Every finding on record at Canterbury Rehabilitation and Healthcare Center

Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to prevent abuse for 1 of 8 residents (Resident #2), in the survey sample which resulted in the identification of Immediate Jeopardy.The findings included: Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to prevent abuse for 1 of 8 residents (Resident #2), in the survey sample which resulted in the identification of Immediate Jeopardy.The findings included: The facility staff failed to prevent Resident #1 from abusing Resident #2 by pushing him out of a chair and onto the floor as well as attempting to hit Resident #2 with a chair while Resident #3 stood in close proximity to the incident. 1. Resident #1 was originally admitted to the facility 2/21/26. The diagnoses included unspecified dementia with other behavioral disturbance, chronic obstructive pulmonary disease, muscle weakness, and major depressive disorder.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired.A review of nursing progress notes dated 6/24/26 at 3:40 PM read: Resident is on constant supervision. Resident was in a resident on resident altercation. at 3:40pm. Writer was counting out/giving report at the nurse's station. A noise was heard of a chair flipping over and a thud on the ground down hallway one. As we came around the nurse's station, a resident was on the floor sitting. Between the resident and writer was (resident name retracted). He proceeded to pick up the chair and directed it towards the resident that was sitting on the floor. A thud was heard after that happened. Staff immediately removed the chair from the resident's possession and the resident on the floor was brought to the nurses station for evaluation. MD has been notified. RP was called and a message left to call back for an update. UM, DON and Administrator were immediately notified and came to evaluate. Statements have been collected. Resident remains on 1:1 supervision.The comprehensive care plan dated 4/7/2026, documented in part, Focus: I have a behavior problem of becoming aggressive during care at times. Interventions: Educate caregivers on successful coping and interaction strategies such as allowing resident time to de-escalate and reapproach at later time. Explain all procedures to the resident before starting and allow the resident to adjust to changes. Dated 5/11/2026 - Resident placed on 1:1 supervision. The care plan further documented, Focus: I am/have the potential to demonstrate physician behaviors related to Dementia, hx (history) of resident-to-resident altercations, I pushed another resident. Interventions: 1:1 supervision (6/24/26). Assess and address for contributing sensory deficits. Close monitoring (5/14/26). 2. Resident #2 was originally admitted to the facility 1/29/26. The diagnoses included Alzheimer's Disease with early onset, unspecified dementia without behavioral disturbance, essential hypertension, and muscle wasting and atrophy.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/12/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were severely impaired.A review of nursing progress notes dated 6/24/26 at 5:19 PM read: At 3:40pm, Writer was informed about a resident-to-resident altercation and noted resident sitting on the floor. Staff immediately check on the resident. Writer assess resident skin, ROM and Vital signs taken. No injuries noted. Resident was helped to the nurses' station for evaluation. UM, DON and Administrator were immediately notified and came to evaluate. Statements have been collected. Resident placed on 1:1 supervision. MD made aware and ordered to send resident out for further evaluation and CT scan. Wife is here at this time and is aware of incident. 911 was called.A review of Resident #2's Hospital Emergency Department documentation dated 6/24/26 read: You have a head injury. It doesn't appear serious at this time. But symptoms of a more serious problem, such as a mild brain injury (concussion) or bruising or bleeding in the brain, may appear later. For this reason, you or someone caring for you will need to watch for the symptoms listed below. Once you're home, also be sure to follow any care directions you're given.On 7/1/26 at 2:35 PM an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated while giving a recount of the event that occurred on 6/24/26 between Resident #1 and Resident #2 that he was in the process of counting medications and heard a thud. LPN #2 also stated that he observed Resident #2 laying on the ground and Resident #1 picking up a chair and directing the head of the chair towards Resident #2. LPN #1 further stated that an Activities Aide 1:1 was assigned to Resident #1 and observed this incident as well. LPN #1 lastly stated that the Activities Aide 1:1 was just watching and should have intervened quicker than she did. On 7/1/26 at 2:53 PM an interview was conducted with the Director of Nursing (DON). The DON stated that Resident #1 was on constant observation for a prior incident that took place regarding another resident. The DON also stated that Resident #1 has a history of displaying aggressiveness. The DON further stated that regarding the incident that took place between Resident #1 and Resident #2, the staff member should have intervened quickly, much quicker than she did.On 7/1/26 at 3:45 PM an interview was conducted with the Leadership Development Manager. The Leadership Development Manager presented a video of the incident that took place between Resident #1 and Resident #2. The video showed Resident #1 standing in front of Resident #2 and pushing him over onto the floor while he was sitting in a chair in the hallway. OSM #6 was sitting in a chair nearby and observed the entire incident. OSM #6 did not intervene until after Resident #2 was pushed by Resident #1 and fell to the floor. The video further revealed that Resident #1 picked up the chair with Resident #3 in close proximity and attempted to strike Resident #2 with the chair, however OSM #6 intervened and put her hand on the chair to stop Resident #1 from hitting Resident #2 with the chair.On 7/1/26 at 4:10 PM an interview was conducted with LPN #2. LPN #2 stated that the incident should not have occurred due to Resident #2 being on constant observation. LPN #2 also stated that the Activities Aide 1:1 was observing the confrontation and should have intervened to prevent Resident #2 from being pushed out of the chair and onto the floor by Resident #1.On 7/1/26 at 4:35 PM an interview was conducted with Activities Aide 1:1. The Activities Aide 1:1 stated, I did not feel like it was typical protocol to intervene. I did not feel like he would take it the physical part. That was my first day taking care of him. I did not think he would physically get him out of the chair. We are told who we are taking care of when we get to work. We are just told they have to be watched. I did not know what the constant observation was for regarding the resident. The facility's Memory Care Unit Policy with an effective date of 5/13/26 read: Phase 2 - Constant Observation/Monitoring Requirements: Staff shall remain within close proximity to intervene immediately if necessary. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy with a revision date of 04/2021 read: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.On 7/2/26 at 11:32 AM the facility's Administrator, Director of Nursing, [NAME] President of Operations, Regional Director of Operations, Regional Nursing Consultant, and Leadership Development Manager were informed of the non-compliance which constituted Immediate Jeopardy at Past Non-Compliance, identified in F-600 Free from Abuse and Neglect at a Scope and Severity Level 4, isolated. The Immediate Jeopardy start date is 6/24/26 due to this being the day the resident-to-resident altercation occurred between Resident #1 and Resident #2. A copy of the Immediate Jeopardy template was reviewed and the facility was provided a copy.The facility provided a copy of their Ad Hoc meeting minutes dated 6/24/2026. The meeting minutes documented: Identified Issue: the facility experienced a resident-to-resident altercation that did not result in injury.Goal: Resident will not sustain serious injurySummary Report: Resident to Resident events reviewed in addition to the plan of correction from survey ending 4/9/26. The plan in place at the time of the event was sufficient to address the escalation of behavior and as a result kept all residents free from harm. The facility has successfully implemented a system for observing resident identified as potential victims or resident with potential for behaviors affecting others. The levels of supervision are determined by a number of factors including but not limited to historical events, assessment by social services, psychiatry consultation recommendations, review of monitoring documentation and input from medical director, staff and families. The success of the system is measured and validated by substantial decrease in incidents, also noting that this was an isolated event and the only time since the date of compliance. Upon debriefing with the team members present at the time, additional educational opportunities were identified. Resident companions received additional training on methods to de-escalate situations and early identification of triggers that can cause an increase in resident behaviors resulting in altercations. The committee will continue to monitor and address educational needs as they are identified. A training session with (name of local police officer) is schedule for August 6, 2026 from 2:00 p.m. to 3:30 p.m. to teach additional methods of protecting resident and staff from potentially aggressive behaviors. Cards provided to Recreational Sitters.Definitions of Levels of Monitoring:1:1 Monitoring: I can see you and touch you. Constant Supervision: I can always see you. Q (every) 15-minute checks: I put my eyes on you every 15 minutes to make sure you are safe.Documentation for all the above: I sign my initial every 15 minutes to document your activity and SAFETY. The survey team entered the facility on 7/1/2026 at 10:30 a.m. Observations were made of the memory care unit. The staff currently assigned to the five residents with enhanced monitoring (15 minute checks, 1:1 and constant observation) were interviewed regarding their understanding of their responsibility. The staff was interviewed at that time and verified immediate educations of 100% of all staff regarding the facility's abuse policy. The Facility's Final/Accepted Removal Plan dated 7/2/26 at 2:28 PM:Upon escalation of behavior of resident # 1 resulting in resident # 2 being pushed to the floor, staff immediately intervened and removed resident # 1 from the area and placed him on 1:1 supervision. Resident # 2 was assessed by licensed staff and verified as having no injuries. Relocation plans were immediately initiated for Resident # 1 and the resident discharged from the facility on June 25, 2026.All residents have the potential to be affected. Full body skin assessments were completed by licensed nurses for all residents residing on the unit with no additional findings. The resident present at the time of the incident was immediately removed from the area.Resident companions were re-educated by department heads on methods to de-escalate situations and early identification of triggers that can cause an increase in behaviors. All staff were re-educated by department heads on identifying and preventing abuse.The facility's final Immediacy Removal Plan was validated through:1. Verified skin assessments on 100% of all residents residing on the memory care unit.2. Verified immediate education of 100% of all staff regarding the facility's abuse policy.3. Verified that 100% of all Resident Companions were re-educated by department heads on methods to de-escalate situations and early identification of triggers that can cause an increase in behaviors.Following the removal of Immediate Jeopardy on 6/25/26 at 5:00 PM, the scope and severity was lowered to a level three, isolated harm.No additional information was provided to the conclusion of the survey.

Based on record reviews and staff interview the facility failed to report the results of a facility reported incident investigation within 5 working days of the incident.The findings included: The facility staff failed to report the results of a facility reported incident investigation within 5 working days regarding Resident #1 abusing Resident #2 by pushing him out of a chair and onto the floor as well as attempting to hit Resident #2 with a chair while Resident #3 stood in close proximity to the incident. On 7/1/26 at 4:55 PM an interview was conducted with the Administrator. The Administrator stated that she had 5 (five) minutes to send the final investigation to the State Agency or she would be in violation of not reporting in the required amount of time. The Administrator also stated that the State Agency was informed of the initial Facility Reported Incident on 6/24/26. The Administrator further stated that she did not know that the reporting requirements under this regulation are based on real (clock) time, not business hours.A review of the Facility Reported Incident dated 6/24/26 read: Staff reported (resident name redacted) pushed (resident name redacted) out of chair causing resident to fall. Both residents were immediately separated. Investigation implemented.On 7/2/26 at 5:30 PM a final interview was conducted with the facility's Administrator, Director of Nursing, [NAME] President of Operations, Regional Director of Operations, Regional Nursing Consultant, Leadership Development Manager, and [NAME] President of Quality. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 8 residents (Resident #2), in the survey sample.The findings included: The facility staff failed to provide supervision to prevent Resident #1 from pushing Resident #2 out of a chair and onto the floor as well as attempting to hit Resident #2 with a chair. 1. Resident #1 was originally admitted to the facility 2/21/26. The diagnoses included unspecified dementia with other behavioral disturbance, chronic obstructive pulmonary disease, muscle weakness, and major depressive disorder.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired.A review of nursing progress notes dated 6/24/26 at 3:40 PM read: Resident is on constant supervision. Resident was in a resident on resident altercation. at 3:40pm. Writer was counting out/giving report at the nurse's station. A noise was heard of a chair flipping over and a thud on the ground down hallway one. As we came around the nurse's station, a resident was on the floor sitting. Between the resident and writer was (resident name retracted). He proceeded to pick up the chair and directed it towards the resident that was sitting on the floor. A thud was heard after that happened. Staff immediately removed the chair from the resident's possession and the resident on the floor was brought to the nurses station for evaluation. MD has been notified. RP was called and a message left to call back for an update. UM, DON and Administrator were immediately notified and came to evaluate. Statements have been collected. Resident remains on 1:1 supervision.The comprehensive care plan dated 4/7/2026, documented in part,Focus: I have a behavior problem of becoming aggressive during care at times. Interventions: Educate caregivers on successful coping and interaction strategies such as allowing resident time to de-escalate and reapproach at later time. Explain all procedures to the resident before starting and allow the resident to adjust to changes. Dated 5/11/2026 - Resident placed on 1:1 supervision. The care plan further documented, Focus: I am/have the potential to demonstrate physician behaviors related to Dementia, hx (history) of resident-to-resident altercations, I pushed another resident. Interventions: 1:1 supervision (6/24/26). Assess and address for contributing sensory deficits. Close monitoring (5/14/26). 2. Resident #2 was originally admitted to the facility 1/29/26. The diagnoses included Alzheimer's Disease with early onset, unspecified dementia without behavioral disturbance, essential hypertension, and muscle wasting and atrophy.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/12/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were severely impaired.A review of nursing progress notes dated 6/24/26 at 5:19 PM read: At 3:40pm, Writer was informed about a resident-to-resident altercation and noted resident sitting on the floor. Staff immediately check on the resident. Writer assess resident skin, ROM and Vital signs taken. No injuries noted. Resident was helped to the nurses' station for evaluation. UM, DON and Administrator were immediately notified and came to evaluate. Statements have been collected. Resident placed on 1:1 supervision. MD made aware and ordered to send resident out for further evaluation and CT scan. Wife is here at this time and is aware of incident. 911 was called.A review of Resident #2's Hospital Emergency Department documentation dated 6/24/26 read: You have a head injury. It doesn't appear serious at this time. But symptoms of a more serious problem, such as a mild brain injury (concussion) or bruising or bleeding in the brain, may appear later. For this reason, you or someone caring for you will need to watch for the symptoms listed below. Once you're home, also be sure to follow any care directions you're given.On 7/1/26 at 2:35 PM an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated while giving a recount of the event that occurred on 6/24/26 between Resident #1 and Resident #2 that he was in the process of counting medications and heard a thud. LPN #2 also stated that he observed Resident #2 laying on the ground and Resident #1 picking up a chair and directing the head of the chair towards Resident #2. LPN #1 further stated that an Activities Aide 1:1 was assigned to Resident #1 and observed this incident as well. LPN #1 lastly stated that the Activities Aide 1:1 was just watching and should have intervened quicker than she did. On 7/1/26 at 2:53 PM an interview was conducted with the Director of Nursing (DON). The DON stated that Resident #1 was on constant observation for a prior incident that took place regarding another resident. The DON also stated that Resident #1 has a history of displaying aggressiveness. The DON further stated that regarding the incident that took place between Resident #1 and Resident #2, the staff member should have intervened quickly, much quicker than she did.On 7/1/26 at 3:45 PM an interview was conducted with the Leadership Development Manager. The Leadership Development Manager presented a video of the incident that took place between Resident #1 and Resident #2. The video showed Resident #1 standing in front of Resident #2 and pushing him over onto the floor while he was sitting in a chair in the hallway. OSM #6 was sitting in a chair nearby and observed the entire incident. OSM #6 did not intervene until after Resident #2 was pushed by Resident #1 and fell to the floor. The video further revealed that Resident #1 picked up the chair with Resident #3 in close proximity and attempted to strike Resident #2 with the chair, however OSM #6 intervened and put her hand on the chair to stop Resident #1 from hitting Resident #2 with the chair.On 7/1/26 at 4:10 PM an interview was conducted with LPN #2. LPN #2 stated that the incident should not have occurred due to Resident #2 being on constant observation. LPN #2 also stated that the Activities Aide 1:1 was observing the confrontation and should have intervened to prevent Resident #2 from being pushed out of the chair and onto the floor by Resident #1.On 7/1/26 at 4:35 PM an interview was conducted with Activities Aide 1:1. The Activities Aide 1:1 stated, I did not feel like it was typical protocol to intervene. I did not feel like he would take it the physical part. That was my first day taking care of him. I did not think he would physically get him out of the chair. We are told who we are taking care of when we get to work. We are just told they have to be watched. I did not know what the constant observation was for regarding the resident. The facility's Memory Care Unit Policy with an effective date of 5/13/26 read: Phase 2 - Constant Observation/Monitoring Requirements: Staff shall remain within close proximity to intervene immediately if necessary. The facility provided a copy of their Ad Hoc meeting minutes dated 6/24/2026. The meeting minutes documented:Identified Issue: the facility experienced a resident-to-resident altercation that did not result in injury.Goal: Resident will not sustain serious injurySummary Report: Resident to Resident events reviewed in addition to the plan of correction from survey ending 4/9/26. The plan in place at the time of the event was sufficient to address the escalation of behavior and as a result kept all residents free from harm. The facility has successfully implemented a system for observing resident identified as potential victims or resident with potential for behaviors affecting others. The levels of supervision are determined by a number of factors including but not limited to historical events, assessment by social services, psychiatry consultation recommendations, review of monitoring documentation and input from medical director, staff and families. The success of the system is measured and validated by substantial decrease in incidents, also noting that this was an isolated event and the only time since the date of compliance.Upon debriefing with the team members present at the time, additional educational opportunities were identified. Resident companions received additional training on methods to de-escalate situations and early identification of triggers that can cause an increase in resident behaviors resulting in altercations. The committee will continue to monitor and address educational needs as they are identified. A training session with (name of local police officer) is schedule for August 6, 2026 from 2:00 p.m. to 3:30 p.m. to teach additional methods of protecting resident and staff from potentially aggressive behaviors.Cards provided to Recreational Sitters.Definitions of Levels of Monitoring:1:1 Monitoring: I can see you and touch you. Constant Supervision: I can always see you.Q (every) 15-minute checks: I put my eyes on you every 15 minutes to make sure you are safe.Documentation for all the above: I sign my initial every 15 minutes to document your activity and SAFETY.The survey team entered the facility on 7/1/2026 at 10:30 a.m. Observations were made of the memory care unit. The staff currently assigned to the five residents with enhanced monitoring (15 minute checks, 1:1 and constant observation) were interviewed regarding their understanding of their responsibility. The staff was interviewed at that time and verified immediate educations of 100% of all staff regarding the facility's abuse policy.Plan of Correction:Upon escalation of behavior of resident # 1 resulting in resident # 2 being pushed to the floor, staff immediately intervened and removed resident # 1 from the area and placed him on 1:1 supervision. Resident # 2 was assessed by licensed staff and verified as having no injuries. Relocation plans were immediately initiated for Resident # 1 and the resident discharged from the facility on June 25, 2026.All residents have the potential to be affected. Full body skin assessments were completed by licensed nurses for all residents residing on the unit with no additional findings. The resident present at the time of the incident was immediately removed from the area.Resident companions were re-educated by department heads on methods to de-escalate situations and early identification of triggers that can cause an increase in behaviors. All staff were re-educated by department heads on identifying and preventing abuse.Verified skin assessments on 100% of all residents residing on the memory care unit.5. Verified immediate education of 100% of all staff regarding the facility's abuse policy.6. Verified that 100% of all Resident Companions were re-educated by department heads on methods to de-escalate situations and early identification of triggers that can cause an increase in behaviors.Compliance was obtained on 6/25/26 at 5:00 PMNo additional information was provided to the conclusion of the survey.

Based on observation, staff interviews, clinical record review and facility document review, the facility staff failed to protect residents' right to be free from abuse by other residents for 4 of 18 residents in the survey sample, Residents #17, #16, #15, and #2, resulting in the identification of immediate jeopardy and substandard quality of care for Resident #2. The findings include:1.For Resident #17 (R17), the facility staff failed to protect the resident's right to be free from physical abuse by Resident #14 (R14) on 3/20/24.R17 was admitted to the facility 10/16/23 with diagnoses to include but not limited to Lewy body dementia with agitation, hereditary idiopathic neuropathy, frontotemporal neurocognitive disorder, type 2 diabetes mellitus, major depressive disorder, bipolar disorder, generalized anxiety disorder, muscle wasting, and tremors. R17's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) 3/22/24 coded her a 03/15 in Section C. Cognitive Patterns, Brief Interview for Mental Status indicating severe cognitive impairment (suggesting significant difficulties with short-term memory and orientation). R14 was admitted to the facility 2/6/24 with diagnosis to include but not limited to vascular dementia with psychotic disturbance, anxiety, rheumatoid arthritis left hip, iron deficiency anemia, malignant neoplasm prostate, insomnia, restlessness and agitation, and major depressive disorder. R14's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/1/25 coded R14 as 03/15 on the BIMS (Brief Interview of Mental Status) indicating severe cognitive impairment with skills of memory, thinking and orientation to place and timeA review of the facility's final synopsis dated 3/20/24 involving R17 and R14 revealed, in part: On 3/20/24, staff reported R17 slapped R14 and R14 pushed R17 to the floor. Residents were immediately separated and assessed for any injuries. Skin and pain assessments were done on both parties following the incident.A review of witness statements from staff revealed the following:Certified Nursing Assistant #3 (C.N.A.#3) stated it was somewhere between 6:30-6:45 PM, she was assisting another resident heard screaming and a hard fall, stated she did not observe the altercation but that R17 told her R14 pushed her down.C.N.A. #2 stated she was in the dining room, heard a scream coming from the third hallway and rushed to the area, noting R17 on the floor next to the food cart, R14 standing up next to the food cart. She stated when the residents were asked what happened both responded saying R17 slapped R14 and then he pushed her to the floor.Per LPN#5, he was alerted to the altercation between R17 and R14 by the activity staff and immediately responded to investigate the situation, R17 had returned to her room and upon assessment R17 had a bump on the top/back of her head.C.N.A. #4 stated she heard a scream and responded noting R17 on the floor and notified the charge nurse.A review of R17's progress note dated 3/20/24 by LPN#5 revealed in part: Resident had an altercation with another resident. There was no witness. Skin check was conducted to assess the bump on the back of her head, two centimeters tall and one inch wide. Pain evaluation completed with R17 denying pain or headache. Resident vital signs are within normal limits with blood pressure 134/77, temperature 97.6 temporal, heart rate 86, respirations 19, oxygen at 94% on room air. The physician was notified of the incident and advised to initiate neuro checks. Every 15-minute monitoring was implemented.On 4/9/24, R17 was evaluated by Psychiatrist Nurse Practitioner, every 15-minute safety check was discontinued due to no behaviors noted since 3/20/24, adjustment was made to medication prescribed to treat her mood disorder.A review of R17's comprehensive care plan dated 3/21/24 revealed revision to include care plan focus psychosocial well-being problem r/t alleged physical altercation.On 4/9/24, the Unit Manager requested the Psychiatrist Nurse Practitioner to re-evaluate R14 for possible discontinuation of every 15-minute safety checks. According to the evaluation by the Psychiatrist Nurse Practitioner, R14 had not had any altercations with co-residents since 3/20/24, therefore every 15-minute safety check was discontinued, and adjustments were made to R14's medication to manage R14's mood and mood fluctuations. 2. For Resident #16 (R16), the facility staff failed to protect the residents' right to be free from abuse by Resident #14 on 12/18/24.R16 was admitted [DATE] with diagnoses to include but not limited to dementia with agitation, major depressive disorder, psychotic disorder with delusions, hallucinations and adult failure to thrive. R16's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 1/9/24 coded her a 99 for Brief Interview for Mental Assessment as R16 not able to complete assessment on cognition.A review of the facility's final synopsis of incident dated 12/18/24 revealed, in part: R16 was noted to be in her bed with her entire body covered including her head with covers resting with R14 laying on top of the covers fully clothed in the same bed. Skin and pain evaluations were completed and no injuries were noted. Neither resident was able to recall the incident, and no evidence of abuse was substantiated. A review of witness statements from staff revealed the following:A review of C.N.A#5's witness statement revealed, CNA#2 informed her that R14 was in R16's room and she went to assist CNA#2 with re-directing R14 out of R16's room. According to CNA #5, she had laid R14 down in his room around 9:00 PM after already getting him from trying to go into R16's room and made sure he was laying down in his own bed. According to C.N.A#2, she overheard nurse tell R14 to exit R16's bed and stated as she was completing her rounds at approximately 10:15 PM, she observed R16's brief undone and her buttocks exposed. A review of R16's clinical record revealed the following progress note dated 12/18/24 at 11:03 PM: Male resident (R14) was observed in R16's bed. R14 was fully clothed and female resident (R16) was fully covered with blankets. The Certified Nursing Assistant (C.N.A #2) pulled the covers back and the female residents brief was deviated to the right side with the buttocks exposed.3. For Resident #15 (R15), the facility staff failed to protect the residents' right to be free from abuse by Resident #14 on 1/22/25.R15 was admitted [DATE] with diagnoses to include but not limited to abdominal aortic aneurysm, ruptured, iron deficiency anemia, Alzheimer's dementia with agitation, major depressive disorder, and anxiety. R15's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 1/2/25 coded him 06/15 on the Brief Interview for Mental Assessment, indicating severe cognitive impairment with skills such as memory, thinking and orientation to place and time.A review of the facility's final synopsis of event dated 1/22/25 revealed, in part: Upon investigation it was reported that R15 wandered into R14's room and called him a racial slur, then R14 hit R15. Neither resident sustained any injuries. Both residents tolerating meals and medications well. A review of witness statements from staff revealed the following:According to LPN#6, she observed R15 exiting R14's room holding a bloody rag on his mouth, saying that (n-word) hit me in my mouth.Per witness statement from C.N.A.#6, R15 was observed at the double doors with his mouth bleeding at approximately 12:30 AM and that R15 said that (n-word) hit me in my mouth.A review of clinical record revealed progress note dated 1/22/2025 at 1:00 AM, Resident was involved in an altercation with another resident. Small cut noted to lower lip right side.A review of the Interim Skin Check evaluation dated 1/22/25 revealed Head to Toe Skin Check and Evaluation, Skin Condition and Integrity Findings, 1a. Are there any skin impairments noted? YES. 1b. Is this a new skin impairment? YES. 1c. Type of Skin Impairment, Laceration.4. For Resident #2 (R2), the facility staff failed to protect the resident's right to be free from abuse by Resident #14 on 12/30/25, where a physical altercation occurred, when he entered her room, resulting in harm and hospitalization for R2.R2 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia without behavioral disturbance, post-traumatic stress disorder, scoliosis, anxiety, psychosis, depression, fibromyalgia, chronic pain syndrome, and long-term use of anticoagulants for treatment of deep vein thrombosis. R2's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 10/13/25 coded her a 07/15 on the Brief Interview for Mental Assessment, indicating severe cognitive impairment with skills of memory, thinking and orientation to place and time.A review of the facility's final synopsis of event dated 12/30/25 revealed, in part: Staff alleges R14 struck R2 in her left eye causing bruising, head to toe skin and pain assessments completed on both residents. Statements obtained from staff reported that another resident had informed them that R2 and R14 were fighting. Upon entering R2's room they observed R14 standing in front of R2 and each resident struggling over R2's reacher/grabber tool, residents were immediately separated. R2 stated to staff that R14 hit her in her left eye. Skin assessment completed on R2 noting swelling and bruising to her left eye. She denied pain and discomfort. R14 was immediately escorted out of R2's room and placed on every 15-minute checks. Skin evaluation was negative for injury to R14.A review of nurse progress note dated 12/30/25 at 9:45 PM read in part, Writer was charting at the nurses' station, and a resident came to call me and said they are fighting. I rushed to the 3rd hall, and I saw R2 and R14 in front of her room pushing and pulling on a reacher/grabber stick. I separated them. R2 stated that he came to my room and I tried to ask him to leave and he hit me in my left eye. Swelling and bruising noted around R2's left eye. R2's responsible party, physician and the Director of Nursing were notified of the incident. Neuro checks were initiated.A review of Interim Skin Check evaluation dated 12/30/25 at 8:30 PM revealed Head to Toe Skin Check and Evaluation, Skin Condition and Integrity Findings, 1a. Are there any skin impairments noted? YES, 1b. Is this a new skin impairment? YES, 1c. Type of Skin Impairment, Bruise.A review of One-on-One Check Observation Log initiated 12/30/25 through 12/31/25 R2 revealed:10:00 PM Resident sitting in chair in her room11:00 PM Resident in wheelchair at nursing station12:00 AM Resident in wheelchair at nursing station1:00 AM through 7:00 AM Resident sleeping8:00 AM through 10:00 AM Resting in bed'A review of neurological checks completed by nurses initiated 12/30/25 through 12/31/25 assessed vital signs, pupil size and response, speech, response to name, pain, environment and seizure activity, headache and vomiting.A review of physician note dated 12/31/25 at 10:07 AM read in part, Patient (R2) recently was involved in an altercation where her orbit was injured. She became more lethargic and her vitals showed temperature 102 degrees Fahrenheit, heart rate 126, blood pressure 224/115, and oxygen saturation in the 50s before rising to 97% on 4L Venti mask (re-breathing mask). Due to risk of deterioration she (R2) was sent to the ED (local hospital emergency department).A review of nurse progress note dated 12/31/25 at 11:45 AM read in part, Writer (LPN#3) informed by charge nurse the resident breathing was abnormal and resident was unresponsive. Writer entered room and resident noted to be lying in bed heavily breathing but not responding to name or sternal rub. Vital signs taken and abnormal, blood pressure 244/119, heart rate 126, respirations 20, oxygen saturation 53% on room air. Physician notified. Oxygen was increased to 15 liters on a non-rebreather, with oxygen saturation up to 96%. R2 was still not responding. The physician was -notified again and with an order to send to the emergency room for further evaluation. Writer called and spoke to responsible party, R2's sister in-law. EMS (Emergency Medical Services) notified and R2 transferred to (name redacted) hospital. A review of R2's clinical record for physician orders revealed an order for Eliquis 5 milligrams by mouth two times a day for the prevention of recurring deep vein thrombosis. (Eliquis is a prescription blood thinner used to prevent and treat blood clots. Adverse Effects/Toxic Reactions may include but not limited to: increased risk for bleeding/hemorrhagic events. May cause serious, potentially fatal, bleeding of the following sites: intracranial (within the skull), intraocular (within the eye) (1).On 4/7/26 at 7:36 AM, an interview was conducted with C.N.A.#2 regarding the altercation between R2 and R14. According to C.N.A.#2, she usually works the day shift but had picked up an extra shift. She stated she and LPN#10 went to R2's room upon notification of the resident-to-resident fighting. She said she observed R2 and R14 pulling and pushing R2's reacher/grabber stick. R2's left eye was red and swollen. She said they removed R14 from R2's room and both residents were placed on every 15-minute safety checks and no further problems from either one of them that she was aware of the rest of the 3-11 PM shift. On 4/7/26 at 7:40 AM, an interview was conducted with LPN#4. According to LPN#4, the Unit Manager, LPN#3 was helping her out the morning of 12/31/26 as it was so busy. She said LPN#3 was taking care of R2 mostly. She stated she had made her rounds on the morning of 12/31/25 and noticed that R2's eye was swollen terrible, swollen shut, and had a purplish reddish bruising around the left eye. She wasn't responding as much as usual. Later the aide told us she wasn't eating her breakfast then we knew something wasn't right. LPN#3 called the doctor. R2 's condition kept getting worse. Her blood pressure and pulse were getting higher and her breathing was labored. She was showing a drastic change, and the doctor told us to send her out.On 4/7/26 at 8:10 AM, an interview was conducted with LPN #3, the Unit Manager on the Memory Care Unit. According to LPN#3 she was notified of the altercation between R2 and R14 on 12/30/25 and came into facility. She stated she called the police and stayed at the facility until the police arrived. She stated R2 was at the nurse's station in her wheelchair watching TV when the police arrived and R14 was in his room. She stated the police did not stay long, they observed R2 and R14, left his card and then exited the facility stating not much he could do when it involved people who were cognitively impaired. She stated she cared for R2 on the morning of 12/31/25 and that R2 was noted not to be eating her breakfast which was out of the norm for her. Shortly after that nurse reported to her that R2's vital signs and mental status began to deteriorate. According to her, she contacted the Director of Respiratory for a non-rebreather mask and the Director of Respiratory and Director of the Dialysis Program arrived on-site to assist her in providing emergency care to R2 with applying the non-rebreather mask and communicating changes in resident condition to the physician via phone while she called 911 after physician gave order to transfer to out for evaluation and treatment. She stated R2 did not return to the facility but that her family had come in a few days later and retrieved her personal belongings. She stated she did not know why R2 did not come back to the facility.On 4/7/26 at 8:41 AM, a telephone interview was conducted with R2's responsible party, who stated that the physician at the hospital had told her R2 suffered a significant brain bleed from being hit in the eye and being on a blood thinner. She said she was told by the hospital doctor that R2 passed away at 2:00 AM on 1/1/26. On 4/7/26 at 9:05 AM, an interview was conducted with the Administrator regarding the altercation between R2 and R14. According to the Administrator, she was notified of the altercation and came into the facility on [DATE] and was present when the police arrived. When asked why the police were notified, she stated because it was a physical resident-to-resident altercation and R2 wanted the police to be notified. She stated she saw R2 in the wheelchair in the nurses' station and that she appeared to be okay and R14 was back in his room and staff had them both on every 15-minute safety checks. She stated she reported the incident to the appropriate authorities and then went home. When asked about the change in condition of R2 on 12/31/25 requiring transfer to the emergency room and why she had not returned to the facility she responded, I don't know why she did not come back. She stated the family came in a few days later and retrieved her belongings but when asked about R2's status they said she would not be returning to the facility and requested a copy of R2's medical records.On 4/7/26 at 9:40 AM an interview was conducted with the Director of Respiratory and Director of the Dialysis Program. According to the Director of Respiratory she had been notified by LPN# 3 for a non-rebreather mask. She said upon entering R2's room she noted resident was in crisis with labored breathing, unresponsive and critically high blood pressures and heart rate. According to the Director of the Dialysis Program, she noted R2's left eye was swollen shut with noticeable purplish black bruising and she and the Director of Respiratory stayed at the bedside and assisted nursing in communicating R2's condition with the physician via phone.On 4/7/26 at 9:45 AM, the Social Services Assistant (Other Staff Member #11) was interviewed. She stated she is responsible for following up with residents after any resident-to-resident altercation to evaluate their psychosocial needs. She stated that more times than not, when she follows up with the residents who reside in the Memory Care Unit, they are unable to recall the incident, but she attempts to ensure they are comfortable and feel safe. She stated she looks for nonverbal indicators or emotional distress/ anxiety as well as conducting follow-up interviews. When asked if resident-to-resident physical altercations or a male resident observed in bed with a female resident that is not consensual would constitute abuse, she responded, Absolutely, abuse can be physical, mental, sexual or financial, and it is our responsibility to protect them and they should be able to feel safe here, but the Memory Care Unit does present with lots of challenging behaviors.On 4/7/26 at 11:10 AM an interview was conducted with the Nurse Concierge (Other Staff Member #10). According to her it is her responsibility to follow up on residents who are sent out to emergency room the next day to see how they are doing and document her findings in the resident's chart and give an end-of-the-day report on all the calls to the Administrator.OSM#10 said she left a message for R2's sister-in-law but did not get a return call. When asked where the documentation for R2's follow-up call, she responded, In all honestly, it just didn't get into her chart. When asked why R2 did not return to the facility, she responded, I just don't know. On 4/7/26 at 1:05 PM, an interview was conducted with the physician regarding R2's change in condition on 12/31/25. According to the physician, he said he was notified on the evening of 12/30/25 after the altercation between R2 and R14 and the nurse informed him that R2 had slight bruising and swelling in her left eye. He stated he asked the nurse if R2 had any changes in level of consciousness, mentation, headaches and vision and he stated the nurse reported none. He said the nurse said R2 was fine. He said the nurse reported vital signs and neurological checks were within normal limits and R2 was drinking fluids with no nausea or vomiting. When asked about R2 being on a blood thinner and getting hit in the eye, immediately resulting in some bruising and swelling would that not have prompted sending R2 to the emergency room for evaluation due to the high risk of bleeding, he responded, The assessment from the nurse did not present with symptoms that would result in sending her out to the emergency room, her vital signs and neuro checks were okay.On 4/7/26 at 2:10 PM, interviews were conducted with several licensed practical nurses on what is the likelihood of injury if a person is hit on the head and is on a blood thinner. According to LPN#11, she said people who are on blood thinners are more vulnerable to excess bleeding and bruising than people who are not on blood thinners. She further stated the type and severity of injury would depend on how hard a blow the hit and where on the head the person was hit. I would expect to see bruising, maybe hematomas or excessive bleeding, perhaps a nosebleed, and maybe internal bleeding, this could be very dangerous and life-threatening.According to LPN#4, she said, They could bleed out.Per LPN#5, he responded I would expect to see increased bruising, a hematoma, aneurysm, heavier bleeding than someone who is not on a blood thinner.According to LPN#12, she said she would expect increase in bleeding, perhaps from the nose or cuts or maybe in the brain. They could bleed out.According to LPN#9, she responded by saying, they may experience a stroke from internal bleeding, more bruising, seizures, hematomas. Blood thinners can be very dangerous if a resident falls and hits their head or they can have some bleeding inside the body that we don't see. They can bleed profusely from small cuts. On 4/7/26 at 4:00 PM, an interview was conducted with the DON (Director of Nursing) on her expectation of what a nurse should be assessing when completing neurological checks, she stated, mentation, pupillary response, level of consciousness, and responding appropriately to questions. When a person is hit in the eye head and is on a blood thinner what is the likelihood of an injury? The DON responded, That would be patient specific and how hard they were hit. When asked about R2 being hit by R14, with immediate swelling and bruising to the eye resulting in a significant change in condition and a transfer to the emergency department she stated she did not necessarily think R2's change in condition was solely as a result from the altercation with R14 on 12/30/25. When asked about what constituted resident abuse, the DON stated, Abuse comes in different forms, it can be physical, emotional, verbal, financial or sexual. When asked is it the residents' right to be free from abuse, the DON responded, Of course, it is their right to be free from abuse and to feel safe in our care. All of these incidents of abuse occurred on the facility's Memory Care Unit and were perpetrated by the same resident, Resident #14 (R14)R14 remains a current resident of the facility and is permitted to ambulate throughout the unit and have direct access to other residents. Therefore. creating an imminent risk to other residents.A review of nurse progress note dated 1/3/2026 revealed R14 observed in a female's room attempting to get into bed with her, clothes on and brief was still on. Resident was given re-direction, to which R14 attempted to fight against and swing at staff. R14 made grabbing motions at staff and attempted to hit staff.A review of Psychiatrist Nurse Practitioner progress note dated 1/5/26 read in part, Facility staff requested consultation related to escalating behavioral disturbances. Facility staff report increasing aggressive and inappropriate behaviors. According to the staff, R14 became verbally aggressive when staff attempted to obtain his weight, refused redirection, and became tense and competitive. Staff further report that the resident entered a female resident's room and attempted to get into bed with her while clothed and wearing a brief. When redirected, the R14 became physically aggressive, making grabbing motions, swinging at staff, and attempting to strike them. R14 poses risks to staff and peers due to aggressive and sexually inappropriate behaviors. Upon assessment, the R14 has significant behavioral disturbances characterized by aggression, poor impulse control, and sexually inappropriate behavior. Presentation is consistent with behavioral symptoms likely related to underlying neurocognitive disorder. Current behaviors place R14 and others at risk Treatment Plan/Recommendations: 1. Discontinue anti-depressant used to treat depression due to concern for activating effects contributing to agitation, aggression, and behavioral dysregulation. Discontinuation is part of behavioral symptom management to reduce stimulation and impulsivity. Monitor for improvement in agitation, aggression, and intrusive behaviors following discontinuation. Monitor for emergence or worsening of depressive symptoms. Continue non-pharmacological interventions including consistent redirection, calm approach, and environmental modifications. Ensure close supervision to reduce risk to staff and peers. Continue to assess risks to harm himself or others. Staff to utilize de-escalation techniques and document behavioral incidents.Review of nurse progress note dated 1/5/26 read in part, R14 no longer on 1:1 supervision per physician's order.On 4/6/2026 between 12:00 PM-1:00 PM, Resident #14 was observed ambulating independently on the Memory Care Unit in the hallways and in the common areas. He was observed in shorts and a long sleeve T-shirt constantly rubbing his arms as he wandered about unit.On 4/6/2026 at approximately 3:00 PM, Resident #14 was observed wandering the hallways and the common area of Memory Care Unit.A review of the facility's abuse policies: Resident Rights and Abuse Prevention Policy and Policy Manual 2001, MED-PASS, Inc; Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, reads in part: All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Resident Rights and Abuse Prevention Policy and Policy Manual, 2001, MED-PASS, Inc; reads in part; Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervison and assistance to prevent accidents are facilty-wide priorities.Facilty-Oriented Approach to SafetyOur facility-oriented approach to safety addresses risks for groups of residents.Safety risk and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance and Improvement Program) committee reviews of safety and incident/accident data; and a faclilty-wide commitment to safety at all levels of the organization.When accident hazards are identified, the QAPI/safety committee shalle evaluate and analyze the cause/s of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Employuees shall be trained on potential hazards and demonstrate competency on how to identify and report accidents hazards, and try to prevent avoidable accidents.The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.The facility's deficient practice placed all residents on the Memory Care Unit at risk of being abused by R14. This resulted in a determination of immediate jeopardy (IJ), and cited at level four, pattern beginning 3/20/24. On 4/7/26 at 4:26 PM, the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional [NAME] President of Operations were informed of these concerns and that the facility was in immediate jeopardy. On 4/7/26 at 9:31 PM, the facility's IJ Immediacy Removal Plan was accepted by the State Agency. Facility Removal Plan: Corrective actions which will be accomplished for those residents found to have been affected. Resident #14 has been placed on one-to-one supervision. This will continue until the medical director has evaluated and established that the risk for resident-to-resident altercations is not present. The care plan will be updated to reflect the one-to-one support. Identification of other residents having the potential to be affected, and corrective actions that will be taken.The facility identified all residents residing on the secured memory care unit as potentially affected. A 100% audit was conducted to identify any residents exhibiting aggressive behavior and residents at risk for victimization due to cognitive impairment or vulnerability. All identified residents had their care plans reviewed and revised as needed. Skin evaluations completed for all current residents that reside on the Grove unit to identify any residents with injuries to ensure appropriate reporting and interventions are placed if indicated. Measures that will be put in place and systemic changes that will be made to ensure that the practices do not recur.Current employees will receive education regarding preventing, recognizing, and reporting abuse, specifically resident-to-resident altercations. No employee will work without receiving designated education. The Administrator/designee will conduct ten interviews with memory care resident family members and/or staff daily to determine concerns related to abuse, specifically resident-to-resident altercations.Any allegations of abuse or neglect identified as a result of the interviews will be immediately reported and investigated. Allegation of ComplianceThe facility alleges compliance with this plan on 11:59pm 04/07/2026. On 4/8/26 at 9:26 AM, the survey team began verification of the facility's removal plan. This verification process included observation of R14 for 1:1 supervision, interviews with multiple staff from various departments and units on education of abuse prevention and all elements of the removal plan, education on preventing, recognizing, and reporting abuse, specifically resident-to-resident altercations. and review of credible evidence binder order for 1:1 monitoring for increased supervision, care plan: I have behavior problems of becoming aggressive during care at times, audit of residents with behaviors and care plans updated to reflect behaviors, skin checks on all residents on the Memory Care Unit. The survey team was able to verify that the facility completed all elements of the removal plan as of 4/8/26 at 1:51 PM. Once the immediate jeopardy was removed, the scope and severity were reduced to a level two, pattern. No further information was provided. (1) This information was obtained from the following nurse drug reference book: [NAME] Nursing Drug Handbook 2016, Kizior, [NAME], J., [NAME], page 81.

Based on observation, staff interviews, clinical record review and facility document review, the facility staff failed to provide adequate supervision in an accident and hazard free environment to protect residents' safety and failed to provide adequate supervision of a resident with known aggressive behaviors (Resident #14) which resulted in altercations with four other residents in a survey sample of 18 residents. Residents #17, #16, #15, and #2, resulting in the identification of immediate jeopardy, substandard quality of care and harm for Resident #2. The findings include:1.For Resident #17 (R17), the facility staff failed to provide adequate supervision from Resident #14 (R14) on 3/20/24 from entering her room and resulting in physical altercation between the two residents. R17 was admitted to the facility 10/16/23 with diagnoses to include but not limited to Lewy body dementia with agitation, hereditary idiopathic neuropathy, frontotemporal neurocognitive disorder, type 2 diabetes mellitus, major depressive disorder, bipolar disorder, generalized anxiety disorder, muscle wasting, and tremors. R17's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) 3/22/24 coded her a 03/15 in Section C. Cognitive Patterns, Brief Interview for Mental Status indicating severe cognitive impairment (suggesting significant difficulties with short-term memory and orientation). R14 was admitted to the facility 2/6/24 with diagnosis to include but not limited to vascular dementia with psychotic disturbance, anxiety, rheumatoid arthritis left hip, insomnia, restlessness and agitation, and major depressive disorder. R14's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/1/25 coded R14 as 03/15 on the BIMS (Brief Interview of Mental Status) indicating severe cognitive impairment with skills of memory, thinking and orientation to place and time.A review of the facility's final synopsis dated 3/20/24 involving R17 and R14 revealed, in part: On 3/20/24, staff reported R17 slapped R14 and R14 pushed R17 to the floor. Residents were immediately separated and assessed for any injuries. Skin and pain assessments were done on both parties following the incident.A review of witness statements from staff revealed the following:Certified Nursing Assistant #3 (C.N.A.#3) stated it was somewhere between 6:30-6:45 PM, she was assisting another resident heard screaming and a hard fall, stated she did not observe the altercation but that R17 told her R14 pushed her down.C.N.A. #2 stated she was in the dining room, heard a scream coming from the third hallway and rushed to the area, noting R17 on the floor next to the food cart, R14 standing up next to the food cart. She stated when the residents were asked what happened both responded saying R17 slapped R14 and then he pushed her to the floor.Per LPN#5, he was alerted to the altercation between R17 and R14 by the activity staff and immediately responded to investigate the situation, R17 had returned to her room and upon assessment R17 had a bump on the top/back of her head.C.N.A. #4 stated she heard a scream and responded noting R17 on the floor and notified the charge nurse.A review of R17's progress note dated 3/20/24 by LPN#5 revealed in part: Resident had an altercation with another resident. There was no witness. Skin check was conducted to assess the bump on the back of her head, two centimeters tall and one inch wide. Pain evaluation completed with R17 denying pain or headache. Resident vital signs are within normal limits with blood pressure 134/77, temperature 97.6 temporal, heart rate 86, respirations 19, oxygen at 94% on room air. The physician was notified of the incident and advised to initiate neuro checks. Every 15-minute monitoring was implemented.On 4/9/24, R17 was evaluated by Psychiatrist Nurse Practitioner, every 15-minute safety check was discontinued due to no behaviors noted since 3/20/24, adjustment was made to medication prescribed to treat her mood disorder.A review of R17's comprehensive care plan dated 3/21/24 revealed revision to include care plan focus psychosocial well-being problem r/t alleged physical altercation.On 4/9/24, the Unit Manager requested the Psychiatrist Nurse Practitioner to re-evaluate R14 for possible discontinuation of every 15-minute safety checks. According to the evaluation by the Psychiatrist Nurse Practitioner, R14 had not had any altercations with co-residents since 3/20/24, therefore every 15-minute safety check was discontinued with adjustments were made to R14's medication to manage R14's mood and mood fluctuations. A review of R14's care plan revealed a care plan focus: I have a psychosocial well-being problem related to alleged physical abuse incident, Date Initiated: 03/21/2024 with intervention of Allow me time to answer questions and to verbalize feelings, perceptions, and fears. Date Initiated: 03/21/2024. The care plan revision does not reflect potential aggressive behaviors. R14 had an additional care plan focus I am at actual /potential risk of wandering related to cognitive impairment, dementia dated 8/1/24 which included interventions of Engage me in group activities to decrease wandering, Evaluate presence of pain, monitor behaviors, monitor side effects of medications, photograph in elopement book, psych consult and treat as indicated, date initiated 2/6/24. 2. For Resident #16 (R16), the facility staff failed to provide adequate supervision from Resident #14 climbing into her bed on 12/18/24.R16 was admitted [DATE] with diagnoses to include but not limited to dementia with agitation, major depressive disorder, psychotic disorder with delusions, hallucinations and adult failure to thrive. R16's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 1/9/24 coded her a 99 for Brief Interview for Mental Assessment as R16 not able to complete assessment on cognition.A review of the facility's final synopsis of incident dated 12/18/24 revealed, in part: R16 was noted to be in her bed with her entire body covered including her head with covers resting with R14 laying on top of the covers fully clothed in the same bed. Skin and pain evaluations were completed and no injuries were noted. Neither resident was able to recall the incident, and no evidence of abuse was substantiated. A review of witness statements from staff revealed the following:A review of C.N.A#5's witness statement revealed, CNA#2 informed her that R14 was in R16's room and she went to assist CNA#2 with re-directing R14 out of R16's room. According to CNA #5, she had laid R14 down in his room around 9:00 PM after already getting him from trying to go into R16's room and made sure he was laying down in his own bed. According to C.N.A#2, she overheard nurse tell R14 to exit R16's bed and stated as she was completing her rounds at approximately 10:15 PM, she observed R16's brief undone and her buttocks exposed. An interview was conducted with C.N.A. #2 on 4/8/26 and she stated she had not witnessed R14 in R16's bed, only heard the nurse tell R14 to get out of R16's room. C.N.A #2 stated shortly after that she completed her rounds and observed R16's brief undone and her buttocks exposed.A review of R16's clinical record revealed the following progress note dated 12/18/24 at 11:03 PM: Male resident (R14) was observed in R16's bed. R14 was fully clothed and female resident (R16) was fully covered with blankets. The Certified Nursing Assistant (C.N.A #2) pulled the covers back and the female residents brief was deviated to the right side with the buttocks exposed.A review of R14's care plan revealed a care plan focus dated 7/9/24, I have a behavior problem related to: -Sexual ideations, -Roaming in rooms and taking other people belongings -I misplace my own belongings around the units, -I wear multiple layers of clothes that don't belong to me including women's apparel, -Defecating on the floor with interventions to include: Administer medications as ordered. Monitor/document for side effects and effectiveness. Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. 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 alternative location as needed. On 12/19/24 an additional intervention was added to the care plan: Make sure to layer resident in multiple layers of his clothes due to the resident's cold nature. R14 had additional care plan focus as noted previously for I am at actual /potential risk of wandering related to cognitive impairment, dementia dated 8/1/24 which included interventions of Engage me in group activities to decrease wandering, Evaluate presence of pain, monitor behaviors, monitor side effects of medications, photograph in elopement book, psych consult and treat as indicated, date initiated 2/6/24. Redirect during wandering episodes of confusion and prevent him from entering other resident's room when he cannot find his own room date initiated 8/1/24Per the Facility Reported Incident Final Summary, it revealed the facility was aware of R14's history of wandering into other resident's rooms and was transitioned from every 15-miniute checks to 1:1 supervision thru 4/7/25 at which time the psych nurse practitioner assessed him and recommended Patient Q15min (every 15-minute) checks discontinued after assessment. Staff will continue to monitor. 3. For Resident #15 (R15), the facility staff failed to provide adequate supervision of resident entering R14's room resulting in a physical altercation between the two residents on 1/22/25.R15 was admitted [DATE] with diagnoses to include but not limited to abdominal aortic aneurysm, ruptured, Alzheimer's dementia with agitation, major depressive disorder, and anxiety. R15's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 1/2/25 coded him 06/15 on the Brief Interview for Mental Assessment, indicating severe cognitive impairment with skills such as memory, thinking and orientation to place and time.A review of the facility's final synopsis of incident dated 1/22/25 revealed, in part: Upon investigation it was reported that R15 wandered into R14's room and called him a racial slur, then R14 hit R15. Neither resident sustained any injuries. Both residents tolerating meals and medications well. A review of witness statements from staff revealed the following:According to LPN#6, she observed R15 exiting R14's room holding a bloody rag on his mouth, saying that (n-word) hit me in my mouth.Per witness statement from C.N.A.#6, R15 was observed at the double doors with his mouth bleeding at approximately 12:30 AM and that R15 said that (n-word) hit me in my mouth.A review of clinical record revealed progress note dated 1/22/2025 at 1:00 AM, Resident was involved in an altercation with another resident. Small cut noted to lower lip right side.A review of the Interim Skin Check evaluation dated 1/22/25 revealed Head to Toe Skin Check and Evaluation, Skin Condition and Integrity Findings, 1a. Are there any skin impairments noted? YES. 1b. Is this a new skin impairment? YES. 1c. Type of Skin Impairment, Laceration.According to R14 psych nurse practitioner progress notes dated 4/7/25, Q15-minute checks were discontinued. R14 had been on 1:1 then transitioned to Q15-minute checks from incident 12/18/24 through 4/7/25. R14 was on Q15-minute checks when this incident occurred.A review of R14's care plan revealed interventions to include Monitor behaviors, Assist resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. 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 alternative location as needed. R14's care plan was reviewed/revised on 1/22/25 on the care plan focus of I have a psychosocial well-being problem r/t alleged physical abuse incident to include intervention of Administer medications as ordered, such as antidepressants, anti-anxiety, sedative/hypnotics, and antipsychotics. Monitor for side effects or adverse reactions. Report to physician or designee as indicated. Date Initiated: 01/22/2025. 4. For Resident #2 (R2), the facility staff failed to provide adequate supervision from Resident #14 on 12/30/25 which resulted in harm and hospitalization.R2 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia without behavioral disturbance, post-traumatic stress disorder, scoliosis, anxiety, psychosis, depression, fibromyalgia, chronic pain syndrome, and long-term use of anticoagulants for treatment of deep vein thrombosis. R2's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 10/13/25 coded her a 07/15 on the Brief Interview for Mental Assessment, indicating severe cognitive impairment with skills of memory, thinking and orientation to place and time.A review of the facility's final synopsis of event dated 12/30/25 revealed, in part: Staff alleges R14 struck R2 in her left eye causing bruising, head to toe skin and pain assessments completed on both residents. Statements obtained from staff reported that another resident had informed them that R2 and R14 were fighting. Upon entering R2's room they observed R14 standing in front of R2 and each resident struggling over R2's reacher/grabber tool, residents were immediately separated. R2 stated to staff that R14 hit her in her left eye. Skin assessment completed on R2 noting swelling and bruising to her left eye. She denied pain and discomfort. R14 was immediately escorted out of R2's room and placed on every 15-minute checks. Skin evaluation was negative for injury to R14.A review of nurse progress note dated 12/30/25 at 9:45 PM read in part, Writer was charting at the nurses' station, and a resident came to call me and said they are fighting. I rushed to the 3rd hall, and I saw R2 and R14 in front of her room pushing and pulling on a reacher/grabber stick. I separated them. R2 stated that he came to my room and I tried to ask him to leave and he hit me in my left eye. Swelling and bruising noted around R2's left eye. R2's responsible party, physician and the Director of Nursing were notified of the incident. Neuro checks were initiated.A review of Interim Skin Check evaluation dated 12/30/25 at 8:30 PM revealed Head to Toe Skin Check and Evaluation, Skin Condition and Integrity Findings, 1a. Are there any skin impairments noted? YES, 1b. Is this a new skin impairment? YES, 1c. Type of Skin Impairment, Bruise.A review of One-on-One Check Observation Log initiated 12/30/25 through 12/31/25 for R2 revealed:10:00 PM Resident sitting in chair in her room11:00 PM Resident in wheelchair at nursing station12:00 AM Resident in wheelchair at nursing station1:00 AM through 7:00 AM Resident sleeping8:00 AM through 10:00 AM Resting in bed'A review of neurological checks completed by nurses initiated 12/30/25 through 12/31/25 assessed vital signs, pupil size and response, speech, response to name, pain, environment and seizure activity, headache and vomiting. A review of physician note dated 12/31/25 at 10:07 AM read in part, Patient (R2) recently was involved in an altercation where her orbit was injured. She became more lethargic and her vitals showed temperature 102 degrees Fahrenheit, heart rate 126, blood pressure 224/115, and oxygen saturation in the 50s before rising to 97% on 4L Venti mask (re-breathing mask). Due to risk of deterioration she (R2) was sent to the ED (local hospital emergency department).A review of nurse progress note dated 12/31/25 at 11:45 AM read in part, Writer (LPN#3) informed by charge nurse the resident breathing was abnormal and resident was unresponsive. Writer entered room and resident noted to be lying in bed heavily breathing but not responding to name or sternal rub. Vital signs taken and abnormal, blood pressure 244/119, heart rate 126, respirations 20, oxygen saturation 53% on room air. Physician notified. Oxygen was increased to 15 liters on a non-rebreather, with oxygen saturation up to 96%. R2 was still not responding. The physician was -notified again and with an order to send to the emergency room for further evaluation. Writer called and spoke to responsible party, R2's sister in-law. EMS (Emergency Medical Services) notified and R2 transferred to (name redacted) hospital. A review of R2's clinical record for physician orders revealed an order for Eliquis 5 milligrams by mouth two times a day for the prevention of recurring deep vein thrombosis. (Eliquis is a prescription blood thinner used to prevent and treat blood clots. Adverse Effects/Toxic Reactions may include but not limited to: increased risk for bleeding/hemorrhagic events. May cause serious, potentially fatal, bleeding of the following sites: intracranial (within the skull), intraocular (within the eye) (1).On 4/7/26 at 7:36 AM, an interview was conducted with C.N.A.#2 regarding the altercation between R2 and R14. According to C.N.A.#2, she usually works the day shift but had picked up an extra shift. She stated she and LPN#10 went to R2's room upon notification of the resident-to-resident fighting. She said she observed R2 and R14 pulling and pushing R2's reacher/grabber stick. R2's left eye was red and swollen. She said they removed R14 from R2's room and both residents were placed on every 15-minute safety checks and no further problems from either one of them that she was aware of the rest of the 3-11 PM shift. On 4/7/26 at 7:40 AM, an interview was conducted with LPN#4. According to LPN#4, the Unit Manager, LPN#3 was helping her out the morning of 12/31/26 as it was so busy. She said LPN#3 was taking care of R2 mostly. She stated she had made her rounds on the morning of 12/31/25 and noticed that R2's eye was swollen terrible, swollen shut, and had a purplish reddish bruising around the left eye. She wasn't responding as much as usual. Later the aide told us she wasn't eating her breakfast then we knew something wasn't right. LPN#3 called the doctor. R2 's condition kept getting worse. Her blood pressure and pulse were getting higher and her breathing was labored. She was showing a drastic change, and the doctor told us to send her out.On 4/7/26 at 8:10 AM, an interview was conducted with LPN #3, the Unit Manager on the Memory Care Unit. According to LPN#3 she was notified of the altercation between R2 and R14 on 12/30/25 and came into facility. She stated she called the police and stayed at the facility until the police arrived. She stated R2 was at the nurse's station in her wheelchair watching TV when the police arrived and R14 was in his room. She stated the police did not stay long, they observed R2 and R14, left his card and then exited the facility stating not much he could do when it involved people who were cognitively impaired. She stated she cared for R2 on the morning of 12/31/25 and that R2 was noted not to be eating her breakfast which was out of the norm for her. Shortly after that nurse reported to her that R2's vital signs and mental status began to deteriorate. According to her, she contacted the Director of Respiratory for a non-rebreather mask and the Director of Respiratory and Director of the Dialysis Program arrived on-site to assist her in providing emergency care to R2 with applying the non-rebreather mask and communicating changes in resident condition to the physician via phone while she called 911 after physician gave order to transfer to out for evaluation and treatment. She stated R2 did not return to the facility but that her family had come in a few days later and retrieved her personal belongings. She stated she did not know why R2 did not come back to the facility.On 4/7/26 at 8:41 AM, a telephone interview was conducted with R2's responsible party, her sister-in-law who stated that the physician at the hospital had told her R2 suffered a significant brain bleed from being hit in the eye and being on a blood thinner. She said the hospital doctor told her R2 passed away at 2:00 AM on 1/1/26. On 4/7/26 at 9:05 AM, an interview was conducted with the Administrator regarding the altercation between R2 and R14. According to the Administrator, she was notified of the altercation and came into the facility on [DATE] and was present when the police arrived. When asked why the police were notified, she stated because it was a physical resident-to-resident altercation and R2 wanted the police to be notified. She stated she saw R2 in the wheelchair in the nurses' station and that she appeared to be okay and R14 was back in his room and staff had them both on every 15-minute safety checks. She stated she reported the incident to the appropriate authorities and then went home. When asked about the change in condition of R2 on 12/31/25 requiring transfer to the emergency room and why she had not returned to the facility she responded, I don't know why she did not come back. She stated the family came in a few days later and retrieved her belongings but when asked about R2's status they said she would not be returning to the facility and requested a copy of R2's medical records.On 4/7/26 at 9:40 AM an interview was conducted with the Director of Respiratory and Director of the Dialysis Program. According to the Director of Respiratory she had been notified by LPN# 3 for a non-rebreather mask. She said upon entering R2's room she noted resident was in crisis with labored breathing, unresponsive and critically high blood pressures and heart rate. According to the Director of the Dialysis Program, she noted R2's left eye was swollen shut with noticeable purplish black bruising and she and the Director of Respiratory stayed at the bedside and assisted nursing in communicating R2's condition with the physician via phone.On 4/7/26 at 9:45 AM, the Social Services Assistant (Other Staff Member #11) was interviewed. She stated she is responsible for following up with residents after any resident-to-resident altercation to evaluate their psychosocial needs. She stated that more times than not, when she follows up with the residents who reside in the Memory Care Unit, they are unable to recall the incident, but she attempts to ensure they are comfortable and feel safe. She stated she looks for nonverbal indicators or emotional distress/ anxiety as well as conducting follow-up interviews. When asked if resident-to-resident physical altercations or a male resident observed in bed with a female resident that is not consensual would constitute abuse, she responded, Absolutely, abuse can be physical, mental, sexual or financial, and it is our responsibility to protect them and they should be able to feel safe here, but the Memory Care Unit does present with lots of challenging behaviors.On 4/7/26 at 11:10 AM an interview was conducted with the Nurse Concierge (Other Staff Member #10). According to her it is her responsibility to follow up on residents who are sent out to emergency room the next day to see how they are doing and document her findings in the resident's chart and give an end-of-the-day report on all the calls to the Administrator.OSM#10 said she left a message for R2's sister-in-law but did not get a return call. When asked where the documentation for R2's follow-up call, she responded, In all honestly, it just didn't get into her chart. When asked why R2 did not return to the facility, she responded, I just don't know. On 4/7/26 at 1:05 PM, an interview was conducted with the physician regarding R2's change in condition on 12/31/25. According to the physician, he said he was notified on the evening of 12/30/25 after the altercation between R2 and R14 and the nurse informed him that R2 had slight bruising and swelling in her left eye. He stated he asked the nurse if R2 had any changes in level of consciousness, mentation, headaches and vision and he stated the nurse reported none. He said the nurse said R2 was fine. He said the nurse reported vital signs and neurological checks were within normal limits and R2 was drinking fluids with no nausea or vomiting. When asked about R2 being on a blood thinner and getting hit in the eye, immediately resulting in some bruising and swelling would that not have prompted sending R2 to the emergency room for evaluation due to the high risk of bleeding, he responded, The assessment from the nurse did not present with symptoms that would result in sending her out to the emergency room, her vital signs and neuro checks were okay.On 4/7/26 at 2:10 PM, interviews were conducted with several licensed practical nurses on what is the likelihood of injury if a person is hit on the head and is on a blood thinner. According to LPN#11, she said people who are on blood thinners are more vulnerable to excess bleeding and bruising than people who are not on blood thinners. She further stated the type and severity of injury would depend on how hard a blow the hit and where on the head the person was hit. I would expect to see bruising, maybe hematomas or excessive bleeding, perhaps a nosebleed, and maybe internal bleeding, this could be very dangerous and life-threatening.According to LPN#4, she said, They could bleed out.Per LPN#5, he responded I would expect to see increased bruising, a hematoma, aneurysm, heavier bleeding than someone who is not on a blood thinner.According to LPN#12, she said she would expect increase in bleeding, perhaps from the nose or cuts or maybe in the brain. They could bleed out.According to LPN#9, she responded by saying, they may experience a stroke from internal bleeding, more bruising, seizures, hematomas. Blood thinners can be very dangerous if a resident falls and hits their head or they can have some bleeding inside the body that we don't see. They can bleed profusely from small cuts. On 4/7/26 at 4:00 PM, an interview was conducted with the DON (Director of Nursing) on her expectation of what a nurse should be assessing when completing neurological checks, she stated, mentation, pupillary response, level of consciousness, and responding appropriately to questions. When a person is hit in the eye head and is on a blood thinner what is the likelihood of an injury? The DON responded, That would be patient specific and how hard they were hit. When asked about R2 being hit by R14, with immediate swelling and bruising to the eye resulting in a significant change in condition and a transfer to the emergency department she stated she did not necessarily think R2's change in condition was solely as a result from the altercation with R14 on 12/30/25. When asked about what constituted resident abuse, the DON stated, Abuse comes in different forms, it can be physical, emotional, verbal, financial or sexual. When asked is it the residents' right to be free from abuse, the DON responded, Of course, it is their right to be free from abuse and to feel safe in our care. A review of the facility's policies on abuse read in part: Resident Rights and Abuse Prevention Policy and Policy Manual 2001, MED-PASS, Inc; Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, reads in part: All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Resident Rights and Abuse Prevention Policy and Policy Manual, 2001, MED-PASS, Inc; Safety and Supervision of Residents, reads in part; Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Individualized, Resident-Centered Approach to SafetyOur individualized, resident-centered approach to safety addresses safety and accident hazards for individualized residents.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specifici accident hazards or risks for individual residents.The care team shall target interventions to reduce indivdual risks related to hazards in the envirnment, including adequate supervision.Implementing interventions to reduce accident risks and hazards shall include the following: coomunication to all revelant staff, assigning responsibility for carrying out interventions, providing training, enxsuring the interventions are implemented and documenting interventions.Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new and revised interventions.Systems Approach to SafetyThe facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards to the environment. The type and frequency of the resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as a change in the resident's condition).All of these incidents of abuse occurred on the facility's Memory Care Unit and were perpetrated by the same resident, Resident #14 (R14)A review of nurse progress note dated 1/3/2026 revealed R14 observed in a female's room attempting to get into bed with her, clothes on and brief was still on. Resident was given re-direction, to which R14 attempted to fight against and swing at staff. R14 made grabbing motions at staff and attempted to hit staff.A review of Psychiatrist Nurse Practitioner progress note dated 1/5/26 read in part, Facility staff requested consultation related to escalating behavioral disturbances. Facility staff report increasing aggressive and inappropriate behaviors. According to the staff, R14 became verbally aggressive when staff attempted to obtain his weight, refused redirection, and became tense and competitive. Staff further report that the resident entered a female resident's room and attempted to get into bed with her while clothed and wearing a brief. When redirected, the R14 became physically aggressive, making grabbing motions, swinging at staff, and attempting to strike them. R14 poses risks to staff and peers due to aggressive and sexually inappropriate behaviors. Upon assessment, the R14 has significant behavioral disturbances characterized by aggression, poor impulse control, and sexually inappropriate behavior. Presentation is consistent with behavioral symptoms likely related to underlying neurocognitive disorder. Current behaviors place R14 and others at risk Treatment Plan/Recommendations: 1. Discontinue anti-depressant used to treat depression due to concern for activating effects contributing to agitation, aggression, and behavioral dysregulation. Discontinuation is part of behavioral symptom management to reduce stimulation and impulsivity. Monitor for improvement in agitation, aggression, and intrusive behaviors following discontinuation. Monitor for emergence or worsening of depressive symptoms. Continue non-pharmacological interventions including consistent redirection, calm approach, and environmental modifications. Ensure close supervision to reduce risk to staff and peers. Continue to assess risks to harm himself or others. Staff to utilize de-escalation techniques and document behavioral incidents.Review of nurse progress note dated 1/5/26 read in part, R14 no longer on 1:1 supervision per physician's order.R14 remains a current resident of the facility and is permitted to ambulate throughout the unit and have direct access to other residents, creating an imminent risk to other residents.On 4/6/2026 between 12:00 PM-1:00 PM, Resident #14 was observed ambulating independently on the Memory Care Unit in the hallways and in the common areas. He was observed in shorts [TRUNCATED]

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the necessary care and services, consistent with professional standards of practice, to prevent a pressure injury for one of 18 residents in the survey sample, Resident #8. A tourniquet was left in place on Resident #8's left upper arm for an extended period causing an unstageable pressure injury, resulting in harm cited at past non-compliance. The findings include:Resident #8 (R8) was admitted to the facility with diagnoses that included but were not limited to quadriplegia (1), chronic respiratory failure (2) and pressure ulcer of sacral region. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/17/2026, the resident was assessed as being severely impaired for making daily decisions. Section GG coded R8 being dependent on staff for all ADL (activities of daily living) care. It further documented R8 receiving oxygen, tracheostomy (3) care, tube feeding, and suctioning while at the facility. R8 was assessed as having one Stage 3 pressure injury (4) and one Stage 4 pressure injury. On 4/7/2026 at 9:01 AM, an observation was made of licensed practical nurse (LPN) #2, wound nurse, performing wound care to R8's pressure injuries. LPN #2 was observed providing treatment per the physician orders to a sacral pressure injury and a pressure injury on the left upper arm. The pressure injury on the left upper arm was observed to encircle the circumference of the upper arm with a larger area on the posterior of the upper arm. When asked the origin of the wound, LPN #2 stated that they were told that it was from a tourniquet. Review of the electronic medication administration record (eMAR) dated 3/1/26-3/31/26 documented in part, - Insert Midline (5) one time only until 03/16/2026. Start Date: 03/16/2026. - Insert peripheral IV (intravenous) for ABT (antibiotic) one time only for IV ABT for 1 Day. Start Date: 03/18/2026. The eMAR further documented R8 receiving the first dose of intravenous antibiotics on 3/18/2026 at 9:00 AM. The progress notes for R8 documented in part,- 03/16/2026 11:50 (AM) Late entry . At approximately 2100 (9:00 PM), MD was notified of no improvement in BP (blood pressure). Writer received a new order for a STAT (now) ammonia level, and UA/ C&S (urinalysis with culture and sensitivity), Midline placement, one-time order of Cefepime 1 gm IM (intramuscular) and Solu-Medrol 125 mg IM. Medication administered as ordered. Pt continues to be closely monitored for new or worsening symptoms.- 03/18/2026 11:09 (AM) Date of Service: 3/18/2026. Visit Type: HP SKIN AND WOUND NOTE . Reason for visit: subsequent encounter for skin and wound care metronidazole Intravenous Solution 500 MG/100ML three times a day .- 03/19/2026 07:57 (AM) Note Text : Resident continues on IV/ABT (intravenous antibiotics) for elevated WBCs (white blood cells), no adverse reactions noted, IV site noted with no signs of infection or infiltration, resident noted with no signs or symptoms of distress noted, will continue plan of care, lab to be in today to obtain CBC/CMP (complete blood count/comprehensive metabolic panel).- 03/23/2026 12:13 (PM) Situation : The Change in Condition/s reported on this CIC Evaluation are/were: Skin wound or ulcer .- 03/23/2026 13:30 (1:30 PM) .Skin Issue: #002: New skin Issue. Location: Left antecubital space. Issue type: Pressure ulcer/injury. Progress: New: new wound. Wound acquired in-house. Length (cm): 20 Width (cm): 4 Depth (cm): 0.1.- 03/23/2026 18:36 (6:36 PM) Note Text: AT 1130 (AM) RN (registered nurse) WAS ALERTED TO A TOURNIQUET ON PTS LEFT BICEP/AC (antecubital) AREA BY THE CNA (certified nursing assistant) WHO WAS WASHING HIM. RN REMOVED THE TOURNIQUET AND SKIN UNDERNEATH WAS DAMAGED DISCOLORED AND BLISTERED. UNIT MANAGER MADE AWARE. MD MADE AWARE. WOUND NURSE MADE AWARE. LEFT HAND ELEVATED. WILL MONITOR LUE (left upper extremity). A change in condition evaluation for R8 dated 3/23/2026 documented in part, The change in condition, symptoms or signs I am calling about is/are: skin wound or ulcer . Describe skin changes: Blister, contusion . Left antecubital: medical device associated contusion with blistering . The evaluation documented notification of the physician and responsible party. The wound nurse practitioner assessment for R8 dated 3/25/2026 documented in part, . Location: Left upper arm; Etiology: Pressure ulcer/injury; Stage/Severity: Unstageable; Acquired in House: Yes; Date Wound Acquired: 03/25/2026; Wound Status: New; 70% epithelial; 10% granulation; 20% slough; 0% eschar . The wound nurse practitioner assessment for R8 dated 4/1/2026 documented in part, . Location: Left upper arm; Etiology: Pressure ulcer/injury; Stage/Severity: Stage 3; Acquired in House: Yes; Date Wound Acquired: 03/25/2026; Wound Status: Improving without complications; 90% epithelial; 10% granulation; 0% slough; 0% eschar . The comprehensive care plan for R8 documented in part, I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) cerebral infarct (5), muscle wasting, metabolic encephalopathy, respiratory failure, quadriplegia. Date Initiated: 07/10/2025. The care plan further documented, The resident has a pressure ulcer or has the potential for pressure ulcer development r/t history of pressure ulcers, immobility, Sacrum wound, Left arm AC wound. Date Initiated: 07/23/2025. On 4/7/2026 at 11:36 AM, an interview was conducted with the wound nurse practitioner (NP) who stated that they followed R8's wounds at the facility weekly. She stated that she was seeing R8 prior to the wound on the left upper arm and was alerted to assess the new wound on her rounds 3/25/2026. The NP stated that she was told that the wound on R8's left upper arm was from a tourniquet that was left in place. She stated that the pressure injury was first assessed as unstageable due to slough obscuring the wound bed on 3/25/2026 and then when she assessed it the second time on 4/1/2026 it was assessed as a Stage 3. The NP stated that the pressure injury has continued to improve and has gotten smaller. She stated that a tourniquet should be short term, and she could not say how long it would have to be in place to create a pressure injury as it would depend on the person. On 4/7/2026 at 12:30 PM, an interview was conducted with licensed practical nurse (LPN) #2, wound nurse, who stated that he was alerted when staff discovered the pressure injury on R8's left upper arm and he assessed the wound and obtained a treatment order from the physician. He stated that he was not sure of when the tourniquet was placed, and he was only told that it was a wound from when they were trying to start an IV for antibiotics. On 4/7/2026 at 12:51 PM, an interview was conducted with the director of specialty care (DSC). She stated that the nurse had received an order to insert a peripheral IV on 3/18/2026 which they had placed in the right arm. She stated that the pharmacy IV team had also come to the facility to a place a midline IV but were not able to and had placed a second peripheral IV in the left arm. The DSC stated that the CNA working on 3/23/2026 had reported to the nurse that there was a tourniquet left on R8's left upper arm that she found when bathing the resident. She stated that the nurse had immediately called her to assess and they had notified the director of nursing, wound nurse and the physician. The DSC stated that there was a little swelling, mild redness and a wound that went around the circumference of the arm. She described the wound as having red edges with a dark purple top and a mild blister on the backside of the arm. The DSC stated that R8 denied any pain, and she did not think that the resident was aware of it due to their diagnoses. She stated that the director of nursing had investigated and completed education for the staff. On 4/8/2026 at 11:40 AM, an interview was conducted with certified nursing assistant (CNA) #7 who stated that she worked with R8 on 3/21-3/22/2026 and she had heard about the wound found on 3/23/2026. She stated that she had only given R8 a washup over the weekend because they did not have any more gowns to put on the resident. CNA #7 stated that she did not take R8's gown off because it was not soiled and she did not have a replacement for it and she felt very guilty for not changing it. She stated that if she had taken the gown off she may have seen the tourniquet on the arm and caught it earlier. On 4/8/2026 at 11:55 AM, an interview was conducted with registered nurse (RN) #2 who stated that she was working on 3/23/2026 when the CNA came to get her to look at R8's left upper arm. She stated that when she went into the room the CNA had loosened the tourniquet from R8's arm but it was still around the arm and there was a #20gauge IV in the forearm dated 3/18. RN #2 described R8's left arm as more swollen that the right, reddened, denuded with blisters on the front and a large blister on the back of the arm. She stated that she apologized to R8 because they understood even if they were not verbal. RN #2 stated that she thanked the CNA for reporting it and got the unit manager who brought the director of nursing. She stated that they advised her on the documentation that needed to be done and reporting process. RN #2 stated that they elevated the arm on a pillow and the wound nurse came over to assess the wound, the physician and the responsible party were notified and a treatment was put into place. On 4/8/2026 at 12:38 PM, an interview was conducted with the director of nursing who stated that she had been called to assess R8's left upper arm on 3/23/2026 when the CNA found the tourniquet in place. She stated that they had investigated and found that R8 had two IV's placed, one in the right arm by facility staff and one in the left arm by the pharmacy IV team on 3/18/2026. She stated that R8 had blood work drawn on 3/19/2026 by the lab in the left hand and they had verified with the phlebotomist that they had placed their tourniquet below the IV in the left arm to draw the blood from the left hand. The DON stated that they had been trying to get the documentation from the pharmacy on the left arm IV placement but had not gotten anything at that time. The DON stated that when she went into R8's room on 3/23/2026 the tourniquet had been removed and there was a wound to the left upper bicep with no drainage. She stated that they asked R8 if they were having any pain and they shook their head no and the wound nurse came and assessed the wound and got an order for a treatment, and the physician and responsible party were notified. She stated that this wound was preventable and if staff were bathing and changing R8's gown they should have seen the tourniquet in place. The DON stated that she had completed a plan of correction and would bring in the credible evidence for review. On 4/8/26 at 12:55 PM, the director of nursing presented a five-point plan of correction (POC) titled Plan of Correction-F686 - Treatment/Services to Prevent and Heal Pressure Ulcers. The POC documented the following: 1. Corrective Action for Affected Resident. The resident identified as having an unstageable pressure ulcer to the arm related to a tourniquet being left in place following IV initiation received immediate intervention. The tourniquet was immediately removed upon discovery.The physician and responsible party were notified.A full wound assessment was completed, and treatment orders were initiated.Wound care services were consulted, and appropriate interventions were implemented.The resident's care plan was updated to reflect the pressure injury, including monitoring and treatment protocols.The resident continues to be monitored for healing and any complications. 2. Identification of Other Residents at Risk. All residents receiving IV therapy are at risk for device-related pressure injuries have potential to be affected. A facility-wide audit of all current residents with IV access was conducted to ensure no tourniquet or constrictive devices were in place.Skin assessments were completed for residents receiving IV therapy to identify any signs of pressure or injury.No additional residents were identified with similar concerns. 3. Systemic Changes to Prevent Recurrence. The facility has implemented the following systemic changes: Re-education of all licensed nursing staff on proper IV initiation procedures, including: Immediate removal of tourniquet after venipuncture.Post-procedure assessment of the extremity.Implementation of a standardized IV initiation checklist requiring:Verification that the tourniquet has been removed.Documentation of site condition and circulation.Increased supervisory oversight by nursing leadership during IV starts. 4. Monitoring Plan. To ensure ongoing compliance, the facility will implement the following monitoring: The Director of Nursing (DON), Unit Managers, or designee will conduct:Weekly audits of IV starts for 4 weeks.Monthly audits thereafter for 2 months.Audits will include:Verification that tourniquets are removed.Documentation compliance.Assessment of the IV site and surrounding skin.Any identified issues will be addressed immediately with corrective action, including re-education and counseling as needed.Audit results will be reviewed in the facility's QAPI (quality assurance, performance improvement) program for ongoing evaluation and performance improvement. 5. Date of Compliance. The facility alleges compliance with F686 on 3/30/2626 (sic) following completion of staff education, and implementation of monitoring systems. This issue has been incorporated into the facility's Quality Assurance and Performance Improvement (QAPI) program. Data from audits will be trended and analyzed to ensure sustained compliance. Additional interventions will be implemented as needed based on findings. Included in the POC binder was a QAPI summary dated 3/26/2026 documenting a review of the incident and the POC plan by the DON and QAPI committee, a timeline for R8 documenting the IV's placed on 3/18/2026, lab drawn on 3/19/2026, 3/20-3/23/2026 no further lab work drawn, 3/23/2026 the tourniquet found during Adl care with removal, notification of the physician, wound care nurse and treatment put into place. The binder further documented an in-service training record dated 3/25/2026 presented by the DON with the education title of IV Insertion/Lab Draws: All residents must have their skin inspected by the primary nurse after each attempt of drawing blood and after IV insertions to ensure that the tourniquet has been properly removed. The sign-in record documented 88 CNA's, LPN's, and RN's educated on the topic. Weekly audits of residents having labs drawn and IV's inserted were reviewed from 3/27/26, 3/31/26, 4/4/26, 4/6/26, lists of facility pressure injuries dated February 2026 and March 2026 with initial stage, onset date and location, current stage, status and status date and witness statements from the nurse who inserted the IV on 3/18/26, staff working with R8 on 3/20-3/22/26, and the CNA who discovered the tourniquet on 3/23/26. The education of staff on proper lab draw/IV initiation procedures including removal of the tourniquet, assessment of the extremity and use of the post procedure checklist was verified by direct interview with multiple licensed nursing staff members. The other points of the plan of correction as described in this writing were verified with facility document review, observation, clinical record review and staff interview. No concerns were identified. Verification was completed of implementation of the plan of correction and facility compliance date of 3/30/2026. On 4/8/2026 at approximately 3:58 PM, the administrator and director of nursing were made aware of the concern for harm cited at past non-compliance. No further information was provided prior to exit. PAST NONCOMPLIANCE Reference:(1) Paralysis of the arms and legs is quadriplegia . This information was obtained from the website: Paralysis | Hemiplegia | MedlinePlus(2) Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems . This information was obtained from the website: Respiratory Failure | Lung Disease | Lung Problems | MedlinePlus(3) A tracheostomy is surgery to create a hole in your neck that goes into your windpipe . This information was obtained from the website: Tracheostomy care: MedlinePlus Medical Encyclopedia(4) A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin . Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white (blanch) when pressed. This is a sign that a pressure ulcer may be forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged. You may be able to see body fat in the ulcer. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. There are two other types of pressure sores that don't fit into the stages. Sores covered in dead skin that is yellow, tan, green, or brown. The dead skin makes it hard to tell how deep the sore is. This type of sore is unstageable. Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore . This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm(5) A Midline Catheter is a thin, flexible tube placed into a vein in the arm. The catheter is 8-10 centimeters long and can stay in the arm for up to 29 days. This allows patients to get IV (intravenous) medicines and have blood samples drawn. The catheter is placed by a trained nurse . This information was obtained from the website: A Midline Intravascular Catheter | Patients & Families | UW Health (6) A stroke occurs when blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. This information was obtained from the website: Stroke: MedlinePlus Medical Encyclopedia

Based on staff interview and employee record review, it was determined that the facility staff failed to ensure that three of five certified nursing assistant (CNA) records reviewed received the required twelve hours of annual trainings.The findings include:On 4/9/2026 at 8:15 AM, a review of the facility's CNA annual training was conducted. Review of five CNA training transcripts revealed three of five CNAs selected for review did not meet the required 12-hours of annual training.1. Review of CNA #8's training transcript documented a hire date of 5/1/2023. Further review of the training transcript documented a total of 7.18 hours completed.2. Review of CNA #9's training transcript documented a hire date of 7/6/2022. Further review of the training transcript documented a total of 0.25 hours completed.3. Review of CNA #10's training transcript documented a hire date of 9/23/2022. Further review of the training transcript documented a total of 4.18 hours completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator who stated that they had been in the position since 12/15/2025 and had been working to coordinate the education schedules and competency calendars to catch them up. She stated that she had a performance improvement plan in place and it was on-going because she was still working on the audits and had not completed the plan at that time. She stated that the facility required the CNA stated to get 12 hours of annual training each year using the computerized education which tracked the hours and they had until December 31st of each year to complete their 12 hours. The facility assessment reviewed 2/26/2026 documented in Staff education and Competency, .Annual education requirements are in place for all staff to ensure robust ongoing education and competency . The facility policy In-Service Training, All Staff dated 2001 documented in part, .Completed training is documented by the staff development coordinator, or his or her designee and includes: .e. The hours of training completed.On 4/9/2026 at approximately 11:12 AM, the administrator, the director of nursing, the vice president of operations, the regional director of clinical services, the assistant director of nursing and the clinical consultant were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to accommodate residents' physical limitations for one of 18 residents in the survey sample, Resident #8.The findings include:For Resident #8 (R8), the facility staff failed to provide an adaptive call bell that the resident could use. R8 was admitted to the facility with diagnoses that included but were not limited to quadriplegia (1), chronic respiratory failure (2) and pressure ulcer (3) of sacral region.On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/17/2026, the resident was assessed as being severely impaired for making daily decisions. Section GG coded R8 being dependent on staff for all ADL (activities of daily living) care. It further documented R8 receiving oxygen, tracheostomy (4) care, tube feeding, pressure injury care and suctioning while at the facility. The comprehensive care plan for R8 documented in part, I have an ADL Self Care Performance Deficit r/t (related to) cerebral infarct (5), muscle wasting, metabolic encephalopathy, respiratory failure, quadriplegia. Date Initiated: 07/10/2025. Under Interventions/Tasks it documented in part, .Be sure Breathcall arm (6) is within reach, and provide reminders to use call for assistance as needed. Breathcall arm in place of traditional button call light due to patient's lack of mobility. Date Initiated: 07/10/2025 .On 4/6/2026 at approximately 2:10 PM, an observation was made of R8 lying in bed in their room. A handheld call bell with a finger press button on the end was observed clipped to the blanket near R8's chest. No Breath call was observed.Additional observations of R8 were made on 4/7/2026 at 9:01 AM and 4/7/2026 at 12:08 PM. The handheld call bell remained in place clipped to the bed linens. No Breath call was observed.On 4/7/2026 at 12:30 PM, an interview was conducted with licensed practical nurse (LPN) #2 who stated that when a resident was admitted the nurse used their judgement to determine what type of call bell the resident required based on their physical ability to activate it. He stated that they also followed any recommendations form therapy regarding specialized call bells as needed. On 4/7/2026 at 12:51 PM, an interview was conducted with the director of specialty care who stated that they assess the mobility of the residents arm, the range of motion, strength and coordination of the fingers when determining the type of call bell that the resident was given. She stated that they had a few options that they could use and they put in a work order for maintenance, and they changed the call bells out right away to an adaptive call bell when requested. The director stated that she was not sure what type of call bell R8 had used in their previous room but had recently switched rooms and she would have to investigate it further. On 4/7/2026 at 1:16 PM, an interview was conducted with certified nursing assistant (CNA) #1 who stated that if residents were contracted or had range of motion problems they gave them a flat call bell or ones they could blow in to call the staff. On 4/8/2026 at 12:38 PM, an interview was conducted with the director of nursing who stated that the interdisciplinary team decided what type of call bell was required for the resident and at times therapy made recommendations. She stated that if the resident changed rooms the adaptive call bell followed the resident to the new room. The facility policy Activities of Daily Living (ADL), Supporting revised April 2025 documented in part, .Interventions to improve a resident's functional abilities or minimize functional decline are in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice .On 4/8/2026 at approximately 3:58 PM, the administrator and director of nursing were made aware of the concern.No further information was provided prior to exit.Reference:(1) Paralysis of the arms and legs is quadriplegia . This information was obtained from the website: Paralysis | Hemiplegia | MedlinePlus(2) Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems . This information was obtained from the website: Respiratory Failure | Lung Disease | Lung Problems | MedlinePlus(3) Pressure sores are areas of damaged skin caused by staying in one position for too long . This information was obtained from the website: Pressure Sores | Bedsores | Pressure Ulcers | MedlinePlus(4) A tracheostomy is surgery to create a hole in your neck that goes into your windpipe . This information was obtained from the website: Tracheostomy care: MedlinePlus Medical Encyclopedia(5) A stroke occurs when blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. This information was obtained from the website: Stroke: MedlinePlus Medical Encyclopedia(6) The Breath Call is a pneumatic (air-activated) nurse call cord that works with virtually any nurse call system. Breath Call is for patients with little to no motor skills and is activated by simply breathing into a disposable straw and filter assembly . This information was obtained from the website: Breath Call (BreathCall(R)) Nurse Call Cord - [NAME] Precision Products

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policies to prevent abuse by one resident, Resident #14, for four of eighteen residents in the survey sample. (Resident #17, # 16, #15, #2)Findings include:A review of the facility's policies: Resident Rights and Abuse Prevention Policy and Policy Manual 2001, MED-PASS, Inc; Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, reads in part: All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Resident Rights and Abuse Prevention Policy and Policy Manual, 2001, MED-PASS, Inc; reads in part; Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Facility-Oriented Approach to SafetyOur facility-oriented approach to safety addresses risks for groups of residents.Safety risk and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance and Improvement Program) committee reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause/s of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Employees shall be trained on potential hazards and demonstrate competency on how to identify and report accidents hazards, and try to prevent avoidable accidents.The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.Individualized, Resident-Centered Approach to SafetyOur individualized, resident-centered approach to safety addresses safety and accident hazards for individualized residents.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision.Implementing interventions to reduce accident risks and hazards shall include the following: communication to all relevant staff, assigning responsibility for carrying out interventions, providing training, ensuring the interventions are implemented and documenting interventions.Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new and revised interventions.Systems Approach to SafetyThe facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards to the environment. The type and frequency of the resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as a change in the resident's condition).1.For Resident #17 (R17), the facility staff failed to prevent abuse from Resident #14 (R14) during a physical altercation on 3/20/24 where after R17 slapped R14, R14 pushed R17 to the floor.R17 was admitted to the facility 10/16/23 with diagnoses to include but not limited to Lewy body dementia with agitation, hereditary idiopathic neuropathy, frontotemporal neurocognitive disorder, type 2 diabetes mellitus, major depressive disorder, bipolar disorder, generalized anxiety disorder, muscle wasting, and tremors. R17's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) 3/22/24 coded her a 03/15 in Section C. Cognitive Patterns, Brief Interview for Mental Status indicating severe cognitive impairment (suggesting significant difficulties with short-term memory and orientation). R14 was admitted to the facility 2/6/24 with diagnosis to include but not limited to vascular dementia with psychotic disturbance, anxiety, rheumatoid arthritis left hip, insomnia, restlessness and agitation, and major depressive disorder. R14's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/1/25 coded R14 as 03/15 on the BIMS (Brief Interview of Mental Status) indicating severe cognitive impairment with skills of memory, thinking and orientation to place and timeA review of the facility's final synopsis for event dated 3/20/24 involving R17 and R14 revealed, in part: On 3/20/24, staff reported R17 slapped R14 and R14 pushed R17 to the floor. Residents were immediately separated and assessed for any injuries. Skin and pain assessments were done on both parties following the incident.A review of witness statements from staff revealed the following:Certified Nursing Assistant #3 (C.N.A.#3) stated it was somewhere between 6:30-6:45 PM, she was assisting another resident heard screaming and a hard fall, st5ated she did not observe the altercation but that R17 told her R14 pushed her down.C.N.A.#2 stated she was in the dining room, heard a scream coming from the third hallway and rushed to the area, noting R17 on the floor next to the food cart, R14 standing up next to the food cart. She stated when the residents were asked what happened both responded saying R17 slapped R14 and then he pushed her to the floor.Per LPN#5, he was alerted to the altercation between R17 and R14 by the activity staff and immediately responded to investigate the situation, R17 had returned to her room and upon assessment R17 had a bump on the top/back of her head.C.N.A. #4 stated she heard a scream and responded noting R17 on the floor and notified the charge nurse.A review of R17's progress note dated 3/20/24 by LPN#5 revealed in part: Resident had an altercation with another resident. There was no witness. Skin check was conducted to assess the bump on the back of her head, two centimeters tall and one inch wide. Pain evaluation completed with R17 denying pain or headache. Resident vital signs are within normal limits with blood pressure 134/77, temperature 97.6 temporal, heart rate 86, respirations 19, oxygen at 94% on room air. The physician was notified of the incident and advised to initiate neuro checks. Every 15-minute monitoring was implemented.2. For Resident #16 (R16), the facility staff failed to prevent abuse from Resident #14 on 12/18/24 when he was observed in R16's bed, R16 was cognitively unable to consent to the male in her bed.R16 was admitted [DATE] with diagnoses to include but not limited to dementia with agitation, major depressive disorder, psychotic disorder with delusions, hallucinations and adult failure to thrive. R16's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 1/9/24 coded her a 99 for Brief Interview for Mental Assessment as R16 not able to complete assessment on cognition.A review of the facility's final synopsis of incident dated 12/18/24 revealed, in part: R16 was noted to be in her bed with her entire body covered including her head with covers resting with R14 laying on top of the covers fully clothed in the same bed. Skin and pain evaluations were completed and no injuries were noted. Neither resident was able to recall the incident, and no evidence of abuse was substantiated. A review of witness statements from staff revealed the following:A review of C.N.A#5's witness statement revealed, CNA#2 informed her that R14 was in R16's room and she went to assist CNA#2 with re-directing R14 out of R16's room. According to CNA #5, she had laid R14 down in his room around 9:00 PM after already getting him from trying to go into R16's room and made sure he was laying down in his own bed. According to C.N.A#2, she overheard nurse tell R14 to exit R16's bed and stated as she was completing her rounds at approximately 10:15 PM, she observed R16's brief undone and her buttocks exposed. A review of R16's clinical record revealed the following progress note dated 12/18/24 at 11:03 PM: Male resident (R14) was observed in R16's bed. R14 was fully clothed and female resident (R16) was fully covered with blankets. The Certified Nursing Assistant (C.N.A #2) pulled the covers back and the female residents brief was deviated to the right side with the buttocks exposed.3. For Resident #15 (R15), the facility staff failed to prevent abuse from Resident #14 on 1/22/25 during a physical altercation between R15 and R14, resulting in a laceration to R15's lip.R15 was admitted [DATE] with diagnoses to include but not limited to abdominal aortic aneurysm, ruptured, Alzheimer's dementia with agitation, major depressive disorder, and anxiety. R15's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 1/2/25 coded him 06/15 on the Brief Interview for Mental Assessment, indicating severe cognitive impairment with skills such as memory, thinking and orientation to place and time.A review of the facility's final synopsis of incident dated 1/22/25 revealed, in part: Upon investigation it was reported that R15 wandered into R14's room and called him a racial slur, then R14 hit R15. Neither resident sustained any injuries. Both residents tolerating meals and medications well. A review of witness statements from staff revealed the following:According to LPN#6, she observed R15 exiting R14's room holding a bloody rag on his mouth, saying that (n-word) hit me in my mouth.Per witness statement from C.N.A.#6, R15 was observed at the double doors with his mouth bleeding at approximately 12:30 AM and that R15 said that (n-word) hit me in my mouth.A review of clinical record revealed progress note dated 1/22/2025 at 1:00 AM, Resident was involved in an altercation with another resident. Small cut noted to lower lip right side.A review of the Interim Skin Check evaluation dated 1/22/25 revealed Head to Toe Skin Check and Evaluation, Skin Condition and Integrity Findings, 1a. Are there any skin impairments noted? YES. 1b. Is this a new skin impairment? YES. 1c. Type of Skin Impairment, Laceration.4. For Resident #2 (R2), the facility staff failed to prevent physical abuse from Resident #14 on 12/30/25, which resulted in harm and hospitalization.R2 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia without behavioral disturbance, post-traumatic stress disorder, scoliosis, anxiety, psychosis, depression, fibromyalgia, chronic pain syndrome, and long-term use of anticoagulants for treatment of deep vein thrombosis. R2's Minimum Data Set assessment (MDS) with Assessment Reference Date (ARD) 10/13/25 coded her a 07/15 on the Brief Interview for Mental Assessment, indicating severe cognitive impairment with skills of memory, thinking and orientation to place and time.A review of the facility's final synopsis of event dated 12/30/25 revealed, in part: Staff alleges R14 struck R2 in her left eye causing bruising, head to toe skin and pain assessments completed on both residents. Statements obtained from staff reported that another resident had informed them that R2 and R14 were fighting. Upon entering R2's room they observed R14 standing in front of R2 and each resident struggling over R2's reacher/grabber tool, residents were immediately separated. R2 stated to staff that R14 hit her in her left eye. Skin assessment completed on R2 noting swelling and bruising to her left eye. She denied pain and discomfort. R14 was immediately escorted out of R2's room and placed on every 15-minute checks. Skin evaluation was negative for injury to R14.A review of nurse progress note dated 12/30/25 at 9:45 PM read in part, Writer was charting at the nurses' station, and a resident came to call me and said they are fighting. I rushed to the 3rd hall, and I saw R2 and R14 in front of her room pushing and pulling on a reacher/grabber stick. I separated them. R2 stated that he came to my room and I tried to ask him to leave and he hit me in my left eye. Swelling and bruising noted around R2's left eye. R2's responsible party, physician and the Director of Nursing were notified of the incident. Neuro checks were initiated.A review of Interim Skin Check evaluation dated 12/30/25 at 8:30 PM revealed Head to Toe Skin Check and Evaluation, Skin Condition and Integrity Findings, 1a. Are there any skin impairments noted? YES, 1b. Is this a new skin impairment? YES, 1c. Type of Skin Impairment, Bruise.A review of physician note dated 12/31/25 at 10:07 AM read in part, Patient (R2) recently was involved in an altercation where her orbit was injured. She became more lethargic and her vitals showed temperature 102 degrees Fahrenheit, heart rate 126, blood pressure 224/115, and oxygen saturation in the 50s before rising to 97% on 4L Venti mask (re-breathing mask). Due to risk of deterioration she (R2) was sent to the ED (local hospital emergency department).A review of nurse progress note dated 12/31/25 at 11:45 AM read in part, Writer (LPN#3) informed by charge nurse the resident breathing was abnormal and resident was unresponsive. Writer entered room and resident noted to be lying in bed heavily breathing but not responding to name or sternal rub. Vital signs taken and abnormal, blood pressure 244/119, heart rate 126, respirations 20, oxygen saturation 53% on room air. Physician notified. Oxygen was increased to 15 liters on a non-rebreather, with oxygen saturation up to 96%. R2 was still not responding. The physician was -notified again and with an order to send to the emergency room for further evaluation. Writer called and spoke to responsible party, R2's sister in-law. EMS (Emergency Medical Services) notified and R2 transferred to (name redacted) hospital. A review of R2's clinical record for physician orders revealed an order for a blood thinner by mouth two times a day for the prevention of recurring deep vein thrombosis. According to [NAME] Drug Handbook 2016, blood thinners increases risk for bleeding and hemorrhagic events, and may cause serious, potentially fatal, bleeding of the following sites: intracranial [within the skull], intraocular [within the eye]). (1).On 4/7/26 at 7:36 AM, an interview was conducted with C.N.A.#2 regarding the altercation between R2 and R14. According to C.N.A.#2, she usually works the day shift but had picked up an extra shift. She stated she and LPN#10 went to R2's room upon notification of the resident-to-resident fighting. She said she observed R2 and R14 pulling and pushing R2's reacher/grabber stick. R2's left eye was red and swollen. She said they removed R14 from R2's room and both residents were placed on every 15-minute safety checks and no further problems from either one of them that she was aware of the rest of the 3-11 PM shift. On 4/7/26 at 7:40 AM, an interview was conducted with LPN#4. According to LPN#4, the Unit Manager, LPN#3 was helping her out the morning of 12/31/25 as it was so busy. She said LPN#3 was taking care of R2 mostly. She stated she had made her rounds on the morning of 12/30/25 and noticed that R2's eye was swollen terrible, swollen shut, and had a purplish reddish bruising around the left eye. She wasn't responding as much as usual. Later the certified nursing assistant told us she wasn't eating her breakfast then we knew something wasn't right. LPN#3 called the doctor. R2 's condition kept getting worse. Her blood pressure and pulse were getting higher and her breathing was labored. She was showing a drastic change, and the doctor told us to send her out.On 4/7/26 at 8:10 AM, an interview was conducted with LPN #3, the Unit Manager on the Memory Care Unit. According to LPN#3 she was notified of the altercation between R2 and R14 on 12/30/25 and came into facility. She stated she called the police and stayed at the facility until the police arrived. She stated R2 was at the nurse's station in her wheelchair watching TV when the police arrived and R14 was in his room. She stated the police did not stay long, they observed R2 and R14, left his card and then exited the facility stating not much he could do when it involved people who were cognitively impaired. She stated she cared for R2 on the morning of 12/31/25 and that R2 was noted not to be eating her breakfast which was out of the norm for her. Shortly after that nurse reported to her that R2's vital signs and mental status began to deteriorate. According to her, she contacted the Director of Respiratory for a non-rebreather mask and the Director of Respiratory and Director of the Dialysis Program arrived on-site to assist her in providing emergency care to R2 with applying the non-rebreather mask and communicating changes in resident condition to the physician via phone while she called 911 after physician gave order to transfer to out for evaluation and treatment. She stated R2 did not return to the facility but that her family had come in a few days later and retrieved her personal belongings. She stated she did not know why R2 did not come back to the facility.On 4/7/26 at 8:41 AM, a telephone interview was conducted with R2's responsible party, her sister-in-law who stated that the physician at the hospital had told her R2 suffered a significant brain bleed from being hit in the eye and being on a blood thinner. She said the hospital doctor told her R2 passed away at 2:00 AM on 1/1/26. On 4/7/26 at 9:45 AM, the Social Services Assistant was interviewed on what constituted abuse. When the Social Services Assistant was asked is resident-to-resident physical altercations or a male resident observed in bed with a female that is not consensual would constitute abuse, she replied, Absolutely, abuse can be physical, mental, sexual or financial, and it is our responsibility to protect them and they should be able to feel safe here, but the Memory Care Unit does present with lots of challenging behaviors.On 4/7/26 at 4:00 PM, an interview was conducted with the DON (Director of Nursing). When asked about what constituted resident abuse, the DON stated, Abuse comes in different forms, it can be physical, emotional, verbal, financial or sexual. When asked is it the residents' right to be free from abuse, the DON responded, Of course, it is their right to be free from abuse and to feel safe in our care. All of these incidents of abuse occurred on the facility's Memory Care Unit and were perpetrated by the same resident, Resident #14 (R14)R14 remains a current resident of the facility and is permitted to ambulate throughout the unit and have direct access to other residents. Therefore. creating an imminent risk to other residents.On 4/6/2026 between 12:00 PM-1:00 PM, Resident #14 was observed ambulating independently on the Memory Care Unit in the hallways and in the common areas. He was observed in shorts and a long sleeve T-shirt constantly rubbing his arms as he wandered about unit.On 4/6/2026 at approximately 3:00 PM, Resident #14 was observed wandering the hallways and the common area of Memory Care Unit.On 4/7/26 a review of R14's clinical record post the 12/30/25 incident revealed the following: Nurse progress note dated 1/3/2026 revealed R14 observed in a female's room attempting to get into bed with her, clothes on and brief was still on. Resident was given re-direction, to which R14 attempted to fight against and swing at staff. R14 made grabbing motions at staff and attempted to hit staff.Psychiatrist Nurse Practitioner progress note dated 1/5/26 read in part, Facility staff requested consultation related to escalating behavioral disturbances. Facility staff report increasing aggressive and inappropriate behaviors. According to the staff, R14 became verbally aggressive when staff attempted to obtain his weight, refused redirection, and became tense and competitive. Staff further report that the resident entered a female resident's room and attempted to get into bed with her while clothed and wearing a brief. When redirected, the R14 became physically aggressive, making grabbing motions, swinging at staff, and attempting to strike them. R14 poses risks to staff and peers due to aggressive and sexually inappropriate behaviors. Upon assessment, the R14 has significant behavioral disturbances characterized by aggression, poor impulse control, and sexually inappropriate behavior. Presentation is consistent with behavioral symptoms likely related to underlying neurocognitive disorder. Current behaviors place R14 and others at risk Treatment Plan/Recommendations: 1. Discontinue anti-depressant used to treat depression due to concern for activating effects contributing to agitation, aggression, and behavioral dysregulation. Discontinuation is part of behavioral symptom management to reduce stimulation and impulsivity. Monitor for improvement in agitation, aggression, and intrusive behaviors following discontinuation. Monitor for emergence or worsening of depressive symptoms. Continue non-pharmacological interventions including consistent redirection, calm approach, and environmental modifications. Ensure close supervision to reduce risk to staff and peers. Continue to assess risks to harm himself or others. Staff to utilize de-escalation techniques and document behavioral incidents.Nurse progress note dated 1/5/26 read in part, R14 no longer on one-one supervision per physician's order.On 4/9/2026 at 11:13 AM, the Administrator, Director of Nursing, Assistant Director of Nursing, Regional [NAME] President of Operations, Clinical Consultant, Regional Director of Clinical Services and were made aware of the concern. No further information was provided prior to exit. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for timely reporting of the final five-day investigative summary to appropriate agencies for one of eighteen residents in the survey sample, Resident #2. Findings include:For Resident #2 (R2), the facility staff failed to implement their abuse policy regarding the timing of reporting the final 5-day investigative summary of abuse to the state survey agency. On 4/7/26 during a review of the facility's synopsis event dated 12/30/25 involving R2 and R14 , it was noted that the final 5-day investigation was not submitted successfully to the state agency until 1/14/26.A review of the facility's final synopsis of incident dated 12/30/25 revealed, in part: Staff alleges R14 struck R2 in her left eye causing bruising, head to toe skin and pain assessments completed on both residents. Statements obtained from staff reported that another resident had informed them that R2 and R14 were fighting. Upon entering R2's room they observed R14 standing in front of R2 and each resident struggling over R2's reacher/grabber tool, residents were immediately separated. R2 stated to staff that R14 hit her in her left eye. Skin assessment completed on R2 noting swelling and bruising to her left eye. She denied pain and discomfort. R14 was immediately escorted out of R2's room and placed on every 15-minute checks. Skin evaluation was negative for injury to R14.A review of the clinical record revealed:Nurse progress note dated 12/30/25 at 9:45 PM read in part, Writer was charting at the nurses' station, and a resident came to call me and said they are fighting. I rushed to the 3rd hall, and I saw R2 and R14 in front of her room pushing and pulling on a reacher/grabber stick. I separated them. R2 stated that he came to my room and I tried to ask him to leave and he hit me in my left eye. Swelling and bruising noted around R2's left eye. R2's responsible party, physician and the Director of Nursing were notified of the incident. Neuro checks were initiated.Physician note dated 12/31/25 at 10:07 AM read in part, Patient (R2) recently was involved in an altercation where her orbit was injured. She became more lethargic and her vitals showed temperature 102 degrees Fahrenheit, heart rate 126, blood pressure 224/115, and oxygen saturation in the 50s before rising to 97% on 4L Venti mask (re-breathing mask). Due to risk of deterioration she (R2) was sent to the ED (local hospital emergency department).Nurse progress note dated 12/31/25 at 11:45 AM read in part, Writer (LPN#3) informed by charge nurse the resident breathing was abnormal and resident was unresponsive. Writer entered room and resident noted to be lying in bed heavily breathing but not responding to name or sternal rub. Vital signs taken and abnormal, blood pressure 244/119, heart rate 126, respirations 20, oxygen saturation 53% on room air. Physician notified. Oxygen was increased to 15 liters on a non-rebreather, with oxygen saturation up to 96%. R2 was still not responding. The physician was -notified again with an order to send to the emergency room for further evaluation. Writer called and spoke to responsible party, R2's sister in-law. EMS (Emergency Medical Services) notified and R2 transferred to (name redacted) hospital. On 4/7/26 at 8:41 AM, a telephone interview was conducted with R2's responsible party, her sister-in-law who stated that the physician at the hospital had told her R2 suffered a significant brain bleed from being hit in the eye and being on a blood thinner. She stated R2 passed away at 2:00 AM on 1/1/26.R14 was admitted to the facility 2/6/24 with diagnosis to include but not limited to vascular dementia with psychotic disturbance, anxiety, insomnia, restlessness and agitation, and major depressive disorder. R14's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/1/25 coded R14 as 03/15 on the BIMS (Brief Interview of Mental Status) indicating severe cognitive impairment with skills of memory, thinking and orientation to place and timeAccording to the fax confirmation sheets for the incident summary, it showed the facility submitted the initial report of the incident to the state survey agency, adult protective services, and the ombudsman on 12/30/25 at 10:12 PM. Further review of fax confirmation sheets revealed the facility submitted the final 5-day investigative summary to the adult protective services 1/7/26 at 5:15 PM and the ombudsmen at 5:19 PM. The fax confirmation sheet showed the final 5-day investigative summary submittal dated 1/7/26 at 5:26 PM to the state survey agency failed.No evidence the facility attempted to re-submit the final investigative summary on business days 1/8/26 or 1/9/26.The fax confirmation sheet showed the final 5-day investigative summary submittal on 1/12/26 at 3:23 PM to the state survey agency failed. No evidence the facility attempted to re-submit the final investigative summary on business day 1/13/26. According to the Administrator, she called the state survey agency supervisor on 1/14/26 and spoke to her about not being able to successfully transmit the final investigative summary and received guidance on how to transmit. A review of an email from state agency IT services support dated 1/14/26 at 1:57 PM confirmed state survey agency's receipt of the final 5-day investigative summary for the event occurring on 12/30/25.A review of the facility policy, Resident Rights and abuse Prevention Policy and Policy Manual, titled, Abuse, Neglect, Exploitation or Misappropriation, 2001 - Reporting and Investigating read in part: All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities - 3. Immediately is defined as: a, within two hours of an allegation involving abuse or result in serious bodily injury, or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Follow-Up Report - 1. Within five (5) business days of the incident, the Administrator will provide a follow-up investigation. 4. The resident and/or resident representative are notified of the outcome immediately upon conclusion of the investigation.According to the clinical record, R2 was transferred to the emergency department on 12/31/25 and did not return to the facility. No evidence in the clinical record or facility synopsis file of resident or the resident representative notification of the outcome of the investigation of the incident 12/30/25 involving R2 and R14.On 4/8/2026 at approximately 4:10 PM, the Administrator and Director of Nursing were made aware of the concern. No further information was provided prior to exit.

Based on clinical record review and staff interview, it was determined that the facility staff failed to maintain an accurate minimum data set (MDS) assessment for one of 18 residents in the survey sample, Resident #13. The findings include:For Resident #13 (R13), the facility staff failed to code the quarterly MDS assessment with an assessment reference date (ARD) of 2/12/2026 for pressure injuries (1) present during the assessment period. Review of the clinical record for R13 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 2/12/2026. Section M0100 of the assessment documented the resident having a pressure injury however Section M0210 and M0300 failed to document whether the resident had unhealed pressure injuries and the current number of unhealed pressure injuries at each stage. The physician orders for R13 documented in part, - SACRUM- Cleanse with wound cleanser apply Calcium Alginate with silver and cover with bordered dressing Qday (every day) and PRN (as needed) one time a day. Order Date: 01/29/2026.- LEFT EAR- Cleanse with wound cleanser apply Manuka HD and cover with bordered dressing Qday and PRN one time a day. Order Date: 01/29/2026. The electronic treatment administration record for R13 documented treatments completed to the sacrum and left ear from 2/1/2026-2/28/2026 as ordered. The comprehensive care plan for R13 documented in part, The resident has a pressure ulcer or has the potential for pressure ulcer development r/t (related to) impaired mobility, incontinence, diabetes. Date Initiated: 10/21/2025. On 4/7/2026 at 1:28 PM, an interview was conducted with licensed practical nurse (LPN) #1, MDS coordinator. LPN #1 stated that she used the RAI (resident assessment instrument) manual as a guide when completing the MDS assessments. She stated that the lookback period for Section M was 7 days and she used the wound care documentation, nursing notes, and evaluations to determine if a resident had a current pressure injury or wounds. LPN #1 stated that R13's quarterly MDS with the ARD of 2/12/2026 should have the pressure injuries documented on it and it should not be left incomplete. According to the RAI Manual, Version 1.20.1, dated October 2025, section M0210: Unhealed Pressure Ulcers/Injuries documented in the Coding Instructions, . Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage . On 4/8/2026 at approximately 3:58 PM, the administrator and director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure sores are areas of damaged skin caused by staying in one position for too long . This information was obtained from the website: Pressure Sores | Bedsores | Pressure Ulcers | MedlinePlus

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 18 residents in the survey sample, Resident #8 and Resident #14. The findings include:1. For Resident #8 (R8), the facility staff failed to implement the comprehensive care plan to A) provide a Breath Call (1) adaptive call bell and B) provide ADL (activities of daily living) care. R8 was admitted to the facility with diagnoses that included but were not limited to quadriplegia (2) and chronic respiratory failure (3). On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/17/2026, the resident was assessed as being severely impaired for making daily decisions. Section GG coded R8 being dependent on staff for all ADL (activities of daily living) care. It further documented R8 receiving oxygen, tracheostomy (4) care, tube feeding, pressure injury (5) care and suctioning while at the facility. The comprehensive care plan for R8 documented in part, I have an ADL Self Care Performance Deficit r/t (related to) cerebral infarct (6), muscle wasting, metabolic encephalopathy, respiratory failure, quadriplegia. Date Initiated: 07/10/2025. Under Interventions/Tasks it documented in part, .Be sure Breathcall arm is within reach, and provide reminders to use call for assistance as needed. Breathcall arm in place of traditional button call light due to patient's lack of mobility. Date Initiated: 07/10/2025 . Provide skin inspection daily during care. Observe for redness, open areas, scratches, cuts, bruises, etc., Report abnormal findings to Physician and document in Nurse's Notes. Date Initiated: 07/10/2025 . BATHING: I am dependent on staff for bathing. Date Initiated: 07/10/2025 . A) On 4/6/2026 at approximately 2:10 PM, an observation was made of R8 lying in bed in their room. A handheld call bell with a finger press button on the end was observed clipped to the blanket near R8's chest. No Breath call was observed. Additional observations of R8 were made on 4/7/2026 at 9:01 AM and 4/7/2026 at 12:08 PM. The handheld call bell remained in place clipped to the bed linens. No Breath call was observed. On 4/7/2026 at 12:51 PM, an interview was conducted with the director of specialty care who stated that they assess the mobility of the residents arm, the range of motion, strength and coordination of the fingers when determining the type of call bell that the resident was given. She stated that they had a few options that they could use and they put in a work order for maintenance, and they changed the call bells out right away to an adaptive call bell when requested. The director stated that she was not sure what type of call bell R8 had used in their previous room but had recently switched rooms and she would have to investigate it further. She stated that the purpose of the care plan was to be a roadmap for staff to provide individualized care and it should be implemented because it guides the staff on how to properly care for the resident and to be aware of any issues and risks. On 4/8/2026 at 12:38 PM, an interview was conducted with the director of nursing (DON) who stated that the interdisciplinary team decided what type of call bell was required for the resident and at times therapy made recommendations. She stated that if the resident changed rooms the adaptive call bell followed the resident to the new room. The DON stated that the purpose of the care plan was to direct the care of the resident for the entire team and address the specific needs of the resident. She stated that the care plan should be implemented to ensure the entire team was on board for the residents' needs. Review of the census for R8 documented a room change on 3/27/2026. B) The ADL documentation for R8 dated 3/1-3/31/2026 documented baths completed by staff from 3/19/2026-3/22/2026 with scheduled shower/bath completed on 3/19/2026. It further documented upper body dressing completed on day and evening shift 3/19/2026-3/22/2026. Review of the electronic medication administration record (eMAR) dated 3/1/26-3/31/26 documented in part, Insert Midline (7) one time only until 03/16/2026. Start Date: 03/16/2026. Insert peripheral IV (intravenous) for ABT (antibiotic) one time only for IV ABT for 1 Day. Start Date: 03/18/2026. The eMAR further documented R8 receiving the first dose of intravenous antibiotics on 3/18/2026 at 9:00 AM. The progress notes for R8 documented in part, - 03/16/2026 11:50 (AM) Late entry . At approximately 2100 (9:00 PM), MD was notified of no improvement in BP (blood pressure). Writer received a new order for a STAT (now) ammonia level, and UA/ C&S (urinalysis with culture and sensitivity), Midline placement, one-time order of Cefepime 1 gm IM (intramuscular) and Solu-Medrol 125 mg IM. Medication administered as ordered. Pt continues to be closely monitored for new or worsening symptoms. - 03/18/2026 11:09 (AM) Date of Service: 3/18/2026. Visit Type : HP SKIN AND WOUND NOTE . Reason for visit: subsequent encounter for skin and wound care metronidazole Intravenous Solution 500 MG/100ML three times a day . - 03/19/2026 07:57 (AM) Note Text : Resident continues on IV/ABT (intravenous antibiotics) for elevated WBCs (white blood cells), no adverse reactions noted, IV site noted with no signs of infection or infiltration, resident noted with no signs or symptoms of distress noted, will continue plan of care, lab to be in today to obtain CBC/CMP (complete blood count/comprehensive metabolic panel). - 03/23/2026 12:13 (PM) Situation : The Change in Condition/s reported on this CIC Evaluation are/were: Skin wound or ulcer . - 03/23/2026 13:30 (1:30 PM) .Skin Issue: #002: New skin Issue. Location: Left antecubital space. Issue type: Pressure ulcer/injury. Progress: New: new wound. Wound acquired in-house. Length (cm): 20 Width (cm): 4 Depth (cm): 0.1. - 03/23/2026 18:36 (6:36 PM) Note Text: AT 1130 (AM) RN (registered nurse) WAS ALERTED TO A TOURNIQUET ON PTS LEFT BICEP/AC (antecubital) AREA BY THE CNA (certified nursing assistant) WHO WAS WASHING HIM. RN REMOVED THE TOURNIQUET AND SKIN UNDERNEATH WAS DAMAGED DISCOLORED AND BLISTERED. UNIT MANAGER MADE AWARE. MD MADE AWARE. WOUND NURSE MADE AWARE. LEFT HAND ELEVATED. WILL MONITOR LUE (left upper extremity). On 4/7/2026 at 12:51 PM, an interview was conducted with the director of specialty care (DSC). She stated that the nurse had received an order to insert a peripheral IV on 3/18/2026 and she had been able to place the line successfully on the right side and the pharmacy had a team that came to the facility to place midline IVs but had placed another peripheral line in the left arm. The DSC stated that the CNA working on 3/23/2026 had reported to the nurse that there was a tourniquet left on R8's left upper arm that she found when bathing the resident. She stated that the nurse had immediately called her to assess and they had notified the director of nursing, wound nurse and the physician. The DSC stated that the expectation was for the CNA staff to bath residents daily and to change their gowns daily. She stated that when she spoke with the CNA she was told that they could not find a clean gown, and she would still expect bathing to occur and the CNA to leave the unit to find a clean gown. She stated that the purpose of the care plan was to be a roadmap for staff to provide individualized care and it should be implemented because it guides the staff on how to properly care for the resident and to be aware of any issues and risks. On 4/7/2026 at 1:16 PM, an interview was conducted with CNA #1 who stated that ADL was provided every morning which included a full bed bath or shower. She stated that the resident was either dressed in their personal clothing or a gown depending on their preference and medical needs. CNA #1 stated that there were times when she ran out of linens and they had to go get them from the laundry or another floor until they were delivered from the laundry. On 4/8/2026 at 11:40 AM, an interview was conducted with CNA #7 who stated that she worked with R8 on 3/21-3/22/2026 and she had heard about the wound found on 3/23/2026. She stated that she had only given R8 a washup over the weekend because they did not have any more gowns to put on the resident. CNA #7 stated that she did not take R8's gown off because it was not soiled and she did not have a replacement for it and she felt very guilty for not changing it. She stated that if she had taken the gown off she may have seen the tourniquet on the arm and caught it earlier. The facility policy Care Plans, Comprehensive Person-Centered revised March 2022 documented in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . On 4/8/2026 at approximately 3:58 PM, the administrator and director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) The Breath Call is a pneumatic (air-activated) nurse call cord that works with virtually any nurse call system. Breath Call is for patients with little to no motor skills and is activated by simply breathing into a disposable straw and filter assembly . This information was obtained from the website: Breath Call (BreathCall ) Nurse Call Cord – [NAME] Precision Products (2) Paralysis of the arms and legs is quadriplegia . This information was obtained from the website: Paralysis | Hemiplegia | MedlinePlus (3) Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems . This information was obtained from the website: Respiratory Failure | Lung Disease | Lung Problems | MedlinePlus (4) A tracheostomy is surgery to create a hole in your neck that goes into your windpipe . This information was obtained from the website: Tracheostomy care: MedlinePlus Medical Encyclopedia (5) Pressure sores are areas of damaged skin caused by staying in one position for too long . This information was obtained from the website: Pressure Sores | Bedsores | Pressure Ulcers | MedlinePlus (6) A stroke occurs when blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. This information was obtained from the website: Stroke: MedlinePlus Medical Encyclopedia (7) A Midline Catheter is a thin, flexible tube placed into a vein in the arm. The catheter is 8-10 centimeters long and can stay in the arm for up to 29 days. This allows patients to get IV (intravenous) medicines and have blood samples drawn. The catheter is placed by a trained nurse . This information was obtained from the website: A Midline Intravascular Catheter | Patients & Families | UW Health 2. For Resident #14, the facility staff failed to implement the comprehensive care plan to ensure he was dressed in multiple layers of clothing due to his cold nature. R14 was admitted to the facility 2/6/24 with diagnosis to include but not limited to vascular dementia with psychotic disturbance, anxiety, rheumatoid arthritis left hip, iron deficiency anemia, insomnia, restlessness and agitation, and major depressive disorder. R14's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/1/25 coded R14 as 03/15 on the BIMS (Brief Interview of Mental Status) indicating severe cognitive impairment with skills of memory, thinking and orientation to place and time. Section GG coded R14 requiring substantial/maximal assistant on staff for all ADL (activities of daily living) care. R14's comprehensive care plan contained a care plan focus, I have a behavior problem related to sexual ideations. roaming in rooms and taking other peoples' belongings, misplacing own belongings around the units, wearing multiple layers of clothes that don't belong to me including women's apparel, defecating on the floor Date. Under Interventions/Tasks it documented in part, Make sure to layer resident in multiple layers of his clothes due to the resident's cold nature. Date Initiated: 12/19/20. On 4/6/26 from 12:00 PM to 1:00 PM, R14 was observed ambulating independently on the memory care unit down the hallways and in the common area dressed in shorts and a long sleeve shirt. He was rubbing his arms and making mumbling noises. On 4/6/26 at 2:58 PM, observed R14 again ambulating randomly around the memory care unit down the halls and in the common area. He was still rubbing his arms and making mumbling noises. On 4/7/26 at 5:20 PM, an interview was conducted with LPN#10 on why R14 had on shorts when his care plan indicated to make sure to layer resident in multiple layers of clothes due to his being cold natured, LPN#10 responded, I was not aware that was on his care plan, he usually tells us when he is cold. An interview was completed with the Unit Manager for the Memory Care Unit (LPN#3) on the purpose of the resident care plan. According to Unit Manager LPN#3, the purpose of the care plan is to provide staff with guidelines on the resident's needs and how to address them. We update them whenever the resident has a change in condition such as a fall, infection or behaviors. On 4/9/2026 at 11:13 AM, the Administrator, Director of Nursing, Assistant Director of Nursing, Regional [NAME] President of Operations, Clinical Consultant, Regional Director of Clinical Services and were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents to one of 18 residents in the resident sample, Resident #8. The findings include:For Resident #8 (R8), the facility staff failed to provide adequate ADL care to include bathing and dressing between 3/19/2026-3/22/2026. R8 was admitted to the facility with diagnoses that included but were not limited to quadriplegia (1), chronic respiratory failure (2) and pressure ulcer (3) of sacral region. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/17/2026, the resident was assessed as being severely impaired for making daily decisions. Section GG coded R8 being dependent on staff for all ADL (activities of daily living) care. It further documented R8 receiving oxygen, tracheostomy (4) care, tube feeding, and suctioning while at the facility. R8 was assessed as having one Stage 3 pressure injury and one Stage 4 pressure injury. The ADL documentation for R8 dated 3/1-3/31/2026 documented baths completed by staff from 3/19/2026-3/22/2026 with scheduled shower/bath completed on 3/19/2026. It further documented upper body dressing completed on day and evening shift 3/19/2026-3/22/2026. Review of the electronic medication administration record (eMAR) dated 3/1/26-3/31/26 documented in part, Insert Midline (6) one time only until 03/16/2026. Start Date: 03/16/2026. Insert peripheral IV (intravenous) for ABT (antibiotic) one time only for IV ABT for 1 Day. Start Date: 03/18/2026. The eMAR further documented R8 receiving the first dose of intravenous antibiotics on 3/18/2026 at 9:00 AM. The progress notes for R8 documented in part,- 03/16/2026 11:50 (AM) Late entry . At approximately 2100 (9:00 PM), MD was notified of no improvement in BP (blood pressure). Writer received a new order for a STAT (now) ammonia level, and UA/ C&S (urinalysis with culture and sensitivity), Midline placement, one-time order of Cefepime 1 gm IM (intramuscular) and Solu-Medrol 125 mg IM. Medication administered as ordered. Pt continues to be closely monitored for new or worsening symptoms.- 03/18/2026 11:09 (AM) Date of Service: 3/18/2026. Visit Type : HP SKIN AND WOUND NOTE . Reason for visit: subsequent encounter for skin and wound care metronidazole Intravenous Solution 500 MG/100ML three times a day .- 03/19/2026 07:57 (AM) Note Text : Resident continues on IV/ABT (intravenous antibiotics) for elevated WBCs (white blood cells), no adverse reactions noted, IV site noted with no signs of infection or infiltration, resident noted with no signs or symptoms of distress noted, will continue plan of care, lab to be in today to obtain CBC/CMP (complete blood count/comprehensive metabolic panel).- 03/23/2026 12:13 (PM) Situation : The Change in Condition/s reported on this CIC Evaluation are/were: Skin wound or ulcer .- 03/23/2026 13:30 (1:30 PM) .Skin Issue: #002: New skin Issue. Location: Left antecubital space. Issue type: Pressure ulcer/injury. Progress: New: new wound. Wound acquired in-house. Length (cm): 20 Width (cm): 4 Depth (cm): 0.1.- 03/23/2026 18:36 (6:36 PM) Note Text: AT 1130 (AM) RN (registered nurse) WAS ALERTED TO A TOURNIQUET ON PTS LEFT BICEP/AC (antecubital) AREA BY THE CNA (certified nursing assistant) WHO WAS WASHING HIM. RN REMOVED THE TOURNIQUET AND SKIN UNDERNEATH WAS DAMAGED DISCOLORED AND BLISTERED. UNIT MANAGER MADE AWARE. MD MADE AWARE. WOUND NURSE MADE AWARE. LEFT HAND ELEVATED. WILL MONITOR LUE (left upper extremity). The comprehensive care plan for R8 documented in part, I have an ADL Self Care Performance Deficit r/t (related to) cerebral infarct (5), muscle wasting, metabolic encephalopathy, respiratory failure, quadriplegia. Date Initiated: 07/10/2025. Under Interventions/Tasks it documented in part, Provide skin inspection daily during care. Observe for redness, open areas, scratches, cuts, bruises, etc., Report abnormal findings to Physician and document in Nurse's Notes. Date Initiated: 07/10/2025 . BATHING: I am dependent on staff for bathing. Date Initiated: 07/10/2025 . On 4/7/2026 at 12:51 PM, an interview was conducted with the director of specialty care (DSC). She stated that the nurse had received an order to insert a peripheral IV on 3/18/2026 and she had been able to place the line successfully on the right side and the pharmacy had a team that came to the facility to place midline IVs but had placed another peripheral line in the left arm. The DSC stated that the CNA working on 3/23/2026 had reported to the nurse that there was a tourniquet left on R8's left upper arm that she found when bathing the resident. She stated that the nurse had immediately called her to assess and they had notified the director of nursing, wound nurse and the physician. The DSC stated that the expectation was for the CNA staff to bath residents daily and to change their gowns daily. She stated that when she spoke with the CNA she was told that they could not find a clean gown, and she would still expect bathing to occur and the CNA to leave the unit to find a clean gown. On 4/7/2026 at 1:16 PM, an interview was conducted with CNA #1 who stated that ADL was provided every morning which included a full bed bath or shower. She stated that the resident was either dressed in their personal clothing or a gown depending on their preference and medical needs. CNA #1 stated that there were times when she ran out of linens and they had to go get them from the laundry or another floor until they were delivered from the laundry. On 4/8/2026 at 11:40 AM, an interview was conducted with CNA #7 who stated that she worked with R8 on 3/21-3/22/2026 and she had heard about the wound found on 3/23/2026. She stated that she had only given R8 a washup over the weekend because they did not have any more gowns to put on the resident. CNA #7 stated that she did not take R8's gown off because it was not soiled and she did not have a replacement for it and she felt very guilty for not changing it. She stated that if she had taken the gown off she may have seen the tourniquet on the arm and caught it earlier. On 4/8/2026 at 12:38 PM, an interview was conducted with the director of nursing who stated that she had been called to assess R8's left upper arm on 3/23/2026 when the CNA found the tourniquet in place. She stated that they had investigated and found that R8 had two IV's placed, one in the right arm by facility staff and one in the left arm by the pharmacy IV team on 3/18/2026. The DON stated that when she went into R8's room on 3/23/2026 the tourniquet had been removed and there was a wound to the left upper bicep with no drainage. She stated that they asked R8 if they were having any pain and they shook their head no and the wound nurse came and assessed the wound and got an order for a treatment, and the physician and responsible party were notified. She stated that this wound was preventable and if staff were bathing and changing R8's gown they should have seen the tourniquet in place. On 4/8/2026 at 2:54 PM, an interview was conducted with the account manager of housekeeping and laundry who stated that laundry was staffed from 7:00 AM through 8:00 PM each day. She stated that each unit received a cart with 50 gowns each shift. Observations conducted revealed gowns stocked on each unit and in laundry storage. The facility policy Activities of Daily Living (ADL), Supporting revised April 2025 documented in part, .Appropriate care and services are provided for residents who are unable to carry out ADLs independently with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a: hygiene (bathing, dressing, grooming, and oral care) . On 4/8/2026 at approximately 3:58 PM, the administrator and director of nursing were made aware of the concern. No further information was provided prior to exit. Reference:(1) Paralysis of the arms and legs is quadriplegia . This information was obtained from the website: Paralysis | Hemiplegia | MedlinePlus(2) Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems . This information was obtained from the website: Respiratory Failure | Lung Disease | Lung Problems | MedlinePlus(3) Pressure sores are areas of damaged skin caused by staying in one position for too long . This information was obtained from the website: Pressure Sores | Bedsores | Pressure Ulcers | MedlinePlus(4) A tracheostomy is surgery to create a hole in your neck that goes into your windpipe . This information was obtained from the website: Tracheostomy care: MedlinePlus Medical Encyclopedia(5) A stroke occurs when blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. This information was obtained from the website: Stroke: MedlinePlus Medical Encyclopedia(6) A Midline Catheter is a thin, flexible tube placed into a vein in the arm. The catheter is 8-10 centimeters long and can stay in the arm for up to 29 days. This allows patients to get IV (intravenous) medicines and have blood samples drawn. The catheter is placed by a trained nurse . This information was obtained from the website: A Midline Intravascular Catheter | Patients & Families | UW Health

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for two of 18 residents in the resident sample, Resident #8 and Resident #2. The findings include:1. For Resident #8 (R8), the facility staff failed to maintain a complete and accurate medical record documenting intravenous (IV) line placement procedures. Review of the electronic medication administration record (eMAR) dated 3/1/26-3/31/26 documented in part, Insert Midline (1) one time only until 03/16/2026. Start Date: 03/16/2026. Insert peripheral IV for ABT (antibiotic) one time only for IV ABT for 1 Day. Start Date: 03/18/2026. The eMAR further documented R8 receiving the first dose of intravenous antibiotics on 3/18/2026 at 9:00 AM. The progress notes for R8 documented in part, - 03/16/2026 11:50 (AM) Late entry . At approximately 2100 (9:00 PM), MD was notified of no improvement in BP (blood pressure). Writer received a new order for a STAT (now) ammonia level, and UA/ C&S (urinalysis with culture and sensitivity), Midline placement, one-time order of Cefepime 1 gm IM (intramuscular) and Solu-Medrol 125 mg IM. Medication administered as ordered. Pt continues to be closely monitored for new or worsening symptoms. - 03/18/2026 11:09 (AM) Date of Service: 3/18/2026. Visit Type : HP SKIN AND WOUND NOTE . Reason for visit: subsequent encounter for skin and wound care metronidazole Intravenous Solution 500 MG/100ML three times a day . - 03/19/2026 07:57 (AM) Note Text : Resident continues on IV/ABT (intravenous antibiotics) for elevated WBCs (white blood cells), no adverse reactions noted, IV site noted with no signs of infection or infiltration, resident noted with no signs or symptoms of distress noted, will continue plan of care, lab to be in today to obtain CBC/CMP. The clinical record for R8 failed to evidence documentation regarding the midline insertion procedure completion, site of the midline placement or resident tolerance of the procedure. It further failed to evidence documentation regarding the peripheral IV insertion, site of the peripheral line or resident tolerance of the procedure. On 4/7/2026 at 12:51 PM, an interview was conducted with the director of specialty care (DSC). She stated that the nurse had received an order to insert a peripheral IV on 3/18/2026 and she had been able to place the line successfully on the right side. She stated that there should be documentation in the progress notes regarding the IV insertion procedure. The DSC stated that the pharmacy had a team that came to the facility to place midline IV but had placed another peripheral line in the left arm. She stated that the pharmacy normally provided them with paperwork regarding the midline and it was put into the medical record, but they had not been able to get the information from the pharmacy. On 4/8/2026 at 11:45 AM, an interview was conducted with registered nurse (RN) #1 who stated that she had entered the initial order for the midline IV placement and had signed off the midline IV placement on the eMAR because it was already inserted when she came in on her shift that day. She stated that she had received report that day shift nurse had started a peripheral line in the right hand and the pharmacy had sent someone in and they had placed the midline in the left arm. RN #1 stated that when the staff place IV lines they document where they place the line and the details of the procedure. On 4/8/2026 at 12:38 PM, an interview was conducted with the director of nursing (DON) who stated that R8 had an IV placed in the right arm by the facility nurse and one in the left arm by the pharmacy. She stated that both IVs were placed on 3/18/2026 and the pharmacy was supposed to give them documentation regarding the procedure. The DON stated that they were still trying to get verification for the placement from the pharmacy and the facility nurse should have documented the peripheral IV in the resident record also. No policy regarding a complete and accurate medical record was provided by the facility. According to Fundamentals of Nursing, 6th edition, [NAME] and [NAME]; page 480, documented in part regarding assessments and documentation, . The record needs to describe exactly what happened to a client. Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record. On 4/8/2026 at approximately 3:58 PM, the administrator and director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) A Midline Catheter is a thin, flexible tube placed into a vein in the arm. The catheter is 8-10 centimeters long and can stay in the arm for up to 29 days. This allows patients to get IV (intravenous) medicines and have blood samples drawn. The catheter is placed by a trained nurse . This information was obtained from the website: A Midline Intravascular Catheter | Patients & Families | UW Health 2. For Resident #2 (R2), the facility staff failed to maintain a complete and accurate medical record documenting medication administration, trauma informed care assessment and neurological assessments on 12/30/25 and 12/31/25. A review of the (MARs) Medication Administration Record for 12/31/25, revealed the nurse documented the administration of 9:00 AM medications at 11:09 AM and 1:00 PM medications at 14:14 PM. On 4/7/26 at 7:40 AM, an interview was conducted with LPN#4 regarding the care and services she provided to R2 on 12/31/25. According to LPN#4, the Unit Manager, LPN#3 was taking care of R2 mostly the morning of 12/31/25. She stated she had made her rounds on the morning of 12/30/25 and noticed that R2's eye was swollen terrible, swollen shut, and had a purplish reddish bruising around the left eye. She wasn't responding as much as usual. Later the aide told us she wasn't eating her breakfast then we knew something wasn't right. LPN#3 called the doctor. R2 's condition kept getting worse. Her blood pressure and pulse were getting higher and her breathing was labored. She was showing a drastic change, and the doctor told us to send her out. When LPN#4 was asked whether she had administered medications to R2 on the morning of 12/31/25 she stated, I don't think so, she was in bad shape and wasn't eating breakfast, so I don't think she would have been able to swallow her medications. A review of R2's eMAR (electronic Medication Administration Record) for 12/31/25 was conducted with LPN#4 to reveal she had signed off all 9:00 AM and 1:00 PM medications. She stated, Oh, I must have signed those off by mistake. Based on [NAME] and [NAME]'s Fundamentals of Nursing, 6th Edition, Chapter 15, read in part.medication administration documentation must be accurate, timely, and complete, occurring immediately after administration. Key documentation standards from [NAME] and [NAME]. Immediate Documentation: Never document medication administration until it has actually been given. On 4/7/26 at 9:45 AM, an interview was conducted with the Social Services Assistant (Other Staff Member #11) regarding her completion of the Trauma Informed Care assessment dated [DATE], completed in part, Information. A. Who assisted in completing this assessment? A. Resident and progress note 12/31/25 at 10:26 AM Resident is doing okay, no issues or behaviors observed. OSM #11 was interviewed on how R2 could assist in the completion of the Trauma Informed Care assessment and be doing okay, no issues or behaviors observed per her progress note as per nurse and physician progress notes and interviews R2 was unresponsive and presenting with abnormal vital signs, labored breathing and in the process of being transferred to the emergency department, OSM #11 states, Oh, I made a mistake in writing that. That is not an accurate note on Ms. (name redacted) R2. On 4/7/26 at 5:20 PM, an interview was conducted with LPN#10 on how to complete a neurological assessment. According to LPN#10, she checks the vital signs that included the blood pressure, heart rate, respirations and temperature, then she checks the residents pupils for size and reaction to light, checks their grip to see if it is strong or weak or if any change for them and she asks them questions such as their name and if they have any pain or headaches and determine if their speech is clear. The neurological assessment record for R2 dated 12/30 through 12/31/25 was reviewed with LPN#10 and when asked her to explain what the X marks indicated on the rows for pupils, extremities, speech and response to pain and environment, she explained the X mark meant she had completed that area of the assessment. When LPN#10 was asked about the legend/code at the top of the page, LPN#10 stated she had not had any training on the legend/code. According to the Director of Nursing, the facility does not have a policy regarding a complete and accurate medical record. She stated her expectation is for all disciplines to document accurate and timely information in the residents' medical record. According to Fundamentals of Nursing, 6th edition, [NAME] and [NAME]; page 480, documented in part regarding assessments and documentation, . The record needs to describe exactly what happened to a client. Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record. On 4/9/2026 at 11:13 AM, the Administrator, Director of Nursing, Assistant Director of Nursing, Regional [NAME] President of Operations, Clinical Consultant, Regional Director of Clinical Services and were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure communication training was completed for one of seven employee reviews.The findings include:For CNA #9, the facility staff failed to ensure communication training was completed.CNA #9 was hired on 7/6/2022. The facility staff failed to provide evidence that CNA #9 had completed communication training. On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. A request was made to the staff development coordinator for any evidence of CNA #9 completing communication training however none was provided.The facility assessment reviewed 2/26/2026 documented in Staff education and Competency, .All Staff Annual Education Course Topics: .Communicating Effectively . The facility policy In-Service Training, All Staff dated 2001 documented in part, .All staff are required to participate in regular in-service education . Required training topics include the following: a. Effective communication with residents and family (direct care staff) .On 4/9/2026 at approximately 11:12 AM, the administrator, the director of nursing, the vice president of operations, the regional director of clinical services, the assistant director of nursing and the clinical consultant were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure QAPI (quality assurance and performance improvement) training was completed for three of seven employee reviews.The findings include:1. For certified nursing assistant (CNA) #9, the facility staff failed to ensure QAPI training was completed.2. For other staff member (OSM) #8, dietary staff member, the facility staff failed to ensure QAPI training was completed.3. For OSM #9, housekeeping staff member, the facility staff failed to ensure QAPI training was completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator (SDC) who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. The SDC stated that she was working to obtain education for the contracted staff members including therapy staff and dietary staff. A request was made to the staff development coordinator for any evidence of CNA #9, OSM #8 and OSM #9 completing QAPI training however none was provided.The facility assessment reviewed 2/26/2026 documented in Staff education and Competency, .All Staff Annual Education Course Topics: .QAPI Basics . The facility policy In-Service Training, All Staff dated 2001 documented in part, .All staff are required to participate in regular in-service education .For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers . Required training topics include the following: . d. Elements and goals of the facility QAPI program .On 4/9/2026 at approximately 11:12 AM, the administrator, the director of nursing, the vice president of operations, the regional director of clinical services, the assistant director of nursing and the clinical consultant were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure compliance and ethics training was completed for two of eight employee reviews.The findings include:1. For certified nursing assistant (CNA) #9, the facility staff failed to ensure compliance and ethics training was completed.2. For CNA #10, the facility staff failed to ensure compliance and ethics training was completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. A request was made to the staff development coordinator for any evidence of CNA #9 and CNA #10 completing compliance and ethics training however none was provided.The facility assessment reviewed 2/26/2026 documented in Staff education and Competency, .All Staff Annual Education Course Topics: .Corporate Compliance . Ethics . The facility policy In-Service Training, All Staff dated 2001 documented in part, .All staff are required to participate in regular in-service education . Required training topics include the following: .The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities) .On 4/9/2026 at approximately 11:12 AM, the administrator, the director of nursing, the vice president of operations, the regional director of clinical services, the assistant director of nursing and the clinical consultant were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure behavioral health training was completed for two of eight employee reviews.The findings include:1. For certified nursing assistant (CNA) #9, the facility staff failed to ensure behavioral health training was completed.2. For other staff member (OSM) #8, dietary staff member, the facility staff failed to ensure behavioral health training was completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator (SDC) who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. The SDC stated that she was working to obtain education for the contracted staff members including therapy staff and dietary staff. A request was made to the staff development coordinator for any evidence of CNA #9 and OSM #8 completing behavioral health training however none was provided.The facility assessment reviewed 2/26/2026 documented in Staff education and Competency, .All Staff Annual Education Course Topics: .Tips on Managing Challenging Behaviors . Managing Aggressive Behaviors . Understanding Trauma-Informed Care . The facility policy In-Service Training, All Staff dated 2001 documented in part, .All staff are required to participate in regular in-service education .For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers . Required training topics include the following: . f. Behavioral health .On 4/9/2026 at approximately 11:12 AM, the administrator, the director of nursing, the vice president of operations, the regional director of clinical services, the assistant director of nursing and the clinical consultant were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5, the facility staff failed to implement the comprehensive care plan for the administration of the medication, Midodrine (used to treat orthostatic hypotension, a sudden fall in blood pressure that occurs when a person assumes a standing position) (1) per the physician orders. The comprehensive care plan dated 11/3/2025 documented in part, Focus: I have hypotension related to ESRD (end stage renal disease). Interventions: Give medications as ordered. Monitor vital signs as ordered and as clinically indicated.An interview was conducted with LPN (licensed practical nurse) #4 on 1/29/2026 at 7:45 a.m. LPN #4 stated the care plan is a guide for the staff on how to care for the residents and their individual needs. The facility policy, Care Plans; Comprehensive Person-Centered documented in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of operations, were made aware of the above findings on 1/29/2026 at approximately 4:45 p.m. No further information was provided prior to exit. (1) this information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify physician orders for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to clarify the physician orders for Midodrine (used to treat orthostatic hypotension, a sudden fall in blood pressure that occurs when a person assumes a standing position) (1) and Clonidine (used to treat high blood pressure) (2). The physician order dated, 1/14/2026 documented, Midodrine HCL (hydrochloride) Oral Tablet 10 MG (milligrams); Give 10 MG via Peg - tube (a feeding tube inserted in the stomach) (3) every 8 hours as needed for orthostatic hypotension. Give for SBP (systolic blood pressure) under 100 mmHg (millimeters of mercury). A second physician order dated 1/14/2026 documented, Clonidine HCL Oral Tablet; Give 1 tablet by mouth every 8 hours as needed for HTN (hypertension) for 30 days; Give for SBP over 170 mmHg. Review of the clinical record failed to evidence that the resident's blood pressure was taken every eight hours to determine if they needed one of the as needed medications. An interview was conducted with LPN (licensed practical nurse) #4, on 1/29/2026 at 7:45 a.m. LPN #4 stated that when there is a medication that requires a blood pressure, the nurse should take the blood pressure and administer or hold the medication per the physician's order.An interview was conducted with administrative staff member (ASM) #4, the regional director of clinical services, on 1/29/2026 at 11:46 a.m. ASM #4 stated orders for Midodrine, the facility was cited on a previous survey, and they had addressed it with the physicians to change the orders from PRN (as needed) to a scheduled dose with parameters to hold it when indicated. ASM #4 stated it was unusual to have a PRN order for Clonidine. She further stated these orders need to be clarified. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of operations, were made aware of the above findings on 1/29/2026 at approximately 4:45 p.m. No further information was provided prior to exit. (1) this information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html(2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682243.html

3. For Resident #22 (R22), the facility staff failed to provide treatment as recommended by the wound nurse practitioner for A) the right heel and B) the right anterior lower leg pressure injury (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/20/25, the resident was assessed as severely impaired for making daily decisions. R22 was assessed as being non-verbal, totally dependent for personal hygiene, bed mobility, toileting and bathing. It further documented R22 always incontinent of bowel and bladder and at risk for pressure injuries but not having any unhealed pressure injuries at the time of the assessment. A) Review of the skin and wound progress note for R22 dated 3/24/2025 by the wound nurse practitioner documented a comprehensive skin assessment completed. It documented in part, . On assessment today right heel noted to be boggy with blanchable redness, recommend skin prep and continue heel booties . Review of the physician orders failed to evidence an order for skin prep to the right heel. Review of the eTAR (electronic treatment administration record) for R22 dated 3/1/25-3/31/25 failed to evidence an order for skin prep to the right heel. Review of the eTAR for R22 dated 4/1/25-4/30/25 failed to evidence an order for skin prep to the right heel. On 5/1/25 at 9:07 a.m., an observation was made of LPN (licensed practical nurse) #4 performing wound care to R22's right anterior lower leg pressure injury. At that time an observation was made of R22's right heel. Observation revealed the skin intact, boggy with blanchable redness. When asked if there were any treatments in place for R22's right heel, LPN #4 stated that he was not aware of any treatment in place. B) Review of the nurse practitioners wound assessment report for R22 dated 3/24/2025 documented a full thickness in house acquired wound to the right anterior lower leg. The description of the wound was 100% eschar with attached wound edges, periwound: intact, dryness, fragile with scant serosanguineous exudate. The treatment recommendations documented were to clean with wound cleanser, treat with calcium alginate, apply bordered gauze daily and as needed. The nurse practitioners wound assessment report for R22 dated 4/1/25 documented two wounds, a right lower leg skin tear and a right anterior lower leg pressure injury. The right anterior lower leg wound was documented as an unstageable pressure injury acquired on 3/24/25 that was improving without complications with 20% granulation, 80% slough and 0% eschar. The treatment recommendations were to cleanse with wound cleanser, apply silver alginate, cover with bordered gauze daily and as needed. The nurse practitioners wound assessment report for R22 dated 4/8/25 documented two wounds, a right lower leg skin tear and a right anterior lower leg pressure injury. The right anterior lower leg wound was described as an unstageable pressure injury acquired on 3/24/25 that was improving without complications with 40% granulation, 60% slough and 0% eschar. The treatment recommendations were to cleanse with wound cleanser, apply Manuka HD alginate, cover with bordered gauze daily and as needed. Review of the eTAR for R22 dated 3/1/25-3/31/25 failed to evidence a treatment to the right anterior lower leg. Review of the eTAR for R22 dated 4/1/25-4/30/25 documented treatment to the right lower leg skin tear with xeroform and dry dressing completed from 4/2/25-4/9/25, right anterior lower leg pressure injury treatment of Manuka Alginate and dry dressing from 4/11/25-4/22/25 and calcium alginate and dry dressing from 4/23/25-4/29/25. The eTAR failed to evidence the treatment recommended by the wound nurse practitioner until 4/11/25 for the pressure injury. The physician orders for R22 documented in part, - Cleanse skin tear to the right lower leg with wound wash apply xeroform and a dry dressing change daily one time a day for wound care. Start Date: 4/2/2025. - Right Anterior Lower Leg: Cleanse with wound cleanser apply Manuka Alginate and cover with dressing Q (every) day one time a day for wound care. Start Date: 4/11/2025. - Right Anterior Lower Leg: Cleanse with wound cleanser apply Calcium Alginate and cover with dressing Q day one time a day for wound care. Start Date: 4/23/2025. The physician orders failed to evidence a treatment to the right anterior lower leg pressure injury prior to 4/11/2025 other than the skin tear treatment starting 4/2/25. The comprehensive care plan for R22 documented in part, The resident has a pressure ulcer or has the potential for pressure ulcer development r/t immobility, diabetes. Right anterior Lower Leg Pressure. Date Initiated: 03/18/2024. Under Interventions/Tasks it documented in part, Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/18/2024 . On 4/30/35 at 12:20 p.m., an interview was conducted with LPN (licensed practical nurse) #4, the acting wound nurse. He stated that if a resident had an established wound that was already being followed by the wound NP (nurse practitioner), the facility's wound nurse accompanied them on them on weekly rounds to assess each resident with a wound. He stated that usually the wound NP gave a verbal order for any new orders needed after the wound NP assessment. LPN #4 stated it was the wound nurse's responsibility to get approval for the new order from the resident's PCP (primary care physician) and then put the order into the computer system. He stated as a backup, the wound NP sent a summary of all visits and new orders after each visit to the facility and the summary was usually reviewed by the DON (director of nursing). On 4/30/25 at 1:16 p.m., an interview was conducted with ASM (administrative staff member) # 4, a wound NP. ASM #4 stated that they assessed each resident at least once a week and communicated treatment changes to the facility's wound nurse. She stated the wound NP also completes a report at the end of each visit to the facility listing all residents/wounds assessed, and including all treatment orders and that this report was sent to the facility's DON. She stated that as far as she knew, the facility nurse communicates the wound NP's recommendation to the resident's PCP and gets approval before implementation. She stated she believes that if a PCP declined a recommendation, the facility staff would communicate this with the wound NP. She stated nothing like this had ever been communicated to her or to any of the NPs employed by her company. She stated the wound NPs did not directly input orders into the facility's EMR (electronic medical record). On 4/30/25 at 1:34 p.m. an interview was conducted with ASM # 3, the regional mobile director of nursing, and ASM #7, the regional clinician. ASM #3 stated the wound NP was always accompanied by a member of the facility's wound team on their weekly rounds. Once the wound NP had completed rounds, they usually talked with the DON and always sent a written report containing a list of residents seen that day and all wound treatments. She stated the facility's wound nurse who had accompanied the wound NP was responsible for reaching out to the PCP to get approval for the wound NP's recommendations. Once the approval was obtained, the facility's wound nurse was responsible for entering the order accurately into the EMR. On 5/1/25 at 4:10 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional clinician, were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure sores appear as ulcers (open wounds) or crater-like areas on your skin. They can happen when a part of your body experiences a long period of excessive pressure that reduces blood flow and leads to skin damage. The medical name for pressure sores is decubitus ulcers. Pressure sores are also called pressure injuries or pressure wounds. This information was obtained from the website: https://www.cancer.org/cancer/managing-cancer/side-effects/hair-skin-nails/pressure-sores.html Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure injuries (1) for six of 25 residents in the survey sample, Residents #13, #6, #22, #23, #1, and #21. For Residents #13 and #6, the facility staff failed to implement treatments as recommended by the wound nurse practitioner (NP), causing the residents' pressure injuries to worsen. This failure resulted in harm to both Residents #13 and #6. The findings include: 1.a. For Resident #13 (R13), the facility staff failed to change a pressure injury treatment according to the wound nurse practitioner's (NP's) recommendation between 5/23/24 and 7/23/24. During this time, the wound worsened by increasing in length. A review of R13's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/4/25, R13 was coded as being totally dependent on facility staff for turning and positioning. He was admitted with a diagnosis of paraplegia. He was coded as being cognitively intact for making daily decisions. A review of R13's weekly skin assessment dated [DATE] revealed, in part: Head to Toe Skin Check and Evaluation .Are there any skin impairments noted? yes .Site .penis. A review of R13's wound NP note dated 5/23/24 revealed, in part: Wound Assessment Report .Measurements: length 2 cm (centimeters) X (by) width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Pressure .100% granulation (2) .0% slough (3) .0% eschar (4) .Treatment: Dressing Change Frequence: Daily and PRN (as needed), Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Silver alginate. A review of R13's May 2024 TAR (treatment administration record) revealed no treatment was implemented for the penile shaft wound. A review of R13's wound NP note dated 5/28/24 revealed, in part: Wound Assessment Report .Measurements: length 1.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Pressure .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: Daily and PRN (as needed), Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Silver alginate .Other Dressings: Rolled gauze, THIN layer. A review of R13's May 2024 TAR (treatment administration record) revealed no evidence that treatment was implemented for the penile shaft wound. A review of R13's wound NP note dated 6/20/24 revealed, in part: Wound Assessment Report .Measurements: length 1.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Pressure .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: Daily and PRN (as needed), Clean Wound With: Cleanse with wound cleanser. A review of R13's June 2024 TAR revealed no evidence that treatment was implemented for R13's penile shaft wound until 6/25/24. On 6/25/24, the wound cleanser and Venelex were implemented, but only once a day, instead of twice A review of R13's wound NP note dated 6/25/24 revealed, in part: Wound Assessment Report .Measurements: length 1.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID (twice a day) .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex (5) .Other Dressings: Leave open to air. A review of R13's June TAR revealed on 6/25/24, the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. A review of R13's wound NP note dated 7/2/24 revealed, in part: Wound Assessment Report .Measurements: length 2.5 cm, an increase in size, X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex .Other Dressings: Leave open to air. A review of R13's July TAR revealed the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. A review of R13's wound NP note dated 7/9/24 revealed, in part: Wound Assessment Report .Measurements: length 2.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex .Other Dressings: Leave open to air. A review of R13's July TAR revealed the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. A review of R13's wound NP note dated 7/16/24 revealed, in part: Wound Assessment Report .Measurements: length 2.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex .Other Dressings: Leave open to air. A review of R13's July TAR revealed the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. A review of R13's wound NP note dated 7/23/24 revealed, in part: Wound Assessment Report .Measurements: length 2.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex .Other Dressings: Leave open to air. A review of R13's July TAR revealed the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. A review of R13's wound NP note dated 7/30/24 revealed, in part: Wound Assessment Report .Measurements: length 2.5 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex .Other Dressings: Leave open to air. A review of R13's July TAR revealed the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. A review of R13's wound NP note dated 8/6/24 revealed, in part: Wound Assessment Report .Measurements: length 2.4 cm X width 0.8 cm X depth 0.7 cm .Location: penile shaft .Etiology: Mucosal Membrane Pressure Injury .100% granulation .0% slough .0% eschar .Treatment: Dressing Change Frequence: BID .Clean Wound With: Cleanse with wound cleanser, Primary Treatment: Venelex .Other Dressings: Leave open to air. A review of R13's August TAR revealed the wound cleanser and Venelex were implemented, but only once a day, instead of twice a day as recommended. R13 was discharged to the hospital on 8/10/24. On 4/30/35 at 12:20 p.m., LPN (licensed practical nurse) #4, the acting wound nurse, was interviewed. He stated if a resident comes in with a wound, the facility gets orders from either the PCP (primary care physician) or the wound NP. If a resident has an established wound that is already being followed by the wound NP, the facility's wound nurse accompanies the wound NP on weekly rounds to assess each resident with a wound. He stated usually the wound NP gives a verbal order for any new orders needed after the wound NP assessment. LPN #4 stated it is the wound nurse's responsibility to get approval for the new order from the resident's PCP and then enters the order into the computer system. He stated as a backup, the wound NP sends a summary of all visits and new orders after each visit to the facility. This summary is usually reviewed by the DON (director of nursing). On 4/30/25 at 1:16 p.m., ASM (administrative staff member) # 4, a wound NP, was interviewed. She stated if a resident is admitted with a new wound or develops a new wound while in the facility, her company's nurse practitioner performs a head to toe evaluation for each resident. Once the assessment is complete, the wound NP makes a verbal recommendation to the facility's wound nurse for treatments for all wounds. She stated the wound NP also completes a report at the end of each visit to the facility listing all residents/wounds assessed, and including all treatment orders. She stated the wound NPs do not directly input orders into the facility's EMR (electronic medical record). She stated if a resident has an established wound, the wound NP follows the same process. This includes assessing each resident at least once a week and communicating treatment changes to the facility's wound nurse. The process remains the same for the report generated after each facility visit. This report is sent to the facility's DON. She stated that as far as she knows, the facility nurse communicates the wound NP's recommendation to the resident's PCP and gets approval before implementation. She stated she believes that if a PCP declined a recommendation, the facility staff would communicate this with the wound NP. She stated nothing like this had ever been communicated to her or to any of the NPs employed by her company. On 4/30/25 at 1:34 p.m. ASM # 3, the regional mobile director of nursing, and ASM #6, the regional clinician, were interviewed. ASM #3 stated if a new wound is identified, either on a current or newly admitted resident, the PCP is called and the PCP gives an order for treatment for the first 24 hours. The following day, the resident is seen by someone on the facility's wound team. The facility's wound nurse assesses, measures, and stages the wound, and makes a recommendation to the PCP for treatment until the wound NP can evaluate the wound. She explained: Something should be in place for each wound within 24 hours of identification. She stated the wound NP is always accompanied by a member of the facility's wound team on their weekly rounds. Once the wound NP has completed rounds, they usually talk with the DON and always send a written report containing a list of residents seen that day and all wound treatments. She stated the facility's wound nurse who has accompanied the wound NP is responsible for reaching out to the PCP to get approval for the wound NP's recommendations. Once the approval is obtained, the facility's wound nurse is responsible for entering the order accurately into the EMR. On 4/30/25 at 2:56 p.m., ASM #7, a primary care physician, was interviewed. He stated he oversees the whole medical process for residents under his care, and this includes wound care. He states he talks clearly to the wound NPs about his expectations. He stated unless the contract wound NP is ordering an unnecessary wound culture for someone who has an underlying systemic infection, he follows their recommendations. He stated: If we have the products, we are going to follow their recommendation. On 4/30/25 at 5:36 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #6 were informed of the concern for harm for R13. These staff members were requested to present any evidence that would indicate R13 was not harmed by the facility's lack of implementation of the wound NP's recommendations. A review of the facility policy, No additional information was provided prior to exit. References: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Granulation tissue is an important component in the wound healing process. Wounds can heal by primary intention (wound edges approximate easily) and secondary intention (wound edges do not approximate). The granulation tissue matrix fills wounds that heal by the second intention. This information is taken from the website https://pubmed.ncbi.nlm.nih.gov/32119289/. (3) 'The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/ (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/ (5) VENELEX (Trademark) OINTMENT helps to deodorize and protectively cover pressure wounds (ulcers). VENELEX (Trademark) OINTMENT provides a moist wound environment. The moisturizing properties of VENELEX (Trademark) OINTMENT may also help in the prevention of cracking around the edges of sores. This information is taken from the website https://dailymed.[NAME].nih.gov. 1.b. On 4/30/24 between 7:45 a.m. and 10:15 a.m., the facility staff failed to turn and position the resident to prevent worsening of pressure injuries. A review of R13's most recent wound NP note dated 4/29/25 revealed R13 had three current pressure injuries at the time of the survey. All three pressure injuries were located on the resident's buttocks. This note contained the following instructions: The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol. On 4/30/25 at 7:45 a.m., R13 was observed sitting up in his bed watching television. This observation continued until 10:15 a.m. No staff member attempted or offered to turn and reposition R13 during this time. On 4/30/25 at 10:17 a.m., R13 was interviewed. He stated no staff member offered to turn and reposition him all night the previous night. A review of R13's care plan dated 5/3/23 revealed, in part: The resident has a pressure ulcer and has the potential for further pressure ulcer development .is not always compliant with turning and positioning (he understands the risks and benefits) .Follow facility policies/protocols for the prevention and treatment of skin breakdown .I require monitoring, reminding, and assistance to turn and reposition at least every 2 hours, more often as needed or requested. On 4/30/25 at 4:20 p.m., (certified nursing assistant) #2 was interviewed. CNA #2 stated residents should be turned and repositioned every two hours and this is evidenced by signing off on the ADL (activities of daily living) records. On 4/30/25 at 4:35 p.m., CNA #3 was interviewed. She stated all dependent residents should be encouraged and assisted to turn at least every two hours. She stated she turns her patients on a rotation as best she can and keeps resident in the same order throughout her shift. On 5/1/25 at 9:20 a.m., LPN (licensed practical nurse) #1 was interviewed. He stated dependent residents should be turned at a minimum of every two hours to prevent pressure injury development and/or worsening. He stated even if a resident is known to have refused turning in the past, the CNA should still offer it to the resident each and every time. On 5/1/25 at 12:52 p.m., CNA #1 was interviewed. She stated that dependent residents should be turned at least every two hours to prevent pressure injuries. She stated if a resident has refused turning in the past, she still offers to assist in turning every single time. She added: If they have refused before, I'm going to ask anyway. I try to encourage them. On 4/30/25 at 5:36 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #6, the regional clinician, were informed of these concerns. A review of the facility policy, Repositioning, revealed, in part: The purpose of this procedure is to .prevent skin breakdown, promote circulation and provide pressure relief for residents .Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief .Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning .Residents who are in bed should be on at least an every-two-hour .repositioning schedule .For residents with a Stage 1 or above pressure ulcer, and every-two-hour .repositioning schedule is inadequate. No additional information was provided prior to exit. 2. For Resident #6 (R6), the facility staff failed to change a pressure injury (1) treatment according to the wound nurse practitioner's (NP's) recommendation between 12/5/24 and 12/24/24. During this time, the wound worsened by increasing in depth and increasing in slough (2), resulting in harm to the resident. In December 2024, on multiple dates, the facility staff failed to provide evidence that resident was turned and positioned through the night. The facility staff failed to follow the wound NP's recommendation to initiate dual antibiotic coverage for a suspected wound infection on 1/2/25. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/2/25, R6 was coded as being completely dependent on facility staff for turning and repositioning. A review of R6's clinical record revealed she was admitted [DATE] with an existing pressure injury on her sacrum. Further review of the record revealed the following treatment was initiated for the pressure injury on 11/28/24: Sacrum wound, every day shift .Cleanse with Dakins (a wound cleanser with antimicrobial properties), pack with Dakins moist gauze, cover with border gauze. A review of R6's TARs (treatment administration record) for November and December 2024 and January 2025 revealed R6 received this treatment from 11/28/24 through 1/6/25 when she was discharged to the hospital. A review of R6's wound NP note dated 12/5/24 revealed, in part: Stage 4 (3) Sacrum 7.5 cm (centimeters) length X (by) 7.5 cm width X 1 cm depth. 80% granulation (4), 20% slough. Moderate serosanguinous (partially bloody) drainage .Cleanse with wound cleanser .Apply medical grade honey fiber to base of the wound .secure with bordered gauze .change daily and prn (as needed). A review of R6's December 2024 TAR revealed this recommendation was never implemented. A review of R6's wound NP note dated 12/12/24 revealed, in part: Stage 4 Sacrum 4 cm length X 4 cm width X 1 cm depth. Cleanse with wound cleanser .Apply medical grade honey fiber to base of the wound .secure with bordered gauze .change daily and prn (as needed). A review of R6's December 2024 TAR revealed this recommendation was never implemented. A review of R6's wound NP note dated 12/19/24 revealed, in part: Follow up assessment for stage 4 sacral pressure ulcer, wound improving .Continue current treatment with honey fiber and preventative measures .Cleanse with wound cleanser .Apply medical grade honey fiber to base of the wound .secure with bordered gauze .change daily and prn (as needed). A review of R6's December 2024 TAR revealed this recommendation was never implemented. A review of R6's wound NP note dated 12/24/24 revealed, in part: Sacrum stage 4 pressure ulcer is worsening with increased measurements and hyperpigmentation noted to wound bed. Treatment changed .Monitor closely for signs/symptoms of infection .Stage 4 Sacrum 3.4 cm length X 3 cm width X 2 cm depth (an increase in depth) .Wound base 80% granulation, 20% slough .Treatment changed to cleanse with Dakins and Apply Dakins fluffed gauze. A review of R6's December 2024 TAR revealed this had been the facility's treatment for this pressure injury since 11/28/24, with none of the changes recommended by the wound NP. A review of R6's wound NP note dated 1/2/25 revealed, in part: Sacrum stage 4 pressure ulcer continues to worsen with increased measurements and hyperpigmentation to wound bed. Recommendation for wound culture and dual coverage antibiotic. Monitor closely for signs/symptoms of worsening infection .Stage 4 Sacrum Worsening .4 cm length (an increase in length) X 3.5 cm width (an increase in width) X 4.2 cm depth (an increase in depth) .Wound base 10% granulation, 90% slough) .Cleanse with 0.125% Dakins solution .apply Dakins moistened fluffed gauze to base of the wound .secure with silicone bordered superabsorb .change daily and prn. A review of the January 2025 TAR (treatment administration record) revealed the facility never ordered or impleneted the dual coverage antibiotic as recommended by the wound NP. A review of R6's point of care records revealed the task of turning and positioning by CNAs was not performed on the following nights in December 2024: 12/1, 12/3, 12/6, 12/13, 12/22, 12/26, and 12/31. A review of R6's comprehensive care plan dated 11/27/24 revealed, in part: The resident has a pressure ulcer .r/t (related to) disease process, immobility. Often refuses treatments/care, refuses to be turned and positioned .Administer treatments as ordered and monitor for effectiveness .I require monitoring, reminding, and assistance to turn and reposition every 2 hours, more often as needed or requested. On 4/30/35 at 12:20 p.m., LPN (licensed practical nurse) #4, the acting wound nurse, was interviewed. He stated if a resident comes in with a wound, the facility gets orders from either the PCP (primary care physician) or the wound NP. If a resident has an established wound that is already being followed by the wound NP, the facility's wound nurse accompanies the wound NP on weekly rounds to assess each resident with a wound. He stated usually the wound NP gives a verbal order for any new orders needed after the wound NP assessment. LPN #4 stated it is the wound nurse's responsibility to get approval for the new order from the resident's PCP and then enters the order into the computer system. He stated as a backup, the wound NP sends a summary of all visits and new orders after each visit to the facility. This summary is usually reviewed by the DON (director of nursing). On 4/30/25 at 1:16 p.m., ASM (administrative staff member) # 4, a wound NP, was interviewed. She stated if a resident is admitted with a new wound or develops a new wound while in the facility, her company's nurse practitioner performs a head to toe evaluation for each resident. Once the assessment is complete, the wound NP makes a verbal recommendation to the facility's wound nurse for treatments for all wounds. She stated the wound NP also completes a report at the end of each visit to the facility listing all residents/wounds assessed, and including all treatment orders. She stated the wound NPs do not directly input orders into the facility's EMR (electronic medical record). She stated if a resident has an established wound, the wound NP follows the same process. This includes assessing each resident at least once a week and communicating treatment changes to the facility's wound nurse. The process remains the same for the report generated after each facility visit. This report is sent to the facility's DON. She stated that as[TRUNCATED]

The facility staff failed to provide a safe environment by monitoring trach residents for two of eight residents, Residents #3 and #1. The findings include: During the abbreviated complaint survey [DATE], night shift staff were identified for interview for Resident #1. On [DATE] at 6:30 AM, surveyor arrived to interview night shift RTs (respiratory therapist) and RNs (registered nurse). During the first interview, surveyor was informed of Resident #3's death with similar conditions as to those in Resident #1's which necessitated a transfer to the hospital. 1. A review of the facility's Multiple Incident QA Reports for Resident #3 revealed incident reports of [DATE] at 1030-:05 PM with 'behavior symptom exhibited' being documented as trach pulled out by resident, was able to be reinserted without problem. A review of the as worked staffing sheets provided by the facility, reveals one RT scheduled for 7PM-7AM shift on 7/28-7/29, 7/30-7/31 and 8/1-8/2. Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to respiratory failure, trach, ESRD (end stage renal disease), hemodialysis and diabetes mellitus (DM). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated [DATE] revealed, FOCUS: Resident has tracheostomy related to disease process. INTERVENTIONS: EMERGENCY EQUIPMENT AT BEDSIDE: Spare trach tube, ambu (artificial manual breathing unit) bag, water soluble lubricant, 10 ml syringe. Ensure that trach ties are secured at all times. Provide tracheostomy care as ordered. Respiratory therapy as ordered. Administer humidified oxygen as prescribed. Monitor for mental status changes: restlessness, agitation, confusion, altered LOC (level of consciousness), lethargy. If observed, report to physician and document findings & interventions. A review of the physician orders dated [DATE] revealed, Change Disposable Inner Cannula BID/once a shift or as needed Inner Cannula Type: disposable Inner Cannula Size: #6 every day and night shift. A review of Resident #3's RAR (respiratory administration record) for July-[DATE] revealed the following missing documentation: Change Disposable Inner Cannula BID: eve shift 7/24. A review of the progress note dated [DATE] at 10:05 PM revealed, At approximately 22:05 nurse had called RT was called to the pt room and stated her trach was out. RT arrived to pt room found her gray blue and unresponsive. Check for pulse. Pt had faint pulse. Trach reinserted Crash cart arrived. Grabbed tank placed pt on 25 liters Resistance while bagging. Pt inner cannula was removed and was fully occluded. Replaced inner cannula. suctioned 2 x. Pt placed on 10 liters, O2 sats 96 HR 109. Bilateral breath sounds. Will continue to monitor. A review of the progress note dated [DATE] at 12:42 AM revealed, At approximately 00:42 RT called to pt. room due to pt. unresponsive, pale color. o2 sats 88 HR 122 on room air. RT removed inner cannula, and pt. inner cannula was occluded on the end. Replaced pt. trach. Lavage and suctioned pt. 2x large amount of thick brown blood tinge secretions. Pt became more responsive and alert, grabbing and hitting RT while securing trach ties. Pt placed on 5 liters, O2 sats 98, HR 114 RR 18. Bilateral Lung sounds. Trach patent and secure. Will continue to monitor closely. Educated patient that she needs to allow RT or nursing to suctioning and provide humidity to prevent secretions from drying and occluding her airway. A review of the progress note dated [DATE] at 3:32 AM revealed, At approximately 0300 Nurse called RT to pt room because she had decannulated herself and was unresponsive. The second RT, I and 2 other nurses arrived with crash cart at the same time. Check for pulse, no pulse pt no breathing. CPR initiated while reinserting a new trach. Continued CPR. During CPR 2 shocks were advised and initiated. AED failed to deliver both shocks. Continued CPR until EMS arrived and took over and continued with ACLS. A review of the nursing progress note dated [DATE] at 4:05 AM revealed, This writer doing rounds observed that patient was not responsive. On assessment, it was noted that resident had pulled the trach out. The writer immediately alerted respiratory and CPR was initiated this was at 300 am. Resident was last checked on at 215am when she was watching TV. 911 was called and it arrived at 310 am and continued with CPR until 345 AM when resident was pronounced. MD was notified. Attempted to reach all responsible parties but no response left message for [NAME] and [NAME] to call back ADON was notified. An interview was conducted on [DATE] at 6:40 AM with OSM (other staff member) #3, respiratory therapy. When asked about Resident #3, OSM #3 stated, she pulled her whole trach out, this was the 4th night, 2nd nights ago, she pulled it out and I was called to room and she was unresponsive. She would not let anybody do any of her care, she would allow two of us to do it. This morning, she was unresponsive to pain / stimuli, was not breathing, grey in color and her O2 saturation was 70%. An interview was conducted on [DATE] at 7:04 AM with OSM #4, respiratory therapy. When asked about Resident #3, OSM #4 stated, was not assigned to her last night. I responded to the code. An interview was conducted on [DATE] at 7:46 AM with RN (registered nurse) #3. When asked to discuss Resident #3, RN #3 stated, at 2:15 AM, she was watching TV. I did not bother her. I repositioned her, close to 3:00 AM, she is not responding. I see the trach is hanging, run to RT. There were no alarms. She did not have an alarm on, they have alarms for some of the patients but I do not know the criteria. She did not have one. EMS was called and we continued with CPR. EMS arrived around 3:10 AM and did IVs meds and worked on her and did not pronounce her till 3:45 AM. She had pulled out her trach. I called the medical director and tried 3 family members. An interview was conducted on [DATE] at 8:24 AM with ASM (administrative staff member) #3, the medical director. When asked about Resident #3, ASM #3 stated, she has been stable. Her behavior included pulling out her trachea as she had done in the hospital. One of the other residents, her behavior was pulling out trach, and she had sitter for 1 week and has calmed down. They called me about Resident #3's earlier code and her condition, I checked on her 7/31, she was stable and calm. We did not change anything after the 7/31 episode as she was stable and calm. An interview was conducted on [DATE] at 10:15 AM with OSM #1, the director of RT. When asked about Resident #3. OSM #1 stated, she was a stable trach patient who do not necessarily need continuous pulse oximetry. When asked what if they pull out their trach several times, would the standard of care be to implement a monitoring of pulse ox for their safety, OSM #1 stated, that will have to be referred to the Administrator. When asked as the Director of Respiratory Therapy, would it be the standard of practice and care to monitor these residents, OSM #1 stated, yes, it would be the standard of practice. An interview was conducted on [DATE] at 8:30 AM with ASM #9, the RRT director of specialty services. When asked the RT staffing with the number of trach and vent patients, ASM #9 stated, two RT on days and two RT on nights. An interview was conducted on [DATE] at 3:16 PM with OSM #6, the staffing coordinator. When asked the number of RTs for each shift, OSM #6 stated, they do 12-hour shift, so 7 AM-7 PM is 2 and 7 PM to 7 AM is 1. When asked about staffing based on patient needs. OSM #6 stated, I do not know how many vents, there are, so for 30 residents the staffing is 1 nurse and 1 RT, I do not have the vent/trach data. I do not know if there is a shortage of RT staff until the next day when I come in. I was asked today to see if there are any agency staff for RT. On [DATE] at 1:15 PM, ASM #1, the administrator, ASM #2, the ADON (assistant director of nursing), ASM #5, the regional nurse consultant and ASM #7, the regional nurse consultant were notified of Immediate Jeopardy (IJ)., On [DATE] at 6:15 PM the Immediacy Plan was Accepted. The Plan documented: The RN (registered nurse) and/or RT (respiratory therapist) completed an audit of all residents with tracheostomy (trach) and/or ventilator to validate the trach is in place, the ventilator is functioning at the ordered settings, interventions for resident monitoring and/or supervision are in place based on the resident risk review and that residents re at their respiratory baseline. Variances from the resident's baseline will be communicated to the resident's physician for further review and recommendations as needed. The IDT (interdisciplinary team) completed a review of residents with a trach and/or ventilator for a history of pulling trach tubes out or behaviors that would place the resident at risk for decannulation to validate that the resident care plan outlines interventions for supervision and/or continuous pulse oximetry monitoring, and/or one to one intervention to minimize risk of decannulation. Variances will be addressed. The facility implemented rounding every 15 minutes on trach and/or vent residents until resident risk assessment have been completed and the resident's care plan was updated to reflect the resident's individualized interventions. RT and licensed nursing staff were re-educated on the need to immediately notify the RT director, DON (director of nursing) and Administrator regarding concerns related to need for residents who require increased supervision, and validating that interventions are in place based on resident behavior, history and risk review. Concerns or variances will be brought to the attention of the Administrator immediately. Education of 90% of RT staff who are working will be completed on [DATE], staff who are not working will be educated upon arrival prior to any resident contact. Licensed nursing staff were re-educated on notifications to clinical provider, the RT director and DON along with care plan revisions implemented to minimize risk of resident removing trach or decannulation. Education of 90% of licensed staff who are working will be completed on [DATE], staff who are not working will be educated upon arrival prior to any resident contact. An Ad-hoc Quality Assurance Performance Improvement Committee meeting was held on [DATE] to review the IJ template concern and facility removal plan. System change has been initiated to include the IDT review of new admissions with a trach and/or vent to evaluate resident risks, implement individualized interventions and provide supervision/monitoring based on resident needs and minimize the risk of resident removing the trach tube/decannulating. The Pulmonologist and facility Medical Director were made aware on [DATE] by the facility administrator of the current IJ concern and the facility removal plan with feedback and recommendations provided by the practitioner. The facility will stop all trach/vent admissions through the weekend [DATE] 5:00 PM till [DATE]. Monday [DATE] An interview was conducted on [DATE] at 8:30 AM with OSM #7. When asked to explain the risk assessment for residents with trachs/vents, OSM #7 stated, we review if they have a history of decannulation in the hospital and monitor them for any pulling on the trach or vent behavior. We escalate that concern immediately to put additional safeguards in place such as 1:1 or continuous pulse oximetry. On [DATE] at 9:00 AM, ASM #8, the VP (vice president) of quality care and ASM #9, the RRT director of specialty services, provided information regarding interventions being put in place for residents who decannulate themselves. ASM #9 stated, we are working on increased supervision, monitoring, hand mitts, put someone in the room to monitor them, decision making and assessments done when resident pulls out trach occurs. ASM #8 stated, as soon as the incident happens, the facility must do an RCA (root cause analysis) and put interventions in place. Then the outside group (corporate) provides further analysis and work on interventions. Facility would look for trends and implement measures and then work with corporate to assist with interventions and improvements. This is part of quality process improvement (QAPI). When asked what they thought had happened, ASM #8 stated, the nursing staff delegated care and responsibility of the trach residents to RT. When asked what the 'trach nurse' job description and responsibilities are, ASM #8 stated, will have to check on that, I do not know. When asked what a 'stable' trach patient was, ASM #9 stated, will have to check on that have come back to you. On [DATE] at approximately 9:30 AM, ASM #8 stated, there is no job description or specific responsibilities for the 'trach nurse'. They are to be identified as such on the staffing sheet. ASM #9 stated, stable trach patient is to speak with pulmonologist, resident would be on pulse oximeter (pulse ox) for 24-72 hours. They would be in the green zone. If FIO2 40 % or less, or increase PEEP 5-8, actively being treated for infection that would not be stable and would be in the yellow zone, if they get worse then go to the hospital. On [DATE] at 10:00 AM ASM #1 was asked if the facility event synopsis had been reported to our office, ASM #1, stated she would check. On [DATE] at 11:12 AM ASM #1 stated, we have not submitted a facility event synopsis for Resident #3. On [DATE] at approximately 12:00 PM, ASM #8 and ASM #9 brought in additional information for the IJ response. ASM #8 and #9 stated, we created these education sheets for RT and a licensed nurse 'Tracheostomy Safety education. There is also a Checklist Education for One-to-One Education for staff who will be sitting with residents with trachs/vents. We started the education this morning and will be on-going till all of staff is completed. On [DATE] at approximately 12:52 PM, ASM #9 and ASM #14, the VP of plant operations stated, the other two monitors for the wing to the left and the wing straight ahead will be mounted in maximum 2 weeks. This will provide both a visual and audio notification of residents with trachs on those wings. After multiple resubmissions, the facility presented the following IJ removal plan which was accepted on [DATE] at 1:00 PM. Plan for Removal The RN (registered nurse) and/or RT (respiratory therapist) completed an audit of all residents with tracheostomy (trach) and/or ventilator to validate the trach is in place, the ventilator is functioning at the ordered settings, interventions for resident monitoring and/or supervision are in place based on the resident risk review and that residents re at their respiratory baseline. Variances from the resident's baseline will be communicated to the resident's physician for further review and recommendations as needed. Date completed [DATE]. The IDT (interdisciplinary team) completed a review of residents with a trach and/or ventilator for a history of pulling trach tubes out or behaviors that would place the resident at risk for decannulation to validate that the resident care plan outlines interventions for supervision and/or continuous pulse oximetry monitoring, and/or one to one intervention to minimize risk of decannulation. Variances will be addressed, outlined in each individual resident assessment. Date completed [DATE]. The facility implemented rounding every 15 minutes on trach and/or vent residents until resident risk assessment have been completed and the resident's care plan was updated to reflect the resident's individualized interventions. Date completed [DATE]. RT were re-educated on the need to immediately notify the RT director, DON (director of nursing) and Administrator regarding concerns related to need for residents who require increased supervision, and validating that interventions are in place based on resident behavior, history and risk review. When a resident has self-decannulated a facility rapid response will be conducted. RT will assess and determine if secretions are a problem, suction as needed and replace trach if able and if emergency services are activated. The MD (physician) and Responsible Party will be made aware. Non-medical interventions to include but not limited to frequent rounding by nursing/RT, medication management, diversional activities, psych as needed, hand mitts and sitter. Residents that refuse continuous pulse ox monitoring will be placed on 1:1 monitoring. Concerns or variances will be brought to the attention of the Administrator immediately. Education of 90% of RT staff who are working will be completed on [DATE], staff who are not working will be educated upon arrival prior to any resident contact. 90% completed [DATE]. Licensed Nursing Staff were re-educated on the need to immediately notify the RT director, DON (director of nursing) and Administrator regarding concerns related to need for residents who require increased supervision, and validating that interventions are in place based on resident behavior, history and risk review. Concerns or variances will be brought to the attention of the Administrator immediately. Education of 90% of licensed nursing staff who are working will be completed on [DATE], staff who are not working will be educated upon arrival prior to any resident contact. 90% completed [DATE]. Licensed nursing staff were re-educated on notifications to clinical provider, the RT and DON along with care plan revisions implemented to minimize risk of resident removing trach or decannulation. Education of 90% of licensed staff who are working will be completed on [DATE], staff who are not working will be educated upon arrival prior to any resident contact. 90% completed [DATE]. An Ad-hoc Quality Assurance Performance Improvement Committee meeting was held on [DATE] to review the IJ template concern and facility removal plan. Completed [DATE]. System change has been initiated to include the IDT review of new admissions, to include interventions based on the resident assessment. Interventions to consider trach ties, trach stabilizer, continuous pulse ox, clinical/pain management assessment to rule out underlying disease process, one to one, 15-minute checks, etc. Interventions will be outlined on the residents' risk assessment and care plan. Completed on [DATE]. The Pulmonologist and facility Medical Director were made aware on [DATE] by the facility administrator of the current IJ concern and the facility removal plan with feedback and recommendations provided by the practitioner. Completed [DATE]. Removal Plan was completed [DATE] at 11:30 PM. Ongoing compliance will be monitored by: 1.Audit of five trach and/or vent residents will be completed for care/safety concerns to include care plan interventions in place for adequate supervision, history of decannulation, use of continuous pulse ox monitoring or 1:1 as indicated daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks, then monthly for two months. 2.The Interdisciplinary Team will review incidents of decannulation Monday through Friday for 3 months during the clinical meeting to confirm that residents that were previously identified at risk for decannulation received adequate supervision to include but not limited to increased monitoring meds as ordered, continuous pulse oximetry and or 1:1 and that new occurrence had the appropriate care plan updates to minimize recurrence. Variances will immediately be addressed. The administrator/designee is responsible for oversight of this process. 3.The administrator will submit the findings from the audits to the Quality Assurance Performance Improvement committee meetings monthly for further review and additional recommendations as needed. Further audit frequency will be determined based on audit findings. The administrator/designee is responsible for the execution of this plan and the management/monitoring for ongoing compliance. On [DATE] at 12:55 PM, the survey team, through observations, interviews, and documentation review, verified the removal plan had been fully implemented by the facility. On [DATE] at 1:00 PM, ASM #8, the VP of Quality and ASM #9, the RRT/Director of Specialty Services, were informed the removal plan had been verified and the IJ has been abated. The F689 tag was lowered to S/S (G) after the IJ was removed. No further information was provided prior to exit. 2. A review of the facility's Multiple Incident QA Reports for Resident #1 revealed incident reports of [DATE] at 12:00 AM, [DATE] 1:50 AM and [DATE] 9:00 PM with 'behavior symptom exhibited' being documented as trach out or resident decannulated himself. A review of the as worked staffing sheets provided by the facility, reveals one RT scheduled for [DATE] 7PM-7AM shift. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to respiratory failure, trach, CVA (cerebrovascular accident), hemiplegia/hemiparesis and diabetes mellitus (DM). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated [DATE] revealed, FOCUS: Resident has tracheostomy related to acute respiratory failure, sob when lying flat at times. INTERVENTIONS: EMERGENCY EQUIPMENT AT BEDSIDE: Spare trach tube, ambu (artificial manual breathing unit) bag, water soluble lubricant, 10 ml syringe. Ensure that trach ties are secured at all times. Provide tracheostomy care as ordered. Respiratory therapy as ordered. Administer humidified oxygen as prescribed. Monitor for mental status changes: restlessness, agitation, confusion, altered LOC (level of consciousness), lethargy. If observed, report to physician and document findings & interventions. A review of the physician orders dated [DATE] revealed, Change Disposable Inner Cannula BID/once a shift or as needed Inner Cannula Type: disposable Inner Cannula Size: #6 every day and night shift. Humidified Air via Trach Collar with Oxygen 5L 28% every shift. Trach Care every shift, and as needed. Trach Present: Make: Shiley Model: flex Size: 6 Type: uncuffed every shift. A review of Resident #1's RAR (respiratory administration record) for May-[DATE] revealed the following missing documentation: Change Disposable Inner Cannula BID: day shift 5/28, 5/30 and night shift 5/29. Humidified Air via Trach: day shift 5/30, evening shift 5/29, 6/3 and night shift 5/29. Trach Care every shift: day shift 5/30, evening shift 5/29, 5/30, 6/3 and night shift 5/29 and 5/30. Trach Present uncuffed every shift: day shift 5/30, evening shift 5/29, 6/3 and night shift 5/29. A review of the progress note dated [DATE] at 4:42 AM revealed, RT (respiratory therapist) called to pt room by CNA. Patient had decannulated himself. Trach was reinserted without any resistance. replaced gauze. large amount of bloody. secretions. o2 sats dropped to 75%. Increased pt FIo2 to 10l 98%. o2 sats went to 98-100% HR 91. Bilateral lung sounds. Nurse notified. After an hour titrated patient fio2 back to 8 liters 35%. Will continue to monitor. A review of the progress note dated [DATE] at 5:45 AM revealed, Pulse ox alarm went off. RT attended and found patient decannulated. Patient was very agitated and desaturated to low 70's. Trach inserted back without any difficult. SpO2 up to 97%. Patient remains agitated and aggressive. RN notified. A review of the progress note dated [DATE] at 12:35 AM revealed, Patient (Pt) pulse ox alarming. Patient O2 77%, Patient disconnected himself from the oximeter, and tired pulling on trach. reconnected patient, replaced soiled trach ties and Velcro strap. suctioned 3x large amount of yellow thin secretions. increased pt fio2 to 10 liters 60%. o2 sat 92-93 HR 100. Trach secured with Velcro strap for extra security. will continue to monitor. A review of the progress note dated [DATE] at 1:50 AM revealed, Pt continuous pulse ox alarming. went into pt room pt had decannulated himself, o2 sats 79. Reinserted trach without resistance. Resecured trach with Velcro strap. suctioned 2x trach patent and secure. pt o2 sats remained low 80s, bagged pt on 1-0% o2 for 5mins. o2 sats went up to 100%. pt left on 10l 98% aerosol t-piece. nurse notified. will continue to monitor every 2 hours. A review of the progress note dated [DATE] at 9:47 PM revealed, RT called to room due to pt desaturation. RT noted pt was in cardiac arrest. Compressions started immediately by RT. RN took over compressions for RT to replace Trach. When ambulance arrived, RT able to change trach to cuffed. Heart rhythm returned. Pt transported to hospital. A review of the progress note dated [DATE] at 10:18 PM revealed, At app 2100, patient found to be without heartbeat or respiration. Patient observed app 15 min prior for med administration and neb treatment. CPR started immediately and AED applied. Noted that trach was out. 911 called. Heartbeat returned and use of ambu bag for respiration continue. Patient to be taken to ER. Medic unsure which ER he will be taken to. NP (nurse practitioner) called and voice mail left regarding event. RP (son) and informed of event. Opportunity provided for question. An interview was conducted on [DATE] at 6:40 AM with OSM (other staff member) #3, respiratory therapy. When asked about Resident #1, OSM #3 stated, he decannulated himself, pulled out his trach a few times. I believe it was on continuous pulse oximetry, however, if you are the only RT on for the shift and on another wing providing care, you do not know that the alarm is going off if they have low oxygen saturations or have pulled out their trach. I have been told there is no set patient to RT ratio. An interview was conducted on [DATE] at 7:04 AM with OSM #4, respiratory therapy. When asked about Resident #1, OSM #4 stated, yes, I remember him, he could be an aggressive patient, pulling out whole trach for the two nights prior. I was the only RT on and I was raising flags that I was the only one here. We had trouble with cables, the pulse oximeter communicating with the central monitoring system and with the internet. I gave a list of the issues to the director of respiratory therapy. When asked issues to providing standard of practice, OSM #4 stated, when we have only 1 RT, you cannot hear the alarms and render care timely. An interview was conducted on [DATE] at 7:31 AM with RN (registered nurse) #2. When asked about Resident #1, RN #1 stated, RT does the trach care, nursing used to do it before RT came on board. A lot of residents pull out their trach. We do not usually do sitters or provide extra staff for pulling out their trach, we do that for fall risk patients and provide a sitter. For the trach patients we partner with RT that we are going to round more often. I do not remember about the alarm system whether it was functioning or not. We did a code and got his heartbeat back; I do not remember if he was arousable after the code. We sent him to the hospital with EMTs. An interview was conducted on [DATE] at 10:15 AM with OSM #1, the director of RT. When asked about trach patients. OSM #1 stated, there are stable trach patients who do not necessarily need continuous pulse oximetry. If they have continuous pulse oximetry it rings outside their room, and at the central station at the nurse's station. When asked what if they pull out their trach several times, would the standard of care be to implement a monitoring of pulse ox for their safety, OSM #1 stated that would have to be referred to the Administrator. When asked as the Director of Respiratory Therapy, would it be the standard of practice and care to monitor these residents, OSM #1 stated, yes, it would be the standard of practice. An interview was conducted on [DATE] at 10:26 AM with RN #1, the nurse practitioner. When asked about Resident #1, RN #1 stated, he was agitated for a few days and we did interventions each time. On [DATE] increase Deprexa, [DATE] again he was back to baseline once trach back in. He was being treated for pneumonia and that night [DATE] he went into cardiac arrest around 2100. Not sure about the trach on him at that time. I believe they should have a sitter if they are pulling out their trach. An interview was conducted on [DATE] at 8:30 AM with ASM #9, the RRT director of specialty services. When asked the RT staffing with the number of trach and vent patients, ASM #9 stated, two RT on days and two RT on nights. An interview was conducted on [DATE] at 3:16 PM with OSM #6, the staffing coordinator. When asked the number of RTs for each shift, OSM #6 stated, they do 12-hour shift, so 7 AM-7 PM is 2 and 7 PM to 7 AM is 1. When asked about staffing based on patient needs. OSM #6 stated, I do not know how many vents, there were, so 1 nurse and 1 RT, I do not have the vent/trach data. I do not know how many vents, there were, so 1 nurse and 1 RT, I do not have the vent/trach data. I do not know if there is a shortage of RT staff until the next day when I come in. I was asked today to see if there are any agency staff for RT. On [DATE] at 1:34 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the ADON, ASM #5, the regional nurse consultant, ASM #8, the VP (vice president) of quality care, ASM #9, the RRT director of specialty services, ASM #10, the regional director clinical services/risk management, ASM #11, the regional VP of operations and ASM #12, the regional director of case management were informed of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigation, the facility staff failed to provide adequate supervision and a safe environment to prevent an avoidable accident for one of 20 residents in the survey sample, Resident #1. Per staff interview and documentation, Resident #1 who was diagnosed with [REDACTED]. The facility staff failed to provide adequate supervision to ensure the resident was safe. At approximately 9:30 a.m. that day, Resident #1, went outside, fell in front of the facility and sustained a closed cervical spine fracture, a left wrist fracture, and a nasal bone fracture. The findings include: Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED].*Alzheimer's disease, major depressive disorder, anxiety disorder and high blood pressure. Resident #1's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/16/16, coded the resident's BIMS (brief interview for mental status) score as a six on a scale from zero to fifteen, indicating the resident's cognition was severely impaired. Section E documented Resident #1 had not exhibited any wandering behavior. Section G coded Resident #1 as requiring supervision and set up help with bed mobility, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, bathing and toilet use. Section G further documented the resident required supervision with one person physical assist with transfers and personal hygiene. G0300 documented Resident #1 was not steady, but able to stabilize without staff assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfer. Section J coded Resident #1 as not having any falls since the prior assessment. Resident #1's quarterly MDS assessment with an ARD of 10/1/15, completed prior to the incident on 11/2/15, coded the resident's BIMS score as a four on a scale from zero to fifteen, indicating the resident's cognition was severely impaired. Section E documented Resident #1 had not exhibited any wandering behavior. Section G coded Resident #1 as requiring supervision and set up help with transfers, walking in room, walking in corridor, locomotion on unit, dressing, toilet use and bathing. Section G further documented the resident required supervision and no set up help with locomotion off unit. Section G0300 documented Resident #1 was not steady, but able to stabilize without staff assistance with moving from seating to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfer. Section J coded Resident #1 as not having any falls since the prior assessment. An activities note dated 10/2/15 documented, Quarterly review: Resident continues to have displayed no changes, in his activity preference since last review. Continues to be up and OOB (out of bed) QD (every day), attends little OOR (out of room) group activities, but does pursue his own independent recreational pursuits consisting of watching television, listening to music, and going to nurses station for snacks. Writer will continue to observe through the next review. An elopement risk assessment dated [DATE] documented Resident #1 was at moderate risk for elopement. A fall risk assessment dated [DATE] documented Resident #1 was at a low risk for falls. Review of nurses' notes from June 2015 through November 2015 failed to reveal documentation of Resident #1 wandering, exit seeking, or verbalizing comments regarding his wife or leaving the facility. A nurse's note dated 11/2/15 at 9:57 a.m. documented, Resident observed in front of facility doorway around 9:30 a.m., faced down on sidewalk. Resident responsive to name being called and voicing head pain. Large amount of blood noted from open area to forehead, pressure applied to site, left fourth finger also observed bent at the joint with open area. 911 services arrived on the scene around 9:35 a.m .Resident remained alert upon departure to (name of hospital), message left with Guardian via voicemail with (name of guardian). A nurse's note dated 11/2/15 at 10:25 a.m. documented, Resident had some confusion, at nursing station at 7:30 am asking what time he was leaving, stated 'I want to go home to my wife,' resident accepted all meds (medications) per order, no c/o (complaint of) pain at this time, no s/s (signs/symptoms) resp (respiratory) distress, and steady gait, resident was redirected easily, ate 76%-100% breakfast in common area. A nurse's note dated 11/2/15 at 10:25 a.m. documented, (Name of physician assistant) in facility and made aware of resident fall in front of facility and being transferred to hospital. An Event Report dated 11/2/15 documented, Fall. Mental Status or Neuro (neurological) Changes: Yes. If Mental Status or Neuro Changes is 'Yes': (a check mark beside) 'Confusion.' Pain level/location/status: Forehead 10/10 (pain rated as a ten on a scale from zero to ten). Change in function/intake/hydration: N/A (not applicable). Change in Skin Color: N/A. Wound Status (if applicable): N/A. Labs (laboratory tests): N/A. Medication changes or new orders in the last two weeks: N/A. Advance Directives: (a check mark beside) Full Code. allergies [REDACTED].' A. ASSESSMENT (RN (registered nurse)) OR APPEARANCE (LPN (licensed practical nurse)). (For RNs): What do you think is going on with the resident? I think that the problem may be: (e.g. cardiac, infection, respiratory, urinary, dehydration, mental status change) - Increased confusion reported this am by staff, resident easily redirected. Breakfast offered to resident in commons area. R. REQUEST: I suggest or request: (a check mark beside) Other- Transfer to hospital. ORDERS: General- Transfer resident to (name of hospital) for fall with injury. NOTES: 11/2/2015 09:57 a.m. - Resident observed in front of facility doorway around 9:30 a.m., faced down on sidewalk. Resident responsive to name being called and voicing head pain. Large amount of blood noted from open area to forehead, pressure applied to site, left fourth finger also observed bent at the joint with open area. 911 services arrived on the scene around 9:35 a.m .Resident remained alert upon departure to (name of hospital); message left with Guardian via voicemail with (name of guardian). Review of Resident #1's hospital records revealed a history of present illness dated 11/2/15 that documented, Pt (Patient) with dementia walking outside, pt states became weak and dizzy, falling face first. Pain in face, left shoulder, left wrist and exposed bone. Tendon L2. Pt denies CP/palps. (chest pain/palpitations). A&O X2 (Alert and oriented times two) (baseline per EMS (emergency medical services)). Pt found to be in **A-fib (atrial fibrillation), (heart) rate 130 with no history of A-fib. The discharge summary dated 11/9/15 documented [DIAGNOSES REDACTED].***odontoid process of axis (cervical spine), left wrist fracture, nasal bone fracture, dementia and debility. **[DIAGNOSES REDACTED](AF) is a problem with the rate or rhythm of the heartbeat. [DIAGNOSES REDACTED](AF) usually causes the heart's lower chambers, the ventricles, to contract faster than normal. When this happens, the ventricles can't completely fill with blood. Thus, they may not be able to pump enough blood to the lungs and body. This can lead to signs and symptoms, such as in part: Dizziness or fainting, Fatigue (tiredness), Confusion. Resident #1's comprehensive care plan most recently reviewed on 3/15/16 documented, Problem Start Date: 10/14/2014. Category: Falls- resident is at risk for falls r/t (related to) slight impaired mobility, imp. (impaired) cognition, use of psychotropic/pain meds (medications)/antihypertensive (high blood pressure) medications, imp. safety awareness, imp. balance/unsteady gait at times, has dx. (diagnosis) of alz. (Alzheimer's) dementia, seizure d/o (disorder), depression/ ****djd (degenerative joint disease)/****O.A. (osteoarthritis), muscle spasm & h/o (history of) falls . The approaches column documented, · Approach Start Date: 10/14/2014- assist resident with repositioning and turning while in bed q (every) 2-3 hrs (hours) and as needed- can usually do himself with sup. (supervision)/set up, staff to assist as needed. · Approach Start Date: 10/14/2014- keep call bell and other personal belongings in easy reach. · Approach Start Date: 10/14/2014- keep room well lighted. · Approach Start Date: 10/14/2014- medicate for pain as ordered. · Approach Start Date: 10/14/2014- remind resident not to sit in rolling chairs. · Approach Start Date: 10/14/2014- report any evidence of the side effects associated with his psychotropic/pain meds/antihypertensive medications such as lethargy, tremors, *****eps (extrapyramidal symptoms), ******tardive dyskinesia, gait disturbance, hypotension (low blood pressure) etc . · Approach Start Date: 10/14/2014- staff to provide assist with toileting q 2-3 hrs and as needed, res. (resident) can usually toilet himself with sup. /setup, staff to provide further assist as needed. The problem section of the care plan was revised on 11/12/15 to include: fell on [DATE] and admitted to hospital for lac (laceration)/fractures. Reported he felt dizzy prior to fall diagnosed with [REDACTED]. · Approach Start Date: 11/02/2015- Resident transferred to Hospital for evaluation of injuries. · Approach Start Date: 11/02/2015- DC (discontinued) ON: 11/10/2015- Discontinued Issue wanderguard for resident upon return to facilities .DC reason: Resident not ambulating on unit upon return from hospital. · Approach Start Date: 11/10/2015- Give *******antiarrhythmic med to treat new onset of a-fib (readmitted from hospital 11/9/15 after fall 11/2/15 with new dx/med). Placed on PT (physical therapy) and OT (occupational therapy) case load. Primary MD (medical doctor) in to see 11/10/15; meds reviewed r/t fall w/ (with) no changes to current meds. · Approach Start Date: 3/15/2016- Res. (Resident) to wear wanderguard as ordered . Resident #1's comprehensive care plan most recently reviewed on 3/15/15 further documented: Problem Start Date: 10/14/2014. Category: Cognitive Loss/Dementia- resident noted with some cognitive impairments, was unable to verbalize correct year, month, day of week, resident able to repeat all 3 words, later recalled 3 words with cues. resident (sic) can make his needs known. resident (sic) has a [DIAGNOSES REDACTED]. Review of the comprehensive care plan did not evidence any interventions prior to the 11/2/15, incident to address Resident 1's assessed moderate risk for elopement completed on 10/10/15. On 3/16/16 at 9:00 a.m., Resident #1 was observed ambulating from the bathroom to the sink in his bedroom. A wanderguard was observed on the resident's left ankle. On 3/16/16 at 9:30 a.m., an interview was conducted with LPN (licensed practical nurse) #4 (the nurse caring for Resident #1 during the day shift on 11/2/15). LPN #4 was asked to describe Resident #1's cognitive and mobility status during the time period leading up to the resident's fall on 11/2/15. LPN #4 stated Resident #1 could ambulate on his own. LPN #4 stated the resident was kind of quiet but would let you know if he needed anything. LPN #4 stated she never had any issues with the resident. LPN #4 stated Resident #1 was alert and oriented to person and situation. LPN #4 stated the resident had no episodes of wandering prior to 11/2/15. LPN #4 was asked to provide details regarding Resident #1's fall on 11/2/15. LPN #4 stated what she could recall was Resident #1 was pretty much already up when she arrived to the facility. LPN #4 stated she started her medication pass at 7:30 a.m. or a little after. LPN #4 stated Resident #1 was walking and talking and always comes to her and asks, 'You got something for me.' LPN #4 stated she gave the resident his medication and the resident was confused. LPN #4 stated Resident #1 wanted to go home to his wife and had never acted like that. LPN #4 stated at that time, she redirected the resident and got him to sit at the table. LPN #4 stated Resident #1 was fine and staff brought his breakfast. LPN #4 stated after that, she proceeded down the hall with her medication pass then staff told her Resident #1 had fell . LPN #4 was asked if Resident #1 had presented with any further confusion. LPN #4 stated, We had noticed that. At the time, I can't recall what they were doing for that. LPN #4 stated usually Resident #1 eats breakfast in his room but she wanted him in the common area (on the second floor adjacent to the elevator) to keep eyes on him. When asked if anything could have been done to prevent Resident #1 from going outside, LPN #4 stated, For one, he should have had an alarm. When asked if she meant a wanderguard, LPN #4 stated, Yes. When asked who was responsible for determining when a resident needs a wanderguard and for placing a wanderguard on a resident, LPN #4 stated she wasn't sure and she had never placed a wanderguard on a resident because they had already been put on. When asked if she reported Resident #1's increased confusion to anyone including the unit manager or CNAs (certified nursing assistants), LPN #4 stated the only thing she remembered was that Resident #1 had confusion and what she (LPN #4) did. LPN #4 stated everything else was like a blur. LPN #4 was asked if the facility had a process for supervision of cognitively impaired residents with increased confusion. LPN #4 stated, Not that I know of. LPN #4 stated she just watches those residents and checks on them all day. LPN #4 stated the situation regarding Resident #1 just happened so fast. On 3/16/16 at 9:53 a.m., an interview was conducted with CNA #4 (a CNA who had known and cared for Resident #1 for approximately three years). CNA #4 was asked to describe Resident #1's cognitive and mobility status in October and November 2015. CNA #4 stated Resident #1 wasn't confused on day shifts and the resident could independently ambulate. On 3/16/16 at 10:05 a.m., an interview was conducted with RN (registered nurse) #1 (Resident #1's unit manager on 11/2/15). RN #1 was asked to describe Resident #1's cognitive and mobility status during the time period leading up to the resident's fall on 11/2/15. RN #1 stated the resident was alert and oriented times three and had no mobility problems. RN #1 stated Resident #1 did everything himself but staff would have to remind him to change his clothes. RN #1 stated Resident #1 might have had periods of redirection; for example, the resident would ask what time lunch was. RN #1 stated other than that, Resident #1 knew what was going on. RN #1 was asked if Resident #1 had previous episodes of exit seeking or wandering prior to 11/2/15. RN #1 stated, No. RN #1 stated Resident #1 was the type of man to ambulate from his room to the desk to the room and Resident #1 typically ate meals in his room. RN #1 was shown Resident #1's elopement risk assessment dated [DATE] and asked why the resident was documented as being at moderate risk. RN #1 stated it may have been because the resident ambulated and was receiving antipsychotic medication. RN #1 stated if a resident was scored as being at moderate risk of elopement then staff would review the resident's care plan. If the resident previously had not wandered then staff would just watch the resident. RN #1 was asked to provide details regarding Resident #1's fall outside on 11/2/15. RN #1 stated she usually arrives to the facility at 8:00 a.m. RN #1 stated on 11/2/15, Resident #1 was wandering on the unit and she heard him say something about finding his wife. RN #1 stated she saw the resident head to the elevator. RN #1 stated she asked Resident #1 to come eat breakfast. RN #1 stated the resident ate breakfast in the common area (adjacent to the elevator). RN #1 stated she believed Resident #1 sat in the common area for a little while and ate his breakfast. RN #1 stated she believed she asked staff to keep an eye on Resident #1 because he was talking about his wife and hadn't done that before. When asked to name the staff she asked to keep an eye on the resident, RN #1 stated she thought she told LPN #4 and a couple of the CNAs. RN #1 stated five minutes into the morning meeting, she got a call from the receptionist at the front desk that Resident #1 was outside and had fallen. RN #1 stated the resident had a gash to his nose and one of his fingers was crooked so staff called 911 and she stayed outside with the resident. RN #1 stated she was going to call the doctor regarding Resident #1's status that morning when she came back upstairs from the morning meeting. RN #1 stated Resident #1 may have seen her get on the elevator and maybe that's why he got up. When asked if anyone saw Resident #1 get up in the common area, RN #1 stated, Not that I am aware of. When asked if anyone saw Resident #1 downstairs, RN #1 stated, Not that I am aware of. RN #1 was asked the process for handling residents who present with increased confusion. RN #1 stated you know there is a problem and possibly some type of infection. RN #1 stated you get vital signs and ask other people to keep an eye on the resident. RN #1 stated you wouldn't immediately call the physician because you would monitor the resident and interview CNAs to obtain information to give to the physician. RN #1 stated the only other thing you can do is engage the resident in an activity to see if that will help. RN #1 was asked if staff engaged Resident #1 in an activity during the morning of 11/2/15; RN #1 stated, Not at all. RN #1 was asked the facility process for initiating a wanderguard. RN #1 stated a wanderguard would have come into play if Resident #1 had continued to wander or if the resident got outside. RN #1 stated she wouldn't initiate a wanderguard for one period of wandering. On 3/16/16 at 10:32 a.m., an interview was conducted with OSM (other staff member) #4 (the front desk receptionist). OSM #4 stated on 11/2/15, Resident #1 walked by the front of the lobby and went out the front door. OSM #4 stated it was common for some residents to go outside and sit. OSM #4 stated the resident didn't have a wanderguard on so she couldn't stop him. OSM #4 stated the resident walked toward the seating area on the left side of the building (from her position), turned around and came back. OSM #4 stated Resident #1 fell in front of the windows. OSM #4 stated she got the nursing staff that went out to the resident. The CNA (certified nursing assistant) caring for Resident #1 during the day shift on 11/2/15 was no longer employed at the facility. On 3/16/16 at 11:32 a.m., an interview was conducted with CNA #13. CNA #13 stated she was working on Resident #1's unit during the day shift on 11/2/15 but she was not caring for Resident #1 that day. CNA #13 stated she had no interaction with Resident #1 on 11/2/15. When asked if anyone had spoken to her regarding Resident #1 and asked her to watch him, CNA #13 stated, I don't recall. No. I remember they said he got downstairs. On 3/16/16 at approximately 2:20 p.m., this surveyor attempted to interview Resident #1 regarding another concern. Resident #1 responded with short answers. Resident #1 did not provide any further information. On 3/16/16 at 3:25 p.m., an interview was conducted with RN #3. RN #3 was asked what should be done for a resident who presents with increased confusion and exit seeking. RN #3 stated staff should try to redirect the resident, get the resident comfortable, spend time with the resident and do an assessment to include vital signs and a head to toe assessment if the residents allows. RN #3 stated staff should increase monitoring if the resident was moving around and if she had to, she would pull a person and have the person stay with the resident. RN #3 further stated if the resident was exit seeking, she would get a wanderguard even if it was temporary, implement one on one (staff member staying with the resident at all times), 15 minute checks or whatever was applicable for the situation. RN #3 stated she would call the physician as soon as she finished her assessment and ask for labs (laboratory tests) because the resident may have an infection. On 3/16/16 at 4:40 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above findings and made aware of the concern for harm. ASM #1 stated RN #1 saw Resident #1 ten minutes before the resident fell outside. ASM #1 stated nothing else should have been done and Resident #1's status during the morning on 11/2/15 did not prompt the need for anything more than redirection. ASM #1 and ASM #2 were asked to provide evidence that Resident #1 was provided supervision and observation during the morning on 11/2/15. On 3/17/16 at 10:24 a.m., another interview was conducted with RN #1. RN #1 was asked to describe the assessment that was completed for Resident #1 before the resident fell on [DATE]. RN #1 stated she didn't know what assessment LPN #4 done. RN #1 stated on 11/2/15 Resident #1 was eating breakfast when she went downstairs (for the morning meeting). RN #1 stated she usually goes downstairs for the morning meeting between 8:45 a.m. and 8:50 a.m. RN #1 stated she knew LPN #4 was upstairs and the residents were eating breakfast. RN #1 was asked to provide any further information. RN #1 stated if she felt Resident #1 was in danger and in harm's way then she would have stayed upstairs on the unit. RN #1 stated Resident #1 would go downstairs to get snacks out of the vending machine in the Westham dining room then go back to his room. RN #1 was asked if Resident #1 ever went outside. RN #1 stated if he did, he would go with activities staff outside on the patio. RN #1 stated she saw Resident #1 going toward the elevator looking for his wife. RN #1 stated she redirected the resident to eat breakfast. RN #1 stated she asked LPN #4 about Resident #1 asking for his wife. RN #1 stated LPN #4 said she heard him say that and that was unusual for Resident #1. RN #1 stated she redirected Resident #1 to sit down and eat. RN #1 stated she went to the morning meeting because she felt like staff would alert her if something else happened. RN #1 stated after Resident #1's fall outside, she went upstairs to ask how the resident got outside. RN #1 stated LPN #4 said she thought Resident #1 was still sitting at the table. On 3/17/16 at 11:15 a.m., during an interview conducted with ASM #5 (Resident #1's physician) and ASM #6 (the physician assistant) regarding another concern, ASM #5 stated he had evaluated Resident #1. ASM #5 stated ASM #6 asked Resident #1 questions such as who was the current president, which state he was in, what place he was in, the date of week and year and Resident #1 was not aware of anything but his name. On 3/17/16 at 1:05 p.m. an interview was conducted with ASM #1 and ASM #2. ASM #1 stated he wanted to go on record to state he disagreed with the above concern. ASM #1 stated no nurse would be expected to or would call the physician regarding Resident #1's status prior to his fall outside the facility on 11/2/15. ASM #1 stated the resident did not exhibit a significant change. ASM #1 stated Resident #1 had a [DIAGNOSES REDACTED]. ASM #1 stated staff in the rehab (rehabilitation) department told him Resident #1 had spoken to his wife. When ASM #1 was asked when the rehab staff made this statement to him, ASM #1 confirmed it was after this surveyor had voiced concern. ASM #1 stated the nurse (LPN #4) who cared for Resident #1 on 11/2/15 was a PRN (as needed) nurse and was not as experienced with the resident as the unit manager. ASM #1 was asked to provide evidence that Resident #1 was supervised and monitored during the morning on 11/2/15; ASM #1 stated the resident was supervised. ASM #1 stated CNAs are in the common area and dining room every day but staff does not document this and no facility does. ASM #1 stated staff documented the amount of food Resident #1 ate for breakfast and this documentation showed he was supervised. ASM #2 stated the nurse's note dated 11/2/15 documented the nurse assessed the resident's pain, food intake and steady gait. ASM #2 stated the nurse documented Resident #1 was easily redirected. ASM #1 stated the unit manager evaluated Resident #1 before she left the unit and felt he was okay. ASM #2 stated the physician assistant stated she would not have expected staff to notify her regarding Resident #1's status prior to his fall on 11/2/15. ASM #2 asked if the physician assistant had spoken to this surveyor regarding that matter earlier in the day during an interview about other concerns. ASM #2 was informed the physician assistant had not stated that information to this surveyor; however, the physician assistant could come speak to this surveyor. The physician assistant did not speak with this surveyor and did not provide this information prior to exit. On 3/17/16 at 2:05 p.m., ASM #1 was asked to provide any further investigation regarding Resident #1's incident on 11/2/15 and to provide any other CNAs that worked the day shift on Resident #1's unit on 11/2/15. ASM #1 stated he believed there was no further investigation and he would check to see if any other CNAs were available. On 3/17/16 at 3:00 p.m., ASM #1 stated all other CNAs working on Resident #1's unit during the day shift on 11/2/15 were no longer employed at the facility. The facility policy titled, ELOPEMENT documented, PURPOSE: To ensure the safety of the residents and ensure interventions have been implemented to decrease the risk of elopement from the facility. JUSTIFICATION: Some residents attempt to exit the nursing facility. Those residents have been assessed and may be wearing a wander alert bracelet. Residents will be observed and every attempt made to keep them safe within the facility. POLICY: The nursing facility staff will take prompt action to ensure the health and safety of residents who have eloped from the facility and take appropriate interventions in attempt to prevent future elopement . The facility policy titled, RESIDENT CONDITION, ASSESSMENT OF documented, PURPOSE: To provide guidance for assessment of residents who have displayed a change in condition. JUSTIFICATION: When a resident displays what is determined to be a change in condition, the nurse will assess the resident to enable him/her to provide the physician with sufficient information allowing physician to make the appropriate medical decisions for the resident's care. POLICY: The licensed nurse assesses the resident as needed to collect data in regards to the resident condition. Sometimes the change is related to a change in condition but at other times the resident's condition requires ongoing assessment. PROCEDURE: 1. Upon identification of a potential or real change in condition, the licensed nurse will assess the resident to obtain all necessary data in relation to the condition. 2. The information collected during the assessment will be communicated to the physician allowing that physician to facilitate his/her ability to make the appropriate clinical decision for the resident . From Fundamentals of Nursing, 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5: Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Complaint Deficiency *Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks. This information was obtained from the website: https://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-fact-sheet ** [DIAGNOSES REDACTED]is a problem with the rate or rhythm of the heartbeat. This information was obtained from the website: <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 62/> and <http://www.nhlbi.nih.gov/health/health-topics/topics/af/signs> ***This information was obtained from the website: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 82/ ****Degenerative joint disease (also known as osteoarthritis) causes pain, swelling and reduced range of motion in your joints. This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/osteoarthritis.html> *****Extrapyramidal symptoms include: muscle rigidity, slow movement and involuntary tremors. This information was obtained from the website: <http://www.consumerreports.org/cro/2013/12/treating-anxiety-adhd-depression-insomnia-and-ptsd-with-newer-antipsychotics/index.htm> ******Tardive dyskinesia is a neurological syndrome characterized by repetitive, involuntary, purposeless movements. This information was obtained from the website: http://www.ninds.nih.gov/disorders/tardive/tardive.htm *******Antiarrhythmic medications are used to treat heart rhythm disorder. This information was obtained from the website: http://www.texasheart.org/HIC/Topics/Meds/antiarrh.cfm

Based on observation, resident interview, staff interview facility document review and clinical record review, it was determined that the facility staff failed to provide care and services to promote prevention and healing of pressure ulcers for two of 32 residents in the survey sample, Residents #3 and #19. 1. The facility staff failed to assess and implement interventions to prevent the development of two *pressure ulcers (one on the right heel and one on the right calf) for Resident #3. By the time the ulcers were identified by the facility staff, both were unstageable (covered with ^eschar). 2. The facility staff failed to ensure Resident #19 wore heel lift suspension boots and to ensure a licensed nurse skin assessment was conducted 4/20/14. The findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment dated [DATE], Resident #3 was coded as having scored ten out of 15 on the Brief Interview for Mental Status. This score indicated that Resident #3 is moderately impaired for daily decision making. Resident #3 was coded as always understanding others and always being understood by others for communication. Resident #3 was coded as requiring extensive assistance of facility staff for bed mobility, transfers, dressing, toileting and personal hygiene; and as being totally dependent on staff for bathing. Resident #3 was coded as always being incontinent of both bladder and bowel. On 5/7/14 at 2:00 p.m., observation was made of the facility staff providing care to Resident #3. LPN (licensed practical nurse) #6, a wound nurse, and CNA (certified nursing assistant) #4 entered Resident #3's room and informed her that they would be providing treatment to both of Resident #3's pressure ulcers. Observation revealed a pressure ulcer on Resident #3's right calf approximately 1.3 cm (centimeters) long by 0.7 cm wide, with a depth of approximately 0.4 cm. The wound bed contained pink tissue with some #slough also visible. LPN #6 stated that this wound was still at a stage four. Further observation revealed a pressure ulcer on Resident #3's right heel approximately 2 cm long by 1.6 cm wide. The wound was covered with eschar, so, according to LPN #6, the wound was unstageable. On 5/8/14 at 8:05 a.m. during an interview, Resident #3 showed the surveyor a pillow approximately 12 inches by 12 inches in width and height, and approximately 1.5 inches deep. The pillow had the picture of a cat on the front. The pillow was firm, but did demonstrate a limited capacity to "give" when pressed. A review of Resident #3's clinical record revealed the following nurse's note, written by LPN #6 and dated 2/27/14: "Unstageable noted to right calf and right lateral heel. Right calf 1.5 X (by) 1 cm wound bed 100% black firmly adhering eschar, peri wound (area around wound) [DIAGNOSES REDACTED] (redness) 11.5 X 3.5 cms. C/o (complains of) pain and discomfort when palpated (touched). No drainage noted. Eschar in place to right lateral (toward the outside of the foot) heel 2.5 X 1.5 cms. 100% brown firmly adhering eschar. No drainage noted, denies pain and discomfort. . .All areas were cleansed with NS (normal saline - salt water) and dry dressing (sic) were applied. NP (nurse practitioner informed. . ." The note contained the text of treatment orders for both pressure ulcers, including daily cleansing and dry dressings. Further review of Resident #3's clinical record revealed the following treatment orders, signed by the physician on 1/10/14 and in place at the time of the discovery of the above-referenced pressure ulcers: "Pressure reduction mattress, check every week 3-11 (evening) shift for functioning/placement. Site: Peri-anal area (area around rectum and genitalia) - Apply **[MEDICATION NAME] (moisture barrier cream) twice daily and as needed. Site: Sacrum (area at top of buttocks) - Apply [MEDICATION NAME] every shift." Review of the TARs (treatment administration records) for Resident #3 reveal that facility staff had been signing off that the pressure reduction mattress was in place for Resident #3 and that [MEDICATION NAME] cream had been applied as ordered. A review of the comprehensive care plan for Resident #3 dated 12/4/13 (the care plan in place at the time of the discovery of the above-referenced pressure ulcers) revealed, in part, the following: "PROBLEM: Resident is at risk for skin impairment r/t (related to) episodes of bladder incontinence, [MEDICAL CONDITION] (swelling) and decreased functional mobility (ability move and position oneself). GOALS: Resident will be free of any breaks in skin integrity due to pressure through next review. APPROACHES: Offer toileting/provide incontinence care q2-3 hours and prn (every two to three hours and as needed). Encourage and provide assistance with turning and repositioning while in bed. Brief off while in bed as guest/family will allow. Observe skin with daily ADLs (activities of daily living, i.e. bathing, transferring, dressing, toileting) and report any signs of potential skin impairment to nurse. Encourage and assist resident to be out of bed daily. Ensure resident rests on a pressure reduction surface in bed and in w/c (wheelchair). Weekly skin assessments as prescribed. Encourage rest and elevation of [MEDICAL CONDITION] extremities." This care plan also contained interventions regarding Resident #3's needs for help with ADLs: "PROBLEM: Resident requires assistance with ADLs r/t weakness r/t her medical conditions including pneumonia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. She is easily short of breath with exertion. APPROACHES: Shower/tub bath 2x week (twice a week). Provide bedbath on non-shower days. Provide good foot care daily, observe for any foot problems and report promptly for early intervention. Observe skin daily with care, 2x week with shower/bath and by licensed nurse weekly for s/s (signs or symptoms of breakdown." A review of the quarterly Pressure Ulcer Risk Assessment form for Resident #3 dated 2/13/14 made no mention of existing pressure ulcers for Resident #3. The form identified several pressure ulcer risk factors: requiring staff assistance for movement to relieve pressure on any one site, being confined to bed or chair, requiring regular turning. The form identified two diagnoses/conditions that elevated Resident #3's pressure ulcer risk: "heart" and "terminal illness." (Of note, this was the only indication in the entire clinical record reviewed that indicated that Resident #3's condition was "terminal.") The form also identified the following treatments and other factors increasing Resident #3's pressure ulcer risk: being newly admitted to the facility, limited range of motion, head of bed elevated most of the time, and devices that can cause pressure (supplemental oxygen tubing). The form contained the following comments in the free writing section: "At risk for pressure ulcers related to decreased mobility. Staff will assist with repositioning q 2-3 hours. Keep call bell within reach." The formed was signed by a nurse who was unavailable for interview during the survey. However, a nurse who frequently performs these quarterly assessments was interviewed on 5/8/14 at 10:05 a.m. LPN #2 stated, "These assessments go with the MDS every quarter. That's why we do them." When asked if she actually performs a head to toe skin assessment for each resident as part of the risk assessment process, LPN #2 stated, "Oh no. The floor nurses do that every week. For this risk form, we just go by what is on the chart. We don't actually look at the resident." A review of the weekly nurse skin assessments for Resident #3 revealed assessments performed on the following dates with the following comments: - 1/5/14: No new areas noted; skin intact - 1/12/14: No new areas noted; Redness remains to peri area (area surrounding female genitalia); continue treatment orders. - 1/19/14: No new area. - 1/23/14: No new areas. - 1/30/14: No new areas. The next weekly skin assessment for Resident #3 was dated 2/27/14, and contained documentation about the above-referenced pressure ulcers. Facility staff were unable to locate, after multiple requests, any evidence that any skin assessments were performed between 1/30/14 and the discovery of the pressure ulcers on 2/27/14. A review of the Pressure Ulcer Investigation form, dated 2/28/14 and related to the discovery of the above-referenced pressure ulcers, revealed the following diagnoses, questions and circled answers: "Diagnoses: [REDACTED]. Was Risk Assessment completed prior to development of pressure ulcer? Yes. Were treatment and interventions implemented based on identified risk factors? Yes." The form also contained documentation identifying the following risk factors/conditions: urinary incontinence, weight loss, impaired mobility, lower extremity [MEDICAL CONDITION] and diabetes. Under the heading "PROBABLE CAUSATIVE REASONS FOR DEVELOPMENT OR Non-HEALING (circle all that apply)," only "Incontinence" was identified. The free writing space labeled "Recommendations" contained the following statement: "Resident has a firm pillow she requests to have positioned under her right lower extremity. Educated resident not to use the pillow due to its firmness. Pillow placed in resident's closet. New order HLSB (heel lifting and protecting boots) to bilateral (both) feet while in bed. New order low air loss mattress to promote wound healing." This form was completed and signed by ASM (administrative staff member) #2, the director of nursing. On 2/8/14 at 8:35 a.m., Resident #3 was interviewed regarding the development and discovery of the above-referenced pressure ulcers. When asked if she recalled whether or not the staff was assisting her with turning/repositioning every two to three hours as indicated on both the comprehensive care plan and the pressure ulcer risk assessment, Resident #3 stated, "Not that I recall. Not before I got these (pressure ulcers). Sometimes, I don't want them to bother me now. But before I got these things, they really didn't pay that much attention." When asked about the pillow described in the pressure ulcer investigation by ASM #2, Resident #3 stated, "Yes, I really wanted to use that pillow. It made me feel better. My family brought it in here. I was using it, and then all of a sudden, when they saw those places on my heel and leg, they told me I couldn't have it anymore. Now they want me keep my heels up on these other pillows (indicating bed pillows), but I don't like them. As soon as they leave the room, I kick them off. I wear the boots. That ought to be enough." When asked if she recalled how long she had been using the pillow from home before the pressure ulcers were identified, Resident #3 stated, "I don't remember exactly. A few weeks anyway. And they didn't say anything about my leg and foot until I started telling them that they hurt. One day, one of them was in here giving me a bath and she touched the place on the back of my leg and it really hurt. That is when she looked at my leg and went to get the nurse." On 5/8/14 at 11:40 a.m., CNA #6 was interviewed regarding the process for observing residents' skin for changes while CNAs are providing care. CNA #6 stated, "Well, you should always look at the resident. Especially if you are giving a bath. It is hard, though, with some residents, to see the legs and feet - especially if they are hard to turn and you are having to give the bath by yourself. But if you see something, you should ask the resident what happened. Then you should let the nurse know - ask the nurse to come and look at it." When asked where these observations are documented, CNA #6 stated, "The shower nurse puts it on a skin sheet. But if we just give a bed bath or we see something while we are getting the residents dressed, we just tell the nurse and then we put it in Care Tracker (a computer-based assessment tool used to CNAs to describe the care they give to residents). CNA #6 demonstrated the Care Tracker tool, as well as the showed the surveyor the format for recording resident skin observations. (Of note, despite multiple requests by the survey team, the facility staff was unable to produce any CNA skin observations for Resident #3 from Care Tracker). A review of the CNA bath/shower records for Resident #3 revealed that on the following days prior to the discovery of the above-referenced pressure ulcers, Resident #3 a bed bath: 2/20/14, 2/21/14, 2/22/14, 2/23/14, 2/24/14, 2/25/14 and 2/26/14. Review of these records also revealed that Resident #3 received a shower on 2/26/14. The facility staff was unable to produce evidence of any CNA skin observations for any of these dates. On 5/8/14 at 9:10 a.m., ASM #2 stated, "The bath records are the only CNA documentation we have. We don't have any other CNA skin records." On 5/8/14 at 1:40 p.m., CNA #9, a CNA who signed off on two bed baths for Resident #3 from 2/20/14 through 2/27/14, was interviewed about her observations of Resident #3's skin. CNA #9 stated, "I never had (name of Resident #3). They don't have the right person written down for giving her a bath. I have never given (Resident #3) a bath or a shower." On 5/8/14 at 1:45 p.m., CNA #5, a CNA who signed off on one bed bath for Resident #3 from 2/20/14 through 2/27/14, was interviewed about her observation of Resident #3's skin. CNA #5 stated, "I don't remember anything. I know she wears those boots now." On 5/8/14 at 1:50 p.m., LPN #6 was interviewed about Resident #3's pressure ulcer discovery. LPN #6 stated, "The CNA called me over. The resident had that hard cat pillow under her legs. The pillow has a picture of a cat on it, and the pillow is really hard. It was 100% eschar under her leg and on her heel. I called the DON (director of nursing) - I always do. She is certified in wound care and she comes to look at all the new wounds. After she looked at them, I talked to the doctor, and he told me to clean them and treat them and put on dry dressings. If you want to know what happened, it was that pillow. She never should have used that pillow to float her heels." On 5/8/14 at 2:10 p.m., ASM #3, the attending physician for Resident #3 was interviewed regarding the above-referenced pressure ulcers. ASM #3 stated, "I am aware of her wounds. She has had these for a few weeks I think. She has a lot of risk factors. Her blood sugars have been all over the place ever since her admission. She has had multiple consults with the endocrinologist (specialist in diabetes). She has so much lower extremity swelling. She is on oxygen 24/7. There is no doubt that these are pressure ulcers, and a result of her acute illness and her immobility." When asked what pressure ulcer prevention interventions would be appropriate for a resident with such risks, ASM #3 stated, "Well, frequent repositioning, even when she is up in a chair. Elevating her legs and feet. Floating her heels. It is always easier in hindsight to see these things." On 5/8/14 at 3:45 p.m., ASM #2 was interviewed regarding Resident #3's pressure ulcers. ASM #2 stated, "Well, the 2/13/14 pressure ulcer risk assessment shows that all is clear. We would not have made wound rounds on (Resident #3) prior to 2/27/14. We only round on residents who have wounds. The girls had noticed something. The CNA or the nurse told me that there was something underneath her leg. When I walked in the door, she had her leg propped up on a hard pillow. I had to talk to her about the pillow. I am wound-certified. And I am [MEDICATION NAME] about that pillow. I know the pillow caused the pressure ulcers. If the staff had asked her, she would not have let them take the pillow away. I know that she would not have." When asked if there is any documentation that the staff made attempts to remove the pillow and that the resident refused these attempts, ASM #2 stated, "No, there's not." ASM #2 further stated, "It probably started out as redness. But then she just kept using the pillow and that is what happened." ASM #2 stated, "She just did not want to give up that pillow." The surveyor invited ASM #2 to provide the survey team with any and all documentation regarding Resident #3's use of the pillow prior to the discovery of the pressure ulcers. This included documentation of education provided to the resident about the risks of using the pillow as a leg/foot prop, the resident's refusal to accept the staff's education, and/or the resident's insistence on using the pillow in spite of understanding the risks. ASM #2 stated, "I don't think we have any of that, but I will check again." On 5/8/14 at 10:25 a.m., ASM #1, the administrator and ASM #2 were informed of these concerns, and were informed that they survey team had identified the potential for harm related to these concerns. ASM #1 and ASM #2 were invited to gather and submit to the survey team any further information that could shed light on these concerns and remove the concern for harm. At this time, facility policies and procedures regarding pressure ulcer risk and prevention were requested. On 5/8/14 at 4:00 p.m., ASM #1 and ASM #2 were again notified of the concern for harm and were informed that none of the evidence presented by facility staff had removed this concern. A review of the facility policy entitled "Pressure Ulcer Risk Assessment" revealed, in part, the following: "POLICY: Facility is committed to providing skin are to maintain skin integrity and prevent pressure ulcers. PROCEDURE: 2. Within 24 hours of admission, the Pressure Ulcer Risk Assessment form will be completed by a licensed nurse. 3. The nurse will assess for factors which place the resident at risk of a pressure ulcer: presence of existing pressure ulcers, extrinsic factors, skin moisture, mobility, mental status, medications, [DIAGNOSES REDACTED]. 4. The nurse shall analyze the data which was entered onto the document and make a summary statement on the back of the document which will indicate if the resident is at risk and identify approaches which are being implemented. 5. The approaches will be entered onto the resident's individualized plan of care. 7. The Pressure Ulcer Risk Assessment will be completed upon admission, quarterly, and with significant change of status." No further information was provided prior to exit. *A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and Charles F. Chapman. Page 155. The following is from the National Pressure Ulcer Advisory Panel website at <http://www.npuap.org/pr2.htm> Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. According to "Fundamentals of Nursing" 6th edition, Perry and Potter, page 1513; "Early identification of clients at risk and their risk factors aids the nurse in preventing pressure ulcers. Prevention minimizes the impact that risk factors or contributing factors may have on pressure ulcer development....Three major areas of nursing interventions for prevention of pressure ulcers are (1) skin care, which includes hygiene and skin care; (2) mechanical lading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3) education." ^Eschar - "Eschar (dried, black, hard, necrotic tissue) covering a pressure ulcer prevents accurate grading. From the National Institutes of Health website http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 48/ #Slough - "Slough is soft, dead yellow, tan, gray, green or brown material in a pressure ulcer wound bed." From the NPUAP (national Pressure Ulcer Advisory Panel) website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/. **[MEDICATION NAME] is an [MEDICATION NAME] and skin protectant. It is used to protect from minor skin irritation associated with diaper rash caused from wetness, urine and/or stool. From the National Institutes of Health website http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=04e8d37a-c8a9-4b11-8b56-62a1110da94c. 2. The facility staff failed to ensure Resident #19 wore heel lift suspension boots (pressure relief boots) and to ensure a licensed nurse skin assessment was conducted 4/20/14. Clinical record review revealed, Resident #19 was a [AGE] year old male admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. His quarterly Minimum Data Set assessment dated [DATE] coded the resident as sometimes able to make himself understood and usually able to understand others. He was not able to complete the Brief Interview for Mental Status. The staff assessment coded him as having no memory problem and moderate cognitive impairment. He was coded as needing extensive staff assistance for bed mobility, dressing and eating. He was coded as being totally dependent on staff for transfers, personal hygiene and bathing. The resident was coded as being at risk for developing pressure areas and as having no pressure areas. The Pressure Ulcer Risk assessment dated [DATE] documented he was at risk for pressure area development due to [MEDICAL CONDITION], incontinence, and cognitive impairment. The assessment documented "...Provide incontinence care per facility protocol, staff to turn & reposition q 2 (every 2 hours) & PRN (as needed) pressure reduction mattress to bed. Weekly skin checks to monitor skin integrity." His care plan dated 6/4/13 and reviewed on 2/26/14 identified that Resident #19 was at risk for skin breakdown due to incontinence, impaired mobility, bilateral foot drop, and [DIAGNOSES REDACTED] as a problem. There were several interventions including provide incontinence care every 2-3 hours and PRN, pressure reduction surface to the bed and wheel chair, observe skin during care for areas of redness/pressure or breakdown, and float heels intermittently when in bed. The care plan was updated on 4/30/14 to include an unstageable ulcer (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) on his left heel. The interventions were updated on 5/5/14 to include heel lift boots at all times except during hygiene. A nurse's note dated 4/30/14 at 12:00 PM, documented an area measuring 2 cm X 2 cm covered with eschar was observed on his left heel. The note documented a new physician's order was obtained to apply skin prep to the heel every shift and float heels while in bed. On 4/30/14, the physician wrote an order to apply skin prep to the resident's left heel every shift and float the resident's heels while in bed. A nurse's note dated 5/5/14 at 8:05 AM, documented the physician wrote an order to apply heel lift suspension boots to both feet at all times except for skin checks and hygiene. A physician's order dated 5/5/14 documented to wear heel lift boots on both feet at all times except for hygiene and skin checks. On 5/8/14 at 9:00 and 9:20 a.m., Resident #19 was observed. A pillow was observed at the bottom of the bed and the resident's heels were on the pillow. The heel lift boots were observed in the resident's wheel chair. At 9:20 a.m., a certified nursing assistant (CNA) was observed repositioning Resident #19. On 5/8/14 at 10:50 AM, and 11:50 AM, Resident #19 was observed in bed his heels were floated over the end of the pillow. The heel lift suspension boots were in the resident's wheel chair. On 5/8/14 at approximately 3:00 PM, Resident #19 refused to allow an observation of his heel. The heel lift boots were on his feet. There was no evidence such as a nurse's note that the resident refused to wear the heel lift boots. On 5/8/14 at 11:55 AM, Licensed Practical Nurse (LPN) #8 stated the resident should have heel lift suspension boots on but they were not on when she checked. She stated she was told to check the laundry. LPN #8 was informed the boots were in the resident's wheel chair. She stated she talked to the supply person the day before. LPN #8 stated someone must have gotten them and put them in the resident's room. CNA #10 was present and stated she was not Resident #19's regular CNA. She stated she did not know the resident should have the boots on in bed. She stated she thought the resident wore the boots when he was up in the wheel chair. On 5/8/14 at 12:05 PM, CNA #10 was interviewed. She stated another CNA explained what interventions should be in place for each resident at the beginning of the shift. CNA #10 stated the other CNA said Resident #19 should have boots on. CNA #10 said she checked on Resident #19 this morning and the boots were not on. CNA #10 stated she thought the boots were supposed to be on when the resident was in his wheel chair. CNA #10 said the resident did not want to get out of bed this morning so she floated his heels. Clinical record review revealed a Nurse Skin Assessment sheet. The sheet was divided into 6 sections with an image of the front and back of the body, and an area for comments. The sheet documented the resident had no areas on 4/5/14 and 4/13/14. There were no other assessments on the sheet. The CNA (certified nursing assistant) Skin Observation Sheet documented the resident's skin was observed in 4/16/14, 4/22/14 and 4/30/14. The sheet documented the resident had an old area on his coccyx and did not have any areas on his heels on 4/16/14 and 4/22/14. On the 4/30/14 section of the sheet there was a line on the right heel. The CNA circled "Clear" and "Pressure Ulcer" on the legend 4/16/14, 4/22/14 and 4/30/14. The sheet was signed by CNA #11. On 5/8/14 at 2:10 PM, the director of nursing (DON) and the wound care nurse Licensed Practical Nurse (LPN) #6 were interviewed. LPN #6 said the wound care nurse who usually treated Resident #19 was not available. She stated the unit manager informed her resident needed heel lift boots and she obtained the physician's order. She stated in the past (a couple of years) Resident #19 had problems with his heels. She said he had not had issues with wounds in the last 6 months. LPN #6 said the heel lift boots were important to provide pressure relief. She stated the resident should wear them all the time. The DON stated some resident's did not like the heel lift boots so the staff tries a different type. She stated the staff also float heels to relieve pressure. On 5/8/14 at 3:50 PM, CNA #11 said the resident she saw a brown area about the size of a dime on the resident's heel in April. She stated she could not remember the date. She stated she told the nurse when she first saw an area. She reviewed the CNA Observation sheet and verified she drew the line on the heel but she did not write anything in the comments section. She stated the area she referred to as a pressure area was an old scar on the resident's back. On 5/8/14 at 2:30 PM, the assistant director of nursing (ADON) was asked for the nurse's weekly assessments for 4/20/14 and 4/27/14. She stated the resident's skin was assessed by the nurse on 4/30/14. The ADON stated she would look for the other assessment. On 5/8/14 at 3:45 PM, the ADON stated she was concerned the licensed staff weekly skin assessment was not completed for the week of 4/20/14. The ADON stated the resident refused care. She said she was not sure if it was a challenge to put the boots on Resident #19. On 5/8/14 at 4:00 PM, this concern was shared with the DON and the Administrator. The DON stated the nurses had to do a weekly skin assessment. The DON stated LPN #6 was going to ask Resident #19 if he refused to wear the boots. The DON was asked if the resident should have the heel lift boots on. She stated yes if the physician ordered the heel lift boots and the resident wants to wear them. She said if the resident does not want to wear them then the physician's order should be changed. A copy of the skin assessment policy and wound care policy was requested. A handwritten note signed by LPN #6 documented "Spoke (with) (name of Resident #19) on 5/8/14 @ 5:30 PM regarding HLSB (heel lift suspension boots). Resident stated when asked if he like (sic) wearing the boots he stated 'yes' When asked if he liked wearing the boots in bed he stated 'no' CNA (initials of a CNA) stated res (resident) will wear the HLSB's while in chair but often refuses them in bed. Clarification order written per resident request to HLSB while in chair encouraged float heels while in bed." The facility policy titled Skin Assessments and dated 6/18/12 documented "Purpose: To ensure the skin integrity of the residents residing in nursing facility. Justification: To provide the resident with care and services which will promote the prevention of avoidable pressure ulcers and promote healing in any existing pressure ulcers...Procedure:...4. A licensed nurse will complete a 'head to toe' skin assessment on each resident each week. The results of this assessment will be documented on a weekly skin assessment flow sheet or in Care Tracker...5. The bath aide will observe each resident's skin two times a week for appearances of reddened areas, bruising, skin tears, abrasions, shearing, etc. This will be documented in Care Tracker or on a weekly skin flow sheet..." The wound care protocol (no date) documented for a wound covered in eschar the best practice was "...Pressure reduction/relief surfaces as indicated...Float heels as indicated..."

Based on staff interview, facility document review, and clinical record review, the facility staff failed to initiate physician ordered CPR (cardiopulmonary resuscitation) for one of 52 residents in the survey sample, Resident #32. Resident #32 had a Cardiopulmonary Resuscitation Directive to administer CPR in the event his heart should stop beating and or his breathing stopped. The directive was signed by her attending physician. On the morning of [DATE] at 5:50 a.m., Resident #32 was found without a pulse or respirations (breathing), facility staff did not initiate CPR as directed and did not call 911, Resident #32 expired. The findings include: Resident #32 was admitted to the facility on [DATE] with a recent readmission on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of [DATE], coded the resident as being severely impaired to make daily cognitive decisions. The resident was coded as being totally dependent of one or two staff member for all of his activities of daily living. The resident was incontinent of bowel and had an indwelling catheter for urine. The face sheet dated [DATE] documented, "Code Status." There was nothing documented under this heading. The facility form, "Advance Directives Checklist" documented, "3. Have you signed a 'Do Not Resuscitate' order?" a check mark was documented next to, "No." The hospital history and physical dated, [DATE], documented, "Code Status: PATIENT REMAINS FULL CODE." The readmission physician orders [REDACTED]." Review of the telephone orders dated, [DATE] through [DATE], did not reveal any orders to change the resident's code status. The physician progress notes [REDACTED]." A check mark was documented next to, "FULL CODE." The physician progress notes [REDACTED]." The physician progress notes [REDACTED]." The clinical record revealed the MAR (Medication Administration Record) for [DATE] that revealed a bright green sticker that documented, "FULL CODE." The MARs dated September, October and [DATE] documented, "Advance Directives: FULL CODE." The nurse's note dated, [DATE] at 6:00 a.m. documented, "Tylenol given @ (at) 5:30 a.m. for temp (temperature) 100.9. F/cath (Foley catheter) draining bloody urine. [MEDICAL CONDITION] care rendered. Toleted (sic) feeding and H2O (water) flush well. No S&S (signs and symptoms) of resp (respiratory) distress noted." The nurse's notes documented, "[DATE] - late entry. Called to Rm (room) @ 5:50 a.m. Assessment done. No V/S (vital signs: pulse, blood pressure or respirations) present. No papable (sic) pulses. No breath sounds noted. Resident cold to touch. Supervisor called to unit and responded. ,[DATE] supervisor arrive on unit." According to Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 1126, "Cardiopulmonary resuscitation: [MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that a client has [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respiration and manual external cardiac massage... The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage (AHA, 2001). The nurse's notes documented, "[DATE] - late entry. ,[DATE] Supervisor observed resident." A nurse's note dated [DATE] at 6:55 a.m. documented, ",[DATE] nurses supervisor came to unit completed assessment." The nurse's noted dated [DATE] at 6:57 a.m. documented, "Assessment completed, resident (an S with a line over it indicating 'without') any breath sounds, absence pulses, pupil non reactive to light, not responsive to command, pronounced dead. Pt (Patient) covered with white sheet will notify family and MD (doctor)." A nurse's note dated [DATE] at 7:18 a.m. documented, "(Name of Doctor) made aware of resident being deceased ." An interview was conducted with LPN (licensed practical nurse) #12 on [DATE] at 7:30 p.m. When asked what she would do if she found a resident without a pulse and respirations, LPN #12 stated, "I would check for a pulse, feel the carotid artery, listen to their heart, check if they are not cold. I would immediately provide privacy and call the supervisor to pronounce." When asked how she determined the code status of the resident, LPN #12 stated, "Oh, I mean I would check the chart for the code status and call a code if they were a full code." When asked how, the code status of a resident is documented in the facility, "LPN #12 stated, "In the chart on the physician orders [REDACTED]. An interview was conducted with LPN #1 on [DATE] at 8:04 a.m. When asked what he would do if he found a resident without a pulse and not breathing, LPN #1 stated, "You yell for help and ask someone to check the code status. Then you administer oxygen and perform a sterna rub. Then you start CPR if need be." When asked if you start CPR before you know the code status, LPN #1 responded, "No, you don't start CPR until you know the code status." When asked how he would identify the resident's code status, LPN #1 stated, "It's on the MAR, the front cover of the chart, the face sheet and it ' s in the physician orders." An interview was conducted with LPN #10 on [DATE] at 8:08 a.m. When asked what she would do if she found a resident without a pulse and respirations, LPN #10 stated, "You call for help. Have someone check the chart for a DNR or full code status. You assess the resident and initiate CPR on all full code residents. Have someone call 911." When asked if she would initiate CPR before knowing the resident's code status, LPN #10 stated, "You must start CPR until you know the resident's code status. If a DNR then you can stop." When asked how it is documented, in the facility, the resident's code status, LPN #10 stated, "There is a tag on the MAR, the chart, on the POS (physician order [REDACTED]." An interview was conducted with LPN #14 on [DATE] at 8:22 a.m. When asked what she would do if she found a resident without a pulse and respirations, LPN #14 stated, "You call the supervisor, get the crash cart and start CPR." When asked to describe the morning on [DATE] when Resident #32 passed away, LPN #14 stated, "I was in there with him around 5:00 a.m. I suctioned him, cleaned him up and then started passing my medications." The CNA (certified nursing assistant) called me to the room at 5:50 a.m. I came up to the desk and called the supervisor. I looked at the chart for his code status but couldn't find it, the other nurse looked too. Then the supervisor came up. He couldn ' t find the code status either. I asked him 'what we gonna do' ? He told me to just clean him and he went back downstairs and called the RN (registered nurse) to come in to pronounce the resident. Another nurse looked at the chart and found the code status. We didn't do nothing. The RN then came up and pronounced him." When asked if the resident's code status is unknown what are you supposed to do, LPN #14 replied, "You have to start CPR." When asked if she started CPR on Resident #32, LPN #14 stated, "No, I didn't." When asked if that was correct procedure, LPN #32 stated, "No." LPN #14 was asked to describe her note where she stated the resident "cold to touch." LPN #14 stated, "His skin was kind a cold anyway. I had just been in there at 5:30 a.m. giving him Tylenol for his temperature. He was always kind of cool to the touch. His eyes were closed which was not unusual for him as he kept them closed most of the time. He wasn't breathing; I tried to get vital signs. The CNA went and got the chart and we couldn't find the code status. I made a mistake with this resident; I should have called the code." An interview was conducted with the resident's physician, administrative staff member (ASM) #4 on [DATE] at 9:28 a.m. When asked if he documented Resident #32's desire for code status, ASM #4 stated, "I don't recall discussing it with (Resident #32)." When asked if he had discussed changing the resident's code status to a DNR with the family when he was declining, ASM #4 stated, "I don't recall speaking with his wife regarding changing the code status." ASM #4 reviewed his progress notes and stated, "I had him as being a full code in my notes and in my orders." An interview was conducted with LPN #13, the supervisor, on [DATE] at 9:35 a.m. When asked to explain his involvement when Resident #32 passed away on [DATE], LPN #13 stated, "I was working the med (medication) cart downstairs. She (LPN #14) called me to tell me a resident that just expired. She was very casual, not alarmed. I asked if the resident was a full code and she told me no. I went upstairs, after I finished a few things, and the CNA and nurse were at the nurse's station. I told her that an RN would be in shortly to pronounce. I advised her to perform post mortem care. I assumed she had anticipated the residen's death. I went back downstairs. My relief came and the RN came. A little while later I was finishing up my work when (LPN #14) called me to tell me the resident was a full code, not a DNR. I went back upstairs. When I asked her what she saw at first she told me she didn't really see a DNR order. The nurse made a mistake. I was misinformed that he was a DNR." When asked if any processes changed after this incident, LPN #14 stated, "The DON (director of nursing) gave me an education form and policies in a situation like that - full code versus DNR. The only outcome that I am aware of is that the resident's family (Resident #32) had made wishes known of no extra ordinary measures were to be used but I didn't see that myself." An interview was conducted with the director of nursing and the administrator on [DATE] at 9:48 a.m. When asked for a policy for following physician orders, the DON stated there was no policy for that. When asked what the facility nurses are to do if they find a resident without a pulse or respirations, the DON stated, "If someone is with me, I tell them to get the chart. If I'm alone I'd have to go get the chart. I'd call a code blue and start CPR." When asked if the nurse on [DATE] followed the facility policy, the DON stated, "No, she didn't." When asked if any education was provided after [DATE], the DON stated, "The two nurses involved, (LPN #14 and LPN #13), the supervisor, were educated." The facility policy, "Code Status" documented, "Purpose: To ensure each resident's wishes in regards to code status is honored by the facility in the event of any emergency. Justification: Each resident in the facility has the potential for an emergency event which could result in cessation of vital signs. In those instances, the licensed nurses must know what the resident's specific directions are for being resuscitated. Each resident must have a code status order which will be honored by the staff ....Procedure: 1. Each resident residing in the facility must have a code status order ...10. In the event of an emergency a person will be designated to obtain the chart during staff response to the resident room. 11. Resuscitation measures will be implemented according to the signed advance directives and the physician orders." According to Lippincott's Manual of Nursing Practice, 8th edition, (2006) page 1129, "Standards of Care Guidelines for Emergency Assessment and Intervention: When a patient presents with a potentially life-threatening condition, proceed swiftly with the following: ...Assess airway, breathing, and circulation in systematic manner. Immediate intervention is needed for such conditions as compromised airway, respiratory arrest, compromised respirations, [MEDICAL CONDITION] and profuse bleeding. Provide emergency airway management, cardiopulmonary resuscitation. Call for help as soon as possible". The administrator and DON were made aware of the concern for harm on [DATE] at 9:50 a.m.

Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to follow the physician orders [REDACTED].#106. A. The physician order [REDACTED]. The order was transcribed to Resident # 106's MAR (medication administration record) with scheduled administration times, and was not administered q (every) four hours as ordered. B. The facility staff failed to administer Tylenol to Resident #106 on 6/13/13 at 8:00 a.m. per physician orders. The findings include: A. Resident #106 was admitted to the facility on [DATE] with a recent readmission on 5/6/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/22/13, coded the resident as usually able to express ideas and wants, and sometimes responds adequately to simple direct communication only. The resident was coded as having both short and long term memory problems and was moderately impaired to make cognitive daily decisions. Resident #106 was coded as having periods of inattention and disorganized thinking during the look back period. In Section E - Behaviors, the resident was coded as having physical behavioral symptoms directed towards others and other behaviors not directed toward others. Resident #106 was coded as requiring extensive assistance of one staff member for moving in the bed, moving off the unit, dressing, toileting needs, and personal hygiene. The resident required limited assistance of one staff member for moving from the bed to the chair. Resident #106 was coded as requiring limited assistance of one staff member for walking in the room or corridor and eating. The resident used a walker and was coded as being occasionally incontinent of both bowel and bladder. Review of the clinical record revealed, "Report of Consultation" dated, 6/10/13, that documented, "Recommendations: Diet as tolerated, Tylenol 325 mg (milligrams) po (by mouth) q 4 h (every four hours) X (times) 18 doses." Per the facility drug handbook, Nursing 2012 Drug Handbook; Lippincott, Williams & Wilkins, page 710, Tylenol is an [MEDICATION NAME] used to treat mild pain or fever. The telephone physician order [REDACTED]. Tylenol 325 mg po q 4 h x 18 doses." Review of the June 2013 MAR (medication administration record), documented, "Tylenol 325 mg po q 4 h x 18 doses." The times listed for the administration of the Tylenol were documented as 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m." There were no doses documented as given after 8:00 p.m. and before 8:00 a.m. A second physician order [REDACTED]." Per the facility drug handbook, Nursing 2012 Drug Handbook; Lippincott, Williams & Wilkins, page 762, [MEDICATION NAME] is a synthetic [MEDICATION NAME] used to treat moderate to moderately severe pain. Review of the MAR indicated [REDACTED]. An interview was conducted with RN (registered nurse) # 2, the unit manager, on 6/13/13 at 11:20 a.m. When asked to review the order for Resident #106 on 6/10/13, RN #2 reviewed it. When asked how the medication should be given, RN #2 stated, "It should be given around the clock according to the order." When asked to review the MAR for June 2013, RN #2 stated, "That's transcribed incorrectly, it didn't state in the order to only give while awake." In "Fundamentals of Nursing" 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 419. "The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]." The administrator and director of nursing were made aware of these findings on 6/13/13 at approximately 5:00 p.m. On 6/13/13 at 5:15 p.m., the administrator informed this surveyor that the facility did not have a policy on following physician orders. B. On 6/13/13 at 11:30 a.m., the MAR indicated [REDACTED]. An interview was conducted with LPN (licensed practical nurse) #5 on 6/13/13 at 11:35 a.m. When asked if the 8:00 a.m. dose of Tylenol had been given to Resident #106, LPN #5 stated, "I'm a floater. I was told that there were only 10:00 a.m. medications on this hall. I didn't scan the MARs before I started." When asked when are medications to be given, LPN #5 stated, "They are to be given an hour before or an hour after the prescribed time." The unit manager, RN #2 was made aware of the dose of Tylenol not administered at 8:00 a.m. The facility policy, "Med-Pass Procedure" did not address the time medications are to be given. According to Fundamentals of Nursing 6th Edition, 2005: Patricia A. Potter and Anne Griffin Perry; Mosby, Inc., page 843, "All routinely ordered medications should be given within 60 minutes of the times ordered." The administrator and director of nursing were made aware of the above concern on 6/13/13 at 5:00 p.m. The director of nursing stated on 6/13/13 at 5:50 p.m. that the administration of medication an hour before or an hour after is a standard of nursing practice. When asked which standard of practice the facility follows, the director of nursing stated, "Fundamentals of Nursing by Perry and Potter."