Every finding on record at Bethany Life

Based on policy, clinical record, and staff interview reviews, the facility failed to complete and document post-accident follow-up assessments after the initial evaluation for 2 of 3 sampled residents (Residents #3 and #5). The resident census was 111. Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented diagnoses of non-Alzheimer's Dementia (brain decline), Parkinson's disease (neurological movement disorder), and depression (mood disorder). Resident #3's MDS showed a Brief Interview for Mental Status (BIMS) score of 5, indicating severely cognitively impaired cognition. Resident #3's Incident Report dated 7/1/26 at 1:45 PM reflected the staff observed Resident #3 lying on the floor in their room on their right side with their head toward the closet door and feet extended toward the dresser. When asked what happened, Resident #3 stated, they were trying to fix the floor as it was broken. When a Registered Nurse (RN) attempted to assess Resident #3, they kicked, hit, and refused vital signs. Staff assisted Resident #3 off the floor into the wheelchair. Staff completed a head-to-toe assessment, observed no new skin issues, and moved Resident #3 to the living room. Resident #3's progress notes lacked fall follow-up assessments and documentation after their fall on 7/1/26. The Incident Report dated 7/12/26 at 12:39 PM indicated Resident #3 lowered themself out of the wheelchair. Staff assisted Resident #3 back into the wheelchair, noting no injury. Resident #3's progress notes lacked documentation regarding Resident #3's fall on 7/12/26 and follow-up assessments. The Incident Report dated 8/7/26 at 3:43 PM identified Resident #3 leaned over and fell out of the recliner at the dining room table. Two Certified Nursing Assistants (CNA) assisted Resident #3 to a seated position in the wheelchair, and staff assessed them. Resident #3's progress notes lacked documentation regarding the fall on 8/7/26 and follow-up assessments. 2. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented diagnoses of bipolar disorder (mood swings), hypertension (high blood pressure), and anemia (low red blood cells). Resident #5's MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #5's Incident report dated 7/14/26 at 6:43 AM reflected the staff called an RN to Resident #5's room while they prepared for a shower. Resident #5 sat on the shower chair with a slight skin tear (skin rip) to their left lateral shin (outer lower leg). Staff stated the shower chair moved backward during transfer as Resident #5 sat, requiring staff to hold them from falling. Resident #5 scraped their shin on the chair and stated they hit the back of their head on the chair. Resident #5's progress notes lacked follow-up assessments. On 8/12/26 at 12:24 PM, the Director of Nursing (DON) stated during an interview they expected nurses to document fall follow-up in the progress notes for 72 hours. On 8/12/26 at 1:15 PM, the Administrator and Assistant Director of Nursing (ADON) acknowledged they couldn't locate fall follow-up documentation in progress notes or Medication Administration Records (MAR). The Administrator stated they recognized the facility had fall documentation problems and they were working on processes to implement Performance Improvement Plan (PIP) teams. The Resident Fall Protocol policy dated 7/8/26 instructed staff to promote resident safety by providing a standardized approach for fall prevention, assessment, and management. The protocol ensured timely response to falls, appropriate medical evaluation, accurate documentation, and implementation of interventions reducing future fall risks. It supported staff accountability, consistent care team communication, and the overall goal maintaining each resident's health, mobility, and quality of life. The policy defined a resident fall as any change in elevation or plane. All falls, whether witnessed or unwitnessed, required completion of a Risk Management report and notification of the following individuals:PhysicianFamily/Responsible PartyNurse ManagerAll falls required a fall follow-up assessment. For every fall, staff must:Follow the facility's Fall ProtocolImplement interventions ensuring resident safetyPerform neurological checks as indicatedThe policy instructed staff to notify the Nurse Manager immediately if uncertainty existed regarding classifying an incident as a fall.

Based on clinical record reviews, staff interviews, resident interview and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 2 of 4 residents reviewed (Resident #12 and #50). 1. A - On 11/21/25 Resident #12 received a second degree burn from a hot pack which took almost 2 months to heal. 1. B - Resident #12 had an intercepted fall on 1/3/26 which resulted in a left foot injury. 2. On 2/11/26 Resident #50 had a fall due to a staff member letting go of the gait belt. The facility reported a census of 102 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #12 dated 10/22/25 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS identified Resident #12 required substantial/maximal assistance with bed mobility and was dependent on staff for all transfers. The MDS documented ambulation did not occur. The MDS included diagnoses of moderate persistent asthma, COPD (chronic obstructive pulmonary disease) (a progressive, incurable lung disease that restricts airflow), spinal enthesopathy of thoracic and cervical region (painful condition involving inflammation or degeneration), congestive heart failure (heart cannot pump blood efficiently causing fluid buildup), major depressive disorder and anxiety.The Care Plan revised 2/26/24 revealed Resident #12 required staff assistance with mobility in her wheelchair and required assistance of one staff member with a sit to stand transfer aid for transfers. In addition, the Care Plan documented Resident #12 as a risk for falls related to previous neck trauma. A. The November 2025 Treatment Administration Record (TAR) included a Physician order dated 7/23/25 for a heating pack to abdomen for 20 minutes one time a day for abdominal discomfort. The order reflected hold dates from 11/21/25 to 11/26/25 and then discontinued on 11/26/25. Review of the November TAR revealed Staff D, Registered Nurse (RN), signed off the heating pack on the evening of 11/20/25 indicating Resident #12 received the heating pack. An Incident Report (IR) title New Skin Issue dated 11/21/25 at 9:20 AM documented Staff C, Licensed Practical Nurse (LPN), went into Resident #12 bathroom, where she sat on the toilet, to reinforce her colostomy appliance, when she noticed a large blister on the lower left quadrant of her abdomen. Resident #12 said it didn't hurt and she didn't know she had a blister there. Resident #12 stated she received a hot pack yesterday afternoon on the same spot and suspected it was from that. When asked who gave her the hot pack, Resident #12 refused to discuss. The facility education form dated 11/25/25 documented Staff D received education on heating devices. The form instructed the nurse could only apply the heating devices and they could only use the heating devices provided from the facility. Residents should not use heating devices from outside the facility and they must have an order obtained for any heating device used. In addition, there should be a barrier over the heating device when applied. The Skin and Wound form dated 11/21/25 revealed a blister to the left lower abdomen that measured 5.2 centimeters (cm) (length) x 2.2 cm (width). The Progress Note dated 11/21/25 at 11:55 AM documented the on-call Physician ordered to hold the hot pack and monitor the blister, leave uncovered and call back to get treatment orders when ruptured. The Progress Note dated 11/26/25 at 2:49 PM documented Resident #12 received education about using a protective covering with her heat packs. Resident #12 verbalized understanding. The Skin and Wound form dated 12/2/25 revealed the blister to the left lower abdomen deteriorated and measured 3.7 cm (length) and 2.6 cm (width). The form lacked documentation of wound characteristics. The wound image revealed the wound bed with 50% dark brown eschar (nonviable tissue) and surrounding skin red in color.The facility fax form dated 12/2/26 revealed Resident #12 blister popped and measured 3-inches. The Physician ordered antibiotic ointment and to cover with nonadherent dressing. The December 2025 TAR listed a Physician order dated 12/3/26 to apply triple antibiotic ointment to the ruptured blister on Resident #12's abdomen and cover with non-adherent dressing one time a day for a ruptured blister.An Outside Provider form titled Wound Treatment Plan dated for 12/27/26 documented they saw Resident #12 to assess the area of concern to the abdomen. Resident #12 used a microwave heating pad and developed a serous blister to the site that ruptured. The skin inspection documented a 2nd degree thermal burn to the left side of the abdomen that measured 3.0 cm x 2.5 cm x 0.1 cm with 100% biofilm (a community of microorganisms, such as bacteria, fungi, or algae, that attach to surfaces and become embedded within a self-produced extracellular polymeric substance (EPS) matrix. This matrix provides protection against external threats, such as antibiotics and the host's immune system, and allows the microorganisms to thrive in a structured community, often described metaphorically as cities for microbes.) with small amount of serous drainage (thin, watery, clear to yellow fluid). New orders received to discontinue current treatment and start the following: cleanse wound with normal saline, apply Santyl (prescription medication used for the debridement (removal) of dead tissue) to wound bed, cover with xeroform gauze (petrolatum impregnated gauze), cover with a border gauze, change daily and as needed. An Outside Provider form titled Wound Treatment Plan dated for 12/31/25 documented skin inspection of the 2nd degree thermal burn on the left side of abdomen measured 2.2 cm x 1.2 cm x 0.1 cm with improving tissue, 100% red granulation (new, vascular connective tissue during the healing process) with small amount of thin serous drainage. The wound treatment plan instructed to continue with current treatment orders. An Outside Provider form titled Wound Treatment Plan dated for 1/14/26 documented the 2nd degree thermal burn to the left side of the abdomen as healed. New order received to discontinue the current treatment. On 3/3/26 at 11:04 AM, Staff D reported Resident #12 had on her treatment plan to have a hot pack on her abdomen. She said sometimes Resident #12 would want it and sometimes she did not. She said on the night of 11/20/25, she changed Resident #12's colostomy bag around 10 PM. She said there was no redness or blisters on her abdomen at that time. She said she did not give her a hot pack that night. She said she was in the wrong for marking on the TAR that she had given one to her. She said a Certified Nursing Assistant (CNA) could have given her a hot pack after she had changed the colostomy bag. She said the facility had small hot packs that were chemical packets that you squeeze to get warm. She said usually the staff would wrap the hot pack in a towel. She said there have been a couple of times, Resident #12 asked for it not to be wrapped or she would unwrap it herself. She said the CNAs would take Resident #12 a hot pack when she asked for it. On 3/3/26 at 11:49 AM, Staff C reported Resident #12 had a big bubble on her abdomen. She said it was quite large, bigger than a quarter and was in a bad spot on her waist band. She said Resident #12 did not know she had a blister there until she went to the bathroom and she didn't voice any pain. She said Resident #12 reported she had a hot pack the evening prior on 3-11 shift and the staff identified the blister that morning. On 3/3/25 at 11:20 AM, Staff B, MDS Coordinator, and the Assistant Director of Nursing (ADON) reported Resident #12 ordered items from Amazon and other outside stores. She said Resident #12 ordered her own beaded/microwavable hot pack and had a staff member warm it up for her. She said Resident #12 did not use the hot pack the facility supplied. The ADON reported Resident #12 would not say who warmed up the hot pack for her. The ADON reported they removed the beaded hot pack from Resident #12's room when they identified the blister. She said outside hot packs are not allowed. She said the facility did not have a policy or protocol for hot packs. On 3/3/26 at 1:20 PM, Resident #12 said she didn't know for sure what caused the blister on her abdomen but guessed it was from the heating pack. She said she ordered her own microwavable heating pack from Amazon. She said a CNA heated the pack up for her. She reported she did not remember the CNA. She said they had the heating pack wrapped up in a towel. She reported Staff B had the heating pack. She said she made arrangements with the previous Director of Nursing (DON) not to use it again. She said she used her own heating pack a couple of times. B. An IR titled Witnessed Fall dated 1/3/26 at 5:30 AM prepared by the previous DON documented Staff E, RN, reported he heard Resident #12 yelling for help. When he came in the room, Resident #12 had her torso on the bed and her bottom off the bed. Staff E reported he intercepted Resident #12 and helped her slide back into bed. Staff E reported Resident #12 tried to go to the bathroom and transferred herself. The IR indicated the facility notified the Physician of the intercepted fall on 1/6/26 and the responsible party on 1/7/26. Review of the Clinical Record lacked documentation of the fall, follow up fall assessments, vital signs, and a fall intervention. The Progress Note on 1/6/26 at 2:25 PM documented Resident #12 complained of left foot pain. The facility notified the Physician was notified and received a new order for an x-ray. They scheduled the x-ray for 1/7/26 due to pain and impaired mobility. The progress note lacked documentation regarding an assessment of the foot. The X-ray report dated 1/7/26 documented the following impression:i. No acute osseous findings. ii. Mild degenerative changes in the interphalangeal jointsiii. Small plantar calcaneal spurThe Progress Note dated 1/8/26 documented x-ray results printed and faxed to the Physician for review. The Clinic Visit Information and Order Sheet dated 1/29/26 documented Resident #12 went to a Physician appointment and complained of foot pain. The order sheet documented they completed a foot x-ray and gave a new order for a referral to Podiatry. The Clinic Visit Information and Order sheet dated 2/4/26 documented Resident #12 went to Podiatry due to a left foot injury. The summary documented the Physician suspected a tendon rupture or tear and would get an MRI (magnetic resonance imaging) to evaluate. They gave new orders for Resident #12 to wear an ace wrap or compression sock on the left foot. The form documented the MRI scheduled for 2/10/26 at 3:00 PM. Resident #12's February 2026 TAR included a Physician order for ace wrap or compression stock to the left foot one time a day until 2/11/26. Staff B, MDS Coordinator, obtained the MRI results on 3/3/26 at 1:13 PM. The MRI documented a comparison x-ray of the left foot on 1/29/26. The impression of the MRI showed the following:i. Mild partial-thickness partial width tear of the distal Achilles involving the deep fibers at the calcaneal insertion. ii. Old full-thickness tear of the anterior talofibular ligament.iii. Moderate full thickness cartilage loss of the posterior tibiotalar joint.iv. Unremarkable peroneal tendons without tear or subluxation. Electronic conversations between Resident #12 and the Podiatrist dated 2/10/26 and 2/11/26 revealed the results of the MRI showed some mild partial tearing of the Achilles tendon. The Podiatrist documented icing, elevation and compression were very important. The Podiatrist documented if Resident #12's swelling improved; she did not have to wear the ace wrap. He said rest and ice would help her overall pain. The Clinical Record lacked documentation Resident #12 went to the MRI on 2/10/26 and lacked follow up or communication with the Physician regarding the MRI results and lacked documentation of any new assessments/interventions related to the partial tear in the Achilles tendon. On 3/4/26 at 7:45 AM, Resident #12 reported when the nurse got her off the floor, she heard a pop in her left foot. She said a couple weeks later her foot still bothered her so she had an MRI completed. She reported the doctor did not think it was necessary to wear the ace wrap all the time. She said the discomfort in her left foot had improved. On 3/4/26 at 10:45 AM, Staff B acknowledged the facility failed to obtain the MRI results. She said Resident #12 made her own appointments and got her own results. She said Resident #12 usually told them if something needed done. On 3/4/26 at 12:34 PM, Staff B reported on 1/3/26 Resident #12 had an intercepted. She said the previous DON had to call Staff E to get information to complete the incident report. She said the previous DON provided education to the nurse regarding what was considered to be a fall. She said she thought the intercepted fall happened on a Saturday. She said the x-ray happened the following week and she would obtain the x-ray results.On 3/4/26 at 2:00 PM, the Administrator reported she expected the nurse to document a fall in the medical record. In addition, she expected the staff to follow up on the diagnostic results, communicate with the Physician, and document the results/notifications in the medical records.On 3/4/26 at 4:05 PM, the Administrator reported she did not have a policy regarding Physician notification/communication.On 3/4/26 at 6:46 PM, the Administrator verified Resident #12 fell on the night of 1/3/26. She reported the nurse who assisted Resident #12 during the incident did not consider the event a fall as the resident was still halfway in her bed and he simply assisted her back into the bed. The Administrator reported Administration found out about the incident the following week on Tuesday when Resident #12 brought up that her foot was sore. The Administrator reported she believed on 1/6/26 when they notified the Physician and notified the family on 1/7/25.In addition, the Administrator reported the facility did not have a specific supervision policy regarding falls.On 3/5/26 at 8:30 AM, Resident #12 verified the nurse who picked her up off the floor was Staff E when she heard the pop in her left foot.The facility policy titled Falls reviewed 2/3/26 documented the purpose of the policy as to ensure an environment that decreases the risk of residents falls while promoting resident independence. The policy documented defined a fall as any unintentional loss of elevation in any plane. The policy directed staff to document the fall in risk management on the electronic health record and follow prompted assessment as necessary. In addition, the policy directed staff to initiate 72-hour documentation. 2. The Minimum Data Set (MDS) assessment for Resident #50 dated 12/31/25 identified a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS identified Resident #50 required substantial/maximal assistance with bed mobility, ambulation. The MDS listed Resident #50 as dependent on staff for all transfers. The MDS included diagnoses of hypertension (high blood pressure), history of traumatic brain injury, and mood disorder. The MDS documented Resident #50 had one fall with no injury since last assessment. The Care Plan initiated 6/29/23 documented Resident #50 as a risk for falls related to gait/balance problems and weakness of the lower extremities. The Care Plan directed staff to provide assistance of one with 4WW (four wheeled walker) with transfers and ambulation. The Care Plan directed staff to use a gait belt according to facility policy. An IR titled Witness Fall dated 2/11/26 at 10:40 AM documented the Certified Nurse Aide (CNA) summoned the nurse to the room and observed Resident #50 on the floor in the bathroom lying on her left side with her knee bent facing the bathroom door. Her walker sat on the outside of the bathroom with a wheelchair beside it. Resident #50 reported she lost her balance. The IR listed the Intervention as a transfer audit. A Hand Written Statement dated 2/11/26 signed by Staff F, CNA, revealed Staff F assisted Resident #50 off the toilet and he thought he was walking Resident #50 to the wheelchair but Resident #50 wanted to go to the recliner. Staff F tried to move the wheelchair while still having a hold of the gait belt but couldn't. Staff F briefly let go of the gait belt to move the wheelchair and at that time Resident #50 fell backwards. On 3/4/26 at 8:58 AM, Staff G, RN reported she went into Resident #50's room and Staff F was in the room. She said as Staff F walked Resident #50 out of the bathroom and her wheelchair was in the way. She said as Staff F went to move the wheelchair, Resident #50 lost her balance and fell. She said there were no injuries. She said the fall was witnessed and Resident #50 did not hit her head. She said they implemented the intervention to complete transfer audits with Staff F to make sure surroundings were clear before walking. On 3/4/26 at 9:14 AM, Staff F reported he helped Resident #50 off the toilet. He said he did not know who put her on the toilet. He said she had her wheelchair already set up and he thought that was where she was going. He said he was helping her walk to the wheelchair and Resident #50 decided she wanted to go to the recliner. He said he tried to move the wheelchair without letting go of Resident #50, but he could not. He said he let go of Resident #50 for a few seconds to move the wheelchair and she fell backwards. He said if he would have known she wasn't going to go to the wheelchair he would have moved it. He said he was using a gait belt. He said Resident #50 did not get hurt. Staff F said he knew Resident #50 needed the assistance of one and he should not have let go of her. On 3/4/26 at 2:00 PM, the Administrator reported she expected the staff to call for help or walk to a safe place and not take their hands off the gait belt.

Based on clinical record review and staff interviews, the facility failed to notify the Long-Term Care Ombudsman of discharge and/or transfer of residents as required for 3 of 3 residents reviewed (Residents #108, #10 and #106). The facility reported a census of 102 residents.Findings include:1. Resident #108's Minimum Data Set (MDS) assessment dated [DATE] indicated they discharged without a anticipate return on 1/20/26.Resident #108's clinical census listed a discharge on [DATE]. The clinical record lacked documentation of notification to the Long-Term Care (LTC) Ombudsman of Resident #108's discharge from the facility in January 2026 as required by federal regulation. 2. Review of the facility EHR for clinical MDS tracking revealed Resident #10 discharged from the facility on 12/27/25 with a return anticipated.Resident #10's Clinical Census reviewed 3/4/26 listed Resident #10 discharged on 12/27/25 from 12/29/25 under an unpaid hospital leave. The clinical record lacked documentation of notification to the LTC Ombudsman of Resident #10's discharge and transfer from the facility in December of 2025. 3. Review of the facility EHR for clinical MDS tracking on 3/4/26 indicated Resident #106 discharged from the facility on 1/3/26 with a return anticipated.Resident #106's Clinical Census reviewed 3/4/26 reflected they had a hospital paid leave status from 1/3/26 until 1/7/26 and 1/13/26. On 1/14/26, Resident #106 discharged from the facility. The clinical record lacked documentation of notification to the LTC Ombudsman of Resident #106's discharge and transfer from the facility in January of 2026 on the 2 occasions. During an interview on 3/4/26 at 8:45 AM, Staff H, Support Services, stated she sends the Ombudsman notification list monthly to the LTC Ombudsman, she prints the list from the facility's computer software program. Staff H acknowledged the list sent to the Ombudsman in December of 2025 and January of 2026 for discharges and transfers didn't include Residents #108, #10, and #106. During an interview on 3/4/26 at 8:55 AM, the Administrator acknowledge the notification list sent to the LTC Ombudsman in December of 2025 and in January of 2026 related to the resident's discharges and transfers didn't include Residents #108, #10, and #106. The Administrator stated they expected the Ombudsman notification report to include all discharges and transfers and sent to the LTC Ombudsman. The Administrator stated the facility didn't have a policy on notification to the LTC Ombudsman.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Residents #102) for a medication error. Resident #102 received medications that were not prescribed to him. The medications were prescribed to Resident #63 who lived across the hallway. The facility reported a census of 102 residents.Findings include: Resident #102's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 07, indicating moderately impaired cognition. The MDS identified Resident #102 required partial/moderate assistance with transfers. The MDS included diagnoses of anemia, hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and cerebral infarction (stroke). An Incident Report (IR) titled Medication Error dated 1/11/26 at 8:20 PM, documented Staff A, Registered Nurse (RN) was passing medications to multiple residents. The IR documented Staff A sat another resident medication behind Resident #102's television. Staff A had Resident #102's medication in hand and reached to grab the water pitcher from the nightstand. Resident #102 quickly grabbed the other resident's medications and put them in his mouth. Staff A had Resident #102 spit out the medications back into the medication cup. Resident #102 was able to spit out all the medications except for two pills which were assumed that he had swallowed. Resident #102's mouth was rinsed out with water, and he was unable to spit up any more medications. Staff A called on the call provider with no new orders. The IR report documented the two medications Resident #102 swallowed were carbidopa/levodopa extended release (ER) 25-100 mg (milligrams) (used to treat the symptoms of Parkinson's disease) and melatonin 5 mg tablet (non-habit-forming sleep aid). The facility form titled Verbal Coaching completed by the Director of Nursing (DON) on 1/15/26 documented she contacted Staff A on 1/12/26 via text and a phone call to explain why coaching was needed and the expectation of supervision at all times with medications. On 3/4/26 at 2:39 PM, Staff A reported on the evening of 1/11/26 she was running around trying to get the medications passed. She said she prepared 2 resident medications at the same time (Resident #102 and Resident #63). She said Resident #63 lived across the hallway from Resident #102. She said she was going to run in and give Resident #102 his medications and then go to Resident #63's room. She said it was not common for her to prepare 2 resident's medications at the same time. She said she was running behind. She said it was not something she liked to do and was trying to give the medications as close to on time as possible. She said she entered Resident #102's room with 2 medication cups. She said she sat Resident #63's medication cup behind Resident #102's TV. She said she did not think Resident #102 saw the medication cup or knew about it. She said as she went to reach for Resident #102's water pitcher, she saw him stand up and grabbed Resident #63's medications and put them in his mouth. She said she had Resident #102 spit the medications out right away. She said she didn't remember which medications Resident #102 swallowed but thought one was melatonin. She said she called the on-call provider and told him what had happened. She said the Physician did not voice any concerns or give any new orders. She said about a week later the DON texted her and said she was going to have to write up a verbal coaching regarding visualizing medications at all times. She said she did not see the verbal coaching and did not sign anything. On 3/4/27 at 4:30 PM, Staff B, MDS Coordinator, said she expected staff to prepare and pass medication to one person at a time and have eyesight on the medications.The facility policy titled Process: Medication Administration reviewed 10/15/25 documented accepted professional standards for drug administration included: right drug, right patient, right time, right dose, and right route. The facility policy titled Process: Medication Error reviewed 10/9/25 documented the purpose of the policy was to ensure quality assurance, to ensure that residents are receiving the medications as prescribed by a medical provider. The policy directed that all medications would be administered following the right of medication management. The 5 rights of Medication Management include the right medication, right dose, right resident, right route and right time.

Based on observation, interviews and policy review, the facility failed to change tubing hooked to a nebulizer (medical device that converts liquid medication into a fine mist to treat respiratory conditions) for 1 of 1 residents reviewed (Resident #12). The facility reported a census of 102 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #12 dated 1/14/26 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of moderate persistent asthma and COPD (chronic obstructive pulmonary disease) (a progressive, incurable lung disease that restricts airflow). The Care Plan initiated on 10/7/23 revealed Resident #12 has asthma related to COPD and used scheduled and as needed nebulizer and inhalers. The care plan directed staff to clean the nebulizer every night per facility cleaning protocol but did not address how often to change the nebulizer tubing and mask. The following Physician Orders pertain to nebulizer treatments for Resident #12:-Written on 11/26/25- Budesonide Inhalation (a steroid used for maintenance treatment of asthma) 0.5 mg(milligrams)/2 ml (milliliters) 1 vial BID (twice a day) for COPD.-Written on 11/26/25- Preformist Inhalation (used to control COPD symptoms) nebulization Solution 20 mcg/ml 1 vial orally via nebulizer BID for COPD.-Written on 11/26/25- Albuterol Sulfate Inhalation Nebulization solution 0/084% 1 vial inhale every 4 hours as needed for wheezing. On 3/2/26 at 2:16 PM, observed nebulizer tubing dated 12/17/25 attached to Resident #12's nebulizer machine.On 3/3/26 at 1:20 PM, witnessed nebulizer tubing dated for 12/17/25 attached to Resident #12's nebulizer machine. Directions for changing the nebulizer mask or tubing could not be located in the Physician orders or on the TAR (Treatment Administration Record). On 3/3/27 at 3:01 PM, the Assistant Director of Nursing (ADON) acknowledged no one changed the nebulizer tubing and mask since 12/17/25. She reported she expected the staff to change the nebulizer tubing and mask every two weeks. She said the clinical coordinator was responsible for changing the mask and tubing. On 3/4/26 at 9:56 AM, the Administrator reported they completed an audit on the residents that used nebulizers and identified the facility had a gap. The Administrator reported they changed all tubing out as of yesterday (3/3) and a put a process in place.The facility policy titled Nebulizer Disinfecting/Cleaning Process approved on 3/3/26 directed staff to change the nebulizer mask and tubing every 2 weeks and mark the tubing with an orange sticker with the date the tubing was changed, time it was changed and who it was changed by. In addition, the nebulizer mask to be dated with a permanent marker.

Based on clinical record review, and staff interviews, the facility failed to notify the Primary Care Physician of a fall in a timely manner, failed to follow up and obtain MRI (magnetic resonance imaging) results and communicate with the Physician who ordered the MRI for further orders/direction for 1 of 21 residents (Resident #12) reviewed. The facility reported a census of 102 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #12 dated 10/22/25 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS identified Resident #12 required substantial/maximal assistance with bed mobility and was dependent on staff for all transfers. The MDS documented ambulation did not occur. The MDS included diagnoses of moderate persistent asthma, COPD (chronic obstructive pulmonary disease) (a progressive, incurable lung disease that restricts airflow), spinal enthesopathy of thoracic and cervical region (painful condition involving inflammation or degeneration), congestive heart failure (heart cannot pump blood efficiently causing fluid buildup), major depressive disorder and anxiety.An Incident Report (IR) titled Witnessed Fall dated 1/3/26 at 5:30 AM prepared by the previous Director of Nursing (DON) documented Staff E, Registered Nurse (RN), reported he heard Resident #12 yelling for help. When he came in the room, Resident #12 had her torso on the bed and her bottom off the bed. Staff E reported he intercepted Resident #12 and helped slide her back into bed. Staff E reported Resident #12 tried to go to the bathroom and was transferring herself. The IR indicated the facility notified the Physician of the intercepted fall on 1/6/26, 3 days after the incident. The Clinic Visit Information and Order sheet dated 2/4/26 documented Resident #12 went to Podiatry due to a left foot injury. The summary documented the Physician suspected a tendon rupture or tear and would get an MRI (magnetic resonance imaging) to evaluate. The form documented Resident #12 had an MRI scheduled for 2/10/26 at 3 PM. Staff B, MDS Coordinator, obtained the MRI results on 3/3/26 at 1:13 PM.The impression of the MRI showed the following:Mild partial-thickness partial width tear of the distal Achilles involving the deep fibers at the calcaneal insertion. Old full-thickness tear of the anterior talofibular ligament.Moderate full thickness cartilage loss of the posterior tibiotalar joint.Unremarkable peroneal tendons without tear or subluxation.The Clinical Record lacked documentation Resident #12 went to the MRI on 2/10/26 and lacked follow up or communication with the Physician regarding the MRI results. On 3/4/26 at 10:45 AM, Staff B acknowledged the facility failed to obtain the MRI results. She said Resident #12 made her own appointments and got her own results. She said Resident #12 usually told them if something needed done.On 3/4/26 at 6:46 PM, the Administrator verified Resident #12 fell on the night of 1/3/26. She reported the nurse who assisted Resident #12 during the incident did not consider the event a fall as the resident was still halfway in her bed and he simply assisted her back into the bed. The Administrator reported Administration found out about the incident the week before on Tuesday when Resident #12 brought up that her foot was sore. The Administrator reported she believed this was on 1/6/26 when the notified the Physician. On 3/4/26 at 4:05 PM, the Administrator reported she did not have a policy regarding Physician notification/communication.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's surveys within the last year, and staff interview, the facility failed to correct their own deficiencies for 1 of 1 area of concern. The facility reported a census of 102 residents. Findings include:The facility had the following concern identified at the current recertification survey that had been cited during a complaint survey in November of 2025 and during a complaint survey in December of 2025:Medication ErrorThe facility's Quality Assurance and Performance Improvement (QAPI) policy, dated 10/15/25, documented it is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The QAA Committee shall be interdisciplinary and shall develop and implement appropriate plans of action to correct identified quality deficiencies. The QAPI plan will address the following elements:Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.Policies and procedures for feedback, data collection systems, and monitoring.Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following:Tracking and measuring performance.Establishing goals and thresholds for performance improvements.Identifying and prioritizing quality deficiencies.Systematically analyzing underlying causes of systemic quality deficiencies.Developing and implementing corrective action or performance improvement activities. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.During an interview on 3/5/26 at 9:56 AM, the Director of Nursing (DON), stated the facility worked on medication errors and addressed it in their QAPI meetings. The DON stated the facility had more work to do in regard to medication errors and acknowledged the facility had repeat concerns with medication errors in prior complaints completed in November 2025, December of 2025, and on the current survey.

Based on the Resident's Rights policy/procedure, facility incident report, resident, and staff interview the facility failed to treat a resident with respect and dignity in a manner that promoted maintenance or enhancement of his or her quality of life for 1 out of 3 residents reviewed (Resident #1). On 1/18/26 at 2:00 AM, Resident #1 requested not to be checked and changed when Staff A, Certified Nursing Assistant (CNA), came into their room. Staff A, did not grant this request and proceeded to check Resident #1 against their wishes. Staff A put their hand in between Resident #1's thighs to check to see if they soiled their brief. Following the situation, Resident #1 became fearful of Staff A, and caused Resident #1 to have trouble sleeping during the night. The facility corrected the concern on 1/30/26 prior to the start of the survey by completing the following:1/29/26: Suspended the staff involved in the situation.1/30/26: Interviewed Residents affected or likely to be affected.1/30/26: Audited employee files for compliance with Dependent Adult Abuse training.1/30/26: Educated the staff related to Resident Rights and Abuse online.1/30/26: Conducted an emergency in-service.1/30/26: Completed abuse education with the nurses.1/30/26: Conducted Abuse and Resident Rights education with the leaders.1/30/26: Offered counseling to Resident #1 affected by the situation.The facility identified a census of 105 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 14, indicating no impaired cognitive decisions. Resident #1 could understand others and others understood them. They had adequate hearing, vision, and no behavior issues. Resident #1 required total staff assistance with toileting and hygiene. The MDS listed Resident #1 as frequently incontinent of bowel. The MDS included diagnoses of hypertension (a condition where blood consistently pushes hard against artery walls), heart failure, anemia, and restless leg syndrome (a neurological disorder by the urge to move the legs, and uncomfortable crawling, tingling, or aching sensations).The Care Plan Focus initiated dated 10/3/25, indicated Resident #1 had an activity of daily living (ADL) self-care performance deficit related to impaired balance. The Interventions instructed the following:a. Follow facility protocol as Resident #1 allowed for incontinence care managementb. Staff assist of one person with toiletingc. Independent with toileting hygiened. Ask yes/no questions in order to determine the resident's needs. The Care Plan Focus dated 10/20/25 reflected Resident #1 had bladder incontinence and needed assistance. The Intervention initiated 1/12/26 directed Resident #1 preferred to be changed between 1:00 AM and 3:00 AM. The Unusual Event dated 1/20/26 at 2:00 AM, documented Resident #1 reported she didn't know the date and time of occurrence, but said while in her chair, which she considered her bed, Staff A, performed cares on her roommate. Afterwards, Staff A, woke up Resident #1 to let her know it was time for check and change. Resident #1 told Staff A; she didn't want bothered. Staff A, proceeded to check her anyways by putting Staff A's hand on the outside of Resident #1's brief to determine if she was wet. Staff A, left without changing Resident #1. Resident #1 stated she was dry. During the next rounds, Resident #1 told Staff A, she did not want to be bothered again, after this happened Staff A, stepped away and got the nurse. Resident #1 stated she would prefer to be woke up and checked. The Social Service Progress notes dated 2/2/26 at 3:39 PM, documented Resident #1 received a supportive visit that day.The Social Service Progress notes dated 2/3/26 at 11:24 AM, documented a referral made to psychotherapy/psychiatry services, both Resident #1 and her daughter aware and agreed to have services provided.The Social Service Progress Note dated 2/6/26 at 2:36 PM, documented the Social Worker met with Resident #1 every day that week for supportive visits.An untitled piece of paper with a date 2/2/26, documented one-on-one with Resident #1 that day. Resident #1 presented in good spirits; she mentioned some trouble sleeping related to an incident with staff. The person provided reassurance.An untitled piece of paper with a date 2/3/26, documented the Social Worker stopped in to see Resident #1 that day, they talked about how things were going. The Social Worker reassured Resident #1 again that the staff person from the recent incident is no longer at the facility.On 2/11/26 at 3:45 PM, Resident #1 stated that during the overnight shift on 1/18/26, about 2:00 AM, Staff A woke her up to check and change her. Resident #1 explained to Staff A, she was dry and don't bother her. Staff A put their hand in between Resident #1's thighs to check the outside of her brief. Resident #1 told Staff A, don't do that again. Since that incident Resident #1 is fearful of Staff A not respecting and granting her request refusing to be checked and changed. She added she had trouble sleeping related to this incident.On 2/11/26 at 1:30 PM, Staff B, Registered Nurse (RN), stated on 1/29/26, when they interviewed Resident #1, she told her on 1/18/26 about 2:00 AM, Staff A, came into her room, to check and change her. Resident #1 told Staff A, that she was dry and not to bother her. Staff A proceeded to check the outside of Resident #1's brief anyway, by putting their hands in between her thighs, even after Resident #1 told Staff A, not to. Staff B, stated they expected the staff to respect the resident's rights and dignity.On 2/11/26 at 3:00 PM, Staff A confirmed the incident happened according to Resident #1. Staff A, explained that sometime around 2:00 AM or later, Staff A woke Resident #1 up and explained it was time to be checked and changed. Resident #1 said that she was dry and not to bother her. Staff A, said they proceeded to check Resident #1 anyway, by taking their hand and putting in between her thighs to check the brief. Staff A acknowledged the facility expected the staff to treat residents with dignity and respect at all times.On 2/11/26 at 3:30 PM, the facility Director of Nursing, (DON) heard about the incident on 1/28/29, and started to investigate. During the investigation the DON found out the incident happened on 1/18/26 on the overnight shift. The DON acknowledged residents are to be treated with dignity and respect at all times. On 2/11/26 at 4:00 PM, Staff C, CNA, explained Resident #1 said an incident happened on 1/18/26 on the overnight shift about 2:00 AM. Staff A, placed their hands in between Resident #1 thighs to check to see if she was soiled after Resident #1 told Staff A that they were dry. The gesture made Resident #1 uncomfortable. Staff C, acknowledged all residents are to be treated with dignity and respect at all times.On 2/12/26 at 9:30 AM, Staff D, Occupational Therapy Assistant, explained on 1/20/26 in the morning, while ambulating Resident #1 to the bathroom, Resident #1 wanted to talk with a nurse. Staff D, proceeded to get the charge nurse. Resident #1 explained Staff A, came into her room a couple of nights before. Staff A put their hands in between Resident #1 thighs to check to see if the brief was soiled even after Resident #1 told Staff A, no she was dry. Resident #1 felt uncomfortable with this. On 2/12/26 at 1:30 PM, Staff E, Social Services, explained she didn't know about the incident with Resident #1 and Staff A, until 1/28/26. Staff E explained she went into Resident #1's room daily to do visits and made a referral to psychotherapy/psychiatry services to assist Resident #1 to work through the incident that happened. Staff E, acknowledged during one-to-one visits, Resident #1 stated she had trouble sleeping due to the incident. On 2/12/26 at 5:30 PM, the Administrator verified they expected all staff to treat residents with dignity and respect at all times.The undated Resident Rights acknowledgement, described the facility must care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life. The facility must promote care for residents in a manner that enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observations, clinical record review, nursing competency, resident and staff interviews, the facility failed to ensure documentation reflected a resident left the facility unattended and returned with staff for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 112 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #1 could understand and be understood by others. They had no documented behaviors, no wandering issues or rejecting of cares. The MDS listed Resident #1 as independent with personal hygiene and ambulation with a 4 wheeled walker. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's, non-Alzheimer's dementia, cataracts (a clouding of your eyes making vision blurry, hazy or less colorful), glaucoma (eye disease that damages the optic nerve, leading to irreversible vision loss and potential blindness) and macular degeneration (damages of the eyes center causing blurred or loss of sight, and difficult reading).The Care Plan Focus initiated 10/1/25, indicated Resident #1 had an elopement risk/wanderer related to impaired safety awareness, wears a wander alert pendent, and independent with mobility with use of 4 wheeled walker.On 1/13/26 at 4:15 PM, observed Resident #1 sitting in a recliner in his room, attempting, unsuccessfully, to use a cellphone. Resident #1 couldn't recall or remember going outside or being moved to another household.The undated Wanderguard List of residents, documented Resident #1 resided in Life Bridges household.The Resident List Report dated 1/13/26 at 3:30 PM, documented Resident #1 resided in [NAME] Place household.On 1/14/26 at 12:20 PM, the facility's Director Of Nursing (DON) and Assistant Director of Nursing (ADON), explained Resident #1 lived in Life Bridges household and went out the north door of the facility while supervised when outside. Due to the incident, the facility decided to transfer Resident #1 to a locked unit in another household. The DON, stated since Resident #1 didn't actually elope, they decided that it was not necessary to document the incident in the clinical record. On 1/14/26 at 1:15 PM, the DON verified that looking back at the situation now, staff are expected to document in the clinical record any incidents or unusual occurrence that happen with all residents. They train the staff with the Nurse Competency Check-off list upon hire, which included documentation.The Nurse Competency Check Off List reviewed 6/24/24, explained that all skills must be initialed by the Trainee and Trainer, including documentation of follow-up notes, family communication, hot charting, changes in condition, behaviors, new skin issues, unusual events, and alleged abuse.

Based on clinical record review, facility policy, and staff interview, the facility failed to follow physicians order for medication administration for which caused a resident not to receive their diuretic medication (medication to remove salt and water from your body) for 1 out of 4 residents. (Resident #1). The facility identified a census of 115 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #1 could understand and understood others with no behavior or mood issues. Resident #1 required supervision to partial assistance with all aspects of activities of daily living. The MDS included diagnoses of high blood pressure, congestive heart failure (poor function heart resulting in a back of fluids in the body), renal (kidney) and respiratory (lung) failure.The Care Plan initiated date 3/27/25, indicated Resident #1 had a self-care performance deficit related to weakness from a recent hospitalization and congestive heart failure. The Care Plan directed Resident #1 required daily weights, Tubi-grips on every morning (AM) and off every evening (PM), and administer diuretic medications as ordered by the physician.The Physician Discharge orders dated 3/27/25 at 11:57 AM, instructed staff to give Lasix (medication use to treat fluid retention) 20 milligrams, 1 tablet (20 mg total) by mouth daily as needed (PRN) if weight increased 3 pounds from baseline.The Admission/readmission assessment dated [DATE] at 6:24 PM, documented a weight of 108.6 pounds at 3:21 PM.Resident #1's March 2025 Medication Administration Record (MAR) instructed staff to administer Lasix oral tablet 20 mg 1 tablet by mouth every 24 hours PRN for increase in weight gain 3 pounds from baseline. The MAR, documented Resident #1 weight on the following dates:3/30/25 = 111 pounds, no Lasix givenResident #1's April 2025's MAR instructed staff to administer Lasix oral tablet 20 mg, give 1 table by mouth every 24 hours as needed for increase in weight gain 3 pounds from baseline. The MAR documented Resident #1 weight on the following dates:4/3/25=112.8 pounds, no Lasix given4/4/25=111.4 pounds, no Lasix given 4/11/25=112.6 pounds, no Lasix givenThe undated Encounter for Adult Medicine dated 3/31/25 documented no edema in the right and left lower leg, with skin warm and dry.The Encounter for Adult Medicine dated 4/7/25 documented daughter requested Resident #1's Lasix to be restarted at their previous dose of 4 times a week. Resident #1 discontinued Lasix given as needed for weight gain of greater than 3 pounds per day. Review of weight showed Resident #1 consistently held around 111 pounds which is up from admission weight of 108 pounds. Patient did report her legs are more swollen than at their baseline. Her right and left lower leg show 3 plus edema present, with skin warm, dry, and erythema (redness of the skin caused by increased blood flow to the surface) to bilateral (both) lower extremities. Due to the edema and borderline weight gain, the provider ordered to schedule a trial Lasix twice a week with the as needed doses.The Clinic Visit and Information and Order Sheet dated 4/15/25 at 11:30 AM, listed orders to give a total of 40 mg Lasix on 4/15/25 and 4/18/25,. In addition, give 20 mg Lasix on 4/16/25, 4/17/25, 4/19/25, and 4/20/25.The Encounter for Adult Medicine dated 4/18/25 documented the primary care provider (PCP) saw Resident #1 on 4/15/25 for an evaluation of edema. The PCP increased the scheduled Lasix to 40 mg twice a week with 20 mg the other days. On 4/15/25 Resident #1 weighed 114 pounds and on 4/16/25 weighed 113 pounds and on 4/17/25 weighed 113 pounds. That day Resident #1 weighed 113.6 pounds. Resident #1's left and right lower leg showed 3 plus edema with skin warm and dry and erythema present on bilateral lower legs.Interview on 12/22/25 at 1:30 PM, the Director of Nursing verified they expected the nurses are to follow the physicians' orders as written. In reviewing Resident #1's clinical record, the facility failed to give the Lasix as needed when Resident #1's weight increased by 3 pounds from the baseline upon admit.The Process: Medication Administration policy dated 10/15/25, instructed the purpose of a physician order includes dosage, route, frequency, duration or other required considerations is required for administration of medication. Access to knowledge regarding classification, action, correct dosage, side effects of a medication and manufactures specifications is required prior to administration by qualified personnel. Specific directions prior to administration of medication will be completed.

Based on facility investigation, policy/procedures, and staff interviews the facility failed to provide a supportive and safe environment for Resident #1. On 10/8/25, the facility staff learned of a Certified Nurse Aide (CNA) being accused of slamming and making Resident #1 not feeling safe in the facility. After learning of this allegation of abuse, the facility staff told the CNA not to help Resident #1 but allowed them to work with other residents. The facility identified a census of 120 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe impaired cognitive decisions, usually understands and is understood by others and no behavior issues. The resident required staff dependence on toileting hygiene and frequently incontinent of bowel. The MDS included diagnoses of Cancer, hypertension, neurogenic bladder (when your brain nerves or spinal cord causes you to lose control of your bladder) and hemiplegia (a condition characterized by paralysis or severe weakness on one side of the body) of the left side.The Care Plan initiated dated 9/26/25, indicated Resident #1 has an activity of daily living (ADL) self-care performance deficit related to recent brain mass, and is resistive to cares due to cognition and grief and will refuse cares at times. Interventions included to assist times two for toileting, give clear explanation of all care activities prior to an as they occur during each contact, keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.The facility investigation dated 10/10/25, stated that on 10/7/25, the facility administrator was notified by Staff A, Registered Nurse (RN) that she received a phone call from Staff B, CNA, who felt that Staff C, CNA, was working to fast and not careful with how she handled the resident. Investigation initiated and employee sent home. After interviewing Staff B, it was again reported that she felt that Staff C, was going fast and not taking the time that Staff B does when she works with the residents. Staff B reported that this upset her as she likes to take everything really slow and stated sometimes that makes my co-workers unhappy because I am behind. While performing peri-care, Staff B, was holding Resident #1 on his side and that Staff C rolled him too quickly and could have been more careful, Staff B, indicated that there were completing peri-care and the residents stated ow. Staff B mentioned she was not sure if Staff C heard him say that. Staff B hands remained on him when he was laid back down. Staff B stated that he may have had a small amount of bowel movement on him, she could not see as he was not facing her and was holding his body. After speaking with Staff C, she stated they went into do peri-care, his wife was still in the room and assisted with another task. Staff C, reports that she did the wiping and he had bowel movement smeared between his butt cheeks. She reported she heard him say ow, I have a hemorrhoid and she did not continue to wipe in that area. She states that she told him there was some bowel movement she was trying to clean off. She did not recall if her hands were still on the resident when they rolled him back and placed a new depends. Staff C said she has performed cares for this resident many times in the past and has not had any concerns and has always gone the same pace. She states she would never purposely cause discomfort for any of our residents. After interviewing the resident, he states that he did not feel safe while the activity was being performed but stated it is her job and she did not do anything on purpose. Interviewed Resident #1's wife and she indicated that yes, he has a hemorrhoid and that is likely what caused the pain/discomfort. She also noted that he had some dry bowel movement on his sheet. I explained the aide was trying to remove the bowel movement from his buttocks, it could have appeared harsh as she had to rub to get some of the stool off.Interview on 10/27/25 at 3:00 PM, Staff A, RN, verified that she received a telephone call from Staff B, CNA, claiming that Staff C, CNA, was rough and slammed Resident #1 while doing peri-care. Staff A, spoke with Staff D, Licensed Practical Nurse (LPN), and told Staff D to keep Staff C away from Resident #1. Staff A indicated that it never crossed her mind that this was an allegation of abuse and that Staff C needed to be sent home. Staff A thought that keeping Staff C away from Resident #1 would take care of the incident.Interview on 10/27/25 at 3:35 PM, Staff C, CNA, stated that peri-cares were being completed on Resident #1 and dried stool was in-between the buttocks. Staff C stated that she was using a wet wipe to cleanse the area. Resident #1 stated ow, that hurts. Staff C, stopped doing cares and proceeded to take a clean brief and place underneath the resident with assistance of Staff B. Staff C, indicated that this incident happened between 5:00 PM - 5:30 PM. Staff C stated that she answered call lights with other residents until 6:45 PM, when she was instructed to leave the facility. Staff C stated Resident #1 had hemorrhoids and they were bleeding.Interview on 10/27/25 at 4:00 PM, Staff D, LPN, explained that Staff B came up to her and explained that Staff C was rough and slamming Resident #1 in bed while performing peri-cares. Staff D, told Staff B to call the on-call nurse to get direction on how to proceed. Staff D, stated that she got a phone call from Staff A, with direction to keep Staff C from doing cares with Resident #1. Staff D, stated that this was her first allegation of abuse and was not sure how to proceed. Staff D, spoke with Resident #1 after the incident and Resident #1 said that he did not feel safe after the incident. Interview on 10/27/25 at 4:15 PM, Staff B stated that peri-cares were being performed with Staff C and herself on Resident #1. Staff B stated that Staff C was rough and slammed Resident #1 around while performing cares and made Staff B uncomfortable. Staff B explained the incident to Staff D and Staff D told Staff B to call the on-call nurse manager. Staff B was not able to determine the time frame for the incident but stated that it was during the supper time meal. Interview on 10/27/25 at 4:45 PM, the facility Administrator verified Staff C needed sent home until an investigation was completed and that the expectation is not to take care of any other residents.The Abuse, Neglect and Exploitation Policy revised September 2025, that the facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property and will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.

Based on resident's right policy/procedure, facility investigation and staff interview the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 residents reviewed (Resident #1). The facility identified a census of 120 residents. Findings include:Resident #1s Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe impaired cognitive decisions, usually understands and is understood by others and no behavior issues. The resident required staff dependence on toileting hygiene and frequently incontinent of bowel. The MDS included diagnoses of Cancer, hypertension, neurogenic bladder (when your brain nerves or spinal cord causes you to lose control of your bladder) and hemiplegia (a condition characterized by paralysis or severe weakness on one side of the body) of the left side.The Care Plan initiated dated 9/26/25, indicated Resident #1 has an activity of daily living (ADL) self-care performance deficit related to recent brain mass, and is resistive to cares due to cognition and grief and will refuse cares at times. Interventions included to assist times two for toileting, give clear explanation of all care activities prior to an as they occur during each contact, keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.The facility investigation dated 10/10/25, stated that on 10/7/25, the facility administrator was notified by Staff A, Registered Nurse (RN), that she received a phone call from Staff B, Certified Nursing Assistant (CNA), who felt that Staff C, CNA, worked fast and not careful with how she handled the resident. Investigation initiated and the employee sent home. After interviewing Staff B, it was again reported that she felt that Staff C, was going fast and not taking the time that Staff B does when she works with the residents. Staff B reported that this upset her as she likes to take everything really slow and stated sometimes that makes her co-workers unhappy because she is behind. While performing peri-care, Staff B was holding Resident #1 on his side that Staff C rolled him too quickly on his side and could have been more careful. Staff B indicated that there were completing peri-care and the residents stated ow. Staff B mentioned she was not sure if Staff C heard him say that. Staff B hands remained on him when he was laid back down. Staff B stated that he may have had a small amount of bowel movement on him, she could not see as he was not facing her and was holding his body. After speaking with Staff C, she stated they went into do peri-care, his wife was still in the room and assisted with another task. Staff C reports that she did the wiping and he had bowel movement smeared between his butt cheeks. She reported she heard him say ow, I have a hemorrhoid and she did not continue to wipe in that area. She states that she told him there was some bowel movement she was trying to clean off. She did not recall if her hands were still on the resident when they rolled him back and placed a new depends. Staff C said she has performed cares for this resident many times in the past and has not had any concerns and has always gone the same pace. She states she would never purposely cause discomfort for any of our residents. After interviewing the resident, he states that he did not feel safe while the activity was being performed but stated it is her job and she did not do anything on purpose. Expectations, education and coaching provided to Staff C, to slow down, listen to the resident and ensure that things are at their pace the way they like it. Staff C verbalized understanding.Resident #1's clinical record lacked documentation of the incident.Interview on 10/27/25 at 4:45 PM, the facility Administrator verified the expectation of all staff are to treat the residents with dignity and respect at all times.The undated Resident Rights acknowledgement, described that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and also be free from verbal, sexual, physical and mental abuse and that the facility must ensure that all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator of the facility.

Based on staff interviews, facility investigation, and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents (Resident #1) were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours. The facility reported a census of 120 residents.Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe impaired cognitive decisions, usually understands and is understood by others and no behavior issues. The resident required staff dependence on toileting hygiene and frequently incontinent of bowel. The MDS included diagnoses of Cancer, hypertension, neurogenic bladder (when your brain nerves or spinal cord causes you to lose control of your bladder) and hemiplegia (a condition characterized by paralysis or severe weakness on one side of the body) of the left side.The Care Plan initiated dated 9/26/25, indicated Resident #1 has an activity of daily living (ADL) self-care performance deficit related to recent brain mass, and is resistive to cares due to cognition and grief and will refuse cares at times. Interventions included to assist times two for toileting, give clear explanation of all care activities prior to an as they occur during each contact, keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.The facility investigation dated 10/10/25, stated that on 10/7/25, the facility administrator was notified by Staff A, Registered Nurse (RN) that she received a phone call from Staff B, CNA, who felt that Staff C, CNA, was working to fast and not careful with how she handled the resident. Investigation initiated and employee sent home. After interviewing Staff B, it was again reported that she felt that Staff C, was going fast and not taking the time that Staff B does when she works with the residents. Staff B reported that this upset her as she likes to take everything really slow and stated sometimes that makes my co-workers unhappy because I am behind. While performing peri-care, Staff B, was holding Resident #1 on his side and that Staff C rolled him too quickly and could have been more careful, Staff B, indicated that there were completing peri-care and the residents stated ow. Staff B mentioned she was not sure if Staff C heard him say that. Staff B hands remained on him when he was laid back down. Staff B stated that he may have had a small amount of bowel movement on him, she could not see as he was not facing her and was holding his body. After speaking with Staff C, she stated they went into do peri-care, his wife was still in the room and assisted with another task. Staff C, reports that she did the wiping and he had bowel movement smeared between his butt cheeks. She reported she heard him say ow, I have a hemorrhoid and she did not continue to wipe in that area. She states that she told him there was some bowel movement she was trying to clean off. She did not recall if her hands were still on the resident when they rolled him back and placed a new depends. Staff C said she has performed cares for this resident many times in the past and has not had any concerns and has always gone the same pace. She states she would never purposely cause discomfort for any of our residents. After interviewing the resident, he states that he did not feel safe while the activity was being performed but stated it is her job and she did not do anything on purpose. Interviewed Resident #1's wife and she indicated that yes, he has a hemorrhoid and that is likely what caused the pain/discomfort. She also noted that he had some dry bowel movement on his sheet. I explained the aide was trying to remove the bowel movement from his buttocks, it could have appeared harsh as she had to rub to get some of the stool off.Resident #1's clinical record lacked documentation of the incident.Interview on 10/27//25 at 4:45 p.m., the facility Administrator confirmed the facility failed to notify DIAL of the incident between Resident #1 and Staff C within the 2-hour time frame. The Policy for Abuse, Neglect and Exploitation dated September 2025, the facility will have written procedures that include, reporting of all alleged violations to the Administrator or designee, state agency, within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on clinic record review, staff interviews, Nurse Practitioner interview, and policy review, the facility failed to administer medications per physician orders for 1 of 4 residents reviewed (Resident #1) for significant medication errors. The facility reported a census of 116 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #1 required substantial/maximal assistance with bed mobility and was dependent on staff for transfers/toileting. The MDS included diagnoses of chronic kidney disease, generalized anxiety disorder, major depressive disorder, and primary insomnia. The MDS identified Resident #1 received antianxiety medication for 7 days during the look back period.The Care Plan revised 12/10/24 documented Resident #1 used an antianxiety medication for an anxiety disorder. The care plan directed staff to administer the antianxiety medication as ordered by the physician. The June 2025 Medication Administration Record (MAR) directed staff to administer the following antianxiety medications:- Ativan (Lorazepam) 0.5 mg (milligrams) before meals (7:30 AM, 11:30 AM and 4:30 PM) for anxiety. Start date 12/24/23- Clonazepam (Klonopin) 0.5 mg one tablet at bedtime for anxiety. Start date 2/3/23An Incident Report titled Medication Error dated 6/17/25 documented a Certified Medication Aide (CMA) went to the nurse because they suspected a medication error. The CMA identified Resident #1's clonazepam had been only signed out every other night on the narcotic record. The Nurse reviewed the most recent narcotic record for the lorazepam and identified on multiple occasions the lorazepam was given four times daily instead of the clonazepam. The report documented the nurse notified the nurse practitioner, family and on call nurse manager of the medication error. Review of the Lorazepam Narcotic Records from 6/1/25 to 6/17/25 revealed Resident #1 received an additional dose of Lorazepam in the evening/bedtime on the following dates: 6/2, 6/4, 6/5, 6/8, 6/10, 6/11, 6/13, and 6/16. Review of the Clonazepam Narcotic Records from 6/1/25 to 6/17/25 revealed Resident #1 did not receive the medication on the following dates: 6/2, 6/4, 6/5, 6/8, 6/10, 6/11, 6/14, and 6/17. A Progress Note dated 6/5/25 documented Resident #1 complained of feeling very shaky and unsteady and did not want to be left alone stating to staff she was going to die. Resident #1 reported it was her anxiety. The note indicated the Advance Registered Nurse Practitioner (ARNP) was notified of the symptoms.A Progress Note dated 6/6/25 documented Resident #1 did not feel well. When the nurse asked to describe how she was feeling, Resident #1 responded in my head, I didn't sleep much. The note documented Resident #1's daughter reported she was getting a lot of phone calls.A Social Service Progress Note dated 6/12/25 documented Resident #1 reported not doing so well because she did not sleep so well last night. A Progress Note dated 6/14/25 documented Resident #1 reported to the nurse that she wasn't feeling well and did not sleep last night.A Progress Note dated 6/14/25 documented Resident #1's daughter requested to speak to the nurse due to concern her mom was not feeling well and needed to be evaluated. The note documented Resident #1 complained of not sleeping well for the past few days, having a hard time emptying her bladder and pain all over. The note indicated Resident #1 appeared anxious, stated I feel tense and wanted to be evaluated in the hospital. The note revealed Resident #1's daughter escorted her to the hospital. A Telehealth Psychiatric Evaluation completed in the emergency room (ER) dated 6/14/25 revealed Resident #1 presented with acute insomnia and associated mood changes. The treatment recommendation was to start Trazodone (antidepressant) 25 mg at bedtime for 7 days for insomnia. A ER Provider Note dated 6/14/25 documented Resident #1 came to the ER with a chief complaint of anxiety and not sleeping. Resident #1 reported she felt tense all over and had trouble sleeping. The note revealed a medical screening was completed and Resident #1 was medically cleared. The note indicated a telehealth psychiatric evaluation was completed and recommended starting Trazodone 25 mg at bed time for 7 days. In addition the note advised the nursing home's own psychiatric provider to re-evaluate Resident #1 to determine the need to continue the medication or if the dosing needed adjusted. The note documented Resident #1 was discharged to the care center to resume her routine medications.A Progress Note dated 6/19/25 revealed Psychiatric ARNP made face to face visit with Resident #1 and no new orders were received. Review of the Lorazepam Narcotic Records dated 9/1/25 revealed the afternoon dose of lorazepam was not logged out indicating a dose was missed/omitted.On 10/7/25 at 3:00 PM, Staff A, Licensed Practical Nurse (LPN), reported she was working as a CMA when Resident #1's medication errors occurred. Staff A said she realized she had been giving Resident #1's medications incorrectly. She said when she was looking at the clonazepam narcotic record, she identified there was not a pill signed out for each night. She said she went to Staff B, LPN, and reported the medication errors. Staff A said she got the lorazepam and clonazepam medications mixed up. She said when the medication errors were identified the Director of Nursing (DON) provided verbal coaching and she had to pass medications with another nurse a couple of times. She said she was removed from the household per the family request. On 10/8/25 at 11:03 AM, Staff B reported she was working when Resident #1's medications errors were identified and brought to her attention. She said the CMA was giving lorazepam instead of the clonazepam. She said both medications were on the resident's medication list. She said she looked at the narcotic records and the CMA had been signing out and giving the lorazepam instead of the clonazepam at night. She said she completed the risk management form and the appropriate notifications. She said Resident #1 was a little bit more anxious, confused and having a little bit more trouble sleeping during that time frame. On 10/8/25 at 2:00 PM, the DON reported the facility did not complete an incident report for the medication error with the lorazepam on 9/1/25. She said the incident report was completed as of 10/8/25. The DON reported the lorazepam medication was signed off on the MAR but the narcotic record did not reflect the medication was logged out to be given. She said the family and the ARNP were notified of the medication error at the time of the incident. The DON acknowledged the progress notes lacked documentation regarding the medication error or notifications. The DON reported the medication error happened on Labor day and she assumed the nurse got busy and forgot to give the medication. The DON said the nurse who completed the medication error was terminated on 10/8/25 when she learned of the error. The DON reported she expected the staff to administer medications according to the physician orders and to follow the 5 rights of medication administration. On 10/8/25 at 2:37 PM, the Psychiatric Nurse Practitioner reported Resident #1 was on a strange combination of medications that included two different benzodiazepine medications. She said if she recalled correctly when she started seeing Resident #1 it was for complaints of not being able to sleep. She said she thought at that time Resident #1 was on lorazepam four times a day along with other medications. She said she decided to try a long acting benzodiazepine at night so she started the clonazepam. She said after starting the medication Resident #1 slept better. She reported the clonazepam medication was a little more sedating and lasted longer than the lorazepam medication. When asked if there could be any negative effects from receiving the lorazepam instead of the clonazepam, she said Resident #1 morning anxiety and difficulty sleeping at night may have contributed to her receiving a shorter acting benzodiazepine versus a long acting benzodiazepine. She said Resident #1's daughter had reported her mom was more anxious and not sleeping well at night during that time frame. A facility policy titled Medication Administration reviewed 7/9/25 documented accepted professional standards for drug administration included: Right Drug, Right Patient, Right Time, Right Dose and Right Route.

Based on observation, clinical record review, resident and staff interviews, family interviews, facility policy/procedure reviews, the facility failed to adequately supervise 1 of 2 residents (Resident #1) This lack of supervision resulted in Resident #2 going to Resident #1 room, and Resident #1 was in a compromising position in bed. Resident #1 has a history of sexual advances towards other residents including Resident #2. The facility reported a census of 121 residents. Finding include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected they usually made themselves understood and understood others. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS listed Resident #1 required supervision or touching assistance with ambulation and a walker as the mobility device. The MDS included diagnoses of non-Alzheimer's dementia, anxiety and depression. The Care Plan Focus revised 5/1/25 reflected Resident #1 had a behavior problem regarding being sexually inappropriate and went in others' rooms at times. The Interventions directed the following: i. Observe body language and facial expressions closely for clues about her needs. ii. Supervision at all times to ensure her well-being. iii. 11/2/23: Assist the resident to develop more appropriate methods of coping and interacting with her peers. Encourage the resident to express feelings appropriately. iv. 11/2/23: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. v. Incident 4/14/25: Resident separated entities notified head to toe assessment physician notification. vi. Resident to resident 4/20/25: Order change for Seroquel (a medication which plays a role in regulating mood, thoughts, and behaviors) 25 milligrams (mg) at noon. vii. 5/1/25: If reasonable, discuss Resident #1's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. The Unusual Event dated 4/20/25 at 3:45 PM, documented the staff found Resident #1 in her room with a male resident (Resident #2). When a Certified Nursing Assistant (CNA) entered the room, they found Resident #1 lying on her bed with her pants and underwear around her knees with Resident #2 laying on top of her. The staff noted Resident #2 had his pants down around his knees, with his underwear still in place. He had an erect penis, lying motionless. Approximately 5 minutes before the incident, the staff saw both residents in the living room. Resident #1 told the CNA who entered her room, You have no business being in here, got out now! When interviewing Resident #1 about the situation that occurred, she stated, Oh yes, I heard about that terrible accident and the hospital people were involved, so sad for his wife. The staff immediately separated the residents, and the nurse completed a head-to-toe assessment. The staff assisted Resident #1 to another unit in the facility. On 6/12/25 at 3:55 PM, observed Resident #1 sitting on the couch in the unit with her eyes closed and walker in front of her. On 6/16/25 at 12:40 PM, when attempted to interview Resident #1, she couldn't recall an incident that happened between her and a male resident. The Orders Administration Note dated 3/24/25 at 1:34 PM, identified a staff member observed Resident #1 put her hand on another male resident's thigh and kept trying to hold his hand. The staff intervened quickly and separated the residents but she kept asking the male resident to sit next to her on the couch. The Nursing Progress Note dated 3/25/25 at 5:42 PM, indicated Resident #1 consistently tried to get a male resident to go in her room to shut the door and watch a movie together. The nurse explained they could watch the movie in the living room. Resident #1 told the other resident once that lady leaves we can go in my room. The nurse observed Resident #1 and Resident #2 hold hands and separated them. The Nursing Progress Note dated 3/26/25 at 5:42 PM, reflected Resident #1 constantly tried touching a male residents' thigh/leg that night. She tried to get in his face to talk to him, no matter how many times the staff separated her from him. She always tried to touch him and constantly tried to call him over to hold hands or sit next to him. The Advanced Registered Nurse Practitioner (ARNP) Progress Notes dated 3/27/25 indicated they saw Resident #1 at the request of staff for an evaluation of her behaviors. The staff reported Resident acting overly friendly with males on her unit with borderline inappropriate touching. The staff reported she had her hand high on their thighs and attempted to follow them into their rooms. In addition, the staff reported Resident #1 acted overly friendly with females on the unit. The facility transferred Resident #1 from one locked unit to the current locked unit for similar behaviors. The Nursing Progress Notes dated 4/2/25 at 1:16 PM, indicated the staff found Resident #1 holding hands with a male resident. When the staff intervened, Resident #1 got upset. When the staff move the male resident, she continued to call him over and tried to hold his hands again. The Nursing Progress Notes dated 4/4/25 at 2:58 PM, identified Resident #1 tried to go into a male's room and closed the doors. The staff witnessed them holding hands, Resident #1 felt his cheeks, and tried to sneak around staff to be next to each other. The staff provided supervision. The Nursing Progress Notes dated 4/6/25 at 1:16 PM, Resident #1 tried to hold hands with multiple residents. She tried to get male residents to sit next to her on couch while making comments about going to her room together and shutting the door. The Nursing Progress Notes dated 4/7/25 at 9:51 PM, a CNA reported Resident #1 asked if she could give her roommate a kiss. The CNA told Resident #1 she couldn't as it was inappropriate. Resident #1 replied One little kiss won't hurt anyone, if you won't tell then I won't tell. The CNA once again told her she couldn't kiss her roommate. Resident #1 went to bed and the CNA did frequent checks. The Nursing Progress Notes dated 4/13/25 at 12:02 PM, identified a CNA reported Resident #1 inappropriately touched another resident. Once witnessed, the staff separated the 2 parties to different units. The nurse completed a head-to-toe assessment without irregularities then notified management and other pertinent parties. The note reflected the staff would continue to separate the residents until they could evaluate their plan of action. The facility collected a witness statement For the CNA, relayed to management. The note reflected they informed all staff. The Nursing Progress Notes dated 4/14/25 at 11:09 AM, indicated as the nurse gave Resident #1 her medications that morning, the nurse observed Resident #1 rubbing another resident's arm and wanting to hold her hand. The nurse told Resident #1 they couldn't hold hands with other residents. Resident #1 responded, oh we can't touch over here too. The nurse reported the incident to the Nurse Manager. The Nursing Progress Notes dated 4/16/25 at 9:50 PM, Resident #1 attempted to persuade a male resident in to her room. Staff intervened before the residents made physical contact and separated them. Resident #1 didn't have further contact with the male resident. The Nursing Progress Notes dated 4/20/25 at 2:00 PM, described Resident #1 as anxious and agitated most of the shift. Resident #1 tried to touch a male resident's shoulder and arm. In addition, she attempted to follow him into his room when he used the bathroom. Resident #1 again tried to sit next to him on the couch. Other residents told Resident #1 to leave them alone due to her constantly trying to help them or ask them the same questions over and over. This made another resident yell at her and get agitated as well. The Nursing Progress Notes dated 4/20/25 at 3:45 PM, as a CNA entered Resident #1's room, they found Resident #1 laying on her bed with her pants and underwear around her knees. Resident #2 laid on top of her with his pants down around his knees, he had his underwear in place. Resident #2 had an erect penis, as he laid still motionless. Resident #1 told the CNA who entered her room, You have no business being in here, get out now! When the nurse interviewed Resident #1 about the situation that occurred, she replied, Oh, yes, I heard about that terrible accident and the hospital people were involved, so sad for his wife. The staff immediately separated the residents and the nurse completed a head-to-toe assessment with no injuries noted. The facility moved Resident #1 was assisted to another unit until further notice. 2. Resident #2's MDS assessment dated [DATE] reflected they could make themselves understood and understood others. The MDS identified a BIMS score of 3, indicating severe cognitive impairment. The MDS listed Resident #2 required supervision or touching assistance and didn't use a mobility device for ambulation. The MDS included diagnoses of non-Alzheimer dementia, vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and depression. The Care Plan Focus initiated 8/6/24 indicated Resident #2 had a behavior problem related to being touchy at times. He always looked for his girlfriend. In addition, he attempted to kiss and grabbed the staff. Resident #2 could be sexually inappropriate, as he went in to others' rooms at times and restless. The Interventions directed the following: i. If reasonable, discuss his behavior, explain and reinforce why the behaviors are inappropriate and/or unacceptable. ii. Incident 4/14/25: The facility separated Resident #2 from another resident. The nurse completed a head-to-toe assessment and notified the physician. iii. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. iv. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. v. Resident encounter 4/20/25. Medication review. On 6/16/25 at 1:35 PM, Resident #2's Representative (RR2) reported they didn't have any issues or concerns with staffing on the day of the incident. RR2 stated an incident happened and they hoped another incident didn't happen again. The Unusual Event dated 4/20/25 at 3:45 PM identified a CNA entered Resident #1's room and found Resident #2 laying on top of Resident #1. Resident #1 had her pants and underwear around her knees. Resident #2 had his pants down with his underwear still in place. The staff noted Resident #2 had an erect penis, lying motionless on top of Resident #1. The staff witnessed both residents in the living room approximately 5 minutes before the situation. When interviewed, Resident #2 couldn't describe the event that occurred. Resident #2 responded, Where are my parents. The staff immediately separated the residents and the nurse completed a head-to-toe assessment. The facility notified RR2, who voiced understanding. The facility assigned Resident #1 to another unit until further notice. The General Note dated 3/25/25 at 2:28 AM, reflected the facility had Resident #2 as a one-to-one (1:1) due to his anxiety, pacing, and going into others room. The note described Resident #2 as sexually inappropriate. The staff provided redirection, snacks, drinks and offered the use of the toilet as well. The Nursing Progress Note dated 4/4/25 at 2:56 PM indicated the staff saw Resident #2 attempt to go into a female's room, close the door, hold hands, rubbed her leg, and tried to sneak around staff to be next to each other. The staff provided supervision. The Nursing Progress Note dated 4/6/25 at 1:59 AM identified staff reported on the previous shift, Resident #2 went from behind a young CNA and put his hand on her breast. The staff redirected Resident #2. During the shift, as the CNA assisted Resident #2 to bed, and turned to cover him up, he had his pants down and stated aren't you going to get on this? The CNA redirected Resident #2 again, and asked him to pull up his pants. After a few minutes as the CNA sat in the den, Resident #2 came in and pulled his pants down again. The staff asked Resident #2 to pull up his pants and go lay down in bed. The Nursing Progress Note dated 4/6/25 at 5:14 AM, reflected a CNA reported Resident #2 came out of his room, into the den where she sat quietly with another male resident, and proceeded to pull down his pants again. The other resident sitting with the CNA became upset at Resident #2's actions. The CNA asked Resident #2 to pull up his pants. Resident #2 pulled up his pants and returned to his room. The Nursing Progress Note dated 4/7/25 at 8:19 AM, documented Resident #2 went into the hallway naked where a female resident tried to grab him and take him into the dining room with her. The CNA immediately separated them. The Nursing Progress Note dated 4/8/25 at 3:19 AM, reflected Resident #2 pulled his pants down twice (twice in his room and twice outside of his room) and attempted another 2 times. The CNA intervened and redirected but this didn't decrease his behavior. The ARNP Progress Note dated 4/10/25 indicated they saw Resident #2 due to his increase with agitation, pacing, and erratic behaviors. In addition, he had some sexual behaviors and urinating in inappropriate locations. The Nursing Progress Note dated 4/13/25 at 12:02 PM, identified a CNA reported Resident #2 touched another patient inappropriately. After the staff witnessed the 2 parties, they separated them to different units. The staff notified management and pertinent parties. They planned to continue to separate patients until they could evaluate a plan of action. The facility collected a Witness Statement from the CNA and submitted to management. The Nursing Progress Note dated 4/14/25 at 10:32 PM, identified a CNA called the nurse and reported when they did walk rounds, they found Resident #2 in a female resident's room. The CNA's immediately separated them and the nurse informed the Nurse Manager. The Nursing Progress Note dated 4/20/25 at 3:45 PM, identified a CNA entered Resident #1's room and found Resident #2 laying on top of Resident #1. Resident #1 had her pants and underwear around her knees. Resident #2 had his pants down with his underwear still in place. The staff noted Resident #2 had an erect penis, lying motionless on top of Resident #1. The staff witnessed both residents in the living room approximately 5 minutes before the situation. When interviewed, Resident #2 couldn't describe the event that occurred. Resident #2 responded, Where are my parents. The staff immediately separated the residents and the nurse completed a head-to-toe assessment. The facility notified RR2, who voiced understanding. The facility assigned Resident #1 to another unit until further notice. The Nursing Progress Note dated 4/21/25 at 8:53 PM, indicated a CNA reported Resident #2 rubbed the back up and down of a female resident. The staff immediately separated them and they had no further behaviors. The ARNP Progress Note dated 4/21/25 reflected the ARNP saw Resident #2 because the staff requested them to evaluate his behaviors. Resident #1 involved in a sexual encounter with another resident at facility. They increased his Zoloft (a medication that helps in the brain that plays a role in mood regulation) on 4/10/25 following the initial encounter with the other resident. The ARPN instructed the staff to separate Resident #2 from the other resident. The staff attempted however the 2 residents managed to get together in one of their rooms. The staff separated the 2 residents prior to any sexual activity. The ARNP recommended to continue separation of Resident #2 from the other resident and to continue monitoring for behaviors. The ARNP Progress Note dated 5/5/25 identified having Resident #2 separated from the other resident that who caused his anxiety, his behaviors returned to baseline. On 6/12/25 at 2:00 PM, Staff A, CNA, explained they worked on 4/20/25, when the incident happened between Resident #1 and Resident #2. Staff A sat on the couch in the living area visiting with another resident. Staff A had her back towards Resident #1 and Resident #2, they didn't see them leave the living room area until Staff B, CNA, asked if she saw the 2 residents leave the living room area. Staff A reported they had difficulty keeping close supervision on Resident #1 and Resident #2, as they both moved independently and described them as very quick. Staff A stated Resident #1 liked to flirt with Resident #2 and attempt to get him in her room. Staff A, said Resident #1 transferred to that unit as she had sexual advances and behaviors in another unit. Staff A verified the facility failed to give directives except to try and keep the 2 residents apart. Staff A, reported the difficulty to keep them apart with only 2 staff working on the unit. On 6/12/25 at 3:30 PM, Staff B, explained she worked on 4/20/25 when the incident occurred between Resident #1 and Resident #2. Staff B sat on the couch doing their charting for the day. When Staff B looked up, they didn't see the 2 residents in the living area. When Staff B, asked Staff A, if she saw the 2 residents, Staff A, replied no. Staff B, said she went looking for the 2 residents. She found Resident #2 in Resident #1's room with her pants and underwear down to her knees and Resident #2 on top of her with his pants down but he still had his underwear on with an erect penis. Staff B said she told Resident #2 to come with her and she took him out to Staff A to watch him, as she called the charge nurse. Staff B went back into Resident #1's room to assist getting her dressed. Staff B, explained Resident #1 had the same type of behaviors in another unit, when they transferred her to that unit. Staff B stated Resident #2 liked to flirt with the men on the unit. Staff B, verified the facility didn't give any directives except to attempt to keep the 2 residents apart and give them closer supervision. Staff B explained having difficulty providing close supervision when they only had 2 staff on the unit at times. On 6/16/25 at 9:00 AM, Staff C, Registered Nurse (RN), stated she worked on 4/20/25 when the incident between Resident #1 and Resident #2 happened. Staff C, explained at the time, she took care of another resident on a different unit when she received a phone call that she needed to go to the unit for an incident. Staff C, stated when she got to the unit the staff had the 2 residents separated and she assessed them. Staff C, explained Resident #1 acted flirty towards Resident #2 and did sexual innuendos for Resident #2 to go to her room. Staff C verified the facility failed to give any extra directives on the 2 resident except to attempt to keep them separated. On 6/16/25 at 3:55 PM, Staff D, CNA, explained Resident #1 liked to flirt with Resident #2. They added it was just a matter of time when the 2 residents would be in the same room together. Staff D verified the facility failed to give any extra directives with the 2 residents except to try and keep them separated as much as they could. Staff D explained the facility transferred Resident #1 to that unit due to having sexual advances on another unit. Since Resident #1 transferred off the unit, Resident #2 didn't have any sexual advances towards staff or other residents. On 6/16/25 at 4:00 PM, Staff E, CNA, verified that the facility did not give any extra directives except to attempt to keep Resident #1 and Resident #2 apart. Staff E, said since both residents moved independently, this made it difficult to supervise them both at all times. Staff E, described Resident #1 as flirtatious with Resident #2 for a while prior to the incident. Staff E added that management knew about the sexual advances but didn't do anything until the incident and then they transferred Resident #1 to another unit. Since Resident #1 transferred, Resident #2 didn't have any sexual advances towards staff or any other residents. On 6/17/25 at 8:30 AM, the Director of Nursing (DON) and Administrator, verified they expected the staff to keep the 2 residents separated at all times and the facility failed to keep close supervision on Resident #1 knowing she had a history of sexual innuendos and being flirtatious to other residents, especially men. They verified the facility failed to give adequate nursing supervision with these 2 residents. The undated Resident Rights pamphlet, directed the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident including abuse: the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion (separation from others by someone other than themselves).

Based on alarm response report, resident, and staff interviews, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 1 of 4 residents reviewed. (Resident #2). The facility identified a census of 117 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated they had adequate hearing, could make themselves understood, and she could understand others. The MDS identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #2 required staff assistance with toilet hygiene and transfers. The MDS included diagnoses of anemia (low blood iron), Alzheimer's disease, non-Alzheimer's dementia, depression, and osteoarthritis. The Plan of Care Focus dated 1/5/24, reflected Resident #2 had bladder incontinence related to needing assistance with mobility. The Interventions directed the following: *Clean peri-area with each incontinence episode. *Monitor/document for s/sx urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. During an interview on 7/24/24 at 2:02 PM, Resident #2 stated it took the staff over a half hour to answer the call light. Review of the Alarm Response Report dated 7/23/24, listed on 7/22/24 at 8:03 AM Resident #2 needed assistance. The report reflected someone answered it at 8:23 AM, for response time from staff of 19:12 minutes. During an interview on 7/24/24 at 2:16 PM, Staff A, Certified Nursing Assistant (CNA), verified it could take over 15 minutes to answer a call light. Staff A confirmed the facility expected them to answer the call light with in 15 minutes. During an interview on 7/24/24 at 2:16 PM, Staff B, CNA, confirmed it took over 15 minutes to answer the call lights. During an interview on 7/24/24 at 9:31 AM, the Administrator confirmed they expected the staff to answer call lights within 15 minutes per the State Rules and Federal Regulations.

Based on observation, clinical record review, facility policy review, resident, and staff interviews, the facility failed to ensure one (1) of six (6) residents (Resident #6) received adequate supervision to protect against hazards in the environment. On 4/22/24, staff witnessed Resident #6 fall. As Resident #6 fell , the staff assisted her without the use of a gait belt to ambulate (walk) and transfer to the bathroom. Resident #6's fall required a transfer to the local emergency department (ED). The (ED) record revealed Resident #6 received fractures of the 1st, 2nd, 3rd, and 5th proximal phalanges (toes). The facility reported a census of 125 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognitive skills for decision making. Resident #6 required substantial/maximal assistance for toilet transfers and total dependence from staff for walking. The MDS included diagnosis of polyosteoarthritis (arthritis that affects multiple joints at once), left artificial knee joint, and atrial fibrillation (irregular heart rate). The MDS reported no previous falls. The Care Plan Focus revised 6/12/23 indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to weakness from her recent left knee replacement. The Care Plan interventions directed the following: a. 6/12/23: Follow facility protocol as Resident #6 allows for gait belt usage. b. 6/15/23: Transfer with an upright walker. Assist of one staff person. The Incident Report dated 4/22/24 relfected Staff A, Certified Nursing Assistant (CNA), reported to the nurse at 6:00 a.m. on 4/22/24, as she walked Resident #6 to the bathroom using her walker, she started to back into the bathroom. As she backed into the room, her walker started to tip sideways. Immediately after, Resident #6 started bending at the knee leading her to believe Resident #6 was going to fall to the floor. Staff A lowered Resident #6 to the floor as gently as could she but Resident #6 still had her knees bent and her right knee caught on the walker breaking the skin. Resident #6 expressed concern for her knees and legs. The 01 Nursing Progress Note dated 4/22/24 at 6:15 a.m. indicated Resident #6 walked to the bathroom with her walker, turned to back into the bathroom, and then sat down on the floor. Resident #6 obtained an abrasion to the right knee from the walker. Resident #6's assessment indicated she could move all of her extremities. Resident #6 stated she hoped she didn't mess up her legs. The 01 Nursing Progress Note dated 4/22/24 at 9:34 a.m. reflected the facility sent Resident #6 to the local ED for evaluation due to her fall that morning. The facility notified Resident #6's family, who planned to meet her there. The 01 Nursing Progress Note dated 4/22/24 at 12:35 p.m. indicated the facility received report from the ED nurse. The nurse stated Resident #6 broke the left digits (toes) #1, 2, 3, and 5. Resident #6 would return with a special shoe. They recommended she rest and do activity as she tolerated. The Facility Investigation Summary Report signed by the Director of Nursing (DON) on 4/22/24 at 6:00 a.m. described Resident #6 as tearful and concerned the fall would set her back if she had an injury. The facility interviewed Staff A, who admitted she didn't use a gait belt to transfer Resident #6. When the staff interviewed Resident #6, she said she asked Staff A to use the gait belt but she just wouldn't do it. Resident #6 added she should never have let her help if she wasn't going to do it right. The facility terminated Staff A for not using a gait belt, due to it being a safety concern and a violation of a policy. On 5/2/24 at 11:30 a.m. observed the Assistant Director of Nursing (ADON) and Provider assess Resident #6. Witnessed Resident #6's left foot exposed, swollen, with the toes and foot darkened in color. Resident #6 stated that she had a lot of pain in the foot. The Provider discussed going to the local ED to have her foot further evaluated due to her pain, discoloration, and swelling. Noted Resident #6 tearful as she agreed. In an interview on 5/6/24 at 10:00 a.m. Resident #6 reported she had told the aide to use the gait belt, but she just wouldn't do it. Clarified that staff always use a gait belt when transferring. Resident #6 denied being afraid of falling again. In an interview on 5/2/24 at 11:05 a.m. Staff A stated that towards the end of her shift, approximately 6:00 a.m. on 4/22/24 she assisted Resident #6 to the bathroom. Staff A described Resident #6's walker as tall and when she turned to back into the bathroom the walker tried to tip sideways and Resident #6's knees bent. Staff A tried to ease her to the floor the best that she could. Staff A stated Resident #6 expressed concern about her knee and her leg immediately after her fall. Staff A responded that she didn't use a gait belt for the transfer even though she knew Resident #6 needed one with transfers. When the Surveyor questioned if she had an available gait belt, Staff A responded someone stole hers that the facility provided, so she didn't have one with her at the time. Staff A added she didn't attempt to get a new gait belt or to borrow a gait belt. Staff A stated she knew the facility required a gait belt for all staff assisted transfers. Staff A stated the facility terminated her for not using a gait belt during the transfer. She hasn't returned to work. On 5/2/24 the Director of Nursing (DON) explained it is a facility policy and an expectation for staff to use a gait belt for all staff assisted transfers. The DON reported the facility educated Staff A, gave her a gait belt, and signed the expectation acknowledgement. The DON stated Resident #6 reported that despite asking Staff A to use a gait belt, she didn't have one on. The DON explained the facility terminated Staff A on 4/22/24 for violation of facility policy and protocol for not using a gait belt for a staff assisted transfer. During a following interview on 5/2/24 at 12:05 p.m. the DON revealed the facility provided gait belts and educated the staff a new gait belt is available at the front desk with access through the charge nurse 24 hours, 7 days a week. Observed 10 new gait belts inside a drawer at the front desk. The Gait Belt Usage document last reviewed 8/8/23 instructed to use gait belts to safely assist residents with transfers and walking. The policy directed to use gait belts on Care Planned residents that require assistance with ambulation and or transfers unless otherwise specified. The Gait Belts facility document directed a gait belt must be with employees at all times and used for every transfer. If staff did not bring their own, the facility will provide one. Staff A signed the agreement on 4/22/24 to use a gait belt for all transfers and have one with them at all times when working and caring for residents at the facility. Additionally, Staff A agreed that not using a gait belt could result in termination. Staff A further indicated by an X that she received a gait belt by the facility. The Employee Action Form dated 4/22/24 identified the facility terminated Staff A for not following the gait belt policy.

Based on video observation, interviews, policy, and record review, the facility failed to supervise a resident who needed cues to slow down while eating and provide adequate staff for supervision for 1 out of 5 residents reviewed (Resident #1). Due to the lack of supervision provided to Resident #1 at meals, he was able to eat his dessert very fast. As he started to choke on the dessert, the Certified Nurse Aide (CNA), passed out the meal to the other residents and didn't hear him choking. When the nurse arrived, she alerted the CNA to the situation and took action, due to the consistency of the dessert, the staff couldn't clear the resident's airway. This resulted in his death. This failure resulted in an Immediate Jeopardy situation to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of March 25, 2024 on April 2, 2024 at 12:14 PM. The Facility Staff removed the Immediate Jeopardy on March 28, 2024 through the following actions: a. 3/25/24 all nursing home staff were educated on Geri Card expectations, purpose being to give a visual reminder of those residents that require supervision during meal time. b. House wide audit completed on 3/28/24 of all Geri-cards and Care Plans for those residents that require supervision during meal time. c. Residents that require supervision were identified, lists of those residents were placed in appropriate households. Those households were provided with education and expectations of supervision at meal time on 3/28/24. d. On 3/28/24, A notice was sent out to all of the staff and they have been reminded of the specific residents and have been trained to make sure they are supervising those that require supervision. e. Staff members that are supervising residents during dining time will be in proximity of all residents needing supervision with no other job duties at that time plan to have supervisors audit every meal for 7 days and make sure the supervision is getting done correctly. f. Starting 4/5/24, We plan to have supervisors audit a random meal every day for 3 months. This will be reported on and reviewed at Quality Assurance Performance Improvement (QAPI). The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 128 residents. Findings Include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. Resident #1's Clinical Record included diagnoses of dysphagia (difficulty swallowing), dementia and history of stroke. Review of untitled and undated facility provided document revealed Resident #1 had a hypoxic episode that caused death, related to an occluded airway. Review of facility document titled Investigation Summary signed and dated 3/25/24 revealed Resident #1 was coughing at mealtime after consumption of brownie and coughed a few times and then showed signs of hypoxia. Heimlich was attempted several times unsuccessfully by multiple staff. The Police department, First Responders and Emergency Medical Technicians then arrived and took over. Review of Resident #1's Care Plan revealed the following information: a. Regular diet, cut all food into bite sized pieces. Half portions of all desserts with date initiated 3/15/24. b. Finger foods when unable to use utensils. Staff supervision with intakes. Provide 1 food at a time. Cue to slow down at meals with a date initiated 3/15/24. c. Monitor, document, report as needed any signs or symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals with date initiated 3/15/24. Review of Resident #1's progress notes revealed the following information: a. 3/25/24 at 2:38 PM, Resident #1's wife left with Resident #1's personal belongings. The Funeral Home was notified and the wife declined an autopsy at this time. b. 3/25/24 at 2:47 PM, order received to release the body to the funeral home of choice. Review of Resident #1's electronic health record lacked documentation regarding information on the incident that occurred on 3/25/24. Review of written statements provided by the facility revealed the following: a. Staff E, Licensed Practical Nurse (LPN) dated 3/25/24 , almost done with lunch and went to tell Staff D, Certified Nursing Assistant (CNA), she was going to another household when she seen Resident #1 coughing. She pulled him back from the table because of dignity concerns and saw his lips turning blue. b. Staff D, (CNA), dated 3/25/24 around noon Staff E got my attention, Resident #1 was blue in the face. In the dining room, was helping serve plates. Didn't notice choking while eating lunch, consumed his plate and moved onto dessert. He had his caramel brownie in front of him for a few minutes before had trouble. He ate his lunch so fast but was not choking prior to this. He often needed verbal cues to slow down eating. c. Staff I, homemaker dated 3/25/24 the CNA helped take orders, she read all the Geri cards and Staff I dished out all the food and handed the plate to the CNA as she was helping serve. Interview on 3/27/24 at 3:09 PM Staff D, (CNA), revealed she was in the dining room and was monitoring the residents when Staff E, LPN, got her attention regarding Resident #1. Staff D revealed the homemakers send Resident #1's food cut up into bite sized pieces for him. Staff D revealed she could not remember if she had given any reminders to Resident #1 to slow down during the meal or not. Interview on 3/27/24 at 3:50 PM Staff E, LPN, revealed she had come around the corner and into the dining room and was going to tell Staff D she was going to another household to give insulin but Staff D did not hear her and she came closer into the dining area and that is when she noticed Resident #1 coughing. At that time, she had noticed Resident #1 had a mess on his clothing protector and was coughing with his mouth closed. Staff E explained she told him to spit it out and a large around of food came out of his mouth and that is when she noted that his lips were starting to turn blue. Interview on 3/27/24 at 3:52 PM Staff F, Homemaker revealed she had come back over to Resident #1's household and the meal plates were already being served. She revealed that she dished up his dessert into the dish and cut up his brownie into bite sized pieces. Interview on 3/27/24 at 4:04 PM Staff H, Certified Medication Assistant (CMA), revealed Resident #1 needed reminders during meals to slow down while eating. Staff H further revealed that reminding Resident #1 needed to be done several times not just a one-time reminder during meals. Interview on 3/27/24 at 4:43 PM the Director of Nursing (DON) revealed upon admission of Resident #1 his wife had explained to the facility what she had been doing at home during meals. The DON revealed Resident #1 was very impulsive and needed supervision. The DON further revealed the facility added the supervision and verbal cues to his Care Plan to continue the care. Interview on 3/28/24 at 11:17 AM the DON revealed all the residents in the dementia unit are to be supervised. The DON revealed there are residents in the facility other than in the dementia unit that need supervision or assistance with eating. Interview on 3/28/24 at 11:21 AM the DON revealed the facility expects when residents are to be supervised for choking issues it means eyes on the resident while serving and eating of the meal is occurring. Interview on 3/28/24 at 11:59 AM Staff E revealed the day the incident occurred she had her medication cart parked on the west wall and was unable to see into the dining room with the long table. Staff E further revealed she has since moved her medication cart to the south wall so that she is able to see into the dining room with the long table. Staff E revealed on 3/25/24 she came around the corner into the dining room to tell Staff D she was going to another household and Staff D was up at the kitchen window with her back to the residents and dining table. That is when she seen Resident #1 coughing. Interview on 3/28/24 at 12:06 PM Staff D revealed she was by the long table at the serving window when Staff E got her attention. Staff D revealed she served Resident #1 his brownie and it was cut up into bite sized pieces. Staff D did not recall hearing any resident cough prior to Staff E getting her attention for Resident #1. Staff D revealed she only turned her back to the residents when she was getting another plate from the kitchen to serve. Staff D further revealed supervision with meals means mostly being in the area and making sure residents are supervised. Interview on 3/28/24 at 12:26 PM Staff G, Registered dietician revealed she had met with the Resident #1's family prior to care conferences being held. Staff G explained Resident #1's wife had cared for him at home and explained Resident #1 needed to have supervision during meals, his food cut up into bite sized pieces, and one item at a time. Staff G stated the physician had ordered him a regular diet but the facility implemented the interventions the wife had done at home. Staff G further explained supervision for Resident #1 means eyes are to be on him and able to cue him as needed. Interview on 4/1/24 at 2:06 PM Resident #1's wife revealed she had talked to the facility on admission regarding the assistance he needed with meals. Resident #1's wife explained to the facility she had been cutting his food up very small, only giving him one item at a time, and being with him and watching him the entire time he would eat. She explained that Resident #1 would eat all the food that was placed in front of him until his plate was empty unless someone was watching him. She further revealed she told the facility staff several times they needed to watch him while he was eating. Interview on 4/1/24 at 5:04 PM Staff F revealed Staff D was at the window helping Staff F and Staff I serve the lunch meal. Staff D was turned facing into the kitchen and had her back towards the dining room and residents eating. Review of facility provided policy titled Meal Supervision and Assistance with an approval date of 8/23/23 revealed the following information: a. The resident will be prepared for a well balanced meal in a calm environment, location of his or her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition and assure an enjoyable event. This includes identifying hazards and risk, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary. b. Definitions include supervision and adequate supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff members required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. c. The facility will develop and implement an individualized Care Plan based on the Resident Assessment Instrument to address the resident's needs and goals and to monitor the results of the planned interventions such as adequate supervision during meal time. d. Do not serve the meal until the attendant is ready to assist the resident.

Based on interviews, record review, and policy review, the facility failed to ensure call lights responded to in a timely manner for 4 out of 4 residents reviewed (Residents #8, #9, #10 and #11). The facility reported a census of 128 residents. Findings include: 1. Interview on 4/2/24 at 2:41 PM Resident #8 revealed she has to wait a long time for the staff to take her to the bathroom, so she takes herself. Resident #8 further revealed she doesn't feel there is enough staff in the facility to take care of her needs. Review of the facility provided document titled Alarm Response Report dated 4/2/24 with report dates from 3/26/24 - 4/2/24 revealed the following: a. On 3/28/24 the call light turned on at 8:08 AM, and was on for 17 minutes. b. On 3/30/24 the call light turned on at 8:46 AM, and was on for 29 minutes. 2. Interview on 4/2/24 at 2:49 PM Resident #9 revealed she does not get out of bed at times because the facility doesn't have enough staff to transfer her to her wheelchair. She continued, she doesn't get dressed on those days either. Resident #9 revealed she would like to get up and get out of her room instead of being in bed all day. Resident #9 further revealed that when she uses her call light, it takes the staff a long time to answer it. Review of the facility provided document titled Alarm Response Report dated 4/2/24 with report dates from 3/26/24 - 4/2/24 revealed the following: a. On 3/26/24 the call light turned on at 6:00 PM, and was on for 17 minutes. b. On 3/30/24 the call light turned on at 5:34 PM, and was on for 24 minutes. c. On 4/2/24 the call light turned on at 9:40 AM, and was on for 22 minutes. 3. Review of Resident #10 progress notes revealed the following: a. Resident #10's wife reported she turned the call light on, but when staff did not come she walked out into the hallway and yelled out to staff while walking up and down the hall. Resident #10's wife reports no staff was able to be found, nor emerged from the other resident's room. Resident #10's wife then ambulated out of the unit into the hall. This is where a Registered Nurse (RN), who was in another household heard a woman calling out from the hallway, [NAME] Hoo!! repeating this call. This RN went to the doorway when the door opened up from the outside. Resident #10's wife had pushed the automatic button and this RN recognized Resident #11 in her nightgown, with no footwear and no walker. Resident #11 was short of breath and reported Resident #10 had fallen and was on the ground in their room. When the RN went to Resident #10's room, she saw him alert and sitting with his back against his recliner. Review of the facility provided document titled Alarm Response Report dated 4/2/24 with report dates from 3/26/24 - 4/2/24 revealed the following: a. On 3/26/24 the call light turned on at 1:52 PM, and was on for 23 minutes 4. Interview on 4/2/24 at 3:52 PM Resident #11 revealed it depends on who is working on quickly the call light gets answered. Resident #11 revealed Resident #10 had fallen and she couldn't find anyone in their household, she left the household to find help Review of the facility provided document titled Alarm Response Report dated 4/2/24 with report dates from 3/26/24 - 4/2/24 revealed the following: a. On 3/26/24 the call light was turned on at 1:52 PM, and was on for 24 minutes. b. On 3/26/24 the call light was turned on at 7:02 PM, and was on for 43 minutes. c. On 3/26/24 the call light was turned on at 9:02 PM, and was on for 23 minutes. d. On 3/30/24 the call light was turned on at 1:01 PM, and was on for 21 minutes. Review of facility provided policy titled Call Light Response with a review date of 8/21/23 revealed the purpose of this policy is to ensure that all call lights are answered promptly (Prompt response being considered as no longer than 15 minutes). The policy continues with the scope of the policy is the call light is to be answered within 15 minutes or less and the responsibility is all staff are responsible for answering a resident's call light any time that was on. Interview on 4/3/24 at 7:52 AM the Director of Nursing revealed the expectation is all call lights are answered in 15 minutes or less.

Based on record review, policy review, and staff interviews the facility failed to provide accurate resident records for 1 of 4 residents (Residents #1). Following Resident #1's death, the facility failed to document the situation in his clincial record until after the start of the survey, two weeks later. The facility reported a census of 128 residents. Findings include: The clinical record for Resident #1 documented diagnoses of dysphagia (difficulty swallowing), dementia and history of stroke. The MDS showed the Brief Interview for Mental Status (BIMS) score not completed. Review of untitled and undated facility provided document revealed Resident #1 had a hypoxic episode that caused death, related to an occluded airway. Review of facility document titled Investigation Summary signed and dated 3/25/24 revealed Resident #1 was coughing at mealtime after consumption of brownie and coughed a few times and then showed signs of hypoxia. Heimlich was attempted several times unsuccessfully by multiple staff. The Police department, First Responders and Emergency Medical Technicians then arrived and took over. Review of Resident #1's progress notes revealed the following information: a. 3/25/24 at 2:38 PM, Resident #1's wife left with Resident #1's personal belongings. The Funeral Home was notified and the wife declined an autopsy at this time. b. 3/25/24 at 2:47 PM, order received to release the body to the funeral home of choice. Review of Resident #1's electronic health record lacked documentation regarding information on the incident that occurred on 3/25/24. Review of facility provided policy titled Documentation in Medical Record with a review date of 12/12/23 revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Review of facility provided policy titled Medical Records with approval date of 8/8/23 revealed the facility will maintain clinical records on each resident in accordance with accepted professional standards of practices that are complete, accurately documented, readily accessible, and systematically organized. Interview on 4/3/24 at 7:52 AM the Director of Nursing (DON) revealed when there is an incident, it should be charted in the resident's chart.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 2 residents reviewed for falls (Resident #103). The facility reported a census of 117 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #103 had a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. The MDS further documented the resident had diagnoses including fractures and other multiple trauma, hip fracture and non-Alzheimer's dementia. Review of medical records from a local Medical Center, dated [DATE] for Resident #103, under history of present illness, documented the resident had an unwitnessed fall on [DATE] at the facility which resulted in a left hip fracture. The Care Plan for Resident #103 at the time of the fall on [DATE], with initiation dates of [DATE] and [DATE], documented under the focus area for activities of daily living (ADL), the resident had an ADL self-care performance deficit related to a right hip fracture. Under the interventions and tasks area, under ambulation, the resident was an assist of one staff with a front-wheeled walker (FWW). Under transfer, the resident was an assist with one staff with the FWW. Under gait belt, staff are instructed to follow facility protocol as resident allows for gait belt usage. Resident #103 had a focus area stating she had impaired cognitive function/dementia or impaired thought processes related to dementia and under interventions and tasks, directed staff to cue, reorient and supervise as needed. During an observation [DATE] at 1:30 PM of the household where Resident #103 resides (Julia's Place), the layout of the household included a locked entry door, which entered into a main family room with a smaller family room in the back, the kitchen and dining areas were to the right of the family room and a long hallway to the left of the family room which housed the resident rooms. The entirety of the hallway with the resident rooms could not be viewed from the dining room, the kitchen, or the family room. During an interview [DATE] at 2:30 PM, Staff K, certified medication aide (CMA), advised she had worked at this facility in Julia's Place household for several years, normally the 7:00 AM to 3:00 PM shift. Staff K stated they are short staffed often on this unit, to be fully staffed they need a CMA or nurse for medication pass, two certified nursing assistants (CNA's) and a homemaker (the homemaker does the kitchen and dining duties). They normally only have one CNA and one CMA, several times they do not have a homemaker and it is just her as a CMA and one CNA working. When it is just her and a CNA working she is trying to do medications and gets pulled into CNA work. She needs to assist the CNA and do CNA work on top of medications, which can be challenging. During these times when they are short staffed it is difficult to get to residents as quickly as they want to, especially if a resident is a two person assist or a mechanical lift. Staff K advised it is challenging when they are short staffed given their population on this household and needing to redirect residents who walk without their walkers or who wander into other resident's rooms. The layout of the unit also makes it difficult to observe the entire unit, with a long hallway with resident rooms and the kitchen and dining area on the other side and the family rooms in the middle, however if a staff is in the dining room or family room, they cannot see down the hallway where the resident rooms are located. Staff K was not working on the date and time Resident #103 fell . During an interview [DATE] at 2:30 PM, Staff R, certified nursing assistant (CNA), advised she was working the day Resident #103 fell , on the 22nd of December, 2023. The fall took place during dinner time. At that time the resident was a 1 person assist with her walker. Staff R advised the resident would normally use her walker, she would not very often get up without using it, however she would get up without waiting for staff to assist her with the gait belt, and assist her with walking. At the time of the fall, it was just Staff R working and a CMA and a homemaker- the homemaker was new and had several questions for Staff R. Staff R stated to be sufficiently staffed on this household, which is a chronic confusion or dementing illness (CCDI) unit with 15 residents, they need 2 CNA's, one CMA, a homemaker, and a registered nurse (RN) who floats. At the time of the fall, they only had 1 CNA, 1 CMA, and a new homemaker. They were just starting to serve dinner and Resident #103 did not have her dinner yet, she was sitting at the table, however she got up and left the table before being served her dinner. Staff R advised the resident was more restless in the evening and had more behaviors in the evenings. She would move around often. Resident #103 got up from the table without a gait belt assist and walking assistance and left the dining room. Staff R advised she could not follow the resident because she was the only one in the dining room and she needed to supervise the other residents, they have residents who are Care Planned to have supervision while eating. She asked the resident to come back to the table, however the resident continued to walk with her walker and went through the family room and turned to go down the resident room hallway, which cannot be observed from the dining room due to the layout of the unit. The CMA working at the time was in another resident's room giving medications. A little while later, another resident came into the dining room and told Staff R that Resident #103 was on the ground in the hallway of the resident's rooms. Staff R went down to the hallway and found the resident on the floor. She yelled out for the CMA and she and the CMA lifted the resident off the ground with a mechanical lift. They immediately called for the nurse who came within a few minutes and called for an ambulance. Staff R advised the next day after the fall she told her scheduler that she did not want to work a shift with just one CNA and one CMA, the scheduler told her that this was going to happen and did schedule her again to work with just a CMA and not another CNA. Staff R told the scheduler she did not feel safe working without another CNA. Staff R felt if they would have been fully staffed the night Resident #103 fell they could have prevented the fall as they could have redirected her back to the dining room and given her the 1 person assist with ambulating and supervision. During an interview [DATE] at 2:50 PM, Staff S, CMA, advised she had worked here for a total of [AGE] years, solidly for the past [AGE] years. She moves around to different households and varying shifts. She was working as a CMA the day Resident #103 fell , this was during dinner time. At that time, the resident used a walker to ambulate and was a one person assist, she was non-compliant at times and would get up without waiting for a gait belt assist and did not want anyone helping her. The night Resident #103 fell , Staff S was passing medication and had just looked down the hallway and the resident was not there, she was in the dining room. At the time of the fall, it was just Staff S and one CNA working with a homemaker, they did not have a 2nd CNA. Staff S said they should always have a 2nd CNA, especially due to this population on the CCDI unit and especially in the evening with sundowning (referring to an increase in confusion/behaviors in the evening, after sundown) and more behaviors and restlessness. Staff S said there have been several times that she has worked on this unit/household and there has only been 1 CNA and one CMA and a homemaker, and sometimes just 1 CNA, a CMA, and no homemaker, only two staff working. Staff S stated this creates a challenging and difficult situation, and she feels an unsafe situation, when they are not sufficiently staffed. It is hard to meet the residents needs and it is hard for her to pass medications and do CNA work, or homemaker worker in the kitchen. Staff S could not recall specifically where she was or what resident's room she was in when the resident fell that day, she only recalls she was passing medication. During an interview [DATE] at 3:44 PM, the Administrator and Director of Nursing (DON) advised normal and sufficient staffing on Julia's Place household is a CMA, a homemaker, 2 CNA's during the day and a nurse who floats between households. During the 2:00 PM -10:00 PM shift, normal and sufficient staffing is a CMA, 2 CNA's until 7:00 PM, a homemaker and floating nurse. The DON stated Resident #103 came to them as high risk with a prior hip fracture and was not compliant at all times. The DON does not feel supervision was a concern at the time of the fall, or adequate staffing, even though she acknowledged they only had 1 CMA and 1 CNA and a homemaker working at the time, it was dinnertime and before 7:00 PM, the household did not have a 2nd CNA at the time of the fall. The DON advised she was informed during her interviews after the fall that the CMA was in the dining room, not that she was passing medications. The DON and Administrator acknowledge supervision needs to take place while residents are eating, some residents on this household have this on their Care Plan. The DON felt the homemaker could help with supervision, even while getting food ready and even though they are not CNA trained or CPR certified. Review of the Facility Assessment, updated July of 2023, under general care- specific care or practices, documents hazards and risks for residents will be identified, care and services will be based on resident population, including assistance with activities of daily living and mobility assistance, mobility and fall/fall with injury prevention.

Based on record review and staff interview the facility failed to follow careplan and implement new interventions after a fall and failed to have functioning call lite in which Resident #97 waited for assistance after falling for 2 of 4 residents. (Resident #67 & Resident #97). The facility reported a census of 122 residents. Findings include: 1. Resident #67's 8/7/19 Minimum Data Set (MDS) documented the resident had severely impaired cognitive function, required supervision for ambulation and had no history of falls since the prior assessment period. The resident's Care Plan included a problem stating the resident had falls related to impaired mobility and dementia. Staff documented in an incident report on 9/29/19 at 10:57 PM they found the resident seated on the bathroom floor in front of the toilet. She denied any pain and specifically denied pain in the head, neck, spine or hip at the time of the fall. They noted a recommendation for the resident to use gripper socks at all times when ambulating. The resident's Care Plan documented an intervention added 2/13/19 which directed staff to encourage gripper socks when not wearing shoes. During interview on 12/12/19 at 2:28 PM the Director of Nursing confirmed the gripper socks had been added to the Care Plan prior to the fall on 9/29/19. He stated the resident had been barefoot when she fell . When asked what interventions could have been added he stated the nurse could have increased frequency of rounding, they could have put the bed in low position or added a floor mat. He stated each unit had a list of possible fall interventions to be implemented in the event of a fall. Staff documented in the Nursing Progress Notes on 9/30/19 at 4:54 AM staff found the resident on the bathroom floor complaining of head, neck and back pain. They noted a decline in mental status and found a large hematoma forming on the back of the resident's head. Staff sent the resident by ambulance to the emergency room . Staff documented in the Nursing Progress Notes on 10/3/19 the resident returned from the hospital at 3:00 PM with a [DIAGNOSES REDACTED]. 2. The Minimum Data Set (MDS) assessment with a reference date of 5/11/19 for Resident #97 identified a Brief Interview for Mental Status (BIMS) score of 7 indicative of severely impaired cognition. According to the MDS, the resident required limited assistance of one person for transfer, toilet use, and personal hygiene and extensive assistance of one person for bed mobility. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, and turning around. The resident had [DIAGNOSES REDACTED]. The resident had experienced no falls since admission or prior assessment. A Morse fall scale completed upon admission reflected the resident at a high risk for falls. The Resident Care Plan, dated as initiated on 5/14/19 included a focus area that identified the resident is at risk for falls related to gait/balance problems. The care plan last revised on 5/14/19 directed staff to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. An incident report dated as initiated on 7/13/19 at 7:15 AM by Staff R, Registered Nurse (RN) documented the resident was found on the floor in resident's room, with back resting against the footboard. The resident reported pain in left hip and was transferred to the hospital via ambulance. The incident report further documented immediate actions taken included gripper socks when in bed, and bed lowered to the floor. The resident returned from the emergency room with no weight bearing-bedrest, and a CT scan on 7/15/19 showed a non-displaced evulsion fracture to L hip. The facility reported no other falls prior to this fall. A progress note dated 7/13/19 at 11:11 AM documented an incident note initiated by Staff R, RN which reflected she was doing walking rounds at 7:15 AM when she found the resident sitting on the floor in room. Staff R, RN noted the red light was on, on the residents call light indicator in her room. The nurse documented she further proceeded to turn the call light off. The nurse noted dried blood smeared on the floor, on the residents hand and dried blood in her hair. There were blood stains on the privacy curtain and the curtain had been pulled half way down. The resident reported to the nurse that she had called for help after she fell , not before. The resident stated to Staff R, RN that she had been sitting there for a long, long time. In an interview on 12/12/19 at 10:39 AM Staff R, RN stated on 7/13/19 the overnight shift left as soon as she and the first shift arrived to work at 7:00 AM, without giving a thorough report. Staff R proceeded down the hall where she found the resident on the floor as described in progress note. Staff R, confirmed that the red light on the call light pad on the wall was blinking which indicated it was activated, however there was no audible sound that had been noticed by staff. Staff R, stated the resident reported she had gotten up to use the bathroom, but denied asking for assistance and confirmed had activated the call light once had fallen. Staff R stated the call light was attached to the blanket on the resident's bed. Staff R reported she deactivated the call light and then reactivated to ask for assistance for fallen resident. Staff R reported that she had investigated and found the sound had been muted on the computer which would silence the alarm. The alarm would have a visual at the computer, but stated the call lights do not go to a pager or other device. Staff R reported they have had concerns with staff muting the alarms, and she usually checks at the beginning of the shift but had been unable to check at that point. Confirmed that the resident is scheduled for every 2 hour incontinency check and change. During an interview on 12/12/19 at 2:10 PM, Staff V, Certified Nursing Assistant (CNA) stated she clocked in at 7:00 AM, and the night shift aid left. She was attending to a resident who was agitated while the nurse went to check residents. Staff V confirmed there was no audible alarm. She responded to the nurse asking for assistance. Reported when she entered the resident's room Staff R, RN stated the red light for the call light was blinking. Staff V saw the resident sitting on the floor, facing the foot of the bed. Stated blood was dried, on the curtain. Further stated the resident stated she had fallen, and it had taken a bit to get to the call light, but stated the resident had been there a long time before she got help. In an interview on 12/16/19 at 11:30 AM Resident #97 reported had fallen and broken her hip. She confirmed that she had not called for assistance prior to her fall, and that was a mistake. Reported she did call for help after had fallen and waited a long time, which she estimated was at least 2 to 3 hours. The resident reported she had not been afraid. In an interview on 12/16/19 at 1:15 PM, the Director of Nursing (DON) stated there was a no tolerance expectation that had been reviewed with all staff that directed the sound on electronic devices could not be turned down or silenced.

Based on observation, clinical record review and staff interviews, the facility failed to implement procedures to monitor exit door alarms to ensure that each resident received adequate supervision to prevent elopement and failed to respond to an exit alarm for 1 of 42 residents monitored by the WanderGuard system which resulted in a resident exiting the facility unsupervised (Resident #2). The facility failed to ensure the proper size sling for a mechanical lift was identified/utilized for 7 of 9 residents reviewed that transferred with a mechanical lift. (Residents #6, #24, #68, #3, #48, #97 & #126). The facility identified a census of 150 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment dated [DATE] that documented [DIAGNOSES REDACTED]. The assessment documented he walked with the assistance of one and displayed no behavioral symptoms. Resident #2's interdisciplinary working plan of care dated 7/31/18 directed staff place a WanderGuard for safety. The Elopement Risk assessment dated [DATE] identified Resident #2 scored a 4 indicated a high risk for elopement and identified the following risk factors: independently mobile, previous history of wandering, and [DIAGNOSES REDACTED]. The Elopement Risk assessment dated [DATE] documented Resident #2 had an actual elopement on 8/26/18, and scored a 7 which continued to indicate a high level of elopement risk and identified the following additional risk factors: episodes of disorientation/confusion and talks of leaving the facility. An Elopement Incident Report prepared by the Assistant Director of Nursing (ADON) on 8/26/18 at 8:00 pm revealed Resident #2 was witnessed outside of the facility without staff assistance, attempting to open the door of a car. The resident was redirected inside and assessed. The document further revealed the WanderGuard as noted to be in place and functioning and all exit doors were checked and found to be functioning properly. The report further documented on 8/28/18 the ADON reviewed the security footage which revealed the resident pushed on the front door long enough to have the WanderGuard function disarm and open, the resident exited and went outside the facility for approximately 8 minutes and out of view of the camera for 4 additional minutes. On 9/3/18 the resident transferred to the facility's Chronic Confusion Dementing Illness (CCDI) unit. During an interview on 9/19/18 at 12:38 p.m. Staff A, Certified Nursing Assistant, CNA stated on 8/26/18 at approximately 8:00 pm she worked in a resident room when she heard a visitor question why a man was trying to get in her car in the parking lot. Staff A recognized the resident, went to the parking lot and redirected Resident #2 back inside. Review of a Wander Management Report confirmed Resident #2 (via transmitter 28) activated the main entry door on 8/26/18 at 7:49 pm and the door alarmed until 8:00 pm. In an interview on 9/19/18 at 10:50 am, the Maintenance Director demonstrated the exit door alarmed when a WanderGuard chip placed near the door, the alarm sounded urgent, loud and audible and the exit door locked down and released after 15 seconds. The urgent alarm sound continued until the Maintenance Director disarmed it by entering a code. He further demonstrated that a phone monitored by the front desk staff makes a non-urgent tone each time an exit door is opened and digitally displayed the door alarmed. The Maintenance Director confirmed on the date of the incident the front desk was staffed from 8:00 AM to 7:00 PM., and revealed the phone monitor is passed from the front desk staff to staff on Ivy's place when they leave. During an interview on 9/19/18 at 2:00 pm Staff B, Licensed Practical Nurse, LPN stated at approximately 6:45 pm on 8/26/18 front desk staff laid the alarm phone monitor on the medication cart in Ivy's Place. Staff B stated she had worked at the facility for 14 weeks, as a contract employee, and had never been trained on the phone monitor. Staff B further stated she was unsure of the purpose of the alarm phone monitor or what to do if she would hear an alarm. Staff B stated she did not hear the alarm and did not know a resident had eloped until later in the shift when she received direction to complete a roll call. During an interview on 9/19/18 at 3:40 pm Staff C, LPN charge nurse Ivy Place revealed he had worked at the facility for 2.5 weeks, and received the phone monitor around 8:00 PM and knew of the expectation to carry the phone. Staff C stated the phone went off frequently, making a 'bubbly' sound, but it never sounded an urgent alarm sound that required him to respond. Staff C had been trained by another contract employee prior to her leaving. Staff C was not aware of the digital display of the alarmed door and the front main entrance as the only door required to respond to. In an interview on 9/19/18 at 3:50 pm, the ADON stated staff were trained to keep the phone monitor with them and to respond to the alarm. She did not know the phone monitor did not make a different sound when alarmed by a WanderGuard sensor and it made the same audible tone when a staff person/visitor exited. The ADON stated staff in Ivy Place would not be able to hear the audible urgent alarm that sounded at the door when a WanderGuard sensor triggered the alarm. they would not be able to differentiate if a guest or a WanderGuard resident had exited. The ADON stated this may have contributed to staff failure to respond to the WanderGuard alarm at the front entrance on 8/26/18. The ADON further revealed no formal training had been provided to staff which gave clear expectations of responsibility to respond to exit door alarms and/or the expectation to monitor alarm device after 8:00 pm. The ADON stated further training and planning would be required. The resident's elopement resulted in an Immediate Jeopardy situation for the facility. The facility abated the Immediate Jeopardy situation on 9/19/18, through policy revision, re-routing door alarms and staff training on the use and check of the WanderGuard alert system. 2. Resident #6 had a MDS assessment dated [DATE] which identified [DIAGNOSES REDACTED]. The MDS further documented short and long memory problems with some difficulty in making daily decisions in new situations and totally dependent on two staff for bed mobility, transfer, dressing, personal hygiene and toilet use. The MDS reflected a weight of 138 pounds and a height of 64 inches. The Incident Report dated 7/18/18 at 1:00 pm, recorded Resident #6 fell while being transferred to bed, described as the resident slid out of Hoyer (mechanical lift) sling and the top half (of their body) landed on the lift legs. The resident sustained [REDACTED]. A History and Physical note dated 7/18/18 at 7:26 pm documented Resident #6 transported to the emergency room after falling during a Hoyer lift transfer at the nursing home. During transfer she developed [MEDICAL CONDITION] (an abnormally fast hear rhythm). The resident had no significant injury from the fall based on imaging studies. Review of Care Plan for Resident #6, reviewed on 6/6/18, revealed staff direction to transfer with a Hoyer lift and a criss-cross sling. The care plan contained no direction for the size of the sling to be used to transfer the resident. During a phone interview on 9/24/18 at 12:27 pm, Staff D, CNA stated on 7/18/18 she completed mechanical lift transfer for Resident #6 from wheelchair to bed. Staff D used the sling labeled with the resident's name, crossed between the legs, and used all 3 straps which she reported were all intact. Staff D stated when the resident lifted from the wheelchair, she could see the resident's lower back through an open area just above where the straps that criss-cross meet and she usually could not see the resident's lower back during transfer. Staff D removed the wheelchair and noticed even more of the resident's lower back visible and exposed through the opening. Staff D felt concerned about the observation but continued to transfer the resident to bed. As the lift turned to position the resident above the bed and staff lifted the resident's legs, the resident's shoulders came through the opening in the sling (the same opening she saw the resident's lower back through). The resident then fell head first, striking her head on the Hoyer which caused a goose-egg size lump to form. The ADON arrived, investigated the incident and the sling and informed staff it was the wrong size sling, too big, and she did not know why this sling was identified for use on the resident. Staff D stated is a new employee at the facility, began employment 3 months ago. She had completed new employee skills checklist which included mechanical lift transfers, however denied being evaluated or observed completing a mechanical lift transfer following the incident. Interview on 9/20/18 at 3:00 pm with the ADON and Director of Nursing (DON) confirmed the ADON had completed the investigation into the fall from mechanical lift for Resident #6. From her investigation the ADON determined that staff failed to use the proper size sling, stated the sling was too large for the resident and referred to it as a bariatric sling. The ADON determined staff also failed to properly position the sling under the resident which caused her to fall through the opening in the sling. The resident's care plan directive for transfer did not specify the size of sling to be used. The DON stated referrals have been sent to therapy to assess all mechanical lift transfers to direct the type and size of sling to be used with the E-Z Way lift, which is the mechanical lift used by the facility. 3. The MDS assessment dated [DATE] documented Resident #24 had [DIAGNOSES REDACTED]. The resident's care plan dated 9/12/18 identified a problem of self-care deficit and included an intervention to use a Hoyer lift with the assistance of 2 with transfers. A document dated 9/25/18 titled Interdisciplinary Working Plan of Care, used by staff to direct daily care, documented the resident required a Hoyer lift for transfers with the assistance of 2. The care plan and working care plan failed to instruct the size and type of sling to use with transfers. 4. The MDS assessment dated [DATE], documented Resident #68 had [DIAGNOSES REDACTED]. The resident's care plan dated 8/22/18 identified a problem of self-care deficit and included an intervention to use a Hoyer lift with assistance of 2 with transfers. A document dated 9/25/18, titled Interdisciplinary Working Plan of Care, used by staff to direct daily care, documented the resident was a Hoyer assist of 2. The care plan and working care plan failed to instruct the size and type of sling to use with transfers. During interview on 9/25/18 at 2:45 p.m., Staff E, CNA stated staff would look at the resident's body size to determine which Hoyer lift sling to use. If the resident looked small she would pick a small sling and if the resident had a large body she would choose a large sling. During interview on 9/26/18 at 9:45 a.m., Staff F CNA and Staff G CNA stated they are supposed to be getting rid of the solid slings and only use the shower slings. They still have several full cloth slings and they thought almost everyone needed a large sized sling. Staff F stated they had no clear direction if a resident needed a specific size sling. 5. The MDS assessment dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The care plan updated on 9/5/18 revealed the resident required a Hoyer and the assistance of two staff for transfers. The interdisciplinary plan of care dated 9/20/18 revealed the resident required a Hoyer and the assistance of two staff for transfers. Neither care plan identified the type or size of sling to be utilized. During observation on 9/25/18 at 8:38 a.m., Staff BB, CNA and Staff Y, CNA, placed a blue mesh Hoyer sling under the resident, attached the sling straps (blue straps on the top bar and purple straps on the bottom bar) to an EZ Way smart lift and transferred the resident from the bed to the wheelchair. 6. The MDS assessment dated [DATE] documented Resident #48 had [DIAGNOSES REDACTED]. The care plan updated on 7/18/18 revealed the resident required a Hoyer for transfers. The interdisciplinary plan of care dated 9/20/18 revealed the resident required a Hoyer and the assistance of two staff for transfers. Both plans of care lacked information regarding the type or size of sling to be utilized. During observation on 9/26/18 at 10:35 a.m., Staff EE, CNA and Staff Z, CNA, placed a blue mesh sling under the resident and connected the sling straps (green straps on the top bar and purple straps on the bottom bar) to an EZ Way Smart Lift. Staff EE and Staff Z then transferred the resident from the bed to a wheelchair. 7. The MDS assessment dated [DATE], revealed Resident #97 had [DIAGNOSES REDACTED]. The care plan updated on 8/22/18, revealed the resident required a Hoyer and the assistance of two staff for transfers. The interdisciplinary plan of care dated 9/20/18, revealed the resident required a Hoyer and the assistance of two staff for transfers. Both plans of care lacked information regarding the type or size of sling to be utilized. During observation on 9/25/18 at 2:25 p.m., the resident sat in a wheelchair and had a tan colored sling under them. Staff DD, CNA and Staff CC, CNA, pulled the sling straps between the resident's legs and criss-crossed the straps. Staff DD and Staff CC attached the sling straps to the EZ Way Smart Lift bars (black straps attached to upper body bar and green straps attached to the lower body bar). Staff DD and Staff CC used the EZ Way Mechanical Lift and transferred the resident from the wheelchair to the bed. During interview on 9/25/18 at 2:15 p.m., Staff DD reported she used the interdisciplinary plan of care to know what cares residents needed or how they transferred. Staff DD confirmed the plan of care (pocket care plan) had no sling type, color, or size listed for the residents who used a mechanical lift. Staff DD checked the linen storage area and found various slings on the cart, and confirmed no chart to determine the sling size for each resident who used the Hoyer/mechanical lift. Staff DD reported three residents in the(NAME)Household used a Hoyer for transfers. Staff DD reported they used a blue sling for two residents and used the sling with straps that criss-crossed for Resident #97. Staff DD reported staff just knew what sling they needed to use for each resident. During interview on 9/25/18 at 2:20 p.m., Staff CC reported only two residents used a Hoyer in the Christine's House household. Staff CC stated staff just knew they needed to use the sling in each resident's room. When the sling became soiled, she obtained another sling, in the same color, and replaced the sling to the resident's room. 8. The MDS assessment dated [DATE], identified Resident #126 had [DIAGNOSES REDACTED]. The care plan revised on 8/29/18, documented the resident as dependent on staff for mobility and required a mechanical lift for transfers. During observation on 9/26/18 at 8:29 a.m., Staff K, CNA and Staff S, CNA utilized the EZ Way Smart lift to transfer Resident #126 into the wheelchair. During interview on 9/26/18 at 9:34 a.m., Staff K stated that they are supposed to be using the solid slings but they now use the shower slings because staff cannot find the solid slings. During interview on 9/26/18 at 9:44 a.m., the ADON stated information related to which mechanical lift sling to use should be on the care plan. Review of the resident's care plan did not identify the type or size of sling to be utilized.

Based on observation, record review and staff interviews, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents (Residents #2, #3 & #4) reviewed. Facility census was one hundred fifty-four (154) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 3/8/18, assessed Resident #2 with impaired long and short term memory impairments. The resident had moderately impaired decision making ability. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident had no behaviors identified including rejection of care. The resident required total staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident did not ambulate and used a wheelchair for mobility. The resident was always incontinent if bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with 2 Stage 3 pressure sores. The largest pressure sore measured 5.2 centimeters (cm.) long by 3 cm. wide by 1 cm. deep. The MDS identified a Stage 3 pressure sore as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. (MONTH) include undermining and tunneling. On 3/23/18 the right ischium measured 6.3 cm. by 3.5 cm. by 2 cm The area was described as a Stage 3 ulcer tunneling superior to wound opening with yellow slough notes to muscle level beneath dermal layer. On 3/30/18 the right ischium measurements were unchanged with greater than 2 cm., tunneling superior to the wound opening. On 4/10/18 the right ischium measured 6.2 cm. by 3.2 cm. by 1.6 cm. with 5 cm. of tunneling. Skin sheets identified the coccyx measurement on 3/30/18 measured 3.1 cm. by 1.9 cm. by 0.2 cm. On 4/10/18 skin sheets revealed the coccyx measured 2.4 cm. by 1.5 cm. with depth of 0.4 cm. Daily notes revealed the resident admitted to Hospice on 3/1/18. Orders for treatment on that date were: pack sacrum and right ischial ulcers with [MEDICATION NAME] moistened gauze and cover with gauze daily. Wound clinic orders dated 3/22/18 at 10:57 a.m. revealed orders for the right ischium was: [MEDICATION NAME] moist gauze covered with dressing of choice. (MONTH) (YEAR) treatment administration records (TARs) identified the order for the area as: [MEDICATION NAME] solution 10%. Apply [MEDICATION NAME] moistened gauze to the sacrum/right ischial wound daily and as needed. Observation showed on 4/2/18 at 1:25 p.m. the resident eating in bed. Following the meal Staff B LPN (licensed practical nurse) completed pressure sore care to a deep right ischial wound and coccyx wound. Staff B soaked 2 by 2 gauze in [MEDICATION NAME] and packed the wound with 3 2 by 2 [MEDICATION NAME] soaked gauze pads into the ischial wound after cleansing with wound cleanser. Staff B then applied a [MEDICATION NAME] to the wound. [MEDICATION NAME] seeped out from under the [MEDICATION NAME]. Staff B then cleansed the coccyx wound and used gauze to wipe out the area. She then applied [MEDICATION NAME] soaked gauze to the coccyx area and covered it with [MEDICATION NAME] border. Staff left the resident on her back in bed. The resident remained on her back in bed at 2:45 p.m., 3:55 p.m. and 4:50 p.m. The resident laid on an air mattress. A 4/2/18 care tool directed staff to reposition the resident every 2 hours from side to side. Dietary progress notes dated 1/8/17 revealed the resident should receive super cereal and fortified potatoes. On 4/4/18 at 1210 p.m. the dietician stated the resident received fortified potatoes when mashed potatoes were on the menu. The resident should receive super cereal every morning. Observation on 4/4/18 at 9:45 a.m. showed the resident rolled up in bed feeding self. At 10 a.m. the resident was asleep with fork in hand. There was no super cereal on the tray. The tray contained biscuits and gravy and thickened water. At 10:08 a.m. staff entered the room to provide pericare. Observation showed the coccyx dressing rolled up and removed by Staff A CNA. The right ischial dressing was coming off and contained a date of 4/3/18. Review of the treatment administration record revealed Staff D LPN (licensed practical nurse) applied dressings to the pressure sores on the 2 p.m. to 10 p.m. shift on 4/4/18. On 4/10/18 at 2:50 p.m. Staff D stated there were no dressing on either pressure sore when she worked the afternoon/evening shift on 4/4/18. She reapplied the dressings around suppertime that night. (Meaning the dressing were off all day until suppertime) On 4/5/18 at 9:42 a.m. observation showed no dressings on the resident's bottom. At that time, Staff C CNA stated the dressings were off and in the bed with the resident when she saw the resident around 8 a.m. Interdisciplinary team care plan notes dated 3/21/18 identified the intervention of fortified potatoes not super cereal. Resident care plan goals with review date of 3/21/18 revealed the goal of the resident would allow staff to turn her from side to side to relieve pressure. 2. A MDS with assessment reference date of 1/4/18, assessed Resident #3 with impaired long and short term memory and moderately impaired decision making skills. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident did not have behavior symptoms identified. The resident required extensive assistance of 2 staff with bed mobility, transfers, dressing and personal hygiene. The resident was nonambulatory. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident at risk for pressure sores. The MDS did not identify pressure sores. A facility form dated 1/7/18 revealed the facility identified a 0.5 cm. by 2 cm. pressure area to the coccyx. A telephone order dated 1/15/18 identified an order for [REDACTED]. The most recent measurement of the coccyx was completed on 3/30/18. The area measured 3.1 cm. by 2.7 cm. with depth 0.1 cm. On 3/23/18 the area measured 3.4 cm. by 2.2 cm. The most recent order for the area was dated 2/9/18 that directed staff to apply [MEDICATION NAME] AG foam (3.2 by 3.2) to open area. Change every 2 days. A clarification dated 2/15/18 revealed staff should discontinue the venalex treatment and apply [MEDICATION NAME] AG foam to open area on bottom after cleansing. Change every 2 days and cover with opsite (transparent) dressing. Review of the 2/18 TAR showed a line through the [MEDICATION NAME] dressing. Review of the 3/18 TAR revealed the [MEDICATION NAME] was on the 3/18 TAR and signed for by staff. (even though it was discontinued). Observation on 4/2/18 showed the last dressing was dated 3/30/18 (3 days). On 4/2/18 Staff B LPN applied [MEDICATION NAME] border and not the ordered [MEDICATION NAME] treatment. The care tool dated 4/2/18 directed staff to ensure the resident used an alternating air mattress and equagel in the wheelchair. The care tool directed staff to reposition the resident every 2 hours and reposition off of coccyx. Observation showed, on 4/2/18 at 12:03 p.m. the resident rolled up in bed. The resident laid on an air mattress which was set on static (not alternating air) normal pressure. At that time Staff A CNA (certified nurse aide) provided pericare to the resident. A large bandage dated 3/30/18 covered the resident's coccyx area. Staff A removed the dressing since it was coming off. Observation showed an open sore on the coccyx. At 12:50 p.m. of the same date Staff B LPN (licensed practical nurse) used wound cleanser to cleanse the coccyx wound, cleansed around the sore with skin prep and applied [MEDICATION NAME] border (and no [MEDICATION NAME] AG). The resident rated pain in her bottom at an 8 on a scale of 0 to 10 with 0 being no pain and 10 being the worst imaginable pain. After the treatment, staff covered the resident and rolled the head of the bed up. On the same date at 2:23 p.m., 2:45 p.m. 3:20 p.m. the resident remained on her back in bed on the static mattress. At 3:55 p.m. the resident was up in a wheelchair at the table in the dining room. Staff did not follow the [MEDICATION NAME]/opsite every 2 days orders to treat the coccyx or reposition every 2 hours per care tool. 3. A Minimum Data Set (MDS) with assessment reference date of 12/28/17, assessed Resident #4 with a brief interview for mental status (BIMS) score of 7 (severe cognitive impairment). The resident sometimes understood other and others sometimes understood the resident. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident had no behavior symptoms. The resident required total staff assistance with bed mobility, eating and personal hygiene. The resident transferred once or twice a week with the assistance of 2 or more staff. The resident did not ambulate or use the toilet. The resident had functional range of motion limitations of one side of the upper and lower extremities. The resident was always incontinent of urine and frequently incontinent of bowel. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident as at risk for pressure sores. The MDS identified one Stage 2 pressure sore. The MDS identified a pressure sore present on the prior assessment. The MDS defines a stage 2 pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough. A 1/14/18 Braden scale identified the resident with a score of 11 (high risk for pressure sores). Hospice notes dated 2/28/18 revealed staff informed Hospice that the resident still had a wound to the coccyx. Review of (MONTH) 2019 treatments administration records (TARs) revealed an order for [REDACTED]. Staff last signed for the treatment on 3/11/18 and then staff wrote repeat. The TAR did not identify further treatment to the area. Telephone orders identified the following order on 3/14/18 discontinue aqua AG foam to coccyx. [MEDICATION NAME] to sacrum change every 3 days The (MONTH) and (MONTH) (YEAR) TARs did not reflect the Meplilex order was carried out. There were no skin assessment records available regarding the coccyx since 11/30/17. On 11/30/17 a skin record identified a 0.6 centimeter (cm.) by 0.2 cm. dry scab on the coccyx. Observation: Observation showed on 4/2/18 at 12:02 p.m., 2:20 p.m., 2:45 p.m. 3:55 p.m. and 4:50 p.m. the resident in bed on her back. Observation on 4/3/18 at 8:42 a.m., 9:05 a.m. and 10:22 a.m. showed the resident on back in bed. On 4/3/18 at 9:05 a.m. observation showed the skin on the coccyx area red and fragile but not open. There was no dressing on the area. Staff provided pericare at this time. Staff did not apply periguard with pericare. The resident laid on an air mattress when in bed. A care tool for CNAs did not contain a repositioning schedule for the resident. The care tool directed staff to apply periguard with all pericare. A resident care plan goals sheet with review date of 1/10/18 did not identify a repositioning plan. The corporate consultant stated on 4/9/18 at 10:18 a.m. stated the facility was aware there were issues with pressure sores. On 4/3/18 the facility did head to toe assessments on all residents and reviewed wound treatment orders for accuracy.

Based on record review and staff interview, the facility failed to ensure that -the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents reviewed. (Resident #6 & #7) Facility census was one hundred fifty-four (154) residents. Findings include: 1. A Minimum Data Set with assessment reference date of [DATE], assessed Resident #6 with impaired short term memory and modified independence with decision making skills. The resident had no behavior symptoms identified. The resident required limited staff assistance with toileting and extensive staff assistance with bathing. The resident was frequently incontinent of bladder. The resident had [DIAGNOSES REDACTED]. The resident had one fall with injury since the previous assessment. A PT (physical therapy) progress and discharge summary dated [DATE] revealed the resident could ambulate safely with 4 wheeled walker and CGA (contact guard assistance) on even surfaces. The resident demonstrated a Tinette balance score of ,[DATE] and a gait score of ,[DATE] for a total balance and gait score of ,[DATE] which is high risk for falls. An incident report dated [DATE] at 5 a.m. identified an unwitnessed fall in the resident bathroom. The resident fell and hit her head on the bathroom door. The resident received a bump on the head. The incident report revealed the resident fell asleep on the toilet. Following the incident, staff instructed the resident to please call for assistance. A care tool dated [DATE] identified the resident was independent with a 4 wheeled walker. An incident report dated [DATE] at 12:45 a.m. revealed an unwitnessed fall in the resident's room. Staff found the resident in a sitting position by the bed. The resident did not sustain injury. The report indicated the resident possibly fell out of bed. The resident stated a woman and baby kicked her out of bed. The report identified the resident with increased use of [MEDICATION NAME] (narcotic) due to pain. The report also stated the resident was more confused lately. The root cause of the fall identified on the incident report was possible footwear and bed was very high for resident to get into and resident was always at the edge of the bed at all times. The report identified the facility may need to speak with the family about a lower bed easier to get into. The intervention was Hospice changed medication for better pain control. There was no evidence the facility approached the family about a lower bed. The care tool in place on [DATE] did not contain any changes in footwear for the resident. An incident report dated [DATE] at 5:15 a.m. revealed an unwitnessed fall in the resident's room. A diagram identified the resident on the floor by the bed. When questioned, the resident said something about magazines. The resident's feet were bare and the call light was not in reach. Contributing factors revealed footwear. The resident said she slid to the floor to look for her remote. The intervention following the incident was for the resident to call to ask for remote and have pendant call light available and pendant on body. Additional care tool changes/interventions was: suggest wrist pendant. Review of the [DATE] and [DATE] care tools showed no care tool changes following the incident. Daily notes dated [DATE] at 2 a.m. revealed the resident was increasingly confused. A nurse walked by the resident's room and found the resident seated on the edge of the bed with no brief or pants on. The nurse asked the resident if she was Ok and she stated she didn't know what she was doing or why she was seated there. An incident report dated [DATE] at 9:15 a.m. revealed an unwitnessed fall in the resident room. The resident fell and hit the left eye possibly on the left corner of the bed frame. A diagram showed the resident on the floor at the foot of the bed. The resident was confused and had slippers on. The contributing factor was identified as amount of assistance in effect. The resident appeared weak and didn't know why or how the fall occurred. The conclusion was that the resident took self to the bathroom and fell into the bed hitting her eye. After the incident, the family provided a lower bed. Daily notes dated [DATE] at 11 p.m. revealed staff found the resident on the floor at 9:15 a.m. facing the bed on her bottom. Staff observed an injury to the left eye. The pupil and iris were completely covered in blood. Staff placed an ice pack over the eye and the resident transported to the ER (emergency room ). The resident returned to the facility (no time listed) with orders for an ice pack and multiple eye drops. The resident was to see an eye doctor in the morning. An ER after visit summary dated [DATE] identified the resident's eye injury as hyphema. Hyphema care instructions identified it as bleeding between the colored part of the eye (iris) and the cornea. The cornea is the outer clear tissue that covers the iris and pupil. Hyphema is usually caused by a [MEDICATION NAME] injury to the face or eye. Because this is a serious injury, the resident will need to see an eye specialist right away. Review of [DATE] nurses notes did not identify a visit to an eye specialist. On the same date at 6:40 p.m. the resident was unresponsive verbally and briefly opened eyes to voices. The resident expired on [DATE] at 9:40 p.m. A death certificate identified the immediate cause of death as [MEDICAL CONDITION] due to [MEDICAL CONDITION] with metastases to the bone. Staff Interviews: On [DATE] at 12:56 p.m. Staff V CNA stated just she and Staff U LPN (licensed practical nurse) worked when the resident fell . She stated she heard the resident yell and found her on the floor. She got Staff U. The resident said she hit her eye on the corner of the bed. She said her foot got stuck when she tried to get out of the recliner. Her bed was kind of high and after the incident, she got a low bed. Her recliner was at the foot of the bed and there wasn't much room to walk in between. Her room was cluttered. Staff V didn't know if the resident wore a wrist pendant. On [DATE] at 3:47 p.m. Staff U LPN stated the resident was laying on the edge of the bed so he helped her into the recliner. 5 to 10 minutes later the resident was on the floor sitting on her bottom and facing the foot of the bed. Staff U stated he was shocked when he saw the resident's eye injury. The iris and pupil were completely covered with blood. The resident was confused and declining prior to the incident. Staff U sent the resident to ER and she returned with orders for multiple eye drops and an eye patch. She was supposed to see an eye specialist. On [DATE] at 11:50 a.m. Staff U stated he thought the resident's wrist pendant was next to her on a table by the recliner. He stated the resident was forgetful and not good about asking for help. 2. A Minimum Data Set (MDS) with assessment reference date of [DATE], assessed Resident #7 with impaired long and short term memory and moderately impaired decision making skills. She rarely understood verbal communication and was sometimes understood by staff with communication ability limited to making concrete requests. The resident had moderately impaired vision and could not read newspaper headlines but could identify objects. She had no behavior symptoms identified including no rejection of care identified. The resident required extensive assistance of 2 or more staff for bed mobility, transfers, toileting, personal hygiene and bathing. The resident did not ambulate. She had functional range of motion limitations of both upper and lower extremities. The resident was frequently incontinent of bowel and bladder. Resident #7 was 65 inches tall and weighed 118 pounds. A care tool dated [DATE] directed staff to transfer the resident with an EZ stand and 2 staff. Daily notes dated [DATE] at 1:40 p.m. and documented by Staff P RN (registered nurse) revealed at approximately 11:15 a.m. Staff P went to the resident's room due to a laceration to the resident's right lower leg during a transfer from the bed to the wheelchair. Staff Q CMA (certified medication aide) had a towel on the resident's leg and it was soaked with blood. Staff P notified the ARNP (advanced registered nurse practitioner) who told staff to continue applying pressure to the wound. Staff P grabbed a bag of ice and another towel and elevated the right leg and applied pressure. Staff P called another nurse for assistance with the situation. After approximately 25 minutes the bleeding was minimal and Staff P completed an assessment of the wound. The right lower leg wound measured 11 centimeters (cm.) long and 2 cm. wide with skin unable to be approximated so staff continued to apply pressure. After the ARNP assessed the wound, the resident was transported to the ER (emergency room ) ED (emergency department) notes dated [DATE] revealed a resident arrived from the nursing home for evaluation of a right leg laceration. This was sustained when transferred by an aide. Her leg caught of the edge of the wheelchair and she sustained the laceration. There is a large gaping C-shaped flap like laceration deep into the subcutaneous tissue over the lateral right leg below the knee. This has a V-shaped component to the upper end of the laceration. Total length is 13 cm. There was a small amount of venous oozing. The ED report identified the the laceration as extensive. Due to the resident's age and the large laceration she was a high risk for healing complications. The wound was closed with a total of 21 sutures. Observation: On [DATE] at 1:15 p.m. observation showed 2 staff transfer the resident from the wheelchair to bed via Hoyer lift. Observation of the right outer leg shower a long black scab approximately 6 to 8 inches long. The resident did not respond to any questions asked about her right lower leg. She just smiled. Staff Interviews: An interview was conducted on [DATE] at 2:29 p.m. with Staff P RN. Staff P stated a nurse aide reported the incident to her. She was not sure who the CNA was but it was not Staff Q who was with the resident. During a transfer to the wheelchair, the resident must have caught her leg on something. Staff Q did not say how she transferred the resident-another aide told Staff P what happened. Staff Q transferred the resident by herself. Staff P found out at the end of the day and Staff Q was then taken to the office. When Staff P entered the room, she saw blood everywhere. There was a trail and then a pool of blood. The resident's leg had a big deep cut approximately 11 centimeters (cm.) long. The skin was sliced and hanging off. It could not be approximated (put back together). The resident went to the ER (emergency room ) and received 21 stitches to close the wound. Staff P didn't know if there were complications after the injury. Staff P stated she did not know of anyone else transferring the resident improperly. On [DATE] at 6:13 p.m. Staff Y CNA stated she was getting a resident up and had told Staff Q she would be right back. When she returned, Staff Q transferred the resident by herself and cut her leg. Staff Y stated blood was everywhere and Staff Q put pressure on the wound. There was blood on the floor, and the resident's leg and foot. Staff Q told Staff Y-You were in here with me weren't you Staff Y stated she would not cover for Staff Q. She reported the information to management and they told Staff Y she didn't the right thing by not covering for Staff Q. Staff Y stated she was not aware of anyone else transferring the resident alone. Staff Y stated she always used 2 to transfer the resident. On [DATE] at 10 a.m. Staff W RN and acting DON (director of nursing) stated she was told that Staff Q asked a staff to cover for her and the other staff said no. She stated then someone else took over the investigation. That person no longer works at Bethany. Staff W stated they couldn't find the investigation into the incident. On [DATE] at 12:10 p.m. Staff Q CMA (certified medication aide) stated she transferred the resident out of bed by herself and she pulled her foot up causing her leg to get caught on the wheelchair. The leg caught on the part where the pedals hooked into the wheelchair. Staff Q stated she knew the resident was a 2 person transfer but the other aide was busy giving a shower. She stated she was suspended for one day and coached regarding the incident. Staff Q stated the care tool said to use 2 staff. She used a gait belt. Staff Q said she didn't mean for the resident to get hurt. It was lunch time and she thought she could transfer her. Staff Q said she wanted the resident to get to her meal. On [DATE] at 1:40 p.m. Staff Q stated she had the care tool with her when the incident occurred and again said she knew the resident was not a 1 assist transfer and that she should have 2 for transfers. On [DATE] at 10:05 a.m. Staff Q denied asking Staff Y to say she assisted with the resident's transfer. Staff Q stated she told Staff Y not to lie. Staff Q didn't know why Staff Y would say that. Staff Q stated the DON and supervisor told her they spoke with a lawyer and Staff Q was told it wasn't reportable. They said they did their own investigation but now they cant find it. On [DATE] at 11:15 a.m. the Administrator stated the facility did not report the incident to the State agency because a major injury form was signed and said no major in jury.

Based on record review and staff interviews, the facility failed to ensure 1 of 4 residents received adequate supervision to prevent accidents (Resident #1). The facility identified a census of 151 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 11/18/16. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 2. A score of 2 indicated the resident had severe cognitive impairments. The MDS indicated the resident required supervision with walking in the resident's room and transfers. The resident also required supervision with toilet use and personal hygiene. The resident used a walker and had no problems with balance during transitions and walking. Review of the Risk Assessment for Falls dated as completed on 11/12/16, identified the following risks for falls: history of falls, balance and gait, sensory impairment, communication and hearing, medications, and incontinence. The Alarm Assessment Sheet indicated the resident as independent with the walker in the unit and the current alarm system identified as adequate. The BLC Daily Notes (nurse's notes) on 12/1/16 at 8:05 a.m. indicated the staff found the resident on the floor with the walker backwards, bottom drawer open. The resident yelled for help and had a 1.5 centimeter (cm) on the right check and bleeding. The staff took the resident's vital signs and called 911 and had the resident transported to the hospital emergency room via ambulance. The BLC Daily Notes dated 12/2/16 at 7:30 p. indicated the neurological assessment and vital signs within normal. The resident had bruising and edema (swelling) to the right side of face and extending to the jawline and top of neckline. Review of the Alarm Assessment Sheet, dated as reviewed on 12/3/16, identified the current alarm system as not adequate. The assessment sheet indicated the chair alarm and bed alarm added subsequent to recent fall. A fall incident report dated 2/8/17 at 7:30 a.m. documented Staff A, licensed practical nurse, (LPN) witnessed Staff B, Certified Nurse Aide, (CNA) ambulated Resident #1 with a gait belt and walker to the dining room table. Staff B placed a chair directly behind the resident and the resident started to sit. Staff B stepped back to get alarm pad and the resident stood back up, turned, tripped and fell back and to the right side landing on right hip. The nurse assessed the resident and noted increased severity of pain with standing and the resident could not move the right leg on own. Staff transferred the resident to the hospital emergency room for an evaluation and treatment. The interventions planned to prevent future events indicated the alarm pads are to be placed in the dining room chairs prior to the resident's arrival (to the dining room). The Interdisciplinary Working Plan of Care, dated 2/8/2017 directed 1 staff member assistance with all cares and ambulation. The Working Plan of Care instructed staff to not leave the resident on the toilet alone, place a sensor alarm and provide15 minute checks. The hospital discharge summary dated 2/11/17 at 8:07 a.m. documented Resident #1 was admitted on [DATE] after falling at the nursing home. The resident received right hip x-ray and diagnosed with [REDACTED]. The hip fracture was surgically repaired, and the resident discharged back to the nursing home in stable condition on 2/11/17. During an interview on 3/6/17 at 10:20 a.m. Staff B, CNA, stated on 2/8/17 she ambulated the resident from bedroom to the dining room with a gait belt and walker. Staff B stated she noticed there was not a pad alarm in the chair. Staff B stated she pulled out the dining room chair and sat the resident in the chair. Staff B demonstrated the chair at an angle away from the dining table. Staff B stated she left the resident to get a pad alarm, approximately five steps away. Staff B confirmed and turned back, and did not see the resident stand. Staff B stated the resident started to fall when she turned back around. Staff B acknowledged she should have stayed with the resident, the resident is to have an alarm at all times due to the fall risk. Staff B confirmed the resident used a bed and chair alarm and stated the facility expectation for care is to not leave the resident unattended when an alarm is not in place. In an interview on 3/6/17 at 1:30 p.m. Staff A, LPN stated on 2/8/17 she was already in the dining room passing medications when Staff B ambulated the resident into the dining room with a gait belt and walker. Staff A reported Staff B pulled out the dining room chair and placed it directly behind the resident and the resident sat in chair. Staff A stated the chair was placed away from the table at an angle. Staff A confirmed that an alarm pad was not present in the chair. Staff A stated she observed Staff B turn back and retrieve a pad alarm from a dining room cabinet. Staff A witnessed the resident stand, turn, trip and fall onto the right hip. Staff A assessed the resident and then the resident transferred to the hospital. Staff A confirmed the resident used a bed and chair alarm and the facility expectation for care is to not leave the resident unattended when an alarm not in place. In an interview on 3/2/17 at 1:12 p.m. Staff C, CNA-House Coordinator, confirmed the care plan had not been followed. Care Plan directed the use of a sensor alarm. Staff C stated the expectation for staff is to follow the care plan directives. Staff C stated she had reviewed the expectation to have an alarm in place with Staff B and to not leave residents unattended when an alarm not in place in order to maintain safety of residents identified at risk for falls. The facility had removed the pad alarms to make the dining room more home-like but the alarms need to be available so have the process. In an interview on 3/1/17 at 1:00 p.m. the Director of Nursing, DON confirmed Staff B ambulated the resident with the use of a gait belt and walker but failed to stay with the resident until a pressure alarm was placed in the dining room chair. The staff person turned her back and left the resident to retreive an alarm in a drawer, approximately 5 paces away. When the staff person turned back around the resident had stood , turned and fell . The DON stated the expectation is not to leave the resident unattended when an alarm is not in use. The expectations are listed at the bottom of the Care Plan.

Based on record review and staff interviews, the facility failed to provide adequate supervision to protect against hazards for one (1) of five (5) residents at risk for falls (Resident #14). The facility reported a census of 146 residents. Findings include: Resident #14 had a Minimum Data Set (MDS) assessment with a reference date of 11/23/16. The assessment identified Resident #14 with and short term memory deficits and moderately impaired cognitive abilities for daily decision making. Resident #14 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #14's [DIAGNOSES REDACTED]. The care plan identified the resident would call for assistance (via pendant). According to the BLC Daily Notes, on 10/7/16 at 7:10 a.m. Resident #14 was discovered on the floor next to his/her bed. Resident #14 reported he/she was attempting to go to the bathroom and following the fall crawled back to his/her bed and activated the call light. The night certified nurse aide (CNA) reported the Resident #14 had been to the bathroom around 5 a.m. The floor had been wet where the resident fell . Resident #14 reported he/she felt like he/she was on the floor for hours, but according to Staff Q, it was maybe 20 minutes as one staff was involved with a shower and Staff Q was toileting another resident. The note made no mention of added or changed safety interventions to keep the resident safe or to prevent further falls. According to the BLC Daily Notes, on 10/14/16 at 7:35 a.m. Resident #14 was discovered on the floor outside of his/her bathroom bleeding from his/her nose and complaining of back and hip pain. Resident #14 was sent out to hospital for further evaluation. At 11:30 a.m. the facility received a call from the emergency room (ER) nurse reporting Resident #14 had a fractured nose and fractured patella (knee cap) and femur condial (knee joint). In an interview on 1/25/17 at 12:02 p.m. Staff P, certified nurse aide, stated on the morning of 10/14/16, she was the only staff working on her assigned unit when Resident #14 fell . Staff P stated she was in another resident's room when she heard Resident #14 yelling. Staff P responded to the room and found Resident #14 on the floor. Staff P stated she had to leave Resident #14 on the floor and leave her unit unattended while she left to find the nurse, who was assigned to two other units besides hers. In an interview on 1/25/17 at 9:45 a.m. Staff Q, registered nurse, stated she was summoned to Resident #14's household on the morning of 10/14/16. Resident #14 had fallen while attempting to get to the bathroom unassisted. Resident was found bleeding from his/her nose and was complaining of back and hip pain. Resident #14 was sent to the hospital for further evaluation. Staff Q stated she later discovered Resident #14 had sustained a fractured nose, patella and femoral condial. Resident #14 returned to the facility with an immobilizer and on non-weight bearing status. Resident #14 was placed on 15 minute checks and bed and chair alarms as a safety intervention. Staff Q stated normal staffing on day shift would be one certified nurse aide and one medication aide on Resident #14's household and the nurse would float between three households. In an interview on 1/25/17 at 2:40 p.m. the Director of Nursing 2 (DON2) stated on the morning of 10/14/16 the schedule had Staff P and Staff R working on Resident #14's household with a float and nurse. The DON2 stated the overnight staff would have left by 6:30 a.m. and Staff R was not scheduled to come in until 8:00 a.m. so it was possible that Staff P was the only one on the household from 6:30 a.m. until 8:00 a.m. The facility investigation revealed Staff P reported she had checked on Resident #14 at 7:00 a.m. A review of the contributing factors identified the amount of assistance in effect and the resident tripped on his/her robe. The root cause noted the resident's refusal to request or wait for help; and staff did not know whether the resident had been wearing the robe or whether he/she pulled it from the back of the bathroom door. Resident #14 returned to the facility with an immobilizer and non-weight bearing status at 12:20 p.m. (same day). Resident #14 had been placed on 15 minute checks with bed and chair alarms as added interventions on 10/14/16. The investigation identified the facility corrected the noncompliance prior to the arrival of this investigation and was in substantial compliance on 10/20/16.

Based on clinical record review and interviews, the facility failed to ensure one (1) of six (6) residents received adequate supervision to protect against hazards in the environment. Record review and staff interviews revealed Resident #1 required 2 staff assistance for walking and during transfers. On 9/25/16, staff left Resident #1 in a standing position and went to assist another resident when Resident #1 walked to the hall and fell backwards sustaining a skull fracture and head injuries. The facility reported a census of 145 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 8/4/2016 for Resident #1 documented a score of 11 of 15 on Brief Interview for Mental Status (BIMS) test which indicated moderate cognitive impairments. According to the MDS, the resident required the extensive assistance of two staff for transfers, dressing, personal hygiene, bed mobility, walking in room/walking in corridor and toileting. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when walking, turning around, moving from a seated to standing position, and surface to surface transfers. The MDS documented Resident #1 had limitations in range of motion on both sides of his/her upper and lower extremity. The resident had [DIAGNOSES REDACTED]. The resident had had no falls since the prior assessment. Review of the Risk Assessment for Falls, dated 8/12/16 identified the resident scored a two or above in the following areas which required review for possible interventions: Balance and Gait, Mood/Acute Confusion, Weakness in Extremities and Sudden changes in medical status, and Medications. The fall risk assessment identified he/she had balance problems while standing, walking and had an unstable gait for the past 4 weeks or longer. The Interdisciplinary Working Plan of Care, dated 9/25/2016 directed two staff assist with all cares and activities of daily living (ADLs). A fall incident report dated 9/25/16 at 3:15 p.m. reflected the staff discovered Resident #1 walking in the hallway and observed falling straight back to the floor hitting back of head. The nurse assessed the resident and noted a head injury. Staff transferred the resident to the hospital emergency room for evaluation and treatment. The hospital course report dated 9/28/16 documented Resident #1 had been admitted on [DATE] after he/she sustained a fall at the nursing home. Resident #1 fell and struck his/her head and reportedly did not lose consciousness. The resident had been evaluated in the emergency room and the head computed tomography (CT) scan diagnosed him/her with non-displaced skull fractures and a small amount of subarachnoid hemorrhage (bleeding in the area surrounding the brain) in both the frontal lobes and the left temporal lobe (areas of the brain). The resident had been admitted to the hospital and followed for further changes until discharged back to the nursing home on 9/28/16. A fall description details form dated 9/28/16 documented prior to the fall (on 9/25/16) Resident #1 had been walking and received no assistance at the time of the fall (alone/unattended). The nursing management review revealed the resident was left unattended while standing (and per care tool was assist of two). During interview on 10/11/16 at 2:04 p.m. Staff A, certified nursing assistant (CNA), stated on 9/25/16 transferred the resident from the chair to the bathroom and back to chair. Staff A stated he had transferred Resident #1 by himself (with only one assist) and had been aware of the directives on the care plan which required two staff persons for assistance with transfers. Staff A stated he had always transferred the resident by himself (with assistance of one). Staff A stated he should have checked the care plan. Resident #1 requested to stand in front of chair for a while and Staff A knew the resident had really bad arthritis. Staff A reported another resident nearby (next room) called out for assistance, so Staff A told Resident #1 he had to help the other resident quickly and Resident #1 continued to stand when he left the room. Staff A reported he was not gone for very long and when he returned, Resident #1 had walked to the hallway. He observed the resident fall backwards and strike his/her head (on the floor). Staff A acknowledged he left the resident in an unsafe position, and the care plan had not been followed and the resident sustained [REDACTED]. In an interview on 10/11/16 at 9:40 a.m. Staff B, CNA stated the care plan directed two staff transfer and assist the resident with ambulation. Staff B stated Resident #1 would be unsafe left in a standing position unattended in room. Staff B reported therapy had been working with Resident #1 but he/she required two staff assistance and she was unsure why Staff A transferred Resident #1 by himself. In an interview on 10/10/16 at 1:00 p.m. the Director of Nursing, DON confirmed the care plan had not been followed. Care Plan directed assistance of two staff for cares and transfers. The DON stated expectation staff follow care plan directives. The DON stated an investigation determined the staff left the resident in an unsafe position in his/her room; and Staff A should have encouraged Resident #1 to sit (down) and offered assistance upon return from helping the other resident. Reviewed Performance Improvement Coaching plan dated 9/27/16, documented Staff A received written coaching plan after she left a resident in an unsafe position and did not follow the care tool which resulted in a major incident.

Based on record review, interviews with the nurse practitioner and staff, the facility failed to implement cardiopulmonary resuscitation (CPR) for one (1) of twenty five (25) residents with an advanced directive for CPR. Record review and staff interviews established the facility staff failed to perform CPR on [DATE] when Resident #1's advance directive indicated he/she wanted CPR. Staff A found the resident at 2:40 a.m., and failed to start CPR until 2:53 a.m., or 13 minutes denying his/her right for self-determination. The Director of Nursing reported the facility did not have a CPR policy. The concern affected 24 additional residents with an advanced directive to receive CPR. The findings constitute an immediate jeopardy to the residents' health and safety. The facility identified a census of 145 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident was independent was decision making skills and required extensive assistance of two staff for bed mobility and toilet use and required extensive assistance of one for moving about the unit. The Care Plan dated [DATE], directed staff to assist the resident with upper body dressing, assist with bed mobility, encourage participation in an active range of motion program ,[DATE] times a week, will cooperate with his/her prescribed oxygen and will express his/her pain. The Patient Admission assessment dated [DATE], revealed the resident returned from a hospitalization and had an order for [REDACTED]. The Iowa Physician order [REDACTED].#1 and updated on [DATE], revealed Resident #1 indicated he/she requested Full Treatment/Cardiopulmonary Resuscitation (CPR) in the event he/she had no pulse and was not breathing. The resident requested intubation, advanced airway interventions, mechanical ventilation and cardioversion be used if indicated. The resident requested transfer to a local hospital. The IPOST indicated the resident made their own decision and these decisions were their known preference. The IPOST identified this form is a medical order sheet based on the person's current medical condition and treatment preference. Daily Notes dated [DATE] at 2:40 a.m., indicated Staff A, Certified Nurse Aide, CNA entered the Nurses Station and reported to Staff B, Licensed Practical Nurse, LPN that the resident did not look well. Staff B left the Nurses Station and found the resident in bed, unresponsive, not breathing and without a pulse. Staff B did not say anything about the resident's code status. Staff B directed Staff A to have the nurse from First floor come to the Second floor to verify the resident's death. Review of the resident's Death Record dated [DATE], documented the resident died at 3:31 a.m. from [MEDICAL CONDITION]. During interview on [DATE] at 9:30 a.m., Staff B, LPN stated he/she worked the night shift on [DATE] into the morning of [DATE] and had responsibility for the resident. Staff B reported Resident #1 had been asleep and breathing when she checked on Resident #1 at 1:25 a.m. (on [DATE]). Staff B stated at approximately 2:40 a.m. and 2:43 a.m., Staff A reported to him/her that they felt the resident did not look well. Staff B went to the resident's room and found him/her in bed, without a pulse and not breathing. Staff B directed Staff A to summon the nurse from the First floor to verify the resident's death. Staff B stated they did not know the resident requested Cardiopulmonary Resuscitation (CPR) if found without a pulse or without breath and failed to initiate CPR according to the resident's request. Staff B returned to the Nurses Station to get a stethoscopes and failed to look at the resident's chart to check on the code status. Staff B indicated she knew where the facility posted each resident's code status and stated she forgot to look. Staff B reported 3 weeks had passed since she worked with the resident and she knew the resident had been in the hospital prior to the incident. During interview on ,[DATE] at 6:00 a.m., Staff C, LPN indicated they worked the first floor the night of [DATE], into the morning of [DATE]. Staff C indicated they were called to the Second floor by Staff A to verify the resident's death as per facility procedure. Staff C went to the Second floor between 2:,[DATE]:45 a.m. and walked to the resident's room. Staff C stated Staff B had been standing a foot from the bed and was not doing CPR nor did Staff B mention the resident's code status. Staff C found the resident without pulse and respirations. Staff C went to the Nurses Station and called the Chaplin, the Nurse Practitioner and the Director of Nurses. Staff C stated when they called the Director of Nurses at 2:53 a.m., the Director of Nurses told Staff C to hang up the telephone and call 911 because Resident #1 was a Full Code (wanted CPR). Staff C did as directed, hung up and called 911. Staff C stated at 2:53 a.m. they told Staff B to go to the resident's room and start CPR because the resident was a Full Code. During interview on [DATE] at 10:35 a.m., the Advanced Registered Nurse Practitioner (ARNP) stated it was their expectation that if staff observes a resident without breath and without a pulse, they are to initiated CPR if they do not know the resident's code status. The Advanced Registered Nurse Practitioner stated they had several conversations with the resident and each time the resident requested a Full Code and for staff to initiate CPR. The ARNP reported she had been providing ongoing staff training and will do mock codes to ensure staff are familiar with code status for residents. The ARNP reported the facility did not have any prior concerns with staff not starting CPR (for other residents). During interview on [DATE] at 11:16 a.m., Staff F, Register Nurse (RN) reported the aide tool did not include resident's code status until after the incident with Resident #1. During interview on [DATE] at 11:03 a.m., Staff G, CNA reported knowing of one other resident who is a full code status prior to the incident with Resident #1 passing (on [DATE]). Staff G reported knowing the residents code status are now located on the care tool and on the chart. During interview on [DATE] at 11:30 a.m., the Director of Nurses (DON) (for the 1st and 2nd Long Term Care) stated the following time frame was from a review of the facility cellular telephone records: Staff C placed a telephone call to the Chaplin at 2:51 a.m., the Nurse Practitioner (no answer) and to the DON at 2:53 a.m. The DON directed Staff C to hang up and initiate CPR on the resident because the resident requested a full code. The DON stated they assisted the resident to sign their IPOST upon readmission to the facility on [DATE], the resident indicated to the DON he/she requested to be a Full Code. The DON reported the code status had not been on the care tool for any resident in the building prior to the incident with Resident #1. The DON identified all residents with full code status (24 residents) are now on the care tool as of [DATE]; and were already identified in their charts. The DON re-educated staff on code status for all residents (either DNR or full code) and updated the care tool for aides and updated the nurse worksheet which are both quick reference guides on [DATE]. The DON stated they reviewed the CPR policy with each nurse on [DATE]. On [DATE], at 11:00 a.m. the DON reported the facility did not have a CPR policy prior to the one formulated on [DATE]. On [DATE], the facility abated the Immediate Jeopardy when they implemented a Resuscitation Policy and educated all nursing staff on the policy. The policy identified provisions for when staff should initiate CPR immediately according to the current American Heart Association guidelines. Quick reference guides were created and updated for all residents regarding their code status (either CPR or Do Not Resuscitate (DRN). All nursing staff were educated on the location of the code status for residents. The facility provided documentation verifying nursing staff had been trained on [DATE] on their new policy. Newly hired staff would receive training at the time of orientation. The facility staff (including the DONs) will provide ongoing monitoring of the policy.

Based on observation, record review, and staff and Advance Registered Nurse Practitioner interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the health service supervisor failed to plan for and direct the nursing care, services in order that each resident ' s needs are met (Resident #1 and # 4). The sample consisted of 4 residents and the facility reported a census of 160 residents. Findings Include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 5/9/2013. The assessment identified the resident had [DIAGNOSES REDACTED]. The MDS reported the resident's cognitive skills to be severely impaired and the resident required extensive assistance for bed mobility, transfer, ambulation, dressing, toileting and hygiene needs. The resident had functional limitation with range of motion in one lower extremity and had a history of [REDACTED]. The resident's Care Plan, with a goal date of 2/12/13, reflected the resident would not get hurt from a fall through the next review. Continued review of an interdisciplinary working plan of care dated 5/17/13 and 6/6/2013 revealed the staff had been directed to use a chair pressure alarm, a bed pressure alarm and a sensor alarm when in bed and during the care of the resident. The incident report dated 5/18/13 indicated the resident had been found on the floor at 5:15 a.m. The report revealed the resident's alarm had not been in place and had not sounded. Information on the report described the resident had pushed the table and stood up from the wheelchair. According to the report, another resident had tried to help Resident #1 and both fell and had been found on the floor. The report indicated the incident had been unwitnessed by staff. The resident did not have an injury. Review of the facility daily notes documented the following entries: On 5/18/13 at 5:15 a.m. (late entry) found on floor, unwitnessed fall in dayroom. Active range of motion in all extremities. Good approximation of hips, legs equal in length, no shortening, of either leg. Assisted with 2 (staff) to the wheelchair. Vitals per protocol on neurological assessment sheet. On 5/18/13 at 1:00 p.m., no injuries notes. No signs and symptoms of increased pain /discomfort. Gait per resident normal. Vital signs and neurological assessment within normal limits. Family member notified. On 5/18/13 at 7:50 p.m. no apparent injury, no bruising noted. CNA (Certified Nursing Assistant) report grimace with ambulation at bedtime. In recliner; no signs or symptoms of pain. On 5/18/13 at 10 p.m. (nurse) called to unit at 8:50 p.m. by CNA ' s, resident showed increased grimacing, lifting weight off right leg with transfer, favoring left side. Resident had stated "I don't know," when asked if having pain. Grabbing at right hip; lifting right hip off bed. Son notified. Family member requested x ray; okay with portable x ray or being sent to hospital. Order received for portable x-ray. On 5/19/13 at 1:50 a.m. the portable x-ray report identified a right acute impacted femoral neck (hip) fracture with minimal angulation. On 5/19/13 at 3:30 a.m. the facility had the resident transported to an acute care setting. The emergency room notes dated 5/19/13, at 4:48 a.m. revealed an active problem list that included the following Diagnoses: [REDACTED]. A review of an acute care history and physical filed on 5/19/13, reported a Cat Scan (Computerized Tomography) of the right hip showed a curvilinear area of increased attenuation in the intertrochanteric region concerning for an impacted fracture. The report continued with information that the resident had been at the acute care setting, the past February of the same year for a left hip fracture which required surgical fixation. The consultation report by an orthopedic surgeon reflected the resident had a non displaced right intertrochanteric hip fracture. The note revealed the surgeon generally recommended surgical stabilization. The report indicated due to the resident's dementia, bone quality, high chance that this would displace and then require operative fixation, the method of treatment recommended to a family member would be a gamma nail like the resident had in left hip. A progress note from the acute care facility, filed on 5/20/13, identified surgical repair of the nondisplaced right-sided hip fracture had been planned for the afternoon to be performed by an orthopedic surgeon. Acute care progress notes dated 5/20/13 reflected an assessment as follows: Post-operative day #1 status [REDACTED]. On 6/15/13 at noon, Staff I (Registered Nurse) was interviewed and stated on 5/18/13, at approximately 2:50 a.m., the resident had attempted to get out of bed and the bed alarm had sounded. Staff I stated at that time, the resident had been assisted into a wheelchair and the chair pressure alarm had not been attached. Staff I stated the resident had been taken to the dayroom in the wheelchair. Staff I reported he/she had provided a 1:1 with the resident at that time. Staff I stated the resident had been given a snack and medication to help her/him rest. Staff I reported when Staff F (CNA) returned to the unit, he/she had instructed Staff F to assist the resident back to bed when he/she got tired. On 6/5/2013 at 12:50 p.m., Staff D, (Registered Nurse) was interviewed and stated she had worked the day shift on 5/18/13 and had cared for the resident. Staff D reported a day shift CNA had reported to him/her that when resident had been assisted between 6 and 6:15 a.m., it had been discovered the pressure pad had been present in the wheelchair, but the alarm box had not been plugged into pressure pad. On 6/5/13 at 1:35 p.m., the Director of Nursing (DON) was interviewed and stated the facility investigation had indicated Staff F and Staff I had not applied the chair pressure alarm as directed in the care tool during the shift when the resident had fallen. The DON commented the alarm sounding would not have prevented the resident from the fall. The DON revealed Staff I could have moved the resident to another unit to be viewed and that had been his/her past practice. The DON reported the investigation had revealed Staff I had failed to notify the Night RN Supervisor about the resident during the night shift. The DON commented Staff I had been moved to a position in an assisted living setting. During a phone interview on 6/5/13 at 4:34 p.m., Staff J (CNA) reported on the morning of 5/18/13 between 6 and 6:15 a.m., he/she had assisted the resident and had discovered the chair pressure pad in the wheelchair had not been plugged into the alarm box. On 6/6/13 at 12:30 p.m., Staff F (CNA) was interviewed and revealed on 5/18/13, the resident had attempted to get out of bed at 12:30 and frequent intervals after that time. Staff F reported the alarm had sounded when the resident had attempted to get out of bed. Staff F stated Staff I had put the resident in the wheelchair at about 2:50 a.m. and told Staff F the resident might be getting tired from the medication which had been given. Staff F commented he/she had helped the resident back to bed at 3:30 a.m. Staff F reported the resident's alarm sounded about 10 minutes later after assisted to bed. Staff F assisted the resident into the wheelchair and transported back to the dayroom so Staff F could observe the resident. Staff F verified he/she had forgotten to put the resident's chair pressure alarm on. Staff F reported he/she had positioned the resident at the table with items to keep the resident busy. Staff F stated 4 other residents had been brought to the dayroom due to restlessness. Staff F reported he/she had been with the residents in the dayroom until an alarm had went off in a resident's room at 5:13 a.m. Staff F reported he/she had heard a resident yell help when leaving the resident's room where the alarm had sounded. Staff F reported he/she went to the dayroom and found the resident and another resident on the floor. Staff F reported the other resident reported Resident #1 had tried to get up and that resident had tried to help him/her walk. Staff F stated Resident #1 had been found positioned on the floor about 2-3 feet from the wheelchair. Staff F commented that she believed the resident would have fallen if the alarm had been on because he/she would not have been close enough to prevent the fall. Staff F reported Staff I had been called to the unit when resident found on floor and had stayed 1:1 with the resident doing vitals while Staff I had completed rounds. On 6/6/13, the Director of Nursing provided a copy of the staff schedule for the date of the resident's fall and a written statement as follows: Night shift staffed with generally 3 nurses/medication aides and 9 CNA's. A tenth CNA is added as an additional float if available. Staffing was full (without additional float) the night of the resident fall. Review of the personnel file for Staff J, revealed the staff person had been given a written coaching and notice of 3 day suspension. Information on the notice indicated the following: Resident # 1 according to interdisciplinary working plan of care is to have chair pressure alarm on due to fall risk. Per Staff J's own written statement dated 5/20/13 for the incident that occurred on 5/18/13 at 2:50 a.m., resident had been placed in wheelchair without an alarm. Further review of the file indicated Staff J had completed retraining; had been moved to a position with less clinical acuity; and had been placed on 90 day probationary status. Review of the personnel file for Staff F, revealed a Performance Improvement Coaching Plan had been given and Staff F had been given a 2 day suspension without pay due to a resident found on floor on 5/18/13 at approximately 5:15 a.m. with no alarm on. The plan described the expectation had been to follow the care tools and have alarms in place according to the care plan. During an observation of the resident on 6/5/13, from 3:40 p.m. to 4:05 p.m., resident had been positioned in the dayroom in the wheelchair with alarm on. Staff person (s) positioned in close proximity of resident during observation time. During the interval, the resident attempted to stand up from the chair multiple times and had attempted to move the wheelchair back from the table. During an observation on 6/6/13, at 7:15 a.m., Staff G (CNA) and Staff D, provided morning cares. Staff H (CNA) entered room at 7:30 a.m. to assist staff with resident's cares. After the resident had been transferred from bed to the wheelchair, Staff G pushed the resident in the wheelchair with no foot pedals on the chair from the area near the bed to the bathroom area. Close observation during the transport, revealed the resident had worn white tennis shoes and had shuffled feet on floor intermittently. Observation of the wheelchair revealed the wheelchair pedals had been present on the back of the wheelchair in a bag. An interview with the Director of Nursing at 11 a.m. on 6/6/13, he/she indicated the expectation would be for wheelchair pedals to be on the wheelchair during transport of a resident. He/she reported staff had been trained on this. At the exit conference in the facility at 9:43 a.m. on 6/10/13, the Director of Nursing shared a written statement as: Based on investigation, as well as staff interviews, it is my conclusion that the resident's fall would not have been prevented, even if the resident's alarms had been on and sounding. According to the statement, the CNA on duty during the time of the fall had gone to assist another resident (who's alarming was standing) when the resident had stood up and fell . Because the CNA was assisting another alarmed resident, she would not have been able to leave that resident until he/she had been cared for, thereby not being able to prevent Resident # 1's fall. During a phone interview conducted with the Advanced Registered Nurse Practitioner on 6/11/3 at 9:52 a.m., he/she indicated not sure if it could be determined if a fracture occurred spontaneously; would recommend consulting with orthopedic surgeon. The provider reported the resident had wandered a great deal on admission and had been very fit. The provider commented he/she would describe the resident as, "hyper." During the interview, the provider commented that the alarms don't prevent falls; just tell you when a resident moves. A written statement from Resident #1's orthopedic surgeon dated 6/12/13 and electronically signed by the surgeon on 6/13/14 revealed, in part, the following: "...I feel it is very unlikely he/she (resident) suffered a spontaneous fracture. Of course, there is no way to determine this. Again, in my experience as an orthopedic surgeon, I feel that almost all hip fractures are a traumatic fracture and not a spontaneous fracture, but again there is no way to determine this". 2. Resident #4 had an MDS assessment with a reference date of 4/11/13 which identified [DIAGNOSES REDACTED]. The MDS revealed the resident had moderately impaired cognitive skills. The MDS indicated the resident had required extensive assistance for transfers, ambulation, dressing, toileting, and hygiene needs. The MDS reported the resident had functional limitation of range of motion in both lower extremities. The resident's Care Plan with a goal dated 4/24/13, indicated the resident would remain free from injury from falls through the next review. The Interdisciplinary Working Plan of care for the resident dated 6/4/13, guided staff to keep the resident's wheelchair out of the room. Review of Life Unusual Event Reports for the resident revealed the following information: On 4/11/13- resident found on floor in room. The report revealed the resident had attempted to transfer self into bed. On 5/4/13 - resident had attempted to transfer self from wheelchair to recliner chair. Found on floor by bed and night stand. During an observation on 6/6/13 at 1:15 p.m., Staff A (CNA) assisted the resident to transfer with a gait belt from the wheelchair to the recliner. The alarm on the wheelchair placed on the recliner. Staff A moved the resident's wheelchair approximately 2-3 feet to the left of the resident's recliner. The locks on the wheelchair were not locked. Staff C (CNA) entered the room and proceeded to give the resident the call light and raise the footrest of the recliner. Both Staff A and Staff C exited the room and did not remove the wheelchair from the room at that time. On 6/6/13 at 1:25 p.m., Staff C (Registered Nurse) was interviewed and acknowledged the resident's wheelchair had been left in the room. Staff C verified the staff had been guided on the care tool to remove the wheelchair from the room when the resident not in the wheelchair. Staff C reported the staff generally removed the chair. On 6/6/13 at 1:30, Staff A removed the resident's wheelchair from the room.