but the resident said that she did not want them. This CNA stated that she then called the nurse and the resident started to curse and punch the nurse. This CNA stated that she asked the resident to calm down; and that, two other CNAs came into the shower room. This staff stated that while one of the CNAs was holding the resident's hand the resident bit her. This CNA bent over to place socks on the resident and that she heard something happen while the resident was screaming and spitting. This CNA said that she did not see what it was but that the nurse and one of the CNAs told her that the other CNA punched the resident. An interview was conducted on September 16, 2024 at 11:21 A.M. with a CNA (staff #22) who stated that she was dismissed from the facility, but that she had been a CNA there. This CNA stated that she had a good relationship with the resident and that she was not her resident on the day of the incident. She stated the nurse requested her assistance; and that, the nurse went into the shower room, and that she heard the resident screaming, Get me out of here and kept getting louder. She stated that she went into the room, and the nurse was screaming back at the resident, That's not how it works; and that, everyone there was yelling. This CNA stated that the resident had a shirt and one leg in her pants; and that, CNA was holding one of the resident's hands; and that, the nurse was holding the resident's other hand, and the resident was yelling, you better not break my finger! This CNA stated that she was trying to deescalate the situation; and that, she took the resident's right hand and the other CNA had the resident's left hand; and that, the resident and the nurse were still going back and forth verbally. This CNA stated that in the midst of that the resident started biting on her finger, so she got her finger out of the resident's mouth and that the resident was spitting. Then the nurse was telling the resident that she was going to jail. This CNA stated that the resident launched herself at her; and that, she put her hand out; and that, the resident smacked into her hand. She stated that she then left the shower room because she was upset and took a break, but when she came back, the nurse had called the supervisor. This CNA stated that the supervisor asked her if she hit the resident and then this CNA stated that because she was attacked she did hit the resident; and that, it was a reflex not done intentionally. This CNA stated that it was only once; and that, she did not have a closed fist; and that, there were no bruises. An interview was conducted on September 16, 2024 at 12:48 PM with the Director of Nursing (DON/staff #71) who stated had not witnessed the event, but concluded, from speaking to the Psychological provider and the staff, was that the Psych provider had seen the resident that morning and that she had told them that she had suicidal thoughts and a plan to kill herself therefore the provider wanted the resident sent out to the hospital and the resident wanted a shower. DON stated that staff #57 gave her a shower, and handed the resident clean clothes but that the resident did not want to wear them; and that, the resident then went off. DON stated that the CNA radioed for help; and that, the nurse came to assist and told the resident that she was going out to the hospital. DON stated that the resident then grabbed the nurse, digging nails in, and the nurse told her to let go. DON stated that the patient was spittiing and hit her twice and refused to let go. This DON stated that CNA #57 told the resident to let go, and that CNA (staff #22) came into the shower room attempting to get the resident to release the nurse. DON stated that the patient bent forward and was biting her finger; and that, staff #22 told the management team that she was gently pushing on the resident's head to release the resident's bite and had not done anything intentional. DON stated that facility did not substantiate abuse because they felt that the CNA (staff #22) was trying to release the resident's grip. However, this statement differs from those told by the persons in attendance and from the facility's report provided day of the incident. DON stated that staff #22 was terminated for attendance issues; and that, she needed to be reinstated because it was an error. This staff member said that it doesn't meet her expectations if a resident was struck in the facility. A policy titled Abuse: Prevention of and Prohibition Against revised October, 2023 revealed that it is the policy of this Facility that each resident has the right to be free from abuse and that the Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse. This policy included that abuse is willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This document included that willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of one resident (#107) to be free from abuse by a resident. The deficient practice could result in residents subjected to further abuse. Findings include: Regarding residents #107 and #15: -Resident #107 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, depression and anxiety. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS)score of 3 indicating the resident had a severe cognitive impairment. The care plan dated September 5, 2024 revealed the resident had the potential for a psychosocial well-being problem related to resident to resident on September 5, 2024. Interventions included to monitor for mood behavior patterns, aggressive behaviors towards other residents and/or staff, fear of other residents and/or staff and notify provider if present; and that, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. A progress note dated September 5, 2024 revealed that resident #107 was sitting in his wheelchair in front of the nurse's station. Per the documentation, the nurse saw resident #15 came up behind resident #107's wheelchair and began yelling that he wanted him to move.; and that, the nurse and two certified nursing assistants (CNAs) went to assist as resident #15's tone became elevated. It also included that resident #15 made contact with the right side of face of resident #107 face with a closed right fist. According to the documentation, resident #107 reported that he was in his wheelchair and the other resident (#15) came up behind him, yelled at him and wanted him to move so resident #15 could get past him in the hall; and then, struck him. -Resident #15 was admitted on [DATE] with diagnoses of secondary Parkinsonism, bipolar disorder, anxiety disorder, unspecified dementia, and unspecified psychosis. The care plan dated March 21, 2024 revealed the resident had a potential to demonstrate verbal and physical behaviors related to dementia and a bipolar disorder. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalates behaviors and document. Also, to assess and anticipate the resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. The minimum data set (MDS) assessment dated [DATE] included a BIMS score of 10 indicating the resident had a moderate cognitive impairment. A progress note dated June 29, 2024 revealed the resident was verbally aggressive, and threatened to hit staff. Per the documentation, the resident was not easily redirected, had to be redirected several times during the shift and was demanding for his pull-ups. A progress note dated September 5, 2024 included that resident #15 was sitting at the dining room waiting for dinner; and, resident #107 was sitting in his wheelchair in front of the nurse's station. Per the documentation, the nurse saw resident #15 came up behind the wheelchair of resident #107 and began yelling at resident #107 that he wanted resident #107 him to move. The documentation also included that the nurse and two certified nursing assistants (CNAs) went to assist as resident #15's tone became elevated; and, resident #15 made contact with the right side of face of resident #107 face with a closed right fist. It also included that both residents were separated immediately; and that, resident #15 kept saying that he was sorry when asked what happened. An interview was conducted on September 10, 2024 at 9:30 a.m. with the Director of Nursing (DON/staff #1), who stated that all staff have received training on abuse, which includes physical abuse, and the willful intent to cause harm. The DON stated that her expectation was that there is always one staff to monitor the residents in the common area, while the other staff were providing care for the other residents. An interview was conducted on September 10, 2024 at 10:53 p.m. with the Assistant Director of Nursing (ADON/staff #27), who stated that staff should be within a reasonable distance to supervise and monitor the residents. If a resident was being physically aggressive, the resident should be taken to a quiet place. Regarding residents #36 and #22: -Resident #22 admitted to the facility on [DATE] with diagnoses that included dementia in other diseases classified elsewhere without behavioral disturbance, unspecified psychosis, and an anxiety disorder. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 11 indicating the resident was cognitively intact. The care plan dated August 23, 2024 revealed that the resident had the potential for a psychosocial well-being problem related to an altercation with another resident. Interventions included monitor /observe resident for changes in mood/behavior patterns, aggressive behaviors towards other residents and/or staff, fear of other residents and/or staff and notify the provider if present. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. A progress note dated August 24, 2024 revealed that at approximately 9:05 p.m. on August 23, 2024 on the behavioral secured unit, the nurse was charting in the common area dayroom and observed resident #22 sitting in a chair doing crossword a puzzle. Per the documentation, at approximately 9:10 p.m., resident #22 got up and headed towards his room; and that, the nurse turned around when she heard resident #22 and resident #36 talking, and their level of tone increased. The documentation included that as the nurse approached both residents, resident #36 took his right hand in a closed position and made contact with the left side of the face of resident #22. It also included that resident #22 reported that resident #36 hit him. According to the documentation, staff separated both residents immediately. -Resident #36 was admitted on [DATE] with diagnoses of unspecified dementia with other behavioral disturbance, unspecified psychosis and anxiety disorder. The care plan dated August 21, 2024 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to dementia, likely advanced, and sundowning. Interventions included a therapy evaluation and treatment as per physician orders. The care plan dated August 21, 2024 revealed the resident was on psychotropic medications related to a brief psychotic disorder, auditory hallucinations/physical aggression. Interventions included to monitor/record occurrence for target behavior symptoms, specifically brief psychotic disorder auditory hallucinations, and document. The care plan dated August 23, 2024 revealed that the resident had the potential for a psychosocial well-being problem related to an altercation with another resident. Interventions included monitor /observe resident for changes in mood/behavior patterns, aggressive behaviors towards other residents and/or staff, fear of other residents and/or staff and notify the provider. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. A progress note dated August 23, 2024 at 5:19 a.m. revealed that the resident wandered around the unit, was verbally and physically aggressive; yelled at staff, pushed and attempted to throw chairs at staff in the dayroom, while other residents were watching. Per the documentation, the resident required redirection at all times, especially from the medication cart and the nurse's station; and that, the resident struggled with interventions. A progress note dated August 24, 2024 included that on August 23, 2024 at approximately 9:05 p.m. on the behavioral secured unit, resident #36 was ambulating in the hallway and the common area, dayroom. At approximately 9:10 p.m. the nurse turned around when the residents were talking and their level of tone was increased. Per the documentation, as the nurse approached the residents, resident #22 took his right hand which was in a closed position and hit the side of the face of the resident #36. Review of the follow up psych evaluation dated August 27, 2024 revealed that the resident had worsening episodes of aggression and agitation; and that, the dose for the antipsychotic medication was increased and and a new medication was started. Per the documentation, staff reported that resident #22 hit another resident in the face four days ago, and the attack was reportedly provoked. It also included that the resident had no recollection of the incident and doesn't remember striking anyone. The discharge minimum data set (MDS) assessment dated [DATE] included the resident was assessed by staff to have severe cognitive impairment. It also included that the resident displayed physical and verbal behaviors towards others 1-3 days during the look-back period. Review of the behavior task sheet dated August 2024 revealed that on August 22, 2024 resident #36 exhibited the following behaviors: kicking/hitting two times, grabbing one time, abusive language two times, and threatening behaviors two times. An interview conducted on September 9, 2024 at 3:57 p.m. with a certified nursing assistant (CNA/staff #7) who stated that if a CNA was going to help a resident in the resident's room, another CNA was supposed to monitor the dining area and the hall. An interview with the Therapy Program Manager (staff #5) was conducted in September 10, 2024 at 8:40 a.m. The therapy program manager reviewed clinical record of resident #36; and stated that the resident had the strength and full range of motion to injure someone. He also stated that resident #36 did not have the cognition for intent because the resident was only oriented to self and can only follow one-step directions. An interview was conducted on September 10, 2024 at 8:56 a.m. with a licensed practical nurse (LPN/staff #31) who stated that the CNAs were putting the residents to bed, so she was the only staff in the dining area and was throwing trash away because the residents had just finished their snack. The LPN stated that resident #22 came to her and told her that resident #36 hit him; and that, resident #36 did not say anything when asked about what happened. The LPN said that she did not realize that resident #36 was still in area. The LPN also stated that resident #36 has a tendency to be aggressive and would push chairs at people; and that, someone would have to keep an eye on him unless he was sleeping. Regarding resident #22, the LPN stated that resident #22 was quiet and had no problems. She also stated that it would be beneficial if she had more support staff. During an interview with the Director of Nursing (DON/staff #1) conducted on September 10, 2024 at 9:30 a.m., the DON stated that the resident to resident incident between residents #22 and #36 occurred on a secured dementia unit between the dining area and the hallway because the residents were free and were allowed to walk about. She stated that the LPN (staff #31) and two CNAs were working on the unit. She stated that the LPN reported that she was standing at the medication cart and had a view of the dining area and the hallway; and that, residents #22 and #36 crossed paths in the hallway and their tone of voices were escalating. The DON said that the LPN could not what the two residents were saying; and that, resident #36 hit resident #22. The DON said that at the time of the incident, the two CNAs were providing care for other residents in their rooms. The DON said that it was her requirement that one staff was present at all times in the common area to monitor the residents, while other staff were doing other things, such as providing care for other residents. She stated that she was not aware that resident #36 had aggressive behaviors. During the interview, a review of the clinical record for resident #36 was conducted by the DON who stated that resident #36 had a diagnosis of unspecified dementia with other behavioral disturbance related to confusion, increased wandering, pacing, and aggression; and that, on August 22 prior to the incident, resident #36 exhibited kicking, grabbing, language, threatening behaviors. The Facility assessment dated 2024 states that residents with behaviors are elvaluated on a case-by-case basis to allow facility leadership the opportunity to evaluate the facility's ability to provide care properly and safely for the individual with the identified behavior as well as maintain the safety of other residents residing in the facility. The facility policy, Abuse: Prevention of and Prohibition Against revised October 2022 states that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Physical abuse includes, but is not limited to hitting, slapping, pinching, and kicking.

Based on clinical record review, resident and staff interviews, and facility documentation and policy review, the facility failed to ensure there was a physician order for the use of oxygen for one resident (#2). The deficient practice could result in resident receiving oxygen not administered appropriately and as recommended by the physician. Findings include: Resident #2 was admitted on [DATE] with diagnoses of chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), and dependence on supplemental oxygen. A physician order dated July 13, 2023 revealed to document temperature and oxygen saturation and monitor for symptoms such as shortness of breath or difficulty breathing. A nurse practitioner (NP) note dated July 14, 2023 included the resident had COPD and respiratory failure with hypoxia and was oxygen dependent. It also included the resident had even and labored respiration while resting in bed. Assessments included COPD and oxygen dependence. Plan was to monitor respiratory status, depot to above 90%, continue with inhalers as ordered and to follow up with pulmonology. A daily skilled note dated July 14, 2023 revealed oxygen saturation at 98% via nasal cannula. On July 16, 2023, a daily skilled note revealed oxygen saturation reading at 94% via nasal cannula. A physician admission progress note dated July 17, 2023 revealed the resident had a medical history that included COPD, respiratory failure with hypoxia, and oxygen dependence. Assessments included COPD and oxygen dependence. Plan was to monitor respiratory status, depot to 90%, continue with inhalers as ordered, and follow up with pulmonology. Review of the admission Minimum Data Sheet (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating that the resident was cognitively intact. The assessment also included the resident had respiratory failure, required extensive one-person assistance for mobility, dressing, and personal hygiene, required extensive two-person assistance for transfers and was totally dependent on staff for toilet use. Further review of the MDS assessment did not indicate that resident was on oxygen. A daily skilled note dated July 23, 2023 revealed the resident's oxygen saturation reading at 96% via room air. An NP progress note dated July 31, 2023 included assessments of COPD and oxygen dependence. Per the documentation, carbon dioxide (CO2) was noted to be >40 secondary to chronic CO2 retention. The plan was to monitor respiratory status, O2 (oxygen) at 2.5 lpm (liters per minute) via nasal cannula, keep O2 saturation above 90%, continue inhalers as ordered, follow up with pulmonology, and repeat basic metabolic panel (BMP). The vitals log for O2 saturation for July 2023 revealed the resident had oxygen saturation rate that ranged from 93% through 99% when she was on oxygen via nasal cannula. Review of the July 2023 Medication Administration Record (MAR) revealed that O2 saturation rate was not taken on the following dates/shift: -July 22 on the night shift; and, -July 25 on the day shift A nursing note dated August 7, 2023 included that the nurse contacted NP for laboratory review since CO2 was critical at 40. Per the documentation, the NP reviewed the laboratory result and stated that this was due to chronic respiratory failure hence CO2 retention. There were no new orders received. Review of the vitals log for O2 saturation for August 2023 revealed the resident had oxygen saturation rate that ranged from 94% through 99% when she was on oxygen via nasal cannula. Despite documentation that the resident was on oxygen, there was no evidence found of a physician order for the use of oxygen to include the oxygen rate and frequency until August 24, 2023; and that, a care plan was not developed with interventions implemented related to the resident's oxygen use until August 24, 2023. A physician order dated August 24, 2023 included for the following orders: -Oxygen at 2-5 lpm as needed via nasal cannula (NC), titrate as needed to keep O2 saturation above 90% for diagnosis of COPD; -O2 saturation rate every shift for SOB, tachypnea, cyanosis, labored respirations, or change in level of consciousness; and, -Oxygen tube change every night shift every 14 days. The care plan initiated on August 24, 2023 included that the resident had oxygen therapy related to COPD. Interventions included medications as ordered by the physician, oxygen at 2-5 lpm as needed via nasal cannula and may titrate as needed to keep O2 saturation above 90%, and to monitor for signs/symptoms of respiratory distress and report to physician as needed. Review of facility documentation on the list of residents on oxygen at the facility revealed that resident #2 was not included in the list. During an interview with a certified nursing assistant (CNA/staff #9) conducted on August 24, 2023 at 12:03 p.m., the CNA stated that she was familiar with resident #2 but had only worked with her 2-3 times; and that, the resident had always been on oxygen since approximately August 14, 2023. The CNA stated that resident #2 was on continuous oxygen and was dependent on the supplemental oxygen and dependent on care from staff. The CNA stated that the only time she has heard the resident complain of shortness of breath was when they are doing a full bed change; however, she did full bed change for resident #2 four times already and the resident complained only once. The CNA stated that when the resident complained about it, the resident had her oxygen cannula on and she then notified the nurse of resident #2's SOB. She stated she was not sure if resident #2 ever had an incident of shortness of breath that resulted in a call to 911. An interview with a licensed practical nurse (LPN/staff #18) was conducted on August 24, 2023 at 2:03 p.m. The LPN said that she saw resident #2 on oxygen. She stated that she was unaware of any incident of shortness of breath for resident #2 that resulted in a 911 call. Staff #18 stated that if a resident required oxygen, a physician order that include the checks for the oxygen saturation, rate and frequency will be in place. The LPN stated that if an order was not in place and the resident needed oxygen, a physician order should be obtained. The LPN said that when resident's O2 sat is low, the resident was in distress, and if the staff was unable to take care of the resident with the orders, staff would call the paramedics or if the resident requested or wanted to go to the hospital. The LPN stated that normally, it was the nurse who would call 911/paramedics but sometimes the residents also take it upon themselves to call when they want help now and the resident was panicked and know they can get help from 911. The LPN said that when a resident call 911, staff sometimes does not know about it since the resident went directly to 911; and if this happens, the nurse should document this in the progress note and inform the DON, physician, and resident family. The LPN said that this will not trigger an incident/accident report but it will trigger a change of condition. Further, the LPN said that it was definitely a problem if a resident was using oxygen and there was no order in place; and that, this was a medication error. Further, the LPN stated that it was also problematic because nobody would know and monitor the resident for complications related to oxygen use. During an interview with another LPN (staff #27) conducted on August 24, 2023 at 2:27 p.m., staff #27 stated that resident #2 was alert and oriented with some confusion with time and events. Staff #27 also stated that resident #2 had a history of COPD and respiratory failure, hypoxic, and has CO2 buildup; and that, the resident was on oxygen and had been on oxygen since approximately at the end of July 2023. Staff #27 stated the resident gets shortness of breath with any kind of exertion even if she was on oxygen; and also, on turning during changing, transfer or dressing. Staff #27 stated she would not want the resident to be off the NC for more than 5 minutes; and, the only time she would consider disconnecting the NC was during transfers. However, staff #27 said that it should really not be removed since the resident gets anxiety and uncomfortable when not on her supplemental oxygen. Regarding the incident on August 9, 2023, staff #27 stated she was aware that the resident had shortness of breath and called 911. She also stated that resident #2 and the roommate told her about the incident when she returned to duty. Staff #27 stated that resident #2 and her roommate told her that a CNA on the night shift removed the oxygen during care; and that, after the care was provided the CNA took the tubing and flipped it to the chair which resident #2 could not reach. Staff #27 said that resident #2 used her call light to ask for help but that no one responded so resident #2 asked her roommate to call for help. Staff #27 said that the roommate tried to call the front desk but no one picked up; and that, the roommate got so nervous because resident #2 was not feeling well so she called 911. Staff #27 stated that resident #2 and the roommate told her that when the paramedics arrived they were mad that staff did not assist and they had to respond. Further, staff #27 said that resident #2 did not go to the hospital since resident #2 felt better after the oxygen was placed back on her. Staff #27 further stated that when she returned to duty, she did not receive any report regarding this issues/incident with resident #2. A telephone interview with a CNA (staff #36) was conducted on August 24, 2023 at 2:52 p.m. The CNA stated that resident #2 was on oxygen, was dependent on staff for care and required 2-person assist for transfer. She also stated that the resident uses her call light if she needs anything and that the resident was able to verbalize her needs. The CNA also said that resident #2 had shortness of breath that can sometimes be triggered during transfers so they have to do transfer quickly. The CNA further stated that the resident's head had to be on elevated position or she will have breathing issues. Further, the CNA stated that she was not aware of any incident of resident being short of breath and called 911. An interview with resident #2 was conducted on August 24, 2023 at 1:15 p.m. Resident #2 stated that she required continuous oxygen and had been on continuous oxygen since before she arrived at the facility. The resident stated that earlier in the month of August, she had an incident in which she suffered from shortness of breath SOB because the CNA who assisted her, took her nasal cannula off and when she was done changing her, the CNA did not place the nasal cannula back on her. Resident #2 stated that the CNA had placed the nasal canula where she could not reach it so she then rang the call bell and kept ringing it to get assistance to retrieve the NC so she can get oxygen but no one responded. Resident #2 stated that her roommate became concerned and tried to call the front desk; however, was also unsuccessful. The resident said that whoever was on the other line would pick up, they would just hang up and not talk to the caller. Resident #2 said that she had progressively started to feel bad due to her shortness of breath and so her roommate called 911. Resident #2 said that the paramedics came shortly and placed her NC back on; and she immediately felt better and did not feel the need to be taken to the hospital. An interview with the Director of Nursing (DON/staff #45) was conducted on August 24 at 3:45 p.m. The DON stated that the expectation was for staff to provide all the care to meet the needs of their residents while they are under their custody/care; and, this included answering call lights as soon as possible. The DON said that it is the expectation that orders are reviewed the next day after the residents' admission; and that, the electronic record reviewed by the Assistant Director of Nursing (ADON) to ensure and to check that treatment and orders needed were in place. The DON said that if a resident was receiving treatment such as oxygen the expectation was that there should be a corresponding physician order for its use. Regarding resident #2, the DON stated that resident #2 was a transferred from another facility, was a long-term care resident and was on oxygen. The DON said that the staff knew resident #2 was on oxygen and her O2 saturations were okay; and, that, the resident can go without supplemental oxygen. However, the DON said that the resident gets anxious. Further, the DON stated that there should have been an order for oxygen; however, staff missed the lack of physician order for the use of oxygen for resident #2. The DON said that resident #2 never went without an oxygen. Regarding the incident, the DON stated that she just found out about the incident today; and that, the ADON was originally made aware by the night nurse. The DON also said that the incident was not documented in the resident's clinical record since the resident was not struggling and it was the roommate who called 911. Further, the DON said that she was not sure if anyone spoke with resident #2 regarding the incident. Review of facility policy on Oxygen Administration reviewed July 2012 revealed that oxygen therapy is administered by licensed nurse as ordered by physician or as a nursing measure and an emergency measure until the order can be obtained. Furthermore, the policy indicated that the resident's clinical record will document that oxygen is to be administered, when and how often it is administered, the type of oxygen devise to use, and charting and documentation related to oxygen use. The facility policy on Comprehensive Person-Centered Care Planning reviewed June 2023, included that within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provided effective and person-centered care. Additionally, the policy noted that the baseline care plan will include minimum healthcare information necessary to properly are for a resident including initials goals, physician orders, and therapy services. Review of the facility policy titled, Physician Orders reviewed August 2022, revealed that it is their policy to accurately implement orders in addition to medication orders, treatment, procedures only upon the written order of a person duly licensed and authorized to do so in accordance with the residents' plan of care. The facility policy titled Documentation and Charting revised July 2022 indicated that the facility is to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care.

Based on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure that risks and benefits of [CONDITION(S)] medications were explained to 3 residents (#111, #37, and #548) and/or their representatives prior to receiving the medications. The sample size was 5 residents. The deficient practice could result in residents and/or their representatives not being informed of the risks and benefits of [CONDITION(S)] medications. Findings include: -Resident #111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's mood care plan, dated January 16, 2022, revealed that the resident had potential for a mood problem related to [CONDITION(S)], anxiety, and depression. Interventions included to provide medications as ordered including an antidepressant medication, and to educate the resident, family, and caregivers about the risk, benefits, and side effects of the antidepressant medication. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating that he was cognitively intact. Also, the assessment indicated that the resident received antidepressant medication every day during the 7-day look-back period of the assessment. Review of the February 2022 recapitulation of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed no evidence that the risks and benefits of the [MEDICATION(S)] were explained to the resident and/or the resident's representative. In an interview with a clinical resource Registered Nurse (RN/staff #193) on February 10, 2022 at 3:30 p.m., she stated that the facility was unable to find the signed form indicating that the resident had been explained the risks and benefits of the [MEDICATION(S)] medication. -Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's [CONDITION(S)] medication care plan, dated August 28, 2021, revealed that the resident was on [CONDITION(S)] medications related to [CONDITION(S)] as evidenced by paranoid delusions. Interventions included to provide medications as ordered and to educate the resident, family, and caregivers about the risk, benefits, and side effects of the medications being given. An admission MDS dated [DATE] revealed that the resident had a BIMS score of 11, which indicated that the resident was moderately cognitively impaired. The MDS indicated that the resident received antipsychotic medication 5 days during the 7-day look-back period. Review of the February 2022 recapitulation of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for November 2021 through February 10, 2022 revealed that medication was administered as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] However, review of the clinical record revealed no evidence that the facility informed the resident or resident's representative of the risks and benefits of [MEDICATION(S)]. The review of the clinical record also revealed no evidence that consent was obtained from the resident or resident representative prior to administration of the [MEDICATION(S)]. -Resident #548 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's antidepressant care plan, dated January 28, 2022 revealed that the resident was receiving antidepressant medication related to depression. Interventions included to educate the resident, family and/or caregivers about risks, benefits, and the side effects of the medication and to give the medication as ordered. The resident's [CONDITION(S)] medication care plan, dated January 28, 2022, revealed the resident received [CONDITION(S)] medications related to [CONDITION(S)] as evidenced by visual hallucinations. Interventions included the use of an antipsychotic medication, to administer the medication as ordered, and to educate the resident, family and/or caregivers about risks, benefits, and the side effects of the medication and to give the medication as ordered. Review of the admission MDS dated [DATE] revealed a BIMS score of 00, indicating severely impaired cognition. The MDS also included that the resident received antipsychotic and antidepressant daily during the 7-day look-back period. Review of the February 2022 recapitulation of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (an antipsychotic medication) 25 mg every 8 hours for [CONDITION(S)]. -[MEDICATION(S)] (an antidepressant medication) 25 mg by mouth at bedtime for depression. Review of the MAR for January through February 7, 2022 revealed that the medications were given as ordered. The resident was discharged from the facility on February 7, 2022. Review of the clinical record revealed no evidence that the facility informed the resident or resident's representative of the risks and benefits of the [MEDICATION(S)] or the [MEDICATION(S)]. The review of the clinical record also revealed no evidence that consent was obtained from the resident or resident representative prior to the administration of these medications. An interview was conducted on February 10, 2022 at 1:16 PM with a Licensed Practical Nurse (LPN/staff #90). She stated the facility definition of a [CONDITION(S)] medication is any medication that could alter your mental state such as an antipsychotic or an antidepressant. She stated she would expect to see an informed consent form for a resident receiving [CONDITION(S)] medication. She said that this is usually done on admission by the nurse or a case manager on shift. She also stated the nurse or case manager would provide copies of the consent to the resident or resident's representative. An interview was conducted on February 10, 2022 at 2:29 PM with the DON (staff #28) and a RN (staff #28). They said that nursing staff should receive some form of consent prior to administering [CONDITION(S)] medications to residents. They said that this could include verbal or written consent from the resident or resident representative when appropriate. A consent means that the facility has the approval to treat the resident for the associated condition and the risks and benefits of the medication have been explained. The DON said it would not meet her expectations if a [CONDITION(S)] consent was not obtained prior to administering the [CONDITION(S)] medication. The DON said that the consent should be completed and uploaded into the clinical record. Review of the facility's psychoactive medication policy, revised November 2020, revealed that the use of psychoactive medication must first be explained to the resident, family member, or legal representative including the potential negative outcomes. The policy included that a consent is to be obtained either from the resident or responsible party if the resident is unable to give consent. A verbal consent may be obtained if no responsible person is available. The person obtaining the consent is to sign the consent once obtained.

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) documentation was complete, accurate, and available for three residents (#12, #100, and #3). The sample size was 4 residents. The deficient practice could result in residents not receiving specialized services that they require. Findings include: -Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of PASRR documentation revealed that a level 1 PASRR was completed prior to admission on November 2, 2022 at an acute care hospital. The document revealed that the resident did have a serious mental disorder, [CONDITION(S)] disorder, and had exhibited hallucinations and delusions. The document further revealed that the resident had experienced an inpatient psychiatric hospitalization within the prior 2 years and the resident required assistance with tasks for which he should be capable. The PASRR level 1 revealed that the resident admission met the criteria for a 30 day convalescent care stay. The document revealed that a referral for a level 2 PASRR was needed. The admission Minimum Data Set (MDS) dated [DATE] revealed that the resident was not assessed for the Brief Interview for Mental Status (BIMS). The assessment indicated that the resident was not determined to have a serious mental illness as evaluated by a level II PASRR. The baseline care plan dated November 12, 2022 revealed that the PASRR level 2 referral had been submitted from the hospital and that the resident did not qualify for a level 2 PASRR. No further information on the determination was included in the care plan. There was no documentation in the clinical record as to how this information had been obtained. An email from the State PASRR coordinator to the social service supervisor (staff #162), dated February 9, 2022, indicated that after review, the resident did not require a level II PASRR. An interview was conducted with the Director of Nursing (DON/staff #28) on February 10, 2022 at 12:00 p.m. She stated that the facility requests the PASRR documentation from the hospital upon a resident's admission. She stated that the social services supervisor (staff #162) audits new admits and follows through on the PASRR documentation. She said that the social service supervisor also audits charts regarding the PASRRs and checks to see if residents would qualify for a level 2 PASRR. She said she would expect audits and documentation to be completed within about 2 weeks of admission. She said this would include all appropriate documentation such as a letter or a copy of the recommendation from the PASRR coordinator after a referral for a level II PASRR. She stated that a delay in having the appropriate PASRR paperwork is not acceptable and is not appropriate follow through. She stated that she expects better follow through on all aspects of resident documentation. She further stated that the facility had recognized that this was a process problem and staff had been working on the process. She said that they started a new audit policy about a month ago but it needs to be tweaked and some adjustments must be made. She stated that the letter from the PASRR coordinator should have been available for review in the clinical record. -Resident #100 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating impaired cognition. The MDS assessment also included the resident received antidepressants. Review of the clinical record revealed no evidence that a level 1 PASRR had been completed before or upon admission to the facility. An interview was conducted on February 8, 2022 at 12:41 p.m. with social services (staff #138) and the medical records director (staff #158). Staff #158 stated that documents are scanned in and uploaded into the electronic clinical record. Staff #138 stated that social services completes the PASRR and will give a copy to medical records to upload into the electronic clinical record. During an interview on February 9, 2022 at 9:33 a.m. with a social services supervisor (staff #162), she stated she was responsible for reviewing the PASRRs every 30 days. She stated that she runs the monthly report on the 15th of every month to do this follow up. An interview was conducted on February 9, 2022 at 1:44 p.m. with the DON (staff #28) who stated that the hospital will send the PASRR before admission. She said that social services conducts an audit to ensure that the residents have completed level 1 PASRRs and/or referrals for level II PASRRs as needed. She said social services will do a new PASRR on residents who enter the facility. The DON said that the resident did not have a level 1 PASRR in the clinical record. -Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the level 1 PASRR revealed that the document was incomplete. The form included the resident's name, date of birth, Social Security Number (SSN), gender, and address. The rest of the form including whether the resident had any dementia diagnoses, any serious mental illnesses, mental disorders, exhibited any interpersonal symptoms or behaviors, exhibited any symptoms related to adapting to change, any history of psychiatric treatment, any diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS dated [DATE] revealed the resident could not complete the BIMS due to the resident being rarely or never understood. The resident was noted to have both short and long term memory problems. The assessment indicated that the resident was not determined to have a serious mental illness as evaluated by a level II PASRR. The resident's mood care plan, initiated July 29, 2021, revealed that the resident had a mood problem. An intervention included behavioral health consults as needed. During an interview with the MDS coordinator on February 9, 2022 at 10:28 a.m., she said that the PASRR for resident #3 was not filled out. She said that social services follows up on PASRRs and would document this in the care plan. The MDS coordinator reviewed the care plan and said that there was no documentation regarding the resident's PASRR. An interview was conducted with a social worker (staff #162) on February 9, 2022 at 11:48 a.m. She stated that the PASRR for resident #3 was not completed. She said that her current process is to run a monthly audit. She said she had run the audit and knew that this resident's PASRR was missing. She said she contacted the PASRR coordinator for the state and he said he had the level 2 PASRR for this resident. She said she obtained this paperwork and scanned it into the clinical record. She said that the resident has been receiving services and this is ongoing. Review of the facility's PASRR policy, dated May 2021, revealed that the facility will ensure that each resident is properly screened using the State PASRR screening form. The policy included that the facility will refer to the State's PASRR policy.

Based on clinical record reviews, facility documentation, observations, staff interviews, and facility policies, the facility failed to ensure 2 residents (#24 and #19) received consistent showers and failed to ensure one resident (#548) received meal assistance. The sample size was 7 residents. The deficient practice could result in resident's needs not being met. Findings include: -Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan was initiated on January 14, 2021 that included the resident had an Activities of Daily Living (ADL) self care performance deficit related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention included to encourage the resident to participate to the fullest extent possible with each interaction. Review of the Certified Nursing Assistant (CNA) documentation for bathing from January through June, 2021 revealed the following: -In January 2021, the resident only received three sponge baths. -In February 2021, the resident only received a full bath once and two sponge baths. -In March 2021, the resident only received two full showers and 1 sponge bath. There was a gap between March 2 and March 31. -In April 2021, the resident only received two showers and two sponge baths. -In May 2021, the resident only received one sponge bath. -In June 2021, there were no showers or bed baths documented for the entire month. Review of the resident's clinical record and facility documentation did not reveal any additional documentation for showers provided or any notes indicating the resident was refusing showers or bed baths. The quarterly Minimum Data Set (MDS) Assessment, dated November 22, 2021 revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The assessment also included the resident required extensive assistance with personal hygiene and total dependence for bathing with the assistance of one staff member. An interview was conducted on February 2, 2022 at 1:14 pm with a CNA (staff #185) who stated showers and bed baths are provided per the bathing schedule and each resident is scheduled twice a week. Staff #185 stated showers and bed baths are documented in the shower task in the electronic clinical record and also on a paper shower sheet. Staff #185 stated if a resident is refusing showers, staff #185 will inform the nurse and ask the resident multiple times if they want to shower. Staff #185 stated all shower refusals would be documented in the shower task as well, and the nurse will write a note in the resident's chart. An interview was conducted with a Registered Nurse (RN/staff #191) on February 9, 2022 at 1:19 pm. She stated all of the residents have scheduled shower days and shower forms to be completed by the CNA when showers are provided. She stated if a resident is refusing showers, it would be documented in the progress notes as well as on the shower sheet. She stated she would let the Director of Nursing (DON) know if a resident was consistently refusing showers. She stated she did not know of any residents in the facility who refused showers regularly. An interview was conducted on February 9, 2022 at 1:45 pm with the DON (Staff #28). She stated all residents have scheduled shower days and the CNAs assist with showers. She stated if a resident is refusing showers, the nurse will talk with the resident and if the resident continues to refuse, the refusal is documented in the resident's record. Resident #24's record was reviewed with the DON at the time of the interview. She stated the documentation indicated resident #24 was not receiving regular showers and had not received a shower at all in the month of June 2021. -Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed the resident scored a 15 on BIMS indicating he was cognitively intact. The MDS indicated that he was totally dependent on staff for bathing with one-person physical assistance. The MDS identified that the resident had an impairment on one side for both lower and upper extremities. Review of the CNA documentation for bathing for January and February 2022 revealed no documentation that the resident received bathing from February 1-8 and January 26-31, 2022. Review of the resident's clinical record and facility documentation did not reveal any additional documentation for showers provided or any notes indicating the resident was refusing showers or bed baths. An interview was conducted with a CNA (staff #80) on February 9, 2022 at 8:23 a.m. The CNA stated that there is an assignment sheet that tells her which days and which shift residents are to receive bathing. She stated that if a resident refuses a shower, the nurse is notified and it is documented in the electronic clinical record and on the shower sheet. She stated that if she noticed a resident had not received a bath or shower in several days, she would notify the nurse. She reviewed this resident's shower documentation and said the resident had not had a shower this week. An interview was conducted with the resident on February 9, 2022 at 8:37 a.m. The resident stated that he did not receive any form of bathing this week. During an interview on February 9, 2022 at 8:37 a.m. with a Licensed Practical Nurse (LPN/staff #75), she stated if a CNA informed her that a resident was refusing a shower she would document this in the nursing notes and fill out a shower sheet showing the resident refused. She stated CNAs fill out the shower sheet logs and the nurse will check over it and sign off on the shower sheet. She stated that if she noticed a resident has not received bathing in several days that she would check the scheduled shower day for the resident, talk to the resident about it, and ask the CNA to work the resident into the schedule. An interview was conducted on February 9, 2022 with the DON (staff#28) at 1:44 p.m. She stated that the process for bathing is to offer residents showers twice a week and as needed. She stated that if a resident refused a shower a nurse would be notified and the nurse would encourage the resident and document this in the clinical record. She stated if a scheduled bathing day is missed a nurse will ask the resident once again and offer a shower another day. She reviewed the resident's record and said that the resident did not have a shower during a week in January and hasn't had one in February 2022 at all. The facility's ADL policy, reviewed May 2021, revealed a policy statement that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. The policy noted that if a resident is unable to carry out ADLs, the services will be provided by qualified staff. The policy included that bathing will be offered at least twice weekly and as needed per resident request and that ADL care provided will be documented in the clinical record accordingly. -Resident #548 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nutrition care plan, initiated January 28, 2022, revealed risk for malnutrition due to decreased appetite from COVID-19 and dysphagia. An intervention included to provide diet as ordered. The diet orders revealed that on January 28, 2022, the resident was to receive a regular diet, mechanical soft texture, with thin liquids consistency. This order was discontinued on February 3, 2022 and a new order for a regular diet, pureed texture, with thin liquids was started. Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 00 indicating the resident had severely impaired cognition. The MDS indicated the resident was on a mechanically altered diet and required supervision with meals with one-person assistance. The assessment indicated that the resident had held food in his mouth or cheeks after meals, had pain or difficulty with swallowing, and was at risk for coughing and choking during meals. On February 7, 2022 at 12:17 p.m., an observation was made of the resident's room during lunch time. The room was dimly lit and on the wall above the resident's head was a sign that read, 1:1 feeder indicating the resident required one on one meal assistance. Instruction on the sign said to ensure the resident was sitting upright, given small bites, reminded to drink small sips and use a straw, can have no citrus, required slow feeding alternating liquids and solids, and to provide a lot of encouragement to eat. The resident was seated at about a 45 degree angle, the food tray was placed near the resident without a straw, and staff was not present in the room during the meal. The resident had sampled the food and verbally indicated that he could not eat the meal. Facility staff did not assist the resident with his meal at any point during the observation. The resident was discharged from the facility on February 7, 2022 at around 7:00 p.m. An interview was conducted on February 9, 2022 at 11:45 a.m. with a CNA (staff #31). The staff member referred to residents in the facility who need assistance with dining as feeders. An interview was conducted on February 10, 2022 at 1:16 p.m. with a LPN (staff #90). She stated residents in her hall do need assistance with meals and that a CNA or a speech therapist will offer this assistance during meal times. She stated there is a board in the nurses station that is specifically for feeders. She stated the sign above the resident labeled feeder is something she would not typically see because she knows who the feeders are. She indicated speech therapy or other staff would post the sign for instructional purposes or at the family's request. An interview was conducted on February 10, 2022 at 1:28 p.m. with the DON (staff #28). She stated her expectation is that all of the residents who need assistance with dining receive that assistance. She stated that Restorative Nursing Assistants (RNA) can help the resident at meals or the CNA can assist as well. She stated she would not expect any of the staff in the facility to refer to residents as feeders. The facility's ADL policy, reviewed May 2021, revealed a policy statement that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. The policy noted that if a resident is unable to carry out ADLS, the services will be provided by qualified staff. This included services necessary to maintain good nutrition. The facility's meal assistance policy, revised October 2021, revealed that the policy of the facility is to ensure residents are provided with a well-balanced diet and are provided adequate nutrition. The procedure included to encourage residents to feed themselves, but if assistance is necessary, to provide this for the resident. The policy included to be alert to the dangers of choking while residents are eating.

Based on closed clinical record review, hospital documentation, staff interviews, and policy review, the facility failed to ensure the physician was notified timely regarding a change of condition for one resident (#374). Findings include: Resident #374 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record and hospital documentation revealed the resident was a status [REDACTED]. The documentation also noted that an MRI (Magnetic Resonance Imaging) of the brain was done, which showed no acute injury. Additional documentation included that the resident had a neck collar, with a torso stabilizer in place. Review of the resident's Advance Directive Statement dated May 1, 2014, revealed the resident was a full code. Physician admitting orders dated May 1, 2014 included the following: -may follow facility interim orders -[MEDICATION NAME] 10 milligrams (mg) two tablets by mouth every four hours as needed for pain of 6-10 -aspirin 81 mg one tablet by mouth daily for anticoagulation therapy -[MEDICATION NAME] (anti-platelet) 75 mg by mouth daily for [MEDICAL CONDITION]/cardiovascular accident A care plan for activity of daily living included a self care performance deficit related to limited mobility, musculoskeletal impairment, fatigue, impaired balance, pain, limited range of motion and external devices. One of the goals was to safely perform transfers. An intervention included to monitor/document/report to physician as needed, any changes or declines in function. A Nursing Progress Note dated May 12, 2014 at 3:40 p.m., included that during a transfer to bed, the resident leaned back and bumped her head against the wall and began crying. The note stated the licensed practical nurse (LPN/staff #1) examined the resident and no injury was found, and that a cool washcloth was applied to the resident's forehead. The note also documented that the resident seemed more upset about the incident than anything else and vital signs were taken and were within normal limits. Review of the Incident Report dated May 12, 2014, revealed that the resident was being transferred from the wheelchair to the bed, with the assistance of two certified nursing assistants (CNAs). The report noted that the resident did not assist with weight bearing and while sitting on the side of the bed, the resident began to lay back and bumped her head against the wall "lightly." The immediate action taken was that the resident was laid in bed, vital signs were taken, the resident's head was checked, and there were no bumps or blood noted. Per the report, the resident was "crying and seemed more anxious/scared from the incident than anything else." The resident's pain was noted as "hurts even more." The report further included the resident was oriented to person, place, time and situation. Continued review of the closed clinical record revealed there was no documented evidence that neuro checks were immediately implemented after the resident "bumped" her head on the wall and was crying, nor was there any documentation that the physician was notified. Per the Medication Administration Record [REDACTED] The next nursing assessment documentation of the resident's condition was at 5:54 p.m. on May 12, which was more than 2 hours after the resident had hit her head on the wall. The note included the resident was awake, was able to answer all questions, vitals were within normal limits, resident was no longer crying, and was medicated for pain per request. There was no further documentation that the resident was assessed and monitored from 6 p.m. on May 12, until 4:20 a.m. on May 13, approximately 10 hours. A nursing note dated May 13, 2014 at 4:20 a.m., by a LPN (staff #2) now documented that the resident was unresponsive to verbal and tactile stimuli and 911 was called. Per the note, the resident was sent to the emergency room and the nurse practitioner was notified. Review of the Hospital Emergency Department records dated May 13, 2014 at 4:27 a.m., revealed the resident scored a five on the initial Glasgow Coma Scale, which indicated no vocalization, abnormal flexion-decorticate, no eye opening, and profound obtundation/coma. The Chief Complaint was noted as altered level of consciousness in an otherwise healthy individual. The hospital nursing assessment noted that the resident was brought by EMS (emergency medical service) from a facility and was told by EMS that the resident had been dropped during a transfer and hit her head. The physical exam noted that the resident presents with a cervical collar in place and an apparatus on her chest to keep cervical collar in place, however, when she arrived her cervical collar was over her chin. The note included the resident will not open her eyes or respond to vocal or noxious stimuli, has decerebrate posturing on the left, moves away from noxious stimuli on the right and toes are downward bilaterally. Review of the Emergency Department Chart disposition dated May 13, 2014, revealed that the resident was transported to another hospital by air ambulance, with altered level of consciousness in otherwise healthy individual with systolic hypertension, decerebrate posturing on the left, and condition at the time of departure was critical. A hospital History and Physical dated May 13, 2014, included the resident had a right subdural bleed, massive with ventricular compression at the midline shift, most likely from a fall while she was at a rehabilitation facility. The resident was taken emergently to the operating room; neurosurgery did an evacuation of subdural hematoma, and resident was on a mechanical ventilator secondary to altered mental status and a large right subdural bleed. An interview was conducted on January 23, 2015, with a CNA involved in the incident. The CNA stated that she and another staff member were assisting the resident from her wheelchair to bed. The CNA said the resident was sitting on the edge of her bed and was holding the mobility bar with her right hand and let go, and fell backwards, bumping her head on the wall. She also stated that the resident was anxious and crying prior to being transferred to bed and cried harder, after bumping her head. An interview was conducted on January 26, 2015, with staff #2, who stated that a family member told her the resident was dropped during a transfer and hit her head on the wall earlier that day. She stated when she questioned staff #1 about the incident, staff #1 stated that the resident was being assisted to bed and fell back and hit her head, but was fine. She stated that her shift started at 6:00 p.m. and when her shift started, the resident was sleeping and a family member was at the bedside. She stated that she could not arouse the resident, so she did not want to give her any medications. Per staff #2, vital signs were within normal limits, but the resident was not acting right. She further stated that the physician was not notified until later that night after she called "911" (note: which was over 12 hours after the resident had hit her head). She stated that this resident did not wake up during her shift, and that she should have sent the resident out to the hospital at the beginning of her shift. An interview was conducted on January 26, 2015, with staff #1. Staff #1 stated that two CNA's reported to him that the resident had fallen back and bumped her head. He also stated that he did not start the resident on neuro checks, because she only bumped her head on the wall, and there was no bump on her head and no bleeding. He further stated that he reported this incident to the next nurse coming on shift, but not to the physician, and that he had medicated the resident with narcotic pain medication at the end of his shift. Review of the facility Interim Orders (preprinted with no date) revealed the following "...minor head injuries: Neuro checks immediately with alert and oriented (A&O) assessment. Start routine neuro checks, apply ice pack wrapped in towel for swelling or hematoma. If nausea, vomiting, or decreased alertness occurs send to emergency room (ER) and notify provider. Otherwise, monitor and notify provider in morning or routinely. The orders also noted to notify the provider "ASAP for; changes in mental status..." Review of the facility's policy on Change of Condition Reporting revealed "...It is the policy of this facility that all changes in resident condition will be communicated to the physician...Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician..."

Based on clinical record reviews, staff interviews, hospital documentation, and policy review, the facility failed to meet professional standards of quality, by failing to provide ongoing assessments and monitoring for one resident (#374) after bumping her head on the wall, and by failing to ensure that pre and post [MEDICAL TREATMENT] assessments were consistently completed for one resident (#21). Findings include: -Resident #374 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record and hospital documentation revealed the resident was a status [REDACTED]. The documentation also noted that an MRI (Magnetic Resonance Imaging) of the brain was done, which showed no acute injury. Additional documentation included that the resident had a neck collar, with a torso stabilizer in place. Review of the resident's Advance Directive Statement dated May 1, 2014, revealed the resident was a full code. A Fall Risk Evaluation dated May 1, 2014, identified that the resident was at risk for falls. A care plan dated May 1, 2014, included the resident was at risk for falls related to deconditioning, gait/balance problems, and incontinence. One of the goals was for the resident to not sustain serious injury. Physician admitting orders dated May 1, 2014 included the following: -may follow facility interim orders -[MEDICATION NAME] 10 milligrams (mg) two tablets by mouth every four hours as needed for pain of 6-10 -aspirin 81 mg one tablet by mouth daily for anticoagulation therapy -[MEDICATION NAME] (anti-platelet) 75 mg by mouth daily for [MEDICAL CONDITION]/cardiovascular accident A care plan for activity of daily living included a self care performance deficit related to limited mobility, musculoskeletal impairment, fatigue, impaired balance, pain, limited range of motion and external devices. One of the goals was to safely perform transfers. An intervention included to monitor/document/report to physician as needed, any changes or declines in function. Physical Therapy Progress notes included the resident presented with decreased strength and endurance, and postural instability. The resident was receiving training with bed mobility, transfers, lower extremity strengthening and endurance and gait and balance training. The notes further included the resident required maximum assistance of two staff members for transfers. Further review of the clinical record revealed a Neurological Record dated May 9, 2014, which revealed the resident's blood pressure was 84/52, was alert, pupils 0.4 millimeters (mm), opens eyes spontaneously, appropriately obeys commands, and has oriented speech. However, the clinical record did not reveal the reason why hourly neuro checks were started. A Nursing Progress Note dated May 12, 2014 at 3:40 p.m., included that during a transfer to bed, the resident leaned back and bumped her head against the wall and began crying. The note stated the licensed practical nurse (LPN/staff #1) examined the resident and no injury was found, and that a cool washcloth was applied to the resident's forehead. The note also documented that the resident seemed more upset about the incident than anything else and vital signs were taken and were within normal limits. Review of the Incident Report dated May 12, 2014, revealed that the resident was being transferred from the wheelchair to the bed, with the assistance of two certified nursing assistants (CNAs). The report noted that the resident did not assist with weight bearing and while sitting on the side of the bed, the resident began to lay back and bumped her head against the wall "lightly." The immediate action taken was that the resident was laid in bed, vital signs were taken, the resident's head was checked, and there were no bumps or blood noted. Per the report, the resident was "crying and seemed more anxious/scared from the incident than anything else." The resident's pain was noted as "hurts even more." The report further included that the resident was oriented to person, place, time and situation. Continued review of the closed clinical record revealed there was no documented evidence that neuro checks were immediately implemented after the resident "bumped" her head on the wall and was crying, nor was there any documentation that the physician was notified. Per the Medication Administration Record [REDACTED] The next nursing assessment documentation of the resident's condition was at 5:54 p.m. on May 12, which was more than 2 hours after the resident had hit her head on the wall. The note included the resident was awake, was able to answer all questions, vitals were within normal limits, resident was no longer crying, and was medicated for pain per request. There was no further documentation that the resident was assessed and monitored from 6 p.m. on May 12, until 4:20 a.m. on May 13, approximately 10 hours. A nursing note dated May 13, 2014 at 4:20 a.m., by a LPN (staff #2) now documented that the resident was unresponsive to verbal and tactile stimuli and 911 was called. Per the note, the resident was sent to the emergency room and the nurse practitioner was notified. Review of the Hospital Emergency Department records dated May 13, 2014 at 4:27 a.m., revealed the resident scored a five on the initial Glasgow Coma Scale, which indicated no vocalization, abnormal flexion-decorticate, no eye opening, and profound obtundation/coma. The Chief Complaint was noted as altered level of consciousness in an otherwise healthy individual. The hospital nursing assessment noted that the resident was brought by EMS (emergency medical service) from a facility and was told by EMS that the resident had been dropped during a transfer and hit her head. The physical exam noted that the resident presents with a cervical collar in place and an apparatus on her chest to keep cervical collar in place, however, when she arrived her cervical collar was over her chin. The note included the resident will not open her eyes or respond to vocal or noxious stimuli, has decerebrate posturing on the left, moves away from noxious stimuli on the right and toes are downward bilaterally. Review of the Emergency Department Chart disposition dated May 13, 2014, revealed that the resident was transported to another hospital by air ambulance, with altered level of consciousness in otherwise healthy individual with systolic hypertension, decerebrate posturing on the left, and condition at the time of departure was critical. A hospital History and Physical dated May 13, 2014, included the resident had a right subdural bleed, massive with ventricular compression at the midline shift, most likely from a fall while she was at a rehabilitation facility. The resident was taken emergently to the operating room; neurosurgery did an evacuation of subdural hematoma, and resident was on a mechanical ventilator secondary to altered mental status and a large right subdural bleed. Review of the Neurology Stroke Consultation Report dated May 14, 2014, revealed the resident was sent to the hospital emergency room , where a CT (computerized tomography) scan of the head showed a large right subdural hematoma with significant right-to-left shift. The resident had an emergent craniotomy, with decompression. A repeat postoperative CT scan showed that there was evidence of acute ischemia in the bilateral occipital lobes. She had an MRI of the brain, which showed acute ischemic stroke in bilateral occipital and parietal lobes, consistent with PCA (posterior cerebral artery) territory [MEDICAL CONDITION], as well as a small stroke in the right corona radiata and insula. The resident was on aspirin and [MEDICATION NAME] due to recent stenting at the time of her subdural hematoma. An interview was conducted on January 23, 2015, with a CNA involved in the incident. The CNA stated that she and another staff member were assisting the resident from her wheelchair to bed. The CNA said the resident was sitting on the edge of her bed and was holding the mobility bar with her right hand and let go, and fell backwards, bumping her head on the wall. She also stated that the resident was anxious and crying prior to being transferred to bed and cried harder after bumping her head. An interview was conducted on January 26, 2015, with staff #2, who stated that a family member told her the resident was dropped during a transfer and hit her head on the wall earlier that day. She stated when she questioned staff #1 about the incident, staff #1 stated that the resident was being assisted to bed and fell back and hit her head, but was fine. She stated that her shift started at 6:00 p.m. and when her shift started, the resident was sleeping and a family member was at the bedside. She stated that she could not arouse the resident, so she did not want to give her any medications. Per staff #2, vital signs were within normal limits, but the resident was not acting right. She further stated that the physician was not notified until later that night after she called "911" (note: which was over 12 hours after the resident had hit her head). She stated that this resident did not wake up during her shift, and that she should have sent the resident out to the hospital at the beginning of her shift. An interview was conducted on January 26, 2015, with staff #1. Staff #1 stated that two CNA's reported to him that the resident had fallen back and bumped her head. He also stated that he did not start the resident on neuro checks, because she only bumped her head on the wall, and there was no bump on her head and no bleeding. He further stated that he reported this incident to the next nurse coming on shift, but not to the physician, and that he had medicated the resident with narcotic pain medication at the end of his shift. Review of the facility Interim Orders (preprinted with no date) revealed the following "...minor head injuries: Neuro checks immediately with alert and oriented (A&O) assessment. Start routine neuro checks, apply ice pack wrapped in towel for swelling or hematoma. If nausea, vomiting, or decreased alertness occurs send to emergency room (ER) and notify provider. Otherwise, monitor and notify provider in morning or routinely. The orders also noted to notify the provider "ASAP for; changes in mental status..." Review of the facility's policy on Change of Condition Reporting revealed "...It is the policy of this facility that all changes in resident condition will be communicated to the physician...Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician..." The policy also included that residents with acute medical changes (and some routine changes) will have progress and needs clearly communicated each shift for at least 72 hrs or until condition has stabled. Review of the facility's policy on Head Trauma revealed "...It is the policy of this facility to determine degree of injury so that proper care can be rendered in a timely manner." The policy included to observed for bleeding, [MEDICAL CONDITION] activity, loss of consciousness or amnesia, observe for double vision, crossing of the eyes, pupils for equality and reaction to light, and dizziness. The policy also included to observe for nausea, vomiting and anorexia associated with lethargy, which are early symptoms of rising intracranial pressure and to evaluate for headaches even in minor trauma, take vital signs, and observe for any behavioral changes. In addition, the policy stated to "evaluate mental status; alert, confused, disoriented, etc...Do not allow alcohol, cigarettes, or drugs of any kind..." -Resident #21 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the physician's orders for December 2014 revealed for [MEDICAL TREATMENT] three times a week. The orders also included to monitor the AV site every shift for bruit and thrill and to notify the physician if not present. Clinical record documentation included the resident had a left femoral AV graft site, which was used for [MEDICAL TREATMENT] treatments. Further review of the clinical record revealed that for December 2014 and for January 2015, there was inconsistent documentation that pre and post [MEDICAL TREATMENT] assessments were completed. An interview was conducted with a LPN on the 600 Unit, who explained that prior to [MEDICAL TREATMENT] she assesses the catheter to make sure it is intact and that there is no swelling or oozing around the catheter site. The LPN stated that vital signs would also be done. She further stated that when a resident returns from [MEDICAL TREATMENT], she would do the same assessment and would recheck in about 2 hours to make sure there was no oozing at the catheter site. On January 27, 2015, an interview was conducted with the Director of Nursing (DON). The DON stated that pre and post [MEDICAL TREATMENT] assessments should be done if the doctor orders it. Review of the facility policy and procedure for [MEDICAL TREATMENT] (Renal), Pre and Post Care revealed to "assess resident's blood pressure (in non-shunt arm) prior to being transported...any staff concerns about resident's condition that may influence the [MEDICAL TREATMENT] treatment should be addressed prior to leaving skilled facility as the resident may need to be assessed in an emergency room ." Regarding Post [MEDICAL TREATMENT] Care the policy included the [MEDICAL TREATMENT] "should be assessed upon return to the facility for patency, and any unusual redness or swelling...bandages should remain in place for at least four hours after treatment, longer if needle site continue to ooze...any problems with a resident's access should be addressed IMMEDIATELY. Excessive bleeding from graft site, redness, swelling, pain, or a non-functioning graft requires medical attention."