Every finding on record at Civita Care Northbridge

Based on observation, clinical record reviews, facility documentation, facility policies, and interviews for three of three residents (Resident ##2 and Resident #3) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment and failed to provide adequate supervision for a resident with known history of aggressive behaviors to prevent resident-to-resident altercations, and failed to ensure a resident was maintained in staff view when on one-to-one monitoring. The findings include: Based on observation, clinical record reviews, facility documentation, facility policies, and interviews for three of three residents (Resident ##2 and Resident #3) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment and failed to provide adequate supervision for a resident with known history of aggressive behaviors to prevent resident-to-resident altercations, and failed to ensure a resident was maintained in staff view when on one-to-one monitoring. The findings include: Resident #1's diagnoses included dementia with agitation and anxiety. The Resident Care Plan (RCP) dated 5/13/2026 identified Resident #1 received psychotropic medications related to dementia with agitation and had a history of escalating agitation, irritability, restlessness, yelling, and combative behaviors toward staff and others. Behavioral symptoms increased during May 2026, including attempts to engage in altercations and inappropriate behaviors during care, resulting in changes to CNA assignments. Interventions directed staff to administer psychotropic medications as ordered and monitor effectiveness and adverse effects each shift, use gentle approaches, redirection, de-escalation, individualized activities, quiet space, and staff familiar with the resident's native language when needed. The plan also required monitoring for and addressing potential underlying medical causes of behavioral changes, including obtaining laboratory and urine testing and monitoring bowel function. The Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen (13/15), indicative of cognitively intact, and was independent with transfers and ambulation. Record review identified Resident #2 had diagnoses of Alzheimer's disease, had a BIMS of two (2) indicating severely impaired cognition, and was dependent on staff for transfers and mobility. The facility Reportable Event (RE) Form dated 5/28/26 at 1 PM identified a recreation aide witnessed Resident #1 walk into the dining room and walk past Resident #2 and hit Resident #2 in the face with a closed fist. The RE indicated the incident was unprovoked, and the aide immediately separated the residents. No injury was noted. RE summary dated 6/2/26 identified on 5/28/26 Resident #1 calmly walked past Resident #2 and suddenly struck Resident #2 in the face/head area using a closed hand. Resident #1 was resistant to redirection & was physically aggressive to the recreation aide when as she was ambulating Resident #1 out of the dining room. Resident #1 was placed on one-to-one (1:1) monitoring. a. Record review identified Resident #3 had diagnoses that included dementia with behaviors, anxiety, had a BIMS of four (4), indicating severe cognitive impairment, and was independent with wheelchair mobility. Additional facility RE dated 5/28/2026 identified at 1 PM Resident #1 was witnessed striking Resident #3 on the back of his/her head while he/she was mobilizing in a wheelchair. Resident #3 complaint of head pain (scan 8/10). Resident #1 was transferred to hospital for evaluation. Facility RE summary dated 6/2/26 identified on 5/28/26 at approximately 1:00 PM, a hospice staff exited a resident room and observed Resident #1 ambulating toward her as Resident #3 exited the dining room and was self-propelling in the hallway in his/her wheelchair. Resident #1 was observed to walk past Resident #3 and hit him/her on the back of the head with a closed hand, and staff immediately separated the residents. Facility investigation identified the Nurse's Aide (NA) performing the 1:1 monitoring after the first incident stated she stopped at the nursing station to ask for assistance to calm Resident #1 (from a staff who speaks Resident #1's native language), as Resident #1 was being resistive. Resident #1 struck Resident #3 while the NA was at the nursing station to request assistance, and Resident #3 had no injury. Psychiatry was notified and directed to transfer Resident #1 to the hospital for evaluation, and Resident #1 was admitted to the hospital. Interview with NA #1 on 8/26/26 at 12:45 PM identified that on 5/28/26, she was supervising and assisting residents with lunch in the dining room when Resident #1 unexpectedly approached Resident #2 and struck Resident #2 on the top of the head with a closed fist. NA #1 immediately separated the residents, and escorted Resident #1 toward the nurses' station to report the incident. NA #1 stated there were no nurses present at the nurses' station, so she brought Resident #1 to the adjacent sitting room, and while walking with Resident # he/she attempted to strike NA #1. Once in the sitting room, NA #1 informed NA #2 and NA #3 that Resident #1 had just had an altercation with Resident #2 and then NA #1 returned to the dining room to resume her assigned duties. NA #1 stated that she did not specifically instruct NA #2 or NA #3 to maintain continuous supervision of Resident #1 or assign either staff member to monitor Resident #1. NA #1 stated she assumed NA #2 and NA #3 would supervise Resident #1 because they were aware of the resident-to-resident incident in the dining room and they were aware she needed to return to the dining room. A few minutes later, NA #5 reported that Resident #1 had hit Resident #3. After the second incident, Resident #1 was maintained on 1:1 supervision pending further instructions. Although attempted, interviews with NA #2 and NA #5 were unable to be obtained during the survey. Review of NA #2's written statement dated 5/28/26 identified NA #2 was in the sitting room with NA #3 when NA #1 came into the room with Resident #1 and reported that Resident #1 had hit another resident in the dining room. NA #1 exited the sitting room, and then Resident #1 exited the sitting room. NA #2 followed Resident #2 into the hallway, and she witnessed NA #5 separate Resident #1 from Resident #3. Interview with NA #3 on 8/26/26 at 12:10 PM identified that on 5/28/26, he and NA #2 were in the sitting room when NA #1 entered the room with Resident #1 behind her and NA #2 stated she was able to de-escalate Resident #1. NA #1 then left the sitting room and returned to the dining room. NA #3 stated that he was unaware Resident #1 had just been involved in a resident-to-resident altercation prior to entering the sitting room, and stated NA #1 did not inform him of the preceding incident or request he monitor Resident #1. Then Resident #1 subsequently left the sitting room. Review of NA #5's written statement dated 5/28/26 identified as she exited a resident room she observed Resident #1 walking down the hallway toward her and she observed as Resident #1 walked past Resident #3, he/she hit Resident #3 in the face/head with a closed fist. NA #5 immediately separated and redirected Resident #3 down the hallway away from Resident #1 and directed Resident #1 to the dining room where NA #5 had alerted NA #1 of the event. Resident #1 was then escorted from the dining room to the nurses station with NA #1. Interview with the DON on 8/27/26 at 10:05 AM identified that the facility investigation included review of video footage. The investigation determined that on 5/28/26 at approximately 12:53 PM, NA #1 witnessed Resident #1 hit Resident #2 unprovoked. NA #1 immediately separated the residents and escorted Resident #1 to the sitting room, where NA #2 and NA #3 were present. NA #1 reported the altercation to both staff members before leaving the sitting room to return to the dining room. Resident #1 subsequently left the sitting room, followed by NA #2, who accompanied the resident to the nurses' station and then NA #2 requested NA #4 speak with Resident #1 in his/her native language. While NA #2 was at the nurse's station, Resident #1 was not within view of NA #2 and NA #5 witnessed him/her hit Resident #3 in the face/head with a closed fist. The DON stated that the staff failed to adequately supervise Resident #1 following the initial resident-to-resident incident (with Resident #2 at about 12:53 PM), which allowed Resident #1 to subsequently hit Resident #3 approximately five minutes later. The DON indicated staff should have kept Resident #1 in sight when he/she was on 1:1 monitoring. Review of the Behavior Management and One-to-One Supervision Policy dated 9/1/2022 identified the facility will ensure residents exhibiting behaviors that pose a risk to themselves or others receive timely assessment, intervention, and appropriate supervision. When clinically indicated, residents will be placed on one-to-one supervision until evaluated and cleared by psychiatric services. One-to-one supervision is identified as continuous, direct observation of a resident by assigned staff who remains within visual range at all times. Review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy dated 10/3/25 identified residents have the right to be free from abuse. This includes but is not limited to freedom from physical abuse. Review of the facility's corrective action documentation identified that, following the incident, staff education was initiated on 5/29/26 and included 1:1 supervision, prevention and recognition of changes in resident behavior, appropriate interventions to prevent behavioral escalation, and timely reporting of resident-to-resident altercations and abuse. Audits were initiated on 6/4/26 and QAPI was held on 6/5/26. Based on facility documentation review, a finding of past non-compliance was identified.

Based on observations, interviews, policy review, and clinical record review, for 2 of 3 sampled residents (Resident #16 and Resident #121), the facility failed to provide care and services consistent with professional standards of practice and the residents' care plans, as required at S483.25 (F684): (1) for Resident #16, the facility did not ensure ongoing, routine blood glucose monitoring after readmission, did not timely renew orders for blood sugar checks, and did not maintain/document provider orders for insulin administration, resulting in severe hyperglycemia ( HI >600 mg/dL), lethargy, hypoxemia, transfer to the ED, and hospitalization with metabolic encephalopathy; and (2) for Resident #121, the facility failed to develop and implement an individualized, 24 hour positioning plan, evaluate and monitor a custom tilt in space wheelchair, and educate staff on its use despite documented positioning needs and risk for impaired skin integrity. The findings include: 1.Resident #16's diagnoses included dysphagia (difficulty swallowing), gastrostomy tube (G-tube) and type 2 Diabetes Mellitus (DM) with hyperglycemia (high blood sugar levels). An admission physician order dated 11/26/25 directed to inject 5 units of Neutral Protamine [NAME] (NPH) insulin every 12 hours. A physician order dated 11/27/25 directed to perform blood sugar checks once daily. A physician order dated 11/30/25 directed to send Resident #16 to the Emergency Department. A nurse's note dated 12/9/25 identified that Resident #16 was discharged from the hospital with diagnoses of acute blood loss anemia from a rectal sheath hematoma (abdominal pain caused by bleeding into the rectus abdominis muscle sheath), aspiration pneumonia, elevated liver enzymes, low sodium levels, along with a resolved acute metabolic encephalopathy, and resolved acute kidney injury. The physician order dated 11/27/25 directing blood sugar checks was placed on hold from 12/1/25 to 12/4/25 during Resident #16's hospital stay. A readmission Nursing assessment dated [DATE] identified that Resident #16 had diabetes, was alert and oriented, and required partial/moderate assistance for upper body dressing, required substantial/maximal assistance for lower body dressing and bed mobility, and transfers were not attempted. The Resident Care Plan in effect from 12/10/25 through 12/22/25 identified Resident #16 was an insulin dependent diabetic. Interventions included performing blood sugar levels per the physician's order and administering insulin as ordered and check for signs of symptoms of hyperglycemia (high blood sugar). A readmission physician order dated 12/9/25 and in effect through 12/16/25, directed to inject 15 units of Glargine insulin at bedtime related to type 2 DM with hyperglycemia. The physician's orders failed to ensure reoccurring blood sugar monitoring for Resident #16. A nurse's note dated 12/15/25 at 10:18 PM identified Resident #16's blood sugar check was noted to show a reading of HI, the blood sugar was rechecked and verified to read HI. [A high blood sugar level indicated that Resident #16's blood sugar level was greater than 600 milligrams per deciliter (mg/dL.) (normal 80 to 130 for diabetics)]. The Advanced Practice Registered Nurse (APRN) was notified and directed to give 10 units of Lispro insulin immediately, and to recheck the resident's blood sugar levels in 1 hour related to type 2 DM with hyperglycemia. The nurse's note failed to identify the reason for checking Resident #16's blood sugar). A one-time physician's order dated 12/15/25 directed to re-check the resident's blood sugar in 1 hour, and if the results were higher than 400, call the clinician. A nurse's note dated 12/16/25 at 12:51 AM identified Resident #16's blood sugar re-check showed a reading of 586 mg/dL The nursing note further identified the resident remained asymptomatic and the nursing supervisor was made aware. A second one-time physician's order dated 12/16/25 identified the provider was updated of the resident's blood sugar reading of 586, and the provider directed to give an additional 5 units of Lispro insulin, to re-check the resident's blood sugar level in 2 hours, and to update the clinician if the blood sugar level re-check was greater than 400. A physician's order dated 12/16/25 directed to check Resident #16's blood sugar twice a day at 8:00 AM and 5:00 PM before meals. A nurse's note dated 12/16/25 at 5:27 AM identified the resident was observed in bed, lethargic but alert, and had an oxygen saturation (SpO2) level of 88% (normal SpO2 level 95% to 100%) on room air. The nurse's note further indicated that Resident #16 blood sugar re-check was 472, and the resident was placed on supplemental oxygen due to their low oxygen saturation level, the supervisor was called to assess the resident, and an Advanced Practice Registered Nurse (APRN) order was received to send the resident to the Emergency Department for further evaluation. The nurse's note also indicated that Resident #16 left the facility around 6:40 AM via ambulance A supervising Registered Nurse (RN) note dated 12/16/25 at 5:33 AM indicated that she was called to the resident's room by the floor nurse at 4:50 AM, the resident's blood sugar level was reported to be 449 mg/dL., the resident was observed to be lethargic, barely responding to verbal commands, and had SpO2 of 88% on room air. The note further identified that the APRN was notified at 5:08 AM, who immediately ordered to provide supplemental oxygen. At 5:30 AM Resident #16's SpO2 was identified to have increased to 95% while on 2 liters of oxygen. An order was received to transfer Resident #16 to the Emergency Department by the APRN, and the resident was given a one-time correctional dose of Lispro insulin of 8 units prior to his/her transfer to the Emergency Department, and 911 was called at 5:48 AM for transport. (The medical record failed to include an APRN order for the additional dose of Lispro). A nurse's note dated 12/22/25 identified that Resident #16 was discharged from the hospital on [DATE] with a diagnosis of metabolic encephalopathy (brain dysfunction caused by systemic illness, organ failure, or chemical imbalances rather than structural brain damage.) Interview with the Director of Nursing (DON) on 3/23/26 at 9:40 AM identified she was unable to locate an active order for Resident #16 to have any routine or reoccurring blood sugar levels taken since his/her readmission back to the facility on [DATE]. She stated she only saw one order to check the resident's blood sugar on 12/16/25, when the resident became symptomatic and prior to Resident #16's hospitalization. The DON also identified the resident should have had reoccurring orders to check blood sugar levels since Resident #16 had a past medical history of Type 2 DM with hyperglycemia. Additionally, the DON indicated no active orders in the clinical record directing a lab test for a Hemoglobin A1c check (measure of blood sugar level over 3 months) and the last Hemoglobin A1c ordered had occurred in 2023. Interview with APRN #3 on 3/23/26 at 12:30 PM identified that when the resident was readmitted on [DATE] she directed staff to perform Resident #16's blood sugar levels be checked daily at bedtime. APRN #3 indicated that there were no active orders to routinely check Resident #16's blood sugar levels prior to his/her being discharged to the hospital on [DATE], stating that I guess they were not renewed after the resident had been re-admitted from the hospital on [DATE]. She indicated that she saw a narrative note written by Supervising Registered Nurse (RN) #3 indicating an order for blood sugars, but apparently the order was incorrectly written. APRN #3 identified that there should have been orders for routine reoccurring blood sugar level checks for Resident #16, and if there were no reoccurring orders, there should be a note indicating why blood sugar levels were not being obtained. A review of the facility policy for Physician's Orders directs, in part that verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, and the date and time of the order. It also directs that verbal orders must be signed by the prescriber on his/her next visit. The policy also directs that the orders for medications must include: name and strength of the drug; number of doses, start and stop date, and/or specific duration of therapy; dosage and frequency of administration; route of administration; clinical condition or symptoms for which the medication is prescribed; and any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.) 2. Resident #121's diagnoses included abnormal posture, unspecified arthritis and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #121 had a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment, and was dependent on staff for toileting, transfers and dressing. Additionally, the MDS identified Resident #121 used a manual wheelchair, had upper extremity impairment on one side, and was at risk for developing pressure ulcers/injuries. The Resident Care Plan dated 10/29/25 identified Resident #121 was at risk for skin breakdown/pressure ulcers related to decreased mobility, bowel incontinence, diabetes mellitus, congestive heart failure and chronic obstructive pulmonary disease. Interventions directed to provide an air mattress, perform weekly skin inspections, and offer turning and repositioning every 2 hours and as needed. Review of the Occupational Therapy (OT) Evaluation and Plan of treatment dated 12/31/25 identified the referral was for positioning following a customized wheelchair (CWC) delivery. The assessment summary identified, in part, that Resident #121 presented with decreased trunk control, overall weakness, and was currently in a tilt in space CWC (custom wheelchair). Overall, Resident #121 was unable to reposition him/herself, and due to documented physical impairments and associated functional deficits, was at risk for behavioral outbursts and decreased skin integrity. A physician's order dated 1/18/26 directed Resident #121 to be out of bed and up into the custom tilt-in-space wheelchair in the morning after morning care, then out of the custom tilt-in-space wheelchair and back to bed in evening prior to evening care. Resident #121 may request to be transferred in or out of the custom tilt-in-space wheelchair at any time and may be tilted in the custom tilt-in-space wheelchair to the resident's tolerance for pressure relief. The Resident Care Plan updated on 2/26/26 identified Resident #121 had a non-pressure skin tear to the left gluteal fold. Interventions directed to provide treatment to the gluteal cleft as ordered, a specialty air mattress was to be set at 200 and be checked for function and setting every shift. Resident #121 was to be out of bed and up into the custom tilt-in-space wheelchair in the morning after morning care, and out of custom tilt-in-space wheelchair and placed back to bed in the evening prior to evening care. Resident #121 may request to be transferred into or out of custom tilt-in-space wheelchair at any time, may be tilted in custom tilt-in-space wheelchair to resident tolerance for pressure relief. Observations on 3/16/26 at 11:37 AM and 3/17/26 at 10:00 AM identified Resident #121 in bed, awake watching television in the supine position. Observation, interview and facility documentation review on 3/19/26 at 10:19 AM with Nurse Aide (NA) #6 identified Resident #121 in bed, awake and watching television in the supine position. NA #6 identified he was the regular NA for Resident #121 and usually got her/him up right before lunch (around 11:45 AM) then back to bed before end of shift, around 2:30 PM, to provide incontinent care. Review of Resident #121's Resident Care Card (care guide) with NA #6 failed to identify any directions for an out-of-bed schedule, tilt in space schedule, or positioning plan. Interview and clinical documentation review with the Director of Rehabilitation, Physical Therapist (PT) #1 on 3/19/26 at 12:58 PM identified it was the facility policy to receive Custom Wheelchairs (CWC) from an outside vendor, with assessments, evaluations and physician's order per the original evaluation from Occupational Therapy (OT). Review of Resident #121's clinical record identified the resident received a CWC on 12/31/25 for abnormal posture, with the positioning plan consisting of a physician's order directing for Resident #121 to be out of bed and up into tilt-in-space CWC in the morning after morning care, then back to bed in evening prior to evening care without timeframes specified leaving it up to the NA's to discretion. PT #1 added that the OT Evaluation and Plan of Treatment dated 12/31/25 and the physician's order dated 1/18/26 was the only information she had for Resident #121's CWC seating plan. Interview with the Director of Nursing on 3/19/26 at 2:25 PM identified that it was facility policy for residents in need of CWC to be assessed by therapy with an outside vendor involved. Additionally, the DON identified that any staff education pertaining to the CWCs, a 24-hour positioning plan, and monthly as well as quarterly notes were all dictated by, and the responsibility of, the Therapy Department. The DON was unable to provide documentation reflecting staff had received education for Resident #121's CWC, quarterly or monthly CWC evaluation notes, or a positioning plan adding that she would expect the Resident Care Card to direct a positioning plan for a Resident #121's tilt-in-space CWC. Re-Interview with PT #1 on 3/23/26 at 9:45 AM identified she did not have documentation reflecting staff were educated for Resident #121's CWC use, any quarterly or monthly CWC evaluation notes, or that a customized 24-hour positioning plan had been developed directing the use of CWC. The only documentation consisted of a physician's order that was reviewed on 3/19/26 directing Resident #121 be out of bed after morning care and back to bed after evening care but that resident with CWC's should have a 24-hour positioning plan and that CWC use required evaluation and monitoring. Going forward, she was going to audit all residents with CWC's for appropriate documentation. Interview with the CWC vendor on 3/23/26 at 12:12 PM identified when CWC are delivered to the facility, the vendor does not put a positioning schedule in place but it is strongly recommended to the facility to put a position schedule in place as well as education for NA's, and evaluation of the CWC quarterly and monthly to see if that plan is followed, if resident needs are met, and if the chair is in good working order. Review of Resident #121's position plan with the vendor identified it was too open ended and should have specific times or at least time frames for out of bed, back to bed and tilting. Additionally, the vendor identified a CWC was a prescribed piece of equipment to prevent contractures and skin breakdown that required monitoring and definition of positioning. Review of the Custom Wheelchair Policy dated 9/1/22 directed in part that all residents requiring a custom wheelchair receive appropriate assessment, fitting, maintenance, and monitoring to promote safety, prevent injury, maintain functional mobility, and enhance quality of life. Review of the Positioning and Repositioning Program Policy revised 8/3/25 directed in part to implement and maintain an individualized 24-hour positioning and repositioning program for residents at risk for skin breakdown, impaired mobility or pressure injuries. Additionally, a 24-hour positioning plan was defined as a comprehensive, individualized schedule outlining positioning, repositioning, support surfaces, and assistive devices across a full day that is specific (ex. every 2 hours in bed). Furthermore, monitoring and evaluation will be completed, and staff will receive education on use of devices and support surfaces. Review of the Repositioning Policy revised on 10/3/25 directed in part that repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. Additionally, evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Review of the Therapy Services Policy revised 10/2/25 directed in part that OT would provide adaptive equipment training. Additionally, therapy documentation requirements included weekly progress notes (or per regulation). Review of the Wheelchair Assessment Policy revised 7/6/25 directed in part that nursing responsibilities included daily monitoring, safe use and documentation and OT responsibilities included seating assessments, recommendations and training. Additionally, that staff will be educated on hire and annually on safe wheelchair operation and transfers, proper positioning techniques and identifying equipment issues.

Based on observations, interviews, review of facility documentation, and policy, the facility failed to ensure fans in resident rooms were maintained in a clean manner. The findings include:Observations on 3/16/26 at 11:01 AM ) identified a gray, fuzzy material on the edges of fan blades, bottom of the fan enclosure, and in the grills of fans located in the resident rooms: 411, 412, 415, 416, 417, 418, 419, 420, 422. Fans were used and running in rooms 411, 412, 416, 418 and 419.Observations on 3/17/26 at 9:31 AM identified a gray, fuzzy material on the edges of fan blades, bottom of the fan enclosure, and in the grills of fans located in the resident rooms: 411, 412, 415, 416, 417, 418, 419, 420, 422. Fans were used and running in rooms 411, 412, 415, 417, 418 and 422.3/18/26 at 10:35 AM (3 consecutive days) identified a gray, fuzzy material on the edges of fan blades, bottom of the fan enclosure, and in the grills of fans located in the resident rooms: 411, 412, 415, 416, 417, 418, 419, 420, 422. Fans were used and running in rooms 412, 416, 417, 419, 420, and 422.Interview on 3/18/26 at 10:40 AM with Housekeeper (HK) #1 identified facility policy directed resident rooms to be cleaned daily, and the housekeeper assigned to the room ensured proper cleaning. HK #1 indicated that her schedule had her assigned to different rooms on different days. She indicated a checklist directed that she clean the bathroom, wipe down all surfaces in the bathroom and room, and swept and mopped the floors. HK #1 indicated that she had never been instructed to clean resident fans and that it was the Maintenance Department's responsibility.Interview with the Assistant Maintenance Director on 3/18/26 at 10:59 AM identified that it was the responsibility of the Housekeeping Department to clean fans in resident rooms and that it has been that way since he began employment at the facility 8 years ago.Interview with the Housekeeping Director on 3/18/26 at 11:06 AM identified that it was the responsibility of the Maintenance Department to clean resident fans. She indicated that it had been that way as long as she could remember. Additionally, she indicated had she been asked, her housekeepers would have cleaned the fans.Interview and observation with the Administrator on 3/18/26 at 11:26 AM identified the fans located in resident rooms 411, 412, 415, 416, 417, 418, 419, 420, and 422 had a gray, fuzzy material located on the fan blades, bottom of the fan enclosure, and in the grills. The Administrator indicated that it was the responsibility of the Housekeeping Department to ensure resident fans were clean. The Administrator could not identify why the fans were not cleaned as they should have been.Review of the Daily Resident Room Routine Audit form failed to direct resident fans to be cleaned.Subsequent to surveyor inquiry, the fans located in resident rooms 411, 412, 415, 416, 417, 418, 419, 420, and 422 were cleaned.Review of the facilities Cleaning and Disinfecting Resident Rooms policy dated 4/13/2025 identified the purpose of the procedure was to provide guidelines for cleaning and disinfecting resident rooms. Additionally, the policy failed to identify cleaning of fans in resident rooms.

Based on interviews, review of the clinical record and policy for 1 of 5 sampled residents (Resident #121) reviewed for unnecessary medications, the facility failed to transcribe physician's orders for psychotropic (psychiatric) medications resulting in the medications not being administered for a resident experiencing mood and behavioral issues. The findings include:Resident #121's diagnoses included unspecified dementia with behavioral disturbances, anxiety disorder and adjustment disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #121 had a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment, and was dependent on staff for transfers and dressing, had a Resident Mood Interview score of 6 indicating a high likelihood of depression, and had physical behavioral symptoms directed toward others (defined as hitting, kicking, pushing, scratching, grabbing or abusing others sexually) occurring 1-3 days of the week.Review of the Resident Care Plan dated 10/29/25 identified Resident #121 had episodes of anxiety, a history of anxiety and depressive disorder. Interventions included administering anti-anxiety medications per the physician's orders and monitoring for effectiveness, observing behaviors and providing psychiatry evaluations and follow up as needed for medication management and counseling.Review of a psychiatry prescriber note and physician's order sheet in the paper record dated 12/2/25 identified worsening of inappropriate sexual behaviors and orders directed to adjust medications, discontinue the current dose of Zoloft 125 milligrams (mg), start Zoloft 75 mg once a day for anxiety, start Prozac 10 mg once a day for anxiety, and start Trazodone 25 mg once a day prior to (assistance with) care for dementia with agitation.Review of the nurses note dated 12/7/25 at 6:07 AM identified Resident #121 slapped a nurse aide twice while receiving incontinent care.Review of the nurses note dated 12/10/25 at 3:07 PM identified Resident #121 was disruptive during activities by yelling out and using profanities.Review of the psychiatry prescriber note dated 12/11/25 identified increased agitation in the dining room the day prior, and to continue with current medications.Review of the nurses note dated 12/23/25 at 5:03 AM identified Resident #121 was difficult with care, yelling profanities in Spanish, as well as grabbing and scratching at the staff's arms.Review of the nurses note dated 1/5/26 at 5:25 AM identified Resident #121 was slapping, grabbing, and scratching staff during care.Review of the nurses note dated 2/19/26 at 3:00 PM identified Resident #121 was disruptive during activities by yelling out and using profanities.Interview and record review with Licensed Practical Nurse (LPN) #2 on 3/18/26 at 8:31 AM identified the facility protocol directed providers to write orders on a paper physician's order form in the chart, then nurses were responsible to transcribe the orders into the electronic health record so nursing staff would know to administer the medications. Review of Resident #121's electronic health record failed to identify the orders directing medication changes from the 12/2/25 psychiatric provider note and subsequent physician orders had been transcribed, stating they should have been, but was unable to identify why no changes had been made.Interview and clinical record review with the Director of Nurses (DNS) on 3/18/26 at 11:35 AM identified the previous psychiatry provider wrote orders on a physician's order sheet in the paper chart and nurses were responsible for transcribing the orders into the electronic health record. Review of Resident #121's clinical record with the DNS identified that the physician's orders dated 12/2/25 had not been transcribed changing Resident #121's orders despite continued behavioral issues with care. Additionally, the DNS identified she felt the orders were never transcribed due to the psychiatry Advanced Practice Registered Nurse (APRN) being unable to reach the Power of Attorney (POA).Interview and record review with psychiatry APRN #1 on 3/23/26 at 9:49 AM identified that although she had access to the electronic health record, the facility practice was to write orders on paper on a physician's order form, get orders approved, then transcribe the orders into the electronic health record. Review of Resident #121's clinical record with APRN #1 identified that she wrote the recommendations and physician's order on 12/2/26 after being notified of Resident #121's increased agitation. She had been unable to reach the POA for medication change notification. Since it was a collaborative effort with the facility, the facility nurses would have been responsible to continue to contact the POA and then subsequently transcribe the orders into the electronic health record. APRN #1 indicated she expected nursing to have notified the POA and transcribe the orders by Resident #121's next psychiatry visit at the latest which occurred on 12/11/25. Although APRN #1 could not identify why she did not follow up on the orders that were not transcribed, she stated at this point, 3 months later, she would have to re-evaluate Resident #121 to determine if the previously ordered medication were still appropriate. APRN #1 was unable to indicate if Resident #121 had any ill effects due to the lack of medication recommendation implementation.Reinterview with the DNS on 3/23/26 at 12:07 PM identified that the 12/2/25 psychiatry recommendations most likely were not flagged which would have indicated nurses needed to pursue the new medication orders for transcription. Additionally, the DNS stated there were no nurses' notes indicating that POA notification was attempted or occurred. Subsequent to surveyor inquiry a nurses note dated 3/19/26 at 5:17 PM identified the in-house APRN was notified of the psychiatry recommendations from 12/2/26, with directives for the psychiatry APRN to evaluate Resident #121 to see if recommendations were still appropriate.Review of the Physician's Orders Policy revised 10/3/25 directed in part that medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.Review of the Physician's Orders Transcription Policy dated 4/2015 directed, in part, that all physician's orders must be duly noted and accurately transcribed.

Based on observations, interviews, review of the clinical record, and facility policy for 1 resident (Resident #64) during the initial resident screening process, the facility failed to ensure medications were not left unattended at the resident's bedside, for a resident without a self-administration physician orders and for 1 of 3 medication carts reviewed for medication storage, the facility failed to ensure medications and biologicals were stored according to professional standards and failed to ensure controlled medications were under double locked. The findings include: The findings include: 1.Resident #64's diagnoses included type 2 diabetes mellitus with diabetic neuropathy (nerve pain) and peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64's short-and long-term memory were okay and further identified the resident as being independent to make decisions regarding tasks of daily life. Resident #64's most recent MDS dated [DATE] was not completed regarding his/her BIMS score but did identify that the resident was independent with eating, toileting hygiene, personal/oral hygiene. The Resident Care Plan (RCP) in effect from 12/6/25 through 3/23/25 identified Resident #64 exhibited behavior problems at times including but not limited to yelling out and becoming verbally agitated towards staff, refusing to participate in mental status testing, and Social Determinates of Health assessments. Interventions included educating the resident on the importance of taking medications and obtaining vital signs taken. Observation and interview with Resident #64 in his/her room on 3/17/26 at 11:15 AM identified 4 medications (meds) in a medication cup stored on his/her bedside tray table next to personal belongings and his/her breakfast. Resident #64 indicated he/she was unaware that meds were there and indicated he/she must have been asleep when the nurse passed meds and leaving them at the bedside to take when he/she woke up. Interview with LPN #3 at 11:30 AM indicated he passed meds to Resident #64 around 8:00 AM but was called out of the resident's room by one of the unit's Nurse's Aids (NA) leaving Resident #64's medications on his/her bedside tray table and walked away. LPN #3 indicated he did not physically see the resident take his meds, he should not have left the medications on the resident's tray table, and that he should have taken the meds with him if he was going to leave the room without seeing the resident take their meds. Interview with the DNS at 11:35 AM indicated that should have never happened, that the medications should have never been left with the resident unattended, and that LPN #3 should have taken the meds with him when he exited the room if he did not observe the resident take their medications. Review of the facility administration of medication policy directed, in part, residents not in their rooms, or otherwise unavailable to receive medication on the pass, the medication administration record may be flagged by the nurse, and after completing the medication pass, the nurse will return to the missed resident to administer the medication. 2.Observation on 3/18/26 at 6:14 AM identified the medication cart on Beardsley Park was unlocked in a resident hallway parked between resident room [ROOM NUMBER] and the game room with no nurse in sight of the medication cart. Observation and interview with Licensed Practical Nurse (LPN) #1 on 3/18/2026 6:20 AM identified her approach the cart from the other end of the hallway. LPN #1 identified it was facility policy for the charge nurse to always keep the medication cart locked when not in use. Although LPN #1 could not identify why the medication cart was left unlocked and unattended, she stated it should have been locked. Review of the Controlled Substances Policy revised 11/1/25 directed in part that the facility complies with all laws, regulations, and other requirements relating to handling, storage, disposal and documentation of controlled medications. Review of the Medication Storage Policy reviewed 10/5/25 directed in part that the facility stores all drugs and biologicals in a safe, secure and orderly manner. Additionally, compartments containing drugs and biologicals are locked when not in use and unlocked medication carts are not left unattended.

Based on review of the clinical record, policy, and interviews, for 1 of 3 sampled residents (Resident #38) reviewed for choices, the facility failed to honor a dependent resident's preference for oral hygiene. The findings include:Resident #38's diagnoses included quadriplegia, contractures of multiple sites and injury of unspecified nerves of the neck.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #121 had a Brief Interview of Mental Status score of 15 indicating intact cognition and was totally dependent on staff to provide oral hygiene, personal hygiene, and all activities of daily living. The Resident Care Plan dated 1/9/26 and in effect through 3/19/26 Identified Resident #38 had oral /dental health problems due to poor oral hygiene. Interventions directed to brush teeth 3 times daily after meals per the Resident #38's request.A review of the Resident Care Card (Nurse Aid care guide) dated 12/4/25 and in effect through 3/19/26 directed staff to provide Resident #38 with mouth care 3 times a day.The physician's order in effect for March 2026, directed assistance with Resident #38's activities of daily living at the bedside due to being totally dependent.Interview with Resident #38 on 3/17/26 at 10:00 AM identified although he/she had requested to have his/her teeth brushed 3 times per day, staff were not following his/her request. Interview and review of facility documentation and policy with Nurse Aide (NA) #7 on 3/19/26 at 10:09 AM identified it was the policy to provide oral hygiene daily, and any resident who required/requested more frequent mouth care would have the information documented on the Resident Care Card. NA #7 reported that Resident #38 was dependent on staff for oral care and she was the primary NA caregiver. During a review of the Resident Care Card, NA #7 indicated Resident #38 was supposed to have oral hygiene provided 3 times daily, including twice during the day shift. NA #7 was unable to explain why she had not been providing mouth care as directed stating the resident was often out and about (but returned to the unit for meals). Additionally, a review of the resident's flowsheet (documentation of care) with NA #7 failed to identify that Resident #38 was consistently receiving oral care 3 times daily but should have been per the Resident Care Card.Interview and clinical record review with the Director of Nurses (DNS) on 3/19/26 at 10:26 AM identified facility practice required NA's to perform oral hygiene/mouth care during morning and evening care and more frequently as indicated in each resident's care plan. Review of Resident #38's clinical record identified his/her plan of care directed oral hygiene to occur 3 times daily. The DNS indicated that the information was documented on the NA Resident Care Card located in the resident's room. A review of Resident #38's electronic health record dated 2/28/26 to 3/19/26 identified Resident #38 had been receiving oral hygiene, on the average, once per day but should have been provided oral care 3 times per day as directed in the plan of care.Review of the Mouth Care Policy 10/3/25 directed, in part, to record the date and time mouth care was provided, complaints of pain or discomfort or refusal.Review of the Resident Rights policy revised on 10/3/25 directed in part that residents had the right to self-determination and participation in his/her treatment.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled residents reviewed for food and nutrition (Resident #15) and for the only sampled resident (Resident # 122) reviewed for hydration the facility failed to follow physician's orders for obtaining weights after a significant weight loss and failed to maintain intake and output fluid amounts for residents receiving Intravenous (IV) fluids. The findings include:1. Resident #15 's diagnoses included acute cholecystitis, diabetes, and encephalopathy.The admission Minimum Data Set assessment dated [DATE] identified Resident #15 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment and required substantial/maximum assistance with bed mobility, total staff assistance with transfers, and was independent with eating. Resident #15's weight was noted to be 177 pounds without a weight loss or gain.The Resident Care Plan dated 2/3/26 identified a potential for impaired nutrition status due to diabetes, anemia, and gastroesophageal reflux disease (GERD). Interventions included, assist with meals as needed, monitor and document percent consumed solids/fluids and snacks, monitor labs and monitor weight as needed, obtain and update preferences as needed, provide diet as ordered, provide selective menu as able. Review of the Resident Care Plan failed to identify a significant weight loss or that Resident #15 was receiving Intravenous (IV) fluids.a. A physician's order dated 3/4/26 directed to reweigh Resident #15 on the day shift daily for 3 days.Review of the weights and vital sign report and Medication Administration Record (MAR) identified that the resident was weighed on 3/5/25, and on 3/6/26, however, the facility failed to obtain a weight for Resident #15 on 3/4/26 or 3/7/26 (missed 1 weight).An Advanced Practice Registered Nurse (APRN) note dated 3/5/26 at 1:27 PM identified complaints of vomiting and weight loss. Weight review showed an 11-pound loss since admission and albumin (protein level) remained low. Etiology of vomiting remained unclear.A dietitian note dated 3/12/26 at 11:42AM identified a significant weight loss. Resident #15 reported poor appetite, history of bariatric surgery. Weight loss was discussed and Resident #15 was agreeable to Boost VHC 120 (ml) twice a day and was currently on liquid protein and weekly weights.An APRN note dated 3/19/26 at 8:11 PM identified poor oral intake and ongoing clinical decline characterized by greater than a 30-pound weight loss since admission despite dietitian involvement and supplementation attempts. Resident #15 was now refusing most protein shakes. Continue Monday, Wednesday, Friday weights. Resident #15 appears volume depleted intravascularly despite third spacing, encourage oral intake as tolerated, consider a trial of IV fluids and or albumin support.Review of the physician's orders failed to identify a physician order for Monday, Wednesday, and Friday weights.A dietitian note dated 3/20/26 at 12:37PM identified a significant weight loss, Resident #15 had a history of gastric bypass. Discussed weight loss and reviewed menu options and identified likes and dislikes. An updated menu to fill out would be provided and the resident was encouraged to increase protein intake. Encouraged to fill out menu or call down to kitchen if he/she wanted something different to eat.An APRN note dated 3/20/26 at 7:22 PM identified Resident #15 continued with poor oral intake but was now agreeable to a trial of a liquid protein supplement and continue Boost supplements. Severe protein calorie malnutrition: abnormal and significant weight loss 178 pounds upon admission on [DATE] and now 141 pounds today, a loss of 37 pounds in less than 2 months.The physician's orders dated 3/20/26 and 3/21/26 directed staff to obtain daily weights due to abnormal weight loss.Review of the weights and vital sign report and Medication Administration Record (MAR) identified that the resident was weighed on 3/23/26, however, the facility failed to weigh Resident #15 on 3/21/26 or 3/22/26. (missing 2 weights).b. An APRN note dated 3/19/26 at 8:11 PM identified poor oral intake and ongoing clinical decline. Resident #15 continued with severe protein calorie malnutrition and poor oral intake. Resident #15 appears volume depleted intravascularly despite third spacing, encourage oral intake as tolerated, consider trial of IV fluids.An APRN note dated 3/20/26 at 7:22 PM identified severe malnutrition with acute kidney injury. Gentle IV fluid trial initiated with normal saline 0.9% at 50 ml per hour for a total of 1 liter then stop and reassess Basic Metabolic Panel (BMP) (labs) on 3/22/26 to evaluate renal response. Initiate normal saline 0.9% at 50 milliliters (ml) per hour for a total of 1 liter via midline then stop.A physician's order dated 3/21/26 directed a gentle trial of normal saline 0.9% Intravenous Fluids (IV) at 50 ml per hour for a total of 1 liter via a midline (type of IV access site) catheter.A nurse's note dated 3/21/26 at 6:20 PM identified a physician's order received to increase the normal saline IV rate to 75 ml per hour due to decreased oral intake.A physician's order dated 3/22/26 directed to administer IV normal saline 0.9% at 75 ml per hour 1 time only for dehydration for 1 day.A nurse's note dated 3/22/26 at 3:44 AM IV fluid completed this shift, no signs of complications noted. Right upper arm midline intact, no infiltration, flushed without concerns.A nurse's note dated 3/22/26 at 7:03 PM identified Resident #15 was started on an additional 1 liter of normal saline intravenous fluid at 75 ml per hour because of poor oral intake.A nurse's note dated 3/23/26 at 7:20 AM identified IV normal saline at 75 ml per hour, no signs of infiltration noted, right upper arm midline in place, intact, flushed without concerns.Review of the MAR from 3/1/26 through 3/23/26 identified although IV fluids were given on 3/20/26, 3/21/26, 3/22/26, and 3/23/26 the MAR failed to indicate that Resident #15 required monitoring of fluid intakes due to his/her IV administration.Review of flowsheets in an intake and output binder at the nurse's station for March 2026 failed to identify that Resident #15 had a monitoring form to record fluid intake during the time he/she was receiving IV fluids.Interview and clinical record review with LPN #3 on 3/23/26 at 10:52 AM identified the intake and output binder failed to include flowsheets for Resident #15. LPN #3 was unable to explain why a flow sheet for Resident #15 was not present in the intake and output binder. LPN #3 reviewed the MAR for IV fluid intakes and daily weights and was unable to explain why the clinical record failed to reflect documentation for IV fluid intake or daily weights.An interview and clinical record review with Director of Nursing Services (DNS) on 3/23/26 at 10:54 AM, identified the IV fluid quantity would be documented on an IV sheet, Medication Administration Record (MAR), and was possibly on a worksheet that was never entered into the MAR. Subsequent to surveyor interview with the DNS on 3/23/26, the DNS initiated an intake and output form dating it for 3/22/26.A re-interview with the DNS on 3/23/26 at 11:49 AM identified the clinical record failed to reflect documentation of Resident #15's oral intake or IV fluid amounts received. The DNS indicated that it was the responsibility of the nursing staff to complete intake and output sheets for oral intakes for a resident receiving IV fluids as well as the amount of the IV fluids administered. Additionally, she was unable to locate Resident #15's missing weights directed to be taken by the physician, but the nursing staff should have followed the physician's orders and obtained the weights. The DNS was unable to explain why Resident #15's intake and output was not recorded or why the residents weights were never obtained. 2. Resident #122 's diagnoses included Alzheimer's dementia, pneumonia, and severe protein calorie malnutrition.The admission Minimum Data Set assessment dated [DATE] identified Resident #122 had a Brief Score for Mental Status score of 8 indicating moderate cognitive impairment and required supervision for eating, substantial maximum assistance with bed mobility and total dependence for transfers with a functional limitation in range of motion for bilateral lower extremities.a. The Resident Care Plan dated 3/3/26 identified Resident #122 was at the end of life and decline in overall status/death was anticipated. Interventions included assisting with meals, encouragement to eat and drink, food for comfort, weight per physician order.A physician's order dated 3/2/26 directed to weigh on admission and then for 4 consecutive weeks post admission then reassess.A physician's order dated 3/20/26 directed weekly weights due to poor oral intake on during the day shift on Mondays for severe protein calorie malnutrition. A review of Medication Administration Record (MAR) dated 3/1/26 through 3/23/26 identified weekly weights failed to be obtained on 3/16/26 and 3/23/26 as directed by the physician's orders.b. The Resident Care Plan dated 3/6/26 identified Resident #122 was receiving IV therapy for hydration. Interventions included changing IV insertion site as ordered, IV as ordered, monitor intake and output every shift, receiving IV via peripheral catheter.The physician's orders in effect from 3/3/26 through 3/19/26 directed staff to document urinary catheter output every shift.A physician's order dated 3/6/26 directed to attempt to place a peripheral IV and maintain with 10 milliliters (ml) normal saline flushes per shift for dehydration for 3 days, administer IV fluids normal saline 0.9% at 50 ml per hour via peripheral IV catheter for a total of 1 liter every shift for dehydration and hypovolemia (blood/fluid volume depletion) for 3 days.An APRN note dated 3/6/26 at 2:54 PM identified the Medical Director was consulted and recommended gentle IV hydration given severe dehydration and inability to tolerate oral fluids. Start normal saline at 50 ml per hour for 1 liter if peripheral IV can be successfully placed.A physician's order dated 3/8/26 directed administer sodium chloride intravenous solution 0.45% use 2 liter intravenously every shift for hydration, poor oral intake for 4 days at a rate of 100 ml per hour for 2 liters.A nurse's note dated 3/8/26 at 7:06 PM identified a family member was updated that 2 liters of IV fluid was ordered for poor oral intake and low blood pressure. The family member identified that Resident #122 consumed approximately 900 ml of fluids, and he/she was concerned regarding additional IV fluids because of pedal edema. The physician was notified and the order was placed on hold.A physician's order dated 3/14/26 directed to insert peripheral IV for IV hydration for 1 day, sodium chloride intravenous solution 0.45% use 75 ml per hour for IV hydration for 4 days for 2 litersAn APRN note dated 3/16/26 at 12:31 PM identified dehydration follow up with generalized weakness and dehydration. She/he completed the second liter of normal saline. Urine remained dark orange in the catheter bag. A review of the [DATE]/1/26 through 3/23/26 identified IV fluids were administered on 3/6/26, 3/7/26. 3/8/26, 3/14/26, 3/15/26, 3/16/26 but failed to identify the quantity administered. A review of the intake and output flowsheets in the binder at the nurse's station identified that output amounts on 3/4, 3/5, 3/12, 1/13, 3/15, 3/16, 3/17, 3/18, 3/19, 3/20, and 3/21/26 were blank for the 24-hour period.A review of the documentation survey report dated March 2026, failed to identify any fluid intake.Interview on 3/19/26 at 11:05 AM with LPN #3 identified that the Nurse Aids (NAs) were responsible for documenting the intake and output on the flow sheets and did not know why Resident #122's outputs were not documented.Interview and record review on 3/19/26 at 2:55 PM with the DNS indicated that a hydration evaluation was completed on 3/17/26 and that intake should be documented on both the MAR and the intake and output flowsheet. The DNS further stated she was not aware that the output flowsheets contained no documentation of urine output. Re-Interview with the DNS on 3/23/26 at 11:49 AM identified she was unable to locate Resident #122's missing weights directed to be taken by the physician, but the nursing staff should have followed the physician's orders and obtained the weights. The DNS was unable to explain why Resident #122's IV fluid administration amounts were not recorded or why output records were left blank. Review of the Weight Assessment and Interventions policy dated 9/1/22 directed, in part, weights are monitored for undesirable or unintended weight loss or gain. Weights are recorded in the individual's medical record.Review of the Intake and Output Monitoring policy dated April 2015 directed in part; residents identified for a potential at risk for dehydration will be placed on intake and output monitoring until adequate hydration status is achieved or until Intake and output monitoring is no longer clinically indicated.Review of the Intake Measurement policy dated 9/1/22 directed in part, fluids taken intravenously are recorded by the licensed nurse. Record all fluid intake on the intake and output record in milliliters.Review of the Intravenous therapy policy dated 9/1/22 directed, in part, track intake and output as indicated. Document in the medical record fluids administered, rate and volume. Nursing will monitor and document fluid intake.Review of the Catheter Care policy dated 6/26/25 directed, in part, to follow the facility procedure for monitoring and documenting intake and output.

Based on clinical record review, facility documentation and policy and interviews for the only sampled resident (Resident #61) reviewed for hemolytic treatments, the facility failed to consistently maintain a fluid restriction according to the physician's orders. The findings include:Resident #61's diagnoses included End Stage Renal Disease (ESRD), cirrhosis of the liver, low sodium, and dependence on hemolytic treatments. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #61 was cognitively intact and required substantial/maximum assistance for toileting, bathing, dressing and personal hygiene and set-up assistance for eating and oral care.The Resident Care Plan in effect from 1/11/26 through 3/24/26 identified Resident #61 had a potential for impaired nutritional status due to ESRD on hemolytic treatment. Interventions included to document the percentage of food and fluids consumed, renal diet with thin liquids, and a fluid restriction of 1000 milliliters (ml) daily with the following shift parameters: 120 ml on 11:00 PM to 7:00 AM, 240 ml on 7:00 AM to 3:00 PM and 240ml on 3:00 PM to 11:00 PM with 400 ml from dietary.A physician's order on readmission dated 2/26/26 directed to keep Resident #61 on a strict 1000 ml fluid restriction with parameters: 120 ml on 11:00 PM to 7:00 AM, 240 ml on 7:00 AM to 3:00 PM and 240 ml on 3:00 PM to 11:00 PM with 400 ml from dietary.Interview and facility record review with Licensed Practical Nurse (LPN #6) on 3/24/26 at 9:39 AM identified that the Nurse Aid (NA) was responsible for reporting to nursing and nursing was responsible for recording any fluid intake into an Intake and output binder at the end of their shift. LPN #6 showed the binder and Resident #61's records indicated that 54 out of 198 opportunities had been missed to record fluid intake since 1/11/26. The binder contained flowsheets to record oral intake and add up the total amount at the end of each day.Interview, review of the clinical record and facility documentation with the Nursing Supervisor Registered Nurse (RN) #3 on 3/24/26 at 11:12 AM identified that both nursing and dietary were responsible for monitoring fluid intakes for Resident #61's fluid restriction orders. RN #3 stated that at the end of each shift licensed nursing staff was responsible for obtaining the intake information from the NAs, adding in the medication pass fluid amounts, and documenting the information under the resident's flowsheet located in the intake and output binder. Interview with the Dietician on 3/24/26 at 11:28 AM indicated that dietary plays a part in helping monitor Resident #61 on fluid restriction. The Dietician stated that on each meal ticket there is a specific amount of fluid to go up on the meal tray and that nursing was responsible for administering and monitoring any other consumed fluids.Interview with the Director of Nursing Services (DNS) on 3/24/26 at 11:58 AM indicated nursing was responsible for monitoring fluid intakes, restriction, and documentation. The DNS was unable to explain why Resident #61's fluid intake was not being consistently monitored.Review of the Fluid Restriction policy dated 8/4/25 directed, in part, if a resident is prescribed a limit on total daily fluid intake, the facility would have a current provider order, care plan the restriction and would accurately measure and document all fluid intake each shift.Review of the Hemodialysis policy dated 4/2015 stated that if a resident is placed on fluid restriction, monitor intake. Allocate fluids to be given by nursing and dietary with amounts documented per shift.

Based on observation, interview, and review of facility policy during a tour of the kitchen, the facility failed to maintain the garbage and refuse storage area in a clean manner. The findings include:During a tour of the garbage and refuse storage area with the Food Service Director (FSD) 3/18/26 at 10:45 AM the following was observed:At the corner of the ramp down to the garbage dumpster area was a pair of used clear gloves inside out and two blue surgical masks on the stone to the left of the rampIn the dumpster area a pair of used clear gloves, a blue surgical mask, and multiple cigarette butts were observed.There were 3 dumpsters in a row, trash dumpster 1, trash dumpster 2, and recycling dumpster 3. The following was observed:The lid and side panel to dumpster #3 was open. A trash bag was visibly coming out of the side of the closed lid on dumpsterMultiple wrappers and pieces of paper were noted scattered around the 2 trash dumpsters to the front, side, and behind. Two wet pieces of cardboard were wedged under dumpster #1. Cigarette butts were scattered around the entire garbage disposal area. Ten cardboard boxes were strewn around dumpster #3 from the curb and throughout the entire disposal field. A black copy machine with the cord placed on top was slightly to the front of dumpster #3. The debris field of trash and cardboard extended 15 feet from the lid opening of the dumpsters. Interview on 3/18/26 at 11:00 AM with FSD identified that this was not normal practice for the facility and the garbage disposal area could use cleaning. The FSD indicated that it was the responsibility of maintenance and housekeeping to keep the area clean.Interview with the Administrator on 3/18/26 at 11:07 AM identified that maintenance and housekeeping were responsible for the cleanliness of the garbage and refuse area. The Administrator stated it was her expectation that any staff disposing of refuse from any department was responsible to maintain a clean area and if anything was dropped it should be picked up and disposed of at that time. Interview and observation with the Assistant Maintenance Director on 3/18/26 at 11:18 AM identified that the condition of the garbage and refuse were, not acceptable, there is a lot of cardboard everywhere.Although requested, the facility policy for garbage and refuse removal was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #11) reviewed for a facility acquired Pressure Ulcer (PU), the facility failed to maintain appropriate infection control practices for a dressing change according to the facility policy. The findings include:Resident # 11's diagnoses included a stage 3 Pressure Ulcer (PU) of the coccyx region (lower back, top of buttocks), fracture of the right lower leg, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 was moderately cognitively impaired, required supervision for eating and a substantial amount of assistance for bathing, toileting, and personal care.The Resident Care Plan dated 2/14/26 identified Resident #11 had a PU on the coccyx, required a mechanical lift for transfer, assist of 1 for care, was a fall risk, was staying as a long-term care resident, and was able to consent for themself.An Advance Practice Registered Nurse (APRN) order dated 2/27/26 directed staff to wound treatment cleanse wound with betadine, apply a sterile, antibacterial foam dressing and to cover with a dry clean dressing. Change daily and as needed.Observation and interview of Resident #11's pressure ulcer dressing change with Licensed Practical Nurse (LPN #6) on 3/19/26 at 12:34 PM identified with her gloved hands she removed the old, contaminated dressing. LPN #6 then, without the benefit of removing her gloves, sanitizing or washing her hands, placed a new clean dressing over the residents PU. LPN #6 indicated that prior to placing the new clean dressing, she should have removed her dirty gloves, washed or sanitized her hands and applied on a new pair of clean gloves. LPN #6 stated that she had not followed the facility wound policy for glove use and hand sanitizing when changing Resident #11's pressure ulcer dressing.Interview on 3/19/26 at 12:44 PM with the Infection Prevention Nurse (LPN # 9) identified when providing wound care, extra gloves if needed should be at bedside, the old dressing removed, gloves removed, then hand hygiene performed prior to the application of the new dressing. The nurse providing the dressing change was responsible to ensure the proper dressing change procedure was followed. Interview with Director of Nursing Services (DNS) at 12:52 PM on 3/19/26 identified that the nurse should have changed gloves and wash hands between the dirty dressing removal and application of a clean dressing.Review of the Wound Care policy dated 7/22/2025 directed, in part, to wash and dry hands, place exam gloves, loosen tape and remove dressing, pull glove over dressing and discard into an appropriate receptacle, wash and dry hands thoroughly and place on clean gloves.

Based on review of facility annual training for nursing staff, facility documentation and interviews, the facility failed to ensure the required 12 hours Nurse Aid training was completed. The findings include:Review of the facility's mandatory yearly in-service for 1 out of 5 nurse's aides, the facility failed to ensure that the required 12 hours of in-service training including abuse prevention, dementia care, effective communication, infection control, resident's rights, and behavioral health were provided to staff in 2025.Interview with the Staff Development Nurse (RN #2) on 3/24/26 at 12:12 PM, identified she was unable to locate the required educational in-service documentation and required competencies for NA #3 in the areas of Abuse/Neglect, Resident Rights, Dementia Care, Infection Control, Effective Communication, and Behavioral Health. RN #2 indicated she referred to the requested educational documentation as yearly competencies, and indicated she stored all the nursing staff's competencies into monthly binders located in the Staff Development office. RN #2 indicated she wasn't sure why the documents were missing, and that she and several other staff members were attempting to locate them. Interview and review of facility documentation with the facility Administrator on 3/24/26 at 2:00 PM identified an inconsistent signature for NA #3's yearly in-service annual abuse education and prevention for the 2025 training. The Administrator indicated that she had been provided with the requested documentation by staff, she had not reviewed the document, and that the signature and date did not match other documentation signed by NA #3. She apologized for unknowingly providing the altered documentation of NA #3's training.Review of the Facility Assessment in effect from 8/18/17 identified that staff competencies are provided upon hire, annually, and as needed when areas of concern arise, or identified. The topics included, but are not limited to: dementia care, abuse prevention, infection control/hand hygiene, resident rights, compliance and ethics, behavioral health, abuse, neglect and exploitation.

Based on observations, review of the clinical record, facility policy and interviews for 2 of 2 sampled residents (Resident #3 and Resident #101) reviewed for Resident Assessment, the facility failed to code a pressure ulcer for Resident #3 on the quarterly Minimum Data Set assessment and failed to submit a death record for Resident #101 to the Internet Quality Improvement Evaluation System (IQIES). The findings include:1. Resident #3 's diagnoses included diabetes, moderate protein calorie malnutrition and anemia.The admission quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment and was independent with eating, hygiene, bed mobility and transfer, was at risk for pressure ulcers and currently did not have a pressure ulcer.The Skin assessment dated [DATE] identified a stage 2 pressure ulcer (top and bottom skin layers affected) blister on right lower leg with an onset of 1/18/26. A wound progress note dated 1/23/26 identified a blister on the right lower leg measuring 1 centimeter (cm) in length by 0.5 cm wide by 0.1 cm deep. 2. Resident #101's diagnosis included adult failure to thrive, dementia, and palliative care.The discharge Minimum Data Set (MDS) tracking form dated 12/13/25 identified although a death in facility MDS had been completed, the form was never submitted through the IQIES system.Interview and clinical record review with RN #1 on 3/19/26 at 2:20 PM identified Resident #3's stage 2 pressure ulcer had not been correctly coded on the quarterly MDS assessment dated [DATE]. Subsequent to surveyor inquiry, RN #1 discussed the coding with LPN #8, indicated the incorrect coding was an oversight, and that a modification to the 1/23/26 MDS would be submitted. RN #1 further indicated that she had been on vacation when Resident #101 passed and a corporate staff was completing the MDS assessments for her. RN #1 indicated that although the covering MDS staff had completed the death record, it was never submitted to CMS through IQIES and subsequent to surveyor inquiry, she would submit the entry. Review of Resident #3's quarterly MDS dated [DATE] identified a modification MDS form had been completed on 3/19/26 to include the stage 2 pressure ulcer.A review of the validation report from IQIES identified Resident #101's MDS tracking form: death in the facility was completed and submitted late.Review of the Resident Assessment Instrument (RAI) manual dated October 2025, page M-2 directed, in part, to enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is a Stage 2.Review of RAI manual page dated October 2025, page 2-38 directed in part, death in facility tracking record must be completed within 7 days after the resident's death and must be submitted within 14 days after the resident's death.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #3) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment and failed to ensure adequate supervision of a resident (Resident #1) on one-to-one observation, resulting in the resident hitting Resident #3. The findings include:A. Resident #1 was admitted to the facility during 9/2025 with diagnoses that included dementia, sensorineural hearing loss, esophageal perforation, anxiety, and depression.Record review identified Person #1 was a court appointed Conservator of Person.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being alert and oriented, had no behaviors noted, and ambulated independently. Physician order dated 9/29/2025 directed regular diet with thin liquids.The Resident Care Plan dated 10/7/2025 identified Resident #1 had episodes of anxiety with combative behaviors with care, and a history of resident-to-resident physical abuse. Interventions directed a private room, monitor resident per facility protocol and physician orders, use whiteboard/cards for communication related to hearing impairment, and psychiatry follow up as indicated.Record review identified Resident #1 had the following behaviors and visual monitoring on the following dates:1. On 10/4/2025, Resident #1 was placed on every 30-minute check related to increased wandering behaviors and was observed eating other resident's food.2. On 10/20/2025, Resident #1 was involved in a resident-to-resident altercation with Resident #2: Resident #1 kicked Resident #2 on the right leg. Interventions included a room change and Resident #1 remained on every 30-minute checks.3. On 10/24/2025, Resident #1 was observed attempting to remove his/her wander guard device and was combative toward nursing staff. Resident #1 and was transferred to the hospital for evaluation. Resident #1 returned from the hospital the same day with a new order for Olanzapine (antipsychotic) 5 milligrams (mg) every 24 hours as needed for agitation. Every 30-minute checks were increased to every 15-minute checks. 4. On 10/25/2025, Resident #1 was involved in a resident-to-resident altercation: Resident #1 hit Resident #4 approximately two/three times, in an attempt to take his/her glasses. Resident #4 retaliated and hit Resident #1 back, causing Resident #1 to fall to the ground. Resident #1 sustained a hematoma and was transferred to the hospital for evaluation. Resident #1 was readmitted to the facility on [DATE] with diagnoses of hypokalemia (low potassium blood level), hypocalcemia (low calcium blood) and hypomagnesemia (low magnesium blood levels). Upon readmission on [DATE], Resident #1 had a new physician order for continuous one-to-one (1:1) monitoring.5. On 11/6/2025, Resident #1 was involved in a resident-to-resident altercation. Resident #1 was in the recreation room waiting in line to purchase an item, when Resident #2 approached Resident #1, stood up from his/her wheelchair, and struck Resident #1 in the face without provocation. Resident #2 indicated it was in retaliation of the previous altercation (occurred on 10/20/2025) between the two. Resident #1 did not sustain any injuries and was maintained on 1:1 monitoring. B. Resident #3's diagnoses included hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), anxiety, and depression.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and was dependent on transfers and ADLs.The Resident Care Plan dated 11/1/2025 identified Resident #3 had a stroke with left side hemiparesis with left side facial droop. Interventions directed assist of two (2) with Hoyer for transfers, and provide emotional support as needed. A facility reportable event form dated 11/19/2025 at 3:35 PM identified Resident #3 was sitting close to the door and observed Resident #1 enter the dining room unaccompanied. Resident #3 alerted staff that Resident #1 entered the dining room, and the staff called out to the Nurse Aide (NA) doing the 1:1 safety monitoring and was not with Resident #1 at the time. Resident #3 reported that Resident #1 came over to his/her side and punched him/her on the right side of the face, knocking off his/her glasses. The form indicated Resident #3 had no injury. The facility investigation identified Resident #3 reported to the DON that Resident #1 had hit him/her - with a closed fist causing his/her glasses to fall off and called him/her derogatory names and racial slurs. Recreation Aide (RA) # 2 called out for the NA assigned to the 1:1 safety monitoring, who was not present with Resident #1. The facility summary dated 11/21/2025 identified the incident was a resident to resident physical assault with injury while Resident #1 was unattended by the NA assigned to 1:1 safety monitoring. Social services note dated 11/21/2025 at 2:44 PM identified Resident #3 was upset but okay.Social services note dated 11/24/2025 at 12:55 PM identified Resident #3 stated he/she was okay.Psychiatry note dated 11/27/2025 at 12:01 PM identified Resident #3 reported increased anxiety related to the incident with Resident #1 on 11/19/2025.Interview with NA #1 on 12/1/2025 at 11:35 AM identified she was providing the 1:1 monitoring for Resident #1 on 11/19/2025. NA #1 stated she was in Resident #1's room with Resident #1 when he/she requested a cup of coffee. NA #1 left the room to obtain the coffee, leaving Resident #1 unattended, and stated she was keeping an eye on Resident #1's room. NA #1 stated she did not see Resident #1 leave his/her room and then heard the RA yell out for help. NA #1 stated while performing continuous 1:1 monitoring, she should have remained with Resident #1 and never left the room leaving the resident unattended.Interview with RA #1 on 12/1/2025 at 12:10 PM identified on 11/19/2025, there was an activity program in the dining room, and Resident #3 alerted staff when Resident #1 entered the room unattended. RA #1 watched Resident #1 walk through the area, and stated initially Resident #1 had no behaviors but then walked over to Resident #3, and allegedly hit Resident #3. RA #1 identified she did not witness the hit, but Resident #3 had yelled he/she hit me, he/she hit me. Resident #3's glasses were observed knocked off his/her face and caught within his/her hair. RA #1 identified she was aware Resident #1 was on continuous 1:1 monitoring due to safety and stated the NA usually maintains Resident #1 within their line of sight if he/she was ambulating/wandering. RA #1 stated she notified the nurse after the incident occurred.Interview with Resident #3 on 12/2/2025 at 9:00 AM identified Resident #1 had punched him/her in the face. Resident #3 stated he/she did not want to see Resident #1, he/she does not feel safe around Resident #1, and watches to be sure Resident #1 is not nearby. Resident #3 stated if he/she saw Resident #1 outside the door to his/her room, he/she would want to hide under the bed.Interview with the DON on 12/2/2025 at 11:10 AM identified a staff member and Resident #3 reported that Resident #1 hit Resident #3 in the face. The DON stated the facility investigation identified NA #1 was assigned as the staff providing 1:1 observed, and NA #1 had left Resident #1's room to get him/her a cup of coffee on 11/19/2025. NA #1 went to the nursing station which was approximately four (4) rooms away from Resident #1's room, to obtain the coffee, and NA #1 did not see Resident #1 leave the room. The DON stated NA #1 should not have left Resident #1 unattended, as the purpose of continuous 1:1 monitoring is to always ensure constant visualization of the resident. After the event, no injuries were noted, NA #1 provided education regarding 1:1 monitoring, and Resident #3 was seen by medical, psychiatry, and social services. Review of the One to One (1:1) Behavioral Monitoring Policy directed in part, 1:1 monitoring is indicated to prevent residents/patients who are uncooperative, unwilling or unable to follow instruction from injuring themselves or exhibit a potential risk of injury to others. The resident/patient will remain on 1:1 until no longer at risk, or cleared by psychiatric practitioner at the facility and/or at the acute care setting.Review of facility Abuse, Neglect, and Exploitation Policy dated 2/2023 directed in part, abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for resident rights, the facility failed to allow an alert and oriented resident to leave the facility at his/her own will. The findings include: Resident #1's diagnoses included dementia, sensorineural hearing loss, anxiety, and depression. Record review identified Person #1 was a court appointed Conservator of Person. The Resident Care Plan dated 8/29/2025 identified Resident #1 was alert and oriented and can communicate daily needs to staff using a communication board. Interventions directed to encourage Resident #1 to ask questions, and orient to facility and routines. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being alert and oriented, and ambulated independently. A physician order dated 8/11/2025 directed Resident #1 may go out on LOA (leave of absence) with medications and responsible party. The Elopement and Wandering assessment dated [DATE] identified Resident #1 was not at risk for elopement. A social services progress note dated 9/9/2025 at 9:12 AM identified SW #1 reached out to Person #1 due to Resident #1 attempted to get on a local city bus to go to Walmart. The note indicated that Person #1 revoked outdoor privileges for Resident #1. A nursing note dated 9/10/2025 at 2:48 PM by the DON identified she was called by the receptionist and notified Resident #1 was outside with SW #1. The note indicated Resident #1 was restricted by Person #1 from going outside the facility. Upon arrival, Resident #1 was agitated and refused to communicate with the DON. Resident #1 communicates via written communication due to hearing impairment and Resident #1 refused to look at written communication. Per SW #1, Resident #1 was physically aggressive towards her and was seen kicking the door to exit the facility. Increased behaviors were noted with an increase in physical and verbal aggression, unable to redirect Resident #1, and transferred to the hospital for evaluation. Record review failed to identify a new Elopement and Wandering Assessment was performed and failed to identify the RCP was updated when Person #1 directed to not allow Resident #1 outside the building on 9/9/2025. Interview with the DON on 11/25/2025 at 12:45 PM identified Resident #1 was alert and oriented with a BIMS of 15 and had a Conservator. The DON stated that prior to 9/8/2025, Resident #1 would routinely go outside and feed the birds but had no attempts on leaving the premises. Person #1 was aware of this and agreed to Resident #1 to continue doing this. On 9/8/2025, Resident #1 attempted to get on the city bus as he/she believed he/she was on the list to go to Walmart with recreation. Person #1 was notified of the incident and agreed that Resident #1 would not be allowed to go outside by him/herself going forward. The DON stated a Conservator can direct care related to allowing or not allowing a resident to go outside, but stated a resident has the right to go outside. Interview failed to identify why Resident #1, who was alert and oriented, was no longer allowed to go outside. Interview with SW #1 on 12/1/2025 at 12:30 PM identified on 9/10/2025, Resident #1 was attempting to go outside at the main lobby entrance and was in between the double doors leading to outside. SW #1 attempted to stop Resident #1 because Person #1 had directed to not allow him/her to go outside. As SW #1 attempted to stop Resident #1 and bring him/her back into the facility, he/she became more aggressive by attempting to kick SW #1 and the doors. Visitors had entered through the doors while SW #1 and Resident #1 were between the doors, and Resident #1 was able to exit to the outside. Resident #1 stated he/she wanted to feed the birds and had bread in his/her possession. SW #1 stated a Conservator can direct care related to allowing or not allowing a resident to go outside, but stated a resident has the right to go outside and the facility team should have allowed Resident #1 to go outside while ensuring his/her safety. Review of the facility Resident [NAME] of Rights Policy dated 7/2021 identified the resident has the right to treat his/her living quarters as their home. The resident has the right to choose activities, schedules, and health care consistent with his/her interest, and the right to participate in community activities both inside and outside the facility. The Policy further directed the resident has the right to make choices about aspects of their life that are significant to themselves.

Based on review of the clinical record, facility documentation, and facility policy, and interviews for one sampled resident (Resident #2) reviewed for discharge, the facility to develop and implement a discharge plan timely. The findings include: Resident #2 had diagnoses that included diabetes mellitus, anxiety, depression, and difficulty walking. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of fifteen (15), indicative of intact cognition, and was independent with personal care, transfers and ambulation with a cane. The MDS further identified Resident #2 had an active discharge plan with a plan to return to the community and a referral was made to the local contact agency. The RCP dated 9/18/2025 identified Resident #2 was admitted for long term rehab. Interventions directed to encourage to ask questions, orient to facility, and introduce self and function to resident at each interaction. Additional review of the care plan failed to identify a discharge plan. Record review failed to identify referrals were made for potential discharge to another level of care. The interdisciplinary care plan meeting dated 9/18/2025 identified Resident #2's care area for Discharge Planning was checked off as N/A (not applicable) and MFP (Money Follows the Person) had been handwritten in the box. Interview with Social Worker #1 on 10/14/2025 at 9:50 A.M. identified when Resident #2's was admitted , he/she initially required assistance with ADLs and was currently independent with ADLs. A referral was sent to MFP during February 2024 for discharge to the community with home health care. SW #1 stated Resident #2 was still at the facility and had no discharge plans because he/she was waiting for MFP (since February 2024 - 20 months prior). SW #1 stated on 10/8/2025, Resident #2 requested to be transferred to a nursing home where his/her spouse resides. A referral was sent at that time, and Resident #2 was placed on their waiting list. Interview failed to identify any additional contacts were made for follow-up with MFP or alternate settings for potential discharge since February 2024. Review of the facility Discharge Planning Policy dated 1/2019, directed in part, discharge planning will be addressed upon admission and throughout the resident's stay. Residents who indicate a desire to return to the community will work with social service staff to formulate a viable discharge plan.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two of three residents (Resident #1 and Resident #2) reviewed for abuse, the facility to develop and implement a comprehensive care plan to address a relationship between the residents. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for two of three residents (Resident #1 and Resident #2) reviewed for abuse, the facility to develop and implement a comprehensive care plan to address a relationship between the residents. The findings include: 1. Resident#1 had diagnoses that included paraplegia, anxiety, and depression. The annual [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicative of intact cognition, and was independent with wheelchair mobility. The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #1 had a history of trauma with the potential for traumatization. Interventions directed to encourage express feelings/concerns, support as needed and to provide a safe place. 2. Resident #2 had diagnoses that included anxiety, depression, and difficulty walking. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of fifteen (15), indicative of intact cognition, and was independent ambulation with a cane. The RCP dated 9/18/2025 identified Resident #2 allegedly touched a peer inappropriately on 6/4/2024. Interventions directed to separate the resident from the peer immediately, psych to follow-up as needed, social service visits as needed, room change and provide emotional support as indicated. Record review identified Resident #1 and Resident #2 had a court appointed Conservator of Person (COP). Facility reportable event dated 9/24/2025 at 12:37 PM identified Resident #1 reported he/she visited Resident #2 daily after lunch and played dominoes, and he/she no longer feels comfortable around Resident #2. Resident #1 reported that he/she had consented to intimate contact with Resident #2 until 9/23/2025. Resident #1 reported Resident #2 asked him/her to get into his/her bed, but Resident #1 was unable to self-transfer into the bed. The Report indicated Resident #2 denied any sexual interaction with Resident #1. Additional facility reportable event information dated 9/30/2025 identified both residents have a COP, and the facility staff were aware that in the past, Residents #1 and #2 would hang out, visit, and play dominos together. Record review for Resident #1 and Resident #2 failed to identify documentation that the care plan included the residents relationship and interventions to provide guidance for the staff regarding the relationship. Interviews with NA #1, NA #2, and NA #3 on 10/14/2025 at various times identified they cared for Residents #1 and #2, and they were aware that Resident #1 and Resident #2 had a friendly relationship. NA #1, NA #2, and NA #3 identified that Resident #1 would come down to visit with Resident # 2 in his/her room with the door closed, and they did not check on the residents, or monitor, when the door was closed when the visits occurred. Interview with Social Worker (SW) #1 on 10/14/2025 at 9:50 A.M. identified she was aware Resident #1 and Resident #2 had a friendship. Interview with SW #2 on 10/14/2025 at 10:01 A.M. identified she was aware that Resident #1 would visit Resident #2 in his/her room with the door closed, and they would also play dominoes in the lounge Interview with the Memory Care Coordinator on 10/14/2025 at 11:25 A.M. identified she was aware Resident #1 and Resident #2 had a friendly relationship. Interview with LPN #1 on 10/14/2025 at 10:48 A.M. identified she was aware Resident #1 and Resident #2 had a friendship. Interview with LPN #2 on 10/14/2025 at 11:08 A.M. identified she was aware Resident #1 and Resident #2 had a friendship and Resident #1 would visit Resident #2 in his/her room with the door closed. Interview with the Administrator on 10/14/2025 at 11:15 A.M. identified Resident #1 and Resident #2 had a friendly relationship, and would visit in Resident #2's room with the door closed. The Administrator was unable to explain why a care plan had not been developed and implemented for Resident #1 and Resident #2 to address their relationship, and care plans should have been developed. Interview with Resident #1 on 10/14/2025 at 11:55 A.M. identified that he/she would visit Resident #2 daily in his/her room and had an intimate relationship with Resident #2 until 9/23/2025. Interview with the Director of Nurses (DNS) on 10/14/2025 at 12:25 P.M. identified Resident #1 and Resident #2 both had COPs. Each residents COP was aware the residents had a friendly relationship and spent time together. The DNS was unable to explain why care plans had not been developed and implemented for Resident #1 and Resident #2 to address their relationship, and indicated care plans should have been developed. Review of the facility Comprehensive Care Plans Policy dated 11/2017, directed in part, care plans reflect the resident preferences by recognizing each resident as an individual to identify and meet those needs in a resident-centered environment.

Based on review of the clinical record, facility documentation and facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to provide adequate supervision to prevent a resident-to-resident sexual incident. The findings include: 1. Resident #1 had diagnoses that included paraplegia, anxiety, and depression. The annual [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicative of intact cognition, and was independent with wheelchair mobility. The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #1 had a history of trauma with the potential for traumatization. Interventions directed to encourage express feelings/concerns, support as needed and to provide a safe place. 2. Resident #2 Resident #2 had diagnoses that included anxiety, depression, and difficulty walking. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of fifteen (15), indicative of intact cognition, and was independent ambulation with a cane. The RCP dated 9/18/2025 identified Resident #2 allegedly touched a peer inappropriately on 6/4/2024. Interventions directed to separate the resident from the peer immediately, psych to follow-up as needed, social service visits as needed, room change and provide emotional support as indicated. Record reviews identified Residents #1 and #2 resided on different floors of the facility, and both residents had a court appointed Conservator of Person (COP). Facility reportable event dated 9/24/2025 at 12:37 PM identified Resident #1 reported he/she visited Resident #2 daily after lunch and played dominoes, and he/she no longer feels comfortable around Resident #2. Resident #1 reported that he/she had consented to Resident #2 touching/sucking on his/her breasts, and he/she touched and kissed Resident #2's XXXX (genitals), until 9/23/2025. Resident #1 reported Resident #2 asked him/her to get into his/her bed, but Resident #1 was unable to self-transfer into the bed. The Report indicated Resident #2 denied any sexual interaction with Resident #1. Additional review identified Resident #2 had no roommate. Social Worker (SW) #1's note dated 9/24/2025 at 2:33 P.M. identified she met with Resident #1, who reported Resident #2 touched him/her in a manner that made him/her uncomfortable. Resident #1 stated the last time it had happened was one week ago when he/she played dominoes with Resident #2. SW #1's note dated 9/24/2025 at 2:39 P.M. identified she met with Resident #2 regarding the reported incident between Resident #2 and Resident #1, and Resident #2 denied the incident. APRN note dated 9/25/2025 at 5:10 PM identified Resident #1 was seen for alleged sexual assault by Resident #2. Resident #1 was tearful while he/she recounted the event, and indicated he/she had a consensual sexual relationship with Resident #2 in the past. Resident #1 reported that Resident #2 engaged in acts that he/she did not want or consent to. Resident #1 denied any penetrative sex and no physical injuries were noted. Facility reportable event summary dated 9/29/2025 identified the residents were separated and educated that if they choose to visit in the future, visiting should occur in a common area with staff knowledge. Further, Resident #2 was placed on every one (1) hour checks. Additional facility reportable event information dated 9/30/2025 identified both residents have a COP, and the facility staff were aware Residents #1 and #2 would hang out, visit, and play dominos together. Resident #2 had no roommate, and during June 2024 had touched another resident inappropriately. Resident #1 will no longer visit Resident #2's floor, Resident #1 stated prior incidents were consensual, and Resident #2 denied the allegation. Interviews with NA #1, NA #2, and NA #3 on 10/14/2025 at various times identified they cared for Residents #1 and #2, and they were aware that Resident #1 and Resident #2 had a friendly relationship. NA #1, NA #2, and NA #3 identified that Resident #1 would come down to visit with Resident # 2 in his/her room with the door closed, and they did not check on the residents, or monitor, when the door was closed when the visits occurred. Interview with SW #1 on 10/14/2025 at 9:50 A.M. identified she was aware of the friendship between Resident #1 and Resident #2. SW #1 identified on 9/24/2025, she was notified that Resident #1 stated he/she did not want to go to the XXX floor anymore because Resident #2 had touched him/her. Resident #1 reported that he/she would meet Resident #2 in the sitting room to play dominoes, and Resident #2 touched Resident #1's breasts. SW #1 identified Resident #1 reported he/she told Resident #2 not to touch his/her breasts and Resident #2 touched his/her breast anyway. SW #1 further identified Resident #2 had a previous history of inappropriately touching another resident. Interview with SW #2 on 10/14/2025 at 10:01 A.M. identified she was aware that Resident #1 would visit Resident #2 in his/her room with the door closed, and they would also play dominoes in the lounge. Although SW #2 stated she was aware Resident #2 had a previous history of inappropriately touching another resident, and she was aware Residents #1 and #2 were visiting in Resident #2's room with the door closed, interview failed to identify intervention's that were taken to prevent Resident #2 from inappropriately touching Resident #1 during visits with the door closed. Interview with the Memory Care Coordinator on 10/14/2025 at 11:25 A.M. identified Resident #1 and Resident #2 had a friendly relationship, and Resident #1 would visit Resident #2 to play dominoes in the side sitting room on the unit. The Memory Care Coordinator stated on 9/24/2025 at approximately 1:00 P.M. she was on the elevator with Resident #1, and she asked Resident #1 if he/she was going to the XXX floor, and Resident #1 stated no, because I don't feel safe going there anymore because I told Resident #2 that he/she can't touch me anymore. The Memory Care Coordinator stated she then reported the alleged incident. Interview with LPN #2 on 10/14/2025 at 11:08 A.M. identified she was aware Resident #1 and Resident #2 had a friendship and Resident #1 would visit Resident #2 in his/her room with the door closed. LPN #2 identified that Resident #2's room door was always closed, and she did not check on the residents, or monitor, when the door was closed when the visits occurred. Interview with the Administrator on 10/14/2025 at 11:15 A.M. identified Resident #1 and Resident #2 had a friendly relationship, and would visit in Resident #2's room with the door closed. The Administrator stated Resident #2 had a previous history of inappropriately touching another resident (9/2024), and was unable to explain interventions that were taken to ensure Resident #1 was not touched inappropriately when in the room with the door closed. Although attempted, an interview with APRN #2 was not obtained during the survey. Interview with Resident #1 on 10/14/2025 at 11:55 A.M. identified on an unidentified date prior to 9/24/2025, while he/she was visiting Resident #2 in his/her room, Resident #2 wanted to touch his/her breast. Resident #1 identified he/she told Resident #2 not to touch his/her breasts, but Resident #2 touched his/her breasts anyway. Resident #1 stated he/she was not going to that unit again and was not upset. Interview with the Director of Nurses (DNS) on 10/14/2025 at 12:25 P.M. identified both Resident #1 and Resident #2 had a COP, the residents had a friendly relationship, and the Conservators were aware. The DNS stated she was aware Resident #2 had a previous history of inappropriately touching another resident while playing dominoes and identified Resident #1 visited Resident 2 in his/her room with the door closed. The DNS was unable to explain why Resident #1 and Resident #2 were alone in the room with the door closed or explain interventions that were taken to ensure Resident #1 was not touched inappropriately when in the room with the door closed. Review of the facility Abuse Prohibition Policy dated September 2020 directed in part, sexual abuse includes but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the RN supervisor was notified timely of a change in condition was identified, to ensure an Registered Nurse (RN) assessment was completed timely. The findings include: Resident #1 had a diagnosis of type 2 diabetes, anemia, and Charcot's joint of the left ankle (nerve damage). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (alert and oriented/intact cognition) and was independent after set up for showering and independent with transfers. The Resident Care Plan (RCP) dated 2/24/2025 identified an Activities of Daily Living (ADL) deficit. Interventions directed to assist gathering and setting up clothing and toiletries. Facility reportable event form dated 4/12/2025 identified on 4/13/2025 Resident #1 indicated that he needed cream applied to the right leg due to a burn that he/she received on 4/12/2025 during a shower. Resident #1 denied discomfort and indicated he/she did not notify staff when the burn occurred on 4/12/2025. Facility summary dated 4/17/2025 identified Resident #1 sustained a first degree burn to the right lower extremity from running hot water over wash cloth that he/she placed on his/her right lower extremity during a shower. Nursing note dated 4/13/2025 at 11:33 PM identified Resident #1 stated he/she needed lotion to his/her right leg, area was noted to be red and bumpy. Resident #1 resident stated he/she burned the leg on 4/12/2025 with a hot cloth during a shower but did not notify any staff. The note further identified the RN supervisor was notified via a text message to call when possible. Nursing note (RN supervisor) dated 4/14/2025 at 10:34 AM identified Resident #1 was noted with a first degree burn to the right leg which the resident stated happened during a shower on 4/12/2025. Area was noted to measure 18 centimeters long, 7.5 centimeters wide and had no depth. The Advanced Practice Registered Nurse (APRN) made notified and treatment orders were obtained. Interview with NA #1 on 5/5/2025 at 12:09 PM identified she gave Resident #1 a shower on 4/12/2025 around 10 AM. NA #1 stated Resident #1 was independent with the shower after she washed his/her back. NA #1 checked the water temperature before washing Resident #1's back, and temperature was not too hot - it was lukewarm, and Resident #1 had no complaints about the water temperature. Resident #1 was then independent with the remainder of the shower. Interview and record review with RN #1 on 5/5/2025 at 12:31 PM identified she was working as the RN supervisor from 7 AM to 11 PM on 4/13/2025 when the burn was identified. Review of a text message on RN #1's phone identified LPN #1 sent a text message that stated, call me when you can, no rush. RN #1 stated she was not notified Resident #1 had a burn. RN #1 stated LPN #1 had sent her a text message to call when possible, however, she forgot to call. RN #1 stated if she had known Resident #1's leg was burned, she would have completed an assessment and notified the APRN. Interview and record review with the Administrator on 5/5/2025 at 2:43 PM identified an RN assessment should have been completed when the burn was identified. The Administrator indicated LPN #1 should have notified RN #1 of the burn, and stated LPN #1 should have followed up with RN #1 after the text message was sent. The Administrator was unable to provide documentation that an assessment was completed when the burn was identified on 4/13/2025. Although requested, an assessment policy was not provided for surveyor review.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident # 1) reviewed for verbal communication, the facility failed to protect the Resident from verbal abuse. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses that included Parkinsons Disease, unspecified dementia, and generalized anxiety disorder. The quarterly MDS dated [DATE] identified Resident # 1 had moderate cognitive impairment, was incontinent of bowel and bladder and required assistance with care with activities of daily living. The care plan dated 10/18/2024 identified an ADL deficit. Interventions included the assistance of one for ADLs and transfer via Hoyer lift. The nurse's note dated 12/13/2024 at 1:20 PM identified that a NA was overheard using foul language to the Resident. Review of the facility documentation dated 12/13/2024 identified that the Resident was yelling to get out of bed, NA#1 went into the Residents room and asked the Resident what she/he needed and the Resident stated to get out of bed, NA#1 told the Resident to give her a minute and the Resident asked again to get out of bed, then the Resident stated fuck you and NA#1 responded fuck you too. The APRN assessed the Resident on 12/13/2024 and directed to provide emotional support and follow up with social services and psychiatry. Review of the Interview with Resident #1 and RN #1 on 12/13/2024 identified that she asked the Resident if NA#1 used foul language and the Resident said yes, we use foul language to each other. Further review identified that the Resident was not offended by the statement because they were only fooling around and he/she did not fear NA#1 and he/she would like NA#1 to continue to care for her/him. Interview with Person #1 on 12/18/2024 at 10:05 AM identified that the Resident was calling for a while, approximately twenty minutes, NA#1 came in and asked the Resident what he/she wanted and the Resident responded that he /she wanted to get up, NA#1 responded then get up, the Resident responded that she/he could not get up, NA#1 responded saying I guess you will have to wait and don't turn the light on again, the Resident then said fuck you and NA#1 responded fuck you too you and don't turn the light on again. Interview with NA#1 on 12/13/2024 at 10:18 AM identified that the Resident is a jovial person and they laugh together, the Resident wanted to get out of bed and NA#1 told her/him that she would be with her/him in a minute and the Resident said fuck you, fuck you and NA#1 replied with ok, with a smiling face and said fuck you, fuck you back in a laughing manner. Further interview identified that NA#1 and the Resident talk to each other like that all the time and she did not think that it was done in an abusive manner because that is the way the Resident talks. Interview with Resident #1 on 12/18/2024 at 11:41 AM identified that she/he did not recall anyone using swear words when they talked with her/him and if anyone did she/he would tell them to get out. Interview and review of the facility documentation with the DNS on 12/13 2024 at 1:00 PM identified that verbal abuse was substantiated and NA#1 was terminated on 12/17/2024. Review of the facility policy Abuse, Neglect and Exploitation dated 2/2023 identified that the facility protects the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled Resident (Resident # 1) reviewed for an allegation of abuse, the facility failed to investigate the allegation. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses that included heart failure, weakness and difficulty in walking. The admission MDS dated [DATE] identified Resident # 1 had severely impaired cognition, was frequently incontinent of bowel and bladder and required maximum to total assistance with activities of daily living. The care plan dated 10/14/2024 identified that the Resident was at risk for falls due to the recent admission, decreased endurance/strength and generalized weakness. Interventions included an assist of one with ambulation and rolling walker and instruct to ask for assistance prior to attempting to transfer or ambulate as needed. Review of the nurse's progress note dated 10/30/2024 at 10:05 PM by the DNS, identified that the DNS was called to the unit to assess Resident #1, who was observed on the floor, upon arrival the Resident was partially lying on the right side on the bedside mat, and no signs or symptoms of bleeding were noted. The Resident identified that he/she was coming from the bathroom. The progress note at that time further identified the Resident also reported significant right hip pain and with the assistance of 3 staff, the Resident rolled to her/his back without significant pain. Additionally, when the right hip was palpated the Resident reported significant pain and denied pain to other sites. APRN #1 was notified and directed to send Resident #1 to the emergency room for evaluation for significant right hip pain, increased confusion and possible head strike. Review of the facility documentation, titled Incident Description, dated 10/30/2024 identified an unwitnessed fall with significant right hip pain, increased redness to the right side of the face and possible head strike. An interview with the DNS on 11/14/2024 at 1:28 PM identified that on 10/30/2024, after the fall Resident #1 was sent to the hospital. Subsequent to the resident transfer, the DNS stated she received a call from the social worker at the hospital who stated that Resident #1 was hit in the face by a nurse. The DNS further indicated that no other information was provided as to where or when it occurred. The DNS stated that she wrote a note about the phone call, but unfortunately, she has not followed up on it yet (16 days later). Further interview identified, that when the Resident left, she/he had redness on the right side of her/his face and the face was swollen and the resident could barely open her/his eyes. She further stated she should of immediately started an investigation, but did not. According to the policy Abuse, Neglect and Exploitation Section V. Investigation of Alleged Abuse, Neglect, and Exploitation dated 2/2023 identified: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation occur.

Based on observation, clinical record reviews, review of facility documentation, and interviews for 1 of 6 residents at risk for elopement (Resident # 8), the facility failed to implement interventions for a resident identified at risk for elopement. Resident #8 was able to exit the facility without staff knowledge and was found 0.6 miles away from the facility by law enforcement. This failure resulted in a finding of Immediate Jeopardy (IJ). The finding includes: Resident #8's diagnoses included paranoid schizophrenia, dementia, depression, anxiety disorder and psychosis. The clinical record identified Person # 3 as Resident # 8's conservator. The quarterly Minimum Data Set (MDS) assessment, dated 2/23/2024, indicated Resident #8 as moderately cognitively impaired and noted no wandering behaviors had occurred at the time of the assessment. The Resident Care Plan (RCP) dated 3/14/2024 for at risk of leaving the facility with a desire to go home, noted tendency to cut off wander guard. Interventions included: the application of a wander guard bracelet, picture identification and description of Resident #8 to all departments and staff located near exits (including the reception desk) to re-direct the resident if seen near an exit, encourage the resident to come with staff and assist Resident #8 with finding his/her own room, bathroom and nursing unit as needed. On 5/9/2024 the facility transferred Resident # 8 to the hospital at 5:59 PM for a psychiatric evaluation due to behavioral changes. Prior to the transfer at approximately 5:30 PM Resident # 8's wander guard was removed by staff. An elopement and wandering evaluation, completed and dated 5/30/2024 (readmission) at 8:21 PM, indicated Resident #8 was at risk for wandering and elopement. The readmission nursing assessment, dated 5/30/2024 at 8:39 PM, failed to reflect the nursing staff implemented measures to address Resident #8's risk for elopement. A Brief Interview for Mental Status (BIMS) assessment, completed 5/31/2024 at 11:32 AM, indicated Resident #8 was severely cognitively impaired. The Emergency Medical System (EMS) Run sheet, dated 6/16/2024 at 5:06 PM, indicated the EMS team was called to respond at 5:01 PM and arrived at 5:06 PM to find Resident #8 on a side street in the same city (0.6 miles away from the facility, across a 4-lane divided busy street, outside temperature was 73 degrees and no precipitation) with a bystander. The EMS form indicated Resident #8 was crying and stated s/he could not go on and did not want to live anymore. The EMS form further indicated Resident # 8 was assisted to a stretcher and transported to the closest hospital arriving at the acute care facility at 5:19 PM. A nursing progress note, dated 6/16/2024 at 11:49 PM, indicated at about 7:30 PM the writer was alerted by the charge nurse Resident #8 was not found in his/her room. The note indicated at the same time a phone call was received from an acute care facility indicating Resident #8 was at the hospital. The note further indicated the Director of Nursing Services (DNS), Administrator, Advanced Practice Registered Nurse (APRN) were notified, and a message was left for the responsible party to call the facility for an update on Resident #8's status. Observation on 6/17/2024 at 9:59 AM identified Resident #8's bedroom was located at the end of the hallway near the elevators that have a coded keypad to access usage. A review of the facility investigation, dated 6/16/24, included a handwritten document with Dietary Aide #2's name, no date/time and no signature, the statement indicated Dietary Aide #2 was on the elevator after delivering the last meal truck to the fourth floor. The elevator stopped on the third floor and a resident unknown to the Dietary Aide #2 got on the elevator and the elevator stopped at the first floor. Dietary Aide #2 indicated s/he did not know where the resident on the elevator went when the elevator stopped on the first floor. The facility investigation statement dated 6/16/2024 (no time) written by Nurse Aide (NA) #3 indicated Resident #8 was seen walking around in the hall. At 7:00 PM when s/he went to Resident #8's room to provide care the resident was not there at which time NA # 3 reported to the charge nurse the resident was not present. The facility investigation dated 6/16/2024 (no time), with Licensed Practical Nurse (LPN #13) indicated the nurse aide assigned to Resident #8 reported to him/her at 7:10 PM s/he was unable to locate Resident #8 who was not in his/her room or bathroom. LPN #13 indicated looking for the resident everywhere. LPN #13 further indicated after speaking with the Receptionist #1, a call came to the unit from the hospital that identified Resident #8 was there. On 6/17/2024 at 10:55 AM the Administrator indicated the facility was currently investigating a Reportable Event involving Resident #8 who eloped (left unattended and without staff knowledge) from the facility on Sunday 6/16/2024. The location where Resident #8 was found, and exact time was unknown to the administrator at that time. The Administrator indicated Resident #8 went down the elevator with Dietary Aide # 2 and then exited the building out the front entrance. Although Receptionist #1 was on duty, and a book containing pictures and descriptions of residents at risk of eloping (including Resident # 8) was present at the desk. Receptionist # 1 was unaware Resident # 8 had exited the building. The Administrator indicated the police found Resident #8 on 6/16/24 and brought the resident to an acute care facility. This resulted in a finding of Immediate Jeopardy (IJ). On 6/17/2024 an interview and record review with the DNS at 11:20 AM indicated it is facility policy to page a Dr. Hunt (emergency paging system to locate a missing person) over the intercom system in the event a resident was missing. The DNS indicated staff did not follow facility policy Dr. Hunt at the time Resident # 8 was identified missing. Review of the physician's orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) with the DNS from 5/30/2024(re-admitted ) through 6/16/2024 failed to reflect a physician's orders for re-application of Resident # 8's wander guard to monitor the resident's location per facility policy for a resident at risk for elopement. The DNS was unable to provide evidence that a wander guard bracelet was applied to Resident # 8 between 5/30/2024 through 6/16/2024 or any other interventions to monitor Resident # 8's location in the facility. Interview with Receptionist #1 on 6/17/2024 at 4:35 PM indicated Resident #8 must have been with a visitor and exited the building when s/he pressed the button to unlock the front entrance door for the visitor to leave. Receptionist # 1 also indicated the incident occurred on Father's Day which was a busy day because s/he was watching the computer monitor looking forward outside the window where the transportation vehicles pick up and drop off residents and watching for visitors wanting to enter and exit the facility. Receptionist #1 further indicated s/he pressed the button to unlock the front entrance door not realizing a resident at risk was with the visitor. Receptionist # 1 further indicated s/he was aware of the elopement risk book and location. However, the day of the incident s/he did not see a wander guard on anyone and did not hear an alarm go off when s/he let the visitor exit. Interview on 6/18/2024 with the Director of Nursing Services (DNS) and Administrator at 1:30 PM indicated the staff noted Resident #8 on the unit at the beginning of the shift (3:00PM) and actively walking on the unit around 3:00 PM-4:00 PM. The DNS and Administrator further indicated through staff interviews they were able to identify that Resident #8 was on the elevator with Dietary Aide #2 around 4:30 PM to 4:45 PM before meals arrived onto the unit about 5:00 PM. The Administrator indicated s/he viewed the video surveillance on 6/17/2024 to determine the time Resident #8 was on the elevator with Dietary Aide #2 and the surveillance video showed Resident #8 exiting the front entrance of the building at 4:37 PM. Interview with the DNS and the Administrator on 6/18/2024 at 1:35 PM indicated at time of Resident # 8's readmission on 5/30/2024 the facility had 8 wander guard bracelets available for use and currently the same 8 bracelets are available for use now. The DNS indicated when a resident is admitted /readmitted an elopement evaluation is completed. If found at risk for elopement the nurse who completed the evaluation is responsible for notifying the supervisor that a wander guard is needed for the resident. The wander guard bracelets are locked in the supervisor's office so the supervisor would need to provide the bracelet to the nurse for application to the resident. Resident #8 was evaluated and found at risk for elopement on 5/30/2024, the charge nurse should have followed the facility policy, updated the supervisor regarding the outcome of the evaluation, obtained physician orders to apply a wander guard bracelet and notified responsible party. The hospital's Initial Psychiatric Evaluation, dated 6/20/2024 at 9:37 AM, indicated Resident #8 was found on the street after eloping in an impulsive and disorganized manner from the skilled nursing facility. The evaluation further indicated Resident #8 was found on the street disheveled and tearful and brought to the Emergency Department for an evaluation. Resident # 8 was assessed and verbalized at the hospital s/he wanted to self-harm without a clear plan at which time Resident # 8 was admitted to the acute care facility under a Physician's Emergency Certificate (PEC). Interview with Licensed Practical Nurse (LPN #14), on 6/20/24 at 9:45 AM, indicated s/he was working on 5/30/2024 when Resident #8 was readmitted . LPN #14 further indicated s/he collected data for the completion of the elopement evaluation on 5/30/2024 but s/he did not inform the supervisor Resident #8 was at risk for elopement. LPN # 14 also indicated the license staff is responsible for applying wander guard bracelet to residents. LPN #14 could not explain why s/he did not notify the supervisor Resident # 8 required a wander guard bracelet on 5/30/24. On 6/20/2024 at 10:21 AM interview with Registered Nurse (RN #6) who was the RN supervisor on 5/30/2024 when Resident #8 was readmitted to the facility. RN #6 indicated the evaluations (including elopement risk) are completed by the charge nurses and indicated the admitting nursing supervisor is responsible for reviewing the evaluations and if a resident is at risk put safety precautions in place per the policy. On 6/20/2024 at 11:20 AM interview and facility document review with the DNS indicated the 24-hour supervisor paper report for 5/30/2024 through 6/16/2024 did not reference Resident #8 was at risk for elopement or the need for a wander guard bracelet. Interview with RN #6 on 6/20/24 at 11:20 with DNS further indicated s/he did not receive any report regarding Resident #8 from the off going supervisor. An interview on 6/20/2024 at 1:05 PM with Nurse Aide (NA #3) assigned to Resident #8 indicated s/he last saw Resident #8 around 5:00 PM or just before the incident. Resident # 8 had not made any attempts to leave the unit that evening. NA#3 indicated s/he noticed Resident #8 was missing at around 7:00 PM when s/he went to Resident # 8's room to provide PM care and was told by the charge nurse to look for the resident. Interview with Licensed Practical Nurse (LPN) #13 on 6/24/2024 at 8:58 AM indicated s/he did not call Dr. Hunt before looking downstairs first and talking to Receptionist #1. LPN # 13 further indicated once s/he was back on the unit s/he received a call from the hospital informing her/him Resident #8 was at the hospital. On 6/25/2024 at 8:58 PM an interview with LPN #13 s/he on 6/16/2024 worked from 7:00 AM through 11: 00 PM as the charge nurse caring for Resident #8. LPN #13 indicated s/he saw Resident #8 walking in the hall on the unit at 3:00 PM when s/he arrived on duty and recalls a nurse aide indicated Resident #8 had been crying. LPN #13 administered Resident #8 her/his 4:00 PM medications and the resident was in her/his room at that time. Later Resident #8 came to LPN #13 in the hall during medication pass and complained of a headache at which time s/he LPN # 13 provided medication to relieve the headache. At 7:00 PM the nurse aide reported Resident #8 was missing at which time s/he stopped the medication pass and began to look for Resident # 8. Attempts to interview Dietary Aide #2 during the survey were unsuccessful. The facility policy titled Elopement consists of screening all residents for risk of elopement, implement preventive strategies for those identified at risk, institute measures for resident identification at the time of admission, and conduct missing resident procedures as warranted. The policy defines elopement as the inability of a resident who is not capable of protecting him or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter harm's way. The Administrator was presented with the Immediate Jeopardy Template on June 16, 2024, at 5:20 PM for F 689 Free of Accident Hazards/supervision /devices. The facility submitted the following IJ removal plan on June 17 and 18, 2024: 1. The facility conducted an in-house audit of all residents at risk for elopement on 6/17/24 and 6/18/24. 2. All staff have been in serviced on the facility elopement and wander guard policy, Dr. Hunt policy, Medical Doctor and family notification and Leave of Absence policy and indicated all policy remains current. 3. All staff have been educated if a resident on admission and readmission triggers for at risk for elopement to place a wander guard on the resident. Staff have been educated to obtain a physician's order for the wander guard, to conduct checks per facility policy. 4. An Interdisciplinary meeting was held to review all residents at risk for elopement and current residents with wander guards. 5. RN supervisor and charge nurse will check all wander guards for placements, to ensure evaluations are completed, physician's orders for wander guard and care plans when a resident is noted at risk for elopement upon admission and readmission. 6. Wander guard book check for pictures on all units 7. The Receptionist will report and review all residents at risk for elopement at mealtime and at shift change. 8. Dr. Hunt Drill conducted 6/17/24 on the 3:00 PM to 11:00 PM shift 9. Audit tool created for all residents with wander guards for tracking and placement. The facility will perform evaluation on admission, readmission, random audits will be conducted weekly time 4 and monthly times 3. The DNS and designee. a. On 6/17/2024 an interview and record review with the DNS at 11:20 AM indicated staff did not follow procedure for paging a Dr. Hunt at the time Resident # 8 was identified missing on 6/16/24. On 6/20/2024 at 10:21 AM interview with RN #6 indicated she did not hear a page for Dr. Hunt to indicate a resident was missing. An interview on 6/20/2024 at 1:05 PM with NA # 3 indicated s/he did not hear a Dr. Hunt paged. Interview on 6/20/2024 at 6:06 PM with supervisor, RN #7 who worked 7:00 AM -7:00 PM on 6/16/2024 indicated s/he did not hear a page for Dr. Hunt initiated while she was on duty. On 6/25/2024 at 8:58 PM an interview via phone with. LPN #13 identified no Dr. Hunt was paged when the resident was noted missing. b. A review of the facility removal plan for the Immediate Jeopardy dated 6/18/24 identified RN # 9 the 3-11 PM supervisor on 6/19/24 at 3 :25 PM placing the transmitter near the wander guard device without pressing the button to activate the device to validate functioning per manufacture directions. Interview with RN # 9 identified s/he had been educated recently on the facility policy and procedure for transmitter use and thought she was doing it correct. Interview with the DNS and the Administrator at the time of the incident identified they would conduct an in-house education with all RN supervisors again to ensure they are aware of how to use the transmitter to test for wander guard functioning every shift. This resulted in the facility not having the removal of the Immediate Jeopardy. c. Observations on 6/20/24 on the 3-11 PM at 4:45 PM to 5:00 PM of the receptionist desk where the location of residents at risk for elopement picture book is located failed to identify Resident # 88 picture in the book per facility removal plan for Immediate Jeopardy. Interview with the Administrator and DNS on 6/20/2024 identified that they have several residents who wander guard location is on the wheelchair and not the resident's persons such as: Residents # 17, # 30, # 55, # 75 and # 97 wander guards are located on the resident's wheelchair. The Administrator also indicated that Resident # 88 refused to have his/her picture taken. The Administrator further indicated s/he did not inform the resident's conservator and the physician of the resident's refusal to have his/her picture taken for at risk for elopement. After inquiry, the Administrator indicated s/he would follow up with the conservator this evening and the physician. The DNS and Administrator also indicated they would follow up with Residents #17, # 30, # 55, # 75 and # 97 location of wander guard by having a discussion in an interdisciplinary meeting to ensure the facility is appropriately monitoring and supervising resident at risk for elopement. However, the state agency could not remove the facility Immediate Jeopardy based on the removal plan was not implemented. 2. Interview with the DNS and the Administrator on 6/18/2024 at 1:35PM identified the function of the wander guard bracelets for all residents are checked on the night shift by the nursing supervisor per physician's orders and the facility obtained a transmitter from a sister facility to initiate the checks and a log to track functioning of the wander guard because there was not one in facility prior to the 6/16/2024 incident of Resident #8 elopement. The Administrator indicated the transmitter is used to check the function of the wander guard bracelets for all residents during the night shift. However, the transmitter had been broken since the middle of April 2024. An interview with the Administrator on 6/18/20254 at 2:00PM indicated the delay in obtaining another transmitter was due to administrative staff member resigning without notice. She/he became sidetracked and did not order the transmitter to check the function of the wander guard bracelets. The Administrator re-ordered the transmitter on 6/17/2024, after surveyor inquiry and provided an invoice (146 days later. Interview with LPN #14 on 6/20/24 at 9:45 AM indicated working 11-7 AM shift at the facility identified s/he was not made aware the transmitter to check the function of the residents wander guard bracelets was broken.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure adequate supervision for a resident who exhibited behaviors to prevent a resident-to-resident altercation. The findings include: Resident #1's diagnoses included hypertension, Alzheimer's Disease, dementia without behavioral disturbances, psychotic disturbances, mood disturbances, anxiety, and depression. The nursing Admission form dated 9/26/2022 identified Resident #1 was cooperative and independent with ambulation. The Brief Interview for Mental Status (BIMS) Minimum Data Set (MDS) form dated 9/27/2022 identified that Resident #1 had severe cognitive impairment. The Resident Care Plan (RCP) dated 9/27/2022 identified Resident #1 had impaired cognition related to dementia. Interventions directed to identify self, speak slowly and clearly, explain all procedures, and use simple, direct communication, verbal cues, and task segmentation. The nurse's note dated 9/27/2022 at 2:58 AM identified Resident #1 was anxious, attempted to remove the air mattress pump from the foot of the bed, wandered into other resident rooms, and was observed attempting to feed other residents his/her evening snack. The nurse's note dated 9/28/2022 at 2:17 AM identified Resident #1 had not slept, continued to wander in and out of other resident rooms and took other resident ' s belongings. Resident #1 was combative at times and punched and shoved staff several times during the 11 PM - 7 AM shift. Snacks were offered, Resident #1 was ambulated, toileted and offered TV programs for diversion, all with no effect. Resident #1 was noted to have no safety awareness and was placed on one-to-one (1:1) supervision for her/his safety and safety of other residents, and the supervisor was updated. The nurse's note dated 9/28/2022 at 4:50 AM identified Resident #1 had not slept, 1:1 supervision continued, and Resident #1 was impulsive and would not stay put in any location for more than a few minutes. The RCP dated 9/29/2022 identified Resident #1 was at risk for social isolation due to a progressive cognitive disorder. Interventions directed to respect the resident's rights, including the right to refuse, and allow Resident #1 to explore the environment in a safe manner. The nurse's note dated 10/2/2022 at 3:18 AM identified Resident #1 was awake and with baseline confusion and had not sleep during the shift. Resident #1 was noted constantly in and out of other resident's rooms while they were sleeping and taking their belongings, was combative at times. Staff were unable to re-direct, and 1:1 supervision was provided as much as possible. Resident #2's diagnoses included hypertension, kidney disease, cataract, Alzheimer's disease, dementia with behavioral disturbance, anxiety, and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had severe cognitive impairment, had no behavioral symptoms, and required supervision with transfer, walk in room, walk in corridor and locomotion on unit. The Resident Care Plan (RCP) dated 8/30/2022 identified Resident #2 had impaired cognition. Interventions directed to identify self, speak slowly and clearly, explain all procedures, use simple, direct communication, verbal cues, and task segmentation. A reportable event form and investigation dated 10/2/2022 identified hallway video footage showed Resident #1 and Resident #2 were ambulating in the hallway, and Resident #2 had a stuffed animal. Resident #1 grabbed Resident #2 ' s stuffed animal and both residents were grabbing each other's arms, pulling, and tugging at the stuffed animal that Resident #2 was holding in her/his hands. Resident #2 threw the stuffed animal on the floor and as he/she turned away, Resident #1 pushed him/her. Resident #2 lost his/her balance and fell to the floor. Resident #2 sustained a laceration with large amount of bleeding to the left temporal area, 911 was called and Resident #2 was transferred to the hospital for evaluation. Resident #1 had bilateral upper arm bruising noted on 10/3/2022 measuring 10 by 6 centimeters (cm) and 8 cm diameter. Review of hospital record physician progress note dated 10/3/2022 identified Resident #2 had a small left frontoparietal subarachnoid hemorrhage (SAH). Resident #2 was monitored overnight in the hospital progressive care unit, and the SAH resolved on 10/3/2022. The nurse's notes dated 10/4/2022 identified Resident #2 returned to the facility with five stiches to left temple area, ecchymosis on left shoulder, both arms, left hip and side of left knee. Interview with the Administrator on 10/26/2022 at 11:00 AM identified she was not aware of Residents #1's behaviors until the altercation with Resident #2. The Administrator further identified if she was aware that Resident #1 was hitting staff, taking other resident ' s belongings, trying to give snacks to other residents, she would do something to make sure that other residents were safe. Interview with the DNS on 10/26/2022 at 2:37 PM identified she was aware Resident #1 wandered into other resident rooms, was combative at times, punched and shoved staff, and had not slept in the past two (2) nights prior to the incident. The DNS indicated Resident #1 was put on 1:1 monitoring on 9/28/2022 and indicated staff should have notified the APRN. The DNS further indicated if she was aware Resident #1 had continued behaviors, she would have continued the 1:1 monitoring to make sure everyone was safe. Interview with APRN #1 on 10/26/2022 at 2:53 PM identified if he was notified of Resident #1 ' s behavior, he would have ordered a psychiatric evaluation, probably continue 1:1 supervision, and consider starting Resident #1 on medications for the behaviors. Subsequent to the incident on 10/2/2022, Resident #1 had a psychiatric evaluation and therapy, was started on Trazadone for insomnia, and was started on Seroquel for psychosis and agitation. Interview with MD #1 on 10/27/2022 at 1:43 PM identified if he had been notified of Resident #1 ' s behaviors, he would have sent the resident to the hospital for psychiatric evaluation. Although Resident #1 was placed on occasional 1:1 observation by staff due to behaviors, the facility failed to put interventions into place timely when Resident #1 exhibited behaviors to prevent the altercation with Resident #2 and subsequent fall with injury. Review of facility Abuse Prohibition Policy directed in part, physical abuse includes hitting, slapping, pinching, and kicking.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #92) reviewed for accidents, the facility failed to follow the plan of care, facility policy and professional standards related to the use of a gait belt and necessary ambulation assistance to prevent a fall with an injury, additionally, for 1 of 3 residents reviewed for accidents (Resident #22) the facility failed to provide adequate supervision of a resident with an altered mental status who was in possession of smoking material and failed to provide adequate supervision of a resident to prevent an elopement. The findings include: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included seizures, dementia, and paranoid [CONDITION(S)]. A physician's order date 10/15/21 directed to transfer the resident via a stand pivot with assistance of 1 staff. The quarterly MDS dated [DATE] identified Resident #92 had severely impaired cognition, was always incontinent of bladder, frequently incontinent of bowel and required extensive assistance for dressing, personal hygiene, transfers, locomotion on unit, and toileting with 1 person. The care plan dated 11/12/21 identified Resident #92 was at risk for falls. Interventions included to transfer the resident via stand pivot with the assistance of 1 staff and a gait belt, ambulation with the assistance of 1 staff and a gait belt, and do not leave the resident unattended in the bathroom. A reportable event form dated 11/30/21 at 7:25 AM indicated Resident #92 lost his/her balance ambulating to the bathroom and complained of pain in the right hip and leg. Resident #92 was alert with confusion at times, required the assistance of 1 for care and ambulation. Resident #92 was sent to emergency room . An agency nurse aide, (NA #1 ' s) written statement identified she walked in front of the resident, not behind the resident, on the way to the bathroom. A nurse's note dated 11/30/21 at 8:55 AM, written by an agency nurse, (RN #1) noted at 7:25 AM, Resident #92 was observed lying on the floor on his/her back. NA #1 was ambulating the resident to the bathroom using a rolling walker. Resident #92 complained of right hip/leg pain on assessment. Resident #92 was able to move upper extremities and left leg without discomfort. The physician was notified and ordered to send Resident #92 to the emergency room for an evaluation. A nurse's note dated 11/30/21 at 4:35 PM identified the resident was admitted to the hospital for closed fracture of the right hip. Although NA #1 started working at the facility on 11/18/21, and had worked 7 shifts/days, review of the agency orientation packet indicated NA #1 was educated on patient safety and the use of the gait belt for residents who transfer status is contact guard or above on 11/30/21, after Resident #92 ' s fall. The nurse's note dated 12/3/21 at 11:04 PM indicated Resident #92 was readmitted around 3:10 PM from the hospital where status post fracture reduction. Resident #92 has wound care orders and appointment to follow. The hospital discharge summary dated 12/3/21 identified Resident #92 sustained a closed hip fracture and had surgery on 12/1/21. A Physical Therapy Evaluation and Treatment note dated 12/4/21 indicated prior to the fall, Resident #92 required an assist of 1 for transfers, and participated in the functional maintenance program for gait. A Functional Assessment status of transfers subsequent to the fall identified Resident #92 required total dependence without attempts to initiate sit to stand due to pain limiting transfers at this time. Recommendations included that Resident #92 be to be a hoyer out of bed with assist of 2 to customized wheelchair. A physician's order dated 12/6/21 directed to transfer the resident via a hoyer lift with the assistance of 2 staff. Observation on 12/6/21 at 12:30 PM identified Resident #92 was sitting up in bed being set up for lunch. Interview with the Director of Rehabilitation (DOR) on 12/6/21 at 11:30 AM noted prior to the fall with fracture on 11/30/21, Resident #92 required assistance of 1 with a rolling walker and a gait belt, and was on the functional ambulation program to ambulate up to 30 - 40 feet, 3 times a week by the therapy aide. The DOR noted the DNS informed him that NA #1 did not use a gait belt and walked in front of resident on 11/30/21 at the time of the fall. The DOR noted his expectation was that the nurse aide would stand to the side of Resident #92 to be closer to Resident #92 to hold onto the resident while walking. The DOR noted assist of 1 means hands on assistance and the expectation was to have one hand on the gait belt on the back side of Resident #92, so if Resident #92 started to lose his/her balance the nursing assistant could use the gait belt to lower the person versus the resident just falling. The DOR indicated all nursing assistants are to use a gait for resident that require assist of 1 for ambulation or need more assistance. The DOR noted Resident #92 since readmission from the hospital required a hoyer lift because of the pain, fear and anxiety. Interview with LPN #1 on 12/6/21 at 12:00 PM noted she had just come in at 7:00 AM and was at the desk across from Resident #92's room and NA #1 came out of Resident #92's room and said the resident was on the floor. LPN #1 noted NA #1 indicated she was walking Resident #92 from the bed to the bathroom with the walker and NA #1 noted Resident #92 lost his/her balance and fell on the floor. LPN #1 noted NA #1 did not have a gait belt on Resident #92 at the time of the fall on Resident #92. LPN #1 noted when interviewed, NA #1 indicated she was standing in front of the resident and his/her walker and LPN #1 indicated that NA #1 should have been standing next to Resident #92 and all nursing assistants know they have to use a gait belt. LPN #1 noted Resident #92 was calling out in pain while on the floor. LPN #1 called for the supervisor to come assess Resident #92 while on floor. LPN #1 noted while the RN supervisor did an assessment and Resident #92 was having pain in the right leg and hip. LPN #1 noted she and NA #1 stayed with Resident #92 while RN #1 went to get a gait belt, then LPN #1, RN #1, and NA #1 applied the gait belt to Resident #92 and got the resident up and off the floor. LPN #1 indicated the expectation was NA #1 should have stood next to the resident and used a gait belt for transferring and ambulating Resident #92. Interview with RN #1 on 12/6/21 at 12:20 PM noted LPN #1 called her, and she observed Resident #92 on the floor near the foot of the bed complaining of pain in the right leg. RN #1 did an assessment of Resident #92 and indicated she tried to bend and move Resident #92's right leg but the resident was in pain, so RN #1 indicated she wanted to send Resident #92 to the emergency room for evaluation due to the pain. RN #1 indicated NA #1 nor LPN #1 had a gait belt, so RN #1 went behind the nurses' station to the storage room and got a gait belt. RN #1 noted Resident #92 had urine on the floor, so NA #1, LPN #1 and RN #1 put the gait belt on Resident #92 and stood him/her up and placed Resident #92 on the bed until EMS arrived. RN #1 noted when Resident #92 stood up he/she yelled in pain. RN #1 noted NA #1 was ambulating Resident #92 from the bed to the bathroom on the right side of the bed and did not use a gait belt on the resident. Interview with the nurse staffing agency coordinator, (Person #1), on 12/6/21 at 12:50 PM noted NA #1 was hired with the Agency Staffing on 11/10/21 and was first scheduled and worked at the facility on November 18th, and subsequently on the 19th, 20th, 23rd, 24th, 26th , 27th , 30th and December 1st and 2nd, 2021. NA #1 worked November 18th - 27th without general orientation. Interview with RN #2 on 12/6/21 at 1:15 PM identified the nursing scheduler informs the nursing supervisors or RN #2 if there will be a new agency person coming to the facility. RN #2 indicated all agency staff on the first day must to do an agency orientation packet with the mandatory education before being allowed to work on the unit RN #2 indicated the expectation was the supervisor goes over the packet with the nursing assistant before they start on the unit. RN #2 noted she was responsible to keep the agency orientation packets for all agency staff and NA #1 did the orientation packet and the competency for gait belt with return demo with her after 8:00 AM on 11/30/21. RN #2 noted she did the general agency orientation packet with NA #1 on 11/30/21 after Resident #92 had fallen. Interview with the DNS on 12/6/21 at 1:30 PM indicated during her investigation, that NA #1 was ambulating Resident #92 from the bed to the bathroom with the rolling walker and Resident #92 had fallen and was sent to emergency room and had then had to have surgery. The DNS indicated when she interviewed NA #1 and did a demonstration of what had occurred NA #1 had positioned herself in the front of the resident's walker in front of the resident and when Resident #92 was turning the corner towards the bathroom Resident #92 lost his/her balance. The DNS indicated NA #1 noted she did not use a gait belt. The DNS indicated after the incident she did education with NA #1 regarding use of the gait belt and proper positioning for transfers and ambulation. The DNS indicated prior to agency staff working at the facility for the first time, they must sign in at the supervisor office and do the general orientation packet with the supervisor before working on the units. The DNS indicated she was not aware NA #1 had worked in the facility prior to receiving the general orientation. The DNS had a log of agency staff who had signed in and did packets, but NA #1 was not on the list. The DNS noted since Resident #92 ' s fall she had done education on gait belt use and had started auditing on 12/1/21. Interview with Administrator on 12/6/21 at 1:29 PM identified the expectation was the supervisor does the orientation packet with the new agency person on the first day prior to starting on the unit. Interview and review of the Attention Nursing Supervisor Book, undated, with the DNS on 12/6/21 at 1:50 PM indicated to make sure every agency nurse completes the posttest attached to the agency orientation packet prior to the start of the first shift and the person has to sign the signature sheet to receive the orientation packet and get access to the computer system. Review of the signature sheets dated 9/6/21 - 12/2/21 with the DNS indicated NA #1 was not on the sheets. Interview with the DNS on 12/7/21 at 7:47 AM indicated when Resident #92 fell , the RN should have done an assessment of the resident on the floor. If Resident #92 had pain when moving the extremities, the resident should have been left on the floor and made comfortable until EMS arrived. The DNS noted her expectation was Resident #92 would stay on the floor until EMS arrived. The DNS noted since Resident #92 was in pain, something was wrong, and staff should not have moved the resident to prevent further injury. The DNS noted this was the standard of practice and facility process but was not a policy. The DNS indicated although she completed the investigation, she was not aware RN #1, LPN #1, and NA #1 moved Resident #92 off the floor and stood the resident up with a gait belt and transferred Resident #92 onto the bed prior to EMS arrival. Interview with the Administrator on 12/6/21 at 1:29 PM identified the expectation was the supervisor does the orientation packet with a new agency person on the first day prior to starting on the unit. Interview with NA #1 on 12/7/21 at 1:10 PM indicated on 11/30/21 the regular nursing assistant gave her the assignment and reported that Resident #92 required the assistance of 1 for transfers and to get Resident #92 up and dressed first. NA #1 indicated the care card identified Resident #92 required the assistance of 1 staff but did not indicate the resident required a walker or a gait belt. NA #1 noted she sat Resident #92 on the edge of the bed and gave the resident the walker. NA #1 indicated she did not use a gait belt. NA #1 noted she stood in front of the resident and the walker to prevent the walker from tilting forward. NA #1 noted Resident #92 stood up and started to walk a few steps without an issue and then his/her left leg gave out and the resident fell on to his/her right side. NA #1 noted she was not able to reach the resident when he/she fell to try to lower the resident because Resident #92 did not have a gait belt on. NA #1 indicated she had not been provided general orientation prior to working on the unit, including when to use a gait belt. NA #1 noted after the fall she was handed an orientation packet to read and complete by herself and was given a gait belt. NA #1 noted after the fall for a few days she heard management overhead paging for staff to get a gait belt from the office. NA #1 indicated after Resident #92 fell , she, LPN #1 and RN #1 got the resident off the floor, stood him/her up, and sat him/her in a wheelchair for a few minutes. After a few minutes, the three staff again stood Resident #92 and transferred the resident onto the bed. NA #1 could not recall if Resident #92 was in pain but did recall the resident saying his/her leg was throbbing. NA #1 noted the nurse told her to dress Resident #92 after the resident was placed in bed and prior to the resident going to the hospital. NA #1 noted she dressed Resident #92 prior to leaving the facility per the nurse ' s directive. Review of the Nursing Agency policy identified temporary agency nursing personnel are to receive an orientation from an assigned staff member of the center for fire and disaster, abuse, neglect, and mistreatment, resident rights, and center protocols specific to certified personnel. Documentation confirming orientation will be maintained in a location designated by each facility. Review of the Gait Belt Use Policy identified gait belts are used to prevent injury and/or discomfort to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. The gait belt provides the means of support for staff to stabilize and assist residents' balance. Gait belts must be used when physically transferring or ambulating residents. The facility failed to provide care according to the plan of care which identified the need for a gait belt and assistance of 1 staff with ambulation. Subsequently, Resident #92 fell while walking to the bathroom without a gait belt and hands on assistance and sustained a hip fracture that required surgical intervention. 2. Resident #22's diagnoses included alcohol abuse, anxiety, and depression. A quarterly MDS dated [DATE] identified Resident #22 had no cognitive impairment and was independent with activities of daily living. a. The care plan dated 6/16/21 identified Resident #22 had a history of being a smoker. Interventions included to offer a smoking cessation patch and to monitor the resident's belongings for smoking material. A physician's order dated 8/13/21 directed Resident #22 may not have alcohol. A nursing progress note dated 8/28/21 at 8:21 PM identified Resident #22 was observed in his/her room with a lighter. When asked to give the lighter to a staff member, Resident #22 refused. Resident #22's speech was slurred, he/she was drooling, and was unable to follow the nurse's finger when a neurological assessment was performed. The nursing note further identified Resident #22 was speaking aggressively and cursing at staff and the APRN was notified. A nursing progress note dated 8/28/21 at 9:13 PM identified staff were monitoring Resident #22 and were awaiting a call back from the on-call provider for any new orders. A nursing progress note dated 8/28/21 at 10:16 PM identified the nurse asked Resident #22 for the lighter and told Resident #22 if he/she did not give the lighter to the staff, he/she would be sent to the hospital. Resident # 22 replied, good. A nursing progress note dated 8/28/21 at 10:29 PM identified Resident #22's conservator was notified that Resident #22 would be sent to the hospital. The nursing note further identified Resident #22 continued on every 15-minute monitoring. A nursing progress note dated 8/28/21 at 11:47 PM identified before the ambulance attendants arrived, Resident #22 released the lighter to the nurse. A search of Resident #22's room identified liquid that looked like cola, and smelt like alcohol in an orange juice bottle. Resident #22 refused a search of his/her bag. The nursing note further identified, upon arrival of the ambulance attendants, Resident #22 became irate and agitated, his/her speech was slurred, and his/her gait was shuffled. After 20 minutes and several attempts to educate Resident #22 that a transfer to the hospital was for his/her safety, Resident #22 complied, and was transferred to the hospital for evaluation. A nursing progress note dated 8/29/21 at 1:59 AM identified a RN had been notified by a nurse that Resident #22 had slurred speech and was in possession of a lighter that he/she refused to give to the nurse. A RN and nurse aide approached Resident #22 and noted Resident #22's speech was slurred. An attempt to interview and assess Resident #22 by the RN was unsuccessful after Resident #22 became very upset and yelled for the RN and nurse aide to leave him/her alone and get out of his/her room. Resident #22 was placed on every 30-minute monitoring. The on-call physicians were notified and directed Resident #22 be sent to the hospital for evaluation. Resident #22 left the facility at approximately 11:50 PM (8/28/21) for transfer to the hospital. The emergency room doctor called the facility and notified the RN that Resident #22 admitted that he/she drank approximately a ½ pint of an alcohol substance. Resident #22 also allowed a search of his/her belongings and no smoking material or alcohol substances were found. Resident #22 returned to the facility at 1:46 AM (8/29/21) and every 30-minute monitoring of Resident #22 was resumed. A nursing progress note dated 8/29/21 at 5:18 AM identified Resident #22 arrived back at the facility from the hospital at 1:45AM after being diagnosed and treated for alcohol intoxication. A social worker note dated 8/30/21 at 7:15 PM identified the social worker met with Resident #22 regarding Resident #22 having a lighter and coming back into the building intoxicated after being outside. Resident #22 admitted he/she drank a little but declined to identify how he/she obtained the alcohol. An APRN note dated 8/30/21 identified Resident #22 went to theER on [DATE] secondary to intoxication from alcohol use and refused to tell the APRN how h/she obtained the alcohol. Interview with the DNS on 12/7/21 at 9:42 AM identified on 8/28/21 Resident #22 was placed on every 15 - 30-minute monitoring after Resident #22 was noted with a change in mental status and observed to be in possession of a lighter. The DNS identified Resident #22 was monitored every 15-30 minutes from the time he/she was observed with the lighter and altered mental status until he/she was transferred to the hospital (approximately 3 hours and 50 minutes). The DNS further identified although Resident #22 was monitored every 15 - 30 minutes, a better intervention would have been to place Resident #22 on 1:1 observation. Interview with RN # 3 on 12/7/21 at 10:45 AM identified he/she could not explain why Resident #22 was not placed on 1:1 observation. RN #3 further identified although he/she did not document in a nursing progress, note, he/she would have notified the DNS that Resident #22 was in possession of a lighter and suspected of being intoxicated, and was placed on every 15 - 30 minute monitoring. RN #3 identified if the DNS determined Resident #22 required additional monitoring/interventions the DNS would have notified the supervisor to implement additional interventions. A policy regarding the supervision of residents in possession of smoking materials and/or with an altered mental status was requested but not provided. The facility's nonsmoking policy identified residents are not allowed to keep smoking materials (i.e., cigarettes, matches, lighters, etc.). b. A physician's order dated 7/6/21 directed that Resident #22 was medically cleared to leave the facility on a leave of absence to spend time with family and the resident must return to the facility on the same day. A nursing progress note dated 7/22/21 at 3:38 PM identified Resident #22 requested to go home for the weekend. A nursing progress note dated 7/23/21 at 8:27 AN identified Resident #22's conservator stated nobody can take Resident #22 out over a weekend, however Resident #22 could go out daily but must return to the facility by 9:00 PM. A physician's order dated 7/23/21 directed per Resident #22's conservator, Resident #22 may go out on a leave of absence daily but must return to facility by 9:00 PM. A nursing progress note dated 7/24/21 at 10:12 PM identified Resident #22 had not returned from a leave of absence and the APRN was notified. A nursing progress note dated 7/25/21 at 1:14 AM identified at approximately 12:30 AM the charge nurse notified the nursing supervisor that Resident #22 had not returned from a leave of absence. When Resident #22's family member was contacted, he/she identified being unaware of Resident #22's location. Calls were placed to Resident #22's cell phone and to another of Resident # 22's family member with no response. A review of the leave of absence sign out sheet identified Resident #22 was signed out by a different family member. A call to that family members cell phone identified the voicemail was not setup. A call to Resident #22's cell resulted with a message of not accepting calls. Resident #22's family member provided the address of the other family member, who had signed Resident #22 out for a leave of absence. The facility notified the police and requested a welfare check for Resident #22. A nursing progress note dated 7/25/21 at 3:43 AM identified the police arrived at the facility and notified the nursing supervisor that Resident #22 was not located at the address provided. A nursing progress note dated 7/25/21 at 7:33 AM identified the RN supervisor called two local hospitals and Resident #22 was not at either hospital. The nursing note identified messages were left for the APRN and Resident #22's conservator regarding Resident #22's failure to return from a leave of absence. A nursing progress note dated 7/25/21n at 6:11 PM identified Resident #22 returned from a leave of absence at approximately 4:00 PM and identified she had been at her boyfriend ' s house. A Physician order dated 7/25/21 directed per Resident # 22 ' s conservator, Resident # 22 ' s leave of absence privileges were rescinded. A Physician order dated 8/13/21 directed Resident # 22 may not have alcohol. An elopement evaluation dated 8/30/21 identified Resident # 22 was not at risk for elopement. A nursing progress note dated 9/8/21 at 11:17 PM identified Resident #22 came back from outside with a smell of alcohol coming from the resident. A room search identified a cup of alcohol (unknown type). Resident #22 became angry and violent. A nursing progress note dated 9/8/21 at 11:46 PM identified Resident #22 left the facility at 11:30 PM and was transferred to the hospital. A nursing progress note dated 9/9/21 at 12:35 AM identified the RN supervisor was called to assess Resident #22 who appeared intoxicated. A room search was done that identified a plastic cup with 4 fluid ounces. Resident #22 became belligerent and began chasing the supervisor. Resident #22 was transferred via 911. A social worker progress note dated 9/9/21 at 4:52 PM identified the social worker contacted Resident #22's conservator regarding Resident #22 drinking in the facility. A nursing progress note dated 9/10/21 at 7:32 PM identified at approximately 6:00 PM, Resident #22 was noted missing from the facility. A Dr. Hunt was initiated, and the police were notified. A nursing progress note dated 9/11/21 at 2:38 AM identified Resident #22 was located by a family member who was directed to bring Resident #22 to the emergency room for evaluation. A nursing progress note dated 9/11/21 at 12:18 PM identified Resident #22 was sent to the emergency room at approximately 3:18 AM and returned to the facility at approximately 10:00 AM. Resident #22 was placed on 1:1 observation to prevent further incident. A nursing progress note dated 9/11/21 at 4:52 PM identified Resident #22 was readmitted to the facility at approximately 10:04 AM after being treated at the hospital for alcohol intoxication. An APRN progress note dated 9/13/21 identified Resident #22 eloped from the facility, was found by a family member, was brought to the emergency room , and diagnosed with alcohol intoxication. The progress note identified a wander guard was placed on Resident #22. The progress note further identified Resident #22 wanted to leave the facility and was angry about his/her placement. Resident #22 refused to speak to the APRN about his/her alcohol consumption. Interview with the DNS on 12/7/21 at 9:42 AM identified the facility did not report Resident #22's failure to return from a leave of absence to the state agency because Resident #22 had a physician's order that directed Resident #22 could go on a leave of absence, therefore the facility did not consider this an elopement. Further interview with the DNS identified on 8/28/21 when Resident #22 was found intoxicated and in possession of a lighter the facility implemented every 15 - 30-minute monitoring of Resident #22 but did not identify a need to supervise Resident #22 when h/she chose to sit outside. The DNS further identified on 9/8/21 when Resident #22 came in from the outside smelling of alcohol the facility placed Resident #22 back on every 15 - 30 minute monitoring but should have implemented an intervention to supervise Resident #22 when he/she chose to sit outside. Subsequent to Resident #22's elopement from the facility, the facility implemented a quality improvement plan initiated regarding the prevention of elopements. A copy of a policy regarding the supervision of residents when outside was requested but not provided.

Based on clinical record review, facility documentation and staff interview for 1 of 3 sampled residents who required a mechanical lift transfer, (Resident # 1) the facility failed to ensure the lift pad was properly secured and/or the appropriate pad was used and/or the lift was in good working condition which resulted in an injury. The findings include: Resident # 1's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The quarterly MDS dated [DATE] identified severe cognitive impairment, total dependence on 2 staff for transfers, wheelchair used for mobility and functional limitations in range of motion to both upper and lower extremities. The RCP dated 7/26/18 identified ADL deficit related to limited mobility and weakness. Interventions included mechanical lift with an assist of two (2) to custom wheelchair. Review of the NA Care Card identified the resident was to be transferred via mechanical lift with an assist of using a medium sized yellow splinting pad. Facility documentation dated 7/30/18 at 7:30PM identified the resident fell from the Hoyer lift while being transferred from the shower chair to the bed. The documentation further identified that the Hoyer lift legs were not fully functioning (wouldn't open) prior to the transfer, and the resident lift pad was only attached to 5 of the 6 loop attachments. Additionally, the documentation noted the resident was transferred to the hospital and diagnosed with [REDACTED]. Nurse's notes dated 7/30/18 at 10:49PM identified the resident was on the floor after sliding from the Hoyer lift pad. The resident's head was noted on top of the Hoyer lift base. The resident was assessed and found the resident's right eye was not able to follow command. Range of motion was completed and the resident was noted to moan when the right leg was moved. The Physician was notified and the resident was sent to the hospital for an evaluation and admitted with a intraventricular bleed. Interview with the DON on 8/27/18 at 11AM stated that after the incident occurred she had the 2 staff involved reenact what they did. During the demonstration it was identified that all the pad hooks were not connected to the lift, the Hoyer lift legs did not open and the pad that was used was not the correct pad for the resident (the resident is to use a crisscross lift pad and what was used was a pad that wraps around the resident thighs). The DON stated that she checked the pad after the incident and found nothing wrong with it. The DON further stated that when a lift is used staff are to do a double check to ensure the lift is appropriately secured to the lift and that the NA and LPN did not do this. In addition, the DNS stated that NA #1 should have reported that the Hoyer lift was not functioning properly and should have selected the appropriate type of lift pad for Resident #1. Interview with NA # 1 on 8/27/18 at 11:25AM stated that when she started her shift she could not find the right kind of lift pad the resident needed so she used a different one and lifted the resident out of bed for a shower with another NA. At that time, NA #1 noted that the legs of the Hoyer lift would not open as they should have. The NA stated after the shower she was waiting for the LPN to come in and hooked up the lift pad to the lift but only hooked up 5 of the 6 loops to the lift pad because one was under the resident's leg. NA # 1 stated that LPN # 1 came in and stood behind the shower chair while the lift was raised and moved. NA # 1 stated that she went to pull the lift from under the shower chair the lift was stuck and the resident fell head first hitting his/her head on the base of the Hoyer lift. NA # 1 stated that she lowered the resident to the ground and removed the pad from the lift. NA # 1 further stated that although she knew she had the wrong lift pad and the legs of the Hoyer lift would not open, she did not report this to anyone because she was busy and she needed to get done with her assignment. Interview with LPN # 1 on 8/27/18 at 12:30PM stated that NA # 1 asked her to assist with the Hoyer transfer of Resident # 1. LPN # 1 stated that when she went into the room the NA hooked up the pad to the lift and she saw the NA hook 4 loops of the pad to the lift. LPN # 1 stated that although she is aware that she should have guided the resident over to the bed and held onto the resident, the NA wanted her to stand behind the chair to move it after the resident was lifted. LPN # 1 further stated that the NA did not report to her that the lift legs would not open and that she could not find the right lift pad for the resident. Interview with RN # 1 on 8/27/18 at 12:45PM stated that she was called to the room and found the resident lying on the floor with his/her head on the base of the lift. RN # 1 stated she assessed the resident and found the resident's neurological exam to be unstable (pupil not reacting like the other) and she notified the MD who directed to send the resident to the hospital for an evaluation. The RN Supervisor further stated that she completed the incident report and asked the staff what happened and both said everything was in place. Review of facility policy for Safe Resident handling identified that the resident care card will identify the type and size of sling, and the number of staff required to operate lift. During the on-site investigation it was noted that the facility had implemented reeducation to all staff on the proper use of a Hoyer lift.

Based on review of the clinical records, and interviews for the only sampled resident reviewed for Hospice services (R #211), the facility failed to ensure the request for hospice services were initiated, and/or for two of five residents (R#43, 201) reviewed for unnecessary medications the facility failed to initiate physician orders/recommendations and/or assess the resident with severe constipation resulting in a fecal impaction. The findings include: 1. Resident #201's [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified R#201 was alert, oriented, cheerful, cooperative and continent of bowel and bladder. The interim care plan dated 7/3/13 identified R#201 had pain and to observe for side effects like constipation. The care plan dated 7/25/13 identified a problem with pain and the utilization of narcotics placing R#201 at risk for constipation. Approaches included to observe for constipation, confusion and lethargy, encourage an increase in mobility, fluids and implement the bowel regimen as ordered. In addition the care plan identified R#201 had a history of [REDACTED]. Interventions included to administer medications as ordered and if a there was a decrease in urinary output or increased confusion or nausea and vomiting, dehydration may be a problem. Review of the nurse aide flow sheets identified R#201 did not have a bowel movement on 7/23, 7/24, or 7/25. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A consult/GI appointment notes dated 7/26/13 identified worsened constipation, rectal pain and internal hemorrhoids with directives to start [MEDICATION NAME] twice a day and if no bowel movement will consider a [MEDICATION NAME] (polyethylene [MEDICATION NAME] electrolyte solution) purge. Nurse's notes dated 7/26/13 identified an enema was administered on 7/26/13 with moderate results. Although the nurse aide flow sheets dated 7/26 through 7/31/13 identified R#201 was incontinent of stool, had medium bowel movements on 7/26, small and medium on 7/27, large and medium stools on 7/28, large and medium on 7/29/ and medium on 7/30 and 7/31, a review of the nurse's notes dated 7/26/13 through 7/31/13 failed to identify a nursing bowel assessment as to the character and quality of the stool, discomfort in the abdominal region and/or abdominal distention. Notes did identify that the resident complained of and was medicated for rectal pain. Nurse's notes dated 8/1/13 identified that R#201 was unable to complete physical therapy secondary to weakness. Family requested that R#201 be transferred to acute care for an evaluation. Review of the acute care documentation dated 8/1/13 identified R#201 was transferred to acute care on 8/1/13 and was admitted with a fecal impaction, [MEDICAL CONDITION], a severely distended bladder that resulted in hydro[DIAGNOSES REDACTED] and hematuria, and a BUN of 40 with a creatinine of 1.6. The resident complained of severe constipation which had progressed into abdominal pain and incontinence with liquid stool for the previous three days. The CT scan in the emergency room demonstrated a large amount of stool, throughout the colon with fecal impaction at the level of the rectum. The resident required manual disimpaction with resolution of his/her rectal pain. Review of facility policy directs that bowel elimination pattern will be monitored every shift and timely intervention provided. 2. Resident #211 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified the resident was alert, but confused at times with clear speech, impaired memory and/or judgment, unsteady gait for ambulatory status and utilizes a wheelchair for mobility. A review of social service notes dated 1/22/13 identified that although a request was made to the facility for R #211 to receive hospice services, documentation was lacking to reflect a physician's response to the request. On 8/30/13 at 11:20 A.M. an interview and review of the clinical record with the Director of Social (DSS) identified that initially when hospice services were requested, Person #2 indicated that he/he/she would prefer to contact the hospice agency on his/her own and when the DSS contacted the hospice agency as well on 1/23/13, the social worker was informed that a physician's orders [REDACTED]. The DSS indicated that at the time of the request, he/he/she informed the facility (i.e. the former DON and Administrator along with the current nursing supervisor and the ADON) during morning report. A review of nursing notes dated 1/25/13 at 2:20 P.M. and 11:00 P.M. identified that although the physician was made aware of the family's request for hospice and that the facility was awaiting a response from the physician, documentation was lacking to reflect that the physician responded to the request and/or that an order was provided for hospice services. On 8/29/13 at 1:35 P.M. and 1:54 P.M. interview with the ADON and the Nurse Supervisor (RN #6) indicated that although they remembered R #211 and may have been in morning report during the aforementioned time frame, the ADON and RN #6 were unable to recall any details concerning the request and/or event. On 8/29/13 at 2:45 P.M. an interview and review of the clinical record with the DON lacked documentation to reflect that the order was obtained and/or received. The DON further indicated that when the resident's attending physician is not available for a response, the nurses are to contact the medical director. 3. Resident #43 ' s [DIAGNOSES REDACTED]. A behavioral health consultant recommendation dated 3/11/13 indicated that the resident needed labs including TSH, Folate, B12, and psychological testing for dementia. Physician orders [REDACTED]. During an interview and review of Resident #43 ' s clinical record with RN#7 on 8/29/13 at 11:30 AM, he/she indicated that the physician order [REDACTED]. RN#7 indicated that he/he/she was not sure why testing was not completed. During an interview and review of Resident #43 ' s clinical record with PA#1 on 8/29/13 at 2:30 PM, he/she indicated that the psychologist should do the psychologist testing for dementia and document in the resident's clinical record.

Based on clinical record reviews, review of facility policies, and interview for two residents (R#201, R#40) of three residents reviewed for hydration, the facility failed to monitor fluid intakes in at risk residents, and/or failed to initiate/develop an immediate plan of care to prevent dehydration when intake declined and/or labs were obtained that indicated signs of dehydration, and/or failed to assess residents for signs and symptoms of dehydration. The findings include: 1. Resident #201 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified R#201 was alert, oriented, continent of bowel and bladder and failed to identify the completion of the dehydration risk assessment. On admission, R#201 was noted to have a Blood Urea Nitrogen (BUN) of 16 (normal 7-25) and a Creatinine (CR) 0.91 (normal 0.6-0.88) and received a diuretic daily. Review of the nutrition evaluation dated 7/6/13 identified R#201 ' s estimated fluid needs were 1750- 2100 cc Intake and output (I&O) monitoring dated 7/7/13 through 7/12/13 noted that the resident failed to meet the estimated fluid needs for three of the six days. No further I&O monitoring was present. Physician orders [REDACTED]. Laboratory data dated 7/22/13 identified an increase in R#201 ' s BUN to 34 and an increase in Cr to 1.3. Nutritional progress notes dated 7/26/13 identified R#201 ' s weight on 7/22/13 demonstrated a five pound weight loss and laboratory data reflected an increase in BUN. Review of the nurse ' s notes from 7/3/13 through 7/31/13 failed to identify that R#201 ' s was assessed for signs and symptoms of dehydration. No intake and output monitoring was present in the record after 7/12/13. Nurse ' s notes dated 8/1/13 identified that R#201 was unable to complete physical therapy secondary to weakness. Family requested that R#201 be transferred to acute care for an evaluation. Review of the acute care documentation dated 8/1/13 identified R#201 was transferred to acute care on 8/1/13 and was admitted with a fecal impaction, [MEDICAL CONDITION], a severely distended bladder resulting in hydro[DIAGNOSES REDACTED] and a BUN of 40 with a creatinine of 1.6. Interview and clinical record review with the Director of Nursing on 8/30/13 at 12:30 PM failed to provide documentation that the resident ' s I&O was monitored with the use of the [MEDICATION NAME]/presence of [MEDICAL CONDITION], and/or that the resident was assessed for signs and symptoms of dehydration, and/or that I&O was initiated when the resident ' s BUN was noted elevated on 7/22/13 or a care plan initiated to ensure adequate hydration. The DNS identified that on admission, intake and output monitoring is completed for three days and then continued if the fluid needs are not met. If fluid needs are not met, it is also expected that the resident be assessed for physical signs of dehydration and laboratory values reviewed. Review of facility policy identified that residents will be assessed and residents at risk will be identified. At risk residents will be reviewed by the Interdisciplinary team and will be provided with interventions to promote hydration based on the resident ' s physical and mental abilities. 2. Resident #40 ' s [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified severe cognitive impairment. The physician orders [REDACTED]. The resident care plan dated 2/5/13 identified a risk for dehydration and electrolyte imbalance related to the utilization of diuretics to treat [MEDICAL CONDITION]. Interventions included to monitor labs as ordered, and assess for dehydration if there was an increased temperature, decreased urinary output or confusion. Nurse ' s notes dated 3/9/13 identified R#40 was observed to be coughing when ingesting thin liquids at breakfast. The resident was placed on nectar thickened liquids and a speech consult requested. On 3/10/13, R#40 was reported to have very poor intake and was without signs and symptoms of dehydration. On 3/12/13, the resident was assessed and determined be severely dehydrated and IV therapy was initiated. The resident ' s BUN was 68 at the time. Review of the APRN progress note dated 3/12/13 identified R#40 had developed difficulty swallowing and his/her diet had been downgraded to thickened liquids. R#40 continued to have poor (PO) intake and became lethargic. Laboratory data identified severe dehydration and intravenous (IV) hydration was initiated. Review of laboratory data identified that R#40 ' s Blood Urea Nitrogen (BUN) was 20 on 10/15/12 and Creatinine was 1.29 and on 3/12/13 had risen to BUN 65 and a creatinine of 1.71. After IV hydration review of the laboratory data dated 3/18/13, R#40 ' s BUN had dropped to 29 and the Creatinine 1.08. Review of the clinical record with the DNS on 8/30/13 at 1:30PM failed to identify any dehydration assessments. Further review noted that the intake and output records dated 3/3/13 through 3/16/16 only recorded urine output from the Foley catheter and not oral intakes despite the poor fluid intake. The DNS identified that on admission, intake and output monitoring is completed for three days and then continued if the fluid needs are not met. If fluid needs are not met, it is also expected that the resident be assessed for physical signs of dehydration and laboratory values reviewed. Review of facility policy directs that residents at risk for dehydration will be place on intake and output monitoring until adequate hydration status is achieved or until I&O monitoring is no longer clinically indicated.

Based on clinical record reviews, review of facility documentation, and interviews for two of five sampled residents (Residents #10 and #74) who were reviewed for accidents, the facility failed to utilize the appropriate assistive device to prevent an injury and/or failed to conduct an assessment when a change in condition was noted. The findings include: 1. Resident #10's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #10 had memory deficits, moderate cognitive impairments, required extensive assistance with transfers between surfaces, was totally dependent on staff for bathing and had functional limitation in range of motion on both sides of the upper and lower extremities. The physician's orders [REDACTED]. The nurse's note dated 3/9/11 at 4:15 PM identified that at 3:30 PM the charge nurse was called to the shower room to assess Resident #10 who fell in the shower room. On assessment the resident was found lying with head down and bleeding from the head. The nurse's note indicated that 911 was called and Resident #10 was transferred to the hospital for an evaluation and was admitted with a cervical spine fracture, head laceration and hematoma. The hospital discharge summary dated 3/14/11 identified that Resident #10 had also sustained an odontoid fracture. Review of the Reportable Event Form dated 3/9/11 at 3:30 PM identified that Resident #10 was seated in the shower chair, was startled by the water and jolted forward from the chair landing on the floor. Review of the facility's investigation identified that the shower chair seat belt was not utilized. Interview with the Staff Development Registered Nurse (RN #4) on 9/7/11 at 2:20 PM identified that when providing a shower for a dependent resident, staff should stand in front, stabilizing the resident with one hand and applying the water in a manner that does not startle the resident. Interview with Nurse Aide (NA) #3 on 9/7/11 at 2:45 PM identified that although she had tested the water temperature on her arm prior to spraying Resident #10's right leg, the resident was startled by the water and "leaped" off the shower chair. NA #3 indicated that she stood on the right side of the resident, was holding the shower head in one hand, a wash cloth in the other and she was not touching the resident. Review of facility documentation identified as "Safety Standards" dated June 2010 identified in part residents are not to be left unattended in a shower chair and safety belts are to be fastened at all times. The safety belt purpose is to provide added safety during transportation and showering and do not make it safe to leave a resident in the chair even a short time. If a resident has been assessed to be safe to shower independently, the resident may be left alone in the shower. The standard further identified that the safety rules listed above are necessary to ensure resident safety. 2. Resident #74's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified that Resident #74 had memory deficits, severe cognitive impairment, required extensive assistance with bed mobility, was totally dependent for transfers between surfaces requiring full staff performance of the activity, had a fall in the past 30-180 days and full loss of voluntary movement on one side that included the arm, hand, leg and foot. The resident care plan dated 9/21/10 identified that the resident was at risk for falls and/or injury due to mobility. Interventions directed to transfer out of my bed to a tilt-in-space custom wheel chair via a mechanical lift (Hoyer) with the assist of two. The nurse's note dated 10/31/10 at 1:15 PM identified that Registered Nurse (RN) #6 was alerted to the family's concern regarding a bruise and pain of Resident #74's left lower extremity. The note indicated that subsequent to physician notification an x-ray was ordered. The 10/31/10 nurse's note at 7:34 PM identified that the x-ray report indicated Resident #74 had an acute non-displaced proximal tibia fracture, the physician was updated and the resident was transferred to the hospital. On 11/1/10 Resident #74 returned to the facility with an immobilizer on the left leg. The Reportable Event Form dated 10/31/10 at 1:00 PM left leg bruising below the knee and the x-ray report identified Resident #74 had sustained a non-displaced acute tibia fracture. Review of the facility's investigation from 10/31/10 through 11/1/10 identified that at first on 10/31/10 Resident #74 stated that he/she fell and on 11/1/10 the resident indicated that the leg got "stuck" a week ago. Statements provided by staff identified that the primary Nurse Aide (NA) did not tell the nurse that Resident #74 was "moaning" because the resident always moans and was combative, no bruising and/or swelling was noticed. The NA stated that on 10/31/10 Resident #74 was louder and moaned as lotion was applied to the left leg but because the resident did not speak English the NA did not understand what Resident #74 was saying no swelling and/or bruising was noted. The 3-11 PM NA (NA #4) on duty 10/30/10, stated that while seated in the wheel chair Resident #74 removed the seat belt and slid down in the chair and the buttock was about where the knees should be. NA #4 and Licensed Practical Nurse (LPN) #7 repositioned the resident in the wheel chair and then Resident #74 was placed back to bed. LPN #7 stated that Resident #74 had slouched and slide out of the wheel chair, the butt was still in the wheel chair at the edge, the right foot was off the leg rest and the left foot was in the boxed leg rest. The resident was pulled up in the chair and at that time the resident did not complain of pain and/or no bruising was noted. The facility's conclusion indicated that the cause of the fracture was when the resident had slide down in the wheel chair. Interview and review of hospital x-ray report dated 10/31/10 with the Radiologist (MD) #3 on 9/6/11 at 3:05 PM identified that Resident #74 had sustained a non-displaced transverse fracture of the proximal tibia approximately 3.0 centimeters below the joint. MD #3 indicated that although there could be different causes of this type of fracture, it was most likely caused by an abrupt impact, i.e. a blow, a fall and/or being dropped landing on the leg.