Every finding on record at Center for Living & Rehabilitation

Based on interview and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent avoidable accidents for 1 of 3 sampled residents (Resident #1). For Resident #1, who was at high risk for falls and required supervision while walking, staff failed to implement person-centered care plan interventions after multiple falls, ensure the resident was care planned for adequate supervision, and ensure staff assigned to care for residents in those rooms had the ability to provide the required supervision. On 6/30/26, Resident #1 experienced an unwitnessed fall and was found on the floor unresponsive and passed away on 7/01/26 from injuries sustained from the fall. These were systemic failures in supervision, care planning, and addressing repeated falls. Findings Include:Per record review, Resident #1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (commonly known as an ischemic stroke), Diplopia (a medical term for double vision, a condition where a person sees two overlapping or separated images of a single object), chronic kidney disease, subarachnoid hemorrhage (a bleeding into the subarachnoid space), and sequelae cerebral hemorrhage (refers to the lingering physical, cognitive, or psychological deficits that remain after a person has experienced bleeding inside the brain). Per record review Resident #1 had 10 falls since 2/27/26. 9 were unwitnessed.Resident #1's care plan created on 1/24/25 stated they are at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, vision/hearing problems and disease process secondary to diabetes, dementia, cerebral vascular accident, hypertension (high blood pressure) and seizures. S/he focuses on toileting/using the bathroom when restless and overestimates his/her abilities. The goal of the fall care plan that was in place in February 2026 was Resident #1 will not sustain serious injury through the review date. The Interventions in place prior to Resident #1 falling on 02/27/26 were:Anticipate and meet Resident #1's needs.Be sure Resident #1's call light is within reach and encourage the resident to use it for assistance as needed. The residents needs prompt response to all requests for assistance.Don't leave alone in the bathroom with the door closed.Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility.Grips Strips left side of Bed and front of bathroom door.Monitor for s/s illness, change in mental status, and/or dizziness.Toilet [Resident #1] before and after each meal and at hours of sleep (HS).[Resident #1] needs to be reminded to use call bell help for help prior to getting out of their chair/bed--offer reminders and encouragement to ask for assistance; Will continue to remind [Resident #1] the importance of calling for help during transfers to improve safety.Resident #1 was care planned for monitoring and falls in their side-effects of pain medication focused care plan:Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician.Resident #1 had a care plan for activities of daily living (ADLs) that identified needs for supervision during toileting, ambulation and transfers. The focus of the care plan was ADL selfcare performance deficit related to Impaired balance, deconditioning and disease process secondary to diabetes, HTN, CVA, CKD, anemia, visuospatial deficit, dementia, and seizures. The interventions for this care plan were:TRANSFER: Resident #1 requires supervision for in-room transfers for transfers using a four wheeled rolling walker. AMBULATION: Ambulatory to tolerance in Nursing hallways using four wheeled rolling walker with 1 person close supervision.AMBULATION: tolerates equal to or greater than 500 feet using four wheeled rolling walker. Ambulate as tolerated/ or to physical therapy's desire. Encourage ambulation to-dine for all meals. [Resident #1] demonstrates decreased safety awareness, impulsive at times, and tends to bump into things (obstacles) due to decreased vision.TOILET USE: [Resident #1] requires supervision assist with toileting. Don't leave alone in bathroom. May wear medium pullups for urinary incontinence. May need reminders to void.Encourage the resident to use bell to call for assistance.There are a group of three private resident rooms where Resident #1's room was located. These rooms are the furthest distance from the nurses' stations on nearby Stark/[NAME] Unit and [NAME]/Frost Unit and are not able to be visualized from either. There are no other nurses' stations on this side of the facility. Staff working on Stark/[NAME] must walk off the Stark hallway, around the corner, through a common area to visualize the rooms. Staff on [NAME] Hallway must walk through a small activities room and around the corner to visualize these rooms. The call bell system for these rooms alerts the [NAME]/Frost nurses station, however the care for residents in those three rooms is assigned to Stark/[NAME] Unit.Per interview with Assistant Director of Nursing (ADON) on 7/6/26 at approximately 1:30 PM confirmed that the residents who live on the hall where Resident #1's room was, are assigned Nurses and Licensed Nurse's Aides (LNA) from the Stark/[NAME] Unit. That unit is located on the adjacent side of the building from the [NAME]/Frost units. The call bell systems for the three rooms on the separate short hall do not ring on the unit of which they are assigned, but at the [NAME]/Frost unit.Per record review, Resident #1 sustained an unwitnessed fall in their room on 2/27/26 at 3:40 PM. Resident #1's care plan was updated on 2/27/26 with the intervention of: Encourage and assist Resident # 1 to go to a quiet area as needed. Is triggered by loud activities. This new intervention does not address safety within their room.On 3/19/26 at 6:45 PM Resident #1 fell in the bathroom located in their room. Resident #1's care plan was updated on 3/19/26 with: Keep water valve in bathroom for the bed cleaning device closed when not in use. However, the care plan for toileting indicates the resident should always be supervised while in the bathroom. Per record review on 3/29/26 at 6:30 AM, Resident #1 had an unwitnessed fall in their room where they fractured and dislocated their right, third finger. Resident #1 was sent to the emergency department for treatment and returned to the facility. The care plan was updated on 3/29/26 with: Encourage Resident #1 to allow privacy curtains to be closed instead of his/her room door. There was a second intervention added after this fall: Perform safety checks on Resident #1 frequently through the night as they do not remember to use their call bell for assistance. These interventions do not address the falls occurring in the morning, afternoon and evening, or address why the resident was continuing to attempt to transfer/ambulate without the care planned supervision previously described.On 4/8/26 at 1:30 PM Resident #1 had an unwitnessed fall in their room. They sustained a head strike resulting in a scalp laceration. They were not sent to the hospital after this fall. The care plan was updated with: Keep walker close to Resident #1 so it will be available at all times.On 4/25/26 at 3:30 PM, Resident #1 had an unwitnessed fall in their room without injury. The resident's care plan was a revision of a previous intervention: Encourage resident to keep room door open. Date Initiated: 10/25/2025, Revision on: 04/27/2026. There was not a new intervention put into place after this fall, and after the fall 3/29/26 the intervention of allow privacy curtains to be closed instead of resident's room door was implemented.Per record review on 4/30/26 at 2:50 PM Resident #1 had an unwitnessed fall in their room without injury. The care plan was updated on 4/30/26 with the intervention of: Daughter will bring in smaller slippers as [Resident #1] needs to be encouraged to wear slip socks until new slippers arrive. However, Resident #1 was previously care planned for footwear initiated on 1/27/26: Ensure that [Resident #1] is wearing appropriate footwear (Shoes or nonskid socks) when ambulating or mobilizing in w/c.On 5/4/26 Resident #1 was sent out to the hospital for changes in mental status where they were admitted until 5/7/26, then returned to long-term care facility.Resident #1's care plan intervention for frequent safety checks at night which also informs staff that they do not remember to use their call bell, was cancelled. The intervention cancelled was: Perform safety checks on [Resident #1] frequently through the night as s/he does not remember to use their call bell for assistance. Date Initiated: 03/29/2026, Cancelled Date: 05/04/2026.Interview with the Assistant Director of Nursing (ADON) on 7/7/26 at approximately 12:55 PM confirmed the intervention should not have been cancelled and Resident #1 should have been care planned for the increased supervision, and safety checks when they returned.Per record review on 5/24/26 at 10:45 AM, Resident #1 sustained another unwitnessed fall in their room. Resident #1 developed facial/eye bruising after this fall with no other noted injuries. The care plan was not updated after this fall.On 6/22/26 at 7:15 AM Resident #1 had a witnessed fall in their room where they sustained bruising to their elbow, a right arm laceration, and a reopening of a scab on the left arm. Resident #1's care plan was not updated after this fall, and the facility's post fall packet was not completed.On 6/30/26 at 9:30 AM Resident #1 had an unwitnessed fall in their room. The care plan was not updated after this fall.Interview with the ADON at approximately 12:55 PM on 7/7/26 confirmed the care plan had not been updated regarding falls since the fall on 5/24/26, and the fall packet for 6/22/26 was not completed.On 6/30/26 at 2:45 PM Resident #1 fell a second time that day and was found on the floor of their room face down, soiled in stool and urine. Resident #1 was then sent to the hospital for evaluation of injuries.Per record review of Southwestern [NAME] Medical Center Emergency Department note written on 6/30/26, Resident #1 was found face down in their room. It is unclear how long they were on the ground. Per Emergency Medical Services who responded, resident was found laying in a pool of blood. Resident #1 was assessed in the emergency department where it was identified they sustained a subdural hematoma (a subdural hematoma is a life-threatening collection of blood that pools between the brain's surface and the dura mater (its tough outer lining)), cerebral hemorrhage (a cerebral hemorrhage (or brain bleed) is a life-threatening medical emergency where a blood vessel bursts or leaks inside the skull), and multiple sinus fractures. Resident #1 was placed on comfort measures and passed away at the hospital on 7/1/26.Per interview on 7/7/26 at 1:25 PM with Licensed Practical Nurse (LPN) assigned to the [NAME]/Stark Halls, they stated that they don't know where the call bells for the group of three rooms where Resident #1 resided alert staff. Confirmed staff on the unit wouldn't know if their call bells were ringing or if they needed assistance unless they walked down to that separate hallway to see the rooms.Per interview on 7/7/26 at 1:44 PM with Licensed Nurses Assistant #1 (LNA) was assigned to the Stark hallway and confirmed their assignment included the rooms on the separate hallway where Resident #1's room was located. LNA #1 stated that it is impossible to supervise a resident with a significant fall risk in those three rooms specifically. LNA #1 confirmed that the call bell system for the rooms on that alert the Frost/[NAME] nurses' station and that staff from Frost/[NAME] will call via telephone to the nurses' station at Stark/[NAME] to notify them a call bell is on. LNA #1 stated they are not always able to get to the phone because they are often in rooms or walking the hall to provide care and assist residents and cannot hear it or get to it.Per interview with LNA #2 on 7/7/26 at 2:14 PM assigned to [NAME] Hall stated that when call bells for the three rooms on the separate smaller hallway are lit s/he will go answer them if they can. LNA #2 confirmed they sometimes work on Stark/[NAME] and it is very difficult for Stark Hall staff to have those rooms on their assignment because the call bells for those rooms do not alert the Stark nurse's station and the rooms are hard to supervise because it is far away from the units. Sometimes staff from [NAME] Hall round on those rooms but it all depends on the staff member, not everyone does or has the time.Per interview with the ADON on 7/7/26 at approximately 2:41 PM Resident #1 ambulated using a four wheeled rolling walker with supervision. ADON felt the facility implemented everything they could to reduce falls, except for moving Resident # 1's room closer to the nurse's station for more supervision or initiating 24/7 one to one supervision.Per review of the facility's policy titled: Accidents and Incidents, which does not contain a revision date, states: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent reoccurrences and improve the management of resident care.Per review of the facility's policy titled: Fall Prevention and Protocol-CLR last reviewed on 6/10/2025.IV. Policy Statement section 7. Care planning: a. Document appropriate interventions on the resident/patients care plan related to fall prevention. Examine previous fall patterns and if known document this on the care plan well. b. During regularly scheduled reviews of the care plan, ensure that all interventions related to prevention of falls remain appropriate.

Based on observation, interview, and record review, the facility failed to provide supervision related to smoking for 1 of 1 sampled residents (Resident #15). Additionally, the facility failed to monitor the storage of Resident #15's lighter and cigarettes. This is a repeat deficiency, with the violation being cited during the past two recertification surveys dated 4/30/25 and 3/27/24. Findings include:Per record review, Resident # 15 is care planned for smoking, revised on 7/28/25. Resident #15's care plan goal is to not smoke without supervision. Care plan interventions include educating the resident on the facility's policy about smoking locations, times, and safety concerns.Per observation, at approximately 12:55PM on 4/7/26 a person is sitting in a wheelchair, outside the entrance to the facility smoking a cigarette. There are no observed staff members outside.Per interview with the Receptionist at 12:57 PM on 4/7/26, the resident outside was Resident #15, and s/he is permitted to sit outside without staff supervision.Per interview 4/7/26 at approximately 1:03 PM with the Assistant Director of Nursing (ADON), they stated that Resident #15 used to smoke and had recently quit. S/he explained Resident #15 signed the facility's admission agreement that states the facility is non-smoking and residents will not smoke while living there. Resident #15 has been seen in the past on several occasions by staff members outside smoking and returning to the facility smelling like smoke. The ADON confirmed the facility has been working with the resident to assist with smoking cessation utilizing lollipops and nicotine replacement. The ADON confirmed there are 7 residents that wander and 26 residents with a diagnosis of dementia on Resident #15's unitPer interview on 4/7/26 at 1:10 PM with the Administrator, Resident #15 used to smoke and had quit on 4/4/26. S/he confirmed that the facility was aware that Resident #1 was smoking on facility grounds prior to 4/4/26 with supervision of staff and Resident #15 has not had a smoking safety assessment. Additionally, Resident #15 manages/stores their cigarettes and lighters/ignition devices independently as they are their own person and alert and oriented.Per interview with Resident #15 at approximately 1:30 PM on 4/7/26 they are trying to quit smoking, but it is challenging. S/he expressed it is a trigger when staff provide care smelling like smoke. Resident #15 stated the facility allows them to go outside to smoke independently without staff supervision. S/he stated s/he keeps their cigarettes and lighter in their shirt pocket or nightstand drawer.

Based on observation and interview, the facility failed to ensure that of 1 of 4 sampled residents had access to the call bell in their room (Resident #1). Findings include:Per record review, Resident #1 was admitted with diagnoses that include chronic pain syndrome, morbid obesity, lymphedema, (Lymphedema refers to tissue swelling caused by fluid that's usually drained through the body's lymphatic system. It most commonly affects the arms or legs, and severe cases of lymphedema can affect the ability to move the affected limb), and osteoarthritis (a diagnosis affecting joint cartilage causing pain swelling and stiffness of the affected joints). Review of Resident #1's Minimum Data Set Assessment (MDS) with a reference date of 10/07/2025 revealed Resident #1 has a BIMS (Brief Interview for Mental Status) score of 14 indicating Resident #1 is cognitively intact.Per observation on 12/30/2025 at 3:10 PM Resident #1 was sitting in a wheelchair in their room, facing the window and vocalized with increased volume help. The call bell was observed pinned on the top sheet of the resident's bed out of their reach.Per interview with Resident #1 at 3:46 PM on 12/30/2025, they stated s/he was brought to their room after bingo and requested to go to bed, staff said they would be right back. Resident stated that s/he could not reach the call bell for assistance and had to use their cell phone to call a friend and ask their friend to call the facility's nurse's station. Resident #1 stated that is the only reason someone came to their room to give them their call bell and turn their chair around. Resident #1 was observed during interview facing the door to the hallway, call bell hanging over the foot board where they could reach it while sitting in the wheelchair at the foot of the bed.Per interview with Licensed Practical Nurse (LPN) #1 on 12/30/2025 at approximately 4:29PM, they stated that Resident #1 is impatient so s/he provided re-education to the resident about their requirement for two-person assistance with transfers. LPN #1 confirmed that resident's friend/family member called the facility to have staff go into the resident's room and assist the resident.

Based upon observations, interviews, and record review, the facility failed to ensure adequate pain control was provided for 1 of 4 sampled residents (Resident #1). Findings include:Per record review, Resident #1 was admitted to the facility with diagnoses that include chronic pain syndrome and osteoarthritis (a diagnosis affecting joint cartilage causing pain swelling and stiffness of the affected joints). Resident #1 has a BIMS [Brief Interview for Mental Status] score of 14, dated 10/7/25, indicating cognitive function is intact.Per observation on 12/30/2025 at 3:10 PM, Resident #1 vocalized with increased volume help. At 3:13 PM, LNA (Licensed Nursing Assistant) #1 entered the room. Resident #1 stated that they wanted to get into bed and that their back hurt. LNA #1 told Resident #1 they needed to stay up in their chair for dinner.Per interview with Resident #1 at 3:46 PM on 12/30/2025, s/he stated that s/he had asked a staff member to lie down in bed because of their back pain and that s/he was told s/he needed to stay up for dinner. Per observation at 3:53 PM, three staff members wheeled the Hoyer lift [equipment to lift and transfer a person] entered Resident #1's room. S/he was transferred to bed at that time. Resident #1 stated pain in their lower back was a 9 out of 10 and that they receive Tylenol for pain management but they won't bring it. Resident #1 pushed the call bell at 4:10 PM to notify the nurse that they would like pain medicine.Per observation on 12/30/2025 at 4:15 PM, LPN #1 (Licensed Practical Nurse) entered Resident #1's room to address the call bell. LPN # 1 told Resident #1 they do not have PRN (as needed) pain medication and that they receive scheduled Tylenol that is not due until 8:00 PM that evening. LPN #1 asked Resident #1 to rate their pain on a scale of 1-10 and describe the location. Resident #1 stated their pain was a 9 out of 10 in their lower back and that the scheduled Tylenol does not seem to be managing the pain. LPN #1 stated they'd notify the provider about Resident #1's concerns of Tylenol not appropriately managing their pain, and that the provider would see Resident #1 on rounds the following day to address this. LPN #1 also stated to Resident #1 they have a topical pain relief cream that will be applied at bedtime. The LPN did not offer any non-pharmacological options (back rub, meditation, music, aromatherapy, etc.) to help with Resident #1's current pain. Per record review, a Progress note from LPN #1 entered at 4:15 PM on 12/30/2025 stated: Summoned to res [resident] room, res c/o [complaint of] pain to lower back and lower leg. MAR [Medication Administration Record] reviewed. No PRN pain medications ordered. educated res that [s/he] have Tylenol scheduled. Res stated Tylenol is ineffective. Message sent over to NP / MD. Per review of Resident #1's orders, an order from the provider dated 7/30/2024 with an indefinite end date states May use facility standing orders. Per review of a document titled Center for Living and Rehabilitation Standing Orders revised/reviewed on 11/21/2024 a standing order for a topical pain relief treatment read Muscle rub: apply topically to affected area every two hours as needed, notify provider if ineffective. Resident #1 has an order that states Acetaminophen Oral Tablet Extended Release 650 milligrams every 8 hours for back pain Notes: FOR PRN PAIN USE - Ensure that Non-Pharmacological Interventions are in Additional Directions and Supplemental documentation as follows: Nonpharmacological Interventions 1. Reposition 2. Back rub 3. Music 4. Diversional activity. At the time of Resident #1's pain assessment, LPN #1 did not offer nonpharmacological interventions, or standing order for topical pain relief ointment.Per interview at 7:40 PM with the Director of Nursing (DON) and Administrator (ADM), they confirmed that an assessment revealing a pain level of 9 on a scale of 1-10 should be addressed timely and before the provider rounds the following day. They also confirmed nonpharmacological approaches should be offered/implemented for pain management.

Based on observations and interviews, the facility failed to ensure that 1 of 4 residents in the sample were treated with dignity and respect (Resident #1). Findings include:Per observation on 12/30/2025 at approximately 4:15 PM, Licensed Practical Nurse #1 (LPN) was observed answering Resident #1's call bell. Resident #1 requested pain medication. LPN #1 addressed the resident as Boo three different times within their interaction.Per interview with Resident #1 on 12/30/2025 at 4:34 PM, Resident #1 stated my name is (proper name omitted), it's not Boo and I don't know why (LPN #1) would call me that. Per interview with LPN #1 on 12/30/2025 at 4:52 PM, they stated Resident #1''s nickname is not Boo it's just a figure of speech and it's what I call everybody.Per interview on 12/30/2025 at approximately 7:45 PM with the Administrator (ADM), she stated that it is not appropriate to address residents with terms of endearment and that staff should address the residents by their preferred name or pronoun.

Based on record review and interviews, the facility failed to review and revise the comprehensive care plans for 2 of 3 sampled residents (Residents #1 and #2) after significant changes in condition related to two resident-to-resident altercations. Despite an initial incident on 8/7/25 and a subsequent altercation on 9/17/25 resulting in Resident #1 sustaining blunt trauma to the nose and expressing fear and distress, the facility did not update either resident's care plan or Kardex to include interventions to prevent recurrence, such as separation or monitoring. Staff interviews confirmed reliance on informal redirection rather than documented interventions. This failure resulted in actual physical harm and psychosocial harm to Resident #1. Findings include:Per record review, the Minimum Data Set (MDS, an assessment tool) dated 10/15/25 reveals that Resident #1 has a BIMS score (Brief Indicator for Mental Status, a test to check if thought processes are intact) of 15 out of 15, indicating cognition is intact. Resident #1 has diagnoses that include anxiety disorder and major depressive disorder. Resident #1 has a care plan focus created on 12/20/23 and revised on 11/14/25 that states, [Resident #1] is at risk for harm r/t [related to] behaviors that impact others. Will repeat statements at times and can become verbally and physically aggressive towards others at times. [Resident #1] can misinterpret situations and/or conversations and can demonstrate accusatory behaviors toward staff when [he/she] doesn't understand what is being communicated.Per record review, the MDS dated [DATE] reveals that Resident #2 has a BIMS score of 15 out of 15, indicating cognition is intact. Resident #2 has diagnoses that include anxiety disorder and bipolar disorder. Resident #2 has a care plan focus created on 3/5/25 and revised on 11/14/25 that states, [Resident #2] has potential to be verbally aggressive and can make accusations towards staff r/t Ineffective coping skills, with an intervention dated created on 3/5/25 and revised on 8/22/25 for, When [Resident #2] becomes agitated: If safe and feasible, gently guide [him/her] away from the source of distress or the current environment to a calmer, less stimulating are (e.g., quiet room, outside if appropriate); Engage in a conversation. If not safe to engage, ensure safety by calmly walking away and allowing [him/her] time to de-escalate before re-approaching and attempting to re-engage.Per record review, Resident #1 and Resident #2 had a physical incident between each other on 8/7/25. A facility reported incident (FRI) was reported to the state on 8/8/25 that describes an observed event where Resident #1 pushed his/her wheelchair into Resident #2 and kicked Resident #2. Resident #2 complained of discomfort to their leg. Per record review, a facility reported incident (FRI) was submitted to the State Agency on 9/18/25, with an allegation of physical abuse related to a resident-to-resident altercation that occurred on 9/17/25 between Resident #1 and Resident #2. Resident #1 ran his/her wheelchair into Resident #2, multiple times. Resident #2 responded by punching Resident #1 in the nose while stating, I am going to get a gun and shoot you, you fat piece of [NAME]. As a result of the 9/18/25 incident, Resident #1 was taking to the emergency department for blunt trauma to the nose with a bleed. A 9/17/25 NP progress note was clearly angry and distressed by the altercation. On 12/15/25 at 12:55 PM, Resident #1 stated that s/he does not feel safe at the facility. See F600 for more information.Per interview with LNA #1 (Licensed Nursing Assistant) at 4:08 PM on 12/15/25, the Kardex (a quick reference tool for referencing patient needs) tells staff what to look for regarding specific residents. LNA #1 was not aware of Resident #1 having trouble with any specific residents.Per an interview with the Unit Manager at 4:10 PM on 12/15/25, the facility's strategy to keep Resident #1 and Resident #2 separated is to try to keep them apart. The Unit Manager stated that information should be care planned and in the Kardex. Per record review, there was nothing to indicate keeping Resident #1 and Resident #2 apart in either resident's Kardex or in either resident's care plan.Per interview with the DON (Director of Nursing) at 4:18 PM on 12/15/25, the facility attempts to keep Resident #1 and Resident #2 separated by kind of just redirecting them. The DON confirmed there is nothing specific in Resident #1 or Resident #2's care plans or Kardex with regard to keeping them apart or protecting them from each other, following either of the two altercations.

Based on interviews and record review, the facility failed to ensure residents' right to be free from physical and verbal abuse from another resident for 2 of 3 sampled residents (Resident #1 and Resident #2). The facility did not implement effective interventions to prevent recurrence after a prior altercation on 8/7/25, nor did it update care plans to address ongoing risk. On 9/17/25, Resident #1 sustained blunt trauma to the nose with bleeding after being struck by Resident #2 during a physical altercation, and Resident #1 expressed feeling unsafe and distressed in his/her home. This deficient practice resulted in actual physical harm and psychosocial harm. Findings include:Per record review, the Minimum Data Set (MDS, an assessment tool) dated 10/15/25 reveals that Resident #1 has a BIMS score (Brief Indicator for Mental Status, a test to check if thought processes are intact) of 15 out of 15, indicating cognition is intact. Resident #1 has diagnoses that include anxiety disorder and major depressive disorder. Resident #1 has a care plan focus dated 12/20/23 and revised on 11/14/25 that states, [Resident #1] is at risk for harm r/t [related to] behaviors that impact others. Will repeat statements at times and can become verbally and physically aggressive towards others at times. [Resident #1] can misinterpret situations and/or conversations and can demonstrate accusatory behaviors toward staff when [he/she] doesn't understand what is being communicated. Per record review, the MDS dated [DATE] reveals that Resident #2 has a BIMS score of 15 out of 15, indicating cognition is intact. Resident #2 has diagnoses that include anxiety disorder and bipolar disorder. Resident #2 has a care plan focus dated 3/5/25 and revised 11/14/25 that states, [Resident #2] has potential to be verbally aggressive and can make accusations towards staff r/t Ineffective coping skills, with an intervention dated 3/5/25 and revised 8/22/25 for, When [Resident #2] becomes agitated: If safe and feasible, gently guide [him/her] away from the source of distress or the current environment to a calmer, less stimulating are (e.g., quiet room, outside if appropriate); Engage in a conversation. If not safe to engage, ensure safety by calmly walking away and allowing [him/her] time to de-escalate before re-approaching and attempting to re-engage. Per record review, Resident #1 and Resident #2 had a physical incident between each other on 8/7/25. A facility reported incident (FRI) was reported to the state on 8/8/25 that describes an observed event where Resident #1 pushed his/her wheelchair into Resident #2 and kicked Resident #2. Resident #2 complained of discomfort to their leg. Per a record review, a facility reported incident (FRI) was submitted to the State Agency on 9/18/25, with an allegation of physical abuse related to a resident-to-resident altercation that occurred on 9/17/25 between Resident #1 and Resident #2. The report describes on 9/17/2025 The ADON (Assistant Director of Nursing) and NP (Nurse Practitioner) were at the opposite end of the hallway at the nursing station when they saw [Resident #1] approach [Resident #2]. Per their report, they heard words exchanged but could not distinguish exactly what was said. The tone appeared negative, so both the NP and the ADON immediately left the nursing station to intervene but before they reached the two residents, they saw [Resident #1] run [his/her] wheelchair more than once into [Resident #2's] wheelchair. [Resident #2] responded by striking [Resident #1] in the face with a closed fist (left hand). Upon assessment, [Resident #1's] nose was noted to bleed and [Resident #2] complained of left-hand discomfort.Per a record review, a 5-day investigation summary, including resident statements and staff witness statements, was submitted to the State Agency on 9/18/25. The summary corroborates that a physical altercation and threats occurred between Resident #1 and #2 on 9/17/25. There was nothing in the facility's investigation that revealed that staff attempted to separate the two residents prior to the event occurring.Per record review, a nursing progress note written on 9/17/25 stated the following, At approximately 1100 [Resident #2] was witnessed by this writer to be sitting in front of [his/her] room in his wheelchair . when another resident [Resident #1] who lives in another area came wheeling down the hallway toward this resident. Words were exchanged between the two residents, but this writer could not hear what was said. This writer began to run up the hallway to intervene just as the [Resident #1] started slamming [his /her] wheelchair into the side of this residents wheelchair. [He/she] slammed into this residents wheelchair 2 or 3 times before this resident [Resident #2] pulled back [his/her] fist and punched the other resident [Resident #1] in the face resulting in a bloody nose. This writer along with another nurse and NP had arrived at the incident and separated the residents at this time. [Resident #1] stated to [Resident #2] 'I am going to get a gun and shoot you, you fat piece of lard' over and over several times. The other resident was taken back to [his/her] room . [Resident #2] was assessed by RN and stated that [his/her] left hand/knuckles hurt.Per record review, a 9/17/25 NP progress note states, I saw [Resident #1] down the hall interacting with [Resident #2]; [he/she] was propelling [his/her] wheelchair around [him/her] and they were conversing. Then they raised their voices and began lashing out at each other physically. When I reached them, [Resident #1] had blood dripping down [his/her] face seemingly from [his/her] nose, and the other resident was gripping [Resident #1's] left forearm. They were separated and I took [Resident #1] back to [his/her] room. [He/she] denied pain but was clearly angry and distressed. Per record review, Resident #1 was sent to the emergency department following the event and discharged back to the facility with blunt trauma to the nose with a bleed. Per interview with Resident #1 on 12/15/25 at 12:55 PM, Resident #1 stated that someone hit him/her on his/her nose. Resident #1 did not know why he/her got hit on the nose and stated that s/he does not feel safe at the facility.Per an interview with Resident #2 on 12/15/25 at 3:50 PM, Resident #2 stated that Resident #1 had run into him/her with his/her wheelchair and that he/her had responded by punching Resident #1 in the nose. With regard to Resident #1, Resident #2 stated, [He/she] has problems. I don't bother [him/her] but [he/she] is relentless. Resident #2 stated that he/her does not believe that Resident #1 seeks him/her out, but that there is a problem when they do see each other.Per interview with the DON (Director of Nursing) at 4:18 PM on 12/15/25, she confirmed there is nothing specific in Resident #1 or Resident #2's care plans or Kardex with regard to keeping them apart or protecting them from each other, following either of the two altercations. See F657 for more information.

Based on interview and record review the facility failed to ensure that one of three residents in the applicable sample, (Resident #1) were free from accidents and hazards, causing the Resident to sustain a skin tear. Per record review on 7/4/2025 Resident #1 was found by staff in bed with a large skin tear on her/his right lower leg. Resident #1 had a care plan focus of ADL (activities of daily living) self-care deficit with a transfer status of 2 staff assist that was implemented on 10/20/2024. Per review of the facility's internal investigation, it states that Resident #1 was care planned for a 2 person stand pivot transfer to all surfaces and for Dermasaver skin tubes (used to protect skin from injury) to always be on when out of bed. The Dermasavers are to be removed only when s/he has been safely transferred back into bed. The investigation further states that Resident #1 had been out of bed in their wheelchair for dinner and was assisted with her/his meal by a nurse. The next time Resident #1 was observed was back in bed by their primary Licensed Nursing Assistant (LNA) when the skin tear was discovered. Per review of staff statements obtained by the facility during the internal investigation the LNA who was assigned to Resident #1's care stated that she had transferred the Resident out of bed to chair for dinner by herself but did not transfer the Resident back to bed. Per interview on 8/27/2025 at 4:10 PM the Director of Nursing confirmed that a staff member had transferred Resident #1 independently and that the Resident had been care planned for 2-assist with transfers. It had been determined through the facility's internal investigation that the skin tear occurred during this transfer.

Based on observation, interview, and record review, the facility failed to ensure that a resident did not develop an avoidable pressure ulcer for 1 of 3 residents in the sample (Resident #1). Findings include:Per record review Resident #1 was re-admitted to the facility on [DATE] after a short discharge to home. A Clinical admission Note reflects that s/he was admitted with a diabetic foot ulcer on her/his left heel. There is no mention of any wound being present on the right heel. Review of the Resident's care plan reveals a Focus dated 5/15/2025 of actual impairment to skin integrity. A Nurse Progress Note dated 6/2/2025 states This writer noted that resident had blood on right sock. Noted to have area to right heel. Supervisor made aware, and came to assess. Family made aware. Another Nurse Progress Note dated 6/2/2025 states resident has a open area on his right heel, supervisor [name omitted] assessed area, 5x5 cm broken blister noted red inner tissue surrounded by white soft tissue with dark pink edges, Slight odor. Resident #1 was transferred to the hospital later in the day on 6/2/2025 and returned to the facility on 6/5/2025. A Nurse Progress Note dated 6/5/2025 reflects that Resident #1 returned to the facility with a Right heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer /injury - partial thickness skin loss with exposed dermis. Wound was present on admission. Length (cm): 7 Width (cm): 5 Depth (cm): 0.1. The right heel wound was present on readmission however, it had been identified in the facility on 6/2/2025, the day that the Resident transferred to the hospital. A Care Plan Focus of actual impairment to skin integrity lists an intervention dated 5/15/2025 lists interventions of Air mattress to bed (applied on admission--uses chronically due to wounds and high risk for wounds). On 6/7/2025 Bilateral heel booties on at all times--remove for skin care and transfers then reapply, was added to Resident #1's care plan. On 6/20/205 the care plan was revised to reflect Use cushion with sides to promote elevation of feet. Another Care Plan Focus for at risk for pain has interventions of Elevate Bil [bilateral] heels when in bed as desired. These protective interventions were not implemented until 6/7/2025, after the right heel pressure ulcer was identified. Per interview with the Director of Nursing on 6/30/2025 at 5:30 PM, she confirmed that the right heel wound had developed in the facility and that there were no documented interventions related to protecting the right heel from developing pressure ulcers prior to 6/2/2025.

Based on interview and record review, the facility failed to ensure 3 residents [Residents #15, #80, and #99] of 5 sampled residents received adequate supervision and create and implement effective, timely interventions that would reduce the likelihood of future falls. Findings include: 1). Review of Resident #15's medical record reveals the resident is diagnosed with Parkinson's Disease [a progressive movement disorder of the nervous system leading to symptoms that include problems with movement, stiffness, and impaired balance], difficulty walking, cataracts, muscle weakness, and bipolar disorder. Review of Res.#15's Care Plan reveals the Resident is identified as at risk for falls related to Gait/balance problems; medications; anxiety; visual deficit; urine retention, and disease process secondary to Parkinsons, bipolar disorder. Review of the facility's Fall Prevention and Protocol policy [modified 4/26/24] includes every resident admitted to [the facility] will have a Fall Risk Evaluation .after each fall. Additionally, per interview with the Director of Nursing [DON] on 4/30/25 at 9:30 AM, the DON stated that after each fall, a resident's Care Plan is updated and revised to include new interventions to prevent future falls. Review of the facility's Fall Risk Evaluation tool lists if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Per record review, after a fall on 2/1/25, Resident #15's Fall Risk score was 22. Per review of Resident #15's medical record, on 4/3/25, nursing was Called to room for fall. [Resident #15] was sitting on the floor parallel to the bed facing the foot of the bed. Right arm on the bed side, left arm holding on to the right side of [h/her] wheelchair which was parked close to the bed as [s/he] was attempting to transfer into bed. I was trying to get in the bed. [H/her] pants were slightly down below [h/her] buttocks as well as the brief which was completely saturated with urine and feces . Staff report [s/he] had been refusing care all evening. Per review of Resident #15's medical record and Care Plan on 4/30/25, there was no Fall Risk Evaluation completed after the fall on 4/3/25, and no revision or interventions added to Resident #15's Care Plan to prevent future falls. Per interview with the Director of Nursing [DON] on 4/30/25 at 9:30 AM, the DON confirmed Resident #15's Care Plan should have been updated and revised to include new interventions, and a Fall Risk completed after the fall on 4/3/25 but was not. 50431 2. Per record review of Resident #80's medical record reveals that Resident #80 had medical diagnoses of hemiplegia and hemiparesis (weakness and/or paralysis) following a cerebral infarction (a stroke) affecting his/her right dominant side, dysphagia (difficulty swallowing), aphasia (a communication disorder that affects how individuals produce and understand language), and paroxysmal atrial fibrillation (an irregular heartbeat). Per record review of Resident #80's care plan states, [Resident #80] has had actual falls r/t [related to] gait/balance problems, psychoactive drug use, right side weakness, and increased behaviors after family leaves. Most falls out of bed are to [his/her] right. Per record review of the facility's Fall Prevention and Protocol policy [modified 4/26/24] states, Every resident admitted to [the facility] will have a fall risk evaluation .after each fall. Per record review of a nursing progress note written on 4/23/25 states, At approximately 330 am [sic], CNA [Certified Nursing Assistant] notified other CNA and myself that the resident was lying face forward on the floor. [Resident #80] had .a red mark above [his/her] left brow and on [his/her] upper left cheek were noted. Per record review, a fall risk assessment was not completed for Resident #80 after the fall on 4/23/25. Resident #80 sustained a subsequent fall on 4/29/25. Per record review of Resident #80's progress notes, Resident #80 sustained falls on 3/17/25, 4/15/25, 4/23/25, and 4/20/25. Per record review of the facility's Fall Prevention and Protocol-CLR policy [no revised/reviewed date] states, a. Document appropriate interventions on the resident/patients care plan related to fall prevention. Examine previous fall patterns if known and document this on care plan well. B. During regularly scheduled reviews of the care plan, ensured that all interventions related to prevention of falls remain appropriate. Per record review of Resident #80's care plan, there are no additional interventions for the falls occurring on 4/23/25. On 4/30/25 at 11:26 AM the DON [Director of Nursing] confirmed that the resident's care plan needs to be updated after every fall. 3. Per record review of a fall note dated 3/16/25 states, Resident [Resident #99] lying on the floor on [his/her] right side facing the doorway with [his/her] back to the bed .Resident was lifted by hoyer back into bed. On 4/30/25 at 11:26 AM the DON [Director of Nursing] confirmed that the resident's care plan needs to be updated after every fall. Per record review of Resident #99's care plan, there are no additional interventions on Resident #99's care plan after the falls occurring on 3/16/25. On 4/30/25 at 11:26 AM the DON [Director of Nursing] confirmed that the residents' care plan needs to be updated after every fall.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented regarding residents on isolation precautions and during a medication pass. Findings include: 1.) Per observation on 4/28/25 at 12:30 PM, signage posted outside of room M105 included an infection control STOP sign, instructing anyone entering the room to check with staff before entering and follow appropriate precautions. Below the STOP sign were instructions for Staff to follow contact precautions. The contact precautions listed included hand hygiene, gowns, gloves, and clean equipment after use. Review of Physician Orders for the single resident in room M105 included Contact precautions every shift with a start date of 5/8/24. Per observation on 4/28/25 at 12:38 PM, a male nurse was observed in resident room M105. The nurse was observed picking up and handing the resident's assorted personal items, then adjusting the curtains around the resident's bed before leaving the room. The nurse was not wearing gloves or a gown during any of the resident interactions. The nurse did not sanitize his hands after leaving the contact isolation room and was observed pushing a lunch tray cart down the hall to room M113, picking up a lunch tray from the cart, and entering room M113 with the tray. Per observation on 4/28/25 at 4:59 PM, a male and female staff member entered resident room M105. The resident reported having an issue with h/her right leg, and both staff members were observed touching both the resident's right and left leg with their bare hands. Neither staff member was observed wearing a gown. The male staff member exited the room, and another female staff member entered. The second female staff member was observed removing bed linen from the resident's bed. Both female staff members were observed exiting resident room M105 with used bed linens with their bare hands. Neither staff member was observed wearing a gown. Neither staff were observed using hand hygiene after exiting the contact isolation room and carrying the used linens down the hall. An interview was conducted with the facility's Infection Preventionist [I.P.] on 4/30/25 at 12:00 PM. The I.P. stated that contact isolation requires Personal Protective Equipment [PPE] which includes gowning and gloves for all resident contact, along with hand hygiene after resident contact and removing PPE. The I.P. confirmed the observations made on 4/28/25 in resident room M105 demonstrated a break in infection control preventions and increased risk in spreading infection to other residents. 43524 2. During observation on 4/29/25 at approximately 9:30 AM of medication passes on the [NAME] Unit, a male nurse pouring/pushing tablets from a blister packet (a form of tamper resistant packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) for Resident #108 into his ungloved hand and then placed these medications into a medication cup and administered them to the resident. The nurse did not perform hand hygiene prior to preparing Resident #482's medications in which he again poured/pushed tablets from a blister packet directly into his ungloved hand and then placed these medications into a medication cup and administered them to the resident. During interview on 4/30/25 at approximetly 9:45 AM, the nurse confirmed that he had poured medications from the blister pack for 2 residents into his ungloved hand. He stated that it was his understanding he was not allowed to wear gloves in the hallway. The nurse confirmed that he did not perform hand hygiene between medication administration for Resident #108 and Resident #482.

Based on observation, interview, and record review, it was determined that the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 3 of the 4 medication carts observed, and 2 of 2 medication storage rooms observed. Findings include: 1. During observations on 4/30/25 at approximately 9:40 AM on the [NAME] Unit, the nurse poured all the residents medications and put them all in the top drawer of the medication cart and stated he was going to get water. He walked away from the medication cart with the water pitcher and left 4 blister packs of medications, 3 bottles of OTC (over the counter) medications, and a bottle of metamucil on the top of the medication cart. Per interview with the nurse on 4/30/25 at approximately 9:45 AM, he confirmed that he had left these medications on top of the medication cart unsupervised and improperly stored. 2. During observation on 4/30/25 at approximately 3:15 PM, the medication storage room on the [NAME] Unit revealed the following issues: (5) DB Bactec Lytic/10 Anaerobic/F Culture vials (used for performing blood cultures) with expiration dates of 2/12/25 and (4) BD Bactec Plus Aerobic/F Culture vials with an expiration date of 2/24/25. Per interview on 4/30/25 at approximately 3:20 PM, the nurse working on the [NAME] Unit confirmed the culture vials had expired and were in the medication storage room and available for use. 3. Per observation on 4/30/25 at 4:57 PM of the medication storage room on [NAME] Unit a jar/container of Vanicream 16 oz was noted to have expired on 2/2025. Per interview on 4/30/25 at approximately 5:00 PM, the nurse on the [NAME] Unit confirmed the Vanicream had expired and was available for use. 4. Observation at approximately 4/30/25 5:05 PM of a [NAME] Hall medication cart revealed an open 10 oz bag of peanut butter pretzels - the LPN went to the med cart and removed them and put them in a room behind the nurses station. Review of the medication cart revealed a blue pill cutter with a white powdery substance and white small particles/crumbs on the blade and within the cutting device, the LPN working this cart, confirmed that the pill cutter needed to be cleaned and the substances noted were pill/medication debris; (21) tablets of Pravastatin Sodium 40 mg tablets with an expiration date of 3/31/25; (30) tablets of Omeprazole DR 20 mg capsules with an expiration date of 12/15/25; (29) capsules of Benzonatate 100 mg capsule with expiration date of 4/14/25; (30) tablets of Meclizine 12.5 mg capsules with an expiration date of 4/14/25; (13) capsules of Biotin 10,000 mcg stock medication with an unknown expiration date due to it being rubbed off. Interview on 4/30/25 at approximately 5:15 PM with the Unit Manager confirmed the above findings of expired medications. 5. Observation of a [NAME] Unit medication cart on 4/30/25 at approximately 5:25 PM revealed the following expired medications: (10) tablets of Vitamin D3 50 mcg (2000 IU) with an expiration date of 4/4/25; (10) tablets of Levocetirizine 5 mg with an expiration date of 6/28/24; (10) tablets of Levocetirizine 5 mg with an expiration date of 7/10/24; (16) 1/2 tablets of Meclizine 25 mg for with an expiration date of 10/29/24; (10) 1/2 tabs of Meclizine 25 mg with an expiration date of 4/20/25; (10) tablets of Ondansetron HCL 4 mg with an expiration date of 3/31/25; (30) 1/2 tablets of Meclizine 25 mg with an expiration date of 4/20/25; Interview on 4/30/25 at approximately 5:40 PM with the Unit Manager confirmed the above findings of expired medications.

Based on interview and record review the facility failed to maintain drug regimen reviews for one out of five sampled residents (Resident #88). Findings include: Per record review, Resident #88 had MRR [Medication Regimen Review] (a monthly review by the pharmacist for any medication recommendations made based on safety and patient specific diagnoses). Resident #88 had medication recommendations made from the pharmacist in June 2024, August 2024, September 2024, October 2024, December 2024, February 2025, and March 2025. Per record review of Resident #88's chart the resident did not have copies of MRRs for the months of June 2024, August 2024, and September 2024. Per record review of Pharmacy Drug Regimen Review-CLR policy [no revised or reviewed date] states, Facility: 1. Shall maintain all Drug Regimen Review recommendations along with prescriber's responses in an easily retrievable location for presentation to surveyors, upon request. 2. Shall file or drug review recommendations with the permanent medical record for each resident after one year. 3. Shall file the findings under the Physicians Order Section. An interview was conducted with the Director of Nursing, RN#1, and the MDS [Minimum Date Set] Coordinator on 4/29/25 at 4:33 PM. The DON, MDS Coordinator, and RN#1 confirmed there were no MRRs for the months of June 2024, August 2024, and September 2024 in Resident #88's chart. The facility did not have the MRRs in the paper chart and were not maintained in the facility to be readily available for review.

Based on interview and record review, the facility failed to ensure that a resident with a nutritional problem was given nutritional supplements and appetite stimulants as ordered by a physician for one resident [Resident #106] of 7 sampled residents. Findings include: 1. Per review of Resident #106's medical record, the resident's diagnoses include cancer of the prostate and bone, and difficulty swallowing. Review of the resident's Care Plan reveals the resident is identified as at risk for malnutrition as I have increased nutritional needs with cancer treatment and altered skin integrity, poor appetite and intake, need for protein/nutritional supplement. Care Plan interventions include Provide me with my supplement as ordered: 8oz House Shake, 8oz Boost VHC and provide further nutrition interventions. Review of Physician Orders for Resident #106 include House shake in the afternoon for at risk for malnutrition and Megestrol Acetate Oral Suspension-Give 10 milliliters by mouth in the morning for Appetite stimulant. Review of Resident #106's Medication Administration Record [MAR] for April 2025 reveals the resident did not receive the Megestrol Acetate Oral Suspension medication for appetite stimulation as ordered on 4/20, 4/22, 4/23, 4/24, & 4/28/25. Per review of Nursing Progress notes for those dates, the medication is documented as on order or unavailable. Further record review reveals a Pharmacy email correspondence dated 4/22/25 reporting that the Megestrol Acetate Oral Suspension medication was delivered on 4/17/25 and was available. Review of Resident #106's Medication Administration Record [MAR] for April 2025 also includes the physician ordered House Shake nutritional supplement not administered on 4/10, 4/18, 4/23, 4/24, 4/25, & 4/26/25. Review of Nursing Progress Notes reveal the House Supplement listed on those dates as not available. An interview was conducted with the Dietary Manager on 4/30/25 at 1:24 PM. The Dietary Manager stated that House Shakes are always available and are made daily in the kitchen and are distributed on the resident units at 10:00 AM daily. Review of Resident #106's medical record reveals the resident underwent a 6.9 pound weight loss from April 1st to April 28th, 2025 [a loss of 4.3% of their total body weight]. An interview was conducted with the Director of Nursing [DON] on 4/30/25 at 9:30 AM. The DON confirmed that both the Megestrol Acetate Oral Suspension medication and House Supplement were available on the listed dates but were not administered as ordered, with the resident suffering from a 4.3% weight loss during this time period.

Based on interview and record review, the facility failed to ensure that the Residents' power of attorney (POA) was assisted with developing advanced directives consistent with their wishes for 1 of 40 residents in the sample (Resident #40). Findings include: Per record review Resident #40 signed a notarized advanced directive on 11/22/16. The notarized advanced directive states If I suffer a condition from which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed to my comfort and dignity, and I authorize my agent to decline and terminate all treatment (including artificial nutrition and hydration) the primary purpose of which is to prolong my life. If the situation should arise in which I am in a terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering, even though this may shorten my remaining life According to the advanced directive a family member is named as the Resident's power of attorney (POA). Further record review reveals a Clinicians Order for Life Sustaining Treatment (COLST) form that was signed and dated by a facility clinician on 1/15/25 that states that Resident #40 is a Full Code. This COLST form is not signed by the Resident or their POA. An additional Clinicians Order for Life Sustaining Treatment COLST form dated 1/21/25 from a hospitalization is signed by a Clinician, but not the Resident or POA. Resident #40's advanced directive and a Clinicians Order for Life Sustaining Treatment COLST do not match and the current COLST does not not reflect the Resident's previous wishes. There is no documented evidence that the Resident or POA was consulted regarding the change to full code status. A physician note dated 3/3/25 states will need to review if [the Resident] has designated a HCP [health care proxy] and discuss goals of care and code status in the context of his/her recent decline. [S/he] remains a Full Code at this time but had previously expressed that living dependent on others was [her/his] worst fear. A physician note dated 4/14/25 states that Resident #40 is a Full code, but unable to continue to make medical decisions due to lack of insight into advanced dementia. During an interview with the Director of Nursing (DON) on 4/30/25 at 11:39 AM, she confirmed that the physician's notes from 3/3/25 and 4/14/25 identified that the Resident was a full code and that there was a need to reassess. The DON also confirmed that the COLST wasn't signed by Resident #40 or her/his POA. The DON reported that they hadn't communicated to the family about it as they don't always agree, and the facility was hoping that Resident #40 would become more alert and orientated and be able to decide for themselves.

Based on observation, interview, and record review, the facility failed to provide necessary maintenance services to ensure residents have a safe, clean, comfortable and homelike environment for 4 of 6 resident units. Findings include: An interview was conducted with the facility's Director of Maintenance [DM] on 2/12/25 at 10:26 AM. The DM reported that the facility utilizes a 'TELS' electronic system [TELS is a software program that facilitates maintenance work orders by allowing users to scan, upload, and access related work orders and repair history]. The DM reported that the facility uses the TELS to identify, report, acknowledge, assign, track, and complete facility maintenance issues and repairs. The DM stated that all staff in the facility have access to system and can access it through a computer or phone, and that all staff, including the DM, received education on using the system in the last month [January 2025]. A tour of the facility and interview was conducted with a facility staff member on 2/12/25 at 10:14 AM. Per observation in the facility's Stark & [NAME] units communal shower room, the center shower stall contained an open hole in the shower wall exposing wooden studs and three missing 6-inch by 6-inch square tiles. The handheld showerhead was hanging upside a few inches from the tile shower floor with water running from the shower head at a slow rate. Per observation, an approximate 4-foot by 3-foot puddle of standing water was on the floor on the adjacent shower stall. The floor drain was located approximately 1 foot away and was dry, with no water was draining into it. Further observations were conducted with the staff member in the Frost & [NAME] units communal shower room at 10:20 AM. Per observation, a shower stall contained approximately 3-foot-long sections of missing grout along 2 of the shower floors where the floor abuts the wall. The shower room contained a toilet with a sign posted above it reading Out of Order. The toilet contained standing water and large amount of wadded toilet paper. The staff member stated that the toilet did not flush but was still being used. The staff member stated that the environmental issues in both the Stark [NAME] and Frost [NAME] communal shower rooms had existed for approximately 6 months and had been reported to Maintenance but nothing had been done. A tour of the facility was conducted with the facility's Director of Maintenance [DM] on 2/12/25 at 10:55 AM. While standing in the facility's Stark/[NAME] communal shower room, the DM confirmed the issues involving the open hole with missing tiles in the center shower stall, the leaking showerhead, and the standing water not draining in the adjacent shower stall. The DM confirmed both shower stalls were actively in use by residents. The DM confirmed that the issues had existed for months but had not been entered into the TELS maintenance tracking system, so there was no documentation regarding how long the issues existed, if maintenance was aware of them, if they had been assigned, and if any attempt had been made to address and/or repair them. Further observations were conducted with the Director of Maintenance [DM] in the Frost/[NAME] communal shower room. The DM confirmed a shower stall contained approximately 3-foot-long sections of missing grout along 2 of the shower floors where the floor abuts the wall. The DM also confirmed the shower room toilet had a sign posted above it reading Out of Order and that the toilet contained standing water and large amount of wadded toilet paper. The DM stated that the toilet in fact did flush and the maintenance department was waiting for a new valve. The DM then attempted to demonstrate that the toilet was functional but the toilet did not flush, no water drained, and the water and the material in the toilet remained. The DM confirmed that the issues in the Frost/[NAME] communal shower room had existed for a while but also had not been entered into the TELS maintenance tracking system, so there was no information regarding how long the issues existed, if they had been assigned, and if any attempt had been made to address and/or repair them. Per interview with the facility's Director of Maintenance [DM] on 2/12/25 at 10:55 AM, the DM reported the facility used the TELS system as a standardized checklist for routine inspections to ensure that repairs are completed on time and that deficiencies are prevented. The DM confirmed that issues in Stark & [NAME] units communal shower room had existed for months and issues in the Frost & [NAME] units communal shower room had existed for a while with no documented plan to address the issues. The DM confirmed that despite the placement of the TELS system and maintenance staff being educated on its use, the maintenance department did not implement the system to identify, report, acknowledge, assign, track, and complete necessary facility maintenance issues and repairs.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice including prevention of complications from the resident's medical condition for 1 of 2 residents in the applicable sample [Resident # 1]. Findings include: Per record review, Res. #1 was admitted to the facility on [DATE] with diagnoses that included diabetic neuropathy [neuropathy is nerve damage that affects the hands and feet, often caused by diabetes or other conditions. Feet and other areas that lack sensation can become injured without the person knowing]. Review of the resident's Care Plan revealed the resident was identified upon admission on [DATE] as having an actual impairment to skin integrity including a right plantar [sole] foot wound. Review of Res.#1's medical record included a 'Clinical Evaluation' dated 12/18/24 which identified the right foot wound as present on admission but now resolved-wound healed and/or closed. Review of 'Skin Checks' for Res.#1 reveal no issues regarding the resident's right foot on 'Skin Checks' dated 12/29/24, 12/31/24, & 1/5/25. An interview was conducted with Res. #1 on 2/3/25 at 12:54 PM. The resident reported that s/he had been admitted to the facility at the beginning of December 2024 and no one removed h/her socks to check h/her feet until December 30th. No one ever touched my feet until [Staff LPN]. Per record review, the first skin documentation of Res. #1's right foot by [Staff LPN] was dated 1/9/25. [The 'Skin Check' dated 1/9/25 only records a 'skin issue' to right plantar foot wound with no further description or assessment]. The resident further stated that due to h/her height, h/her feet had been rubbing against the foot board of the bed since h/her admission on [DATE]. The resident stated s/he reported this to several people including Maintenance personnel but the footboard was not removed from the bed until after the development of the wound on the right foot. An interview was conducted with the facility's Wound Nurse Practitioner [NP] on 2/3/25. The Wound NP stated that s/he received a phone call from Res.#1's daughter on 1/18/25 regarding the footboard on the bed causing skin issues to the resident, and the footboard was removed on 1/18/25 [2 days after the Wound NP's Integrated Wound Care consult]. Review of the Wound NP's Integrated Wound Care notes dated 1/16/25 record Res.#1 is referred for assessment of the right plantar foot ulcer .the right plantar foot ulcer is large, measuring 5 cm [centimeters] x 5 cm and it is a large blister type wound with open edges around the wound. 'Skin Check' notes dated 1/23/25 record Right plantar foot wound-blister has popped. Review of Res.#1's 'Skin Check' dated 1/26/24 reveals an extensive note recording Bottom of right foot [plantar]. Blister. Wound acquired in-house. Wound is new. Signs and symptoms of infection: smell increased. Painful: Yes. Review of Res.#1's Skin Check dated 1/31/25 reveals the bottom of the right foot wound as deteriorating, Signs and symptoms of infection: smell increased. Painful: Yes with the length increasing to 6 cm and the width 5.5 cm. An interview was conducted with the Director of Nursing [DON] on 2/3/25 at 2:40 PM. The DON confirmed Res.#1 was identified as at risk for skin impairment and had existing skin issues upon admission to the facility on [DATE]. The resident's Care Plan on admission included monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infections, maceration etc. to [the Physician]. On 12/9/24 the Care Plan was updated to include inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. The Care Plan noted that Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease. Identify areas or difficulties in resident diabetic management, modify the problem areas so that it may be more manageable for the resident/family. The DON confirmed that bed footboard issues and skin concerns voiced by Res.#1 and their family were not evaluated or addressed by the facility until after development of a new, acquired in-house wound to Res.#1's right foot, which was assessed as painful and included signs and symptoms of infection. The DON further confirmed that although Nursing noted a 'skin issue' to the right plantar foot wound on 1/9/25, the wound was not assessed by the facility's Wound Nurse Practitioner until 1/16/25, and Res.#1's Care Plan was not revised to include any new interventions to address current skin issues or prevent future issues until 1/17/25, when the right foot 'skin issue' had deteriorated into a a large blister type wound with open edges around the wound.

Based on observations and staff interview, the facility failed to provide necessary maintenance services to ensure residents have a safe, clean, comfortable, and homelike environment for 6 of 6 resident units. Findings include: Per observation on 11/20/24 from 12:10 AM to 12:30 PM, all nursing units (Stark, [NAME], [NAME], Frost, [NAME], and [NAME]) needed multiple functional and cosmetic repairs in several resident rooms. * room [ROOM NUMBER]- There was a double electrical outlet receptacle and cover that was broken. One of the top plugs in the receptacle was also broken exposing the electrical wiring. There were two cords plugged into the bottom receptacles. A bulletin board had been removed from the wall and there was a large square of brown paint where the bulletin board had been. There were two pieces of plywood used as a wall covering, both boards were delaminating, exposing splintered wood. * Walls in rooms R6, R13, R11, C4, C5, C6, C7, C8, C10, 102, 103, 113, 115, 120, and 126 had unrepaired holes, scratches, peeling wallpaper, or unpainted spackle. * Missing baseboard trim in the bathroom of room [ROOM NUMBER] exposing peeling paint and broken sheet rock. Missing baseboard trim was also noted in room [ROOM NUMBER]. * A wardrobe in room [ROOM NUMBER] had a broken drawer. * The cover over the florescent light above the resident's bed in room [ROOM NUMBER] was broken and had been placed against the wall at the foot of the bed. The left side of the bed was against the wall and there were large scratches and missing paint on the wall at the head of the bed. * The bathroom in 146 had two broken tiles with missing pieces in front of the toilet creating an infection control concern due to the inability to properly clean the floor. * There were signs of leaking at the base of the toilet in room [ROOM NUMBER], presenting as black liquid on the floor that was partially dried. This room was not currently occupied. Per interview on 11/20/24 at 3:10 PM, with the facility Administrator some of the repairs needed had been identified through environmental rounds and preventative maintenance. These repairs have not been completed due to residents residing in the rooms and admissions. A walk through of the facility was conducted at this time and the Administrator confirmed the environmental observations listed above.

Based on interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue the drugs for 1 of 5 sampled residents (Resident #13); failed to ensure that there was a specific diagnosis/condition documented in the medical record for psychotropic medications for 1 of 5 sampled residents (Resident #100); and failed to ensure that residents who use psychotropic drugs are accurately monitored for behaviors and medication side effects (Residents # 13, #100, and #30). Findings include: Facility policy titled, Psychotropic Medication Use, last modified on 10/2/2022, states, Psychotropic medications should only be given when necessary to treat a specific diagnoses and documented condition. GDR will be attempted using the following guidelines and limits (unless clinically contraindicated): 1. For all psychotropic medications: within the first year following admission or initiation of medication; attempt taper in 2 separate quarters with at least one month between attempts, Reevaluation should occur at least annually. 1. Record reveals that Resident #13 was admitted to the facility on [DATE] and has diagnoses that include major depressive disorder, schizophrenia, and drug induced subacute dyskinesia (movement disorder). Resident #13 has physician orders for Escitalopram Oxalate [psychotropic; antidepressant] Tablet 20 MG Give 30 mg by mouth in the morning for Depression, with a start date of 05/05/2022, fluphenazine Decanoate [antipsychotic] Solution Inject 50 mg intramuscularly at bedtime every 14 day(s) for schizophrenia, with a start date of 10/03/2022, fluPHENAZine HCl [antipsychotic] Tablet 10 MG Give 1 tablet by mouth at bedtime for schizophrenia, with a start date of 10/27/2021, fluPHENAZine HCl Tablet 10 MG Give 1 tablet by mouth in the afternoon for schizophrenia, with a start date of 10/27/2021, fluPHENAZine HCl Tablet 10 MG Give 1 tablet by mouth in the morning for schizophrenia, with a start date of 10/28/2021, and OLANZapine [antipsychotic] Tablet 2.5 MG Give 1 tablet by mouth at bedtime related to UNDIFFERENTIATED SCHIZOPHRENIA, with a start date of 7/11/2023. a.) Review of Resident #13's pharmacist medication regimen review for the past year show that no recommendations were made by the pharmacist, including recommendations for a GDR. There is no evidence that a GDR was attempted in the past year in the medical record for any of the above medications, as required per regulations and facility policy. Per interview on 3/20/24 at 2:47 PM, Resident #13's Physician confirmed that there should have been a GDR attempt made in the past year and was not. b.) Per observation on 3/18/24 at 4:47 PM, Resident #13 was sitting in was wheelchair in the dining room. S/He was fidgeting, had repetitive right foot movements, tongue rolling, and a tremor in his/her left hand. Resident #13 was observed again during breakfast and lunch on 3/19/2024 and 3/20/2024 with similar tremors and repetitive movements. After breakfast on 3/20/2024 at approximately 9:30 AM, the Unit Manager was bringing Resident #13 from the dining room to the bathroom and explained that Resident #13 was feeling anxious. Per interview on 3/19/2024 at 8:52 AM, Resident #13's Representative explained that s/he visits Resident #13 frequently and has observed Resident #13's tremors are happening regularly and have been getting worse. Record reveals that Resident #13 has the following care plan focuses and interventions related psychotropic medications: [Resident #13] is at risk for a mood problem r/t [related to] Disease Process secondary to Schizophrenia and depression, revised on 2/27/2024 with an intervention to, Administer medications as ordered. Monitor/document for side effects and effectiveness, created 8/15/2018. [Resident #13] has an alteration in neurological status (movement disorder/chronic tremors) r/t chronic use of psychoactive medications and PTSD [post-traumatic stress disorder]. Tremors worsen when [s/he] feels that others are watching [him/her], revised on 2/27/2024 with an intervention to Give medications as ordered. Monitor/document for side effects and effectiveness, created 3/3/2022. [Resident #13] uses antidepressant and psychotropic medications r/t behavior management, depression, and schizophrenia, revised on 6/29/2020 with an intervention to, Monitor/record occurrence of behavior symptoms and document per facility protocol, revised on 6/15/2023. Per review of progress notes from January 1, 2024, through March 20, 2024, staff documented about potential side effects from medications 3 times (twice possible medication side effects, once that s/he had no medication side effects) and documented about behaviors 1 time (that s/he did not have behaviors). This does not reflect the observations or interviews made during the recertification survey about Resident #13's behaviors or medication side effects. 2. Record reveals that Resident #100 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease and dementia. Resident #100 has a physician order for Risperidone 0.25 MG Give 1 tablet by mouth in the morning for psychosis history, with a start date of 10/20/2023. a.) A pharmacist medication regimen review dated 10/16/2023 states that Resident #100 is Recently admitted on Risperidone with no clear diagnosis to support current use. Please consider obtaining a psychological workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors, Should the workups and nursing behavioral monitoring reveal no significant behaviors or identification of a chronic psychiatric condition, please consider implementing a tapering schedule and/or discontinue Risperidone. A box next to this recommendation is checked Disagree, and a handwritten response states psychosis history. A pharmacist medication regimen review dated 1/7/2024 states that Resident #100 is Currently receiving allow dose of Risperidone (Risperdal) for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficiency. Consider discontinue, if appropriate. A box next to this recommendation is checked Agree, will do, and a handwritten response states diagnosis psychosis. No changes were made to Resident #100's diagnoses or changes to the physician order for Risperidone after either of the medication evaluations above. As of 3/20/24, Resident #100 did not have a documented diagnosis that Risperidone would be necessary to treat. Per interview on 3/20/2024 at approximately 4:30 PM, the Director of Nursing confirmed that there was no evidence that the physician followed the recommendations in the medication regime reviews listed above. b.) Per observation and interview on 3/18/24 at 3:44 PM, Resident #100 is in bed. S/He is talking about people that are not in the room and is describing things hanging from the ceiling by the door that do not exist. Shortly after, at 4:24 PM, Resident #100 is seen in his/her wheelchair in the common area. S/He is swearing at the surveyors and appears to be significantly agitated. Record reveals that Resident #100 has the following care plan focuses and interventions related psychotropic medications: [Resident #100] uses psychotropic medications r/t disease process secondary to delusional disorder, dementia and CVA [stroke]. Noted to sundown and have hallucinations at times, revised on 10/23/2023, with interventions that include, Monitor/document/report PRN [as needed] any adverse reactions of PSYCHOTROPIC medications, created on 7/28/2023, and Monitor/record occurrence of for target behavior symptoms, revised on 9/11/2023. [Resident #100] is at risk for depression, revised on 10/20/2023, with interventions that include, Monitor/document/report PRN any s/sx [signs/symtoms] of depression, created on 8/16/2023. Per review of progress notes from January 1, 2024, through March 20, 2024, staff documented about potential side effects from medications 1 time (once that s/he had possible medication side effects) and documented about behaviors 15 times (that s/he did not have behaviors). This does not reflect the observations or interviews made during the recertification survey about Resident #100's behaviors. 3. Record reveals that Resident #30 was admitted to the facility on [DATE] and has diagnoses that include dementia, anxiety, and major depressive disorder. S/He has a physician order for Mirtazapine (psychotropic, antidepressant) 22.5 mg once daily at bedtime for depression. Per observation on 3/18/2024 at 4:18 PM, Resident #30 was seen lying in his/her bed, awake, with the covers pulled to his/her chin. S/He was crying in his/her bed; when asked if s/he was okay, Resident #30 appeared afraid and was weeping while s/he tried to explain concerns s/he had about his/her mother and father and their skin. S/He repeated incoherent phrases about the skin of her father and the skin of her mother and how s/he needed to get it to them and they would not be happy. Per observation on 3/19/2024 at 2:25 PM, Resident #30 was in bed crying. On approach, s/he appeared distressed and was sobbing about his/her father and his skin. Per interview on 3/19/2024 at 3:34 PM, the Unit Manager (UM) and this surveyor observed Resident #30 in his/her bed crying about his/her father, his skin, and taking the skin to give to his/her mother. The UM explained that the observed behavior for Resident #30 is typical. Per review of progress notes from January 1, 2024, through March 20, 2024, staff documented potential side effects from medications 0 times and documented behaviors 4 times (once that s/he did not have behaviors, and three times that she did). This does not reflect the observations or interviews made during the recertification survey about Resident #30's behaviors. Per interview on 3/20/24 at 2:14 PM, the Unit Manager demonstrated how nursing staff do not have a place to document what medication side effects or behaviors a resident might be having in the medication administration record or treatment administration record, and explained that nursing staff should be putting in a progress note every time a resident has a behavior or a possible medication side effect. She explained that documenting behaviors used to be easier because there was a form in the electronic medical record that would give structure to documenting behaviors. The Unit Manager reviewed Resident #13, #100, and #30's progress notes and confirmed that behaviors were not accurately documented for all three and medication side effects were not accurately documented for Resident #30. (We start talking about 2 more residents here with no information about those - this may need to be copied to the end?) Per phone interview on 3/26/2024 at 11:30 AM, the Administrator and the Director of Nursing confirmed that they were unable to provide any additional evidence to show that staff were documenting medication side effects or behaviors for Residents #30, #13, and #100.

Based on interview, record review, and policy review, the facility failed to implement policies for screening employees by not completing the required criminal background checks for 4 out of 5 sampled staff. Findings include: Facility policy titled Background Checks, Arrests, and Conviction Notification, last revised on 3/4/2024, indicates that the facility will conduct criminal background checks for all current employees at least annually. Per review of employee human resource files, 4 of 5 sampled direct care staff who have worked at the facility for over a year do not have annual federal background checks completed. Per interview on 3/20/24 at 11:45 AM, the Human Resource Staff explained that there is no system in place for obtaining annual national background checks for staff that have been here over a year but has worked with the Administrator to implement completing annual background checks in starting in June.

Based upon interview and record review, the facility failed to ensure a resident receiving enteral feedings maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 resident [Res. #67] of 1 residents receiving tube feedings. Findings include: Review of the medical record for Res. #67 reveals the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Res. #67's Care Plan reveals the resident was identified as having 'a PEG tube due to [CONDITION(S)]' [Percutaneous Endoscopic Gastrostomy (PEG) is a procedure to place a feeding tube, called PEG tubes]. Review of Res. #67's Minimum Data Sheet [MDS] Quarterly Review, dated 1/5/22, under Sec. K: Swallowing and Nutritional Status lists Res. #67's Nutritional Approach as 'Feeding Tube', with 'Portion of total calories the resident received through tube feeding' marked as 51% or more. Review of the facility's Tube Feeding Infusion Monitoring policy- [modified 2/18/21] reveals: - 'Every shift the nurse will enter the volume infused, in a cumulative manner in the patient's/resident's electronic chart, IV hydration folder. The Nurse will verify solution, infusion rate against MD orders.' - 'Rate will be reflected by entering it when documenting assessments and evaluations.' - 'At the end of the shift, the 8 hour volume infused will be entered in the patient's/resident's electronic chart, IV hydration folder, and volume infused cleared on the pump.' Per record review of Physician Orders, beginning 10/14/21, Res. #67 was to receive tube feeding at 60 ml [milliliters] an hour for 12 hours, and increase by 5 ml (if tolerated) every 4 days, to a goal of 90 ml an hour for 12 hours. [The goal rate of 90 ml an hour would be achieved in one month, on 11/14/21]. The tube feeding was ordered to be administered from 7:00 PM to 7:00 AM. Per review of Res. #67's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, per review of Nurses Notes for Res. #67, there are multiple times between the start date of Oct. 14, 2021, and the Survey date of 2/14/22 when the tube feeding is documented as being stopped up to one hour prior to the ordered time of 7:00 AM. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes for December 2021 include Taken off at 1:38 AM [12/19/21], Taken off at 3:00 AM [12/27/21], and Requested to start a couple hours late, said he felt full at 7:00 PM [12/27/21] with no start time and no total amount infused. Review of Res. #67's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ½ and 2 ½ hours early, with no record of the rate or the amount of the tube feeding administered. Review of February 2022's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation of the infusion rate. Per review, the volume infused is less than the minimum rate ordered [60 ml over 12 hours = 720 ml] on 6 of 10 days, with no amounts recorded on the 4 other days. [From 2/1/22 thru the Survey date of 2/14/22]. Nurses notes in February 2022 regarding the tube feeding include Was off when I got here [2/6/22] and Resident reports he did not receive tube feeds last night [2/14/22]. Review of Res. #67's Care Plan reveals the resident was identified as 'at risk for sub-optimal intakes and weight loss due to sore on [his/her] gums and need for mechanically altered diet. [He/she] has had weight loss that was felt to be due to a combination of fluid loss and sub-optimal intakes.' Care Plan goals include '[Res. #67] will maintain adequate nutritional and hydration status as evidenced by weight stability and/or hydration' and 'maintain [his/her] weight within 5% of 122'. Care Plan interventions to be implemented to achieve the goals include: 'Weigh per policy'. Review of the facility's Weight Assessment Monitoring procedure- [modified 7/15/2020] reads: - 'Nursing staff weighs resident/patient per nursing protocol weekly, or as ordered for the first 4 weeks after admission. If resident/patient is identified to be at risk for weight loss/gains, weights may be continued weekly. - 'If a resident/patient is noted to have a weight loss/gain of 5 or more pounds since their last weight, a re-weight is to be obtained by nursing within 24 hours.' - 'Registered Nurse or Licensed Practical Nurse reports any confirmed weight loss to the Registered Dietician or diet tech/Certified Dietary Manager, nurse manager, physician, and family.' Additionally, per review of Res. #67's medical chart, included under Licensed Nursing Aide Tasks is Weight weekly / Monday. Review of Res. #67's medical chart on 2/14/22 revealed the two most recent weights dated 11/8/2021 and 1/19/2022- greater than 7 weeks apart. Res. #67's weight on 11/8/2021 is recorded as 115.6 pounds. The weight on 1/19/2022 is 103 pounds: a 10.9% loss of weight in under 3 months. According to 'Involuntary Weight Loss and Protein-Energy Malnutrition: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .medscape.org/viewarticle/ 9_2] The definition of significant weight loss is a loss of 10% of body weight over a 6-month period. Further review reveals To improve quality of care for the elderly and the incapacitated, the federal government defined specific healthcare criteria in the Omnibus Reconciliation Act (OBRA) of 1987. The OBRA Act defines significant unintentional weight loss as a 5% loss in 30 days and a 10% loss in 6 months and considers this process a deviation from proper care. the OBRA Act . requires that long-term care facilities develop strategies to prevent involuntary weight loss in their residents. Nutritional plans and body weight monitoring are mandatory for all patients. An interview was conducted with Res. #67 on 12/14/22 at 3:38 PM. The resident stated that [he/she] had not been weighed since January. During an interview between the facility's Dietician and the resident the next day, 2/15/22, the resident repeated [he/she] had not been weighed since January and requested [his/her] weight be checked. Per record review, Res. #67's weight on 2/15/22 was 99.6 pounds, an additional weight loss of 3.4 pounds since the previous weight, less than a month earlier. Res. #67's total weight loss from 11/8/2021 to the day [he/she] requested to be weighed, 2/15/2022 was 13.84% in under 4 months. An interview and record review were conducted with the facility's Director of Nursing [DON] on 2/16/22 at 9:59 AM. The DON confirmed the following: - There was no documentation that Res. #67's tube feeding was administered as ordered regarding the infusion rate increased as tolerated. - There was no documentation regarding the amount of tube feeding infused for 105 consecutive days. - There were multiple Nursing Notes from the date of the tube feeding order on 10/14/21 through the survey date of 2/14/22 that indicated the tube feeding was stopped before the ordered time. Additionally, when the amount of tube feeding was recorded, it was lower than the minimal amount ordered on multiple dates. - There was no documentation that weights were monitored per policy and per the resident's Care Plan. - There was no documentation that the Physician was ever notified when the resident was not receiving the minimal amount of tube feeding as ordered, or that the tube feeding was not increased by increments as ordered. - The DON also confirmed the resident suffered a significant weight loss of 13.84% in under 4 months, during the time the resident's tube feedings and weights were not monitored per the facility's policy or the resident's Care Plan.

Based upon interview and record review, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for 1 resident [Res. #67] of 1 residents receiving tube feedings. Findings include: Review of the medical record for Res. #67 reveals the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Res. #67's Care Plan reveals the resident was identified as having 'a PEG tube due to [CONDITION(S)]' [Percutaneous Endoscopic Gastrostomy (PEG) is a procedure to place a feeding tube, called PEG tubes]. Review of Res. #67's Minimum Data Sheet [MDS] Quarterly Review, dated 1/5/22, under Sec. K: Swallowing and Nutritional Status lists Res. #67's Nutritional Approach as 'Feeding Tube', with 'Portion of total calories the resident received through tube feeding' marked as 51% or more. Review of the facility's Tube Feeding Infusion Monitoring policy- [modified 2/18/21] reveals: - 'Every shift the nurse will enter the volume infused, in a cumulative manner in the patient's/resident's electronic chart, IV hydration folder. The Nurse will verify solution, infusion rate against MD orders.' - 'Rate will be reflected by entering it when documenting assessments and evaluations.' - 'At the end of the shift, the 8 hour volume infused will be entered in the patient's/resident's electronic chart, IV hydration folder, and volume infused cleared on the pump.' Per record review of Physician Orders, beginning 10/14/21, Res. #67 was to receive tube feeding at 60 ml [milliliters] an hour for 12 hours, and increase by 5 ml (if tolerated) every 4 days, to a goal of 90 ml an hour for 12 hours. [The goal rate of 90 ml an hour would be achieved in one month, on 11/14/21]. The tube feeding was ordered to be administered from 7:00 PM to 7:00 AM. Per review of Res. #67's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, per review of Nurses Notes for Res. #67, there are multiple times between the start date of Oct. 14, 2021, and the Survey date of 2/14/22 when the tube feeding is documented as being stopped up to one hour prior to the ordered time of 7:00 AM. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes for December 2021 include Taken off at 1:38 AM [12/19/21], Taken off at 3:00 AM [12/27/21], and Requested to start a couple hours late, said he felt full at 7:00 PM [12/27/21] with no start time and no total amount infused. Review of Res. #67's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ½ and 2 ½ hours early, with no record of the rate or the amount of the tube feeding administered. Review of February 2022's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation of the infusion rate. Per review, the volume infused is less than the minimum rate ordered [60 ml over 12 hours = 720 ml] on 6 of 10 days, with no amounts recorded on the 4 other days. [From 2/1/22 thru the Survey date of 2/14/22]. Nurses notes in February 2022 regarding the tube feeding include Was off when I got here [2/6/22] and Resident reports he did not receive tube feeds last night [2/14/22]. Review of Care Plan interventions regarding Res. #67's tube feeding include 'Registered Dietician to evaluate quarterly and as needed.' Review of Res. #67's medical chart reveals a Nutritional Evaluation completed the day after his/her admission on 7/1/21. Further record review reveals the next Nutritional Evaluation dated over 7 months later, on 2/14/22. The Nutritional Evaluation dated 2/14/22 lists the resident's 'Most Recent Weight' as unknown, and available weight as 103 pounds dated 1/19/22. The evaluation further lists the resident's usual weight as unknown, and the resident's ideal weight as 154 pounds [51 pounds more than the resident's listed weight on the evaluation]. The evaluation cites the resident requires a special order for tube feeding due to inadequate PO [oral] intake. Review of Res. #67's Care Plan reveals the resident was identified as 'at risk for sub-optimal intakes and weight loss due to sore on [his/her] gums and need for mechanically altered diet. [He/she] has had weight loss that was felt to be due to a combination of fluid loss and sub-optimal intakes.' Care Plan goals include '[Res. #67] will maintain adequate nutritional and hydration status as evidenced by weight stability and/or hydration' and 'maintain [his/her] weight within 5% of 122'. Care Plan interventions to be implemented to achieve the goals include: 'Weigh per policy'. Review of the facility's Weight Assessment Monitoring procedure- [modified 7/15/2020] reads: - 'Nursing staff weighs resident/patient per nursing protocol weekly, or as ordered for the first 4 weeks after admission. If resident/patient is identified to be at risk for weight loss/gains, weights may be continued weekly. - 'If a resident/patient is noted to have a weight loss/gain of 5 or more pounds since their last weight, a re-weight is to be obtained by nursing within 24 hours.' - 'Registered Nurse or Licensed Practical Nurse reports any confirmed weight loss to the Registered Dietician or diet tech/Certified Dietary Manager, nurse manager, physician, and family.' Additionally, per review of Res. #67's medical chart, included under Licensed Nursing Aide Tasks is Weight weekly / Monday. Review of Res. #67's Minimum Data Sheet [MDS] Quarterly Review, dated 1/5/22, under Sec. K: Swallowing and Nutritional Status includes: 'Weigh: base weight on most recent measure in last 30 days. Measure weight consistently, according to standard facility practice.' The space to record the resident's weight was left blank. Review of Res. #67's medical chart on 2/14/22 revealed the two most recent weights dated 11/8/2021 and 1/19/2022- greater than 7 weeks apart. Res. #67's weight on 11/8/2021 is recorded as 115.6 pounds. The weight on 1/19/2022 is 103 pounds: a 10.9% loss of weight in under 3 months. According to 'Involuntary Weight Loss and Protein-Energy Malnutrition: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .medscape.org/viewarticle/ 9_2] The definition of significant weight loss is a loss of 10% of body weight over a 6-month period. Further review reveals To improve quality of care for the elderly and the incapacitated, the federal government defined specific healthcare criteria in the Omnibus Reconciliation Act (OBRA) of 1987. The OBRA Act defines significant unintentional weight loss as a 5% loss in 30 days and a 10% loss in 6 months and considers this process a deviation from proper care. the OBRA Act . requires that long-term care facilities develop strategies to prevent involuntary weight loss in their residents. Nutritional plans and body weight monitoring are mandatory for all patients. An interview was conducted with Res. #67 on 12/14/22 at 3:38 PM. The resident stated that he/she had not been weighed since January. During an interview between the facility's Dietician and the resident the next day, 2/15/22, the resident repeated he/she had not been weighed since January and requested his/her weight be checked. Per record review, Res. #67's weight on 2/15/22 was 99.6 pounds, an additional weight loss of 3.4 pounds since the previous weight, less than a month earlier. Res. #67's total weight loss from 11/8/2021 to the day he/she requested to be weighed, 2/15/2022 was 13.84% in under 4 months. An interview and record review were conducted with the facility's Director of Nursing [DON] on 2/16/22 at 9:59 AM. The DON confirmed the following: - There was no documentation that Res. #67's tube feeding was administered as ordered regarding the infusion rate increased as tolerated. - There was no documentation regarding the amount of tube feeding infused for 105 consecutive days. - There were multiple Nursing Notes from the date of the tube feeding order on 10/14/21 through the survey date of 2/14/22 that indicated the tube feeding was stopped before the ordered time. Additionally, when the amount of tube feeding was recorded, it was lower than the minimal amount ordered on multiple dates. - There was no documentation that weights were monitored per policy and per the resident's Care Plan. - There was no documentation that the Physician was ever notified when the resident was not receiving the minimal amount of tube feeding as ordered, or that the tube feeding was not increased by increments as ordered. - A Nutritional Evaluation was not conducted quarterly by a Registered Dietician per the facility's policy and per the resident's Care Plan, and when completed 7 months after the previous evaluation, the resident's listed weight was 51 pounds less than the evaluation's ideal weight. The DON also confirmed the resident suffered a significant weight loss of 13.84% in under 4 months, during the time the resident's tube feedings and weights were not monitored per the facility's policy or the resident's Care Plan.

Based on record review and staff interview the facility failed to ensure that 1 of 4 residents (Resident #1) receives adequate supervision and assistance devices to prevent accidents. The practice also has the potential to affect all other residents of the facility. The findings include; 1. Per review of the medical record of Resident #1, the record indicates that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the facility internal investigation dated 11/8/13, on 11/6/13, Resident #1 purposefully ingested an unknown amount of Valium pills in an attempt to end his/her life. Per review of the facility internal investigation, Resident #1 indicated in interview that he/she had the Valium and other pills on admission to the facility. Per interview with Interim Director of Nursing Resident #1 also had Lexapro and an over the counter medication possibly Miralax in his/her possession on 11/6/13. Per interview with the IDNS on 11/13/13, he/she indicated that the facility does not ask upon admission if a new resident has any medications in their possession. The IDNS indicated that the facility does not have any system on admission that would ensure that medications prescribed to a resident prior to admission did not enter the facility without the staff's knowledge. 2. Per the facility internal investigation Resident #1 was placed on immediate supervision with facility staff after informing staff on the morning of 11/6/13 that Resident #1 wants to kill him/herself. Per the internal investigation, because Resident #1 had not made any other negative statements, per nursing judgment, the resident was placed on 15 minute checks. Per the investigation, the resident was left alone and when the nursing student left the room, the resident purposefully ingested an unknown amount of Valium. Per the investigation, when the nurse reentered the room Resident #1 informed the nurse that he/she had just taken a handful of pills in attempt to take his/her own life. Per review of the facility policy and procedure titled Suicidal Ideation Prevention and/or Management of Harmful behaviors indicates that; "Any resident/patient verbalizing that he/she wishes to harm him/herself or demonstrating self-destructive behavior will be taken seriously, no matter how vague or seemly immaterial". The policy also indicates "A staff or family member will be immediately assigned to stay with a resident/patient until the resident/patient is appropriately evaluated or transferred."

Based on record review and staff interview the facility failed to provide medically-related social services for 1 resident of 4 in the sample (Resident #1) to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings include; 1. Per review of the medical record of Resident #1, the record indicates that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the behavior documentation; On 6/23/13 Resident #1 exhibits behavior to intentionally cause harm when lifting in wheelchair tries to fall forward, holds pills in throat and tries to choke, displays extreme anger. On 9/2/03 Resident #1 is "easily agitated, threatening to throw self from bed" and that resident's behaviors are increasing. On 9/8/13, Resident #1 expresses depressed or hopeless thoughts "Would rather be dead". On 9/29/13, Resident #1 is withdrawn and negative. On 9/30/13, Resident #1 expressed that "I am nothing", "I am no use to anyone", "nothing matters", "would rather be dead", "what's the use", "why can't I die." On 10/5/13 Resident #1 verbalizes that "I am of no use to anyone", "Nothing matters", "what's the use" and is easily annoyed. On 11/6/13, Resident #1 threatens to commit suicide in the morning and then when left alone for a minute by staff on 11/6/13, he/she swallows an undetermined amount of Valium that he/she had, and the resident is transferred to the emergency room . On 11/10/13, Resident #1 verbalized that he/she said "I wish I had a gun so I could clean house around here." On 11/11/13, Resident #1 verbalizes that "the resident across the hall should be shot." Resident #1 also verbalizes that he/she knows she is in crisis and that he/she needs help and feels neglected. On 11/12/13, Resident #1 verbalized that he/she was "going to go postal with a gun", and "If I really wanted to kill myself then I would wait until night because the night shift takes naps." Per review of the Social Service notes there was no evidence that Social Services addressed any of the documented concerns regarding Resident #1 on 6/23, 9/2, 9/8, 9/29, 9/30, 10/5, 11/10. 11/11 and 11/12/13. Per interview with the Short Term Rehab Social Worker, on 11/12/13, he/she indicated that he/she went to see Resident #1 on the morning of 11/6/13 to discuss the resident's interest to transfer to another facility. The Social Worker indicated that he/she saw the fax to the physician on 11/6/13 that indicated that the resident had expressed thoughts of suicide, that Resident #1 indicated he/she had to "get out of here", that "the nurse was out to get (him/her)", and "the doctor wanted (him/her) dead." The Social Worker indicated that Resident was "weepy" at the time also. The Social Worker indicated that he/she was made aware later in the day that Resident #1 had attempted suicide by swallowing undetermined amount of Valuim. The Short Term Rehab Social Worker confirmed that Resident #1 had a long history of increasing behaviors and accusations, especially accusations voiced by Resident #1 regarding a specific staff member, and Resident #1's accusations of poor care. Per interview on 11/13/13, the Long Term Care Social Worker reviewed the behavior documentation (noted above from 6/23/13 to 11/12/13) and he/she confirmed that there was no evidence that the Social Worker addressed any of these areas of concerns. The Long Term Care Social Worker confirmed that he/she was aware that Resident #1 had attempted to commit suicide on 11/6/13, and confirmed that Resident #1 had a long history of increasing behaviors and accusations especially accusations voiced by Resident #1 regarding a specific staff member and Resident #1's accusations of poor care.

Based on record review and interview the facility failed to assure each resident is free from neglect and mistreatment, by failing to provide services necessary to avoid mental anguish for 1 of 4 residents (Resident #1) identified. The findings include; 1. Per review of the medical record of Resident #1, the record indicates that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the facility internal investigation dated 11/8/13, on 11/6/13, Resident #1 purposefully ingested an unknown amount of [MEDICATION NAME] pills in an attempt to end his/her life. The investigation indicated that the Resident #1 indicated that he/she wanted to kill themselves because of feelings he/she had that a facility staff member (LNA #1) was isolating Resident #1, stealing his/her things and trying to get the physician and other staff to drive Resident #1 crazy. The facility was aware that the Resident made frequent allegations/accusations about LNA #1, but did not take steps to avoid mental anguish for the resident. The direct care staff on the unit had to step in to make the decision that the LNA should not care for Resident #1 anymore; facility administration/leadership had not instituted that measure despite ongoing concerns/allegations. The resident indicated to staff at the Nursing home and at the hospital that the suicide attempt was related to LNA #1. Per interview with LNA #1, he/she confirmed that Resident #1 made numerous accusations regarding the LNA from 9/2013 to 11/6/13 and that the LNA reported these via email to the IDNS (Interim Director of Nursing). The LNA confirmed that he/she did not do direct care on Resident #1 after 10/15/13 but was still on the same unit as the resident and would see resident in hallway and in his/her room when the LNA walked by. Per review of the facility staffing sheets the LNA from 10/15/13 to 11/13/13 was not providing direct hands on care to Resident #1. Review of the staffing sheets indicated that the LNA was still working on the same unit (Moses) that the resident's room was on. Per interview with Resident #1 on 11/13/12, he/she confirmed that he/she was in need of help and that he/she did not want to be around LNA #1. Resident #1 during the interview was observed to be weepy, shaking and broke into tears when speaking regarding the situation with the staff member. The Short Term Rehab Social Worker confirmed that Resident #1 had a long history of increasing behaviors and accusations towards LNA #1 and accusations of poor care and improper treatment. Per interview the IDNS confirmed that Resident #1 had made accusations for months regarding issues surrounding LNA #1. The IDNS confirmed that since admission Resident #1's behaviors and accusations would increase when in the presence of the LNA. Per review of the physician's assessment made on 11/6/2013, the physician indicates that Resident #1 is increasingly paranoid that one of the LNA's in the facility is conspiring to make his/her life miserable and today stated Resident #1 took a handful of [MEDICATION NAME]. The physician also indicates that Resident #1's perception of the LNA over powers any medical condition that the resident may be experiencing.

Based on observation, record review and staff interview the facility failed to ensure that 1 of 4 residents (Resident #1) who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem. 1. Per review of the medical record of Resident #1, the record indicates that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the facility internal investigation dated 11/8/13, on 11/6/13, Resident #1 purposefully ingested an unknown amount of [MEDICATION NAME] pills in an attempt to end his/her life. The investigation indicated that the Resident #1 indicated that he/she wanted to kill themselves because of feelings he/she had that a facility staff member (LNA #1) was isolating Resident #1, stealing his/her things and trying to get the physician and other staff to drive Resident #1 crazy. The facility failed to meet the psychosocial needs by failing to identify, recognize and provide services for signs of psychosocial difficulties prior to the suicide attempt, failing to protect the resident from mental anguish by allowing LNA #1 to continue to be around Resident #1 despite months of ongoing allegations against LNA #1, failing to implement their policy regarding a resident who makes suicidal statements, failing to revise and implement the resident's plan of care, failing to thoroughly investigate allegations and complaints made by the resident, and failing to provide services by qualified mental health professionals as indicated. Per interview with LNA #1, he/she confirmed that Resident #1 made numerous accusations regarding the LNA and that the LNA reported these via email to the IDNS. The LNA confirmed that he/she did not do direct care on Resident #1 since 10/15/13 but was still on the same unit as the resident and would see resident in hallway and in room when the LNA walked by. Per interview with the Interim Director of Nursing (IDNS), he/she confirmed that he/she was aware of the accusations made by Resident #1 when at the emergency room regarding LNA #1 on 11/6/13. Per interview the IDNS confirmed that Resident #1 had made accusations for months regarding issues surrounding a facility Licensed Nursing Assistant (LNA). The IDNS confirmed that since admission Resident #1's behaviors and accusations would increase when in the presence of the LNA and that the floor staff had decided on 10/15/13 to not have the LNA care for Resident #1 because of the increase in behaviors. Per interview with the IDNS on 11/12/13 he/she indicated that since Resident #1 returned to the facility on [DATE] psychiatric services were attempting to be obtained for Resident #1 but that United Counseling Services had indicated that they would not follow this resident because of who his/her doctor was. The IDNS was unable to explain the rationale for this decision but felt it maybe of a political nature. See also F224, F225, F226, F250, F280, F282.

Based on regulatory violations found at the actual harm level at F224, F250, F319 and F323, and violations regarding the same resident at F225, F226, F280 and F282 (Resident #1), the facility is not administered in a manner that enables it to use its resources effectively to attain the highest practicable mental and psychosocial well being for residents of the facility. 1. The facility failed to assure Resident #1 is free from neglect and mistreatment by staff (Refer to F224); 2. The facility failed to assure allegations of abuse are thoroughly investigated and failed to implement abuse policies (Refer to F225 & F226); 3. The facility failed to provide adequate social services (Refer to F250); 4. The facility failed to revise the care plan to reflect significant changes in psychosocial well-being and failed to implement the existing plan of care as written (Refer to F280 and F282); 5. The facility failed to provide adequate treatment for [REDACTED]. 6. The facility failed to have any process to evaluate if residents bring prescription and/or over the counter medication from home that is accessible to them during their stay (Refer to F323).

Based on record review and staff interview the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores for Resident #41 (R#41) in a sample of 3 residents with pressure ulcers reviewed in Stage 2. Findings include: Per record review Resident #41 was admitted to the facility with long standing venous ulcers, chronic skin rash and history of [MEDICAL CONDITION]. The resident was admitted to the facility in 2004. A note in the record on 12/29/12 states that R#41 has a Stage 3 pressure ulcer of the coccyx/Right Upper Buttocks. The first mention of a pressure area is a note dated 12/23/12 which states there is an unstageable area on the L Buttock. The note of 12/29/12 states that the area on the L buttock cannot be found. In an interview on 11/6/13 the acting Director of Nursing Services (DNS) and the Care Coordinator/MDS Coordinator (CC/MDSC) confirmed that there is no indication in the record that the pressure area was noted to reported before it had reached Stage 3. They also both stated that they were not aware of what the frequency or circumstances were regarding skin assessments by nurses. LNAs are expected to monitor the skin and report issues during care. They are not aware of any specific process for nurses regularly assessing the skin of residents at risk for skin impairments. In an interview on 11/6/13 an LPN Medication/Treatment nurse stated that s/he assesses the resident's skin if an LNA reports an issue or if s/he is providing skin treatments. In an interview on 11/6/13 at 10:30 AM the DNS stated that the facility had a wound nurse who saw residents weekly. The wound nurse moved to per diem status in October of 2012 and per the DNS' statement s/he saw residents very sporadically after that until the visits stopped entirely. The facility hired a new wound nurse approximately 3 1/2 months ago. In record review of the care plan currently in place no prevention strategies are noted for the present pressure ulcer and earlier prevention strategies are in the discontinued care plan.