Every finding on record at Civita Care Center at Salmon Brook

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Residents #2) reviewed for abuse, the facility failed to provide adequate supervision for a resident that ambulated independently with a known history of dementia, to prevent a resident-to-resident incident. The findings include: 1. Resident #1's diagnoses included major depressive disorder and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (was alert and oriented), and ambulated independently. The Resident Care Plan (RCP) dated 7/1/26 identified Resident #1 may require assistance performing ADLs. Interventions directed independent with transfers and ambulation (there were no active behavior care plans in place). Resident #2's diagnoses included dementia with behavioral disturbances. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition ((BIMS score of 8), and ambulated independently. The RCP dated 5/12/26 identified Resident #2 wandered and an elopement risk due to disorientation to place. Interventions directed to distract from wandering by offering pleasant diversions, structured activities, food, conversation, television or books; provide structured activities including toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; Resident #2 has a wander guard (a tracking device that prevents doors from opening for residents at risk for elopement) in place to the left ankle. A nursing note by RN #7 dated 7/29/26 at 7:14 AM identified she was notified that Resident #1 punched Resident #2 in the right lower eye. Resident #1 stated Resident #2 came into his/her room, took off his/her clothes and voided on the floor. Resident #1 told Resident #2 to leave multiple times, but Resident #2 refused and Resident #1 reported he/she had no other choice but to punch Resident #2 in the face. Resident #1 was placed on one-to-one (1:1) observation until seen by psychiatric services. Record review failed to identify any history of aggressive behaviors from Resident #1 within the last year prior to 7/29/26. A nursing note by RN #7 dated 7/29/26 at 7:00 PM identified Resident #2 was hit by another resident and sustained a skin tear measuring 0.5 centimeters (cm) by 0.5 cm with slight swelling noted to the right lower eye. Resident #2 was transferred to the hospital for evaluation. A nursing note written by RN #9 dated 7/30/26 at 2:51 AM identified Resident #2 returned from the hospital with no new findings were identified, and a lower right eye skin tear was open to air. Record review failed to identify Resident #2 had any wandering behaviors within the 30-days prior to 7/29/26. Interview with Resident #1 on 8/14/26 at 10:04 AM identified Resident #2 routinely wandered into other resident rooms, including his/her own, prior to 7/29/26. Resident #1 stated Resident #2 had wandered into his/her room earlier that day and urinated on the floor, and he/she notified staff. When Resident #2 entered again later that evening and refused to leave, Resident #1 reported striking Resident #2 in self-defense. Interview with LPN #3 on 8/14/26 at 12:04 PM identified she normally works the 11:00 PM to 7:00 AM shift and indicated Resident #2 consistently wanders the hallways and goes into other resident rooms. Prior to 7/29/26, she had seen Resident #2 in Resident #1's room multiple times, and Resident #2 was easily redirected (would always leave told to leave the room). LPN #3 stated she did not report the wandering incidents to the nursing supervisor because she thought it was not new behavior. Interview with LPN #5 on 8/14/26 at 12:56 PM identified he was aware Resident #2 had a history of wandering into other resident rooms that were located near his/her room. Interview with NA #7 on 8/14/26 at 12:14 PM identified she was aware Resident #2 had a history of wandering into other resident rooms. Interview with NA #9 on 8/14/26 at 12:31 PM identified she was aware Resident #2 had a history of wandering into other resident rooms. Interview with NA #5 on 8/14/26 at 12:46 PM identified she was aware Resident #2 had a history of wandering into other resident rooms. Interview with NA #4 on 8/14/26 at 2:57 PM identified on 7/29/26 she heard Resident #1 yell for someone to get out of his/her room. When she arrived at the room she observed Resident #1 dragging Resident #2 by Resident #2's arm into the doorway of Resident #1's room and Resident #2's pants were half down. Resident #1 stated he/she was upset that Resident #2 kept coming into his/her room. Resident #2's right eye was swollen, bleeding and red, and RN #7 to his/her room. Although attempted, interviews with RN #7, LPN #4, NA #6 and NA #8 were not obtained during the survey. Interview with the DON on 8/14/26 at 2:24 PM identified the DON was not aware Resident #2 had behaviors of wandering into other resident rooms, and stated staff should have notified the charge nurse and/or nursing supervisor that Resident #2 had wandering behaviors. These notifications would have allowed appropriate documentation, implementation of interventions, and updates to the plan of care prior to the 7/29/26 incident and may have prevented the resident to resident incident on 7/29/26. Interview failed to identify why the staff did not notify the supervisor of the wandering behaviors into other resident rooms. Review of the Residents Right to Freedom from Abuse, Neglect, and Exploitation policy (undated) directed in part, to monitor for behaviors, verbally or physically aggressive actions, and other triggers that may provoke reactions between residents. Review of facility documentation identified staff education was initiated on 7/31/26 and included residents identified with wandering behaviors and prevention of resident-to-resident altercations. Audits were initiated on 7/31/26 and a QAPI meeting was held on 8/5/26.

Based on observations, review of the clinical record, facility policy and interviews for one of three residents (Resident #1) reviewed for infection control, the facility failed to follow required infection control practices when dirty linen and a soiled incontinence brief were left unbagged on a resident's floor. The findings include: Observation of Room XXXX on 8/13/26 at 11:36 AM identified dirty/used soiled linen and a soiled incontinence brief were directly on the floor to the right side of Resident #3's bed. Interview with NA #1 on 8/13/26 at 11:37 AM (at the time of the observation) identified that she was Resident #1's assigned NA for the day, and stated that she left the soiled linen and a soiled incontinence brief on the floor of Resident #3's room. NA #1 stated she was not yet finished in the room, she had not yet cleaned up and had not picked up the soiled items. NA #1 stated she should have bagged the soiled linen and soiled brief in plastic bags, and she should not have left them directly on the floor. Subsequent to surveyor inquiry, NA #1 discarded both the soiled linens and the soiled incontinence brief appropriately. Interview with the Regional nurse (RN #1) on 8/13/26 at 12:35 AM identified that staff should never place dirty linens or incontinence briefs directly on surfaces and soiled linen and soiled incontinence briefs should be placed in plastic bags until they are removed from a residents room. NA #1 should not have placed the soiled items on the floor. Review of the facility Cleaning and Homelike Environment Policy dated 3/3/2026 directed in part, that resident rooms and environmental surfaces must be maintained in a clean, sanitary, and odor free condition, and that soiled linens must be handled minimally and transported in designated covered containers or bags to prevent contamination. Further, the policy directed to prevent placing of dirty items directly on environmental surfaces.

Based on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure ulcers, the facility failed to ensure appropriate assessment, monitoring, and treatment of existing pressure ulcers. This included failure to complete Braden Scale for Predicting Pressure Sore Risk assessments in accordance with facility policy; failure to complete weekly skin assessments using the Skin Observation Tool; failure to obtain and document weekly pressure ulcer measurements and wound assessments; and failure to ensure an as needed dressing change order was in place to address dressing dislodgement or soiling. The findings include:Resident #1's diagnoses included spinal stenosis of the lumbar region, spina bifida with hydrocephalus, muscle weakness, anxiety disorder, and major depressive disorder.The clinical record identified Resident #1 was transferred to the hospital on [DATE] with an unhealed stage 4 pressure ulcer.The Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] identified Resident #1 was at moderate risk for pressure ulcer development.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13), required supervision assistance for bed mobility, substantial assistance for personal hygiene and transfers, utilized a wheelchair for mobility, was always incontinent of bowel and bladder, was at risk for pressure ulcer development, and had one (1) current unhealed stage 4 pressure ulcer.The Resident Care Plan (RCP) dated 1/23/26 identified Resident #1 had potential for pressure ulcer development related to a history of pressure ulcers and immobility, had an actual stage 4 pressure ulcer to the sacrum and left buttocks, and a pressure area to the right buttocks. Interventions directed staff to follow facility policies and protocols for the prevention and treatment of skin breakdown, provide assistance to turn and reposition at least every two (2) hours or more often as needed or requested, administer treatments as ordered, and monitor for effectiveness.A. The clinical record failed to identify a Braden Scale for Predicting Pressure Sore Risk assessment had been completed between 10/10/25 and 4/3/26 (a period of five (5) months and twenty four (24) days).A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] identified Resident #1 as at risk for pressure ulcer development.B. A Physician's Order dated 3/30/22 directed licensed nursing staff to complete a weekly skin assessment (Skin Observation Tool assessment) every Wednesday during the 7:00 AM to 3:00 PM shift.A Skin Observation Tool assessment was completed on 2/24/26.The March 2026 Treatment Administration Record (TAR) identified weekly skin assessments were signed as completed on 3/4/26, 3/18/26, and 3/25/26, with 3/11/26 left blank and no refusals documented.The April 2026 TAR identified weekly skin assessments were signed as completed on 4/1/26, 4/8/26, 4/15/26, 4/22/26, and 4/29/26, with no refusals documented.Review of the Skin Observation Tool assessments failed to identify any completed weekly skin assessments between 2/25/26 and 4/12/26. A Skin Observation Tool assessment was opened on 4/13/26 but contained no documentation. A fully completed Skin Observation Tool assessment was not identified until 5/2/26, which was nine and one half (9.5) weeks after the last completed assessment on 2/24/26.The May 2026 TAR identified blank administrations on 5/6/26 and 5/13/26, with no refusals documented. Skin Observation Tool assessments were completed on 5/17/26 and 5/27/26. The clinical record failed to identify a completed weekly skin assessment between 5/1/26 and 5/19/26, and failed to identify a completed assessment on 5/20/26 despite a completed entry on the TAR.C. The clinical record identified Resident #1 had been followed weekly by an outside community wound clinic since 2024 and was not receiving wound care evaluations from the facility wound physician.Wound Care After Visit Summary notes dated 2/26/26, 3/5/26, and 3/12/26 identified Resident #1 had pressure ulcers to the coccyx, left buttocks, and right buttocks but failed to identify wound stage, wound measurements, condition of the skin or tissue, or presence of drainage.Wound Care After Visit Summary notes dated 3/19/26 and 3/26/26 identified wound measurements but failed to identify wound stage, condition of the skin or tissue, or presence of drainage. The 3/26/26 note identified the right buttocks wound had resolved.Wound Care After Visit Summary notes dated 4/2/26, 4/9/26, 4/16/26, 4/23/26, 4/30/26, 5/7/26, 5/14/26, and 5/21/26 failed to identify wound stage, wound measurements, condition of the skin or tissue, or presence of drainage.The clinical record from 2/26/26 through 5/21/26 failed to identify any facility completed pressure ulcer assessments, including wound measurements, surrounding skin condition, or documentation required by facility wound protocols.D. A Physician's Order dated 2/5/26 directed to cleanse the open area to the coccyx with warm soap and water, pat dry, apply a thick layer of zinc oxide paste to the area around the wound, apply Iodosorb paste to the wound bed, apply calcium alginate, cover with gauze, secure with a bordered foam dressing, and change the dressing every shift.A Physician's Order dated 3/20/26 directed to cleanse the coccyx wound with warm soap and water, pat dry, apply zinc oxide paste to the surrounding area, apply Iodosorb to the wound bed, apply calcium alginate, secure with a super absorbent dressing, and change every shift.The February, March, and April 2026 TARs failed to identify an as needed dressing change order for Resident #1's coccyx pressure ulcer until 4/16/26.Interview with RN #1 (the wound care nurse) on 5/28/26 at 11:28 AM identified Resident #1 had been evaluated weekly by a community wound clinic due to a history of refusals to be seen by the facility wound provider. RN #1 identified licensed nurses should have assessed and measured the wounds weekly and documented the wound condition and measurements with the weekly skin assessment, but this had not occurred since Resident #1 began visiting the outside wound clinic. RN #1 identified she had been instructed by the previous wound nurse to obtain wound status and measurements from the wound clinic rather than assess the wounds herself. RN #1 identified the wounds should have been assessed and measured weekly and documented in the clinical record. She identified Resident #1 should have received Braden Scale assessments at least quarterly due to existing pressure ulcers. She identified an as needed dressing change order should have been in place since February 2026 and had been overlooked.Interview with Resident #1 on 5/28/26 at 1:30 PM identified Resident #1 was incontinent of bowel and bladder and required frequent dressing changes due to soiling. Resident #1 identified he/she had not refused dressing changes or wound measurements at the facility.Interview with the Director of Nursing (DON) and the Regional Nurse on 5/28/26 at 2:28 PM identified Resident #1 should have received Braden Scale assessments at least quarterly and with any change in condition. They identified that although Resident #1 was seen by a community wound clinic, licensed nursing staff should have continued to assess, measure, and document the wounds weekly. They identified the facility should have obtained its own wound measurements and added wound clinic measurements to the facility wound tracker. They identified Resident #1 should have had an as needed dressing change order to address dressing soiling or dislodgement and were unsure why the order was not in place until 4/16/26.The Braden Scale Assessment policy dated 12/1/25 directed staff to complete Braden Scale assessments upon admission, readmission, quarterly, with significant change in condition, and as clinically indicated. Residents with scores of 18 or below were identified as at risk and required implementation of preventative interventions.The Skin Assessment policy dated 1/23/25 directed residents at risk for skin impairment, wounds, or pressure injuries to receive a comprehensive weekly skin assessment by licensed nursing staff, with findings documented and communicated to the interdisciplinary team. Required elements included full body assessment and wound measurements.The Weekly Wound Measurement and Documentation policy dated 12/14/25 directed that residents with wounds receive weekly wound assessments and measurements, documented with wound stage, exact measurements, wound appearance, treatment regimen, changes from previous assessment, and provider notifications as indicated.The Dry Clean Dressing Changes policy dated 9/1/22 directed licensed nursing staff to verify orders, assess the wound and surrounding skin, complete dressing changes, and document wound appearance and measurements.Although requested, a policy on as needed dressing changes was not obtained.

Based on facility documentation review and interviews, the facility failed to provide sufficient laundry services to ensure resident laundry was completed timely due to broken washing machines. The findings included: Review of a grievance dated 8/4/2025 identified Resident #2 was displeased with the amount of time it was taking his/her personal items to be laundered. The grievance identified Resident #2 had sent personal items to be laundered about one (1) week prior, and was still waiting for them to be washed and returned. The grievance further identified a response from the facility administration indicating the facility was were working on buying a new washing machine. Review of Vendor #1 invoice dated 8/14/2025 identified a sixty (60) pound washing machine was purchased and due to the facility on 8/29/2025. Review of Resident Council minutes dated 8/29/2025 and 9/25/2025 identified residents were displeased with the delay in having personal items laundered. Interview with the Environmental Services Director on 10/1/2025 at 9:29 AM identified two (2) of the three (3) washing machines that broke down were irreparable due to replacement parts were not available to fix the washing machines. The Environmental Services Director stated the facility replaced one (1) of broken machines about six (6) weeks ago. The Environmental Services Director further indicated he was unsure as to the reason for the delay in replacing the washing machines as the corporate office, the regional manager, and Administrator were all aware of the issue. Interview with Laundry Technician #1 on 10/1/2025 at 10:38 AM identified the facility utilized three (3) washing machines to launder resident's laundry and linens, however, one (1) of the three (3) washing machines (the large washing machine) broke down over two (2) years ago and the second washing machine broke down about one (1) year ago, leaving staff with only one machine to launder the resident's items, causing a delay in completion of the laundry. Interview with Laundry Technician #2 on 10/1/2025 at 10:45 AM identified the facility had only one (1) functioning washing machine to launder resident's items for approximately six (6) months before adding a second washer. Laundry Technician #2 stated outsourcing the resident's soiled clothing started two months ago at a rate of one time per week. Housekeeping #3 further indicated that the facility did add an additional shift of employees (third shift) to better manage the facility's laundry needs and the facility is still down/short one (1) washing machine and one (1) dryer, causing a continued delay in completing resident laundry. Interview with the Central Supply Manager on 10/1/2025 at 10:50 AM identified Nurse Aides (NAs) would at times have to retrieve clothes from lost and found bins to provide clean clothes for the residents who did not have any clean closed due to the delay in completing the personal laundry. Review of Vendor #1 invoice dated 9/12/2025 identified a quote for an additional sixty (60) pound washing machine to replace the third washing machine. Interview with the Administrator on 10/1/2025 at 9:41 AM identified that he was aware the facility was having laundry issues as two (2) of the three (3) washing machines were not working at one time, and that the facility had only replaced one (1) washing machine as of 10/1/2025 (58 days after the grievance was filed, and 48 days after the invoice dated 8/14/2025).

Based on review of clinical records, interview, and review of clinical documentation and policy for one resident (Resident #1) reviewed for resident rights, the facility failed to allow an alert and oriented resident access to an enclosed courtyard. The findings included:Resident #1 had diagnoses that included spina bifida with hydrocephalus, osteoarthritis, anxiety and major depressive disorder. Review of the RCP dated 7/7/2025 identified Resident #1 meets his/her emotional, intellectual, physical, and social needs by socializing with peers, and going outside when it's nice out, and dining in the Rosewood dining room for lunch. Interventions directed Resident #1 to go outdoors, and on short trips when able. Review of the annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition and was independent with wheelchair mobility.Review of a facility grievance dated 9/27/2025 identified Resident #1 had a concern that he/she was withheld from access to the outdoor Recreational Courtyard due to a lost facility key. Interview with the Recreation Director on 10/1/2025 at 12:18 PM identified she was aware residents could not use the Recreation Courtyard on Saturday, 9/27/2025 as the door leading to the courtyard was locked and the facility key was lost. The Recreation Director further indicated no other copies of that key existed in the facility on 9/27/2025 and that the key was located on 9/28/2025. Observation and interview with the Administrator and Recreation Director on 10/1/2025 at 12:32 PM identified the Recreation Director was unable to locate the key to unlock the courtyard door, and interview identified the key had been missing for an undetermined length of time prior to 9/27/2025. Further, interview identified that the nursing supervisor did not have a spare key to the door. Surveyor waited while the Recreation Director called another staff member to come to the Recreation Room and search for the key. Observation through the door window identified the courtyard was enclosed on all four (4) sides by the facility. The Administrator stated the door was kept locked to prevent a resident from eloping from the building, and interview identified the courtyard was secured by the facility building on all four (4) sides of the courtyard - there was no access to the grounds surrounding the facility. Another staff member arrived, the key was located, and the door unlocked to allow access to the courtyard. The Administrator stated the facility did not want residents sitting outside the building (due to the risk of elopements) and Resident #1 was prevented from using the courtyard on 8/27/2025. The Administrator was unable to explain why the key was missing previously and stated residents should be able to access the courtyard without the need to ask staff to unlock the door. Although requested, the Administrator indicated the facility did not have a policy regarding courtyard access. Review of the Resident's Rights Policy directed in part, residents have the right to exercise his/her rights as a resident of the facility and as a resident of the United States, and to be supported by the facility in exercising his/her rights.

Based on review of clinical records, interview, and review of clinical documentation and policy for one resident (Resident #1) reviewed for medication administration, the facility failed to ensure the nurse who prepared a medication was the nurse who administered the medication, in accordance with facility policy. The findings included:Resident #1 had diagnoses that included anxiety and major depressive disorder. Review of the RCP dated 7/7/2025 identified chronic back pain and pain medication therapy. Interventions directed to administer analgesic medications as ordered by the physician. Review of the annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition, and received pain medication. The MDS further identified Resident #1 as dependent with bathing, toileting, and personal hygiene. A physician's order directed Morphine Sulfate (Concentrate) Solution, 20 milligrams/milliliter, give 10 milligrams by mouth every four (4) hours as needed for pain. Review of Resident #1's Narcotics Log Sheet dated 9/30/2025 at 4:00 AM identified Morphine Sulfate (Concentrate) Solution 10 milligrams (mg) was administered. Interview with LPN #1 on 10/1/2025 at 1:32 PM identified she was working on X-Wing of the facility on the morning of 9/30/2025 and was asked to administer a medication to Resident #1, who resided on a different wing in the facility. LPN #1 stated RN #1 was the nurse assigned to care for Resident #1. RN #1 had prepared the medication (had the medication poured in the medication cup ready to administer), so LPN #1 needed to do was to administer the medication poured/prepared by RN #1 to Resident #1. RN #1 signed the medical record on the Treatment Administration Record (TAR) that the medication was administered. LPN #1 stated it was okay for her to administer medication that was prepared by another nurse. Interview failed to identify why LPN #1 administered the medication that she did not prepare. Interview with RN #1 on 10/3/2025 at 11:37 AM identified although he had poured/prepared the requested dose of Morphine on 9/30/2025 at 4:00 AM for Resident #1, it was LPN #1 that administered the dose of Morphine to the resident. Interview failed to identify why RN #1 did not administer the medication. Interview with the DNS on 10/1/2025 at 3:45 PM identified resident medications were to be prepared and administered by the same nurse. Interview failed to identify why LPN #1 administered the medication that she did not prepare. Review of the Administration of Medications Policies and Procedures dated September 2025 directed medications should always be prepared and administered by the same licensed person.

Based on observation of the noon meal dining and staff interview, the facility failed to provide a meal that was appealing and palatable to residents. The findings include: Interviews conducted with residents during the survey identified that food was not appealing and palatable On 6/23/25 at 12:47 PM the facility lunch provided to residents identified pasta with water like tomato sauce and mixed vegetables. Observation on 6/23/25 at 12:47 PM of the tomato sauce identified the sauce was a water like consistency. The interview with the Food Service Director on 6/23/25 at 1:35 PM indicated he noticed the sauce was watery and believes it might have been due to the excess liquid from vegetables.

Based on a review of employee files and staff interviews for 1of 2 employees (Rehabilitation Aide # 2), the facility failed to provide evidence that a background check had been conducted for the employee. The findings include: An interview and facility document review with the Administrator on 6/23/2025 at 11:00 AM indicated no background check information were found in employee for (Recreation Aide # 2). The Administrator also indicated the current Human Resource Manager for the facility only worked onsite a couple days a week. An interview with the Human Resource Manager on 6/23/2025 at 1:06 PM identified she/he only started the position a few months ago and had noticed files had not contained background checks. She/he was told the prior Human Resource Manager only worked remotely therefore the forms were never printed and placed into the employee files. The Human Resource Manager indicated s/he would be coming to the facility later in the afternoon and would print the forms from the electronic reporting system and leave with the administrative staff. An interview with the Administrator on 6/23/2025 at 2:30 PM indicated the prior owner of the facility would have obtained the background check for the employee and she/he would attempt to obtain it. On 6/25/2025 at 8:45 AM an interview and facility document review with the Assistant Director of Nursing Services (ADNS) indicated she/he was unable to provide a background check for Recreational Aide # 2. However, on 6/25/2025 at 3:00PM no background check documents were provided by the facility for Recreational Aide # 2.

Based on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 4 residents reviewed for abuse (Resident #20), the facility failed to ensure a suspected incident of intimidation was reported to the Administrator. The findings include: Resident #20's diagnoses included depression, anxiety, and panic disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was cognitively intact and exhibited fluctuating inattention. The MDS assessment also identified Resident#20 did not exhibit behavioral symptoms directed towards others nor rejection of care. A care plan revised on 6/4/2025 identified Resident #20 had a mood problem related to psychiatric diagnoses. Interventions included: providing psychosocial and emotional support from social work to enhance overall well-being, providing psychiatric services, and supportive counseling from facility staff. The care plan also identified Resident #20 had a behavior problem related to suicidal ideation. Interventions included approaching the resident in a calm manner, diverting attention, and removing the resident from the situation to take them to an alternate location as needed. On 6/18/2025 at 10:40 AM, an interview with Nurse Aide (NA #2) identified she had heard from other staff member a (Laundry Aide) that on 6/16/2025, the Director of Nursing Services (DNS) had been antagonizing Resident #20 in the recreation room. NA #2 indicated she did not witness the incident or report the incident. On 6/18/2025 at 12:32 PM, an interview with Resident #81 identified she/he was present in the recreation room during the incident between the DNS and Resident #20. Resident #81 indicated that although the DNS did not yell, she/he thought the DNS had been unprofessional when interacting with Resident #20. Resident #81 was unable to provide further details as she/he left the recreation room. On 6/18/2025 at 1:19 PM, an interview with the Laundry Aide indicated she heard a commotion coming from the recreation room around 3:15 PM on 6/16/2025. The Laundry Aide indicated she went into the recreation room, where she witnessed Resident #20 yelling at the DNS to leave the room. The [NAME] Aide indicated that instead of leaving, the DNS pulled a chair up and sat in front of Resident #20 to continue the conversation. The Laundry Aide then indicated she told the DNS to leave 2 or 3 times, and that the DNS did not leave. The Laundry Aide indicated she thought the DNS's behavior was intimidating. The Laundry Aide indicated she did not tell the Administrator about the incident because she felt the Administrator would not do anything to address the incident . On 6/18/2025 at 1:55 PM, an interview with the Recreation Aide identified Resident #20's voice was louder than normal during talking with the DNS while in the recreation room but did not recall the nature of the conversation. The Recreation Aide indicated he told the DNS to take the conversation with Resident #20 somewhere else, behind closed doors, so other residents would not be disturbed. The Recreation Aide indicated he did not witness the DNS yelling. The Recreation Aide indicated he did not report the incident to the Administrator but indicated that he reported it to his immediate supervisor, the Director of Recreation. . On 6/18/2025 at 2:42 PM, an interview with Resident #20 identified she/he was in the recreation room when the DNS came. Resident #20 indicated she/he was upset and anxious about the availability of his/her medications and yelled at the DNS. Resident #20 indicated she/he did not recall if the DNS was yelling. Resident #20 indicated she/he did not tell the DNS to leave. Resident #20 indicated she/he left the recreation room before the DNS. On 6/18/2025 at 4:05 PM, an interview with the Recreation Director identified she was in her office, which is located inside the recreation room, at the time of the incident. She heard the discussion between Resident # 20 and the DNS getting louder, and she heard the Recreation Aide tell the DNS to take the conversation somewhere else since some of the residents were getting upset. The Recreation Director indicated Resident #20 was yelling, but the DNS was not yelling. The Recreation Director indicated she told the Administrator about the incident the next day, on 6/17/2025, but could not recall the time. On 6/18/2025 at 4:50 PM, an interview with the Administrator indicated she was not aware the Laundry Aide was concerned that the DNS may have been intimidating Resident #20. The Administrator indicated she had spoken to the Director of Recreation about the conversation between the DNS and Resident #20 and indicated she was not made aware Resident #20 had been yelling at the DNS. The Administrator indicated that if she had been made aware of a concern, she would have investigated it. A review of Resident #20's clinical record failed to identify a nursing note, recreation note, social work notes, or behavior monitoring that indicated Resident #20 was upset, anxious, or yelling at staff members. Additionally, a review of facility documents failed to identify an incident report with the Laundry Aides' concerns of intimidation. On 6/23/2025 at 10:30 AM, an interview with the DNS indicated he had gone to the recreation room where Resident #20 started talking to him about her/his medications and about a sign that had been posted by the employee time clock. The DNS indicated Resident#20 started to escalate and raised his/her voice. The DNS denied yelling at the resident and denied Resident #20 had asked him to leave. The DNS indicated Resident #20 wanted to discuss the issue there and continued yelling. The DNS denied sitting down in front of Resident #20 to intimidate the resident. The DNS indicated she/he sat down to listen to Resident #20 and tried to apologize for their missing medications. The facility policy for abuse prevention notes mental abuse may occur through either verbal or non-verbal conduct, which causes a resident to experience feelings including intimidation and fear. Additionally, the facility policy indicated that any person who has a reason to believe that a resident has been a victim of abuse or mistreatment shall report the mistreatment to the Administrator or the DNS.

Based on review of the clinical record reviews and staff interviews for 2 of 2 residents reviewed for discharge (Resident #97 and Resident #98), the facility failed to provide evidence of Ombudsman notification for transfers and discharge The findings included: 1.Resident #97's diagnosis included pneumonia and sepsis. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated in part, the discharge date for Resident #97 was 3 months or less. A nursing progress note dated 3/25/2025 at 1:56 PM indicated Resident #97 was discharged from the facility with medications and services on 3/25/2025 at 12:00 PM. On 6/24/2025 at 1:10 PM an interview with the social worker indicated the administrator was in charge of notifying the state's Ombudsman with resident's discharged from the facility. An interview with the Administrator on 6/24/2025 at 1:20 PM identified the facility has a remote staff who notifies the state Ombudsman of discharges, and she/he would obtain the information for Resident #97. On 6/25/2025 02:15 PM an interview and facility documentation review with the Administrator identified she/he was only able to provide documentation regarding dates of transfer that did not include the resident's name and date of discharge. The Administrator indicated s/he would ask for the details of the date. On 6/25/2025 at 3:00PM no information was provided by the facility. 2. Resident #98's diagnoses included acute kidney failure, anxiety and sleep apnea. The admission Data Set (MDS) assessment dated [DATE] identified Resident #98 was moderately cognitively impaired and required moderate assistance with lower body dressing, toileting hygiene and showering. The MDS also indicated that active discharge planning is already occurring. A review of the clinical record failed to identify ongoing communication with the Ombudsman related to discharged residents. Interview with Social Worker #1 on 6/24/25 09:12 AM indicated she has never sent any notification for residents who are discharged from short term stays. On 6/25/26 at 12:04PM Social Worker #1 reported the part-time social worker, or the Administrator may have further information related to discharge communication with the Ombudsman. Interview with the Administrator on 6/25/2025 at 2:15 PM reported the facility has some form of communication with the Ombudsman, however, the documents did not indicate names of residents discharged or discharged dates. Documents were requested to show the evidence of the notification but were not provided.

Based on clinical record review, facility documentation, facility policy and interview for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to refer a resident with known mental health diagnosis to the appropriate state- designated authority for a Level II evaluation and determination. The findings include: Resident #64's diagnoses included delusional disorder, hypertension and Type 2 diabetes mellitus. The care plan dated 3/11/25 identified Resident #64 receives antipsychotic medications. Intervention included observing resident mood state/behavior and report changes to physicians. A physician's order dated 4/4/25 directed to give 5 Milligrams (MG) of Risperdal one time a day related to delusional disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was moderately cognitively impaired and dependent with eating, bed mobility and transfers. The MDS also indicates Resident #64 has frequent symptoms of feeling down, depressed or hopelessness. Review of Resident #64 clinical record indicated she/he had a known mental health diagnosis upon admission. However, the facility was unable to provide documentation indicating Resident #64 had a level II PASARR evaluation. Interview with Social Worker #1 on 6/23/25 at 12:10 PM identified a resident with a mental health diagnosis (described above) should have a level 2 PASARR completed. She also reported that the social work department is responsible for ensuring that referrals for PASARR evaluations are completed. Though requested a facility policy was not provided.

Based on review of the clinical record review, facility policy and interviews for 2 of 2 residents reviewed for behaviors (Resident #20 and Resident #89), the facility failed to follow and or develop a resident care plan for addressing the residents' mood and behaviors for the only resident reviewed for Hospice ( Resident #74) the facility failed to ensure a comprehensive care plan was developed for a resident receiving specialized services. The findings included: 1.Resident #20's diagnoses included depression, anxiety, and panic disorder. The quarterly MDS assessment dated [DATE] identified Resident #20 as cognitively intact and exhibited fluctuating inattention. The MDS assessment also identified Resident#20 did not exhibit behavioral symptoms directed towards others nor rejection of care. A care plan revised on 6/4/2025 identified Resident #20 had a mood problem related to psychiatric diagnoses. Interventions included: providing psychosocial and emotional support from social work to enhance overall well-being, providing psychiatric services, and supportive counseling from facility staff. The care plan also identified Resident #20 had a behavior problem related to suicidal ideation. Interventions included: approaching the resident in a calm manner, diverting attention, and removing the resident from the situation to take them to an alternate location as needed. On 6/18/2025 at 1:55 PM, an interview with the Recreation Aide indicated Resident #20 had been going in and out of the recreation room, looking upset, and was not participating in an activity. While Resident #20 was in the recreation room, the DNS entered the room. The Recreation Aide identified Resident #20's voice was louder than normal when talking with the DNS but did not recall the nature of the conversation. The Recreation Aide indicated he told the DNS to take the conversation with Resident #20 somewhere else, behind closed doors, so other residents would not be disturbed. The Recreation Aide indicated he did not witness the DNS yelling. The Recreation Aide further indicated he approached the Director of Recreation, asking if she could assist in having Resident #20 and the DNS converse somewhere else. The Recreation Aide indicated he did not recall the Director of Recreation saying or doing anything to address Resident #20's yelling in the recreation room. On 6/18/2025 at 4:05 PM, an interview with the Recreation Director identified she was in her office, which is located inside the recreation room, at the time of the incident. She heard the discussion getting louder, and she heard the Recreation Aide tell the DNS to take the conversation somewhere else since some of the residents were getting upset. The Recreation Director indicated Resident #20 was yelling, but the DNS was not yelling. However, the Director of Recreation indicated she felt the discussion was not appropriate in front of the residents. The Director of Recreation indicated she did not intervene because the incident was beyond anything that could be intervened, although she indicated she could have told the DNS to leave or offer her office for the discussion instead. On 6/23/2025 at 10:30 AM, an interview with the DNS indicated he had gone to the recreation room where Resident #20 started talking to him about her/his medications and about a sign that had been posted by the employee time clock. The DNS indicated Resident#20 started to escalate and raised his/her voice. The DNS indicated that although he told Resident #20, he would speak about the issue later, Resident #20 wanted to discuss the issue there and continued yelling. The DNS indicated the Recreation Aide had told him they should not be having the discussion in the recreation room. The DNS indicated he did not know what to do and therefore sat down and tried to apologize for Resident #20's missing medications however, the resident was too worked up. The DNS indicated that if he had left the room, it may have made the situation worse since the resident felt like venting at that moment and felt it was his responsibility to listen to her/him. The DNS indicated he later asked Social Worker #1 to speak to Resident #20. On 6/23/2025 at 12:13 PM, an interview with Social Worker #1 identified she first found out about the incident between the DNS and Resident #20 on 6/18/2025 from Resident #20. Social Worker #1 identified Resident #20 could get very vocal and raise her/his voice, get flustered and anxious over minor things. Social Worker #1 further indicated that staff is aware of how to address the behavior, such as moving Resident #20 to her/his room or an office away from a common area. Social Worker #1 indicated she did not leave the facility until 5:30 PM or 6:00 PM on 6/16/2025 but was not made aware of how upset Resident #20 had been. Social Worker #1 indicated that it would have been appropriate for the social work to have visited Resident #20 that day. A review of Resident #20's medical record failed to identify a nursing note, recreation note, social work notes, or behavior monitoring that indicated Resident #20 was upset, anxious, or yelling at staff members. 2. Resident #89's included hallucinations, non-traumatic brain dysfunction, dementia, and seizure disorder. The annual MDS assessment dated [DATE] identified Resident #89 was visually impaired and cognitively intact. The MDS assessment further indicated Resident #89 exhibited fluctuating inattention and disorganized thinking and was dependent for transferring and ambulating. A care plan revised on 6/16/2025 identified Resident #89 had a behavior problem related to being physically aggressive and threatening staff. Interventions included: caregivers stopping and talking when passing by and provide opportunities for positive interactions, intervene as necessary to protect the rights and safety of others, approach in calm manner, divert attention, remove from the situation and take to alternate location as needed, monitor behavior and determine underlying cause, document behavior and potential causes. On 6/16/2025 at 1:49 PM, the resident was observed sitting in front of the D-wing nurses' station yelling profanities and threats such as F-- you, I have my boys with me, not directed towards other residents. Although there was one resident sitting next to the resident and other residents walking in the hallway (Resident #10). It was observed that NA #7 and NA#8 were at the nurses' station, and NA #6 was standing in the hallway near Resident #89, neither of whom intervened when the resident began to get visibly agitated by moving her/his head and yelling profanities. LPN #6 walked down the hall from C-wing, told Resident # 89 what she/he was saying was not nice, and moved Resident #89's wheelchair about two feet away from Resident #10. Resident #89 continued yelling and cursing, and LPN #6 walked back up the hallway to C-wing. At 1:53 PM, LPN#6 returned to stand in front of Resident #89 without speaking to the resident and told NA#6 to wheel the resident around to see if the resident would calm down. LPN #6 then walked back up the hallway to C-wing. NA#6 proceeded to continue standing near the resident but did not attempt to wheel the resident around. At 1:57 PM observation identified Resident #89 had stopped yelling and was calmer. An interview with LPN#6 at 1:57 PM indicated Resident #89 sometimes gets more agitated when he/she is moved too fast, but also indicated she was covering for the nurse who was on lunch break. An interview with NA#6 indicated he does not get an assignment, and his responsibilities include passing out water, food trays, and pushing residents in wheelchairs. NA#6 was unable to identify why he did not attempt to push Resident #89 in the chair. On 6/17/2025 at 10:00 AM, an interview with the DNS indicated Resident #89 had vision impairment and would not know who she/he may be yelling at, and that the resident's yelling and agitation were part of behaviors being treated. On 6/18/2025 at 12:11 PM, an interview with LPN#4 indicated she was taking care of Resident #89 on 6/16/2025, but she was at lunch during the incident. LPN#4 indicated she was told the resident got agitated, they were moved and redirected, which allowed the resident to calm down. LPN #4 indicated Resident #89 had vision impairment and sometimes hallucinate, which may cause him/her to get agitated and yell. LPN #4 further indicated that interventions that assist Resident #89 to calm down include pushing the resident's wheelchair around the building or outside in the front. LPN # 4 also indicated talking to the resident, offering a snack, or toileting sometimes helps. On 6/18/2025, a review of behavioral monitoring flowsheet failed to identify the behavior Resident #89 was observed exhibiting on 6/16/2025. A note by LPN#6, timestamped at 3:15 PM, indicated Resident #89 was agitated and the resident was removed from beside other residents. The facility policy for behavioral assessment and intervention identified the care plan for behaviors would include targeted and individualized interventions for the behavioral and psychosocial symptoms and describe how staff would monitor for effectiveness of the interventions. 3. Resident # 74's diagnosis includes end of life with less than 6 months life expectancy. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 was receiving hospice services. The quarterly MDS assessment dated [DATE] indicated Resident #74 was receiving hospice services and had a life expectancy of six months or less. An interview and record review with RN #3 (MDS) Nurse on 6/18/25 at 1:11 PM indicated s/he was unable to locate a comprehensive care plan regarding hospice. RN #3 indicated the face sheet in the electronic chart would have the hospice provider. Further review of the clinical record identified Resident #74's did not have an active physician's order in place for hospice. However a one-time completed physician's order was found in the discontinued orders. RN #3 indicated s/he and the nurses on the units complete the care plans but could not explain why Resident #74 was missing a comprehensive care plan for hospice and indicated she/he would put in a terminal illness care plan in the clinicasl record. RN# 3 also indicated she/he would confer with hospice and nursing for interventions. The facility policy labeled Care Plans indicated in part the resident care plans will include the resident's needs, realistic goals, and the care and services needed to meet the goals. The policy further indicated the policy would address the physical, cognitive and psychosocial problems on an individualized basis.

Based on review of the clinical record, facility policy and staff interview for the only resident reviewed for Dementia Care (Resident #89), the facility failed to revise the resident's comprehensive individualized interdisciplinary dementia care plan timely. The findings include: Resident #89's diagnosis includes dementia with behavioral disturbance. The Minimum Data Set assessment dated [DATE] identified Resident #89 had a diagnosis of non-Alzheimer's dementia and indicated care planning for cognitive loss/dementia would be addressed in the care plan. A care plan dated 8/15/2024 indicated Resident #89 had cognition/acute delirium/hallucinations. Interventions included 1:1 visit in a quiet environment to provide reality orientation offering opportunity to verbalize needs, feelings, to involve family and supportive care Advanced Practice Registered Nurse (APRN). The annual MDS assessment dated [DATE] indicated Resident #89 was noted with a diagnosis of dementia and cognitive loss/dementia to be addressed in the care plan. Resident #89's cognition/acute delirium/hallucinations care plan dated 6/16/2025 had no revisions made from 8/15/2024 to present. An interview and record review with the MDS Coordinator (RN #3) on 6/25/25 at 9:56 AM indicated the admission MDS identified a diagnosis of dementia. However, RN # 3 was not able to find a dementia care plan other than a cognition/acute delirium/hallucinations care plan written by the social worker with no other disciplines. S/he further indicated s/he would develop a comprehensive interdisciplinary dementia care plan. The facility policy labeled Care Plans notes the resident care plans will include the resident's needs, realistic goals, and the care and services needed to meet the goals. The policy further indicated the facility will address physical, cognitive and psychosocial problems on an individualized basis.

Based on clinical record review, review of facility policy and staff interviews only the resident (Resident #65), reviewed for Activities of Daily Living (ADL), the facility failed to ensure ADL care was provided every two hours per facility practice. The findings include: Resident #65's diagnosis includes spinal cord injury. A care plan dated 4/28/2025 identified Resident #65 was dependent for ADL and required two people for care The quarterly MDS assessment dated [DATE] identified Resident #65 was cognitively intact and was dependent for toileting and personal hygiene. An interview on 6/17/2025 at 12:00 PM with Resident #65 identified she/he had to wait 5 hours to get changed after a bowel movement on 6/13/2025. The resident indicated that the nurse aide from the evening shift informed him/her the nurse aide needed to wait for help from a staff member in the other wing secondary to she was the only one assigned to the wing. The resident indicated that she/he called his/her family member, who then called the supervisor. The resident indicated that she/he was finally changed around 10:00 PM. A review of Resident #65's clinical record, including the nurse aide care card identified Resident #65 required incontinence care every two hours. The nurse aide flow sheets failed to identify any incontinence care was provided on 6/13/2025 and failed to provide evidence of every two-hour incontinence checks. On 6/18/2025 at 9:47 AM, a phone interview with Person #2 indicated Resident #65 called him/her on 6/13/2025 in the evening to complain that she/he had not gotten changed for several hours despite asking staff. Person #2 indicated she/he called the supervisor but could not recall the name. On 6/24/2025 at 12:00 PM, an interview with Nurse Aide (NA#3) indicated she was the only aide in the D-wing and the two nurse aides in the C-wing helped her with some residents. NA#3 indicated that NA#4 and NA#5 provided care to Resident #65 on the evening shift on 6/13/2025. On 6/23/2025 at 11:28 AM, a phone interview with the DNS identified the DNS was not made aware Resident #65 complained of not having received care for five hours in the evening of 6/13/2025. The DNS indicated that the supervisor may have more information. On 6/24/2025 at 12:42 PM, a phone interview with the nursing supervisor Registered Nurse (RN#4) identified that he did not recall a conversation with Resident #65's Person # 2. RN #4 also indicated he did not recall getting a complaint that Resident #65 waited 5 hours to get changed after an episode of bowel incontinence. RN#4 indicated he remembered feeding dinner to Resident #65 on 6/13/2025 but could not recall the time. On 6/25/2025 at 11:11 AM, an interview with Licensed Practical Nurse ( LPN #5) indicated that she went to Resident #65's room to administer medications at 5:30 PM and at that time, the resident informed her she/he had asked NA#3 for incontinence care around 5:00 PM or 5:15 PM. LPN#5 indicated she was unsure if the resident had been incontinent of stool at the time. LPN#5 indicated that she reminded NA#3, who indicated to her that she was waiting for the other nurse aides to be available to assist her with the resident because Resident #65 required assistance of 2 to 3 people. LPN#5 further indicated she helped NA#4 and NA#5 clean Resident #65 between 8:00 PM and 8:30 PM and Resident # 65 had been incontinent of stool. LPN#5 indicated she did not think the resident had spent 5 hours without incontinence care and that it was most likely about 3 hours. LPN#5 further identified that 3 hours was too long to wait for incontinence care, but indicated the resident required maximum assistance with care, and the nurse aides from the C-wing were helping residents on their assignment, and she had to continue administering medications and performing glucose checks . On 6/26/25 at 10:02 AM, a phone interview with NA#4 indicated she, NA#5, and LPN#5 provided care to Resident #65 around 8:30 PM (3 hours after the resident had requested to be changed). NA#4 indicated that she was not aware if Resident #65 had received care prior to that time. On 6/26/2025 at 1:48 PM, a phone interview with NA#11 indicated she took care of Resident #65 on the day shift (7:00 AM to 3:00 PM) on 6/13/2025. NA#11 indicated the last time she provided care to Resident #65 was during her last resident rounds at 2:30 PM (3 hours prior to when the resident requested care, and 6 hours prior to when the resident received care in the evening). On 6/26/2025 at 3:50 PM, a follow-up phone interview with the DNS indicated Resident #65 should have been provided incontinence care every two hours and indicated that any documentation for the care provided would be in the nurse aide flowsheets in the electronic medical record. The DNS also indicated that nurse aides would usually document whenever they get a chance, and not in real time, but indicated that if the facility was short-staffed, they may have overlooked the required documentation. The facility policy for Incontinent Care identified that incontinence care will be provided to any resident who is incontinent of bowel and bladder by the nursing aide. Additionally, the policy indicated that the frequency of incontinence care would be determined by the interdisciplinary team.

Based on review of the clinical record, facility policy and interview for the only sampled resident (Resident #20) reviewed for Communication/ Sensory, the facility failed to administer eye medications according to physician's orders.The findings include: Resident #20 's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tremor, unspecified and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 as cognitively intact, vision was reported as adequate, and noted resident uses corrective lenses. Independent in eating, toilet hygiene and bed mobility. The care plan dated 6/11/25 identified impaired visual function related to cataracts and glaucoma. Interventions included: to review medications for side effects which affect vision. Arrange consultation with eye care practitioner as required. Monitor/document/report when needed (PRN) any signs and symptoms of acute eye problems. A physician's order dated 6/8/25 directed to give 1 drop of Moxifloxacin HCl Ophthalmic Solution 0.5 % in right eye four times a day. On 6/16/25 11:42 AM Resident #20 reported that the facility was out of her/his eye medication and stated she/he missed one dose on/ around June 5, 2025. The Medication Administration Record (MAR) for the month of June 2025 indicated Resident #20 only received 2 of the 4 drops of Moxifloxacin HCl Ophthalmic Solution 0.5 % in right eye four times a day as ordered. Interview with DNS on 6/23/25 at 10:31 AM indicated Resident #20 missed a dose of his/her Moxifloxacin HCl Ophthalmic Solution, due to the medication not available in the cart during medication pass. He reported that the medication was available at the facility, however, he was unsure why it was not available in the medication cart during medication administration time. The DNS further reported it is the responsibility of the nursing team to ensure all medication needed is in the medication cart and ready to be administered.

Based on clinical record review, review of facility staffing posting, resident interviews, review of the Facility Assessment and staff interviews, the facility failed to provide sufficient staff to care for the needs of a dependent resident (Resident #65) in accordance to facility staffing ratios. The findings include: Resident #65's diagnosis includes spinal cord injury. A care plan dated 4/28/2025 identified Resident #65 was dependent for ADL and required two people for care The quarterly MDS assessment dated [DATE] identified Resident #65 was cognitively intact and was dependent for toileting and personal hygiene. An interview on 6/17/2025 at 12:00 PM with Resident #65 identified she/he had to wait 5 hours to get changed after a bowel movement on 6/13/2025. The resident indicated that the nurse aide from the evening shift informed him/her the nurse aide needed to wait for help from a staff member in the other wing secondary to she was the only one assigned to the wing. The resident indicated that she/he called his/her family member, who then called the supervisor. The resident indicated that she/he was finally changed around 10:00 PM. A review of Resident #65's clinical record, including the nurse aide care card identified Resident #65 required incontinence care every two hours. The nurse aide flow sheets failed to identify any incontinence care was provided on 6/13/2025 and failed to provide evidence of every two-hour incontinence checks. On 6/18/2025 at 10:40 AM, an interview and schedule review with the facility nursing Scheduler identified on 6/13/2025, there were a total of two nursing aides on D-wing scheduled for the 3:00 PM to 11:00 PM shift. The Scheduler also indicated the shift had been an extra shift for both nurse aides. The Scheduler indicated that there were two callouts for the evening shift on 6/13/2025. To account for the callouts, the second nurse aide from D-wing was reassigned to B-wing, leaving one nurse aide for D-wing. The Scheduler further indicated she usually tries to have 2 to 2.5 nurse aides on the D-wing which has been proven difficult since there are not enough regularly scheduled staff causing her to rely on existing staff to pick up extra shifts. A review with the Scheduler of facility documentation titled Position Control Analysis Worksheet for the current pay period at the time of the interview (6/15/2025 through 6/28/2025) identified for the 3:00 PM to 11:00 PM shift there were seven open positions including three 40 hour/week positions, one 32 hour/week position. Additionally, the Scheduler indicated that one nurse aide is currently on a medical leave of absence, and there is no one assigned to fill her position temporarily. The Scheduler indicated when new staff are hired, they do not stay long and cannot explain why staff leave. The Scheduler indicated that she provides the preliminary schedule to the DNS and Administrator every Wednesday for their review, either by email or in person, including the number of open shifts left to fill. After the preliminary schedule is given to the Administrator and DNS, the Scheduler indicated she continues to call staff for open shifts according to a set call order list. The Scheduler identified that the facility does not contract with a staffing agency for open positions or shifts not covered, and she was informed by administration LPNs should not be scheduled as nurse aides or be given as a nurse aide assignment when there are gaps in nurse aides coverage. On 6/23/2025 at 11:28 AM, a phone interview with the DNS identified the DNS was not made aware Resident #65 complained of not having received care for five hours in the evening of 6/13/2025. The DNS also indicated the Scheduler give him the schedule by email or in person. The DNS indicated he was not aware of low nurse aide staffing on D-wing on 6/13/2025. The DNS also indicated the facility has had difficulty with callouts and when there are callouts, staff are called to ask if they would like to pick up an extra shift. On 6/24/2025 at 12:00 PM, an interview with NA#3, who was assigned to work on D-wing on 6/13/2025 for the 3:00 PM to 11:00 PM shift, identified she had picked up an extra shift since she had already worked in C-wing for the 7:00 AM to 3:00 PM shift that day. NA#3 indicated when she noticed she would be the only nurse aide assigned to the D-wing; she notified the nursing supervisor (RN #4). NA#3 indicated after speaking to the supervisor, the two nurse aides from C-wing (NA#4 and NA#5) agreed to take care of some of the residents from D-wing. NA#3 indicated that each nurse aide took one total care resident, including Resident #65. On 6/24/2025 at 12:10 PM, a review of the Nurse Aide Assignments binder with NA#3 identified on 6/13/2025, she took the entirety of Assignment #1, which consisted of 12 residents, including seven residents who required total care. Additionally, NA#3 indicated she took nine residents from Assignment #2, which included four residents requiring total care. In total, NA#3 was responsible for 21 residents, including 11 residents who required total care. The N.A. Assignments binder further identified Resident #65 required total care with the assistance of three staff members. On 6/24/2025 at 12:38 PM, an interview with the nursing supervisor (RN#4) indicated the facility was short on nurse aides on 6/13/2025 and he arranged for the nurse aides from C-wing to help the nurse aide on D-wing with the assignments. RN#4 indicated he helped to pass out dinner trays, feed residents, and perform other miscellaneous work to assist the nurse aides. RN#4 did not recall getting a complaint that Resident #65 had been waiting five hours for incontinence care. RN #5 further indicated he and the staff did the best they could with what they had. On 6/25/2025 at 11:11 AM, an interview with LPN#5 indicated she started her shift at 4:00 PM on 6/13/2025, and when she realized there was not enough nurse aides on D-wing, she called the supervisor. LPN # 5 indicated that there had already been an arrangement where the C-wing nurse aides would help NA#3. LPN #5 indicated she went to Resident #65's room to administer medications at 5:30 PM, and at that time the resident informed her she/he had asked NA#3 for incontinence care around 5:00 PM or 5:15 PM. LPN#5 indicated that she was unsure if the resident had been incontinent of stool at that time. LPN#5 indicated she reminded NA#3 that Resident #65 had requested care, and NA#3 indicated to her that she was waiting for the C-wing nurse aides (NA#4 and NA#5) to be available to assist her, since the resident is assisted by 2 to 3 people. LPN #5 identified she and NA#3 had to wait because NA#4 and NA#5 had to take care of other residents, and each had 14 residents in the C-wing to provide care. LPN#5 further indicated she helped NA#4 and NA#5 clean Resident #65 between 8:00 PM and 8:30 PM and the resident had been incontinent of stool. LPN#5 indicated she did not think the resident had spent 5 hours without incontinence care and it was most likely about 3 hours. LPN#5 further identified that 3 hours was too long to wait for incontinence care but indicated the resident required maximum assistance with care, and the nurse aides from the C-wing were assisting residents on their assignment. LPN # 5 indicated she had to continue administering medications and performing glucose checks. Additionally, LPN#5 indicated RN#4 had assisted with pass out dinner trays and feeding residents. On 6/26/2025, additional information was requested from the Administrator which included the posted Daily Nurse Staffing Form for 6/13/2025 for public view. The Daily Nurse Staffing Form indicated the facility would have had 9 nurse aides scheduled for the 3:00 PM to 11:00 PM shift on 6/13/2025. However, the daily staffing schedule sheet indicated that only 6 nurse aides worked the evening shift of 6/13/2025 (3 nurse aides less than the posted amount). A review of the Facility assessment dated [DATE] identified the average daily census was between 92 and 95 residents. Staff-to-resident ratio goals for nurse aides were one aide to 12 residents in the evening. However, the Facility Assessment did not indicate how many nurse aides would be required to achieve ratio goal. The Facility Assessment also indicated individual staff assignments were made based on resident acuity, such as the level of assistance residents needed for toileting. The Facility Assessment further indicated that 34 residents were dependent for toileting and 37 required the assistance of 1 to 2 staff members. Additionally, the Facility-Based Risk Assessment (a part of the Facility Assessment) identified the staff attendance policy as an identified facility weakness and identify strategies to mitigate the risk.

Based on observations, review of facility policy and interviews, the facility failed to ensure staff closed and locked the nursing supervisor's office door with medications stored on counters in unsecured containers and unlocked cabinets when leaving the area. The facility failed to ensure Residents #20, # 21, 38, 71 and #80's eye drops located in one medication cart were dated once opened and failed to remove expired Intravenous Therapy equipment and medication. The facility failed to remove discharge resident medications timely. The findings included: 1.An observation on [DATE] at 09:45 AM identified the nursing supervisor's office door open with no staff inside and or within eyesight. Further observations identified a clear plastic case labeled with emergency medications inside and under the clear box was an orange emergency medication box with a handle without a lock allowing ease of removal from the office. After a few minutes at 9:48 AM with no staff returning to the office the Regional Nurse (RN #1) was contacted. Observation and interview identified the supervisor door should have been closed and locked and RN #1 verified the code pad on the right side of the door was the lock and code to allow entrance. The Infection Preventionist (LPN #1) arrived at the supervisor office when asked to identified the door should have been closed and locked. Further observation of the shelves identified 2 small tackle boxes unlocked with an expired IV tubing from 2023 with a brown tainted color and a small bottle labeled diphenhydramine capsules expired 2023. The ADNS and the Administrator arrived and inside a cabinet were IV bags Vancomycin from a previous resident. The ADNS indicated since s/he started at the facility at the end of February 2025she/he had been disposing of or sending back to the pharmacy many medications. The ADNS indicated she/he was still working on the process. 2. An observation of the A wing medication cart and interview with the A wing charge Nurse (LPN # 8) on [DATE] at 11:30 AM identified the Artificial Tears eye drops for Residents #20, # 21, 38, #71 and #80's without a date opened, LPN #8 indicated she/he did not know how long the eye drops were good for once opened and indicated she/he would find out. The Regional Nurse (RN #1) was informed and indicated once eye drops are opened, they need to be dated. The facility policy, labeled Storage of Medications indicated in part, medications are to be stored safely, securely, properly and accessible only to licensed nursing personnel, pharmacy personnel, or other staff members lawfully authorized to administer medications and medication supplies are to be locked when not attended by people with authorized access. The facility policy, labeled Medication Storage in The Facility, notes once the original seal of a manufacturer's container or vial is initially broken the container would be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration.

Based on observations of glucometer monitoring, review of facility policy and interviews, the facility failed to ensure that used lancets were disposed of in a manner to contain and prevent any potential contamination/spread of bloodborne pathogens. The findings include: An observation and interview on 6/17/2025 at 7:38 AM of the facility procedure for glucometer use while obtaining a fingerstick with a retractable one time use sharps lancet for a blood glucose reading on unit B. Further observation identified once the procedure was completed the lancet was placed into a plastic disposable drink cup with no lid and not secured, then placed on top of the treatment cart which did not have any sharps containers available. RN #2 indicated once all finger sticks were completed the cup was brought to the sharp's container located on the medication cart where the used lancets were then poured into the sharp's container. An observation and interview on 6/17/25 7:43 AM on the A-wing with LPN #3 indicated the plastic disposable drink cup with no lid and not secured located on top of the treatment cart was used to obtain finger sticks for blood glucose readings to collect all the used lancets. LPN # 3 indicated once all the readings were completed the cup is then brought to the sharp's container on the medication cart and poured inside. An observation on 6/17/2025 at 7:45 AM identified the C wing charge nurse with the treatment cart noted with a plastic disposable drink cup with no lid and not secured sitting on top of the treatment cart. LPN #7 the charge nurse indicated when all the fingerstick readings were obtained the cup of used to collect lancets were then placed into the sharp's container located on the medication cart. An interview and policy and procedure review with the Director of Nursing Services (DNS) on 6/18/25 8:32 AM identified staff should not be using a cup to collect the used lancets. After inquiry, the DNS indicated sharps containers would be attached to the treatment carts to correct the issue. The facility policy labeled Disposal of Sharp's indicated used sharps will be disposed of in a manner to contain and prevent any potential contamination/spread of blood borne pathogens and are to be disposed of in Occupational Safety and Health Administration (OSHA) approved receptacle and disposed of in an approved container that is secured and emptied when half full.

Based on observations, facility policy and interviews, the facility failed to ensure that laundry equipment within the facility was maintained timely and in proper working order. The findings include: Interview with Resident #15 on 5/28/25 at 12:19 PM identified staff complain there is not enough washcloths for care, it has taken weeks to get personal laundry back and staff have told him/her the facility has only one (1) working washing machine. Interview with Resident #2 on 5/28/25 at 12:24 PM identified his/her personal laundry was sent to laundry eight (8) days ago, he/she had not received it back, and he/she had to wear dirty clothing because he/she had no clean clothing left to wear. Resident #2 identified he/she reported the laundry delay to the Administrator a few days prior and inquired with the laundry staff who reported the facility had only one working washing machine. Interview with Resident #3 on 5/28/25 at 12:38 PM identified the facility does not have enough washcloths or towels for bathing, he/she has had to use sheets as towels, and staff told him/her they do not have washcloths or towels to provide. Interview with NA #1 on 5/28/25 at 12:41 PM identified the facility always had a shortage of washcloths and towels and if she did not rush in the morning to get what she needed for residents prior to starting care, she would be unable to find linens later in the shift. She identified that, at times, she needed to use more washcloths and towels when providing care to residents, but could not, due to the linen shortage, despite staff reporting the shortage to the Administrator. Observation of the B-wing laundry cart on 5/28/25 at 12:42 PM identified no washcloths and five (5) towels. Interview with NA #2 on 5/28/25 at 12:50 PM identified that it is a struggle every shift to find enough washcloths and towels for resident care. She reported that if they need additional linens for a resident after morning care, there is none left in the carts, and they are difficult to obtain from laundry. Interview with the Administrator on 5/28/25 at 12:46 PM identified there was only one reliable laundry equipment vendor in the area and at times it took months to get parts. She identified the equipment vendor was currently in the facility fixing a washer that was inoperable, after having looked at the washer a month ago. Further, she identified the facility had not sent any personal laundry to an outside facility to be washed while waiting on parts and was unable to explain why. She identified the facility could borrow linens from sister facilities if needed. She identified that the facility did not have audits for linen levels but reported audits would be started twice weekly. Observation of the laundry area on 5/28/25 at 12:52 PM identified a vendor working on the leftmost washer, the middle washer was washing laundry, and the rightmost washer had an out of order sign on it. In the dryer area, dryer #2 had an out of order sign on it. Interview with Laundry Aide #1 on 5/28/25 at 12:53 PM identified the 3:00 PM to 8:00 PM shift stocked the linen carts for the following 7:00 AM to 3:00 PM shift, but due to shortages on washcloths and towels, staff were requesting more linens early into the shift. Laundry Aide #1 identified they frequently do not have more linens to provide and must launder before dispersing. She identified she reported the shortage to the Director of Housekeeping and the Administrator multiple times over the prior 6 months and they said they would order more but the supply never grew. She reported that personal laundry should have a 24-hour turnaround time but turnaround time was around 72-hours due to having only one consistently working washing machine. She identified that residents often asked where their personal laundry was and that she offered to work overtime and extended shifts to keep up with the dirty laundry but administration would not allow it. Subsequent to surveyor interview, an invoice was provided on 5/28/25 identifying 32 dozen bath towels and 32 dozen washcloths were ordered. Observation of the B-unit linen cart on 5/29/25 at 8:11 AM identified no washcloths or towels available. Observation with RN #2 (Regional) on 5/29/25 at 8:17 AM identified no available washcloths or towels in the C-unit linen closet. The D-unit linen closet identified 13 towels and twenty washcloths. She indicated staff reported they already took what they needed for morning care but was unable to identify when and if the empty linen closets would be restocked for care later in the shift or at mealtime. Re-interview with Laundry Aide #1 on 5/29/25 at 9:50 AM identified the middle washer was the only washer working for four (4) to five (5) months. She identified the units linen closets and carts were not restocked during the shifts unless staff specifically requested linens and restocking was contingent on clean linen availability. Interview with the Director of Housekeeping (also the Director of Maintenance) on 5/29/25 at 9:57 AM identified he was employed at the facility for three (3) months, and the leftmost washing machine had not consistently worked since he started. He identified he did not know how long the rightmost washing machine or dryer #2 had been out of order, but reported he was only directed to call about the leftmost washing machine by the Administrator. He identified he did not have the ability to view or approve invoices so was unsure exactly what needed to be repaired. He identified that he was unsure if the facility was short washcloths or towels, but was aware the facility could obtain extra linens from sister facilities. He identified that personal laundry had not been sent to a laundry facility to be laundered and identified that personal laundry should be laundered and returned within one (1) day. Interview with Laundry Aide #2 on 5/29/25 at 10:04 AM identified that prior to 5/28/25, the middle washing machine was the only consistently functioning washing machine for several months, and laundry staff were expected to do all facility linens and personal laundry in one machine. She further indicated it was not possible to return personal laundry to residents within one (1) day with only one washing machine in use. She reported there was a shortage of washcloths and towels, and facility staff were often upset about there not being enough linen to stock. Interview with Laundry Aide #3 on 5/29/25 identified the rightmost washing machine had not functioned for almost two (2) years and dryer #2 had not functioned for close to four (4) years. Additionally, he identified that the middle washing machine, the only consistently functioning washing machine, had a broken pressure line which is used for opening and closing the latch of the machine door. He reported that a pen is pushed into the mechanism to latch and unlatch the door which is hazardous to staff. He identified that the Director of Laundry was aware of the problem but that the washing machine had not been repaired. Observation of the middle washing machine door latch with RN #2 on 5/29/25 at 10:12 AM identified the only way to open and close the middle washing machine door was to forcefully push the back of a pen into the door latch to engage/disengage the latch. She identified she was not aware of the issue and it needed to be repaired. Additionally, she reported that she would discuss the out-of-order machines with corporate staff. Although repair invoices were requested, only one washing machine invoice, dated 4/28/25, was provided. Review of the Maintenance Department Infection Control policy dated 8/2023 directed, in part, that the Maintenance Supervisor is to maintain safe status of the physical plant systems and equipment.

Based on observations, facility documentation and interviews, the facility failed to ensure that building equipment was maintained to provide a clean, comfortable, home-like environment for the residents. The findings include: Interview with Resident #15 on 5/28/25 at 12:19 PM identified staff complain there is not enough washcloths for care, it has taken weeks to get personal laundry back and staff have told him/her the facility has only one (1) working washing machine. Interview with Resident #2 on 5/28/25 at 12:24 PM identified his/her personal laundry was sent to laundry eight (8) days ago, he/she had not received it back, and he/she had to wear dirty clothing because he/she had no clean clothing left to wear. Resident #2 identified he/she reported the laundry delay to the Administrator a few days prior and inquired with the laundry staff who reported the facility had only one working washing machine. Interview with Resident #3 on 5/28/25 at 12:38 PM identified the facility does not have enough washcloths or towels for bathing, he/she has had to use sheets as towels, and staff told him/her they do not have washcloths or towels to provide. Interview with NA #1 on 5/28/25 at 12:41 PM identified the facility always had a shortage of washcloths and towels and if she did not rush in the morning to get what she needed for residents prior to starting care, she would be unable to find linens later in the shift. She identified that, at times, she needed to use more washcloths and towels when providing care to residents, but could not, due to the linen shortage, despite staff reporting the shortage to the Administrator. Observation of the B-wing laundry cart on 5/28/25 at 12:42 PM identified no washcloths and five (5) towels. Interview with NA #2 on 5/28/25 at 12:50 PM identified that it is difficult to find enough washcloths and towels for resident care on every shift. She reported that if staff needed additional linens for a resident after morning care, there was none left on the carts, and they were difficult to obtain from laundry. Interview with the Administrator on 5/28/25 at 12:46 PM identified there was only one reliable laundry equipment vendor in the area and at times it took months to get parts. She identified the equipment vendor was currently in the facility fixing a washer that was inoperable, after having looked at the washer a month ago. Further, she identified the facility had not sent any personal laundry to an outside facility to be washed while waiting on parts and was unable to explain why. She identified the facility could borrow linens from sister facilities if needed. Observation of the laundry area on 5/28/25 at 12:52 PM identified a vendor working on the leftmost washer, the middle washer was washing laundry, and the rightmost washer had an out of order sign on it. In the dryer area, dryer #2 had an out of order sign on it. Interview with Laundry Aide #1 on 5/28/25 at 12:53 PM identified the 3:00 PM to 8:00 PM shift stocked the linen carts for the following 7:00 AM to 3:00 PM shift, but due to shortages on washcloths and towels, staff were requesting more linens early into the shift. Laundry Aide #1 identified they frequently do not have more linens to provide and must launder before dispersing. She identified she reported the shortage to the Director of Housekeeping and the Administrator multiple times over the prior 6 months and they said they would order more but the supply never grew. She reported that personal laundry should have a 24-hour turnaround time but turnaround time was around 72-hours due to having only one consistently working washing machine. She identified that residents often asked where their personal laundry was and that she offered to work overtime and extended shifts to keep up with the dirty laundry but administration would not allow it. Subsequent to surveyor interview, an invoice was provided on 5/28/25 identifying 32 dozen bath towels and 32 dozen washcloths were ordered. Observation of the B-unit linen cart on 5/29/25 at 8:11 AM identified no washcloths or towels available. Observation with RN #2 (Regional) on 5/29/25 at 8:17 AM identified no available washcloths or towels in the C-unit linen closet. The D-unit linen closet identified 13 towels and twenty washcloths. She indicated staff reported they already took what they needed for morning care but was unable to identify when and if the empty linen closets would be restocked for care later in the shift or at mealtime. Re-interview with Laundry Aide #1 on 5/29/25 at 9:50 AM identified the middle washer was the only washer working for four (4) to five (5) months. She identified the units linen closets and carts were not restocked during the shifts unless staff specifically requested linens and restocking was contingent on clean linen availability. Interview with the Director of Housekeeping (also the Director of Maintenance) on 5/29/25 at 9:57 AM identified he was employed at the facility for three (3) months, and the leftmost washing machine had not consistently worked since he started. He identified he did not know how long the rightmost washing machine or dryer #2 had been out of order, but reported he was only directed to call about the leftmost washing machine by the Administrator. He identified he did not have the ability to view or approve invoices so was unsure exactly what needed to be repaired. He identified that he was unsure if the facility was short washcloths or towels, but was aware the facility could obtain extra linens from sister facilities. He identified that personal laundry had not been sent to a laundry facility to be laundered and identified that personal laundry should be laundered and returned within one (1) day. Interview with Laundry Aide #2 on 5/29/25 at 10:04 AM identified that prior to 5/28/25, the middle washing machine was the only consistently functioning washing machine for several months, and laundry staff were expected to do all facility linens and personal laundry in one machine. She further indicated it was not possible to return personal laundry to residents within one (1) day with only one washing machine in use. She reported there was a shortage of washcloths and towels, and facility staff were often upset about there not being enough linen to stock. Interview with Laundry Aide #3 on 5/29/25 identified the rightmost washing machine had not functioned for almost two (2) years, dryer #2 had not functioned for close to four (4) years, and administration said they are too expensive to fix. Observation of the laundry area with RN #2 (Regional) on 5/29/25 at 10:12 AM identified she was not aware of the out of order washing machine and dryer and that she would discuss the out-of-order machines with corporate staff. Review of the Residents Rights policy dated 6/2023 did not speak to ensuring residents the right to a clean, homelike environment. Although requested, a policy on resident laundry and facility environment were not provided.

Based on observations, record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident identified as high risk for wandering received adequate supervision to ensure the resident was not able to leave the facility without staff knowledge, which resulted in the facility unable to locate the resident for 4 hours and 40 minutes. The failures resulted in a finding of Immediate Jeopardy. The findings include: Record review identified Resident #1 had a diagnosis of Alzheimer's disease and delusional disorders, and Resident #1 had a Power of Attorney (POA) for care decisions and finances. Wander risk evaluation dated 1/10/2025 identified Resident #1 scored a 12 which indicated Resident #1 was a high wander risk. Admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition, and ambulated independently. The Resident Care Plan (RCP) dated 1/14/2025 identified an elopement risk/wanderer related to disoriented to place. Interventions directed to distract from wandering by offering diversions, identify patterns of wandering, reorient, and use wander guard bracelet. Nursing note dated 2/10/2025 at 3:52 PM identified Resident #1 was found wandering in the laundry room and was escorted back to his/her room. Social Worker (SW) note dated 2/12/2025 at 1:52 PM identified the Administrator, nursing supervisor and SW held a meeting with Resident #1's family to discuss potential discharge to a facility with a dementia locked unit. The family agreed that moving Resident #1 to another facility would be in his/her best interest. The family was provided with an application to one (1) facility. Nursing note dated 2/12/2025 at 5:43 PM identified Resident #1 was observed with wandering behavior. Nursing note dated 2/13/2025 at 2:21 PM identified the resident was wandering into other rooms. Facility reportable event dated 2/18/2025 at 5:00 AM identified Resident #1 was noted to be missing from his/her room at 4:00 AM. Staff were alerted and the building and grounds were searched. The local police, the Administrator, DNS, responsible party and physician were notified, the police responded, and the search continued. The report further indicated Resident #1 wandered and found him/herself in the dryer/laundry area and was located while police were searching for resident with dust and lint on person. Resident #1 was located at 8:30 AM. Review of local police report dated 2/18/2025 identified the police were dispatched to the facility at 5:59 AM on a missing person complaint. The facility reported they had conducted numerous room checks prior to contacting the police. Staff reported all facility doors had alarms on them and Resident #1 was wearing an ankle bracelet that would alarm if the resident got too close to a secured door. Police and staff searched each unlocked room in the facility, and later an employee arrived with a master key to allow search of every locked door inside the facility. NA #1 reported Resident #1 was wearing a short sleeve red shirt with dark pants and black shoes. Staff informed the police that Resident #1 would walk into the kitchen frequently and ask for coffee. Police observed no access code was needed to get into the kitchen, and the rear entrance/exit to the kitchen was not alarmed and did not have an access code. Police determined there was a possibility that Resident #1 left the facility, and an exterior search was initiated, a Silver Alert was issued and area hospitals were contacted with negative results. At approximately 8:35 AM Resident #1 was observed walking outside near the rear kitchen entrance/exit and brought inside. Resident #1 was observed to have dryer lint on his/her clothes. The Report indicated the police believed Resident #1 walked outside the rear kitchen exit and entered an unlocked maintenance door to the industrial dryers around the corner. The Report indicated the door was checked by multiple officers and was always locked. Maintenance Worker #1 informed police that the door was normally left unlocked. Police observed that the door could be locked from the inside and Resident #1 most likely locked the door accidentally. The maintenance room was only accessible from the exterior of the facility. EMS arrived on scene and evaluated Resident #1, and the family did not want transport to the hospital. Emergency Medical Services (EMS) run sheet dated 2/18/2025 at 8:36 AM identified Resident #1 was missing for four (4) to five (5) hours and was found alert by staff in a dryer room. History of dementia and is confused at baseline, skin was pink, warm and dry, color and circulation were normal. No signs of trauma or injury. Spoke with the POA over the phone who indicated (hospital) transport was not necessary. Weather report review for 2/18/2025 identified the overnight weather was 17 degrees Fahrenheit (F) with wind up to 29 miles per hour, and dry. The temperature at 8:51 AM was 21 degrees F. Interview with Maintenance Worker (MW) #1 on 2/19/2025 at 9:53 AM identified after 8:00 AM he went outside and found Resident #1 outside the building. MW #1 stated he observed Resident #1 walking between the generator located on the other side of the parking lot and the back side of the building near the laundry service room where the laundry dryers vent outside. MW #1 stated it was cold outside, and Resident #1 was wearing pajama bottoms, socks, and a sweatshirt or sweater, was not sure if Resident #1 was wearing shoes or slippers, and indicated Resident #1 was not shivering. MW #1 held the resident's hand to bring him/her back into the building and the resident's hand was warm. MW #1 stated Resident #1 did not answer when he asked the resident what he/she was doing outside, and MW #1 brought Resident #1 inside the facility to the DON office. Observations on 2/19/2025 identified directly across the hall from Resident #1's room was a door with a keypad lock that led directly into the laundry room. To the left of that door was a double swinging door that had no locks or alarms on the doors. The double swinging door led into a hallway, and there was a door on the left side of the hallway that led into the kitchen and a door on the right side that led into the laundry room. At the far end of the hall was a door that led to the back of the building exit. All three (3) doors were observed to have keypad locks on them. Inside both the kitchen and the laundry room were doors that exited directly to the outside with no locks or alarms on the doors; the doors opened freely when pushed outward. Observations when standing outside and facing the back of the building, there were dryer vents on the left side of the building. Located around the left side corner of the building was a separate access door that led into the dryer service room. Observation of the laundry service room on 2/19/2025 at 3:20 PM identified it was a long narrow room, approximately four (4) feet wide, with no light (unable to locate a light switch or light bulb), and had a metal wall behind the dryers with dryer vents and electrical wiring through the wall. The room was clean without any lint observed. Wiring was visible behind each dryer, and on the floor were four (4) silver-colored dryer vent tubing approximately 15- or 18-inches diameter behind each dryer, from left to right in front of the door. A written statement from NA #1 dated 2/18/2025 identified during her shift (11 PM to 7 AM), Resident #1 kept trying to come out of his/her room and she redirected him/her back into the room. NA #1 last observed Resident #1 at 3:15 AM when she went to check on other residents. About 3:50 AM, Resident #1's roommate rang the call bell and when NA #1 answered the call bell she noticed Resident #1 was missing. NA #1 then notified the supervisor and started searching for the resident. Interview with RN #1 on 2/19/2025 at 9:08 AM identified he was the supervisor on 2/18/2025 when Resident #1 was missing. RN #1 stated he had reported to the day shift supervisor and the DNS several times that Resident #1 had exit seeking behaviors, wandered into other resident rooms, had no orders for frequent checks or monitoring and during his shift staff keep an eye on his/her room. When RN #1 was notified Resident #1 was missing, he paged a missing resident announcement (Dr. Hunt). All staff responded and searched the facility and grounds. RN #1 stated when staff did not locate Resident #1, he notified the DNS about 4 AM, and the DNS arrived at the facility about 15-minutes later and took over the search. RN #1 stated after he was home, he was notified that Maintenance Worker #1 found Resident #1 by a door where the dryers get serviced, and Resident #1 could have been inside the (service) room. RN #1 stated the door to enter the dryer service area was outside the building, about 10 feet from the laundry room exit door, and Resident #1 exited the facility and then could have been inside the dryer service room when he/she was missing. Interview and observation with Director of Maintenance, Laundry Worker (LW) #1, LW #2 and LW #3 on 2/19/2025 at 10:44 AM identified MW #1 found Resident #1 outside the building, behind where the dryers vent to the exterior (behind the dryer service room). Interview identified Resident #1 had wandered into the laundry room multiple times and laundry staff would call the Administrator to come get Resident #1. The interview further identified the keypad locks observed on the laundry room and kitchen doors from the hallway were broken prior to when staff were unable to locate Resident #1, and laundry staff would place large buckets (approximate 5-gallon bucket size) of laundry soap against the inside of the door to prevent Resident #1 from accessing the laundry room. Interview identified the locks were replaced after Resident #1 was located and brought back into the building. Interview and observation with [NAME] #1, [NAME] #2 and the Food Service Director (FSD) on 2/19/2025 at 11:15 AM identified the lock on the kitchen door from the hallway had been broken for a few weeks, and they had notified maintenance. The lock was replaced on 2/18/2025 after Resident #1 was returned to the facility. Further, the FSD stated the exit door from the kitchen to the back parking lot had no lock or alarm, and observation identified the door opened freely when pushed. Interview, observation, and record review with the DNS, Administrator, and Regional Nurse on 2/19/2025 at 12:50 PM identified Resident #1 ambulated independently, was identified a high wander risk on 1/10/2025, had been found in other resident rooms and the laundry room in the past, and Resident #1's room was directly across from the laundry and kitchen areas. When Resident #1 was observed in the laundry room on 2/10/2025 the facility capacity was 126 and the census was between 99 and 101. Although the facility had approximately 25 beds available, a room change to an area away from an unalarmed exit was not considered and staff did not have a discussion to move Resident #1. The DNS stated the laundry and kitchen locks were installed on 2/18/2025 after the incident because the locks were not working. Regional Nurse #1 stated the staff believe Resident #1 exited the facility and was in the dryer service room until MW #1 found Resident #1 outside the building, in the parking lot area. Interview identified that the dryer service room was unlocked, the room should have been locked, and the room was not searched when looking for the resident. Interview and record review with the DNS and Administrator on 2/19/2025 at 2:38 PM identified the DNS was notified Resident #1 was missing at 5:09 AM (1 hour and 19 minutes after staff identified Resident #1 was missing). The DNS stated he arrived at the facility about 5:15 AM, and the Administrator arrived about 5:30 or 5:40 AM. The DNS stated when he arrived, he drove to the back parking lot while looking for Resident #1. When behind the building, the DNS stated he brushed the handle of the doorknob to the dryer service room but he did not check to see if the door was locked, and he did not open the door to search for Resident #1 inside the room. The DNS stated the dryer service room should have been searched; the entire facility should have been searched. He then checked all the unit exit doors were locked and walked the perimeter to the front of the building searching for Resident #1. The DNS stated he called the police to notify them Resident #1 was missing about 5:20 AM or whatever (1 hour 30 minutes after Resident #1 was missing). Further, the DNS indicated he was aware the facility policy directed to notify the local police within five (5) to seven (7) minutes after not locating the resident, but stated that time was not feasible, and was unable to indicate a timeframe to notify the police that was feasible. Interview with Police Dispatch #1 on 2/19/2025 at 2:03 PM identified the police received a call at 6 AM (2 hours and 10 minutes after Resident #1 was identified missing) from the facility to notify them of a missing resident. Review of the facility undated Elopement Search Policy directed in part, the designated person in charge to coordinate the search after main business hours is the nursing supervisor. A facility and grounds search are initiated, and 5 to 7 minutes is required for the search. Step 4 directed staff that if the resident is not located during the initial search, to notify the police, Administrator, DNS, resident responsible party, and physician. The Policy further directed the person in charge will determine when to proceed to Step 4 (approximately 7 minutes).

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders and the plan of care to prevent an injury. The finding included: Resident #1 was admitted to the facility with diagnoses that included dementia, Parkinson's disease, atrial fibrillation, and chronic kidney disease. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment and required extensive assistance with one (1) staff member for transfers. A Resident Care Plan (RCP) dated 10/6/2023 identified Resident #1 was at high risk for falls due to gait and balance problems, history of falls and had fragile skin. The RCP directed to use a lifting device to move Resident #1. A physician's order dated 10/7/2023 directed a Hoyer lift for transfers and Resident #1 was non-ambulatory. A facility incident report dated 10/11/2023 at 3:45 PM identified Resident #1 sustained a laceration to his/her right lower extremity during a transfer that required sutures. The report identified the laceration measured seven (7) centimeters (cm) long and required 14 sutures. The summary dated 10/17/2023 identified Resident #1 required a Hoyer (mechanical) lift for transfers, and on 10/11/2023 at approximately 3:45 PM two (2) staff were transferring Resident #1 when he/she complained of pain in the right lower extremity. The summary identified the physician order was for a Hoyer lift and the NAs followed different orders that were entered in the electronic charting under task and performed the transfer with the assist of two (2) staff. Interview with NA #1 on 11/7/2023 at 10:15 AM identified she and NA #2 transferred Resident #1 from the wheelchair to the bed on 10/11/2023 at 3:45 PM with a stand pivot transfer (no Hoyer/mechanical lift was used). NA #1 indicated they placed the wheelchair by the bed, with NA #1 on the right side and NA #1 on the left side. They stood Resident #1 and NA #2 moved the wheelchair out of the way. As she and NA #2 started to pivot Resident #1 to the bed, Resident #1 yelled out my leg, my leg. NA #1 looked down and saw blood on Resident #1's leg, and she called for the nurse. NA #1 identified the NA care card indicated Resident #1 was a stand pivot with the assistance of one NA for transfers and due to Resident #1's right leg stiffness she and NA #2 completed the stand pivot transfer. Further, NA #1 identified she did not use a gait belt to aid in the transfer as she thought Resident #1 could stand and NA #2 was assisting, and due to Resident #1's right leg stiffness Resident #1 had difficulty pivoting. NA #1 indicated she always transferred Resident #1 as a stand pivot transfer with another NA and she did not notify the nurses of the difficulty pivoting. NA#1 identified that after the incident on 10/11/2023, she received education that Resident #1 was supposed to be a Hoyer lift transfer and the NA care card was updated. Interview with NA #2 on 11/7/2023 at 10:35AM identified she assisted NA #1 with a stand pivot transfer on 10/11/2023 for Resident #1. NA #1 indicated she did not regularly provide care for Resident #1 but had assisted with transfers in the past. NA #2 indicated both of Resident #1's legs were stiff, and that Resident #1 could hardly straighten them enough to stand. When NA #1 assisted Resident #1 to stand, she pulled the wheelchair out of the way and put her arm under Resident #1's left arm to assist, grabbed the back of the Resident's pants to steady Resident #1 and assist her/him to pivot and move towards the bed. Resident #1 didn't move her/his legs and it was more of a lift transfer. As Resident #1 sat onto the bed he/she began to yell out and saw that Resident #1's right leg was bleeding. NA#2 identified that after the incident on 10/11/2023, she learned that Resident #1 was supposed to be a Hoyer lift transfer and had since received education. Interview with the Director of Therapy on 11/7/2023 at 11:30 AM identified that upon discharge from therapy services in 2022 Resident #1 required a Hoyer lift for safe transfers, and the order was entered into the electronic medical record (PCC). Interview with the DON on 11/7/2023 at 12:30 PM identified Resident #1's physician order directed use of a Hoyer lift for transfers, and NA #1 and #2 did not follow the physician orders for transfers when they transferred Resident #1 as a stand pivot transfer on 10/11/2023. The DON indicated the NA care card had listed Resident #1's transfer status as one (1) assist. When the order was obtained for a Hoyer lift transfer on 10/7/2023 the order was entered incorrectly; the information was on the NA care card, but it was not listed in the correct location. The DON indicated the information should have been easily accessible for the NAs providing care, and she would have expected the staff to notify the nurse if the resident had difficulty with a transfer. During the on-site visit, a review of facility documentation identified subsequent to the incident, the record was updated to reflect Hoyer lift transfers were required, staff were educated regarding how to enter the transfer orders into the Electronic Medical Record, a facility wide audit of transfer orders was conducted and a QAPI meeting was held, resulting in a finding of past non-compliance. The facility policy, Resident Profiles, dated 7/2023 directed in part that it us the goal of the facility to provide the safest care possible for all residents and that the nursing staff must be aware of all resident's current needs for care to provide safe care.

Based on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were at risk for elopement, a facility receptionist failed to inform either the Charge Nurse, Nursing Supervisor or the Director of Nursing, that Resident #1 exited through the front door and as a result, the resident was not assessed for elopement risk and subsequently eloped again shortly thereafter. This resulted in a finding of Immediate Jeopardy and failed to maintain a list of residents who were at risk for elopement along with current photographs at the receptionist's desk. The finding includes: Resident #1's diagnoses included Alzheimer's disease, dementia, schizophrenia, obsessive-compulsive disorder, and anxiety. The Elopement Risk Scale evaluation dated 12/28/22 identified Resident #1 had no history of wandering, walked with intentional destination, knows how to return to unit, and had no episodes of walking aimlessly. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some short and long-term memory deficits, and was independent with transfers, walking in the room, in the corridor and locomotion on the unit. The Resident Care Plan dated 2/21/23 identified Resident #1 had impaired cognitive function related to diagnosis of dementia with behavioral disturbances. Interventions directed to administer medications as ordered, monitor for side effects and effectiveness, cue and re-orient, supervise as needed, staff to anticipate and meet Resident #1's needs. The psychiatric evaluation and consultation progress note dated 4/5/23 identified Resident #1 was seen per the Director of Nursing's request. Resident #1 appeared anxious, was pacing, yelling out, and had exacerbation of targeted behaviors. Resident #1 was agitated with the evaluation questions and difficult to engage. Resident #1's behaviors were not stable at this time, recommend increasing Xanax from 0.5 milligram (mg) to 1 mg twice daily and increasing Olanzapine 5 mg to 10 mg once daily. The Facility Reported Incidents form dated 4/6/23 at 4:00 PM identified Resident #1 was observed by a staff member on the sidewalk, approximately a half a mile from the facility. Resident #1 stated to the staff member he/she was going to Hartford and Resident #1 was observed agitated and non-redirectable. Facility staff were onsite with attempts to redirect Resident #1 back to the facility, 911 was called and Resident #1 requested to go to the hospital. During the investigation dated 4/6/23 the facility identified Resident #1 had exited the front door at 3:45 PM. In a written statement Receptionist #1 indicated she saw Resident #1 going out the front door, she asked Resident #1 where are you going, and followed Resident #1 to bring Resident #1 back in. The statement identified Resident #1 turned around and Receptionist #1 followed Resident #1 back into the facility. Receptionist #1 wrote she directed Resident #1 back down to the D wing where Resident #1 was heading, Resident #1 appeared upset, the incident happened at approximately 3:45 PM. In the statement Receptionist #1 does not reference she informed staff that Resident #1 had walked out the front doors, however she did comment apparently Resident #1 needs to have a wanderguard. The nurse's note dated 4/7/23 at 5:14 AM identified Resident #1 returned from the hospital at 5:00 AM. The note identified a wander guard was applied to the right ankle and Resident #1 was placed on every fifteen (15) minute checks until Monday 4/10/23 due to being at risk for elopement. Interview with Resident #1 on 4/27/23 at 10:00 AM identified he/she left on 4/6/23 because he/she did not feel that good. Resident #1 indicated he/she had fifteen (15) dollars and was going to the hospital because his/her teeth and gums were hurting, and his/her throat was bothering him/her. Interview with the Nursing Supervisor, Licensed Practical Nurse (LPN) #1 on 4/27/23 at 10:20 AM identified Resident #1 walked about the facility as per usual behavior and the day Resident #1 eloped, he saw Resident #1 close to 4:00 PM ambulating in the hallway on the B unit. Interview with the 4-7PM receptionist, Receptionist #1, on 4/27/23 at 11:42 AM identified she was sitting at the receptionist's desk and observed Resident #1 on 4/6/23 around 3:45 PM going out the main door, she followed Resident #1 and asked where he/she was going. Receptionist #1 indicated Resident #1 exited through the main entrance of the facility, walked through the double doors, went down the ramp but then Resident #1 turned around at the end of the ramp and walked back inside the facility. Receptionist #1 identified she followed behind Resident #1 and redirected Resident #1 back to his/her unit, the D unit. Receptionist #1 indicated she has not witnessed Resident #1 exit seeking before and she thought Resident #1 would not do it again. Receptionist #1 identified she was trying to find someone, however she was rushing to get back to the receptionist's desk because the management did not like her to leave the receptionist's desk unattended. Receptionist #1 indicated she should have reported the incident to the someone, however she did not see anybody to report that Resident #1 had walked out the front door of the facility. Receptionist #1 identified she did report similar situations in the past when a resident had left the facility. Receptionist #1 indicated she did not witness Resident #1 leaving the facility the second time and was surprised when the nursing supervisor told her Resident #1 had left the facility about fifteen (15) minutes after the first time attempt. Interview with the Director of Nursing, (DON) #1 on 4/27/23 at 12:45 PM identified Resident #1 ambulated independently throughout the facility and never exhibited exit seeking behavior before. The DON indicated Resident #1's Elopement Risk and Wandering assessment was last completed on 12/28/22 and Resident #1 was considered a moderate/medium risk for wandering and there were no interventions necessary as Resident #1 was not exit seeking. The DON indicated Receptionist #1 witnessed Resident #1 leaving the facility the first time, however Receptionist #1 did not witness Resident #1 leaving the facility the second time. The DON identified the expectation was for Receptionist #1 to notify the nursing supervisor when she redirected Resident #1 back into the facility the first time. Interview with the Food Service Director on 4/27/23 at 1:18 PM identified she left the faciity on [DATE] around 4:05-4:10 PM, was driving towards the highway and noticed someone resembling Resident #1 walking on the sidewalk of the main road approximately a half a mile from the facility. The Food Service Director identified Resident #1 wanted to go to the hospital and would not go back to the facility. The Food Service Director identified 911 was called and Resident #1 was transferred to the hospital for evaluation. The Elopement Management Nursing Policy and Procedure directed it was the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the Charge Nurse as soon as possible. Any Employee observing resident leaving was to instruct another staff member to inform the Charge Nurse or Supervisor or the Director of Nursing that a resident had left the premises or of the resident's attempt to leave. All attempts by a resident to leave were to be reported to the Charge Nurse and documented. The Wandering Risk Assessment Nursing Policy and Procedure directed a wandering risk assessment will be utilized and completed on all residents to determine their risk level. This assessment will be used to establish an individualized plan of care for elopement risk residents. The RCP team will then decide if the plan of care requires further interventions to address the elopement risk. Subsequent to the 4/6/23 incident the facility implemented an immediate plan of correction that included immediate and on-going education of facility staff on the facility policies Elopement Management to inform the Charge Nurse or the Nursing Supervisor or the DON that a resident has left the premises or of a resident attempting to leave, a wander guard was placed on Resident #1 upon return from the hospital, Resident #1 was placed on every fifteen (15) minutes checks for seventy-two (72) hours, the elopement book was reviewed and Resident #1's information including a picture was added, and Maintenance to audit the wander guard system daily. Review of facility documentation identified the Immediate Jeopardy was corrected on 4/10/23. b. Interview and review of the Receptionist Wander Guard Book with Receptionist #2 on 4/27/23 at 9:05 AM identified the Wander Guard Book was kept in the closet and identified fourteen (14) residents at risk for elopement. Upon further review, the Receptionist Wander Guard Book identified three (3) residents who were at risk for elopement had no pictures included with their information. Receptionist #2 indicated she knew what the residents looked like because she was an aide and a receptionist. Interview with the Director of Nursing, (DON), on 4/27/23 at 9:15 AM identified the three (3) residents who had no pictures included with their information were either newly admitted to the facility or newly wander guarded. The DON indicated the residents had their pictures in the electronic record and she just had to print it. Subsequent to surveyor inquiry, pictures of Residents #2, #3 and #4 were included in the Receptionist Wander Guard Book. The Elopement of Patient Policy and Procedure directed to maintain a list of residents at risk for elopement along with current photographs at receptionist desk.

Based on clinical record reviews, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who was a new admission, the facility failed to ensure the admission physician's orders [REDACTED]. Resident #1's [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified Resident #1 was lethargic, unable to make decisions regarding tasks of daily life and dependent of staff for activities of daily living. The hospital's discharge medication order dated 8/14/19 directed to administer [MEDICATION NAME] ([MEDICATION NAME]) 2.5 milligrams (mg) nightly, [MEDICATION NAME] 1.25mg daily in the morning and [MEDICATION NAME] 1.25mg twice a day as needed for agitation. The facility's hand written admission physician's orders [REDACTED]. The nurse's note dated 8/16/19 indicated Resident#1 was alert and oriented to self and noted with a blood sugar of 467mg/dl at dinner time, insulin coverage was administered and the resident would not eat the dinner meal. The note identified although Resident #1 was asymptomatic subsequent to physician notification of the poor oral intake and [MEDICAL CONDITION] Resident #1 was transferred to an acute care hospital for an evaluation. Review of the August 2019 Medication Administration Record [REDACTED]. The nurse's note dated 8/17/19 at 3:44 AM identified the pharmacy called the facility questioning the [MEDICATION NAME] dosage order because the transcribed [MEDICATION NAME] dosage orders were noted to be different from the hospital's medication list. The facility's Reportable Event Form dated 8/19/19 indicated that on admission to the facility the [MEDICATION NAME] orders were erroneously transcribed as [MEDICATION NAME] 12.5mg in the morning and 25mg in the evening, and [MEDICATION NAME] 12.5mg every twelve (12) hours as needed for agitation. The incident identified that the correct [MEDICATION NAME] dosages were 1.25mg in the morning, 2.5mg in the evening and 1.25mg as needed. The incident report indicated Resident #1 was transferred to an acute care hospital for poor oral intake and [MEDICAL CONDITION]. Review of the acute care hospital discharge summary dated 8/24/19 indicated that one of Resident #1's admitting [DIAGNOSES REDACTED].#1 was admitted to the intensive care unit on 8/17/19 for metabolic [MEDICAL CONDITION] and [MEDICATION NAME] toxicity. In an interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #3, on 1/22/20 at 3:10 PM she indicated on 8/14/19 she was in a hurry trying to complete the admission process for Resident #1 and placed a decimal point in the wrong place when writing the order for [MEDICATION NAME] 25mg daily and [MEDICATION NAME] 12.5mg as needed, instead of the 2.5mg and 1.5mg as per the physician's orders [REDACTED]. Interview with Resident #1's attending physician, Medical Doctor (MD) #1, 1/23/20 at 8:20 AM he indicated the hospital discharge summary and medication list were faxed to him, he signed the orders and faxed the documents back to facility agreeing with the continuum of care from the hospital. MD #1 identified that the faxed orders should be treated like a telephone order and it is his expectation for the licensed nurse to transcribe the orders as written. MD #1 identified the error was the decimal point was noted the wrong place when the orders were transcribed. In an interview with the Director of Nursing (DON) on 1/23/20 at 2:45 PM she indicated that RN #3 made a transcription error when transcribing Resident #1's admission orders [REDACTED].

Based on clinical record review, facility documentation, and interviews for 1 of 6 residents (Resident #1) reviewed for mechanical lift transfers, the facility failed to follow the facility's policies and procedures during a mechanical lift transfer to prevent an accident. The findings include: Resident #1 had a [DIAGNOSES REDACTED]. Review of a Resident Care Plan dated 1/12/16 identified that the resident had a decreased ability to transfer and required the use of a mechanical lift. Review of the Nurse Aide (NA) care card for Resident #1 identified that the resident required a mechanical lift with a medium full body Hoyer sling and assistance of 2 nurse aides. Review of a reportable event (RE) dated 1/27/17 identified that the resident had a fall from the mechanical lift during a transfer by NA#3 and NA#4, the resident was assessed by the physician's assistant and remained in the same position until 911 arrived, and was transported to the emergency department for evaluation. Review of a nurses note written by Licensed Practical Nurse (LPN) #1 dated 1/27/17 identified that the resident had a witnessed fall, and was observed laying on the floor complaining of back pain and vital signs were taken. The resident was assessed by the Physician's Assistant, and sent to the emergency department. Interview with NA#3 on 3/16/17 at 12:00 PM identified on the morning of 1/27/16 he/she had washed and dressed Resident #1, and placed the medium sized Hoyer pad underneath the resident. The sling was connected to the mechanical lift, then NA #3 requested NA#4 come into the room to assist with the transfer. NA#3 was operating the mechanical lift, lifting the resident while NA#4 was guiding the resident towards the resident's wheelchair. While in mid-air the sling nearest to the resident's right leg came undone from the mechanical lift, causing the resident to slide out of the sling onto the floor, NA#4 immediately went to get the nurse. NA#3 further identified that although he/she had connected the sling to the mechanical lift after he/she finished care, he/she had not re-checked the connections prior to the transfer and was unaware of the policy to do so. Interview with NA#4 on 3/15/16 at 11:30 AM identified that he/she had been called into Resident #1's room by NA#3 to assist with the mechanical lift transfer. NA#4 stated that the resident's sling was already connected to the mechanical lift when he/she entered the resident's room. NA#4 further identified that as the resident was being lifted out of bed to the wheelchair, one of the sling loops near the resident's right leg wasn't hooked on correctly and came undone, causing the resident to slide out of the sling onto the floor . NA#4 further stated that he/she did not check the sling connections to the mechanical lift prior to the transfer, but was unaware that the mechanical lift policy identified to do so. Interview with LPN#1 on 3/15/16 at 1:00 PM identified that he/she was Resident's #1's charge nurse on 1/27/17. When he/she entered the room, the Hoyer sling was still suspended in the air, with one strap disconnected from the mechanical lift. The resident was on the floor with her back resting on one side of the Hoyer's legs, with her legs draped over the other side of the Hoyer. The resident was complaining of back pain, so he/she was not moved. Subsequently, the Physician's Assistant was notified, assessed the Resident and directed that the resident be transferred to the hospital. Interview with RN #1 (the facility nurse practice educator) on 3/15/17 at 1:30 PM identified that while interviewing NA#3 and NA#4 on 1/27/17 it became apparent that the loop to the sling was not fully engaged into the mechanical lift and became dislodged, causing the resident to slip out of the sling while still suspended in the air onto the floor. RN#1 further identified that he/she had questioned NA#3 and NA#4 if they had re-checked the connections between the sling and the mechanical lift prior to the transfer, and NA#3 and NA#4 identified it had not been done, and concluded that the NA's failed to ensure the sling lops were securely attached to the mechanical lift. RN#1 identified that NA#3 and NA#4 were given immediate in servicing and competency testing on 1/27/17. Interview with the mechanical lift manufacturer sales representative on 3/16/17 at 12:30 PM identified that if a sling loop is not securely attached to the mechanical lift, it could become dislodged causing the resident to slide out of the sling. Interview with the Director of Nurses on 3/15/17 identified that the staff were immediately in serviced on 1/27/17 regarding mechanical lift transfers policy and procedure, and NA's immediately had competencies on mechanical lift transfers. The DNS further identified NA#3 and NA#4 were given written warnings for not ensuring the sling was securely latched to the mechanical lift prior to a transfer. Review of a discharge summary form from Hospital #2 dated 2/9/17 identified that the resident sustained [REDACTED]. A Commuted Tomography (CT) scan of the chest identified anterior fracture of the right ribs 2-7, and posterior fractures of ribs 8 and 9 with a small pleural effusion and atelectasis and required the insertion of a chest tube. Review of the mechanical lift policy identified to ensure that before and during the transfer that all sling hooks are securely attached to the mechanical lift.

Based on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #2) who was reviewed for falls, the facility failed to ensure the resident was supervised as outlined in the plan of care to prevent a fall with injury and/or for 1 of 3 sampled residents (Resident #3) reviewed for elopement, the facility failed to provide the appropriate supervision to prevent the resident from leaving the building. The findings include: 1. Resident # 2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Nursing assessment dated [DATE] identified Resident #1 was alert, oriented to person only, had behaviors of agitation, verbalizing and/or a history of a desire to leave had falls in the past month prior to admission. The interim care plan dated 12/1/15 identified a risk for falls related to cognitive loss, poor safety awareness and a history of multiple falls at home. Interventions directed to bring the resident out to a supervised area when restless for more social interactions and reorientation opportunities and to keep the call light within reach at all times while in bed and when sitting in the chair by the bed. The nurse's note dated 12/1/15 written at 11:40 PM identified the resident had an unwitnessed fall at the nurse's station. The resident was assessed, noted to have pain in the left hip, was transferred to the hospital and diagnosed with [REDACTED].#2 was sitting in his/her wheelchair at the nursing station and fell out of chair. The documentation identified Resident #1 was frequently attempting to get up on his/her own and was brought to the nursing station for close monitoring. The investigation identified the resident was continuously trying to stand up from the wheelchair, was very unsteady on his/her feet, had heightened anxiety, unsafe behaviors and was brought to the nursing station for staff to closely supervise the resident. Interview with 3-11 PM charge nurse, Registered Nurse (RN) #1, on 4/19/16 at 1:30 PM identified that Resident #2 was very anxious and continually tried to get up from the wheelchair and ambulate. RN #1 stated that the resident's gait was very unsteady and needed frequent reminding to sit back in the wheelchair. RN #1 stated she brought the resident to the nursing station for staff to monitor the resident more closely and when she went to assist another resident she could not recall if she directed the staff to monitor him/her while she was away from the desk. RN #1 identified that she was paged back to the desk and found the resident on the floor complaining of pain to his/her left hip. Interview with NA #1 on 4/20/16 at 3:00 PM identified Resident #2 kept trying to get up from the wheelchair and ambulate but he/she was not steady. NA #1 stated that she could not recall if she was directed not to leave the resident alone and went to answer a call bell and when she returned to the desk the resident was on the floor. Interview with NA #2 on 4/20/16 at 3:25 PM identified Resident #2 was standing up from the wheelchair all shift. NA #2 stated she went to assist another nurse aide with a resident and when she returned the resident was on the floor. Interview with the Director of Nursing (DON) on 4/20/16 at 3:35 PM identified that knowing the resident was trying to stand all night and ambulate, one of the staff should have been supervising the resident at all times to keep the resident in their sight. 2. Resident #3's [DIAGNOSES REDACTED].#3 had moderate impaired cognition, no behavior of wandering at this time and was independent with ambulating. The Resident Care Plan dated 5/28/15 identified the resident was at risk for elopement related to dementia and cognitive loss. Interventions directed to redirect resident when security system sounds and/or when the resident attempts to leave and utilize and to monitor the security bracelet, wander guard, per facility protocol. The nurse's note dated 7/4/15 written at 7:27 PM identified Resident #3 attempted to elope this morning. The Reportable Event Form dated 7/4/15 at 10:15 AM identified Resident #3 was observed in the parking lot to the right side of the building and was taken back inside without incident. The resident wears a wander guard and may have possible gone through the side unnoticed when staff attempted to dispose of garbage. A facsimile sent to the attending physician on 7/4/15 identified the physician was notified Resident #3 was observed outside. The resident had reported he/she went out the side door which has no alarms. The facility reviewed the need to have all doors alarm secured for wander guards. The documentation noted upon review of the video surveillance tape, a dietary aide went through the service door into the service hallway and Resident #3 followed the staff member into the hallway. The video showed the dietary aide return to the main corridor and Resident #3 was noted to exit the building. Interview with Dietary Aide #1 on 4/20/16 at 1:05 PM identified he could not recall if he let the resident through the door or if the resident had followed him, but he did see the resident in the service corridor. Dietary Aide #1 stated that he did not report the resident was back there nor did he ask anyone if the resident should be back there. Interview with the Director of Nursing (DON) on 4/21/16 at 10:00 AM identified they reviewed the video surveillance tape after Resident #3 was found outside and the tape showed the Dietary Aide holding the door open for the resident to go through into the service hallway, the resident was noted to be alone in the hallway and was observed going out the door to the parking lot. The DON stated staff had been in-service on residents at risk for elopement and not allowing residents in the service hallway unless accompanied by a staff member.

Based on clinical record review, observations, and staff interview, for two of three sampled residents (Residents #210 and 237) who were reviewed for pressure ulcers, the facility failed to ensure that care and services were provided to prevent a pressure ulcer from deteriorating and/or developing. The findings include: 1. Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1` 1Admission nursing assessment dated [DATE] identified redness to the coccyx with a 0.5cm open area and a skin risk assessment identified a score of 17, which indicated a mild risk for skin breakdown. The admission MDS dated [DATE] identified the resident had severely impaired cognition (BIMS 00), required extensive assistance of two staff for bed mobility, did not transfer, was at risk of developing pressure ulcers, and had one stage I pressure ulcer that contained granulation tissue. Skin integrity reports dated 6/12/14, 6/14/14 and 6/21/14 identified the resident had a stage I pressure ulcer that measured 0.5cm by 0.2cm with intact/pink and granulation tissue. The skin integrity report failed to reflect who the licensed staff were that completed the assessment on 6/12/14 and 6/14/14. Review of the June 2014 Treatment Administration Record (TAR) directed a skin inspection to be competed every week on Tuesday during the 3-11 shift, however, there was no documentation to show that a skin inspection was completed on Tuesday 6/24/14, per the TAR. A skin integrity report dated 6/30/14, 9 days after the last wound assessment, identified the resident had a facility acquired stage III pressure ulcer on the coccyx that measured 3.0cm by 1.6cm with associated pain. After physician notification, [MEDICATION NAME] dressing to the open area on the coccyx, to be changed every three days was ordered. Interview and review of the clinical record with the DNS on 9/4/14 at 3:00PM identified the area on the coccyx was initially documented as a stage I, however, should have been documented as a stage II because it was open. Additionally, the DNS stated that he/she does not see a specific treatment for [REDACTED]. Further, the DNS stated that a physician's orders [REDACTED]. Review of the skin integrity care delivery process directs that a skin inspection is to be done weekly and documented by the licensed nurse on the TAR. Additionally, the physician is to be notified, and a treatment order obtained. 2. Resident #237 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The skin risk assessment dated [DATE] identified a score of 14 which indicated a moderate risk for skin breakdown. Admission physician's orders [REDACTED]. A dietary note dated 7/28/14 identified the resident was receiving tube feedings as the main source of nutrition due to dysphagia and a recent stroke. Additionally, the resident was noted with severe recent weight loss and a very low pre-[MEDICATION NAME] in hospital prior to admission. The care plan dated 8/11/14 identified the resident was at risk for skin breakdown due to impaired mobility and incontinence. Interventions included to monitor the skin for signs/symptoms of breakdown, a weekly skin assessment by a licensed nurse, observe skin during care, pressure redistribution surfaces, and report abnormalities. The 30 day scheduled MDS assessment dated [DATE] identified the resident had severely impaired cognition (BIMS 4), required extensive assistance of two staff for bed mobility, transfers and toilet use, required extensive assistance of one staff for eating, normally utilized a wheelchair, was totally incontinent of bowel and bladder, and was at risk of developing pressure ulcers. Review of the August 2014 TAR identified that a skin assessment was not completed on Wednesday 8/6/14 during the 3-11 shift. Additionally, although there was a 'mark' on the TAR which indicated that a skin assessment had been done on Wednesday 8/27/14 during the 3 - 11 shift, interview with the DNS on 9/5/14 at 10:20AM identified that he/she could not identify the 'initial' or 'mark' on the TAR or find the licensed staff who completed the skin assessment that shift. The DNS stated that the charge nurse, LPN#2, who was on duty on 8/27/14 during the 3-11 shift stated he/she did not do the skin assessment because the resident refused the shower that night. Additionally he/she stated that the mark on the TAR was not his/her initials. A call was placed to LPN#2 for an interview; however, an interview was not obtained. Review of the computerized record identified that the resident's weight on 9/3/14 was documented as 119lbs, a loss of 5.8lbs since admission. Observation on 9/4/14 at 11:30AM identified the resident in an adapted wheelchair with a chair cushion in place. The resident was noted to slide down at times while in the wheelchair. Interview with Person #2 on 9/4/14 at 2:30PM identified the resident has lost a lot of weight and has very fragile skin. Additionally, Person #2 stated that when he/she visits, the resident is in the wheelchair too long. A skin integrity report dated 9/2/14 identified the resident developed a stage II pressure ulcer on the right buttock that measured 1.5cm by 1cm. Observation of the resident on 9/4/14 at 2:30PM identified the resident had an additional new open area on the left buttock. Subsequently, the staff was made aware and after physician notification an order to cleanse the area with normal saline and apply barrier cream twice daily was obtained. Interview and review of the clinical record with the DNS on 9/5/14 at 1:30PM identified the resident was put into a tilt in space wheelchair for trunk control and lethargy. Additionally, subsequent to the skin breakdown, occupational therapy would now be working with the resident and a 24 hour positioning plan would be developed for positioning in the tilt in space wheelchair. Further, after it's development, staff would be educated. The DNS could not identify the specifics of how the resident was currently repositioned while in the wheelchair and stated that repositioning should be part of the care plan. Review of the care plan at that time failed to reflect that interventions related to how the resident is repositioned while in the wheelchair were addressed. The facility failed to ensure measures were in place to prevent the developement of or the deterioration of a pressure ulcer.

Based on clinical record reviews, facility policy and interviews for 2 of 4 residents reviewed for physician notification of change (Residents #125 and #278), the facility failed to notify the physician in a timely manner when a change in the resident's condition was noted. The findings include: 1. Resident #125's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified cognitive impairment, extensive assistance for transfers from the bed to chair and toileting. The care plan dated 6/13/13 identified a risk for fall related to impaired mobility and poor safety awareness. Interventions included monitoring the resident frequently, remind the resident to use the call bell, assist the resident to a recliner chair in a supervised area if the resident is unable to sleep or is restless. The Reportable Event and investigation dated 10/28/13 at 5:15 AM identified Resident # 125 was found lying on the floor in his/her room. The documentation indicated the physician was called on 10/28/13 at 7:00 AM of the resident's fall. The nurse's note dated 10/28/13 at 6:11 AM identified the resident was found on the floor in her/his room. An assessment identified the resident had right shoulder pain upon palpation and a cold pack was applied to the area as treatment. The neurological flow sheet dated 10/28/13 indicated the resident had right upper extremity pain from 5:15 AM to 12:45 PM. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An Advanced Practice Registered Nurse (APRN) progress note dated 10/28/13 at 9:30 AM identified the resident was evaluated and an X-ray of the right shoulder was ordered The nurse's note dated 10/28/13 at 12:38 PM identified the resident was transferred to the hospital for an evaluation and treatment of [REDACTED]. Interview with RN #2 on 11/7/13 at 11:00 AM indicated the physician's answering service was called on 10/28/13 about the fall, however, RN #2 could not recall the time the call was placed. RN #2 indicated he/she never spoke to the physician because the message was left with the answering service and the Attending Physician did not call back to the facility. Interview with the Director of Nurses on 11/7/13 at 11:00 AM indicated the facility policy directs staff to contact the physician when there is a change in a resident ' s condition. The DNS noted that the nursing staff should have contacted the Attending Physician immediately of the complaint of pain and change in condition. 2. Resident # 278 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The skin integrity report dated 10/29/13 identified a 1 centimeter (cm) x 1cm x 0.05 cm open are on the penis. The surrounding tissue was identified as healthy. The care plan dated 10/30/13 identified actual skin breakdown related to altered skin integrity on the penis with interventions that included to evaluate the wound area daily for presence or absence of drainage/infection or new wound pain and to report to the physician as indicated. The 5 day Minimum (MDS) data set [DATE] identified the resident had moderate cognitive impairment, required extensive assistance for activities of daily living and had an indwelling Foley catheter. The skin integrity report dated 11/6/13 identified the wound was 1 cm x 2 cm x 0.1 cm and light serous drainage with inflamed and indurated surrounding tissue was noted. Review of the physician's orders [REDACTED]. Interview with RN #4 (the wound nurse) on 11/7/13 at 11:00 AM identified he/she was unaware the resident had an open area on the penis. RN #4 further stated that when a new open area is identified the charge nurse is responsible to notify the nursing supervisor. The nursing supervisor is then responsible to notify RN #4 of any skin concerns. RN #4 identified that if notified of the open area, an assessment of the area would be conducted, the physician notified and a treatment obtained and initiated. Interview with MD #1 on 11/7/13 identified he was unaware of the open area on Resident # 278's penis. MD #1 indicated if aware he/she would have directed the facility to obtain a consultation with a wound physician for evaluation and subsequent treatment. Subsequent to surveyor inquiry MD #2 on 11/6/13 evaluated the open area on the resident's penis. Review of MD #2's evaluation on 11/6/13 identified the resident had blanitis of the penis and Normal Saline wash followed by [MEDICATION NAME] and Xeroform gauze was ordered. The resident was also placed on Keflex 500 milligrams every 12 hours for 7 days. Furthermore, the consultation requested a follow up appointment with an Urologist. Review of the facility notification of change policy identified licensed staff will notify the Attending Physician upon identification of a resident change in condition and/or call the Medical Director if the Attending Physician is unavailable.

Based on clinical record review, and interviews for one of two residents reviewed for alteration in skin (Resident #278), the facility failed to implement interventions to promote the healing of an alteration in skin timely. The findings include: Resident # 278 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The skin integrity report dated 10/29/13 identified a 1 centimeter (cm) x 1cm x 0.05 cm open are on the penis. The surrounding tissue was identified as healthy. The care plan dated 10/30/13 identified actual skin breakdown related to altered skin integrity on the penis with interventions that included to evaluate the wound area daily for presence or absence of drainage/infection or new wound pain and to report to the physician as indicated. The care plan failed to reflect interventions to minimize irritation and/or trauma to the penis from the Foley catheter were implemented. The 5 day Minimum (MDS) data set [DATE] identified the resident had moderate cognitive impairment, required extensive assistance for activities of daily living and had an indwelling Foley catheter. The skin integrity report dated 11/6/13 identified the wound was 1 cm x 2 cm x 0.1 cm and light serous drainage with inflamed and indurated surrounding tissue was noted. Review of the physician's orders [REDACTED]. Interview with RN #4 (the wound nurse) on 11/7/13 at 11:00 AM identified he/she was unaware the resident had an open area on the penis. RN #4 further stated that when a new open area is identified the charge nurse is responsible to notify the nursing supervisor. The nursing supervisor is then responsible to notify RN #4 of any skin concerns. RN #4 identified that if notified of the open area, an assessment of the area would be conducted, the physician notified and a treatment obtained and initiated. Interview with MD #1 on 11/7/13 identified he was unaware of the open area on Resident # 278's penis. MD #1 indicated if aware he/she would have directed the facility to obtain a consultation with a wound physician for evaluation and subsequent treatment. Subsequent to surveyor inquiry MD #2 on 11/6/13 evaluated the open area on the resident's penis. Review of MD #2's evaluation on 11/6/13 identified the resident had blanitis of the penis and Normal Saline wash followed by [MEDICATION NAME] and Xeroform gauze was ordered. The resident was also placed on Keflex 500 milligrams every 12 hours for 7 days. Furthermore, the consultation requested a follow up appointment with an Urologist.

Based on review of the clinical records, staff interviews and a review of policies and procedures for three of five residents reviewed for pressure ulcers (Residents #40, 151 and 156), the facility failed to ensure the care plan was implemented and/or that care and services were provided to promote the healing of pressure ulcers. The findings include: 1. Resident #40's [DIAGNOSES REDACTED]. The care plan dated 9/12/13 identified actual skin breakdown related to impaired mobility as evidenced by a stage 3 area to the coccyx with interventions including a low air loss mattress, physical and occupational therapy to improve functional mobility, incontinent care as needed and wound treatment as ordered. The 14 day Minimum Data Set ((MDS) dated [DATE] identified the resident was alert and oriented and needed extensive assist with assist of 2 for bed mobility and transfers, impaired range of motion in the upper and lower extremities, occasionally incontinence of urine and the presence of a stage 4 pressure ulcer to the coccyx. A physician's orders [REDACTED]. Revisions of the skin integrity care plan dated 11/7/13 included changing the pressure ulcer stage from a stage 3 to a stage 4, and to have the resident sit no longer than 2 hours at a time. Observations of Resident #40 on 11/6/13 identified the resident up in the wheelchair from 8:00 am until 1:00 pm, a total of 5 hours. The observation at 8:00 am identified the resident up in the wheelchair waiting for breakfast, at 8:25 am the resident was observed eating breakfast, at 9:00 the resident was sitting in the wheelchair in her/his room. At 10:30 am the resident was observed in physical therapy, which included ambulating a few steps and then returning to the wheelchair. At 11:15 am the resident was brought back to his/her room. At 11:30 am the resident was toileted by the nurse aide and brought back to his/her room, and at 11:45 am the resident was noted receiving speech therapy. At 12:30 the resident was observed in the wheelchair eating lunch. At 1:00 pm the resident was put back to bed. Interview with Physical Therapist (PT) #1 on 11/6/13 at 1:10 pm identified that the resident was offered to go back to bed at 11:15 am, however, the resident wanted to stay up. PT #1 identified he/she did not inform Licensed Practical Nurse (LPN) #2 that the resident did not go back to bed. Interview with Nurse Aide (NA) #2 at 11/6/13 at 1:15 pm he/she was aware the resident should be put back to bed after 2 hours of sitting up in the wheelchair. NA #2 indicated he/she did not ask the resident to go back to bed because the resident was busy with therapy. Interview with LPN #2 on 11/6/13 at 1:30 pm identified that the positioning plan included Resident #40 sitting no longer than 2 hours in the wheelchair. LPN #2 identified she/he was unaware the resident had been sitting in the wheelchair from 8am -1 pm and should have been put back to bed after the 2 hour time frame. LPN #2 stated that if he was aware the resident did not want to go back to bed at that time, he would have talked to the resident to identify the risk involved in staying up and most likely the resident would have agreed to go back to bed. 2. Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden risk assessment dated [DATE] indicated a high risk for pressure ulcer development. The Minimum Data Set ((MDS) dated [DATE] identified short and long term memory loss, severe cognitive impairment; extensive assistance required for bed mobility, no repositioning program and no pressure ulcers. The nursing care plan dated 5/16/13 identified the resident was at risk for skin breakdown with interventions that included to assess the skin for signs and symptoms of skin breakdown, observe skin condition with daily care and report abnormalities, provide incontinent care as needed, weekly skin inspection by a licensed nurse and pressure redistribution surfaces to chair. The skin integrity reported dated 7/23/13 identified a 2 centimeter (cm) by 2 cm excoriation on the coccyx with physician orders [REDACTED]. On 7/30/13 the area was measured as 1 cm by 1 cm and failed to identify an additional measurement until 8/26/13 (26 days later), however physician's orders [REDACTED]. Interview with RN #4 on 11/6/13 at 1:00PM identified weekly skin measurements should have been conducted and were not. Further interview with RN #4 indicated although a measurement was not completed and/or documented on 8/22/13 an open area on the coccyx was present as the treatment that was ordered would only be implemented for open wounds. The skin integrity reported dated 8/26/13 and 9/3/13 identified a 3.9 cm by 4.7 cm by 0.1cm coccyx wound that was not staged. physician's order [REDACTED]. The skin integrity report dated 9/4/13 identified a 1.1 cm by 0.5 cm stage two coccyx wound and an order was obtained for a low air mattress. Interview and review of the clinical record with RN #4 on 11/6/13 at 1:10 PM identified the areas that were identified on 8/26/13 and 9/3/13 must have been measured incorrectly and the nurse did not differentiate between the reddened outside area and the wound itself. physician's order [REDACTED]. The pressure sentinel event tracking review report dated 9/12/13 identified the wound measured 1.4 cm by 0.2 cm by 0.1 cm. Physician orders [REDACTED]. Review of the clinical record identified on 9/19/13 and 9/23/13 the wound increased in size to 2.2 cm by 1.7.cm by 0.5cm and was identified as a stage three wound with 20% necrotic tissue and 30 % slough. Although the pressure ulcer was noted to deteriorate, a change in treatment did not occur until 10/8/13 (15 days later) when physician orders [REDACTED]. Interview and review of the clinical record with APRN #1 on 11/7/13 at 11:00 AM identified although she directed the telephone orders for wound treatment on 7/23/13, 8/22/13, 9/6/13 and 9/12/13 the clinical record failed to indicate a physician or mid-level provider examined Resident #151's wound. Further interview with APRN #1 indicated it is not the procedure of the facility for the APRN to examine skin integrity after providing an order for [REDACTED]. Interview and review of the clinical record with RN #4 on 11/5/13 at 11:30 AM identified the resident's responsible party requested the resident was up in his/her customized wheelchair during the day for approximately seven hours until dinner without returning to bed. RN #4 indicated although education was provided to the responsible party on 9/19/13 by nursing that identified the need to relieve pressure to the coccyx an alternate plan of care for repositioning was not implemented to prevent further deterioration to the wound. RN #4 further identifed that facility policy directed staff to turn and reposition residents who are unable to turn themselves. Review of the nursing care card and flow sheets with RN #4 on 11/5/13 at 11:40 AM failed to identify a turning and repositioning schedule for Resident #151. Review of the clinical record identified on 9/23/13 MD #2 who is a wound specialist was consulted by the facility to examine and treat Resident #151. On 9/23/13, MD #2 recommended to continue the hydrogel once daily, to off load the wound, and reposition the resident. Further interview with MD #2 on 11/6/13 at 11:00 AM identified the resident should have been placed back into bed off of the wound on a repositioning schedule as directed on 9/23/13. Interview with MD #1 on 11/7/13 at 12:00 PM identified although he directed telephone orders for wound treatment and management on 9/3/13 and 9/4/13 he failed to examine Resident #151's wound. MD #1 indicated a physician or midlevel practitioner should have examined the wound, and provided ongoing education to the responsible party to prevent and/or heal the pressure ulcer. The facility policy for skin integrity care delivery process directed in part weekly skin assessments and skin integrity reports, frequent repositioning, weight shifting with specifics schedules that are based on individual need, risks, tissue tolerance and the characteristics of surfaces. Turning and repositioning schedules may be more frequent than every two hours. The policy further directed to implement actions to redistribute pressure from the area, and observe for tissue tolerance to any new interventions. The plan of care should be individualized and updated to reflect monitoring, new risk factors and/or new interventions. Education and the plan of care should be provided to the responsible party. 3. Resident #156's [DIAGNOSES REDACTED]. A physician's order [REDACTED]. Review of the Treatment Administration Record for the period of 11/1/13 through 11/6/13 identified that the resident's heels were offloaded at all times. Observation on 11/2/13 at 11:00 AM identified the resident in his/her adapted wheelchair with leg and footrests in a foot box with feet flush on the footrest. The resident's heels were not afforded the benefit of offloading. Observation on 11/6/13 at 10:30 AM identified the resident in his/her adapted wheelchair with leg and footrests in a foot box with feet flush on the footrest. The resident's heels were not observed to be offloaded. Observation on 11/6/13 at 12:45 PM identified the resident in bed with heels on bed without the benefit of a device to offload his/her heels. Interview with Licensed Practical Nurse (LPN) #3 on 11/6/13 at 1:00 PM identified that the resident's heels should be offloaded when he/she was in bed and in the wheelchair. Subsequent to surveyor inquiry and observation on 11/6/13 at 1:25 PM, the resident was observed in bed with a pillow under his/her legs to facilitate the offloading of the resident's heels.

Based on review of the clinical records, and interviews for one of three residents who required [MEDICATION NAME], (R #3) the facility failed to provide the necessary services to maintain the highest practicable physical well-being in accordance with the plan of care. The findings include: R #3's [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, independence with activities of daily living (ADLs) and mobility activities, continence of bowel and bladder, and use of anticoagulant medications in the last seven days. A physician's orders [REDACTED]. Review of a facility investigation dated 02/02/11 identified that on 01/27/11 at 5:00 PM a transcription error was discovered. R #3 was to receive [MEDICATION NAME] 0.5 mg, but received 7 milligrams in error for the last 3 days. The PT/INR was elevated to 69.1, normal range of (9.5-12 seconds) and 6.9, normal range (2.5-3.5 for therapy in prosthetic valve replacement). MD #2 was notified and directed to administer Vitamin K 10 mgs orally and repeat the INR the following morning. The INR drawn 01/28/11 was greater then 7.5, normal range (2.5-3.5) and R #3 was transferred to Acute Care Hospital #1. Review of the Discharge Summary dated 01/30/11 identified a [DIAGNOSES REDACTED]. Secondary to R #3's comorbidities, R #3 was admitted and treated with administration of Vitamin K and Fresh Frozen Plasma (FFP). Interview with LPN #1 on 03/23/11 at 10:30 AM identified that RN #3 had transcribed a new order for [MEDICATION NAME] and PT/INR on R #4's physician's orders [REDACTED].[REDACTED]. Interview with RN #4 on 03/24/11 at 1:00 PM, who administered the inaccurate dose of [MEDICATION NAME] on 01/25, 01/26, and 01/27, identified that he/she did not compare the order in the MAR indicated [REDACTED].