Every finding on record at Carrara

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #55) reviewed for PASRR assessments. The facility failed to ensure Resident #55 was referred to the appropriate state-designated mental health authority for review when she received a new diagnosis of schizoaffective disorder, bipolar disorder and anxiety disorder. This failure could place residents at risk of not being evaluated and receiving PASRR services needed. Findings included: Record review of Resident #55's quarterly MDS Assessment, dated 05/21/2026, reflected the Resident #55 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #55 had active diagnoses of bipolar disorder (mental health condition characterized by extreme, dramatic shifts in mood, energy, and activity levels, alternating between intense highs (mania or hypomania) and lows) and anxiety (a natural human emotion characterized by feelings of worry, nervousness, or unease, typically about an event with an uncertain outcome), and the resident had moderate cognitive impairment with a BIMS score of 08. Record review of Resident #55's care plan, undated, reflected Focus: Behavior Problem: Resident has a behavior problem as related to feelings of shame. Goal: Resident will maintain psychosocial well-being. The Residents will express triggered stresses and verbally share concerns and goals. Interventions/Task: Refer to Behavioral Health Professional, Psychiatric consult, Notify MD of any changes in mood or behavior, Assess resident for suicidal or homicidal ideations. Record review of Resident #55's PASRR Level 1 Screening, dated 05/09/25, reflected the screening did not indicate Resident #55 had primary diagnosis of dementia, did not have a mental illness. During an interview on 05/07/2026 at 12:11 p.m., the MDS Nurse stated she was the facility's PASRR Coordinator. The MDS Nurse stated that if a resident admitted to the facility with a mental health, intellectual disability, or a developmental disability diagnosis the resident's PL1 mental illness should have been checked yes. The MDS Nurse pulled up Resident #55's medical chart and reviewed her medical chart and stated Resident #55 had a diagnosis of bipolar disorder and anxiety disorder on 05/09/25. She pulled up Resident #55's PL1 and stated it was completed on 05/09/2025 the day Resident #55 admitted to the facility. She stated Resident #55's PL1 was negative, and she did not know how Resident #55 had no marked for mental health diagnoses. The MDS Nurse stated she was unable to state why the facility did not draft a new PL1 once diagnoses were found. She stated failure to perform screening and involving the authority, the resident failed to get required assessments and that could lead to her not receiving services that could have benefited her. The MDS Nurse stated there were limited risks to Resident #55 since she was already on medication, had psychiatric services, but she would have missed the local authority's visitation. During an interview on 06/25/26 at 04:04 p.m., the DON stated the facility would not accept a resident without a PASRR. The DON stated that the MDS Nurse was responsible for reviewing the PASRR for accuracy. The DON stated that if there was a discrepancy or the resident was not screened, the facility would have to submit a PL1. The DON stated that she did not know why Resident #55's PL1 was incorrect and not resubmitted with accurate mental health diagnoses. The DON stated Resident #55 could be missing out on services by not having the correct information on her PL1. During an interview on 06/25/2026 at 1:12 p.m., the ADM stated that it was his expectation that the MDS Nurse ensured residents had a PASRR completed prior to the resident's admission to the facility and to review for accuracy; and if errors were found then to send it back to the facility for them to fix. The ADM stated that if any resident, while in the facility, received a new MI the facility MDS Nurse was responsible for creating a PL1 to submit to the local authorities. Record review facility policy titled Resident Assessment - Coordination with PASRR Program dated December 2025 revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.A record of the pre-screening shall be maintained in the resident's medical record.If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days:The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for three of five residents (Residents #1, #2, and #3) reviewed for catheters. The facility failed to ensure Resident #1, #2, and #3's urinary catheters were anchored/secured to protect the resident's urethral openings and maintain proper urine flow.This failure could place residents with urinary catheters at risk of pulling/tension, kinks, and accidental dislodgment which could result in trauma and increase the risk of urinary tract infections.Findings included:Record review of Resident #1's MDS, dated [DATE], reflected she was a [AGE] year-old female who admitted on [DATE]. The resident's diagnoses included stroke affecting her speech and ability to swallow, diabetes, and pressure ulcers. The resident's BIMS score was not calculated due to her medical conditions. Her Functional Ability assessment reflected that she was totally dependent on staff for all her ADLs. Record review of Resident #1's care plan, dated 02/18/26, reflected she was incontinent of bowel and bladder, requiring the use of briefs and a urinary catheter. Record review of Resident #1's physician orders, dated 04/14/26, reflected: Foley catheter, change catheter anchor as needed. During observations on 05/06/26 at 10:59 AM and 3:10 PM, Resident #1's urinary catheter collection bag hung on the resident's bed frame. The urinary catheter was not anchored to the resident's leg. Record review of Resident #2's quarterly MDS, dated [DATE], reflected he was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, diabetes, and seizures. His BIMS score was 3, indicating severe cognitive impairment. His Functional Ability assessment reflected he was totally dependent on staff for his ADLs. Record review of Resident #2's care plan, dated 05/05/26, reflected he had an indwelling urinary catheter. During observations on 05/06/26 at 11:23 AM and 1:10 PM, Resident #2's urinary catheter collection bag hung from the resident's bed frame. The catheter was not secured to the resident's leg. Record review of Resident #3's admission MDS, dated [DATE], reflected he was a [AGE] year-old male who admitted on [DATE]. The resident's diagnoses included low oxygen levels due to poor breathing, high blood pressure, and pneumonia. His BIMS score was 14, indicating he was cognitively intact. His Functional Assessment revealed he required minimal assistance with his ADLs. Record review of Resident #3's care plan, dated 03/02/26, reflected he had a urinary catheter related to and enlarged prostate. During observations on 05/06/26 at 10:10 AM and 12:28 PM, Resident #3's urinary catheter collection bag hung from the resident's bed frame. The catheter was not secured to the resident's leg. During an interview on 05/06/26 at 1:40 PM, LVN A stated the nurse was responsible for ensuring the urinary catheter was secured to the resident's upper leg. She stated the risk if it was not secured could be the catheter being pulled out accidentally. During an interview on 05/06/26 at 1:53 PM, LVN B stated it was ultimately the nurse's responsibility to ensure the urinary catheter was properly secured to the resident's leg. She stated there was a risk of the catheter being pulled out if it wasn't anchored properly. During an interview on 05/06/26 at 2:00 PM, LVN C stated the nurse had the ultimate responsibility to ensure the catheter was secured to the resident's upper leg. Often the CNAs would let them know they had replaced the anchoring device. She stated the biggest risk was the catheter being pulled out and causing trauma if it was not anchored properly. During an interview on 05/06/26 at 2:15 PM, the ADON stated the CNAs and nurses were responsible for ensuring urinary catheters were properly secured to the resident's legs. He stated the obvious risk was the catheter being pulled out accidentally, causing severe trauma to the urethra (tube from the bladder out of the body). The balloon that secured the catheter in the bladder was much larger than the urethra and pulling the catheter out before deflating the balloon would cause severe trauma to the urethra. During an interview on 05/06/26 at 4:00 PM, the Administrator stated the DON had been hired but was currently in training. Record review of the facility's Catheter Care policy, dated 12/01/25, reflected it did not address anchoring the catheter to the resident's leg. Record review of the CDC's Healthcare Infection Control Practices Advisory Committee's Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 reflected: .II. Proper Techniques for Urinary Catheter Insertion.E. Properly secure indwelling catheters after insertion to prevent movement and urethral traction.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #1 and Resident #2) of 5 residents reviewed for resident rights. The facility failed to ensure LVN A introduced herself and spoke to Resident #1 while administering pain medication. The facility failed to ensure LVN A introduced herself and spoke to Resident #2 while moving his call light. These failures could place residents at risk of not being treated with respect and dignity.Findings included: Review of Resident #1's admission MDS Assessment, dated 02/20/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 14, which indicated she was cognitively intact. Her diagnoses included arthritis and pelvic fracture. An observation and interview on 02/19/26 at 11:15 AM with Resident #1 revealed she was lying in bed. She was groaning, grimacing and said she was in pain. LVN A walked into the room. She had a cup of water and a cup with a pill in it. She handed it to Resident #1. LVN A did not speak to the resident. She did not introduce herself or explain what medication she was giving to the resident. Resident #1 said she was used to the nurse not introducing herself. An interview on 02/19/26 at 11:25 AM, LVN A revealed she had been trained to introduce herself to residents and explain the medication she was giving, but this time she just did not. She said it was important to introduce herself and explain medication to residents for assessment. Review of Resident #2's admission MDS Assessment, dated 11/09/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills were severely impaired. His diagnoses included non-Alzheimer's dementia and Parkinson's disease. An observation and interview on 02/19/26 at 11:35 AM, Resident #2 did not answer questions. He was lying in bed awake and alert. His call light was at the end of the bed. LVN A was asked about the call light being out of reach. LVN A walked into the room and did not speak or introduce herself. LVN A went to the resident, picked up the call light and tossed it up to the resident. The resident was looking at the LVN. The LVN straightened the resident's blanket and walked away from the resident. Resident #2 did not reach for the call light. An interview on 02/19/26 at 11:40 AM with LVN A, Resident #2 would move around a lot and the call light would be moved. She said she did not speak to the resident because she was just in her head. She said she had been trained to introduce herself and interact with residents. She said it was important to interact with residents because it was their right. An interview on 02/19/26 at 11:30 AM, the DON revealed nurses were supposed to introduce themselves and explain the medication they were administering to the residents. She said failure to do so could keep the residents from having the right to be informed. Record review of the facility policy, Resident Rights, revised 12/01/25, reflected: .10. All residents will be treated equally.11. The facility will ensure that all direct care.are educated on the rights of residents and the responsibility of the facility to properly care for its residents.

Based on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents reviewed for pain management. The facility failed to ensure LVN A assessed the pain level for Resident #1. This failure could place residents at risk of not having their pain managed.Findings included: Review of Resident #1's admission MDS Assessment, dated 02/20/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were not impaired. Her BIMS score was 14. Her diagnoses included arthritis and pelvic fracture. Review of Resident #1's Comprehensive Care Plans, dated 02/16/26, reflected:The resident was on pain medication therapy.Facility interventions included: Monitor/document/report adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinaryretention. Review of Resident #1's Physician Orders for February 2026 reflected:02/16/26: Oxycodone 15 milligrams every 6 hours as needed for pain02/16/26: Methocarbamol (muscle relaxer) 1000 milligrams four times [NAME] scheduled Review of Resident #1's Medication Administration Record reflected:02/19/26 - Oxycodone 15 milligrams administered by LVN A at 11:18 AM. Pain Scale Score: 5 02/19/26 Methocarbamol administered as ordered. An observation and interview on 02/19/26 at 11:15 AM, Resident #1 was lying in bed. She was groaning, grimacing and said she was in pain. Resident #1 said her pain level was a 12 on a scale of 1-10. It hurts so bad if I move around. LVN A walked into the room. She had a cup of water and a cup with a pill in it. She handed it to Resident #1. LVN A did not introduce herself. LVN A did not ask Resident #1 what her pain level was. LVN A walked back out of the room. An interview on 02/19/26 at 11:25 AM, LVN A gave Resident #1 oxycodone for her pain. LVN A said she did not assess Resident #1's pain level because she just did not. She said she did not know Resident #1 had a pain level of 12. LVN A said the resident would ask for the pain medicine every six hours and the nurses would administer it to her. She said she was supposed to ask what the pain level was to see if the medicine was working. She said she would call the physician because Resident #1 said her pain level was a 12. A follow-up interview on 02/20/26 at 4:15 PM, Resident #1 was lying in bed. She said her pain was at a good level. She said staff offered additional pain medicine (Tylenol), but she did not want to take it. An interview on 02/19/26 at 11:30 AM, DON said nurses were supposed to assess the pain level of residents to see if pain medicine was working. Record review of the facility policy, Pain Management, dated 12/01/25, reflected: .Pain Assessment.Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident.

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #1) of 5 residents reviewed for reasonable accommodations. The facility failed to ensure CNA A removed Resident #1's lunch tray from the bedside table to accommodate him when requested.The noncompliance was identified as past noncompliance (PNC) that began on 11/03/25 and ended on 11/03/25. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk of not being able to meet their needs. Findings included:During a record review of Resident #1's face sheet, dated 11/20/25, revealed an [AGE] year-old man admitted on [DATE] with anxiety disorder (mental health conditions characterized by excessive worry or fear that interferes with daily life). During a record review of Resident #1's quarterly MDS assessment, dated 09/18/2025, revealed Resident #1 had a BIMS score of 5, which indicated severe impairment. Resident #1's functional limitation in range of motion revealed he was impaired on both sides for his upper and lower extremities and required setup or clean-up assistance with eating.During an interview on 11/20/25 at 10:00 a.m., the ADM revealed that on 11/03/25 Resident #1's family member notified me that an aide entered Resident #1's room and Resident #1 wanted to use his iPad that was located under his lunch tray. Resident #1 requested that the lunch tray be removed, and the staff member refused to remove the tray. The ADM stated that he learned through his investigation that the staff member did not remove the lunch tray and it was confirmed that it was a customer service issue and unprofessional. The ADM stated that the aide was suspended for a week, upon return was in-serviced on customer service and resident rights and reassigned and no longer worked with Resident #1. During an interview on 11/20/25 at 12:30 p.m., CNA A revealed that she had cared for Resident #1 on 11/03/25. CNA A stated that she was on the hall and heard a loud beeping noise and had entered his room, saw that his IV treatment had finished. The nurse assigned to the hall had dining room duties so informed Resident #1 that she was unable to disconnect the IV treatment that a nurse had to disconnect him from treatment and that she was going to find a nurse and would be right back. CNA A found a nurse, but the nurse had just entered another resident's room to perform trach care and informed CNA A to go and stay with the resident until she was able to get there. CNA A went back to Resident #1 room and told him that the nurse would be there shortly. CNA A stated that she saw that his colostomy bag needed to be emptied so started to change Resident #1's colostomy bag and Resident #1 requested her to remove his tray. CNA A stated that she had asked Resident #1 if he could wait until she had finished due to hands being dirty. She said she did not refuse to take the tray just delayed. CNA A stated she just wanted to finish what she was doing and would remove the tray on her way out. CNA A stated that she could have moved the tray off the table but was under the impression Resident #1 wanted her to remove the tray from the room. CNA A stated that she was suspended for a week and when she returned to work, she was reeducated on customer service and resident rights. Verified via record review in-services for CNA A were completed on 11/11/2025 and they were conducted by the ADM, Director of nursing and staffing coordinator. During an interview on 11/20/25 at 1:01 p.m., Resident #1 stated that on 11/03/25 an aide came into his room, he asked her to take his lunch tray so that he could utilize his bedside table, but the aide refused. Resident #1 stated he had called his family member by accident and the interaction was recorded on voicemail and it was reported to the ADM. Resident #1 stated that the aide had emptied his colostomy bag and still refused to remove the tray. Resident #1 stated he wanted the lunch tray removed from the beside table not the room, she could have placed it on the counter or sink area. Resident #1 stated that the aide was suspended for about a week, but when the aide returned, she could not care for him. Resident #1 stated that it did not cause him any harm or mental anguish, he just could not understand why she would not take the tray.During record review of Resident #1's recording on 11/20/25 at 1:05 p.m., revealed the aide refused to remove Resident #1's tray as requested. During an interview on 11/20/25 at 1:47 p.m., LVN B revealed that she entered Resident #1's room to disconnect his IV treatment that had finished. LVN B stated that Resident #1 and the aide was talking back and forth but she was focused on the disconnection and then left Resident #1's room. LVN B stated that she believed his lunch tray was on his bedside table as lunch had just finished. LVN B stated she did not hear what Resident #1, and the aide was talking about. LVN B stated that no voices were raised and did not hear anything derogatory or would have intervened. LVN B stated that she did not recall Resident #1 asking for his lunch tray to be removed, because she would have removed it herself. LVN B stated she was just focused on the task so she could get back to her hall. During an interview on 11/20/25 at 4:30 p.m., the ADM revealed that he had listened to the voice recording and did not believe that it was demeaning or intentional because we would have partied ways with the staff member, but there was a customer service issue. The ADM revealed his expectations of his staff was to provide good customer service and do whatever we can for the residents if it is safe. Record review of a Resident Rights policy, dated February 2021, revealed:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included the residents' right to:a. a dignified existence b. be treated with respect, kindness and dignityg. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility h. be supported by the facility in exercising his or her rights

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records in that: The facility failed to document Resident #1's blood pressure before she was transported to dialysis on 08/13/25. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner.Findings included: Record review of Resident #1's face sheet, dated 09/17/25, reflected a [AGE] year-old female with an admission date of 01/24/23. Resident #1 had a diagnosis of Stage 5 Chronic Kidney Disease (the most advanced stage of kidney disease), Acute or Chronic Heart Failure (sudden life-threatening or worsening heart condition), Bacterial Infection (harmful bacteria enter the body and can cause damage), End Stage Renal Disease (kidneys have lost most of the function), Type 2 Diabetes Mellitus (body cannot regulate blood sugar levels), Fluid Overload (excessive amount of fluid in the body), Cardia Arrhythmia (abnormal heart rhythm), Presence of Heart Assist Device, Chest Pain, Unspecified Dementia (cognitive decline and memory loss), and Hypotension of Hemodialysis (a drop in blood pressure that occurs during dialysis). Record review of Resident #1's quarterly MDS assessment, dated 07/16/25, reflected she had a BIMS score of 11 in Section C, which indicated she was moderately impaired. Section N of the quarterly MDS assessment noted Resident #1 had anticoagulant, antibiotic, and hypoglycemic medications. Section O of the quarterly MDS assessment noted Resident #1 received dialysis while she was a resident. Record review of Resident #1's physician orders reflected the following orders: 04/21/25Dialysis MWF11:00 AM 04/21/25Vital Signs Every Shift Record review of Resident #1's Dialysis Communication Form, dated 08/13/25, reflected the following: Dialysis date: 08/13/25 Most Recent Blood Pressure Blood Pressure 102/65 Date 08/12/25 18:22 (6:22 PM) Record review of Resident #1's care plan with an initial date of 05/15/25 reflected the following: Resident #1 required hemodialysis 3 times per week due to ESRD Monitor vital signs. Notify MD of significant abnormalities Resident #1 has an implanted cardiac pacemaker Monitor vital signs. Notify MD of significant abnormalities Record review of the progress notes on Resident #1's electronic record reflected not vital listed for 08/13/25. Record review of the main page of the electronic record, dated 09/17/25, reflected the last blood pressure vital was taken on 08/12/25 at 18:22 (6:22 PM), and Resident #1's blood pressure was 102/65. Record review of the Vitals tab on Resident #1's electronic record reflected the last blood pressure recorded was on 08/12/25 at 18:22 (6:22 PM) by Nurse A. Record review of the August 2025 NAR reflected no blood pressure vitals documented on 08/13/25. Record review of the August 2025 MAR reflected no blood pressure vitals documented on 08/13/25. Record review of the August 2025 TAR reflected no blood pressure vitals documented on 08/13/25. During an interview on 09/17/25 at 11:10 AM, with the Director of Clinical Services, the DON, and the Administrator, Resident #1's Dialysis Binder was requested but not received prior to exit. In an interview on 09/17/25 at 11:40 AM, LVN B stated he prepped Resident #1 for dialysis on 08/13/25. He stated he took her to the transportation person and sent her dialysis folder with her. LVN B stated he checked all of her vitals before she left, and all were within the appropriate range. In an interview with the Director of Clinical Services and the ADON on 09/17/25 at 2:09 PM, The Director of Clinical Services stated he reviewed Resident #1's electronic record and did not locate documentation of Resident #1's blood pressure reading from 08/13/25. The ADON stated it could have been a coincidence that the blood pressure reading from 08/12/25 was the same reading for 08/13/25, and that LVN B probably just documented the wrong date for the blood pressure reading of 102/65. The Director of Clinical Services stated all staff were trained on quality of care, following physician's orders, and documentation. The Director of Clinical Services stated Resident #1's vitals would usually be checked before she left for dialysis. The Director of Clinical Services stated the risk of LVN B not possibly checking the blood pressure or recording the vitals of the patient could negatively affect the patient's care. In a follow-up interview on 09/17/25 at 2:26 PM, LVN B stated he recalled he manually checked Resident #1's blood pressure, but he could not remember what the reading was. LVN B stated he did remember that the blood pressure was within the normal range. LVN B stated vitals are checked on all dialysis residents before they leave for dialysis. He stated he must not have documented the blood pressure. He stated he thought he just wrote the wrong date on the dialysis communication form. LVN B stated the risk of not checking or not documenting the vital check was there could be a problem with the resident and staff would not be aware of before sending the resident to dialysis. In an interview on 09/17/25 at 2:59 PM, the Administrator stated the facility staff were trained on quality of care, documenting, and following physician's orders. The Administrator stated the risk of Resident #1's blood pressure not checked or documented as checked on 08/13/25 was a negative impact on the resident's care. Record review of the facility's in-service titled, Physician's orders, dated 08/20/25, reflected the following: Key Points Physician orders provide the medical plan of care for the patient. Nurses are responsible for carrying out those orders safely and documenting accurately. Following orders ensures continuity of care, patient safety, and compliance with regulations.

Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored, in a plastic bag with the resident's name and date on it, when not in use on 08/13/2025.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 08/13/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included COPD (disease of the lungs and airway that affects breathing), diabetes (the body does not use insulin effectively), and chronic kidney disease (reduced kidney function). Record review of Resident #1's MDS (tool used to measure health status) Quarterly Assessment, dated 06/16/2025, reflected moderate impaired cognition with a BIMS (tool used to assess cognitive function) score of 12. Section I (active diagnoses) reflected Resident #1 was treated for COPD and asthma (lung disease that causes the airway to narrow and can make breathing difficult).Record review of Resident #1's Comprehensive Care Plan, dated 07/14/2025, reflected the resident had COPD and the approaches were to monitor for shortness of breath and administer medication as ordered.Record review of Resident #1's Physician's Order, dated 08/13/2025, reflected to administer Ipratropium Albuterol Solution 0.5-2.5 (3) mg/3ml - inhale 1 vial orally three times a day for shortness of breath. During an observation and interview on 08/13/2025 at 9:30 AM, Resident #1 was lying in bed. A nebulizer was on top of Resident #1's night stand next to the bed. A nebulizer mask and tubing was connected to the nebulizer. The nebulizer mask was in the top drawer of the night stand with Resident #1's personal items. The mask was not bagged. Resident #1 stated she had a breathing treatment earlier that day. In an interview on 08/13/2025 at 9:42 AM, the RN stated the nebulizer mask should have been in a bag. She stated nebulizer masks and tubing were changed weekly for all respiratory care items. She stated it was important to keep them covered to prevent contamination and infection. During an interview on 08/13/2025 10:05 AM, the CNA stated she also looked at nebulizer masks. She stated nebulizer masks should always be in a bag when the resident was not using it. She stated if a nebulizer mask were not in a bag, she reported it to the nurse so the nurse could get a new mask and put in a bag. She stated she had not noticed the nebulizer mask was not in a bag. She stated if it was not kept in a bag, it was exposed to whatever was in the air. She stated if the resident put the mask back on her face, the risk could be infection. During an interview on 08/13/2025 at 10:12 AM, the ADON stated staff members changed oxygen tubing and nebulizer masks weekly on Sunday night. She stated items should be dated and stored in bags when not being used by residents. She stated this was a risk for infection to residents.During an interview on 08/13/2025 at 1:25 PM, the facility's Regional Nurse Consultant stated in-service training for staff was in progress. He stated there were dust particles in the air and it was important to keep respiratory items in bag to prevent the risk of infection to residents. Record review of the facility's policy Administration Through a Small Volume (Handheld) Nebulizer, undated, reflected 29 . store in a plastic bag with the resident's name and the date on it.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed on 05/01/2025 to ensure dented cans dated 04/28/2025 was placed in a separate storage area to keep from being used for residents' meals. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of dry storage on 4/29/2025 at 9:22am revealed the following: two 6lbs 9oz cans of marinara sauce dated 4/28/2025 was dented on the front. In an interview with [NAME] A on 05/01/2025 at 1:05pm she stated it was the cook's responsibility to store and inspect dry goods in the dry storage upon delivery. She stated if she observed a dented can, she would let the DM know, and placed the dented can in the separate area the kitchen had for dented cans. She stated the DM took a picture of the dented can and sent the photo to the vendor. [NAME] A stated the after the food was stored, labeled, and dated, the DM would go behind staff and inspect items. [NAME] A stated failure to keep dented cans separated could be used and cause sickness because dented cans could have bacteria. In an interview the DM on 05/01/2025 at 1:10pm who stated when the delivery truck delivered food to the facility, the kitchen cooks was responsible for dry storage food items to be properly labeled, stored, and inspected. He stated it was his responsibility to go behind the cooks and inspect all food items from the previous delivery. He stated if staff identified a dented can, he took a picture of the dented can and sent the picture to the vendor and was credited for the dented can. He stated dented cans was kept in separate area. He stated dented cans could cause botulism. The DM provided the facility's food storage policy and indicated the facility did not have a policy regarding dented cans. Record review of the U.S. FDA Food Code 2022 reflected: Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent incidents and accidents for one resident (Resident #1) of five residents reviewed for possible accident hazards and incidents. The facility failed to provide adequate supervision for Resident #1 on 07/23/2024 when he slid out of the sling during a mechanical lift transfer from wheelchair to bed. The noncompliance was identified as past noncompliance (PNC). The PNC began on 07/23/24 and ended on 07/28/24. The facility had corrected the noncompliance before the state's survey began. This failure could place residents at risk for possible injuries due to lack of adequate supervision. Findings included: Review of Resident #1's Face Sheet reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including dementia, hypertension (elevated blood pressure), diabetes mellitus (alteration in blood sugar), aphasia (communication disorder resulting from a brain injury and may include inability to speak well), and stroke. The MDS reflected Resident #1 required substantial/maximal assistance for transfers to and from the bed and wheelchair. Record review of Resident #1's Care Plan dated 03/15/2022 and effective at the time of the incident (07/23/2024) reflected Resident #1 was dependent with activities of daily living and required the use of a mechanical lift for transfers. Review of Provider Investigation Report reflected the facility reported to Health and Human Services on 07/24/2024 at 05:15 p.m. that on 07/23/35 at 07:45 p.m. an incident occurred in which Resident #1 fell out of a sling during a mechanical lift transfer as reported to the charge nurse on duty by CNA A and CNA B. Review of written witness statement obtained by the facility and signed by CNA B dated 07/23/24 were reviewed and stated, sling never detached from hoyer and As I along with another staff were preparing to transfer 405 we hooked and secured the sling to the hoyer lift. As he started to push the button to go up everything seem to be ok. Then patient slipped out legs first head cushioned by a pillow that was on the wheelchair. We checked on his wellbeing immediately and then transferred by hand to the bed.(unable to read) arranged and checked again verbalize to make sure patient was ok. No concern of pain. Nurse Notified. Review of written witness statement obtained by the facility, signed by CNA A, and dated 07/23/24 stated, As we were transferring the resident in room [ROOM NUMBER] with another CNA, the sling was properly hooked on the hoyer but along the line the patient slipped. We notified the nurse, picked him up and got him situated. The patient, when asked said he did not feel any pain. Review of records- Clinical Note dated 07/23/24 and entered by LVN H for Resident #1 stated, 1945 (07:45 p.m.) the CNAs reported to this nurse that during transfer the resident from the wheelchair to bed by use of the mechanical lift, the resident slipped out of the Sling and fell down. The sling never detached from the Hoyer. The clinical note reflected that the nurse completed a head-to-toe assessment of Resident #1, notified the nurse practitioner, the hospice company, the ADON, and the family. LVN H reported he received orders for x-rays, and initiated neuro checks. The clinical note did not indicate that Resident #1 experienced any injury or any pain. Review of records reflected that on 07/24/2024 that x-rays revealed compression fracture of the T11 vertebral body that was of indeterminate age. The physician was notified, and Resident #1 was sent to emergency room for follow up. Record review of hospital records reflected that Resident #1 had no acute injuries: Hospitalist Progress Note dated 07/24/24 and written by MD A was reviewed and revealed that Resident #1 cat scan of the brain and x-rays showed no acute bleed or fractures or dislocations and that T-spine showed chronic T3 and T11 compression fractures. In an interview and observation on 12/10/24 at 11:00 a.m. Resident #1 was observed laying in bed. The bed was in low position and the call light was in reach. He denied remembering any incident of falling from a lift. His answers to questions did not always correspond appropriately to the questions. A wheelchair was noted at the bedside and a sling was on the back of the chair. The sling was noted in good condition. In a telephone interview on 12/10/24 at 12:46 pm, LVN H reported he was the nurse for Resident #1 on 7/23/24 and that CNA A and CNA B reported to him in the evening that Resident #1 had slid out of the sling when they were transferring him from the wheelchair to the bed. He stated, I went to the room and the resident was on the floor. The CNAs reported they assisted the resident to the floor when he began to fall. They did not state that he hit his head or anything else. I looked and the Hoyer lift was okay, the sling was okay. LVN H reported he immediately went to Resident #1's room and noted Resident #1 lying on his back on the floor with his legs pulled up in a fashion typical for the resident, and that his hands were laying across his chest. LVN H stated the sling was under the resident but that he did not note the positioning of the sling. He reported that the resident was within one or two feet of the bed and was not contacting any object. He stated, I'm not sure what might have caused the slide, they did not mention anything. I assessed the resident, and he denied any pain. The facility policy to do neuro checks, we notified the hospice, management (unit manager), an x-ray was ordered, the family was contacted. The resident was not transferred on my shift, but I think maybe the next day. He also stated, A resident could slip out of a Hoyer lift if the resident was not properly positioned and that a resident who fell from a mechanical lift, could have a fracture or other injury. He reported that, Since the incident, the facility continues training on Hoyer lifts, but also nurses now monitor transfers with the Hoyer lift, when possible, to monitor for safe technique. In a telephone interview on 12/10/24 at 02:00 p.m., CNA A reported that on 7/23/24 he was working on evening shift when, the aide that was working that hall called me to help with Resident (Resident #1) to put him to bed. When we lifted him off of his chair, we noticed that his butt was almost off the sling, we lowered him to the floor with our arms and called the nurse to come and assess him. There was a pillow behind him on the neck area when he was in the chair and when we brought him down, we used the pillow as well to bring him down. He did not hit his head. He did not hit anything that we were aware of. When he was lifted from bed to chair, because of the way his legs are wide open, it may have created a wrinkle in the sling that made it not positioned well when we tried to transfer him. CNA A reported he received mechanical lift training about two weeks prior to the incident and again following the incident which including the need for two persons, locking the lift, manual controls, and the safe use of the lift. He stated he felt safe with the use of the mechanical lift at the time of the incident. He reported that the nurses are now more likely to check on the CNAs who are using mechanical lifts. In an interview on 12/10/24 at 12:50 p.m., the ADM reported that CNA B recently quit working at the facility, and they do not have an active contact number for her. The only phone number available for CNA B was noted as a non-working number. In a telephone interview on 12/10/24 at 04:04 p.m., NP A reported that Resident #1 did not have any injuries related to the fall from the mechanical lift in July. She denied any knowledge of any other residents at this facility having an injury related to a mechanical lift. She stated she has frequently seen Resident #1 and has had no concerns related to abuse or neglect in relation to this resident or the use of the mechanical lift by the facility staff. In an interview on 12/10/24 at 11:46 a.m., the ADM reported she had worked at this facility for 8 months. She reported she did the investigation related to the fall from the mechanical lift by Resident #1. She stated that based on the investigation at that time, When they were doing the transfer, the patient slipped out of the sling when going from wheelchair to the bed. They guided him as much as they could. He hit his back on the floor. They notified the charge nurse and the Hospice nurse and notified the family. X-rays were ordered and done 7/23/24 on the 2-10 shift. The x-ray came back negative through the hospice company, and we ordered a second x-ray through our company. The second x-ray done the next morning showed a possible compression fracture. The patient had no pain. The patient was sent out to the emergency room for a cat scan on 7/24/24. The cat scan showed the fractures were chronic and no new fractures were noted. The patient was kept for a urinary tract infection, but he returned to the facility after 4 days. ADM reported that the positioning of the patient on the sling was indicated as possible cause of the fall as CNA reported that the sling may have been mispositioned on the resident. She stated, If I remember correctly the patient wasn't up far enough on the sling. She reported there are 5 mechanical lifts at the facility. She reported that if a resident falls out of the mechanical lift, they could sustain a trauma or a fracture. In an interview on 12/10/24 at 12:00 p.m., LVN I stated she was here on 7/23/24 but that she was not here on the evening shift when the incident occurred. She reported that she was notified by CNA A and CNA B who were transferring resident #1 from the wheelchair to the bed, and they said he slid out of the sling, that basically Resident #1 was moving and that they guided him to the floor. The CNAs stated that the positioning of the resident on the sling may have and the resident moving, may have resulted in him sliding down, and they guided him down to the floor. LVN I reported the accident/injury assessment was done, the family and hospice were notified, the resident received an x-ray, and the facility did an x-ray as well. The resident was sent out to the hospital the next day for a cat scan which was negative. Review of Employee Coaching and Counseling Record dated 07/24/24 and signed by CNA B revealed, Employee in-service and re-evaluated on transferring and procedures when using lift with residents. The facility training records for CNA B were reviewed and noted to include signed Fall prevention competency testing dated 07-09-24 as well as a signed mechanical Lift Competency Skills Checklist dated 07/09/24 and a Transfer Skills Checklist signed and dated 07/09/24. Employee Coaching and Counseling Record dated 07/24/24 and signed by CNA A revealed, Employee inserviced and re-evaluated on transferring and procedures when using lift with residents. The facility training records for CNA A were reviewed and noted to include signed Fall prevention competency testing dated 07-09-24 as well as a signed mechanical Lift Competency Skills Checklist dated 07/09/24 and a Transfer Skills Checklist signed and dated 07/09/24. Review of Facility Accident/Incident Reports dated from 07/07/24 to 12/05/24 were reviewed with no incidents indicating the involvement of a mechanical lift. In an observation on 12/11/24 at 09:00 a.m., CNA C and CNA D were observed transferring Resident #1 from the bed to the chair using the mechanical lift. Proper technique including the proper positioning of the sling was utilized, and no safety concerns were identified. In an observation on 12/10/24 at 09:30 a.m., CNA E and CNA C were observed transferring Resident #2 from her electric wheelchair to her bed using the mechanical lift, providing incontinence care, and then transferring Resident #2 back to her wheelchair using the mechanical lift. The CNAs utilized the mechanical lift safely. The CNAs positioned the sling beneath the resident and attached it to the lift appropriately. The resident tolerated well, and no safety concerns identified. In an interview on 12/10/24 at 09:45, Resident #2 reported she has received assistance with mechanical lift transfers three to four times a day for months due to incontinence. She stated she has never been injured, fallen, or slipped during the use of the mechanical lift and that many different CNAs have assisted her. Review of facility Mechanical Lift Protocol (undated) reflected, 7. Complete return demonstration with all nursing staff with the Hoyer Lift transfer checklist. Review of the facility Full Mechanical Lift Competency Skills Checklist dated May 2024, reflected, 17. Ensure the patient is centered in the lift sling before raising the lift to transfer. The facility took the following actions to correct the noncompliance prior to the investigation: In an interview on 12/10/24 at 11:23 a.m., the DON reported he has worked at this facility for 9 months. He stated that he was not here and had been on leave during the time surrounding Resident #1's fall from the mechanical lift. He stated he was aware that post-incident training was completed with staff and that the unit manager for long-term, LVN I, was responsible for that. He stated that since the incident what the facility does differently is that he himself and LVN I often walk in to see if a resident being transferred is being transferred appropriately. He also stated that LVN I reinforces in-service trainings with the staff. He reported that staff receive mechanical lift training annually and prn and that mechanical lift training had been done within 8 months prior to the incident. The DON reported he did not know how Resident #1 might have fallen out of the sling. Review of facility Employee In-Service Training Report dated 07/24/2024 and titled, Abuse and Neglect in Skilled nursing Facilities: An Overview was reviewed and noted to include staff signatures. The Inservice Training Report dated 07/24/2024 and Titled Sling Care was reviewed and included the content, This sling must be inspected prior to each use for any rips, tears, frayed, or bleached areas which are unsafe and could result in injury. Do not exceed max. weight specified. Refer to Owner's manual for operation of your lift. The in-service training included staff signatures. In-service Training Report dated 07/24/2024 and titled, Mechanical Lift/Hoyer Training included topics of Hoyer lift storage, Battery Charging, and Procedure and Correct Use and was noted to include signatures of nurses and CNAs. Staff return demonstration checklists date 07/24/24 through 07/28/24 titled, Mechanical Lift Competency Skills Checklist were reviewed. Training record for CNA B revealed a Transfer Skills Checklist and a Mechanical Lift Competency Skills Checklist and Fall Prevention Competency Test were completed and signed by CNA B on 07/24/24. Fall Prevention Competency Test, Mechanical Lift Competency Skills Checklist, and Transfer Skills Checklist were completed and signed by CNA A on 07/06/22 and on 07/03/24, and these were repeated and signed post-incident on 7/24/24. In an interview on 12/10/24 at 12:00, LVN I reported she did one on one training with the two aides involved in the incident and all the nursing staff beginning the next day following the incident. She was assisted in training by the therapy department. She reported all staff have received training including the proper use of the mechanical lift and transferring, including the need for two people. She reported mechanical lift training will be done upon hire and quarterly and with annual training and that the staff will be required to do a return demonstration. She reported that in-services will be done as needed between the trainings. She reported that since the incident, the facility does more spot checking to go in and see that mechanical transfers are being done correctly. This is done by the unit managers, nurses, the DON, and staffing coordinator. The frequency of these checks can vary but are often done when it is noted a mechanical lift is being used. Mechanical lift training was reported as completed fully on 7/28/24 after the weekend staff received training. In an interview and review of records on 12/10/24 at 11:46 a.m., the ADM reported that retraining on mechanical lift transfers were done with the two CNAs involved as well as all nursing staff throughout facility beginning 07/24/24. The training completed on 07/28/24 in order to include the weekend staff. She reported that mechanical training continues to occur with all staff upon hire, quarterly and prn. The ADM reported that during the training staff were required to give return demonstration to assure competency and that nursing staff are conducting periodic random checks on mechanical lift transfers to monitor for proper technique. The ADM reported that an emergency QAPI meeting was called on 07/25/24. The QAPI cover sheet dated 07/25/24 titled, Emergency QAPI Plan. System Identified: Transfer Techniques was noted with Participants listed as the executive director, DON, Medical Director, Unit Managers, and Director of Rehab. In an interview on 12/10/24 at 03:34 p.m., DOR reported she began assisting with mechanical lift training for nursing staff including the safe use, safe procedures, including sling placement on 07/24/24. She reported that she required staff to provide a return demonstration of mechanical lift use. She stated she is aware that managers, RN's and LVN's are also checking in during mechanical lift transfers with residents. She reported she believed all staff were trained in mechanical lift transfers and that this was completed within a few days of the incident with Resident #1. A record review of the facility's Hoyer Transfer Audit revealed that Hoyer transfer audits were conducted on a weekly basis from 07/25/24 through 08/29/24 and then bi-weekly from 09/25/24 until 10/31/24. These audits included a sample of six residents each week and no concerns were identified. In an interview on 12/10/24 at 09:50 a.m., CNA E reported she has worked at this facility for about 3 years. She reported she last received mechanical lift training at this facility about 3 months ago and that this included the CNAs transferring each other from chair to bed using the mechanical lift. She denied having ever witnessed any resident falling out or sliding out of a mechanical lift sling. She stated that this would only occur if, the CNA did the transfer by themselves, or they positioned the sling wrong. In an interview on 12/10/34 at 09:55 a.m., CNA F reported she has worked at this facility about 6 years. She stated she received mechanical lift training about 3 weeks ago and that this involved demonstrating the transfer of a fell ow CNA using the lift. She stated she has not witnessed or experienced a resident injured or fall during a mechanical lift. In an in an interview on 12/10/24 at 03:15 p.m., CNA G reported he has worked at this facility for about 7 months and that he last received mechanical lift training including the safe use of the mechanical lift including placement of the sling in July 2024. He stated that this occurred a day or two after an incident involving a resident in a mechanical lift. He stated that immediately following that training and since the nurses have been going around making sure we are doing Hoyer transfers right. In an interview on 12/10/24 at 03:18 p.m., RN I reported he has worked at this facility for five months (since August) and was not here at the time of the incident with Resident #1. He reported he last received mechanical lift training a few weeks ago. He stated that this included the safe use of the lift and sling placement as well as return demonstration. He reported that when he hired on, he was informed by his unit manager that nurses are expected to randomly pop in to monitor for the safety of residents receiving mechanical transfer. He stated that he assists and watches to ensure resident safety with mechanical transfers. In an interview on 12/10/24 at 03:20 p.m., LVN K reported he has worked at this facility for five months (since August) and was not here at the time of the incident with Resident #1. He reported he last received mechanical lift training a few weeks ago. He stated that this included the safe use of the life and sling placement as well as return demonstration. He reported that when he hired on, he was informed by his unit manager that nurses are expected to randomly pop in to monitor for the safety of residents receiving mechanical transfer. He stated that he assists and watches to ensure resident safety with mechanical lift transfers. In an interview on 12/10/24 at 03:45 p.m., LVN L reported he has worked at this facility for 6 or 7 years and that he received mechanical lift training in July. He reported the training included a return demonstration of the safe use of the mechanical lift including the positioning of the sling. He stated he was informed that nurses must always make sure that 2 CNAs are used when a resident is transferred and that he was told during training that nurses must check in on mechanical lift transfers periodically to ensure safety and he does this. In an interview on 12/10/24 at 09:00 a.m., CNA D (staffing coordinator) reported he often does random drop-ins to monitor mechanical lifts for proper techniques and safety, and that this began following the mechanical lift incident in July 2024.

Based on observation, interview and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Resident #2 and Resident #4) reviewed for dignity and respect in that: 1) The facility failed to provide Resident #2 with help using the toilet and was told by staff to wear an adult brief after her preference to use the tiolet with help was voiced. 2) The facility failed to answer call lights in a timely manner for Resident #2 and Resident # 4's. These faillures could place residents at risk of diminished quality of life and loss of dignity and self-worth. The findings were: 1) Record review of Resident #2's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Right Arm Arthritis (swelling and tenderness causes joint pain or stiffness), Overactive Bladder (a problem with bladder function that causes the sudden need to urinate), Unspecified Osteoarthritis (a progressive joint disease that causes inflammation and pain in joints). Record review of Resident #2's admissions MDS dated [DATE] revealed a BIMS score of 15 which is cognitively intact. Record review of Resident #2's Care Plan revealed it was not completed. Interview on 5/22/24 at 11:23 a.m. Resident #2 stated she was admitted last Thursday evening, 5/16/24 after having surgery on her shoulder. Resident #2 said she fell when she got on a treadmill and the speed was too high. She dislocated her shoulder and had to have surgery. Resident #2 stated she has had a pretty bad experience at the facility. She stated the night shift is scary and they did not want to take her to the bathroom. They told her to pee in her diaper instead of helping her use the restroom. Resident #2 stated a female on the night shift told her she had over 30 residents to take care of by herself. She stated this is why they wanted her to wear a diaper. Resident #2 stated she could walk but needed assistance to use the restroom. She had told the facility staff she wanted help using the bathroom instead of wearing a diaper but stated they take so long to come when she used her call light. She stated she would almost wet herself or would wet herself. Resident #2 said it was better to wear the diaper than wet herself. She stated last night, 5/21/24, she needed two changes and used her call light but got no response. 2) Record review of Resident #4's face sheet revealed a [AGE] year-old man who was admitted on [DATE]. Diagnoses included: Acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), Cardiac arrhythmia (improper beating of the heart, whether irregular, too fast, or too slow), Hypertension/High Blood Pressure (a condition in which the force of the blood against the artery walls is too high), Long term use of anticoagulants (blood thinners which could increase the risk of bleeding, which can be fatal or affect critical organs), Pain, and Shortness of Breath. Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 09, which is moderately cognitively impaired. Resident #4's MDS revealed he needs partial/moderate assistance (helper does less than half) with eating. Also, Resident #4's MDS revealed he needed substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, dressing, and personal hygiene. Furthermore, Resident #4's MDS revealed he was dependent for chair/chair to bed transfer and uses a wheelchair and is incontinent. Record review of Resident #4's Care Plan revealed he was at risk for falls with interventions for staff to respond promptly to calls for assist to the toilet. Also, Resident #4's care plan stated he was always incontinent, and interventions were to check for incontinence; change if wet/soiled to keep skin intact. Furthermore, Resident #4's care plan stated he was at risk for pressure ulcer development with interventions for incontinent care provided every 2 hours and as needed. Interview and Observation on 5/22/24 at 11:56 a.m. with Resident #4 was in a wheelchair and was unable to speak but agreed to shake his head yes or no to questions. He shook his head yes and put his hands outstretched wide when asked if call lights took a long time to be answered. Resident #4 shook his head yes when asked if the night shift took longer to answer call lights. Interview on 5/22/24 at 12:01 p.m. with LVN B stated they do abuse/neglect training every week. He stated the call lights should be answered in 5 to 10 minutes. LVN B said residents should be checked on every two hours. Interview on 5/22/24 at 12:46 p.m. with CNA C stated they do abuse/neglect training weekly or bi-weekly at least. He stated call lights should be answered as soon as the call light went on. He said the call light beeps at the nurse's station also. CNA C stated resident should be checked on every 2 hours or more frequently if they are a fall risk or cannot use their call light. Interview on 5/22/24 at 12:59 p.m. with CNA D stated they do abuse/neglect training weekly and as needed. She stated they are supposed to answer call lights promptly. CNA D stated if you were with a resident, you went to the next resident when you were done. CNA D said all the nurses help each other out answering call lights. She stated residents were to be checked on every 2 hours and as needed. CNA D said she would check on fall risk residents more often. Interview on 5/22/24 at 1:17 p.m. with CNA E stated they do abuse/neglect training every week and as needed. He said call lights should be answered as soon as possible. CNA E said residents are to be checked every two hours or if their call light was on. Interview on 5/22/24 at 4:04 p.m. with DON stated calls lights were expected to be answered within 5 - 10 minutes. He stated residents were to be checked on rounds every 2 hours and as needed. The DON said it was not ok to tell a resident to wear a brief instead of getting help to use the bathroom. The DON stated they had a staff meeting every morning and the nurses would go to each resident's room and ask the resident if they were getting the proper care. Record Review of Resident Council minutes from 3/18/24 showed weekend and night shift take longer for call lights. Also, on 5/21/24, call light need answered timelier. Record Review of the facility's Resident Rights Guidelines for All Nursing Procedures, dated October 2010, stated under Preparation: a. Preventing, recognizing, and reporting resident abuse. b. Resident dignity and respect. Record Review of the facility's Abuse Prohibition Protocol policy dated April 2019, stated under 7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient Abuse: and l. l. Neglect is the failure of the facility, it is employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record Review of facility's Call Light policy, dated June 14, 2006, stated under Responsibility All Staff. Under Purpose To respond promptly to Patient's call for assistance and to ensure call system is in proper working order. Under Procedure Answer ALL call lights promptly whether or not you are assigned to the Patient. Answer all call lights in a prompt, calm, courteous manner. Never make the Patient feel you are too busy to give assistance; offer further assistance before you leave the room. Record Review of facility's Incontinent Care Protocol dated June 2013 stated under Goal: Maintain the Patient in a clean and dry state and prevent complications of incontinence by maintaining and providing incontinent care to the Patient at regular intervals. Under Procedure: Incontinent care will be provided after each incontinent episode. The incontinent product will be changed as indicated. Also, under Document/Review: Care plan and Daily Care Guide reflects every 2- hour checks, preventive skin care and turning/repositioning.

Based on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 3 out of 8 residents (#2, #5, and #6) reviewed for ADL care. The facility failed to provide timely incontinence care for every two hours or as needed for Resident #2, # 5 and # 6 from 5/17/24 through 5/21/24. The facility failed to provide timely incontinence care on a regular basis for residents #2, #5, and #6. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity. Findings included: 1) Record review of Resident #2's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Right Arm Arthritis (swelling and tenderness causes joint pain or stiffness), Overactive Bladder (a problem with bladder function that causes the sudden need to urinate), Unspecified Osteoarthritis (a progressive joint disease that causes inflammation and pain in joints). Record review of Resident #2's admissions MDS dated [DATE] revealed a BIMS score of 15 which is cognitively intact. The MDS was not completed as Resident #2 was admitted on [DATE]. Record review of Resident #2's ADL care sheet showed incontinent care was documented on 5/17/24 at 1:10 p.m. and at 6:37 p.m., 5/18/24 at 1 a.m., 7:29 a.m. and at 5:42 p.m., 5/19/24 at 2:10 a.m., 6:59 a.m. and at 5:03 p.m., 5/20/24 at 7:44 a.m. and at 7:12 p.m., 5/21/24 at 12:28 a.m., 7:11 a.m., 7:44 p.m. and at 11:31 p.m., 5/22/24 at 9:19 a.m. Interview on 5/22/24 at 11:23 a.m. Resident #2 stated she was admitted last Thursday evening, 5/16/24 after having surgery on her shoulder. Resident #2 said she fell when she got on a treadmill and the speed was too high. She dislocated her shoulder and had to have surgery. Resident #2 stated she has had a pretty bad experience at the facility. She stated the night shift is scary and they did not want to take her to the bathroom. They told her to pee in her diaper instead. Resident #2 stated a female on the night shift told her she had over 30 residents to take care of by herself. She stated this is why they wanted her to wear a diaper. Resident #2 stated she could walk but needed assistance to use the restroom. She had told the facility staff she wanted help using the bathroom instead of wearing a diaper but said they take so long to come. She stated she would almost wet herself or would wet herself. Resident #2 said it was better to wear the diaper than wet herself. She stated last night, 5/21/24, she needed two changes and used her call light but got no response. 2) Record Review of Resident #5's face sheet revealed a [AGE] year-old female, who was admitted on [DATE]. Diagnoses included: Vascular Dementia (occurs when blood flow to brain is reduced which can lead to problems with memory, thinking and behavior), Presence of Right Arthritis (swelling and tenderness causes joint pain or stiffness), Insomnia (sleep disorder in which one has trouble falling asleep, staying asleep or getting quality sleep), Generalized Anxiety, Psychotic Disorder (a mental disorder characterized by a disconnection from reality), Depression and Shortness of Breath. Record Review of Resident #5's Quarterly MDS dated [DATE], revealed a BIMS score of 99 which revealed the resident was unable to complete interview. The MDS revealed Resident #5 was in a wheelchair and is dependent on ADL care provided by 2 or more staff. Furthermore, Resident #5's MDS revealed she was always incontinent. Record Review of Resident #5's Care Plan dated 4/18/24, revealed she required ADL care due to contracture and was incontinent of bowel and bladder. The care plan stated Resident #5 would remain clean, dry and odor free by being placed on a 2-hour toileting program. Resident #5 was also care planned as a fall risk, had dementia, and rejected care/medications at times. Record Review of Resident #5's ADL care sheet revealed incontinent care was documented as given on 5/17/24 at 3:27 a.m. and at 1:30 p.m., 5/18/24 at 1:15 a.m. and at 9:59 a.m., 5/19/24 at 12:58 p.m., 5/20/24 at 8:41 a.m., 9:58 p.m. and at 10:30 p.m., 5/21/24 at 9:58 p.m. 1:32 a.m. and at 11:16 a.m. Observation and attempted interview on 5/22/24 at 12:07 p.m. Resident #5 was watching television. Surveyor introduced herself, and asked if she could talk to her, but Resident #5 closed her eyes. Surveyor asked if she was all right, and she closed her eyes tighter. Surveyor left the room and less than a minute later, Resident #5 started moaning loudly. 3) Record Review of Resident #6's face sheet revealed an [AGE] year-old man who was admitted on [DATE]. Diagnoses Included: Unspecified Dementia (Dementia (loss of memory, language, problem solving and other thinking abilities that interfere with daily life) without a specific diagnoses), Unspecified Convulsions (fits or seizures), and Parkinsonism (disorder of central nervous system that affects movement, often including tremors). Record Review of Resident #6's Admission MDS on 4/19/24 revealed a BIMS of 03; significantly cognitively impaired. The MDS for Resident #6 revealed he was in a wheelchair, and he was totally dependent on staff for ADL care including incontinent care with 2 or more people assisting. Record Review of Resident #6's Care Plan dated 4/19/24 showed he was a fall risk and had dementia. Record Review of Resident #6's ADL care sheet revealed incontinent care was documented as given on 5/17/24 at 12:45 a.m., 5/18/24 at 1:04 a.m. and 9:47 a.m., 5/19/24 at 12:14 p.m., 5/20/24 at 8:45 a.m., 5/21/24 at 9:57 p.m. and on 5/22/24 at 1:39 a.m. and 11:14 a.m. Interview on 5/22/24 at 12:01 p.m. LVN B stated they do abuse/neglect training every week. LVN B said residents should be checked on every two hours. Observation and attempted interview on 5/22/24 at 12:09 p.m. Resident #6 was sitting in his wheelchair in his room watching television. He was unable to answer any questions and just smiled and laughed when Surveyor told him she would let him go. Interview on 5/22/24 at 12:46 p.m. CNA C stated they do abuse/neglect training weekly or bi-weekly at least. CNA C stated resident should be checked on every 2 hours or more frequently if they are a fall risk or cannot use their call light. Interview on 5/22/24 at 12:59 p.m. CNA D stated they do abuse/neglect training weekly and as needed. She stated residents were to be checked on every 2 hours and as needed. CNA D said she would check on fall risk residents more often. Interview on 5/22/24 at 1:17 p.m. CNA E stated they do abuse/neglect training every week and as needed. CNA E said residents are to be checked every two hours or if their call light was on. Interview on 5/22/24 at 4:04 p.m. the DON stated residents were to be checked on rounds every 2 hours and as needed. The DON stated when incontinent care was done, the CNAs are to document it on the computer. The DON stated he would be concerned if an ADL dependent resident only had 2 documented incontinent care times documented in the computer in a day. The DON stated there were several risks to a resident such as a UTI, Neglect, and patient's rights as well if resident's ADL care was done in a timely manner. The DON stated it was not all right for staff to tell a resident to wear an adult brief instead of helping them use the restroom. The DON stated they had a staff meeting every morning and the nurses would go to each resident's room and ask the resident if they were getting the proper care. Record Review of the facility's Resident Rights Guidelines for All Nursing Procedures, dated October 2010, stated under Preparation: a. Preventing, recognizing, and reporting resident abuse. b. Resident dignity and respect. Record Review of the facility's Abuse Prohibition Protocol policy dated April 2019, stated under 7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient Abuse: and l. l. Neglect is the failure of the facility, it is employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record Review of facility's Incontinent Care Protocol dated June 2013 stated under Goal: Maintain the Patient in a clean and dry state and prevent complications of incontinence by maintaining and providing incontinent care to the Patient at regular intervals. Under Procedure: Incontinent care will be provided after each incontinent episode. The incontinent product will be changed as indicated. Also, under Document/Review: Care plan and Daily Care Guide reflects every 2- hour checks, preventive skin care and turning/repositioning.

Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #79) resident of three residents reviewed for elopement. RN A on 07/30/23 failed to report to the Administrator (at that time), the DON (at the time) or communicate to oncoming nursing staff when Resident #79 became agitated and stated he was going to leave the facility. On 08/02/23 Resident #79 became agitated and frustrated and told LVN B he was leaving the facility. LVN B redirected him and did not provide adequate supervision to prevent him from eloping from the facility on 08/02/23. Resident #79 was able to leave the building without staff being aware that he left the building on 08/02/23 sometime after 4:00 p.m. and was later found by the police approximately three miles from the facility. It was determined these failures placed Resident #79 in an Immediate Jeopardy(IJ) situation from 07/30/23-08/03/23. The facility corrected the noncompliance before the survey began. This failure placed residents at risk for harm and /or serious injury. Findings included: Record review of Resident #79's Admission MDS assessment, dated 07/10/2023 reflected the Resident was a [AGE] year-old-male who admitted to the facility on [DATE] and discharged on [DATE]. The resident had diagnosis which included: Parkinson's Disease (disease that affects the nervous system producing tremors and stiffness), left nephrectomy (removal of left kidney), spinal stenosis (disease of the spine causing difficulty in walking long distances), fall with head strike, functional decline, generalized weakness, and ETOH (alcohol abuse). The MDS reflected he had a BIMs score of 10, which indicated moderate cognitive impairment and the resident was ambulatory with an unsteady gait and required assist of one staff for activities of daily living. The MDS did not reflect any wandering behavior. Record review of Resident #79's care plan, dated with a review date of 07/14/2023, addressed the resident's impaired cognition due to short term memory loss (unable to remember after 5 minutes), risk for falls and assistance required for activities of daily living. Further review of the clinical record reflected, the resident's moderate risk for elopement was not addressed, until 08/03/2023. Record review of Resident #79's Elopement [NAME] Assessment completed 07/05/2023 scored Resident #79 as no risk for elopement. Review of the clinical record reflected no Elopement Risk Assessment completed on 07/30/2023. Record review of Resident #79's Elopement Risk Assessment completed on 08/02/2023 scored Resident #79 as high risk for elopement. This assessment was completed after the elopement. Record review of the Provider Investigation Report, dated 08/03/2023, revealed Resident #79 was independently ambulatory and was noted missing from the facility on 08/02/2023 at approximately 4:00 p.m. The resident was last seen at approximately 4:30 p.m. in his room. Facility staff searched the facility, the entire campus, and the surrounding neighborhood. Resident #79 was not located. The police were called, and the resident was located and taken to the hospital, where he was found to be in stable condition, under the influence of alcohol and drugs, for which the hospital provided care. The Provider Investigation Report reflected a finding of unconfirmed (for neglect). The hospital communicated they would assist in finding a secured unit SNF for the resident. The facility started in-service on the elopement policy and procedure with all staff and conducted an elopement drill with all staff. The facility changed all the door codes in the facility. Review of Provider Investigation Report dated 08/03/2023 reflected a finding of Unfounded for Neglect. Review of the External/Internal/Systemic Approach Investigation Summary dated 08/02/2023 completed on 08/08/2023 reflected: . an emergency QAPI meeting was held on 08/03/2023 with Medical Director in attendance . all residents had a new elopement assessment to identify any current patients that are imminent risk for elopement (no other residents were found to be at imminent risk of elopement) . (who was responsible: Nurse Management . who will monitor: Regional Director of Clinical Services/Director of Nursing.elopement assessment will be completed upon admission and quarterly by the charge nurse and/or nurse managers and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated Any patient that triggers elopement risk will be placed on 1:1 monitoring until no longer deemed necessary. DON will monitor for compliance for 3 weeks until 08/27/2023 and then monthly on an ongoing basis .Who will monitor: Regional Nurse of Clinical Services Until alternative and or safe living arrangements are made they will be placed on one-one-supervision with facility staff. The resident's picture and face sheet will be placed in an elopement binder. Resident care plans will also be updated. The Director of Nursing and/or Nurse Manager will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. Audits will be completed weekly for 3 weeks until 08/28/2023 and monthly on an ongoing basis Monitoring .Starting 08/02/2023 Director of Nursing and/or Nurse Managers will receive in hand, the resident monitoring/every 2-hour body check documentation at the end of each shift for the first 72 hours, each day for one week, then weekly for 4 weeks. The Regional Director of Clinical Services will review the documentation each week for compliance The Executive Director will monitor daily to ensure compliance for four weeks and will review . Further review of the Providers Investigation Report reflected monitoring and audits by the designated staff (DON Nurse Managers and Regional Nurse consultant) had occurred. Record review of progress notes reflected Resident #79 on 07/30/2023 had previously indicated he had reported to RN A stating he is leaving this place. Further review of the progress note reflected Resident #79 was agitated. Record review of progress notes reflected Resident #79 on 08/02/23 he was observed wandering in the hallway stating, I'm going home today The nurse redirected the resident back to his room, educated the resident his discharge date was not today, and he would be notified when his discharge date was. The resident indicated to the nurse he understood and he would stay in his room for a nap. The nurse when rounding later around 1800 it was noted the resident was not in his room, the nurse made rounds in the hallways and other residents rooms looking for resident #79 and he was unsuccessful in locating him. Review of In-service dated 08/03/2023 reflected all staff attended and the subject matter was regarding Facility policy on elopement and reducing the risk for elopement: initiating a frequent monitoring form and updating the care plan. In an interview on 04/02/2024 with LVN C at 1:30 p.m. revealed he did recall a resident leaving the facility but was not working when it happened. LVN C stated he did not recall Resident #79 or being told anything about the resident trying to leave. LVN C stated he did recall having an in-service given by the administrator (at the time) about elopement. LVN C knew what to do and who to report to if a resident was exit seeking, but he currently did not have any residents that were, but stated he would be telling the administrator and the DON. An observation on 04/02/24 at 4:00 p.m. revealed the surrounding outside area, parking lot, and streets adjacent to the facility. The facility was in an industrial area with multiple car lots, a concrete/gravel company, a large hospital, and multiple businesses. The street in front of the facility was very busy with cars parked on both sides of the street and large 18 wheelers were observed delivering cars. Dump trucks and container trucks were observed driving down the street. There was a popular highway less than a third of a mile away, as well as a very busy main four lane street that leads to residential areas, and large shopping centers, that has heavy traffic on the road all times of the day and night. Where the resident was found (in another city than the facility) is approximately three miles away through busy streets, the industrial areas, and residential areas. In an interview on 04/03/2024 with Social Worker at 8:45 a.m. revealed she had worked here since September 2023 there had not been any elopements. The Social Worker stated she had been in-served by the new Administrator. The staff is supposed to report any exit seeking behaviors, that would include a resident talking about leaving. The resident is immediately replaced on 1:1 until they can locate a safe place for them to reside. The Social Worker stated the facility is not equipped to handle wandering and exit seeking residents. In an interview on 04/03/2024 with the DON at 9:00 a.m. revealed he had only worked at the facility for less than two weeks. The DON stated he had been trained on the policy and procedure for elopement. The DON stated an elopement could be very serious, and the resident could get hurt while out of the facility. In an interview on 04/03/2024 with the Administrator at 10:00 a.m. revealed she had worked at the facility since September. The Administrator stated the staff had been in-serviced on elopement and her expectations. The Administrator stated even if the resident talks about leaving she must be notified immediately. She would then determine if they need 1:1 assist monitoring until they can safely find placement for the resident. She said this facility is not set up for any type of wandering residents. In an interview on 04/03/2024 with Regional Nurse Consultant (RNC) at 10:10 a.m. revealed he knew Resident #79 and he was involved with the occurrence. The RNC stated Resident #79 was alert and oriented and the resident knew he wanted to leave and wanted cigarettes, so he went to the store he was used to going to. RNC stated he did not think Resident #79 eloped, he just possibly forgot to sign out. RNC stated, he thought Resident #79 just wanted to go visit with his buddies. He said they have a lot of residents that talk about leaving, they talk with them and explain why they are here, and they do not leave. During the interview the RNC was given the opportunity to provide the sign in sheets for the in-services 07/2023 and 08/2023, but none were provided by the exit. In an interview on 04/03/2024 with LVN B at 10:45 a.m. revealed he recalled Resident #79; he had admitted to the facility for rehabilitation. LVN B stated Resident #79 was a wandering resident. LVN B said he thought he was new and needed to be redirected. LVN B stated Resident #79 was a very nice resident and he was not exit seeking. LVN B stated he just walked around all the time, but he did appear to be frustrated about being there. The LVN stated he had not been made aware that the resident had talked about leaving before. LVN B stated when he arrived for his shift, he received report and counted medications with the nurse that was leaving, then he made rounds and located all his residents. He stated Resident #79 was walking in the hallway, and he asked him if he needed anything; he stated, no. LVN B stated he took a break and then he came back in at 3:00 p.m. LVN B stated when he was performing finger sticks for blood sugars around 4:00 p.m. he asked Resident #79 if he needed anything and he stated he wanted to leave. LVN B said Resident #79 was getting agitated, so he spoke with him, and he agreed to go back to his room. LVN B said he showed him where it was and just thought he was still trying to acclimate to his room and the facility. LVN B said when he got Resident #79 to his room, he told him No buddy this is where you live now at least for a while. And he agreed to lie down. LVB stated he left him there and went to complete finger sticks and dinner and when he made his next rounds around 6:00 p.m. he was not in his room. LVN B stated he looked for him, and he was not walking in the hallway. LVN B said he told the staff he could not find him; they all begin to look. Someone notified the DON and the police. LVN B stated he called the family, the Physician, and the Nurse Practitioner. LVN B stated he was worried about the resident because he could get hurt out there. LVN B confirmed he had in-service training on the next day on elopement and could not return to work until he did. In an interview on 04/03/2024 at 1:00 p.m. with RN A revealed she was the weekend RN Supervisor on 07/30/2023. RN A stated Resident #79 was agitated and frustrated acting on that day and he kept walking around in the hallways. RN A said he was not exit seeking, just agitated. RN A stated Resident #79 approached her and stated, I am going to leave this place When she spoke to him, he wanted to talk to his family member, so she called the family member. RN A said after Resident #79 spoke to her, he went back to his room with the CNA ( she could not recall her name). RN A said but later he came out of his room, and he was walking in the hallways again. She said he was not agitated just frustrated acting, and not exit seeking. RN A stated she did not report this to anyone, and she did not do an elopement risk assessment, because he had been easily redirected and he was no longer agitated, just walking and appearing frustrated. RN A stated she did not think she needed to report to anyone that Resident #79 was talking about leaving because he was redirectable. In an interview on 04/05/2024 at 10:00 a.m. with DOR (Director of Rehab) revealed she did recall Resident #79. The DOR stated she had treated him as a Speech Therapist when he was there. The DOR stated he was difficult to treat, he was not interested, and could not focus because he was not interested in what they were doing for his rehabilitation. The DOR said she completed a screening at the beginning, at the middle, and at the completion. His screening showed he had not made any progress, if very little during his therapy. He was just very basic in his thinking. She stated he was alert but not completely oriented and could not communicate effectively and make decisions for himself. The DOR stated that he did talk about where he was going when he left there, and he used to tell her he was leaving soon. The DOR stated she thought he was talking about when he went back to where he had come from. The DOR stated he was living in a group sobriety home. Attempts were made to contact the previous DON on 04/02/2024 at 11:00 a.m. and 1:45 p.m., and on 04/04/2024 at 3:00 p.m. Attempts were made to contact the previous Administrator on 04/03/2024 at 3:30 p.m., 04/04/2024 at 10:00 a.m. and 2:00 p.m., and 04/05/2024 at 2:15 p.m. Attempt was made to returen call to the Medical Director on 04/05/2024 at 11:30 a.m. without success and a message was left. The Medical Director did not return call prior exit. Review of the Facility's Policy titled Abuse protocol dated March 2012 reflected: 14. If patient begins to exhibit inappropriate behavior, the facility will assess the patient and take appropriate steps to both minimize further inappropriate behavior and to protect these steps will include, as appropriate, providing additional supervision .obtaining appropriate medical/psychiatric evaluation and treatment, adjusting facility practices to minimize the risk of further inappropriate behavior and using activities and interventions that redirect the energies of . patients Review of Facility's Policy titled Elopement Response Protocol dated January 2023 reflected the following Upon the occurrence of an elopement or a suspected elopement, the following steps must be immediately taken: 1. Conduct thorough search of the facility and its grounds. 2. If the Patient is not found within 30 minutes notify the Executive Director, DON, Regional [NAME] President Operations 3. Notify the patient's responsible party and attending physician. 4. Notify the police department. 5. Organize search teams composed of facility staff to search the vicinity of the facility on a continuous basis. Search teams should conduct their searches in one-hour shifts and cover defined areas identified on a street map. Unless the specific circumstances dictate otherwise, searches should begin with an area that consists of a circle with a one-mile diameter with the facility at its center and then expand to incrementally broader areas. 6. Communicate updates frequently (i.e. every hour) to the Regional Director of Clinical Services, Regional [NAME] President of Operations and the [NAME] President of Clinical Operations until the patient is located or you are directed to report at a different frequency .

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #80) of 5 residents reviewed for clinical records. 1. The facility failed to ensure staff kept copies of Resident #80's shower sheets from February and March 2024. 2. The facility failed to provide nurses notes on Resident #80's refusals to shower from February and March 2024. These failures could affect residents and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #80's face sheet, dated 03/27/2024, reflected the resident was a [AGE] year-old woman who was admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included chronic obstructive pulmonary disease, unspecified infectious disease, unspecified fall, hemorrhage of left cerebrum without loss of consciousness, and urinary tract infection. Review of Resident 80's MDS assessment, dated 2/26/2024, reflected she had a BIMS score of a 3. Review of shower log provided by the facility for Resident #80 revealed there were no showers for the month of February 2024 and four showers the entire month of March 2024. Interview on 04/04/24 at 2:12 PM with CNA D revealed he cared for Resident #80 and provided her only four bed baths while she was at the facility. CNA D said Resident #80's shower days were Tuesdays, Thursdays, and Saturdays. CNA D said when a resident refused a shower he would notify LVN E and if Resident #80 continued to refuse he would fill out a shower sheet and give it to the LVN E. CNA D said he was not sure what happened to the shower sheets after that. Interview on 04/04/24 at 2:45 PM with the LVN E revealed he was not able to locate any shower sheets for Resident #80 or nurses notes documenting the refusal for February and March 2024. Interview on 04/04/24 at 3:08 PM with the DON revealed he was unable to locate any additional shower sheets for Resident #80 for the months of February and March 2024. The DON said the shower sheets were pulled and discarded at the end of each month. The DON said the CNA's were responsible for providing showers and filling out the shower sheet and then showing it to the Nurse and placing it in a specific place to be held until the end of the month. He revealed the purpose of keeping shower sheets was to prove that the resident was offered a shower on that date and if they refused it was annotated on the shower sheet. The DON revealed no nurse documented shower refusals of resident 80 and no notification to family. Review of the facility's policy, revised July 2017, and titled Charting and Documentation reflected: Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations; Treatment or services performed; changes in resident's condition. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting.

Based on observation, interview and record review failed to ensure resident receive treatment and care in accordance with professional standards of practice, based on the comprehensive assessment of a resident, the comprehensive person-centered care plan, and the resident's choices for one (Resident #1) of 5 residents reviewed for quality of care. The facility failed to follow-up with Resident #1's hospital referral for the orthopedic doctor and provide treatment to promote healing of a right should fracture according to professional standards of practice and resident's choice for treatment from 06/08/2023-07/15/2023. This failure affected one resident and placed residents who require follow up with an orthopedic doctor at risk for improper healing by not receiving the necessary services to maintain proper healing. Findings included: Record review of Resident #1's face sheet, dated 07/15/23, revealed the resident was an [AGE] year-old female initially admitted to the facility on [DATE]. Her diagnoses included: Primary hypertension (elevated blood pressure), fracture of the shaft of right humerus (broken right shoulder), urinary tract infection, gastro-esophageal reflux (stomach acid in a backward flow through the esophagus, pain, vitamin deficiency, type 2 diabetes (decrease insulin in the body). Review of Resident #1's Quarterly MDS Assessment, dated 06/19/23, revealed a BIMS score of 11 which indicated the resident had moderate cognitive impairment and functional status of independent, requiring limited assistance in ADLs. Interview on 07/15/23 at 9:56 AM with Anonymous Person revealed, Resident #1 fractured her right shoulder over a month ago while trying to get ice out of nutrition room. They stated the resident had gotten a referral from the hospital upon discharge to follow up at [Hospital Name] with Orthopedic doctor. Anonymous Person stated she was unable to recall the date of the fall. Observation on 07/15/23 at 10:16 AM revealed Resident #1 took items from her bathroom and placed the items on the her sink using mostly her left hand. The resident would utilize her right arm, which was in a sling, to hold items and when she put the items down, she would move her arm outward far enough to put items down on her sink. Interview on 07/15/23 at 10:18 AM with Resident#1 revealed, she was in the nutrition room and slipped on a puddle of water located on the floor and fell . Resident #1 was unable to recall the date of the fall. She stated the staff removed her from the nutrition room and assisted her back to bed. She stated her right shoulder and arm was in pain. She stated the nurse did give her pain medicine. Resident #1 stated she had an x ray and was sent to the emergency room . Resident #1 stated she was trying to get to a follow-up appointment with orthopedic doctor. She stated she needed to go see orthopedic doctor and start physical therapy. Resident #1 stated staff were aware that she had not gone to see orthopedic doctor and had no urgency to make her appointment. Resident #1 stated she was discharged from the hospital with a sling for the right arm and was instructed to follow up with an orthopedic doctor. She stated after the fall she needed assistance with getting dressed and showers. She stated she was right-handed, and she would get frustrated and upset because her ability to care for herself was limited and the use of the right hand and arm was not improving. Review of Resident #1 care plan dated 01/04/23-present revealed it had been updated since the resident's fall. Interventions included keeping the areas free of obstruction to reduce the risk of falls or injury. Place call light within easy reach, remind resident to call for assistance before moving from bed to chair and from chair to bed. Respond promptly to calls for assist to the toilet, footwear, will fit properly and have non-skid soles, and x ray to shoulder and arm secondary to complaints of pain. Review of the facility's incident/accident report for June 2023 revealed Resident #1 fell on [DATE] with injury to right shoulder. Interview on 07/15/23 at 12:56 PM with Administrator revealed Resident #1 fell in the nutrition room on 06/07/23 at 11:30 PM. She stated the Incident report states Resident #1 fell and with right shoulder pain, but she was able to move right arm. On 06/08/23 1:31 AM, X-Ray resulted in a mild displaced humerus head fracture (broken shoulder). She stated the resident was sent to the hospital on 06/08/23 at 9:20 AM. She stated Resident #1 had returned from the hospital with a sling. The Administrator stated Resident #1 would benefit from physical therapy. She stated Resident #1 completed a consult for physical therapy and was on the list to start physical therapy. She stated she was aware the resident was diagnosed on [DATE] with a fracture shoulder and had not been scheduled for a follow up appointment as of 07/15/23. She stated the Unit Manager was handling the referral. Review of Resident #1 Interdisciplinary patient screen completed by physical therapy stated, screening completed. Awaiting MD appointment for therapy to evaluate. Pt will continue to wear sling. Interview on 07/15/23 at 1:30 PM with Unit Manager revealed Resident #1 fell on [DATE]. On 06/08/23 the X-Ray was completed, and the results were fracture to the right shoulder. She stated Resident #1 had been seen by her primary doctor and the primary doctor did not specialize in broken or fractured bones. She stated the resident had not gone to orthopedic doctor because the doctor office stated they had not received a referral for a follow-up. Unit Manager revealed she faxed a referral on 06/20/23, and 07/11/23 because referral was not written by the primary care doctor until 06/20/23. She stated she was unable to find a copy of confirmation for the referral faxed to the orthopedic doctor on 06/20/23. She stated Resident #1 had 14 days from the time the referral was written to get the appointment scheduled. She stated it had been almost 30 days since the referral was written and an appointment has not been scheduled. She stated the risks of not going to follow up appointment with orthopedic doctor could result in Resident #1 arm healing improperly, blood clots could form, and the fracture could get worse. Review of Resident #1 referral, dated 07/11/23, stated the transmission was ok, which indicated the referral was received, on 07/11/23 at 1:38 PM. Review of Resident #1 progress notes for June 2023 revealed no progress notes for 06/07/23 the day of the incident. Review of Resident #1's progress notes, dated 06/08/23, revealed at 9:23 AM Resident #1 pain level was 6/10 (1 was low pain and 10 was worse pain). LVN A called NP because there were no PRN pain medications ordered the Resident #1. The NP gave LVN A orders to give Tylenol 100mg every 6 hrs PRN. Review of Resident #1 progress notes, dated, 06/08/23, revealed, at 9:31 AM, X-Ray results showed an acute fracture. LVN A notified NP and received an order to send Resident #1 to the hospital and informed Resident #1 family. Review of the progress notes on 06/08/23 at 11:30 PM revealed Resident #1 returned from the hospital in a wheelchair with a sling applied to the right arm. The orders given from hospital for PRN Norco 10-325mg as needed for pain. Review of Resident #1's X ray results, dated 06/08/23, revealed mild displaced humerus head fracture. Review of Resident #1 discharge summary from [Hospital name] revealed Resident #1 was seen for a right shoulder fracture. There was a sling applied to right arm. She received an order for Hydrocodone/Acetaminophen 10-325mg and a Self-Referral to PCP and orthopedic doctor with a note that stated, your health care plan may require a referral from your primary care provider prior to making an appointment. Interview on 07/15/23 at 3:35 PM with PCP revealed Resident #1 went to ER and found out about the shoulder fracture. She stated due to the shoulder fracture, the hospital ordered Resident #1 to wear a sling and follow up with orthopedic doctor outpatient. She stated hospital referral usually worked as an outpatient referral; however, the insurance stated the PCP needed to write the referral. She stated the Insurance company called the daughter and the daughter notified her of the Orthopedic referral. She stated she was aware Resident #1 had not gone to orthopedic follow up appointment. She stated it takes 6 weeks to heal the type of fracture Resident #1 had and understood 5 weeks had already passed without follow up with orthopedic doctor. Interview on 07/15/23 at 3:25PM with Social Worker revealed, the orthopedic office was closed on Friday 06/23/23. She stated she faxed the referral and e-faxed the number provided by the doctor and sent it to two fax numbers. The Social Worker sent another e-fax and did not follow up with e-fax because her last day was 06/28/23. Social Worker stated she had passed the task to the Unit Manager. She stated she was unable to provide confirmations of the faxes that were sent to the Orthopedic office. Telephone interview on 07/16/23 at 9:39 AM revealed RN B had made rounds on 200 and 400 halls on 06/07/23. He had heard a loud sound on 200 wing. RN B stated he went to investigate and saw Resident #1 on floor in the nutrition room. He stated he had called out to the staff for assistance. His assessment findings for Resident #1 revealed she had feeling in all of her extremities but complained of pain in the right arm. He stated he had applied a pain-relieving cream to the right arm per Resident #1 request. RN B stated he was able to get the resident up off the floor and safely in bed. He stated the Nurse Practitioner, the resident family, and the supervisors was notified of the fall, and he had received new orders for an X-rRay. He stated the X-Ray was completed after his shift was over. Requested a policy on Resident Quality of Care. The facility did not provide the document upon exit.

47229 Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices and the resident environment remains as free of accident hazards as is possible for one (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure residents' environment remained free from accident hazards as is possible by removing water slipping hazard from floor near ice dispensing machine or preventing residents access to the area resulting in Resident #1 slipping and falling in the nutrition room causing the resident to sustain a fracture and pain to her right shoulder. This failure affected residents and placed them at risk for decreased ADL function, physical and mental impairment, and serious injury or harm and resulted in harm to Resident #1. Findings included: Record review on 07/15/23 of Resident #1's face sheet revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE]. Her diagnoses included: Primary hypertension (elevated blood pressure), fracture of the shaft of right humerus (broken right shoulder), urinary tract infection, gastro-esophageal reflux (stomach acid in a backward flow through the esophagus, pain, vitamin deficiency, type 2 diabetes (decrease insulin in the body). Review of Resident #1's Quarterly MDS Assessment, dated 06/19/23, revealed a BIMS score of 11 indicating resident had moderate cognitive impairment and functional status of independent with limited assistance in ADLs. Interview on 07/15/23 at 9:56 AM with Anonymous revealed, Resident #1 had fracture right shoulder while trying to get ice out of nutrition room. She stated the resident had gotten a referral from the hospital upon discharge to follow up at [Hospital Name] with Orthopedic doctor. She stated Resident #1 had fractured right shoulder over a month ago and had not had her follow up appointment scheduled with [Hospital Name]. Anonymous stated she was unable to recall the date of the fall. Observation on 07/15/23 at 10:16 AM revealed Resident #1 taking items from her bathroom and placing the items in the on her sink using mostly her left hand. The resident would utilize her right arm, which was in a black sling, to hold items and when she put the items down, she would move her arm outward enough to put items down on her sink. Interview on 07/15/23 at 10:18 AM with Resident#1 revealed, she was in the nutrition room and slipped on a puddle of water located on the floor and fell . Resident #1 was unable to recall the date of the fall. She stated the staff removed her from the nutrition room and assisted her back to bed. She stated her right shoulder and arm was in pain. She stated the nurse did give her pain medicine. Resident #1 stated she had an x ray and was sent to the emergency room . Resident #1 stated she was trying to get to a follow-up appointment with orthopedic doctor. She stated she needed to go see orthopedic doctor and start physical therapy. Resident #1 stated staff were aware that she had not gone to see orthopedic doctor and had no urgency to make her appointment. Resident #1 stated she was discharged from the hospital with a sling for the right arm and was instructed to follow up with an orthopedic doctor. She stated after the fall she needed assistance with getting dressed and showers. She stated she was right-handed, and she would get frustrated and upset because her ability to care for herself was limited and the use of the right hand and arm was not improving. Review of the facility's incident/accident report for June 2023 revealed Resident #1 fell on [DATE] with injury to right shoulder. Interview on 07/15/23 at 12:56 PM with Administrator revealed Resident #1 fell in the nutrition room on 06/07/23 at 11:30 PM. She stated the Incident report states Resident #1 fell and with right shoulder pain, but she was able to move right arm. On 06/08/23 1:31 AM, X-Ray resulted in a mild displaced humerus head fracture (broken shoulder). She stated the resident was sent to the hospital on 06/08/23 at 9:20 AM. She stated Resident #1 had returned from the hospital with a sling. The Administrator stated Resident #1 would benefit from physical therapy. She stated Resident #1 completed a consult for physical therapy and was on the list to start physical therapy. She stated she was aware the resident was diagnosed on [DATE] with a fracture shoulder and had not been scheduled for a follow up appointment as of 07/15/23. She stated the Unit Manager was handling the referral. Review of Resident #1 Interdisciplinary patient screen completed by physical therapy stated, screening completed. Awaiting MD appointment for therapy to evaluate. Pt will continue to wear sling. Review of Resident #1 care plan dated 01/04/23-present revealed it had been updated since the resident's fall. Interventions included keeping the areas free of obstruction to reduce the risk of falls or injury. Place call light within easy reach, remind resident to call for assistance before moving from bed to chair and from chair to bed. Respond promptly to calls for assist to the toilet, footwear, will fit properly and have non-skid soles, and x ray to shoulder and arm secondary to complaints of pain. Interview on 07/15/23 at 1:30 PM with Unit Manager revealed Resident #1 fell on [DATE]. On 06/08/23 the X-Ray was completed, and the results were fracture to the right shoulder. She stated Resident #1 had been seen by her primary doctor and the primary doctor did not specialize in broken or fractured bones. She stated the resident had not gone to orthopedic doctor because the doctor office stated they had not received a referral for a follow-up. Unit Manager revealed she faxed a referral on 06/20/23, and 07/11/23 because referral was not written by the primary care doctor until 06/20/23. She stated she was unable to find a copy of confirmation for the referral faxed to the orthopedic doctor on 06/20/23. She stated Resident #1 had 14 days from the time the referral was written to get the appointment scheduled. She stated it had been almost 30 days since the referral was written and an appointment has not been scheduled. She stated the risks of not going to follow up appointment with orthopedic doctor could result in Resident #1 arm healing improperly, blood clots could form, and the fracture could get worse. Review of Resident #1 referral, dated 07/11/23, stated the transmission was ok, which indicated the referral was received, on 07/11/23 at 1:38 PM. Review of Resident #1 progress notes for June 2023 revealed no progress notes for 06/07/23 the day of the incident. Review of Resident #1's progress notes, dated 06/08/23, revealed at 9:23 AM Resident #1 pain level was 6/10 (1 was low pain and 10 was worse pain). LVN A called NP because there were no PRN pain medications ordered the Resident #1. The NP gave LVN A orders to give Tylenol 100mg every 6 hrs PRN. Review of Resident #1 progress notes, dated, 06/08/23, revealed, at 9:31 AM, X-Ray results showed an acute fracture. LVN A notified NP and received an order to send Resident #1 to the hospital and informed Resident #1 family. Review of the progress notes on 06/08/23 at 11:30 PM revealed Resident #1 returned from the hospital in a wheelchair with a sling applied to the right arm. The orders given from hospital for PRN Norco 10-325mg as needed for pain. Review of Resident #1's X ray results, dated 06/08/23, revealed mild displaced humerus head fracture. Review of Resident #1 discharge summary from [Hospital name] revealed Resident #1 was seen for a right shoulder fracture. There was a sling applied to right arm. She received an order for Hydrocodone/Acetaminophen 10-325mg and a Self-Referral to PCP and orthopedic doctor with a note that stated, your health care plan may require a referral from your primary care provider prior to making an appointment. Interview on 07/15/23 at 3:35 PM with PCP revealed Resident #1 went to ER and found out about the shoulder fracture. She stated due to the shoulder fracture, the hospital ordered Resident #1 to wear a sling and follow up with orthopedic doctor outpatient. She stated hospital referral usually worked as an outpatient referral; however, the insurance stated the PCP needed to write the referral. She stated the Insurance company called the daughter and the daughter notified her of the Orthopedic referral. She stated she was aware Resident #1 had not gone to orthopedic follow up appointment. She stated it takes 6 weeks to heal the type of fracture Resident #1 had and understood 5 weeks had already passed without follow up with orthopedic doctor. Interview on 07/15/23 at 3:25PM with Social Worker revealed, the orthopedic office was closed on Friday 06/23/23. She stated she faxed the referral and e-faxed the number provided by the doctor. Sent it to two fax numbers. Did another e-fax and did not follow up with e-fax because her last day was 06/28/23. Social Worker stated she had passed it to Unit Manager. She stated she was unable to provide confirmations of the faxes that were sent to the Orthopedic office. Telephone interview on 07/16/23 at 9:39 AM revealed RN B had made rounds on 200 and 400 halls on 06/07/23. He had heard a loud sound on 200 wings. RN B stated he went to investigate and saw Resident #1 on floor in the nutrition room. He stated he had called out to the staff for assistance. His assessment findings for Resident #1 were she had feeling in all of her extremities but complained of pain in the right arm. He stated he had applied a pain-relieving cream to the right arm per Resident #1 request. RN B stated he was able to get the resident up off the floor and safely in bed. He stated the Nurse Practitioner, the resident family, and the supervisors was notified of the fall, and he had received new orders for an X-Ray. He stated the X-Ray was completed after his shift was over. Requested a policy on Resident Quality of Care. The facility did not provide the document upon exit.

Based on observation, interview, and record review, the facility failed to ensure the resident received reasonable accommodation of needs and preferences for one (Resident #2) of five residents reviewed for accommodations of needs. The facility failed to ensure Resident #2's call light was withing reach. This failure could place resident at risk for not being able to contact staff and their needs not being met. Findings included: Review of Resident #2's face sheet undated reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's primary diagnoses included dementia. Review of Resident #2's MDS undated reflected she had a BIMS score of 04 , which indicated she had severe cognitive impairment. She required assistance with activities of daily living (ADL) with two-person physical assist, including bed mobility, transfer, dressing, and toilet use. Review of Resident #2's care plan dated 05/21/22 revealed Problems Falls: at risk for falls R/t altered mental status, history of falls prior to admission. Interventions Place call bell/light within easy reach. Observation on 07/15/23 at 10:22 AM, revealed Resident #2 was alert and was lying in bed. When asked where her call light was, Resident #2 responded it's here somewhere. Resident #2 then attempted to roll from left to right in the bed. When asked if she could reach her water, Resident #2 attempted to pull herself up to reach the water cup located on the bedside table. Resident #2 was unable to reach the water cup. Call light was observed on the floor next to resident #2's bed. Interview with CNA C on 07/15/22 at 3:05 PM revealed that the call light was needed for residents to be able to indicate when they need help with something. If the call light was not within reach the resident could be at risk of falling. Review of the facility's call light policy dated 06/14/05 reflected, Purpose: to respond promptly to Patient's call for assistance wand to ensure call system is working order. When providing care to Patients, be sure to position the call light convenient for the Patient to use. Tell the Patient where the call light is and show him/her how to use the call light.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to implement the developed care plan for Resident #1, which included an intervention for the use of fall mats, as it related to her being a fall risk due to her diagnosis of unspecified dementia. This failure could place residents at risk for not receiving necessary care and services. Findings included: Record Review of Resident #1's electronic Facesheet, dated 07/03/23, indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and muscle weakness. Record Review of Resident #1's Nursing Home Discharge MDS, dated [DATE], reflected Resident #1 had a BIMS of 4, which indicated her cognition was severely impaired. Additional review of the MDS reflected, Resident #1 required assistance for transfers and bed mobility and was always incontinent of bowel and bladder. Record Review of Resident #1's Care Plan , dated 06/23/23, reflected Resident #1 was at risk for falls due to unspecified dementia. The interventions included All staff: Place call bell/light within easy reach. Provide reminders to use ambulation and transfer assist devices. Remind [Resident] to call for assistance before moving from bed-to-chair and from chair-to-bed. Respond promptly to call for assist to the toilet. Monitor more frequently, frequent checks fall mats are in place. Record Review of Resident #1's Clinical Notes, dated 06/26/23, by the ADON, reflected Patient was observed on the floor laying on the left side, on assessment noted that patient had bruising to chin on left hand and left knee, Patient denies pain, Able to move BUE/BLE, Patient unable to state what happened, Patient assisted back to bed x(times) 2 person assist, MD notified, no new orders, RP notified. Will monitor Patient frequently. In an interview on 07/03/23 at 10:13 AM, CNA A stated she was walking pasts Resident #1's room and saw her on the floor. She stated she called CNA B, who was covering Resident #1's hall and she went to get LVN C. She stated LVN C assessed Resident #1 and then they got her off the floor. CNA A stated Resident #1's bed was at the lowest position, but there was not a fall mat in place. CNA A stated there should have been a fall mat and after Resident #1 fell , they immediately put the fall mats down. In an interview on 07/03/23 at 10:19 AM, CNA B stated CNA A called her to Resident #1's room because she fell . She stated she was the CNA assigned to Resident #1's hall. CNA B stated she let LVN C, who was the nurse responsible for Resident #1's hall, know that Resident #1 fell . CNA B stated Resident #1 did not have a fall mat in place. She stated LVN C assessed Resident #1 and they removed her from floor. CNA B stated they did put a fall mat in place after Resident #1 fell . She stated Resident #1 had bruising on her face, hand, and knee. In an interview on 07/03/23 at 10:23 AM, LVN C stated he was called to Resident #1's room by CNA B. He stated Resident #1 was on the floor. LVN C stated he took Resident #1's vitals and assessed her for injury and fractures. He stated she had a bruise on her face near her chin. LVN C stated he believed it was on the right side of her face. He stated she had bruising on her knee as well. LVN C stated he could not remember if there was fall mat in place before she fell , but he knew for sure one was there after Resident #1 fell because he was doing frequent checks on her. In an interview on 07/03/23 at 10:30 AM, the ADON stated she was called to Resident #1's room by LVN C. She stated Resident had fell on the floor from her bed and was laying she believed on her left side. The ADON stated LVN C took Resident #1's vitals and assessed her for fractures. She stated Resident #1 did not have any fractures or serious injuries. The ADON stated Resident #1 had bruising on her chin and knee. She stated Resident #1 was a fall risk and required a fall mat. The ADON stated she could not remember if a fall mat was in place prior to Resident 1 falling. In an interview on 07/03/23 at 2:50 PM, the Administrator stated she was on vacation when Resident #1 fell . The Administrator stated she believed Resident #1 entered the facility the day before she left for vacation, and she recalled putting a fall mat in her room. The Administrator stated she was not sure why the fall mat was not in place, prior to her fall, but there should have been one there. She stated Resident #1 was a fall risk and was care planned to have a fall mat. The Administrator stated she would complete an in-service with staff. Record Review of the facility's policy titled Patient Care Management System 12, dated November 2017, reflected Upon admission (including readmission) each Patient/Resident's diagnoses must be reviewed with the physician to develop individualized care plan interventions, including the touchscreen daily care guide. The facility will use Patient/Resident observation, communication, family input and clinical history as the primary source of information.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to put fall mats in place for Resident #1, when she fell from her bed on 06/26/23, which could have potentially helped avoid Resident #1's bruising. This failure could place residents at risk of pain, injuries, and hospitalization . Findings included: Record Review of Resident #1's electronic Facesheet, dated 07/03/23, indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and muscle weakness. Record Review of Resident #1's Nursing Home Discharge MDS, dated [DATE], reflected Resident #1 had a BIMS of 4, which indicated her cognition was severely impaired. Additional review of the MDS reflected, Resident #1 required assistance for transfers and bed mobility and was always incontinent of bowel and bladder. Record Review of Resident #1's Care Plan , dated 06/23/23, reflected Resident #1 was at risk for falls due to unspecified dementia. The interventions included All staff: Place call bell/light within easy reach. Provide reminders to use ambulation and transfer assist devices. Remind [Resident] to call for assistance before moving from bed-to-chair and from chair-to-bed. Respond promptly to call for assist to the toilet. Monitor more frequently, frequent checks fall mats are in place. Record Review of Resident #1's Clinical Notes, dated 06/26/23, by the ADON, reflected Patient was observed on the floor laying on the left side, on assessment noted that patient had bruising to chin on left hand and left knee, Patient denies pain, Able to move BUE/BLE, Patient unable to state what happened, Patient assisted back to bed x(times) 2 person assist, MD notified, no new orders, RP notified. Will monitor Patient frequently. Record review of the facility's policy titled Fall Management Guidelines, dated November 2022, reflected 8. During daily Clinical Stand Up, any Patients who have had a recent fall and any patients admitted who are at risk fall will be discussed to ensure that fall prevention interventions have been implemented. 9. Staff assigned to the units will conduct rounds for residents at risk for falls or who have experienced a fall to ensure their fall prevention interventions are implemented. In an interview on 07/03/23 at 10:13 AM, CNA A stated she was walking pasts Resident #1's room and saw her on the floor. She stated she called CNA B, who was covering Resident #1's hall and she went to get LVN C. She stated LVN C assessed Resident #1 and then they got her off the floor. CNA A stated Resident #1's bed was at the lowest position, but there was not a fall mat in place. CNA A stated there should have been a fall mat and after Resident #1 fell , they immediately put the fall mats down. In an interview on 07/03/23 at 10:19 AM, CNA B stated CNA A called her to Resident #1's room because she fell . She stated she was the CNA assigned to Resident #1's hall. CNA B stated she let LVN C, who was the nurse responsible for Resident #1's hall, know that Resident #1 fell . CNA B stated Resident #1 did not have a fall mat in place. She stated LVN C assessed Resident #1 and they removed her from floor. CNA B stated they did put a fall mat in place after Resident #1 fell . She stated Resident #1 had bruising on her face, hand, and knee. In an interview on 07/03/23 at 10:23 AM, LVN C stated he was called to Resident #1's room by CNA B. He stated Resident #1 was on the floor. LVN C stated he took Resident #1's vitals and assessed her for injury and fractures. He stated she had a bruise on her face near her chin. LVN C stated he believed it was on the right side of her face. He stated she had bruising on her knee as well. LVN C stated he could not remember if there was fall mat in place before she fell , but he knew for sure one was there after Resident #1 fell because he was doing frequent checks on her. In an interview on 07/03/23 at 10:30 AM, the ADON stated she was called to Resident #1's room by LVN C. She stated Resident had fell on the floor from her bed and was laying she believed on her left side. The ADON stated LVN C took Resident #1's vitals and assessed her for fractures. She stated Resident #1 did not have any fractures or serious injuries. The ADON stated Resident #1 had bruising on her chin and knee. She stated Resident #1 was a fall risk and required a fall mat. The ADON stated she could not remember if a fall mat was in place prior to Resident 1 falling. In an interview on 07/03/23 at 2:50 PM, the Administrator stated she was on vacation when Resident #1 fell . The Administrator stated she believed Resident #1 entered the facility the day before she left for vacation, and she recalled putting a fall mat in her room. The Administrator stated she was not sure why the fall mat was not in place, prior to her fall, but there should have been one there. She stated Resident #1 was a fall risk and was care planned to have a fall mat. The Administrator stated she would complete an in-service with staff.

Based on observation, record review and interview, the facility failed ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers from developing 1 (Resident #1) of 10 residents reviewed for pressure ulcers. The facility failed to use wedges and/or pillows under Resident #1's heels to reduce pressure. This failure could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers. Findings include: Record review of Resident #1's face sheet, dated 04/24/23, revealed a [AGE] year-old female, with an admitted [DATE], and diagnosis of Metabolic Encephalopathy (brain issue caused by chemical imbalance), Cardiomegaly (enlarged heart), Hypertensive Heart Disease, Muscle Weakness, Dementia, Acute Embolism and Thrombosis of Unspecified Vein (blockage), Thyrotoxicosis(thyroid hormone condition), Hyperlipidemia (High Cholesterol), Insomnia, Nutritional Deficiency, Deficiency of other Vitamins, and Unspecified Open Wound. Record review of Resident #1's Care Plan dated 01/11/23 noted the following: Problems Ulcer Prevention Status: Active Goals: [Resident #1] will not develop new pressure ulcers. Status: Active C4.7- Use suspension devices, pillows, and/or wedges to reduce pressure on heels and boney prominences Status: Active In an observation on 04/21/23 at 1:00 PM, Resident #1 was observed, laying in bed, being fed her lunch. Resident #1 did not have a pillow or wedge under her feet. In an observation on 04/22/23 at 9:45 PM, Resident #1 was observed, laying in bed, watching television in her room. Resident #1 did not have a pillow or wedge under her feet. During an interview on 04/22/23 at 9:45 PM, Resident #1 was observed laying in bed. She stated she was just watching television. She stated she was tired and a little sore. Resident #1 did not say where the soreness was on her body. In an interview on 04/22/23 at 10:13 PM, CNA C stated he was familiar with Resident #1 and that he worked with Resident #1. He stated that if he looked at Resident #1's feet and her feet did not appear swollen or had fluid, he would not put the pillow under her feet. He stated that usually he would put the pillow under Resident #1's feet. In an interview on 04/22/23 at 10:36 PM, ADON stated that it was in Resident #1's care plan to place a pillow under her feet. She stated that Resident #1 should have had a pillow under her feet at all times. She stated the only time the pillow would not be placed under her feet was if she was being changed, bathed, or re-positioned in bed. ADON stated the pillow should have been replaced after any of those activities. She stated that she would complete an in-service to remind the staff. In a follow up interview on 04/24/23 at 12:20 PM, ADON stated that the staff knew to place the pillow under Resident #1's feet. ADON stated one risk of not placing the pillow under the resident's feet is the re-opening of a wound or Resident #1 having a new wound. In an interview on 04/24/23 at 2:26 PM, Assistant Administrator stated the care plans should be followed. He stated a risk of not putting the pillow under the resident's feet was diminished quality of life. Record review of the facility's policy titled Skin Treatment Protocol 1-A, dated November 2015, stated the following: This general skin protocol must be followed for all patients: 1. Use appropriate pressure-reducing devices to include but not limited to special care areas i.e. tracheostomy, O2, contractures, orthotic devices, etc. 3. Turn and reposition based on patient's individualized need and clinical condition.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one (medication cart #1) of 3 medication carts reviewed. The facility failed to ensure medication cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: An observation on 04/19/23 at 9:10 AM revealed Medication Cart #1 was unlocked and unattended. All drawers of the medication cart were unlocked, and medications were easily accessible. Surveyor was able to open all drawers of the cart, and prescription medication was accessible. Nurse Manager B walked over and locked the medication cart while Surveyor was standing by the cart. In an interview on 04/19/23 at 9:20 AM, Mediation Aide A stated the medication cart belonged to him. He stated he thought he locked it when he left to go do medications for a different hall. He stated he was trained that the medication cart should be locked at all times. He stated that one risk of leaving the medication cart unlocked was that any resident could get medications off the cart that was not theirs. In an interview on 04/19/23 at 10:15 AM, Nurse Manager B stated that all medication aides had been trained on not leaving their medication carts unlocked. He stated one risk of an unlocked medication cart was a resident or anyone could get medications off the medication cart. In an interview on 04/19/23 at 10:45 AM, Assistant Administrator stated all medication aides had been trained on locked medication carts, and that they had been trained on the risks, like missing medications. Record review of the facility's policy titled Storage of Medication, last revised April 2007, revealed the following: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being, for 1 of 3 Residents (Resident #3) reviewed for treatment and services, in that: 1. PTA Z held Resident #3 's wrist while the resident was displaying combative behaviors on 12/19/22. 2. On 12/22/22 Resident #3 was discharged into the hospital with multiple bruises on the wrist, left shoulder, right upper arm, knees, lower legs, and hands with handprints noted. This deficient practice could place residents with dementia at risk for their medical, physical, and psychological needs not being met and result in a decline in health. Findings included: Review of Resident #3's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #3's diagnoses included Dementia, Delirium and Type 2 diabetes. Resident #3 was discharged on [DATE] to a psychiatric hospital. Review of Resident #3's clinical record revealed no baseline care plan was completed. The base line care plan had no areas completed. Review of the comprehensive care plan dated 12/16/22 revealed Resident #3 was newly admitted resident. Resident#3 had recent deterioration in behaviors evidenced by biting staff and visitors, laying and crawling on the floor. The Comprehensive Care Plan included the facility would document behaviors, Notify the MD of decline in behaviors. No additional concern areas were addressed on the comprehensive care plan. Review of Resident #3's undated Discharge MDS revealed Resident #3 was discharged to psychiatric hospital. Resident # 3 was severely impaired making decision regarding tasks of daily life. Resident #3 had short-term and long-term memory issues. Review of the Medication Administration Record for Resident #3 for December 2022 revealed she was being monitored for Anticoagulant (Blood for Aspirin, no bruising had been noted on the MAR Review of Resident #2 admission nursing assessment dated [DATE] revealed no bruising was noted to Resident #3's body. Review of the shower sheet dated 12/18/22 for Resident # 3 revealed 4 areas of purple discoloration. One area on the left and right forearm and one each of the upper arm on the right and left side. Review of Resident #3's progress note dated 12/21/22 at 6:48 am, revealed Resident #3 was ambulating down the hallway with no brief or no clothing. Resident #3 grabbed the nurse's arm and tried to bite the nurse. Review of Resident #3's progress note dated 12/21/22 at 11:48 am, revealed the resident being noncompliant with care and taking her medication. Resident #3 was abusive to staff and residents. The progress note reflects that several staff members reported that they had been hit, scratched, kicked and slapped by Resident #3. Review of a progress note dated 12/19/22 for Resident # 3 revealed This said nurse was informed by Nurse and [CNA A] upon entering room resident has pooped on floor and was attempting to lay down on the floor as nurse had entered the room. CNA and Nurse eventually lifted resident off the floor and unto the bed as [PTA Z] assisted with putting brief and clothes on resident. Review of the Incident/Accident log for December 2022 revealed no evidence or report of the incident involving Resident #3. Review of the Transportation Ambulance Report dated 12/22/22 revealed Resident #3 had bruises on arms and what appears to be consistent with handprint bruises on left upper arm. Reddish purpled bruising left upper posterior triceps into armpit and latissimus dorsi. The Upper left arm injury-Location Modifier: Injury: Contusion Injury Modifier: Comments: Proximal LUE (Left upper Extremity) lateral aspect of triceps 4 horizontal bruises approximately 3 inches long and 0.5 inches wide. Yellowing around edges, estimated 4 to 5 days old. Right upper Arm injury - Location Modifier: Injury: Contusion Injury Modifier: Comments: Reddish purpled bruising L upper posterior triceps into armpit and latissimus dorsi . Review of the hospital records dated 12/22/22 revealed Resident #3 had green and blue bruising to the lateral left shoulder. An interview with CNA A on 12/23/22 at 9:42 am revealed she had worked with Resident #3 since admission on 12/16/22. She stated Resident # 3 had behaviors that included profanity, refusal of care, biting staff, biting herself, punching, not wearing clothes. Resident #3 preferred to lay on the floor instead of her bed. On 12/19/22 she was involved in picking Resident #3 from the floor with the admission staff and PTA. On 12/19/22 CNA A assisted Resident #3 from the floor to the bed to provide incontinent care, while on the floor the resident was laying in feces. While she and the admission staff were struggling to place the resident in bed, PTA Z joined in Resident#3's room and assisted. The resident was using profanity and was not very cooperative at all. Resident #3 was attempting to hit and scratch PTA Z. She did not recall if PTA Z had grabbed Resident wrist. She did recall seeing bruising on the resident following that incident. She reported the incident and bruising (Left shoulder, left leg, shin, right arm and right shoulder) to the nurse. Resident #3 often would not allow staff to get close to her without attempting to punch or scratch the staff. She informed the charge nurse following the incident, she was not asked to complete a report. CNA A stated she should have allowed Resident #3 to calm before attempting to provide care. An interview with PTA Z on 12/23/22 at 1:46pm revealed Resident #3 was not on her schedule for therapy services. On 12/19/22 PTA Z saw the staff struggling with Resident #3. Resident #3 was being combative and did not want staff to put Resident #3 in bed and provide incontinent care. Resident #3 was on the floor in feces. PTA Z assisted the admission staff and CNA to help clean the resident up, the resident was fighting. The PTA assisted by rolling the resident to the side using a draw sheet. Resident #3 was attempting punch and scratch her, so she grabbed the resident wrist to prevent from being hit by Resident #3. PTA Z stated she also held the resident arm, to prevent injuries. She revealed there was no marks or bruises before and or immediate after the incident. She had never worked with Resident #3 prior. She had not been asked about the incident with Resident #3 on 12/19/22, PTA Z stated she did not report to the facility nurse. PTA Z revealed she should not have held Resident #3's wrist. An interview with the DON on 12/23/22 at 1:22pm revealed he was not aware of Resident #3 being held by the arms and wrist on 12/19/22. He stated Resident #3 had some purple discoloration, that was noted on a shower sheet on 12/18/22. He stated the purple discoloration on located on Resident #3 for arm and upper arm on both sides. Resident # 3 was being monitored for Anticoagulant (Blood Thinner) for ASPIRIN and (Brilinta (a blood thinner that is used to prevent heart attack or stroke) medications. Resident #3 physician had not been informed of the bruising noted. The facility staff were not allowed to grab a residents wrist during care. If a resident is combative, the staff should leave the resident safe and return later to provide care. An interview with the ED on 12/23/22 at 2:01 pm revealed she was not aware of the staff member holding Resident #3's wrist while she was displaying combative behaviors. The facility nurse and staff were not all to get close to the resident because she was combative. The nursing staff had been unable to assess the resident skin. Staff are not allowed to grab any resident wrist or arm when a resident displays behavior. An interview with the MD and NP for Resident #3 on 12/23/22 at 2:08 pm revealed they were not aware Resident #3 having any bruising. They had not been informed Resident #3 being held by the arms or wrist while providing incontinent care. The resident had behaviors and was discharged to a psychiatric hospital on 12/22/22 for treatment. The facility staff had not informed her of the bruising noted in the facility. Review of the facility's Change in Behavior policy dated 06/13 revealed staff must evaluate residents for sign and symptoms of behaviors, that include, dangers to self of others to the staff must notify the MD and NP.