Every finding on record at Complete Care at Harrington Court

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for suicidal ideation, the facility failed to ensure that when Resident #1 continued to experience pain after administration of scheduled analgesics, licensed nursing staff assessed the ongoing pain and implemented available interventions, including review of the Medication Administration Record (MAR) and timely administration of ordered PRN pain medication. As a result, Resident #1's pain remained unrelieved, contributing to the escalation of distress and self harm behaviors. The findings include:Resident #1's diagnoses included nondisplaced oblique fracture of the shaft of the right femur (a diagonal break in the thighbone that remains aligned), periprosthetic fracture around internal prosthetic right hip joint (broken bone that occurs in the area surrounding a surgically implanted joint), pain due to internal orthopedic prosthetic devices (hardware), major depressive disorder, bipolar disorder with mild depression and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), and required setup assistance for eating, bed mobility and transfers and was independent with ambulation.The Resident Care Plan (RCP) dated 6/9/26 identified Resident #1 exhibited or was at risk for alterations in comfort related to a periprosthetic fracture of the right hip. Interventions included utilizing the pain scale, medicating the resident as ordered for pain, monitoring for effectiveness and side effects and reporting to the provider as needed.A nurse's note by RN #4 dated 6/9/26 at 3:02 PM identified, in part, Resident #1 was readmitted to the facility with a diagnosis of a periprosthetic fracture around internal prosthetic of the right hip joint. Two (2) dressings were intact to the right hip with an order for dressings to stay in place for seven (7) to ten (10) days. Resident #1 arrived with a foley catheter for urinary retention (inability to fully or partially empty the bladder). Acetaminophen and tramadol were ordered for pain.A physician's order dated 6/9/26 directed to administer acetaminophen 325 milligrams (mg), give two (2) tablets by mouth every eight (8) hours for pain for fourteen (14) days.A physician's order dated 6/9/26 directed to administer tramadol 100 mg, give one (1) tablet by mouth every six (6) hours as needed for severe pain for fourteen (14) days.The facility Accident and Investigation (A & I) form dated 6/13/26 identified at 4:51 AM Resident #1 was found with a sheet wrapped around his/her neck, witnessed by both RN #1 and LPN #1. The on-call provider was notified, and Resident #1 was transferred to the Emergency Department (ED) for evaluation. Prior to the incident, Resident #1 was confused and complained of pain.A Situation, Background, Assessment and Recommendation (SBAR) note by RN #1 dated 6/13/26 at 4:51 AM identified Resident #1 had a change in condition related to behavioral symptoms, was a danger to self and/or others and was experiencing pain. Resident #1's behavior seemed to be in response to pain, but to err on the side of caution, Resident #1 was transferred to the ED for evaluation by a psychiatric provider.Review of the Medication Administration Record (MAR) identified prior to the 6/13/26 incident, Resident #1 was administered scheduled acetaminophen at 12:00 AM by LPN #1. The administration did not require subsequent evaluation of the effectiveness of the acetaminophen. Additionally, the MAR identified Resident #1 was administered Tramadol 100 mg at 3:38 AM, however, the Controlled Substance Disposition form for tramadol 50 mg tablets dated 5/20/26 identified one (1) 50 mg tablet was borrowed for Resident #1 on 6/13/26 at 4:00 AM, despite a physician's order for tramadol 100 mg.Review of the clinical record dated 6/13/26 failed to identify documentation regarding pain or interventions offered or administered.Interview with Resident #1 on 7/13/26 at 11:39 AM identified he/she was slightly confused on 6/13/26 and recalled having severe pain to the right leg and groin with no relief which caused him/her to tie a sheet around his/her neck for relief.Interview with NA #1 on 7/13/26 at 12:20 PM identified on 6/12/26, Resident #1 started to ring the call bell and complain of pain at around 11:50 PM. NA #1 notified LPN #1 immediately and repositioned Resident #1 several times with the assistance LPN #1 but Resident #1 remained awake and continued to ring the call bell numerous times complaining of pain and discomfort.Interview with RN #1 on 7/13/26 at 1:45 PM identified LPN #1 notified her just before 4:00 AM on 6/13/26 that Resident #1 had been complaining of pain. Resident #1 reported issues with urinating and feeling as if something was stuck in his/her rectum. RN #1 assessed Resident #1's abdomen, which was not distended, but Resident #1 yelled out and grimaced on palpation. LPN #1 reported a bladder scan yielded fifteen (15) milliliters (mL) of urine. RN #1 reviewed the MAR and confirmed PRN tramadol was available. She helped LPN #1 locate the tramadol but could not recall where it was obtained and identified if it were not sent from the pharmacy for Resident #1, it should have been obtained from the Pyxis (automated medication dispensing machine of an emergency stock of medications). When they returned to Resident #1's room with the tramadol, Resident #1 had a sheet tied around his/her neck and stated, If you care, take it down, but if not, then leave it. Resident #1 had no apparent injuries, was placed on one-to-one observation, was administered the PRN tramadol, and sent to the ED for evaluation. RN #1 identified Resident #1 appeared to attempt self-harm to draw attention to his/her pain. She was unaware Resident #1 had been complaining of pain since around 11:50 PM and identified LPN #1 should have medicated Resident #1 with PRN tramadol within one (1) hour of the acetaminophen administration when pain was unrelieved.Interview with LPN #1 on 7/13/26 at 3:19 PM identified on 6/12/26 at around 11:50 PM, Resident #1 began complaining of groin pain. She administered the scheduled acetaminophen at 12:00 AM on 6/13/26. After 45-60 minutes, Resident #1 rang the call bell again and continued to complain of pain. LPN #1 performed a bladder scan, which identified 15 mL of urine in the bladder. Resident #1 appeared to be in pain and seemed confused so was repositioned without effect. LPN #1 reported she did not notify RN #1 of the ongoing pain until around 3:30 AM. She was unaware that Resident #1 had a PRN tramadol order. She acknowledged she should have reviewed the MAR when the pain was unrelieved after the acetaminophen administration and repositioning, and that she should have administered the PRN tramadol. She identified she was busy that shift and notified RN #1 when she got the chance. LPN #1 could not recall where the tramadol was obtained from. Interview with the DON on 7/14/26 at 10:24 AM identified LPN #1 should have reviewed the MAR and administered PRN tramadol within one (1) hour of the acetaminophen administration when pain remained unrelieved. Licensed nurses were required to follow physician's orders and administering the incorrect dose of tramadol was a medication error. LPN #1 should have ensured Resident #1 was administered tramadol 100 mg as the order directed. Completing a pain assessment within 1-hour of administering the scheduled acetaminophen and administering the PRN tramadol timely following the continued pain and per physician's order may have prevented the self-harm incident.Interview with APRN #1 on 7/14/26 at 10:47 AM identified following the administration of pain medication, a resident should be reevaluated for pain within the hour. If a PRN medication is available, the pain level should be assessed and documented and the medication should be administered as soon as able. Licensed staff are responsible for following physician's orders and administering the correct dose as ordered.Review of the Pain Management policy dated 9/1/24 directed, in part, staff must identify when pain is present or anticipated, evaluate pain at admission and with any change in condition, and use both verbal and non verbal indicators to recognize discomfort. Once pain is identified, the licensed nurse is responsible for timely assessment, documentation, and implementation of appropriate interventions consistent with the resident's care plan, professional standards of practice, and the resident's goals. Licensed nurses are to use appropriate pain assessment tools; gather detailed information on the resident's pain history, characteristics, precipitating factors, and impact on quality of life; review prescribed pain medications, including PRNs, and administer them as ordered when pain is not controlled; reassess pain within one hour after administering pain medication, document effectiveness, and revise treatment as needed; notify the provider when pain remains uncontrolled and ensure correct dosing of all analgesics, including opioids. When pain persists or worsens, staff are to reassess, document findings, and adjust the care plan or medications accordingly. Failure to follow the physician's orders for PRN pain medication or failure to reassess within the required time frame places the resident at risk for unmanaged pain, decreased quality of life, and behavioral or psychosocial decline.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for behaviors, the facility failed to ensure controlled substances were obtained, stored, and administered according to policy and federal requirements. Specifically, staff borrowed a controlled substance from another resident's supply and failed to administer the controlled medication according to the physician's order. The findind include:Resident #1's diagnoses included nondisplaced oblique fracture of the shaft of the right femur, periprosthetic fracture around the internal prosthetic right hip joint, pain due to internal orthopedic prosthetic devices, major depressive disorder, bipolar disorder with mild depression, and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), required setup assistance for eating, bed mobility, and transfers, and was independent with ambulation.The Resident Care Plan (RCP) dated 6/9/26 identified Resident #1 exhibited or was at risk for alterations in comfort related to a periprosthetic fracture of the right hip. Interventions included medicating the resident as ordered, reviewing pain medications, and monitoring for effectiveness.A physician's order dated 6/9/26 directed tramadol 100 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for severe pain.Review of the Medication Administration Record (MAR) identified Resident #1 was administered tramadol 100 mg at 3:38 AM on 6/13/26 by LPN #1.Review of the Controlled Substance Disposition form for Resident #6's tramadol 50 mg tablets dated 5/20/26 identified one (1) 50 mg tablet was borrowed for Resident #1 on 6/13/26 at 4:00 AM, despite Resident #1 having a physician's order for tramadol 100 mg. The disposition form was signed by RN #1 and LPN #2.Interview with RN #1 on 7/13/26 at 1:45 PM identified medications are to be administered per physician's orders. RN #1 reported helping LPN #1 locate tramadol for Resident #1 but could not recall where it was obtained, adding that if it was not sent from the pharmacy for Resident #1, it should have been obtained from the Pyxis.Interview with LPN #1 on 7/13/26 at 3:19 PM identified she could not recall where the tramadol was obtained and stated that if the medication was not available in Resident #1's supply, it should have been accessed from the Pyxis, though she reported she had difficulty accessing the Pyxis on 6/13/26. LPN #1 acknowledged that controlled medications must be administered according to the physician's order.Interview with the Director of Nursing (DON) on 7/14/26 at 10:24 AM identified that controlled substances are not to be borrowed from another resident's supply and must be obtained through approved systems such as the Pyxis. The DON identified she learned on 7/14/26 that both RN #1 and LPN #1 were unable to access the Pyxis on 6/13/26 and instead borrowed tramadol from Resident #6. The DON stated LPN #1 should have ensured Resident #1 received tramadol 100 mg as ordered.Interview with APRN #1 on 7/14/26 at 10:47 AM identified licensed nurses are responsible for following physician's orders and administering controlled substances in the correct dose.Review of the Controlled Substance Administration & Accountability policy dated 7/1/24 directed that controlled substances are to be stored securely, obtained only through approved dispensing systems, documented accurately, and administered exactly as ordered. Borrowing controlled substances from another resident's supply and administering a dose different from the physician's order does not comply with facility policy or federal requirements.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for behaviors, the facility failed to ensure targeted behavior monitoring was initiated for an anti-psychotic medication. The findings include:Resident #1's diagnoses included major depressive disorder, bipolar disorder with mild depression and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), required setup assistance for eating, bed mobility and transfers and was independent with ambulation.The Resident Care Plan (RCP) dated 6/9/26 identified Resident #1 had the potential for changes in mood, behavior and psychosocial well-being due to a history of alcohol abuse, depression and was recently widowed. Interventions included administering medication per order, monitoring for therapeutic effects and side effects of medications and completing behavior monitoring.A physician's order dated 6/9/26 directed to complete generic behavior monitoring every shift.The facility Accident and Investigation (A & I) form dated 6/13/26 identified at 4:51 AM Resident #1 was found with a sheet wrapped around his/her neck, witnessed by both RN #1 and LPN #1. The on-call provider was notified, and Resident #1 was transferred to the Emergency Department (ED) for evaluation. Prior to the incident, Resident #1 was noted to be confused and complaining of pain.A psychiatric APRN note by APRN #2 dated 6/15/26 identified she was asked to see Resident #1 urgently following return from the Emergency Department (ED) after an emergent hospitalization for psychiatric concerns. Resident #1 reported continued delusions and at times, hallucinations, which primarily occurred in the evening. Resident #1 also reported mood liability as well as having a hard time getting ahold of his/her emotions at times. Recommendations included starting Seroquel 25 milligrams (mg) daily at bedtime for delusions and visual hallucinations and monitoring for change of mood, appetite and sleep.A physician's order dated 6/15/26 directed to administer Seroquel 25 mg, give one (1) tablet by mouth at bedtime for bipolar disorder, visual disturbances and hallucinations.Review of physician's orders from 6/15/26 through 7/13/26 failed to identify that targeted behavior monitoring was initiated to include delusions and visual hallucinations.Interview with the DON on 7/13/26 at 2:25 PM identified upon initiation of antipsychotic medications, targeted behavior monitoring is to be completed every shift while the medication is utilized. For Resident #1 the targeted behaviors for the Seroquel should have included monitoring for delusions and visual hallucinations. She was unsure why an order for the targeted behaviors was not initiated when the new order for the Seroquel was entered, reporting it must have been missed.Review of the Use of Psychotropic Medications policy dated 4/1/25 directed, in part, that psychotropic medications are to be used only when clinically indicated and after appropriate non-pharmacological interventions have been considered or attempted, unless contraindicated. Ongoing behavior monitoring by requiring assessment of the resident's physical, behavioral, mental, and psychosocial signs and symptoms before initiating, changing, or discontinuing medication. The policy further requires continuous monitoring and documentation of the resident's response to treatment, including progress toward treatment goals, the presence or absence of adverse effects, and regular physician, nursing, pharmacist, and interdisciplinary reviews to ensure medications remain appropriate, effective, and used at the lowest effective dose.

Based on clinical record review, interviews, and facility document review, the facility failed to ensure that medication orders were accurately transcribed and verified for one (1) of two (2) residents reviewed for medication administration (Resident #1), resulting in a significant medication error when Methotrexate, ordered to be administered one time per week, was incorrectly transcribed and administered daily for nine (9) consecutive days. The error was not detected through required reconciliation processes, including RN transcription, supervisory second check, APRN review, physician review, and pharmacy consultant review, despite active MAR dose warnings. As a result, Resident #1 developed progressive methotrexate toxicity characterized by mucositis, gastrointestinal symptoms, severe neutropenia, respiratory failure, ICU admission, and subsequent death, placing the resident in Immediate Jeopardy and demonstrating a failure to protect the resident's health and safety. The findings include: Resident #1's diagnoses included rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders dated [DATE] identified an order for Methotrexate (used to treat severe autoimmune conditions) 2.5 mg take four (4) tablets in the AM and three (3) tablets in the PM one (1) time per week.The facility transcribed orders dated [DATE] identified an order for Methotrexate 2.5 mg take four (4) tablets in the am and three (3) tablets in the PM one (1) time per day.The Medication Administration Record (MAR) dose warning for Methotrexate dated [DATE] identified the entered dose of Methotrexate 2.5 mg four (4) tablets by mouth in the morning and three (3) tablets by mouth in the evening were outside of the recommended dose or frequency. The warning further identified the dosing exceeded the usual dosing regimen of one (1) to ten (10) tablets every seven (7) days and the frequency of daily exceeded the usual frequency of every seven (7) days.The on-call physician note dated [DATE] at 1:33 PM identified APRN #2 reviewed the discharge paperwork and discharge medication list from the hospital and approved all medications as written on the discharge paperwork.The Electronic Medical Record (EMR) generated progress note dated [DATE] at 5:52 PM identified the Methotrexate dose that was entered by RN #1 was outside of the recommended dose or frequency. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 12), and required moderate assistance for toileting, dressing, transfers, and ambulation.The Resident Care Plan (RCP) dated [DATE] identified Resident #1 developed thrush and interventions directed to provide oral care as frequently as tolerated and report changes in vital signs.The on-call physician's note dated [DATE] at 1:15 PM identified the physician was notified by nursing staff and video observation that Resident #1 complained of mouth pain and upon assessment had mouth sores and thrush around the lips and cheeks. The physician directed Fluconazole 200 mg to begin one (1) time daily for seven (7) days then 100 mg one (1) time daily for seven (7) days and Lidocaine two (2) % oropharyngeal viscous solution 20 milligrams (mg)/one (1) milliliter (ml) every six (6) hours for seventy-two (72) hours.The nurse's note dated [DATE] at 3:24 PM by LPN #5 identified Resident #1 complained of mouth sores and inability to eat. The provider was notified, and medication orders and bloodwork orders were obtained.The nurse's note dated [DATE] at 1:56 PM by LPN #2 identified Resident #1 ate poorly due to mouth and throat discomfort, had a very large loose stool, and complained of nausea.The nurse's note dated [DATE] at 7:01 PM by LPN #2 identified Resident #1 vomited after eating.Bloodwork drawn on [DATE] identified a white blood cell (WBC) count of 0.8 (normal range: 4.8-10.8).A note by APRN #1 dated [DATE] at 12:00 AM identified the cause of leukopenia (abnormally low number of white blood cells in the blood which increases the risk of infection) was likely due to Methylprednisolone (a potent synthetic corticosteroid used to reduce inflammation and suppress the immune system) and Actemra ACT (biologic designed to treat moderate to severe inflammatory diseases) pen injection that Resident #1 last received on [DATE] and directed to place both medications on hold due to the low WBC count, to place Resident #1 in a private room, start leukopenia precautions to prevent infection, and repeat labs in two (2) days.The RCP was revised on [DATE] and identified Resident #1 was neutropenic and had an altered respiratory status and directed to administer medications as ordered, proper handwashing, to keep the resident away from others that were ill, monitor for signs of infection, monitor labs, elevate the head of bed, and monitor for signs of respiratory distress.The Hospital Transfer form dated [DATE] at 5:30 PM identified Resident #1 was hypoxic and on six (6) liters of oxygen upon transfer and was on isolation precautions.The Emergency Medical Service (EMS) run sheet dated [DATE] at 5:32 PM identified upon arrival to the facility the RN reported Resident #1 was neutropenic the day before and on [DATE] was found to have a pulse oxygen level of seventy seven (77) % (Normal range: 95% to 100%) on room air, was placed on six (6) liters of oxygen, was administered albuterol and Solu-Medrol (a fast-acting injectable corticosteroid used to treat severe inflammation, allergic reactions, and autoimmune disorders) intramuscular (IM) without improvement. Resident #1 became winded between sentences and had evidence of a prior bloody nose. While in the ambulance, Resident #1 was placed on two (2) liters of oxygen, administered albuterol, and IM methylprednisolone 125 mg.The Hospital Records for the [DATE] to [DATE] hospitalization identified Resident #1 was admitted with diagnoses of neutropenic fever, methotrexate toxicity, and sepsis. Resident #1 could not tolerate Bilevel Positive Airway Pressure (BiPAP) (a non-invasive ventilation machine that uses a mask to deliver higher pressure when you breathe in and lower pressure when you breathe out to assist with breathing) and was intubated and admitted to the Intensive Care Unit (ICU). The Methotrexate medication error was discovered at the hospital and recommendations were made for the resident to be transferred to another hospital that could further investigate and manage methotrexate toxicity as well as recommendations to conduct a bone marrow biopsy to further work up Resident #1 for diagnoses and treatment. The family declined due to the residents rapidly declining health. Resident #1 was extubated and expired on [DATE].Interview with APRN #1 on [DATE] at 1:40 PM identified she evaluated Resident #1 after Resident #1 sustained a fall on [DATE]. APRN #1 ordered bloodwork. Upon review of the bloodwork results, APRN #1 identified Resident #1 as neutropenic and discussed a course of action with MD #1. APRN #1 believed Resident #1 was receiving the Methotrexate one (1) time per week per the original hospital discharge summary and because Resident #1 had received the Acterma injection on [DATE] directed to hold both medications and repeat bloodwork. APRN #1 was not aware of the medication error until after Resident #1 was admitted to the hospital. APRN #1 identified the increased amount of Methotrexate administered to Resident #1, although not definitive, could have been the cause of the thrush and neutropenia. APRN #1 further identified the incorrect administration of Methotrexate as a significant medication error. (APRN #1 clarified that in her note dated [DATE] at 12:00 AM she referenced Methylprednisolone in error and should have noted Methotrexate).Interview with RN #3 (the [NAME] President of Clinical Services) on [DATE] at 2:20 PM identified RN #1 entered the Methotrexate order incorrectly on the MAR on [DATE] and RN #2 (the 11:00 PM to 7:00 AM supervisor) who was responsible to do the second check of the medication reconciliation did not see the error. RN #3 identified the medication orders were then sent electronically to the pharmacy, who then filled the medication according to the incorrect orders. The pharmacy consultant who was responsible for reviewing the medication orders of all new admissions did not identify the incorrect dosing of the Methotrexate. RN #3 further identified the medication error as a significant medication error.Interview with RN #1 on [DATE] at 3:00 PM identified she reviewed the hospital discharge medications from [DATE] with APRN #2 on [DATE] and APRN #2 approved the orders. RN #1 then transcribed the frequency of Methotrexate incorrectly to be administered daily instead of weekly.Interview with MD #1 on [DATE] at 3:30 PM identified that although APRN #2 reviewed the medications for Resident #1 on admission, he also reviewed all discharge medications from the hospital prior to seeing Resident #1. He was not aware RN #1 transcribed the Methotrexate order incorrectly and further identified the medication error as a significant medication error.Interview with RN #2 on [DATE] at 9:50 AM identified it was her responsibility as a supervisor to perform a second check of all admission orders and requirements for Resident #1 to include medication reconciliation against the hospital discharge paperwork. RN #2 further identified she did not identify the error made by RN #1.The facility Medication Error Policy identified a medication error as the preparation or administration of drugs not in accordance with physician's orders. The policy further identified a significant medication error, in part, as an error that causes the resident discomfort or jeopardizes his/her health and safety.Review of facility documentation identified that a Plan of Correction was initiated immediately:All licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers were educated on medication administration including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR. RN #1, RN #2, and pharmacy staff received one-to-one education.Random Audits of residents with Methotrexate, other high-risk mediations, and all newly admitted residents were conducted and ongoing. There were no additional residents identified with concerns or errors regarding Methotrexate, High-Risk medications or transcription errors.Results were reviewed through QAPI on [DATE] and were ongoing.The Director of Nursing was responsible for the implementation and monitoring with the Administrator maintaining overall regulatory oversight.Alleged compliance as of [DATE].The plan of correction was reviewed on [DATE] during an on-site visit and the facility met all components for past non-compliance.

Based on clinical record reviews, facility documentation/policies and interviews for one (1) of two (2) sampled residents (Resident #3), reviewed for a change in condition, the facility failed to notify the residents Conservator of Person (COP), in accordance with facility policy, over an 8 day period, when the facility requested the provider evaluate the resident on two (2) occasions, due to a change in condition. The findings include: Resident #3's diagnoses included heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, chronic obstructive pulmonary disease, and Alzheimer's Disease The provider's note dated [DATE] at 12:00 AM by APRN #1 identified APRN #1 was asked to see Resident #3 due to respiratory symptoms. APRN #1 directed Resident #3 continue cardiac medications and ordered a chest x-ray due to an episode of increased wheezing. APRN #1's plan was discussed with nursing.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 14), was dependent for dressing, required maximum assistance for toileting, hygiene, and transfers, and was independent with wheelchair use.The Resident Care Plan (RCP) dated [DATE] identified Resident #3 had multiple cardiac diagnoses with interventions that directed to administer medications as ordered, monitor blood pressure and notify the physician for abnormal readings, monitor labs as ordered, monitor for abnormal breath sounds or difficulty breathing, monitor for signs of heart failure such as edema.The provider's note dated [DATE] at 12:00 AM by APRN #1 identified APRN #1 was asked to see Resident #3 to evaluate Resident #3's respiratory status.The provider 's note dated [DATE] at 12:00 AM by APRN #1 identified Resident #3 was seen due to increased respiratory distress and APRN #1 administered Lasix 40 mg intravenous (IV) and ordered a STAT (now) chest x-ray.The nurse's note dated [DATE] at 12:25 PM by RN #4 (the 7AM to 3PM nurse supervisor) identified Resident #3 was short of breath and vital signs were normal. Resident #3 became hypoxic with a pulse oxygen saturation of 72% (normal range: 95% to 100%) on room air and RN #4 administered two (2) liters of oxygen with an increase of pulse oxygen level to 93%. APRN #1 was notified and administered Lasix via IV push and directed STAT lab work, a STAT chest x-ray, and continued Resident #3 on oxygen at 2 liters. The note identified Resident #3's COP was notified of the change in condition.The nurse's note dated [DATE] at 7:20 PM by RN #7 (the 3:00 PM to 11:00 PM supervisor) identified Resident #3's death was pronounced on [DATE] at 7:09 PM.Review of the clinical record from [DATE] to [DATE] failed to identify that Resident #3's COP was notified of a change in condition between [DATE] to [DATE].The Death Certificate dated [DATE] identified the primary cause of death as Heart Failure due to Sick Sinus Syndrome and Chronic Obstructive Pulmonary Disease.Interview with RN #3 (the [NAME] President of Clinical Services) on [DATE] at 2:20 PM identified the nurse that asked APRN #1 to see Resident #3 for a change in respiratory condition should have notified the COP.Interview with APRN #1 on [DATE] at 12:05 PM identified she assessed Resident #3 on [DATE] and ordered a chest x-ray. APRN #1 identified she indicated the plan was discussed with the nurse who was responsible for ordering the chest x-ray. APRN #1 was unable to recall which facility staff member she spoke to about Resident #3's condition or direction to order a chest x-ray. APRN #1 evaluated Resident #3 again on [DATE] at the request of nursing staff but was unable to recall specific details of the request and could not recall specific concerns. APRN #1 was again asked to evaluate Resident #3 on [DATE] and Resident #3 showed signs of respiratory distress. APRN #1 administered Lasix IV push, ordered lab work, and a STAT chest x-ray. Resident #3 responded to the initial treatment but at 7:09 PM on [DATE] died. Interview with the ADON (Assistant Director of Nursing) on [DATE] at 2:15 PM identified nursing staff should have reported any change in condition to Resident #3's COP. The ADON further identified the facility failed to follow the Facility Notification of Change Policy.The facility Notification of Change Policy identified, in part, that the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. In addition, notification is required, in part, for a new treatment, acute condition, deterioration in health, or exacerbation of a chronic condition.

Based on review of clinical records, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #3) reviewed for changes in condition, the facility failed to ensure the provision of necessary care and services to assess and address a change in condition when a provider-directed chest x-ray was not ordered and completed as indicated. The findings include: Resident #3's diagnoses included heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, chronic obstructive pulmonary disease, and Alzheimer's Disease The provider's note dated 12/15/25 at 12:00 AM by APRN #1 identified APRN #1 was asked to see Resident #3 due to respiratory symptoms. APRN #1 directed Resident #3 continue cardiac medications and ordered a chest x-ray due to an episode of increased wheezing. APRN #1's plan was discussed with nursing.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 14), was dependent for dressing, required maximum assistance for toileting, hygiene, and transfers, and was independent with wheelchair use.The Resident Care Plan (RCP) dated 12/16/25 identified Resident #3 had multiple cardiac diagnoses with interventions that directed to administer medications as ordered, monitor blood pressure and notify the physician for abnormal readings, monitor labs as ordered, monitor for abnormal breath sounds or difficulty breathing, monitor for signs of heart failure such as edema.The provider's note dated 12/18/25 at 12:00 AM by APRN #1 identified APRN #1 was asked to see Resident #3 to evaluate Resident #3's respiratory status. APRN #1 identified Resident #3 had no signs of dyspnea, congestive heart failure, or hypoglycemia or hyperglycemia. Resident #3 was sitting up in the chair, and no acute cardiopulmonary process was noted. Resident #3 was not in any apparent distress. There was no mention of the previously ordered chest x-ray in the physician's note.The provider 's note dated 12/23/25 at 12:00 AM by APRN #1 identified Resident #3 was seen due to increased respiratory distress and APRN #1 administered Lasix 40 mg intravenous (IV) and ordered a STAT (now) chest x-ray.The nurse's note dated 12/23/25 at 12:25 PM by RN #4 (the 7AM to 3PM nurse supervisor) identified Resident #3 was short of breath and vital signs were normal. Resident #3 became hypoxic with a pulse oxygen saturation of 72% (normal range: 95% to 100%) on room air and RN #4 administered two (2) liters of oxygen with an increase of pulse oxygen level to 93%. APRN #1 was notified and administered Lasix via IV push and directed STAT lab work, a STAT chest x-ray, and continued Resident #3 on oxygen at 2 liters.The nurse's note dated 12/23/25 at 7:20 PM by RN #7 (the 3:00 PM to 11:00 PM supervisor) identified Resident #3's death was pronounced on 12/23/25 at 7:09 PM.Review of the clinical record from 12/15/25 to 12/23/25 failed to identify a chest x-ray was ordered and failed to identify documentation for the reason the chest x-ray was not performed.The Death Certificate dated 12/23/25 for Resident #3 identified the primary cause of death as Heart Failure due to Sick Sinus Syndrome and Chronic Obstructive Pulmonary Disease.Interview with APRN #1 on 3/25/26 at 12:05 PM identified she assessed Resident #3 on 12/15/25 and ordered a chest x-ray. APRN #1 identified the plan was discussed with the nurse who would have been responsible for ordering the chest x-ray but she was unable to recall which nurse she spoke to about Resident #3's condition or direction to order a chest x-ray. APRN #1 had no recollection of why the chest x-ray was not entered and was unable to locate documentation to indicate the reason it was not performed.Interview with RN #5 on 3/25/26 at 2:54 PM identified she worked on 12/15/25 during the 7:00 AM to 3:00 PM shift and could not recall APRN #1 directing her to add an order for a chest x-ray on 12/15/26 and that APRN #1 would have given the order to the supervisor.Interview with LPN #2 on 3/25/26 at 3:12 PM identified she worked on 12/15/25 during the 3:00 PM to 11:00 PM shift and could not recall APRN #1 directing her to add an order for a chest x-ray on 12/15/26.Interview with RN #7 on 3/26/26 at 10:20 AM identified she worked on 12/15/25 and could not recall APRN #1 directing her to add an order for a chest x-ray on 12/15/26. She further identified that if an x-ray were ordered, the provider would give the supervisor a verbal order and the supervisor would enter the order for the x-ray.Review of the facility policy titled Verbal Orders identified physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who is legally authorized to do so and then enter the order into the medical record manually or electronically and follow through with orders by making appropriate contact or notification (e.g., lab or pharmacy).

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of two (2) sampled residents (Resident #1), reviewed for medication administration, the facility failed to ensure the pharmacy reported irregularities in medication orders for Methotrexate to the physician when the frequency ordered was inconsistent with accepted standards of practice. The facility transcribed the medication dose for Methotrexate to be administered two (2) times per day instead of one (1) time per week. The pharmacy filled the medication at a daily frequency and when the monthly medication review for new admissions was conducted, the pharmacist failed to identify the order as a medication irregularity. The findings include: Resident #1's diagnoses included rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders dated [DATE] identified an order for Methotrexate (used to treat severe autoimmune conditions) 2.5 mg take four (4) tablets in the AM and three (3) tablets in the PM one (1) time per week.The facility transcribed orders dated [DATE] identified an order for Methotrexate 2.5 mg take four (4) tablets in the am and three (3) tablets in the PM one (1) time per day.The Medication Administration Record (MAR) dose warning for Methotrexate dated [DATE] identified the entered dose of Methotrexate 2.5 mg four (4) tablets by mouth in the morning and three (3) tablets by mouth in the evening were outside of the recommended dose or frequency. The warning further identified the dosing exceeded the usual dosing regimen of one (1) to ten (10) tablets every seven (7) days and the frequency of daily exceeded the usual frequency of every seven (7) days.The on-call physician note dated [DATE] at 1:33 PM identified APRN #2 reviewed the discharge paperwork and discharge medication list from the hospital and approved all medications as written on the discharge paperwork.The Electronic Medical Record (EMR) generated progress note dated [DATE] at 5:52 PM identified the Methotrexate dose that was entered by RN #1 was outside of the recommended dose or frequency. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 12), and required moderate assistance for toileting, dressing, transfers, and ambulation.The Resident Care Plan (RCP) dated [DATE] identified Resident #1 developed thrush and interventions directed to provide oral care as frequently as tolerated and report changes in vital signs. The RCP was revised on [DATE] and identified Resident #1 was neutropenic and had an altered respiratory status and directed to administer medications as ordered, proper handwashing, to keep the resident away from others that were ill, monitor for signs of infection, monitor labs, elevate the head of bed, and monitor for signs of respiratory distress.The Hospital Records for the [DATE] to [DATE] hospitalization identified Resident #1 was admitted with diagnoses of neutropenic fever, methotrexate toxicity, and sepsis. Resident #1 could not tolerate Bilevel Positive Airway Pressure (BiPAP) (a non-invasive ventilation machine that uses a mask to deliver higher pressure when you breathe in and lower pressure when you breathe out to assist with breathing) and was intubated and admitted to the Intensive Care Unit (ICU). The Methotrexate medication error was discovered at the hospital and recommendations were made for the resident to be transferred to another hospital that could further investigate and manage methotrexate toxicity as well as recommendations to conduct a bone marrow biopsy to further work up Resident #1 for diagnoses and treatment. The family declined due to the residents rapidly declining health. Resident #1 was extubated and expired on [DATE].Interview with RN #3 (the [NAME] President of Clinical Services) on [DATE] at 2:20 PM identified RN #1 entered the Methotrexate order incorrectly on the MAR on [DATE] and the medication orders were sent electronically to the pharmacy, who filled the medication as written on the incorrect orders. The pharmacy consultant who was responsible for reviewing the medication orders of all new admissions did not identify the incorrect dosing of the Methotrexate. RN #3 further identified the medication error as a significant medication error.Interview with RN #1 on [DATE] at 3:00 PM identified she reviewed the hospital discharge medications from [DATE] with APRN #2 on [DATE] and APRN #2 approved the orders. RN #1 then transcribed the frequency of Methotrexate incorrectly to be administered daily instead of weekly.Interview with Person #1 (Registered Pharmacist at dispensing pharmacy) on [DATE] at 1:45 PM identified the pharmacy received the orders from the facility electronically. Upon initial review, a pharmacist reviewed all orders and once approved, the blister packs were filled by a medication technician. After the medication technician was done, they passed the medications on to a different pharmacist for final review. Neither pharmacist identified the irregularity in medication frequency ordered for the Methotrexate. Person #1 further identified the pharmacist had the knowledge of the correct medication dosage and attributed the error to human error. Person #1 identified training was conducted with the pharmacists that filled and checked the medication order as well as all pharmacists the company employs.Interview with RN #2 on [DATE] at 9:50 AM identified it was her responsibility as a supervisor to perform a second check of all admission orders and requirements for Resident #1 to include medication reconciliation against the hospital discharge paperwork. RN #2 further identified she did not identify the error made by RN #1.Review of the facility contract with Guardian Consulting identified that Guardian Consulting would conduct all pharmacy reviews on newly admitted residents.The facility Medication Error Policy identified a medication error as the preparation or administration of drugs not in accordance with physician's orders. The policy further identified a significant medication error, in part, as an error that caused the resident discomfort or jeopardized his/her health and safety.Review of facility documentation identified that a Plan of Correction was initiated immediately:All licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers were educated on medication administration including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR. RN #1, RN #2, and pharmacy staff received one-to-one education.Random Audits of residents with Methotrexate, other high-risk mediations, and all newly admitted residents were conducted and ongoing. There were no additional residents identified with concerns or errors regarding Methotrexate, High-Risk medications or transcription errors.Results were reviewed through QAPI on [DATE] and were ongoing.The Director of Nursing was responsible for the implementation and monitoring with the Administrator maintaining overall regulatory oversight.Alleged compliance as of [DATE].The plan of correction was reviewed on [DATE] during an on-site visit and the facility met all components for past non-compliance.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of two (2) sampled residents (Resident #3), reviewed for a change in condition, the facility failed to maintain complete and accurate clinical records for Resident #3 in accordance with the facility Documentation Policy when they failed to document assessments related to Resident #3's change in condition. The findings include: Resident #3's diagnoses included heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, chronic obstructive pulmonary disease, and Alzheimer's Disease The provider's note dated [DATE] at 12:00 AM by APRN #1 identified APRN #1 was asked to see Resident #3 due to respiratory symptoms. APRN #1 directed Resident #3 continue cardiac medications and ordered a chest x-ray due to an episode of increased wheezing. APRN #1's plan was discussed with nursing.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 14), was dependent for dressing, required maximum assistance for toileting, hygiene, and transfers, and was independent with wheelchair use.The Resident Care Plan (RCP) dated [DATE] identified Resident #3 had multiple cardiac diagnoses with interventions that directed to administer medications as ordered, monitor blood pressure and notify the physician for abnormal readings, monitor labs as ordered, monitor for abnormal breath sounds or difficulty breathing, monitor for signs of heart failure such as edema.The provider's note dated [DATE] at 12:00 AM by APRN #1 identified APRN #1 was asked to see Resident #3 to evaluate Resident #3's respiratory status. APRN #1 identified Resident #3 had no signs of dyspnea, congestive heart failure, or hypoglycemia or hyperglycemia. Resident #3 was sitting up in the chair, and no acute cardiopulmonary process was noted. Resident #3 was not in any apparent distress. The physician progress note by APRN #1 dated [DATE] at 12:00 AM identified Resident #3 was seen due to increased respiratory distress and APRN #1 administered Lasix 40 mg intravenous and ordered a stat chest x-ray.The nurse's note dated [DATE] at 12:25 PM by RN #4 (the 7AM to 3PM nurse supervisor) identified Resident #3 was short of breath and vital signs were normal. Resident #3 became hypoxic with a pulse oxygen saturation of 72% (normal range: 95% to 100%) on room air and RN #4 administered two (2) liters of oxygen with an increase of pulse oxygen level to 93%. APRN #1 was notified and administered Lasix via IV push and directed STAT lab work, a STAT chest x-ray, and continued Resident #3 on oxygen at 2 liters.The nurse's note dated [DATE] at 7:20 PM by RN #7 (the 3:00 PM to 11:00 PM supervisor) identified Resident #3's death was pronounced on [DATE] at 7:09 PM.Review of the clinical record from [DATE] to [DATE] failed to identify that a chest x-ray was ordered on [DATE], failed to identify documentation for the reason the chest x-ray was not performed, and failed to identify documentation of respiratory related assessments performed for Resident #3 prior to [DATE].The Death Certificate dated [DATE] for Resident #3 identified the primary cause of death as Heart Failure due to Sick Sinus Syndrome and Chronic Obstructive Pulmonary Disease.Interview with APRN #1 on [DATE] at 12:05 PM identified she assessed Resident #3 on [DATE] and ordered a chest x-ray. APRN #1 identified the plan was discussed with the nurse who would have been responsible for ordering the chest x-ray but she was unable to recall which facility staff she spoke to about Resident #3's condition or direction to order a chest x-ray. APRN #1 had no recollection of why the chest x-ray was not entered by the nurse and was unable to locate documentation to indicate the reason it was not performed. APRN #1 evaluated Resident #3 again on [DATE] at the request of nursing staff but was unable to recall specific details of the request and could not recall specific concerns. APRN #1 was again asked to evaluate Resident #3 on [DATE] and Resident #3 showed signs of respiratory distress. APRN #1 administered Lasix IV push, ordered lab work, and a STAT chest x-ray. Resident #3 responded to the initial treatment but at 7:09 PM on [DATE] died. APRN #1 further identified Resident #3 may have suffered a pulmonary embolism.Interview with LPN #1 on [DATE] at 1:15 PM identified she worked with Resident #3 the week prior to [DATE] and was unable to recall if Resident #3 had presented with any respiratory symptoms prior to [DATE].Interview with the ADON (Assistant Director of Nursing) on [DATE] at 2:15 PM identified nursing staff should have documented a change in condition when they requested APRN #1 see Resident #3 due to a change in respiratory condition on [DATE] and [DATE]. The ADON further identified the facility failed to follow the Facility Documentation Policy.Interview with RN #3 (the [NAME] President of Clinical Services) on [DATE] at 2:20 PM identified the nurse that asked APRN #1 to see Resident #3 for a change in respiratory condition should have documented the assessment in the clinical record.Interview with LPN #4 (the 3:00 PM to 11:00 PM charge nurse) on [DATE] at 12:20 PM identified she recalled Resident #3 having an episode of wheezing in the week prior to [DATE]. LPN #4 further identified she reported the concerns to a supervisor and was told by the supervisor that she was aware of Resident #3's condition. LPN #4 was unable to recall who she reported Resident #3's change in condition to.The facility Documentation Policy identified, in part, that each residents' medical record shall contain an accurate representation of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation and documentation must occur no later than the end of the shift in which the assessment, observation, or care service occurred.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for Activities of Daily Living (ADLs), the facility failed to review and revise the plan of care to include the resident's refusal of showers and implement alternative interventions. The findings include:Resident #1's diagnoses included adult failure to thrive, anorexia, type II diabetes mellitus, muscle weakness and lack of coordination. The admission Record dated 8/13/25 identified a family member was named Power of Attorney for medical, care conference person, and authorized HIPPA contact. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation, required extensive assistance with bed mobility and was totally dependent on staff for transfers, personal hygiene and bathing. The Resident Care Plan dated 8/14/25 identified Resident #1 was at risk for decreased ability to perform ADLs related to limited range of motion and limited mobility. Interventions directed to provide the resident with extensive assistance of one (1) for personal hygiene and bathing. Review of the Care Plan Meeting documentation dated 11/25/25 at 2:51 PM identified Resident #1's family had requested a care conference to discuss concerns. The documentation identified they discussed showering and the facility offered to meet regularly and call the family with updates when Resident #1 refused care. Review of the Documentation Survey Report (Nurse Aide documentation) for August 2025 through November 2025 identified Resident #1 was not provided a shower on 8/14/25, 8/18/25, 8/21/25, 9/4/25, 9/11/25, 9/22/25, 9/25/25, 9/29/25, 10/2/25, 10/6/25, 10/13/25, 10/16/25, 10/23/25, 10/30/25, 11/6/25, 11/10/25, 11/13/25, 11/17/25 or 11/24/25 and there was no follow-up documentation as to why the showers were not provided or if Resident #1 had refused to be showered. The documentation failed to identify what shift the showers were scheduled for. Review of the shower schedule identified Resident #1 was scheduled for showers on the 7AM-3PM shift on Tuesdays. Review of the revised care plan dated 11/26/25 identified Resident #1 refused ADL care at times. Interventions included explaining all care, including procedures and the reason for performing the care before initiating, and evaluating the nature and circumstances of the resistive behavior with the resident and/or resident representative and discuss the findings with the resident and family members and adjust care delivery appropriately. Interview with nurse aides, Nurse Aide (NA) #1 and NA #2, on 12/8/25 identified although Resident #1 had been refusing showers since his/her admission, Resident #1 would agree to a bed bath instead and they would notify the charge nurse when Resident #1 refused. Interview with the 3-11PM nursing supervisor, Registered Nurse (RN) #1, on 12/8/25 at 1:15 PM identified on 11/18/25 Resident #1's family member approached her and reported Resident #1 had not been showered and requested to see documentation regarding showering. RN #1 indicated she reviewed the documentation and identified although Resident #1 had not received a shower in several weeks Resident #1 did receive a bed bath on the day shift on 11/18/25. RN #1 identified she offered to have the nurse aide shower Resident #1, but both Resident #1 and the family member declined and stated the shower could wait until another day. Interview with the Director of Nursing (DON) on 12/8/25 at 12:30 PM identified during the 11/25/25 care plan meeting with Resident #1's family, the family voiced concerns with Resident #1 being showered. The DON explained, through staff interviews she identified Resident #1 had been refusing showers but allowing bed baths and the nurse aides had been notifying the charge nurses and nursing supervisors however they did not document the refusals, revise the care plan to include refusal of care and showering, or initiate targeted behavior monitoring as they should have when the behaviors were first observed so interventions could have been put into place and the behaviors could be monitored. The DON identified a care plan was developed after the 11/25/25 meeting and when she reviewed the nurse aide documentation, the showering documentation did not match up to the unit shower schedule. The DON stated the schedule should have been customized to identify which shift and day of the week the shower was scheduled for and she was unsure why the shower was scheduled for every shift multiple days a week, which made it confusing to follow. Review of the Comprehensive Care Plans policy dated 07/01/23 directed, in part, that the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Other factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be addressed in the plan of care. The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, any services that would otherwise be furnished but are not provided due to the residents' exercise of his or her right to refuse treatment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternative methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the intervention, initially and when changes are made. Review of the Resident Showers policy dated 07/01/23 directed, in part, that it is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided with showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths will be given between regular shower schedules as per facility policy.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was at risk for weight loss, the facility failed to ensure weekly weights were obtained per the physician's order and failed to ensure a re-weight was obtained at the time a significant weight loss was identified and not wait one (1) week. The findings include:Resident #1's diagnoses included adult failure to thrive, anorexia, dysphagia (difficulty swallowing) and type II diabetes mellitus. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation, required full dentures but did not wear them and was independent with eating. A physician's order dated 8/14/25 directed to obtain the resident's weight every day shift every Thursday for four (4) weeks. The Resident Care Plan dated 8/14/25 identified Resident #1 met the criteria for moderate protein calorie malnutrition diagnosis due to weight loss and inadequate oral intakes. Interventions directed to monitor the resident's weight and laboratory results as available. The Medical Nutrition Therapy assessment dated [DATE] identified, in part, Resident #1 was admitted from the hospital, Resident #1's appetite and intakes were poor and a low albumin (a type of protein in the blood) level was noted. The assessment identified Resident #1 was a risk for malnutrition related to poor intakes, low albumin, need for oral nutritional supplements, and the plan and interventions included eight (8) ounces of Glucerna twice daily, continue current diet, honor food preferences as able, weekly weights for four (4) weeks, monitor all nutrition parameters and follow-up for nutrition plan of care as needed. A physician's order dated 8/19/25 directed to obtain the resident's weight every day shift every Tuesday for four (4) weeks. A physician's order dated 9/22/25 directed to obtain the resident's weight every evening shift every Monday for four (4) weeks and then every evening shift once a month starting on the 10/20/25. Review of the August and September 2025 Medication Administration Records identified weights were scheduled to be obtained on Resident #1 on 8/19/25, 8/26/25, 9/2/25, 9/9/25, and 9/16/25. Upon further review, although the weights were signed off on the Medication Administration Record as being obtained on 8/19/25, 8/26/25, 9/2/25, 9/9/25, and 9/16/25, no weights were recorded in the clinical record on those dates. Review of the September 2025 Medication Administration Record identified on 9/22/25 Resident #1 weighed 154.6 pounds and on 9/29/25 Resident #1 weighed 129.4 pounds showing a twenty-six (26.2) pound weight loss in one (1) week. Upon further review, the Medication Administration Record failed to reflect documentation Resident #1 was re-weighed to ensure accuracy of the 9/29/25 weight. An Advanced Practice Registered Nurse (APRN) note dated 10/1/25 identified she was requested by nursing to evaluate Resident #1 for weight loss, reporting Resident #1's weight was currently 129.4 pounds and directed to continue with a regular diet ground texture, encourage by mouth intake, continue working with speech therapy and continue to monitor weights. Review of the clinical record failed to identify a re-weight was obtained on Resident #1 until 10/6/25, seven (7) days after a weight loss of 26.2 pounds was documented. The weight on 10/6/25 was documented as 127.6 pounds, a two (2) pound further weight loss from the 9/29/25 weight. Review of the clinical record identified the Dietician did not follow-up with Resident #1's significant weight loss until 10/9/25, ten (10) days later. The dietary note dated 10/9/25 at 1:31 PM identified Resident #1 presented with a significant unplanned weight loss of 28 pounds loss related to decreased intake and overall decline and chronic conditions with cirrhosis of the liver (late stage liver disease characterized by scarring to the liver tissue). The note indicated the provider was aware and interventions were added and there was a pending discussion on goals of care and possible transition to hospice. The note identified Resident #1 remained at risk for malnutrition and the dietician will continue to monitor labs, intakes, mediations, skin and weights as needed. Interview with the Regional Dietician on 12/8/25 at 11:53 AM identified although the dietician was responsible for tracking weights for residents at risk for weight loss, they do not implement any new interventions or meet with the resident until the weight was confirmed as accurate and the 9/29/25 weight on Resident #1 was not confirmed with a re-weight until 10/6/25. The Regional Dietician stated the facility did not have a policy on re-weights and was unable to identify when a re-weight should have been obtained on Resident #1 after the significant weight loss was documented on 9/29/25. Interview with the APRN on 12/8/25 at 12:15 PM identified weights should have been obtained weekly on Resident #1 per physician's orders and a re-weight should have been obtained within one (1) day of the documented significant weight change on 9/29/25 to confirm the accuracy. Interview with a charge nurse, Licensed Practical Nurse (LPN) #1, on 12/8/25 at 2:15 PM identified that although she documented on Resident #1's Medication Administration Record on 8/19/25, 8/26/25 and 9/2/25 weights were obtained, she was unsure if they were and stated she just signs them off as it does not require a weight to be entered into the Medication Administration Record. LPN #1 explained when the nurse aides obtain weights they would usually write it on a piece of paper, put it on her medication cart and the nursing supervisors or unit managers would often come by, take the paper off of her medication cart and they will enter the weights. Interview and clinical record review with the Director of Nursing (DON) on 12/8/25 at 3:48 PM identified weights should have been obtained weekly and documented in the clinical record per physician's orders and she was unable to find documentation the weights had been obtained. The DON explained the Medication Administration Record did not require a weight be entered prior to the nurse signing off it was obtained and the charge nurse should be ensuring the weight was documented in the clinical record. The DON identified there was a time span in August and September when the facility did not have a dietician on staff and the interdisciplinary team did not review triggered weights in morning report, as that was the dietician's responsibility, so although Resident #1 should have been reweighed sooner than 10/6/25, the dietician should have prompted the reweight following the 9/29/25 significant weight change. The DON identified the facility did not have a policy on re-weights following a significant weight change, and she was unable to identify when the reweight should have been obtained by. Review of the Weight Monitoring policy dated 09/01/24 directed, in part, that the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility will utilize a systemic approach to optimize a resident's nutritional status including identifying and assessing each resident's nutritional status and risk factors, evaluating and analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. Interventions will be identified, implemented, monitored and modified, consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule will be developed upon admission for all residents and weights should be recorded timely. Weights are to be monitored weekly for 4 weeks for newly admitted residents. For residents with weight loss, weights are to be monitored weekly or per dietician recommendation and if clinically indicated, weights are to be monitored daily. The newly recorded resident weight should be compared to the previously recorded weight, as a significant change in weight is identified as a 5% change in weight in one month. The physician should be informed of a significant change in weight and may order nutritional interventions. The facility identified the deficient practice and developed an immediate plan of correction on November 25, 2025.Staff will be educated on the importance of obtaining weights and on how to enter orders correctly. Education initiated to staff and the dietician on communicating changes in resident weights. Education initiated to dietician about notification to staff on interventions implemented. Education initiated to staff on documentation of refusals of weights and updating the care plan to include refusal behaviors. Random weekly audits will be conducted on weekly weights, weight orders, refusals of weights, and notification of refusals to MD and family. Random weekly audit will be conducted on resident food preferences.Results will be reviewed at the next QAPI meeting.Completion date: November 28, 2025

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who had targeted behaviors, the facility failed to ensure a comprehensive care plan was developed and interventions implemented to address the resident's behaviors which included the tendency to transfer him/herself without assistance. The findings include:Resident #2's diagnoses included dementia without behavioral disturbances, depression, anxiety disorder, obsessive compulsive disorder and insomnia. A physician's order dated 9/16/25 directed Resident #2 was non-weight bearing to the right lower extremity every shift. The nurse's note dated 9/16/25 at 9:31 PM identified Resident #2 was admitted to the facility following a right third toe amputation. The note indicated Resident #2 was confused, restless, displayed poor safety awareness, required close observation for safety due to non-weight bearing status to the right foot, required assistance of two (2) for transfers. The Resident Care Plan dated 9/17/25 identified Resident #2 was at risk for complications related to the use of psychotropic, antipsychotic for OCD, antianxiety for depression, and antidepressant for insomnia. Interventions directed to complete the behavior monitoring flow sheet as indicated, monitor for changes in mental status and functional level and report to the physician, and monitor for continued need of medication as related to behavior and mood. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) indicating poor memory recall, was dependent on staff for transfers in and out of the bed and chair, and received antipsychotic, antianxiety, and antidepressant medications on a routine basis. Review of the October 2025 Treatment Administration Record (TAR) identified Resident #2's targeted behavior was wandering and insomnia. The TAR failed to include restless, obsessive-compulsive behaviors and non-compliant with transfers. The nurse's note dated 10/10/25 at 11:09 AM identified around 12:15 AM Resident #2 was observed seated in his/her wheelchair next to the roommate's bed and the roommate reported Resident #2 had come to his/her bedside, removed the bed linens, pulled up his/her clothing and touched him/her inappropriately. The note indicated Resident #2 was immediately taken to the nurse's station and placed on one-to-one (1-1) observations and the provider and resident representative were notified of the incident. Review of the care plan dated 10/10/25, following the 10/10/25 allegation the care plan was revised to address Resident #2's potential for changes in mood, behavior and psychosocial well-being related to dementia and signs and symptoms of depression. Interview with Resident #2's roommate, Resident #1, on 11/13/25 at 8:18 AM identified prior to the 10/10/25 incident, Resident #2 would often get out of bed unassisted into the wheelchair, rummage through his/her (Resident #1's) belongings on the bedside table and often sit on his/her (Resident #1's) bed. Resident #1 reported that although he/she had not formally complained about Resident #2's behavior, it bothered Resident #1, and he/she identified the staff had observed Resident #2's behavior numerous times. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #3, on 11/13/25 at 8:25 AM identified Resident #2 required assistance for transfers, resided in a window bed and would sometimes transfer him/herself and be found sitting close to or on Resident #1's bed. NA #3 explained when she observed this, she would redirect Resident #2, assist him/her back to the wheelchair, attempt to meet his/her needs and bring him/her to the nurse's station. NA #3 indicated Resident #2 had also been observed standing at the nurse's station. Interview with a 3-11PM nurse aide, NA #1, on 11/13/25 at 11:57 AM identified she worked on 10/9/25. NA #1 explained she put Resident #2 to bed just after 9:00 PM and observed Resident #2 in bed with his/her eyes closed around 10:30 PM when she did her last rounds. NA #1 indicated Resident #2 was calm and displayed no behaviors that night, Resident #2 did not use the call-bell and had a history of getting out of bed unassisted and self-transferring and needed to be checked-in on frequently. Interview with a 11PM-7AM nurse aide, NA #2, on 11/13/25 at 12:08 PM identified that she worked the 11PM-7AM shift the night of the accusation, reporting that although she last saw Resident #2 in bed around 11:20 PM she was unsure when Resident #2 got out of bed and into the wheelchair, as observed at 12:15 AM. NA #2 identified Resident #2 had a history of getting out of bed unassisted several times nightly. Interview with the 11PM-7AM nursing supervisor, Registered Nurse (RN) #1, on 11/13/25 at 12:19 PM identified Resident #2 had a history of getting up unassisted and wandering around his/her room on the 11PM-7AM shift. RN #1 indicated Resident #1 had complained to her about the behavior previously of how Resident #2 had been taking Resident #1's stuff. RN #1 identified when the behaviors were noted staff would redirect Resident #2 and would keep Resident #2 at the nurse's station until ready to go to sleep but she did not update the care plan. Interview with Social Worker #1 on 11/13/25 at 12:56 PM identified although she had not observed Resident #2 self-transfer or observe him/her sitting on Resident #1's bed, she was aware Resident #2 exhibited these behaviors through staff reports. Social Worker #1 explained although she was responsible for developing non-compliance care plans and working with nursing to develop resident specific interventions, the care plan was not developed. Social Worker #1 identified a care plan should have been developed prior to the 10/10/25 allegation, and she developed the mood and behavior care plan after the incident. Interview and clinical record review with the Director of Nursing (DON) on 11/13/25 at 1:52 PM identified that both nursing and social services should have worked together to develop a comprehensive care plan addressing Resident #2's behaviors of getting out of bed without assistance, self-transferring and sitting on Resident #1's bed and implementing resident specific safety interventions to help prevent any incidents associated with the behavior. The DON indicated although she was not made aware of the behaviors prior to 10/10/25 and should have been. Review of the Comprehensive Care Plans policy dated 07/01/23 directed, in part, that the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Other factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be addressed in the plan of care. The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, any services that would otherwise be furnished but are not provided due to the residents' exercise of his or her right to refuse treatment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternative methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the intervention, initially and when changes are made.

Based on review of the clinical record, facility documentation, facility policies, and interviews for 1 of 8 residents (Resident #35) reviewed for abuse, the facility failed to ensure a resident was treated in a dignified manner by nursing staff. The findings include: Resident #35 was admitted to the facility in September 2024 with diagnoses that included atrial fibrillation, congestive heart failure, and encephalopathy. The quarterly MDS dated [DATE] identified Resident #35 had intact cognition, mood interview identified the following symptoms and frequency: little interest or pleasure in doing things (half or more days), feeling down, depressed, hopeless (several days), trouble falling asleep or staying asleep (several days), feeling tired or having little energy (half or more days), poor appetite or overeating (several days), feeling bad about yourself (several days), trouble concentrating on things (several days), and moving or speaking slowly that other people could have noticed (half or more days). The care plan dated 2/26/25 identified Resident #35 exhibited or was at risk for distressed/fluctuating mood symptoms related to: sadness/depression caused by functional changes, etc.). Interventions included refocusing resident to something positive and allowing time to express feelings, providing empathy, encouragement, and reassurance. Interview with Resident #110 on 4/6/25 at 10:26 AM identified that around 4:00 AM, he/she had heard an agency nurse aide and Resident #35 arguing. Resident #110 indicated that he/she heard Resident #35 ask the nurse aide for her name, but did not hear a response. Resident #110 further indicated that he heard Resident #35 say you're hurting me and being rude, to which the nurse aide replied, it's my first time here and I'm not being rude. Interview with Resident #35 on 4/6/25 at 10:39 AM identified that an agency nurse (NA #18), whom he/she had never met before, entered his/her room around 4:00 AM, without a name badge, and when the resident asked her name, NA#18 responded, Pudding [NAME]. Resident #35 indicated that NA #18 had an attitude and was rude immediately upon entering the room, and NA #18 had told him/her, look, there are only 2 nurse aides here, you could have at least cleaned up your bed for me, referencing the resident's glasses and iPad that were laying on the bed. Resident #35 identified that he/she had asked NA #18 to leave his/her room, and NA #18 stated, why don't you like me, is it my voice or is it because I'm black? Resident #35 indicated that NA #18 then went to assist his/her roommate (Resident #8), and he/she could hear NA #18 making comments about him/her (Resident #35), and when NA #18 was finished providing care for Resident #8, NA #18 had seen him/her (Resident #35), crying and very nicely said, oh honey, why are you crying? Resident #35 indicated that he/she was confused as to why NA #18 was now acting nicely, and the resident reported the concerns to the night shift Nurse Supervisor. Interview with the 11:00 PM - 7:00 AM Nursing Supervisor (RN #12) on 4/6/25 at 10:55 AM identified that around 5:45 AM, Resident #35 had brought to her attention that NA #18 had an attitude while providing care and had made a racial comment. RN #12 indicated that Resident #35 asked NA #18 to leave and she left. RN #12 further indicated that Resident #35 required 2 staff members for care because the resident has made accusatory statements, but RN #12 indicated that NA #18 identified she did not ask another staff member to accompany her while providing care because they had been short staffed. The Psychiatric Evaluation and Consultation form dated 4/6/25 identified that Resident #35 was evaluated after making an allegation towards a nursing assistant. The resident rescinded the allegation and reported frustration with the nurse assistant because she was rude. There was no abuse reported. Interview with NA #17 on 4/8/25 at 12:50 PM identified that she was an agency nurse aide, and this was her first time working at the facility on 4/5/25 11:00 PM - 7:00 AM shift, and she was assigned to the west wing with NA #18. NA #17 denied witnessing any verbally abusive or disrespectful behavior from NA #18 towards Resident #35. NA #17 indicated that she assisted NA #18 to boost Resident #35 in bed. NA #17 indicated that Resident #35 reported that he/she had been crying because he/she had been in pain and was frustrated, and then Resident #35 asked both nurse aides to leave once they were done repositioning him/her in bed. Interview with NA #18 on 4/8/25 at 3:03 PM identified that she was an agency nurse aide and had worked at the facility on the 4/5/25 11:00PM - 7:00 AM shift, for the first time. NA #18 indicated that she was assigned to Resident #35, and that the resident began arguing with her, as soon as she walked into the room. NA #18 indicated that she told Resident #35 that the facility was short staffed and there were only 2 nurse aides on the floor, both from agencies. NA #18 indicated that she was not provided with a photo ID badge from her agency and could not recall if she told Resident #35 her name was Pudding [NAME] when the resident asked her name. NA #18 indicated that she did not ask Resident #35 why he/she did not clean up the bed before she came in, as cleaning up the resident's bed was her responsibility, and she always cleans up. NA #18 further indicated that she has a heavy voice and that she tried to explain that to Resident #35. NA #18 then asked Resident #35 if he/she was judging her because she was black, to which Resident #35 replied now you're pulling the race card. NA #18 indicated that Resident #35 was the only resident that took issue with her out of the 60 residents on that unit. NA #18 identified that when she spoke with RN #12, she identified that Resident #35 has made accusatory comments, in the past. Interview with Resident #35's roommate (Resident #8) on 4/9/25 at 11:30 AM identified that he/she had been sleeping but could not remember hearing any verbal abuse or rude behavior, during the early morning of 4/6/25. Interview with the DNS on 4/10/25 at 10:44 AM identified that it is the expectation that facility and agency staff treat residents with dignity and respect. The facility's Promoting/Maintaining Resident Dignity policy directs all staff members to be involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The policy further directs staff members to speak respectfully to residents. The facility's Professionalism-Customer Service policy directs the facility to provide professional, courteous service to all customers. Every employee is accountable for conducting themselves in a professional manner at all times. The facility is the resident's home and will be regarded as such. Each resident will be treated with compassion and respect at all times.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #9, 91 and 81) the facility failed to ensure the physician and resident representative were notified according to facility policy. For 1 of 5 residents (Resident #9) reviewed for medication administration, the facility failed to ensure the physician was notified when medications were not given per the physician order. For 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure the physician and resident representative were notified when a new pressure ulcer was identified. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to notify the physician and resident representative with episodes of hypo and hyperglycemia, and when a medication was not administered. The findings include: 1. Resident #69 was admitted to the facility in February 2025 with diagnoses that included leg surgery, chronic kidney disease and dependent on dialysis, hypertension, and gastroparesis. A physician's order dated 2/13/25 directed to give Gabapentin 600 mg by mouth three times a day for phantom pain, Lactobacillus give 1 capsule by mouth one time a day for supplement, and Bumetanide 2 mg give 1 tablet two times a day for hypertension. The care plan dated 2/17/25 identified Resident #69 was at risk for impaired renal function and complications related to hemodialysis. Interventions included providing medications as ordered. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, dressing, and personal hygiene. Additionally, Resident #69 was on antibiotics, diuretics, opioids, and anticonvulsants. Review of the April 2025 MAR dated 4/6/25 at 11:48 PM identified Bumetanide 2 mg due to be administered twice daily for hypertension was not available. Medication observation with RN #4 on 4/7/25 at 9:17 AM indicated she had taken Resident #69's blood pressure earlier and it was 176/84. RN #4 prepared Resident #69's medications then identified she did not have the Gabapentin 600mg, Lactobacillus capsule, or the Bumetanide 2 mg available. RN #5 indicated that she had searched the medication cart and there was not any available and these medications were not in the emergency supply. An interview with RN #4 on 4/7/25 at 9:25 AM indicated that Resident #69 had not received the evening dose of Bumetanide 2 mg the day prior, and the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were not available. RN #4 indicated that the nurses were responsible for reordering medications before the resident ran out of a medication. RN #4 indicated that she would reorder the medications from the pharmacy. Review of the nurses' notes dated 4/6/25 to 4/7/25 failed to reflect the APRN or physician had been notified that the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were unavailable and had not been administered. Review of the MAR dated 4/7/25 at 9:28 AM identified RN #4 documented the scheduled 9:00 AM doses of Gabapentin 600 mg for phantom pain, Lactobacillus capsule for supplement, and Bumetanide 2mg's for hypertension were not available in facility and pharmacy was notified. Review of the MAR dated 4/7/25 identified Resident #69 did not receive the scheduled 1:00 PM dose of Gabapentin 600 mg. Interview with RN #5 (Regional corporate nurse) on 4/8/25 at 11:01 AM indicated that when a nurse does not have a medication available to give a resident per the physician order, he or she is responsible for notifying the pharmacy and the physician to see if there was an alternate medication(s) or could change the time of administration. Interview with APRN #1 on 4/8/25 at 11:18 AM indicated Resident #69 was on Bumetanide for fluid retention because of his/her diagnosis and if Bumetanide was not available nursing must notify her. APRN #1 indicated if Resident #69 misses a dose she would want to find out why and do an intervention and evaluate resident's blood pressures to see if it was elevated and if he/she has sustainable blood pressures with dialysis treatments. APRN #1 indicated that her expectation would be she must be notified if of any resident miss doses of medications. APRN #1 indicated that Resident #69 was on gabapentin for phantom pain due to the BKA. APRN #1 noted Resident #69 came into the facility on a low dose but because Resident #69 has complaints of pain the dose has been going up a couple of times, so it is important to give it and have it available, and the Lactobacillus is because nephrology ordered it from dialysis for the gastrointestinal system. APRN #1 indicated that she was not aware Resident #69 had missed the Bumetanide the evening of 4/6/25 or medications on 4/7/25 in the am or afternoon. APRN #1 indicated it was the nurse's responsibility to reorder the medications timely. APRN #1 indicated that the nurses were responsible for documenting who they notified and when if a resident had missed a scheduled medication. Interview with the DNS on 4/8/25 at 12:52 PM indicated that when a resident does not receive a dose of a scheduled medication the charge nurse is expected to notify the RN supervisor who must notify the APRN or physician and it needed get an order for an alternate medication or any other new orders from the provider and then write a nurses note with who the nurse spoke with and any recommendation or new orders from the provider. After clinical record review, the DNS indicated that from 4/6/to 4/8/24 she did not see the APRN, or physician were notified of the missed doses of medication. The DNS indicated that the Lactobacillus was house stock and if the nurse had asked the supervisor, she would have gotten it for RN #4. An interview with the DNS on 4/9/25 at 12:54 PM indicated her expectation was the nurses follow the physician orders and give the medications at the time they are scheduled within the hour before or hour after window. The DNS indicated the expectation was the nurses will reorder the medications when there are 6 doses left in the blister pack, so the resident does not run out of medications. Review of the facility Unavailable Medications Policy identified mediations may be unavailable for several reasons. Staff should take immediate action when it is known that the medication is unavailable. Notify the physician of inability to obtain medication upon notification or awareness that the medication is not available. Obtain alternate treatment orders and/or specific orders for monitoring residents while medication is on hold. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Review of the Medication Eror Policy identified the facility shall ensure medications will be administered according to the physician's orders. Medication that is administered not in accordance with the prescriber's order, for example a medication omission. 2. Resident #91 was admitted to the facility in July 2023 and a readmission to the facility on 1/30/25 with diagnoses that included fall with left femur fracture, and dementia. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition and required maximum assistance with perineal hygiene and dressing. Resident #91 was at risk for developing a pressure ulcer but did not have any pressure ulcers. The readmission nursing assessment dated [DATE] identified Resident #91's skin was intact except for periorbital bruising to the face status post fall. The assessment did not identify any open areas or pressure areas. The care plan dated 2/13/25 identified Resident #91 was at risk for skin breakdown related to decreased mobility and left hip surgical incision. Interventions included applying barrier cream after each incontinent episode, dietitian consultation as needed, and weekly skin checks by the licensed nurse. The weekly skin check assessment documented by RN #2 dated 2/15/25 identified Resident #91's left heel had a blister with slough measuring 6cm by 6cm intact. (first time noted wound) The weekly skin check assessment documented by LPN #1 dated 2/22/25 at 7:23 PM identified a previously identified wound to the left heel. (second time noted wound) The APRN note dated 2/24/25 at 1:04 PM identified she was notified by RN #1 and had seen Resident #91 for a deep tissue injury (DTI) to left heel today noted by nursing. Recommended Santyl topically with daily dressing change to facilitate until seen by wound provider later this week. Nursing to off load heels for Resident #91. The Change of Condition Evaluation documented by RN #1 dated 2/24/25 at 1:21 PM identified Resident #91 noted to have a new injury to his/her left heel. RN #1 noted this is the leg affected by his/her broken hip and surgical fixation. Left heel measurements were 2.5 cm by 1.4 cm by 0.1 cm. APRN in the facility and notified. Dressing order recommendation for Santyl and dry clean dressing in place and wound physician to evaluate. Resident representative was notified. A physician's order dated 2/24/25 directed to cleanse left heel wound with normal saline, pat dry, apply Santyl to wound bed, and cover with dry clean dressing daily on evening shift for 30 days starting on 2/25/25. The dietitian note dated 4/2/25 identified Resident #91 triggers for significant weight loss over 1 month and pressure ulcer to the left heel. Resident #91 remains at risk for malnutrition related to unplanned weight loss and need for mechanically altered diet and requires total assistance for feeding. Recommendations included Glucerna once a day in the evening to assist with stability and protein supplement to support wound healing in view of pressure injury to left heel. A physician's order dated 4/2/25 directed to start Glucerna 1.5 give 8 ounces once a day and Prostat AWC (Advance Wound Care) 30 ml's 2 times a day for at risk for malnutrition. Interview with LPN #1 on 4/7/25 at 8:55 AM indicated that she did the weekly skin assessment on 2/22/25 for Resident #91. LPN #1 indicated that she thought the left heel was already noted and not new, so she did not call for an RN assessment, or call the APRN or Resident #91's representative. Interview with RN #1 on 4/7/25 at 9:46 AM indicated she had not been informed that Resident #91 had a pressure ulcer on the left heel until she found it on 2/24/25 when auditing the weekly skin assessments. RN #1 indicated after clinical record review on 2/24/25 she noted that the left heel pressure ulcer started on 2/15/25 in a weekly body audit. RN #1 indicated that she immediately went to Resident #91 to assess the left heel, and the blister had opened and was an unstageable DTI that measured 2.5 cm by 1.4 cm by 0.1 cm. RN #1 indicated that the first complete RN assessment for the left heel pressure area was completed on 2/24/25, 9 days after first found. RN #1 indicated that there was no treatment in place for the left heel from 2/15/25 to 2/24/25. RN #1 indicated that on 2/24/25 when she identified the area, she notified the APRN and resident representative. RN # 1 indicated that on 2/15/25 when the left heel pressure ulcer was first identified there should have been a complete wound assessment by an RN that day and shift with notification to the APRN or physician to obtain a treatment order. Further, the resident representative should have been notified at that time. Interview with the DNS on 4/7/25 at 11:21 AM indicated Resident #91 had a left heel pressure ulcer noted on 2/24/25 by the wound nurse, RN #1, on 2/24/25. The DNS indicated that when a pressure ulcer is first identified the charge nurse notifies the RN supervisor to do the initial wound assessment including measurements, description of wound and wound bed, and the surrounding skin. The DNS indicated that she thought the left heel started on 2/24/25 and she was first notified about it on 2/24/25. The DNS indicated that after the surveyor inquiry she started an investigation into the left heel and noted the left heel was first identified on 2/15/25 during the weekly body check by RN #2. The DNS indicated that RN #2 should have notified the RN supervisor to come assess the new pressure ulcer and do the change of condition assessment, notify the ADNS or physician and get a treatment order put into place that day, and notify the resident representative. The DNS indicated that the APRN and resident representative were not notified until 2/24/25, 9 days after being first found. An interview with RN #2 on 4/7/25 at 11:11 AM indicated that she was the charge nurse on the unit and was responsible on 2/15/25 to do the weekly body assessment on Resident #91. RN #2 indicated that she had noted an intact 6 cm by 6 cm blister with yellow drainage inside the blister but the skin under the blister was not viable skin. RN #2 indicated that she assumed the DTI to the left heel was old. RN #2 indicated that if it was new she would have told the supervisor so she could have done a change in condition assessment, get a treatment order, and notify the APRN and resident representative. RN #2 indicated that because she thought it was old she did not notify the RN supervisor or the APRN, or resident representative. RN #2 indicated that if she had she would have documented it. Interview with the Dietitian on 4/9/25 at 11:35 AM identified the wound nurse was responsible for providing her with a weekly wound report for all wounds that would include new wounds and if wounds are getting worse. The Dietitian indicated that she did not receive any wound reports for the month of February 2025 and only 1 report in March 2025. The Dietitian indicated the wound report for the week of 3/7/25 did not have Resident #91 on it. The Dietitian indicated that she had reported several times to the DNS that she was not receiving the weekly wound reports. The Dietitian indicated that if a resident receives a new facility acquired pressure ulcer and she is notified she would have seen the resident within a week at the most. The Dietitian indicated she would assess the resident and make sure the resident is meeting nutritional needs and would recommend some type of protein supplement based on the stage of the wound. The Dietitian indicated that Resident #91 was seen on 2/9/25 and 2/19/25 and was noted with no pressure ulcers. The Dietitian noted on 2/28/25 Resident #91 was only seen for weights and she was not aware of any wounds. The Dietitian indicated that on 4/2/25 after Resident #91 was readmitted on [DATE] she went to do the nutritional evaluation and noted the documentation of the left heel pressure ulcer. The Dietitian indicated at that time she had recommended the protein supplement (Prostat Advanced Wound Care) and the order was put into place. The Dietitian indicated that if she was aware on 2/15/25 when someone had first found the left heel, she would have seen Resident #91 right away. The Dietitian indicated that it is the protocol for stage 3, stage 4, or unstageable to immediately start the protein supplement to promote wound healing. Interview and clinical record review with DNS on 4/10/25 at 8:00 AM identified that Resident #91 had a DTI to the left heel identified on 2/15/24 which was not reported to the APRN and resident representative until 2/24/25. Further, she did not see that the dietitian was notified in any notes until a dietitian evaluation on 4/2/25. Review of the Notification of Change Policy identified the purpose was to ensure the facility promptly informs the resident, the physician, and the resident's representative when there is a change requiring notification. Review of the Facility Responsibilities Policy identified the facility will immediately inform the resident, physician, and resident representative a significant change in the residents physical, mental, or psychosocial status. Also, a need to alter a treatment such as a new, discontinue or change in an existing treatment. Review of Pressure Injury Prevention and Management Policy identified the facility as committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to promote treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injures. The attending physician will be notified of the presence of a new pressure injury identification. A review will be performed on each pressure injury that develops in the facility. Review of the Nutritional Management Policy identified the facility promotes care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in his/her overall condition. A comprehensive nutritional assessment will be completed by the dietitian within 72 hours of admission, annually, and upon significant change in condition. Components of the assessment will include, but not limited to residents' general appearance, height, weight, cognitive, physical, and medical conditions, food and fluid intake, poor intake, weight loss, review of medications, and review of labs. 3. Resident # 81 was admitted to the facility in July 2023 with diagnoses that included COPD, diabetes with hyperglycemia, and dementia. The care plan dated 11/17/24 identified Resident #81 has a diagnosis of Insulin dependent diabetes and hyperglycemia. Interventions included monitoring signs and symptoms of hyper/hypoglycemia and report abnormal findings to the physician, assess and record blood glucose levels as ordered, and administer hypoglycemic medications as ordered. A physician's order dated 12/16/24 directed to inject Glucagon 1 mg (a medication used to treat low blood glucose) IM as needed for blood glucose less than 70 if Resident #81 was unable to swallow or was unresponsive, monitor vital signs and stay with the resident, notify the provider and recheck the blood glucose in 15 minutes, repeat protocol if less than 70 and document response in the progress notes. A physician's order dated 12/16/24 directed to administer Glucose oral gel 15 mg/32ml (a medication used to treat low blood glucose) one application by mouth as needed for blood glucose less than 70 if Resident #81 was asymptomatic or symptomatic but responsive with the ability to swallow. The order further directed to repeat the blood glucose level in 15 minutes, document the results, and if still below 70, notify the provider and administer a second dose of the glucose gel. A physician's order dated 12/19/24 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 3 times daily (7:30 AM, 11:30 AM, 4:30 PM) before meals and administered for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The 5 day MDS dated [DATE] identified Resident #81 had intact cognition, was always incontinent of bowel and bladder and dependent on staff to assist with toileting, bathing, and dressing. An APRN note dated 12/28/24 at 11:58 AM identified that a telehealth visit was conducted with RN #7 due to Resident #81's blood glucose result of 480 on that date. The APRN note identified Resident #81 was asymptomatic and the treatment orders included a total of 14 units of Insulin Lispro, recheck blood glucose in one hour, if blood glucose was above 400 in 2 hours to contact telehealth APRN for further instructions, and notify a clinician of any change in condition. A nurse's note dated 12/28/24 at 12:03 PM by LPN #2 identified Resident #81's blood glucose was 480 and 12 units of Insulin Lispro were administered, the supervisor was notified, and the physician would be contacted. Review of the clinical record failed to identify any documentation that Resident #81's resident representative was notified related to Resident #81's hyperglycemic episode requiring treatment visit. A physician's order dated 1/31/25 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 4 times daily (7:30 AM, 11:30 AM, 4:30 PM, and 9 PM) before meals, at bedtime, and administer for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The January 2025 MAR identified LPN #2 documented Resident #81 had a blood glucose of 459 on 1/31/25 at 4:30 PM and received a partial dose of Insulin Lispro. The MAR failed to identify the dose administered. Review of the clinical record failed to identify any additional documentation related to Resident #81's blood glucose of 459 on 1/31/25 including notification to the provider per the physician's order due to the blood glucose level above 450, or that Resident #81's resident representative was notified. The February 2025 MAR identified Resident #81 had a blood glucose of 63 on 2/13/25 at 7:30 AM. The MAR identified that the blood glucose parameters were out of range and no Insulin was administered. Review of the clinical record for 2/13/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 50 obtained by LPN #2 on 2/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 47 obtained by LPN #2 on 2/18/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/18/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 51 obtained by LPN #2 on 2/22/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/22/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. A nurse's note dated 3/3/25 at 10:26 PM by LPN #1 identified that Resident #81 had a blood glucose of 54. The note identified glucose gel was administered. Review the clinical record for 3/3/25 failed to identify any additional documentation that the provider or Resident #81's resident representative was notified. A nurse's note dated 3/14/25 at 8:52 AM by RN #12 identified Resident #81 had a morning blood glucose of 45, that Resident #81 was given juice and breakfast, a repeat blood glucose 15 minutes later was 78, and that the APRN was notified. Further review of the clinical record failed to identify that Resident #81's resident representative was notified of the hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 62 on 3/16/25 at 11:30 AM. Further review of the MAR identified that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/16/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 68 obtained by LPN #2 on 3/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 55 obtained by LPN #2 on 3/20/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/20/25 failed to identify any additional documentation including that the provider or Resident #81's representative were notified. A nurse's note dated 3/21/25 at 3:49 AM by RN #12 identified Resident #81 had a blood glucose of 53 at 3:00 AM. The note also identified that an IM Glucagon injection was given, and Resident #81 had a repeat blood glucose of 112 at 3:45 AM. Further review of the clinical record for 3/21/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified. A nurse's note dated 3/22/25 at 7:54 AM by RN #12 identified that at 3:30 AM, Resident #81 was observed to be alert but lethargic with skin warm to the touch but clammy. The note further identified Resident #81 had a blood glucose of 50 and was administered glucose gel, and a recheck 20 minutes later identified a blood glucose of 69. The note identified Resident #81 reported feeling better and was offered orange juice, and a repeat blood glucose was 112 after an hour. The note also identified Resident #81 received Insulin Glargine 52 units at bedtime and that Resident #81 had a blood glucose of 149 at 7:30 AM. Review of the clinical record for 3/22/25 failed to identify that the provider or Resident #81's resident representative were notified. The March 2025 MAR identified on 3/22/25 at 8:00 PM that 52 units of Insulin Glargine was held by LPN #3 due to Resident #81's blood glucose levels dropping to 50 overnight. The clinical record failed to identify that the provider was notified that Resident #81 did not receive his/her nightly dose of Insulin Glargine on 3/22/25 or that Resident #81's resident representative was notified of the medication hold due to hypoglycemia. Review of the clinical record and MAR for March 2025 identified on 3/23/25 at 1:30 AM, LPN #3 identified Resident #81 had a blood glucose level of 50 and was administered glucose gel. Review of the clinical record identified on 3/23/25 at 2:00 AM, LPN #3 documented Resident #81 had a blood glucose recheck of 63. A nurse's note dated 3/23/25 at 2:32 AM by LPN #3 identified Resident #81 was clammy, cold, and lethargic and glucose gel was administered. Review of the clinical record identified on 3/23/25 at 2:30 AM, RN #12 documented Resident #81 had a blood glucose of 112. Review of the clinical record for 3/23/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. Review of the clinical record identified on 3/25/25 at 2:00 AM LPN #3 documented Resident #81 had a blood glucose of 45. Further review of the clinical record identified a recheck by LPN #3 done at 3:44 AM was 70. Review of the clinical record and March 2025 MAR for 3/25/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. A nurse's note dated 3/26/25 at 1:20 AM by LPN #1 identified she was notified by a nurse aide that Resident #81 was profusely sweating. LPN #1 identified that Resident #81 had blood glucose check of 41, that emergency glucose was given immediately, and that a recheck would be done in a few minutes. The March 2025 MAR identified LPN #1 administered glucose gel on 3/26/25 at 1:20 AM. A nurse's note dated 3/26/25 at 1:45 AM by LPN #6 identified Resident #81 had a repeat blood glucose check of 54. Further review of the nurse's note identified LPN #1 documented a repeat blood glucose check of 131 at 2:14 AM. Review of the clinical record for 3/26/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 67 obtained by LPN #2 on 3/31/25 at 11:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/31/25 failed to identify any documentation that Resident #81's resident representative was notified of Resident #81's hypoglycemic episode. Interview with APRN #1 on 4/8/25 at 11:52 AM identified that she was aware that Resident #81 had variable blood glucose levels but felt these were related to dietary noncompliance and a recent course of antibiotics. APRN #1 identified she could not remember if she was notified that if Resident #81 received IM Glucagon or of all the blood glucose levels under 70 since 2/13/25, but if the resident had a blood glucose above 450 or below 70, she would expect that the nurses would assess the resident to ensure he/she was not symptomatic and that she or the on call provider would be notified if the resident had symptoms. Interview with LPN #1 on 4/9/25 at 10:50 AM identified that she was assigned to Resident #81 on 3/3 and 3/26/25. LPN #1 identified that LPNs in the facility were not allowed to complete an assessment of the residents or contact the physician/APRN and resident representative regarding a change in condition, so that should have been completed by the RN. LPN #1 identified she was unsure who she reported Resident #81's hypoglycemic episodes to and she did not document the information in the clinical record. Interview with RN #12 on 4/9/25 at 11:56 AM identified that she was the nurse assigned to Resident #81 on 3/20/25 on the 11:00 PM - 7:00 AM shift and was the RN supervisor working with LPN #3 on 3/22/25 on the 11:00 PM - 7:00 AM shift. RN #12 identified on 3/21/25 at 3:00 AM a nurse aide notified her that Resident #81 was very lethargic, and she administered IM Glucagon which was the standard order for all diabetics in the facility for hypoglycemia. RN #12 identified she obtained vital signs on Resident #81 and completed a repeat blood glucose check at 3:45 AM and documented a progress note. RN #12 identified that on 3/23/25 Resident #81 had a similar hypoglycemic episode with LPN #3 overnight and required glucose gel and juice. RN #12 identified she did not notify the on-call provider or Resident #81's resident representative regarding Resident #81's hypoglycemic episodes on 3/21 or 3/23/25 and that she would have passed the information on in morning report to the day shift or told APRN #1 in person if she was in the facility at shift change. RN #12 identified that she did not feel that it was necessary to notify the on-call provider but was aware that the physician orders and facility protocol for hypoglycemia directed to contact the physician or APRN for a blood glucose less than 70 Interview with LPN #2 on 4/9/25 at 12:15 PM identified she could not remember any blood glucose issues for Resident #81 from 12/28/24, 1/31/25, 2/2025, or 3/2025. LPN #2 identified that unless she noticed a specific issue or it was listed in her tasks in the MAR or TAR, she did not document a note or assess Resident #81 related to blood glucose issues. LPN #2 identified any documentation would be in a progress note, and that she would notify the RN superviso[TRUNCATED]

Based on review of the clinical record, facility documentation, facility policy, and interviews for residents 4 of 8 residents (Resident #42, 88, 92 and 99,) reviewed for allegations of abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1a. Resident #7 was admitted to the facility in August 2024 with diagnoses that included paranoid schizophrenia, borderline personality disorder, and diabetes. The care plan dated 11/7/24 identified Resident #7 exhibits or has the potential to exhibit physical behaviors related to psychiatric disorder and is combative with care. Interventions include postponing care/activity and allowing time to regain composure. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition and was independent walking 150 feet. The physician's order dated 1/1/25 directed to monitor behavior for hitting and swatting every shift. Review of the change in condition evaluation form dated 1/15/25 identified Resident #7 was observed by nursing staff striking his/her roommate (Resident #88). Resident #7 indicated he/she asked Resident #88 to get off his/her bed and identified he/she only touched Resident #88's leg to get off the bed. The APRN and conservator of person were notified. Resident #7 is on 1:1 monitoring until psychiatric evaluation. b. Resident #88 was admitted to the facility in May 2023 with diagnoses that included wandering, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. The care plan dated 11/9/24 identified Resident #88 was an elopement risk and wanderer related to impaired safety awareness and wanders aimlessly. Intervention included wanderguard to left wrist, distract resident from wandering by offering pleasant diversions, and structured activities. Further, the care plan identified Resident #88 had a behavior problem related to dementia and could be difficult to redirect when anxious. Interventions included intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to an alternate location as needed. The care plan dated 11/26/24 identified Resident #88 had the potential to exhibit physical behaviors related to cognitive loss and dementia. Resident #88 exhibited physical aggression toward another resident without injury. Interventions included gently guiding the resident from the environment while speaking in a calm, measuring voice, divert resident by giving alternative objects or activities. The quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition and was independent with walking 150 feet. Additionally, Resident #88 had no physical or verbal behaviors directed at others and had exhibited no wandering behavior. (This is in conflict with the care plan that identified Resident #88 wanders aimlessly and exhibited physical aggression toward another resident). The physician's order dated 1/1/25 directed to monitor behavior for wandering and exit seeking at the end of each shift for anxiety, monitor behavior for nighttime restlessness every evening and night shift and monitor behavior for anxious and panic every shift. Review of the change in condition evaluation form dated 1/15/25 identified Resident #88 was struck by roommate (Resident #7). The APRN, police, and resident representative were notified. Resident #88 will be evaluated by psychiatric APRN. The reportable event form dated 1/15/25 at 4:15 PM identified staff overheard yelling coming from Resident #7 and Resident #88's room. Upon entering the room, Resident #7 was observed hitting Resident #88 on the left shoulder twice with an open hand. Resident #7 indicated that Resident #88 was lying in his/her bed and when she asked Resident #88 to move the resident became upset and began yelling. Resident #7 was placed on 1:1 supervision pending psychiatrist evaluation. Both residents were evaluated for injury with none found. The APRN, police, Administrator, and conservator of person, and resident representative were notified. Neither resident was injured in the incident. Resident #7 has been moved to a different hallway. Both residents were evaluated by psychiatrist services. Resident #88 was given a one-time dose of Ativan with positive effect. Both residents will continue to receive psychiatric services. A written statement by LPN #4 dated 1/15/25 identified at approximately 3:50 PM she heard loud yelling and arguing coming from Resident #7 and Resident #88 room. LPN #4 indicated she approached the room and witnessed Resident #7 hitting Resident #88 while Resident #88 was on the floor. LPN #4 indicated she ran and called for help. A written statement by LPN #5 dated 1/15/25 identified she was in the middle of medication pass when LPN #5 indicated she was informed by another nurse at 3:50 PM that there was a resident-to-resident altercation between Resident #7 and Resident #88. LPN #5 indicated the supervisor informed her that Resident #88 would be on every 15 minutes monitoring for the remainder of the evening, and Resident #7 would be relocated to the 400 wing. The social service note dated 1/15/25 at 4:42 PM identified SW #2 spoke with Resident #7's conservator of person regarding incident that occurred between his/her and roommate. A room change was initiated for Resident #7. SW #2 will follow up with Resident #7 and the resident has been added to the psychiatrist book to be seen. The nurse's note by RN #10 dated 1/15/25 at 5:23 PM identified it was reported to her from LPN #4 that Resident #7 was observed in a physical altercation with roommate (Resident #88) at 4:15 PM. Resident #7 indicated Resident #88 sat on his/her bed, and he/she moved Resident #88's leg off the bed and Resident #88 sat on the floor. Resident #7 denies striking roommate. Both residents were separated at the time of the incident. Resident #7 was cleared by the psychiatrist with no new orders. The nurse's note by RN #10 dated 1/15/25 at 5:27 PM identified it was reported to her from LPN #4 that Resident #88 was observed in a physical altercation with Resident #7 at 4:15 PM. Resident #88 has no recollection of the event and was calm, and cooperative. The summary report dated 1/22/25 at 3:45 PM identified Resident #88 began yelling at Resident #7. Staff responded to the yelling and witnessed Resident #7 slapping Resident #88 on the left shoulder twice with an open hand. Both residents were immediately separated and placed on 1:1 supervision pending on psychiatrist evaluation. Both residents were evaluated for injury with none found. Both residents were evaluated by the psychiatrist and cleared from 1:1 monitoring. Resident #88 was given a dose of Ativan with positive effect. Resident #7's room has been relocated to a different hallway. Both residents will continue to receive psychiatric services. Behaviors will continue to be monitored. Interview with RN #10 on 4/14/25 at 12:18 PM identified she does remember the resident-to-resident physical and verbal altercation due to it was so long ago. 2a. Resident #42 was admitted to the facility in September 2022, with diagnoses that included anxiety disorder, depressive disorder, and chronic kidney failure disease stage 4. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition and required substantial/maximum assistance with personal hygiene. The care plan dated 11/25/24 identified Resident #42 has the potential to exhibit physical behaviors related to ineffective coping skills, (example poor anger management). Resident #42 was in a physical altercation with another resident without injury. Interventions include monitor for emotional distress as ordered. Review of the change in condition evaluation form dated 11/26/24 identified Resident #42 was involved in a resident-to-resident altercation. The APRN, police, and the resident representative were notified. Resident #42 was monitored for emotional distress every shift for 72 hours. b. Resident #88 was admitted to the facility in May 2023, with diagnoses that included wandering, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition and was independent with walking 150 feet. Additionally, Resident #88 had no behaviors (physical or verbal) directed at others, and no wandering behavior. The care plan dated 10/16/24 identified Resident #88 was an elopement risk with wandering related to impaired safety awareness and wanders aimlessly. Intervention included wanderguard to left wrist, distracting resident from wandering by offering pleasant diversions, and structured activities. Additionally, Resident #88 had a behavioral problem related to dementia and could be difficult to redirect when anxious. Interventions included intervening as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to an alternate location as needed. The physician's order dated 11/1/24 directed to monitor for wandering/exit seeking each shift for anxiety, monitor behavior for nighttime restlessness every evening and night shift and monitor behavior for anxiety and panic every shift. The reportable event form dated 11/26/24 at 8:00 PM identified Resident #88 wandered into Resident #42's room. When Resident #42 asked Resident #88 to leave and stop touching him/her belongings, Resident #88 struck Resident #42 on the arm. Staff responded to yelling from Resident #42's room. Resident #42 reported that Resident #88 had wandered into his/her room and sat in his/her wheelchair. Resident #42 reported he/she grabbed Resident #88's arm to stop and guide him/her out of the room, when Resident #88 struck him/her on the left arm. Both residents were immediately redirected away from each other and assessed for injuries. No injuries were found on either resident. Resident #88 was placed on 1:1 supervision pending psychiatric evaluation. Investigation initiated. The APRN, Administrator, police, and resident representatives were notified. The LCSW #1 progress note dated 11/26/24 at 8:00 PM - 8:16 PM identified she met with Resident #88 in response to screaming in the hallway of the 500 wing. Resident #88 was screaming help, help and attempting to push his/her way past a nursing staff who was blocking the doorway to Resident #42's room. LCSW #1 redirected Resident #88 to walk with her to the day room area and participated in a breathing activity and it was successful. LCSW #1 provided Resident #88 with a cheese and cracker snack as a distraction. Resident #88 continues to be increasingly confused and agitated. Resident #88 was observed to wander in and out of resident rooms. Resident #88's roommate indicated Resident #88 wanders in the night hours and moves things in the room. It was reported that Resident #88 wandered into Resident #42's room thinking that it was his/her room, attempted to get into Resident #42's roommates bed after redirection Resident #88 sat in Resident #42's wheelchair. Resident #42 touched Resident #88's arm to redirect the resident to leave and Resident #88 reacted and assaulted Resident #42. The LCSW #1 progress note dated 11/26/24 at 8:53 PM - 9:12 PM identified Resident #42 was assaulted by Resident #88 while he/she was in bed. LCSW #1 met with Resident #42 to offer supportive therapy and provide support after the incident. Resident #42 was presented as anxious with constricted affect, was alert and oriented and friendly. Resident #42 indicated Resident #88 wandered into his/her room and attempted to lay in the roommate's bed. Resident #42's roommate redirected Resident #88 to leave, however, Resident #88 sat in Resident #42's wheelchair. Resident #42 touched Resident #88's arm to redirect him/her from sitting in the wheelchair and to leave the room. Resident #88 was agitated, confused and hit Resident #42 in response to being touched. Resident #42 indicated he/she was not expecting to be assaulted, but it did not hurt and there was no physical injury. Resident #42 indicated that Resident #88 often wanders into his/her room and Resident #42 verbalized the fear that it will happen again, noting that Resident #88's room was directly across from his/her room. A written statement by RN #4 dated 11/26/24 identified she was notified by RN #10 that there was an unwitnessed resident to resident altercation between Resident #88 and Resident #42. Resident #88 wandered into Resident #42's room and began sitting in his/her wheelchair. Resident #42 was shocked, annoyed, and grabbed Resident #88's arm to try and remove him/her out of the room. Resident #88 hit Resident #42 multiple times on the left arm. Resident #42 screamed, and NA #8 came into the room. A written statement by NA #8 dated 11/26/24 at 8:15 PM identified she last check on Resident #88 at 7:45 PM who was sitting at the nurse's desk eating a snack. NA #8 indicated she did not witness the incident. NA #8 indicated she heard Resident #88 screaming in the hallway. NA #8 indicated Resident #88 was physically aggressive towards her because she was blocking Resident #42's room door to prevent him/her from entering the room again. The psychiatric APRN note dated 11/27/24 identified urgent telehealth visit with Resident #42 after Resident #88 came into his/her room and sat in his/her wheelchair and would not leave. Resident #42 indicated she recalled the incident and asked Resident #88 to leave. Resident #42 indicated he/she grabbed Resident #88's arm to get Resident #88 to leave and Resident #88 slapped him/her in the face. Both residents were screaming at each other and the nursing staff came in and separated them. The psychiatrist APRN note dated 11/27/24 identified urgent telehealth visit With Resident #88 after a resident-to-resident incident last evening. It was reported that Resident #88 went into Resident #42's room and sat in his/her wheelchair and refused to leave. Resident #42 attempted to get Resident #88 to leave, and Resident #88 allegedly slapped him/her in the face. This was not witnessed by staff. Review of the summary report dated 12/4/24 at 1:24 PM identified on 11/26/24 at 8:00 PM Resident #88 wandered into Resident #42's room and sat in his/her wheelchair. Resident #42 touched Resident #88 right arm and asked him/her to leave. Resident #88 started yelling at Resident #42 and lightly swatted his/her on the left arm with an open hand. Resident #42 indicated staff immediately responded to the yelling and redirected Resident #88 out of the room. Resident #88 was placed on 1:1 supervision pending psychiatric evaluation and both were assessed for injury with none found. Resident #88 remains on every 15 minutes checks. Resident #88 continues to receive psychiatric services, and psychoactive medication has been reviewed. A Velcro stop sign was ordered for Resident #42's room door. Interview with the DNS on 4/9/25 at 8:00 AM identified Resident #88 is alert, confused, ambulates independently, and has a history of wandering. The DNS indicated Resident #88 wandered into Resident #42 room and sat in his/her wheelchair. Resident #42 attempted to have Resident #88 leave the room when Resident #88 hit him/her on the arm. The DNS indicated the social service department has met with Resident #88 representative regarding searching for another facility with a dementia secure unit. The DNS indicated the facility is addressing Resident #88 wandering behavior with ongoing staff monitoring the resident throughout the day, and Resident #88 attending recreation activities of his/her choice. 3. Resident #92 was admitted to the facility in August 2023 with diagnoses that included dementia with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety disorder, and cerebrovascular disease. The quarterly MDS dated [DATE] identified Resident #92 had severely impaired cognition and required setup or clean-up assistance with toileting hygiene. Additionally, Resident #92 had exhibited no physical or verbal behavior symptoms directed toward others. The care plan dated 3/19/25 identified Resident #92 requires assistance for ADL care related to dementia, decreased ability to perform ADL'S. Interventions included providing extensive assistance of 1 for bed mobility, toileting and hygiene. The care plan dated 3/19/25 identified Resident #92 was resistive to care related to dementia. Refusing care at times. Interventions included to give a clear explanation of all care activities prior to and as they occur during each contact. Further, Resident #92 had the potential to be physically aggressive related to dementia, and poor impulse control. Interventions included giving the resident as many choices as possible about care and activities. The physician's order dated 4/1/25 directed to monitor behavior for anxiety, resistive/combative with care, and emotional distress every shift. The reportable event form dated 4/8/25 at 12:00 PM identified Resident #92 was alert, oriented to self, pleasant, and cooperative. Resident #110, who resides across the hallway from Resident #92, reported to the social worker between 2:00 AM and 3:00 AM that he/she overheard NA #3 telling Resident #92 to shut up and be quiet. The care plan dated 4/8/25 identified Resident #92 was involved in an alleged verbal incident involving a staff member. Interventions included to monitor for emotional distress. The psychiatric APRN note dated 4/8/25 identified Resident #92 was seen for alleged negative interaction with staff member. Resident #92 was seen in bed, alert, smiling upon approach, calm, and cooperative. Resident #92 was unable to accurately state day, month, year. Resident #92 does not recall having a negative interaction with staff. A statement by LPN #1 dated 4/8/25 identified she worked on 4/7/25 on the 11:00 PM - 7:00 AM shift on the [NAME] wing. LPN #1 indicated RN #6 came over to the unit. LPN #1 indicated Resident #110 reported to her that NA #3 was in Resident #92's room and was aggressive with Resident #92 and told him/her to shut up. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 was in Resident #92's room and was aggressive with Resident #92 and told him/her to shut up. A statement by NA #3 dated 4/8/25 at 5:01 PM identified she provided care to Resident #92 around 1:00 AM and 5:00 AM as she does every morning when she works. NA #3 indicated some mornings Resident #92 can be a bit loud talking to his/herself as he/she was on the morning of 4/8/25. NA #3 indicated she had to go to the resident room several times to reassure him/her that it was in the middle of the night, and he/she had to be quiet. NA #3 indicated she sat with Resident #92 and gave him/her a tuna sandwich and a drink. NA #3 indicated she put the television on animal planet with no volume, and Resident #92 eventually fell asleep. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked on 4/7/25 on the 11:00 PM - 7:00 AM shift on the [NAME] wing. LPN #1 indicated she observed NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home, leaving the [NAME] wing with only with 2 nurse aides instead of 3 nurse aides. LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to act like a damn man and that he/she was behaving like a child. LPN #1 indicated RN #6 stated that NA #3 and her (LPN #1) need to get along and she will address the issue with the DNS in the morning. LPN #1 indicated that was not the first time she has witnessed NA #3 yelling, using profanity, and being argumentative with agency nurse aides or other staff on the 11:00 PM - 7:00 AM shift on the [NAME] wing. Interview with Resident #110 on 4/10/25 at 9:55 AM identified he/she does not sleep throughout the night, so he/she ambulates up and down the hallway and watches television in the common area on the wing (which is across from the nurse's station). Resident #110 indicated on Monday night his/her bedroom door was open, and Resident #92's bedroom door was also open. Resident #110 indicated Resident #92 was talking out loud to his/herself which the resident does sometimes. Resident #110 indicated around 2:00 AM or 3:00 AM overheard NA #3 across the hallway in Resident #92's room yelling at Resident #92 to shut up and be quiet. Resident #110 indicated NA #3 said it four times to Resident #92. Resident #110 indicated he/she got up and stood in the doorway of his/her bedroom and listened. Resident #110 indicated afterward NA #3 left Resident #92's room. Resident #110 indicated a little while later he/she witnessed and heard NA #3 was yelling and arguing with LPN #1 in front of the nurse's station saying who is going to clean Resident #99 and the urine on the floor. Resident #110 indicated Resident #99 was sitting in the wheelchair at the nurse's station. Resident #110 indicated he/she reported to LPN #1 that he/she overheard NA #3 in Resident #92's room yelling at Resident #92 to shut up and be quiet. Resident #110 indicated he/she told SW #2 that morning that he/she overheard NA #3 in Resident #92's room yelling at Resident #92 to shut up and be quit, and NA #3 was yelling and arguing with LPN #1 in front of the nurse's station saying who is going to clean Resident #99 and the urine on the floor. Interview with the DNS on 4/10/25 at 12:00 PM identified she was made aware on 4/8/25 at 12:00 PM that Resident #110 had reported to SW #1 between 2:00 AM and 3:00 AM he/she overheard NA #3 telling Resident #92 to shut up and be quiet. The DNS indicated she reported the allegation of verbal abuse to the survey team immediately. The DNS indicated she placed NA #3 on administrative leave immediately. The DNS indicated RN #6, and LPN #1 did not inform her of the allegation by Resident #110. The DNS indicated she must investigate and see if LPN #1 had reported the allegation of staff to resident abuse to RN #6. DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. The DNS indicated that the expectation of the facility is that when there is an allegation of abuse the staff member is to be removed from the unit and sent home immediately. The DNS indicated NA #3 should have been removed from the unit and sent home until further notice. DNS indicated she is not aware if LPN #1 had reported to RN #6 about the alleged staff to resident abuse of Resident #99. DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. Review of the facility abuse, neglect, and exploitation policy identified facility to provide protection for 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 resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical arm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs: antipsychotic and antidepressant for agitation, restlessness, and sleeplessness. Interventions included monitor for continued need of medication as related to behavior and mood. Resident #99 exhibits or is at risk for distress/fluctuating mood symptoms related to sadness, depression caused by current medical diagnoses and functional decline. Interventions included refer to behavioral health specialists as needed. Resident #99 has bowel incontinence and mixed bladder incontinence related to confusion, impaired mobility, and Parkinson's disease. Interventions included to provide peri-care with each incontinent episode. The physician's order dated 4/1/25 directed to monitor behavior for agitation, resistive, excessive wandering, intrusive behavior, and sleeplessness every shift. A statement by LPN #1 dated 4/8/25 identified she worked 4/7/25 on the 11:00 PM - 7:00 AM shift and indicated Resident #99 was sitting at the nurse's station when she came arrived. LPN #1 indicated Resident #99 had a fall and hit his/her head and sustained a laceration at the beginning of the shift. LPN #1 indicated Resident #99 was restless and would not remain still. LPN #1 indicated NA #3 was getting very agitated and aggressive with Resident #99 because the resident was grabbing everything and pushing chairs and at some point Resident #99 was yelling out another resident's name and yelling help. LPN #1 indicated that is when she observed NA #3 turn around and pull/yank Resident #99's wheelchair and say to Resident #99 (act like a damn man you're behaving like a child). LPN #1 told NA #3 that Resident #99 has dementia and will not understand her and that was inappropriate. LPN #1 indicated at 5:00 AM she started her medication pass and heard Resident #99 saying that he/she needed to go to the bathroom. LPN #1 informed NA #3 of the resident's request, however, NA #3 walked by her and ignored her. LPN #1 indicated at some point she walked by Resident #99 and observed a puddle of urine on the floor. LPN #1 indicated she notified NA #3 and NA #4 that Resident #99 had urinated on the floor, and again she got no response from the nurse aides. LPN #1 indicated she placed a few towels on the floor and underneath Resident #99's wheelchair and the resident's feet to soak up the urine. LPN #1 indicated that is when NA #3 approached her and stated, (oh you couldn't pick the piss off the damn floor). Resident #99 was present and could hear this comment. LPN #1 indicated she told NA #3 that she was in the middle of a medication pass and that if she had taken Resident #99 to the bathroom when he/she asked, the resident would not have urinated on the floor. LPN #1 indicated NA #3 insisted that LPN #1 provide incontinent care to Resident #99 and clean the floor with the urine. LPN #1 indicated she told NA #3 that she was in the middle of medication pass and that she (NA #3) was assigned to the resident. LPN #1 indicated NA #3 began shouting, cursing, speaking inappropriately to her in the [NAME] wing hallway in front of the nurse's station with Resident #99 present. LPN #1 indicated she told NA #3 that she would be calling the RN supervisor. LPN #1 indicated she walked down to the 400 wing with NA #3 still screaming at her while NA #3 was pushing Resident #99 down the hallway to the 600 wing to go and provide incontinent care to the resident. LPN #1 identified she called RN #6 to report the incident with NA #3. LPN #1 indicated Resident #110 reported to her that NA #3 had been in Resident #92's room and was aggressive with Resident #92 and told the resident to shut up. LPN #1 indicated Resident #110 also reported that NA #3 was yelling and screaming being disrespectful to the nurse and he/she was going to report NA #3 to the DNS. Interview with NA #3 on 4/9/25 at 11:23 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and was not assigned to Resident #99. NA #3 indicated at the beginning of the shift there were 3 nurse aides, and one of the aides, the agency nurse aide, left and went home which NA #3 indicated is an on-going issue with the agency nurse aides. NA #3 indicated Resident #110 was ambulating on the wing and was in the common area watching television. NA #3 indicated she was upset and probably loud when Resident #99, who was at the nurse's station in a wheelchair, urinated on himself/herself and the floor. NA #3 indicated LPN #1 placed a towel down on the floor and left it there. NA #3 indicated there was only 2 nurse aides overseeing the 400, 500, and 600 wings answering call lights and providing care, and she expected LPN #1 to help. NA #3 indicated she and LPN #1 had words. Interview with RN #6 on 4/9/25 at 11:50 AM identified she worked on 4/7/25 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #6 indicated LPN #1 called her to the [NAME] wing because NA #3 was being disrespectful towards her. RN #6 indicated LPN #1 reported Resident #99 had urinated on the floor and she placed a towel on the floor and NA #3 told her it was everyone's job to provide resident care. RN #6 indicated LPN #1 never informed her that NA #3 was getting very agitated and aggressive with Resident #99 and pulled/yanked Resident #99's wheelchair and said to Resident #99 (act like a damn man you're behaving like a child). Further, RN #6 identified LPN #1 did not report to her that Resident #110 reported NA #3 was verbally abusive to Resident #92. RN #6 indicated she told LPN #1 and NA #3 to work out their issues or take it to Human Resource in the morning. RN #6 indicated she educated LPN #1 not to discussed what took place between her and NA #3. The reportable event form dated 4/10/25 at 11:30 AM identified during another investigation, it was discovered that LPN #1 witnessed NA #3 allegedly yank Resident #99's wheelchair and told the resident to (act like a damn man, you're behaving like a child). LPN #1, and NA #3 remain on administrative leave pending an investigation. Resident #99 was evaluated by psychiatrist and social services. The APRN, Administrator, police, and the resident Power of Attorney were notified. A statement by NA #3 dated 4/10/25 at 11:29 AM identified that she denied the allegations. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home leaving the [NAME] wing with only 2 nurse aides instead of three. LPN #1 indicated NA #3 had an attitude and was upset that Resident #99 was at the nurse's station for monitoring. LPN #1 indicated she observed NA #3 pull/yank Resident #99's wheelchair and said to the resident (act like a damn man and that he/she was acting like a child). LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to (act like a damn man and that he/she was behaving like a child). LPN #1 indicated RN #6 stated that she and NA #3 need to get along and s[TRUNCATED]

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 8 residents (Resident #69, 99 and 269) reviewed for abuse and misappropriation, the facility failed to immediately report the allegations of abuse and misappropriation to the Administrator and the State Agency according to established timeframes. The findings include: 1. Resident #69 was admitted to the facility in February 2025 with diagnoses that included chronic kidney disease, diabetes, and surgery of the left leg. A physician's order dated 2/13/25 directed Resident #69 may go on a leave of absence with medications and responsible party. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, lower body dressing, transfers, and personal hygiene. The care plan dated 2/20/25 identified Resident #69 is resistive to care. Interventions included providing consistent, trusted caregiver, and structured daily routine, when possible. The social worker note dated 4/3/25 at 12:38 PM indicated that she met with Resident #69 to discuss concerns related to money being missing from his/her wallet. Resident #69 states that he/she had $152 and now is missing $150. Resident #69 reported last seeing his/her wallet in his/her backpack, and now only $2 dollars were left. Resident #69 was unsure if he/she had dropped it in the reception area prior to going out for an appointment but he/she is adamant that it was in his/her backpack. The Missing Item Form dated 4/3/25 identified at approximately at 9:00 AM Resident #69 reported he/she was missing $150, and it was one $100 bill and a $50 dollar bill. Attached was a statement from SW #1 that indicated she had spoken with RN #11 who reported that Resident #69 had told her that $150 was missing from his/her wallet. RN #11 reported that the wallet was given to her by a staff member, and that she had returned it to Resident #69 who said there was money missing. The social worker note dated 4/7/25 at 9:12 AM identified this social worker met with the resident following the allegation of stolen money. This writer will continue to follow-up with Resident#69 and offer support as needed. Interview with the Administrator on 4/8/25 at 2:20 PM indicated that she was responsible to complete an investigation related to Resident #69's missing money, and that she did it as a grievance because SW #1 informed her that the money was missing, not that it was stolen. The Administrator indicated that she did not know when Resident #69 last had seen the money or where Resident #69 kept his/her wallet. The Administrator indicated that she does not know if the resident really had the money or not because he does not keep it in the facility's account. The Administrator indicated that Resident #69 could have dropped it in the lobby that day when going out for an appointment. The Administrator indicated that the wallet was found by Laundry #1, and he opened it to see who it belonged to and brought it to the supervisor RN #11. Reviewing the investigation and missing item form, the Administrator could not provide statements from the supervisor RN #11 or Laundry #1. The Administrator indicated that she does not know how Resident #69's wallet had gotten out of the backpack into the laundry. The Administrator indicated that she could not confirm or deny if Resident #69 had the $150 but she was not informed until yesterday that the money was stolen, she thought it was just missing. The Administrator indicated that if she was informed on 4/3/25 that the money had been stolen, she would have immediately reported it to the State Agency, called the police, the regional team, DSS, and the Medical Director. Interview with Resident #69 on 4/9/25 at 1:00 PM indicated that he/she did not know his/her wallet was gone until the nurse brought the wallet to him/her after returning from an appointment Thursday morning on 4/3/25 about 11:00 AM when the charge nurse was giving him/her the morning medications. Resident #69 indicated that when the nurse stated that someone found the wallet in the laundry, he/she opened the wallet and reported there was $150 missing. Resident #69 indicated that he/she cannot make sense of how his/her wallet was found in the laundry. Resident #69 indicated that someone here took my $150 because he/she knew exactly how much he/she had the evening before. Resident #69 indicated that his/her wallet had $152 in it the evening before and was in his/her backpack in the pocket where it is always kept. The interview with SW #2 on 4/9/25 at 1:05 PM indicated that the supervisor, RN #11, had informed her that Resident #69 was missing money, and she could not name or identify who given it to her. SW #2 indicated that the wallet was found in the laundry and Laundry #1 had given the wallet to RN #11. Interview with SW #2 on 4/10/25 at 7:45 AM indicated that she was informed by RN #11 at approximate 11:00 AM that Resident #69 had reported there was $150 missing from his/her wallet. SW #2 indicated she immediately went and informed the DNS that Resident #69 had reported there was $150 missing from his/her wallet and then went to see Resident #69. SW #2 indicated Resident #69 had informed her maybe the wallet had fallen in the lobby before going to the appointment the morning of 4/3/25, but he/she always keeps the wallet in the backpack, and the backpack in always with him/her. SW #2 indicated Resident #69 was missing a $100 dollar bill and a $50 dollar bill and in the wallet was left the two $1 bills. SW #2 indicated that Resident #69 was adamant that his/her wallet was kept in his/her backpack in a specific area. Interview with RN #11 on 4/10/25 at 8:46 AM indicated the morning of 4/3/25, a guy with shorts brought her a wallet found outside and placed it on the desk and stated the owner of wallet, so she kept the wallet on her table and brought the wallet to Resident #69 when he/she returned from an appointment. RN #11 indicated she gave Resident #11 the wallet in the hallway while the nurse was giving medications, and Resident #69 immediately opened the wallet and reported there was $150 in there and it was gone. RN #11 indicated that she told the DNS and was not told to write a statement. RN #11 indicated then she informed SW #2. RN #11 indicated that Resident #69 reported he/she was not aware the wallet was missing until she handed it to him/her. Review of the facility Abuse, Neglect, and Exploitation Policy identified it is the policy of the facility to provide protection for 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 resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the residents' consent. The abuse prevention coordinator designee was responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state agency and other officials in accordance with the state law. Investigation of alleged abuse identified the staff responsible for the investigation identifying and interviewing all involved people, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. Focusing the investigation on determining if abuse, neglect, and/or mistreatment has occurred, the extent, and cause. Providing complete and through documentation of the investigation. Reporting all alleged violations to the Administrator, state agency, adult protective services law enforcement within specified timeframes: immediately, but not later than 2 hours after the allegation is made and not later than 24 hours if the event that causes the allegation do not involve abuse and do not result in serious bodily injury. Review of the Compliance with Reporting Allegations of Abuse, Neglect, or exploitation Policy identified the facility will report all allegations of abuse, neglect, or exploitation or mistreatment and misappropriation of resident property are reported immediately to the Administrator of the facility and appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. 2. Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs: antipsychotic and antidepressant for agitation, restlessness, and sleeplessness. Interventions included monitor for continued need of medication as related to behavior and mood. Resident #99 exhibits or is at risk for distress/fluctuating mood symptoms related to sadness, depression caused by current medical diagnoses and functional decline. Interventions included refer to behavioral health specialists as needed. Resident #99 has bowel incontinence and mixed bladder incontinence related to confusion, impaired mobility, and Parkinson's disease. Interventions included to provide peri-care with each incontinent episode. The physician's order dated 4/1/25 directed to monitor behavior for agitation, resistive, excessive wandering, intrusive behavior, and sleeplessness every shift. A statement by LPN #1 dated 4/8/25 identified she worked 4/7/25 on the 11:00 PM - 7:00 AM shift and indicated Resident #99 was sitting at the nurse's station when she arrived. LPN #1 indicated Resident #99 had a fall and hit his/her head and sustained a laceration at the beginning of the shift. LPN #1 indicated Resident #99 was restless and would not remain still. LPN #1 indicated NA #3 was getting very agitated and aggressive with Resident #99 because the resident was grabbing everything and pushing chairs and at some point Resident #99 was yelling out another resident's name and yelling help. LPN #1 indicated that is when she observed NA #3 turn around and pull/yank Resident #99's wheelchair and say to Resident #99 (act like a damn man you're behaving like a child). LPN #1 told NA #3 that Resident #99 has dementia and will not understand her and that was inappropriate. LPN #1 indicated at 5:00 AM she started her medication pass and heard Resident #99 saying that he/she needed to go to the bathroom. LPN #1 informed NA #3 of the resident's request, however, NA #3 walked by her and ignored her. LPN #1 indicated at some point she walked by Resident #99 and observed a puddle of urine on the floor. LPN #1 indicated she notified NA #3 and NA #4 that Resident #99 had urinated on the floor, and again she got no response from the nurse aides. LPN #1 indicated she placed a few towels on the floor and underneath Resident #99's wheelchair and the resident's feet to soak up the urine. LPN #1 indicated that is when NA #3 approached her and stated, (oh you couldn't pick the piss off the damn floor). Resident #99 was present and could hear this comment. LPN #1 indicated she told NA #3 that she was in the middle of a medication pass and that if she had taken Resident #99 to the bathroom when he/she asked, the resident would not have urinated on the floor. LPN #1 indicated NA #3 insisted that LPN #1 provide incontinent care to Resident #99 and clean the floor with the urine. LPN #1 indicated she told NA #3 that she was in the middle of medication pass and that she (NA #3) was assigned to the resident. LPN #1 indicated NA #3 began shouting, cursing, speaking inappropriately to her in the [NAME] wing hallway in front of the nurse's station with Resident #99 present. LPN #1 indicated she told NA #3 that she would be calling the RN supervisor. LPN #1 indicated she walked down to the 400 wing with NA #3 still screaming at her while NA #3 was pushing Resident #99 down the hallway to the 600 wing to go and provide incontinent care to the resident. LPN #1 identified she called RN #6 to report the incident with NA #3. LPN #1 indicated Resident #110 reported to her that NA #3 had been in Resident #92's room and was aggressive with Resident #92 and told the resident to shut up. LPN #1 indicated Resident #110 also reported that NA #3 was yelling and screaming being disrespectful to the nurse and he/she was going to report NA #3 to the DNS. Interview with NA #3 on 4/9/25 at 11:23 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and was not assigned to Resident #99. NA #3 indicated at the beginning of the shift there were 3 nurse aides, and one of the aides, the agency nurse aide, left and went home which NA #3 indicated is an on-going issue with the agency nurse aides. NA #3 indicated Resident #110 was ambulating on the wing and was in the common area watching television. NA #3 indicated she was upset and probably loud when Resident #99, who was at the nurse's station in a wheelchair, urinated on himself/herself and the floor. NA #3 indicated LPN #1 placed a towel down on the floor and left it there. NA #3 indicated there was only 2 nurse aides overseeing the 400, 500, and 600 wings answering call lights and providing care, and she expected LPN #1 to help. NA #3 indicated she and LPN #1 had words. Interview with RN #6 on 4/9/25 at 11:50 AM identified she worked on 4/7/25 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #6 indicated LPN #1 called her to the [NAME] wing because NA #3 was being disrespectful towards her. RN #6 indicated LPN #1 reported Resident #99 had urinated on the floor and she placed a towel on the floor and NA #3 told her it was everyone's job to provide resident care. RN #6 indicated LPN #1 never informed her that NA #3 was getting very agitated and aggressive with Resident #99 and pulled/yanked Resident #99's wheelchair and said to Resident #99 (act like a damn man you're behaving like a child). Further, RN #6 identified LPN #1 did not report to her that Resident #110 reported NA #3 was verbally abusive to Resident #92. RN #6 indicated she told LPN #1 and NA #3 to work out their issues or take it to Human Resource in the morning. RN #6 indicated she educated LPN #1 not to discussed what took place between her and NA #3. The reportable event form dated 4/10/25 at 11:30 AM identified during another investigation, it was discovered that LPN #1 witnessed NA #3 allegedly yank Resident #99's wheelchair and told the resident to (act like a damn man, you're behaving like a child). LPN #1, and NA #3 remain on administrative leave pending an investigation. Resident #99 was evaluated by psychiatrist and social services. The APRN, Administrator, police, and the resident Power of Attorney were notified. A statement by NA #3 dated 4/10/25 at 11:29 AM identified that she denied the allegations. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home leaving the [NAME] wing with only 2 nurse aides instead of three. LPN #1 indicated NA #3 had an attitude and was upset that Resident #99 was at the nurse's station for monitoring. LPN #1 indicated she observed NA #3 pull/yank Resident #99's wheelchair and said to the resident (act like a damn man and that he/she was acting like a child). LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to (act like a damn man and that he/she was behaving like a child). LPN #1 indicated RN #6 stated that she and NA #3 need to get along and she will address the issue with the DNS in the morning. LPN #1 indicated that was not the first time she has witnessed NA #3 yelling, using profanity, and being argumentative with agency nurse aides or other staff on the 11:00 PM - 7:00 AM shift on the [NAME] wing. Interview with Resident #110 on 4/10/25 at 9:55 AM identified he/she does not sleep throughout the night, so he/she ambulates up and down the hallway and the common areas on the unit. Resident #110 indicated on Monday night he/she overheard NA #3 yelling and arguing with LPN #1 at the nurse's station and the hallway. Resident #110 indicated Resident #99 was sitting in a wheelchair at the nurse's station and NA #3 continued yelling, arguing, and was disrespectful to LPN #1 about who was going to clean Resident #99 and clean the urine off the floor. Resident #110 indicated NA #3 she was yelling, very angry and had an attitude that night. Interview with the DNS on 4/10/25 at 12:22 PM identified she was not aware that NA #3 was witnessed to pull/yank Resident #99's wheelchair and say to the resident (act like a damn man you're acting like a child) because until surveyor inquiry, she had not read LPN #1's statement that was written on 4/8/25. The DNS indicated NA #3 was not removed from the facility after LPN #1 witnessed NA #3 pull/yank Resident #99's wheelchair and say to the resident (act like a damn man, you're acting like a child). The DNS indicated that the expectation of the facility is that when there is an allegation of abuse, the staff member is to be removed and sent home immediately. The DNS indicated NA #3 should have been removed from the unit and sent home until further notice. The DNS indicated she is not aware if LPN #1 had reported the incident to RN #6. The DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. Review of the facility abuse, neglect, and exploitation policy identified facility to provide protection for 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 resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical arm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility abuse, neglect, and exploitation policy identified the facility will provide protection for 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 resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will have written procedures that include reporting of all alleged violations to the Administrator, State Agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 3. Resident #269 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and dementia. The care plan dated 4/1/25 identified Resident #269 was at risk for decreased ability to perform ADLs in grooming, bathing, personal hygiene, transfers. Interventions included providing assist of 1 for transfers using a rolling walker. Additionally, Resident #269 it was important that he/she had the opportunity to engage in daily routines that are meaningful relative to his/her preference. Resident #269 expressed it was important for staff to know which of his/her personal belongings he/she prefers to take care of him/herself. The admission MDS dated [DATE] identified Resident #269 had moderately impaired cognition and was dependent on staff for toileting and dressing and required maximum assistance with bathing and personal hygiene. Additionally, the MDS did not identify any psychiatric or mood disorders. Residents' overall goal indicated from Resident #269 was to be discharged to the community. Interview with Resident #269 on 4/6/25 at 10:30 AM indicated that he/she had been robbed. Resident #269 was lying in bed with sheets covering him/her and his/her pocketbook was on the bed at his/her left side. Resident #269 indicated that when he/she went to bed, his/her pocketbook was at his/her left side and when he/she woke up this morning it was on the bedside chair to the right side of the bed. Resident #269 indicated that he/she asked the nurse aide this morning to get the pocketbook from the bedside chair in the corner of room and place it back on the bed next to him/her. Resident #269 indicated that she felt uneasy about it because he/she did not know how it got over to the bedside chair during the night, so he/she checked the pocket when he/she kept the money and found it was missing $80. Resident #269 indicated that since then this surveyor was the first person in the room to inform about being robbed during the night last night. Surveyor reported the allegation of Resident #269 being robbed $80 to the charge nurse, LPN #2, on 4/6/25 at 10:40 AM. LPN #2 stated she would inform the supervisor immediately and started walking down the hallway towards the nurse's station. The interview with RN #11 on 4/7/25 at 12:55 PM indicated that she was the day supervisor on Sunday 4/6/25 from 7:00 AM to 3:00 PM. RN #11 indicated that there was a lot going on yesterday but did not remember LPN #2 reporting to her anything about Resident #269 or that Resident #269 had stolen or missing money. RN #11 indicated that if LPN #2 had reported stolen money she would have immediately reported it to the DNS because it was a reportable event. A Reportable Event Form dated 4/7/25 at 2:00 PM identified resident reported to a visitor that he/she had been robbed and was missing money. Resident #269 reported he/she had been robbed. Resident #269 reported he/she usually keeps the purse in bed with him/her, but when he/he woke up the purse was in the chair and reported $80 missing. Interview with DNS on 4/7/25 at 2:22 PM indicated that she was not aware there was an allegation from Resident #269 of being robbed or stolen money on 4/6/25 of $80. Interviewed with LPN #2 with the DNS present on 4/7/25 at 2:30 PM indicated that she did recall being informed that Resident #269 had reported being robbed but could not recall how much it was if it was $40 or $80. LPN #2 indicated that she had immediately gone to RN #11 and informed her that Resident #269 was reporting money was taken, but RN #11 informed her she was busy with 3 admissions and would talk to Resident #269 later. LPN #2 indicated that she did not question Resident #269 regarding the money because she thought the RN supervisor would. Interview with the DNS on 4/7/25 at 2:45 PM indicated that she had not reported the allegation to the State Agency and would do so now and start an investigation. The social worker note dated 4/7/25 at 3:10 PM indicated it was a late entry for 4/6/25 at 3:08 PM as a follow up to Resident #269 reporting to charge nurse LPN #2 he/she noticed $40 cash missing from purse this morning. Resident #269 reported to this writer it was $80 he/she reported this morning. Resident #269 informed this writer that he/she knows he/she had it when admitted in his/her wallet. Resident #269 reports that he/she always leaves his/her purse in his/her bed next to him/her so he/she can access the tissues inside when he/she needs them. Resident #269 presents as alert and cooperative during this interview. The social worker note dated 4/7/25 at 3:27 PM identified as a late entry for 4/6/25 Resident #269 was alert and oriented times two and was lying in bed. Resident #269 reported he/she had $80 inside his/her wallet inside the purse that was always kept with him/her in the bed. Resident #269 had shown social worker the wallet that had some change. Interview with the DNS on 4/10/25 at 9:49 AM indicated her expectation with any allegation involving money or abuse that staff would immediately report the allegation to the RN supervisor who she would expect to notify her immediately. The DNS indicated that the allegation occurred on 4/6/25 in the morning and she was not notified until 4/7/25 in the afternoon. The DNS indicated that she was aware she only had 2 hours from the time of the initial allegation and her staff were aware. The DNS indicated that she would have expected to be notified immediately. The DNS stated she spoke with the resident representative who verified that Resident #269 had $38 or $39 in his/her pocketbook when he/she left the assisted living to go to the hospital then came to the facility. The DNS indicated that they looked in Resident #269's pocketbook and there was no money left. The DNS indicated that she does not believe Resident #269 had spent any money at the hospital and something happened between the assisted living when the resident had the money and the facility. The DNS indicated that she was still working on the investigation. Review of the Abuse, Neglect, and Exploitation Policy identified it is the policy of the facility to provide protection for health, welfare, and rights of each resident by developing and implementing in written policies that prohibit ad prevent abuse, neglect, and misappropriation of resident's property. Misappropriation of residents' property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the residents' consent. Reporting all alleged violations to the Administrator, state agency, and to all other required agencies within the specified timeframes would be immediately, but no later than 2 hours after the allegation is made. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state agency and other officials in accordance with state law.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 8 residents (Resident # 99) reviewed for abuse, the facility failed to take immediate steps to prevent further abuse from occurring while the investigation was in progress. The findings include: Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs: antipsychotic and antidepressant for agitation, restlessness, and sleeplessness. Interventions included monitor for continued need of medication as related to behavior and mood. Resident #99 exhibits or is at risk for distress/fluctuating mood symptoms related to sadness, depression caused by current medical diagnoses and functional decline. Interventions included refer to behavioral health specialists as needed. Resident #99 has bowel incontinence and mixed bladder incontinence related to confusion, impaired mobility, and Parkinson's disease. Interventions included to provide peri-care with each incontinent episode. The physician's order dated 4/1/25 directed to monitor behavior for agitation, resistive, excessive wandering, intrusive behavior, and sleeplessness every shift. A statement by LPN #1 dated 4/8/25 identified she worked 4/7/25 on the 11:00 PM - 7:00 AM shift and indicated Resident #99 was sitting at the nurse's station when she arrived. LPN #1 indicated Resident #99 had a fall and hit his/her head and sustained a laceration at the beginning of the shift. LPN #1 indicated Resident #99 was restless and would not remain still. LPN #1 indicated NA #3 was getting very agitated and aggressive with Resident #99 because the resident was grabbing everything and pushing chairs and at some point, Resident #99 was yelling out another resident's name and yelling help. LPN #1 indicated that is when she observed NA #3 turn around and pull/yank Resident #99's wheelchair and say to Resident #99 (act like a damn man you're behaving like a child). LPN #1 told NA #3 that Resident #99 has dementia and will not understand her and that was inappropriate. LPN #1 indicated at 5:00 AM she started her medication pass and heard Resident #99 saying that he/she needed to go to the bathroom. LPN #1 informed NA #3 of the resident's request, however, NA #3 walked by her and ignored her. LPN #1 indicated at some point she walked by Resident #99 and observed a puddle of urine on the floor. LPN #1 indicated she notified NA #3 and NA #4 that Resident #99 had urinated on the floor, and again she got no response from the nurse aides. LPN #1 indicated she placed a few towels on the floor and underneath Resident #99's wheelchair and the resident's feet to soak up the urine. LPN #1 indicated that is when NA #3 approached her and stated, (oh you couldn't pick the piss off the damn floor). Resident #99 was present and could hear this comment. LPN #1 indicated she told NA #3 that she was in the middle of a medication pass and that if she had taken Resident #99 to the bathroom when he/she asked, the resident would not have urinated on the floor. LPN #1 indicated NA #3 insisted that LPN #1 provide incontinent care to Resident #99 and clean the floor with the urine. LPN #1 indicated she told NA #3 that she was in the middle of medication pass and that she (NA #3) was assigned to the resident. LPN #1 indicated NA #3 began shouting, cursing, speaking inappropriately to her in the [NAME] wing hallway in front of the nurse's station with Resident #99 present. LPN #1 indicated she told NA #3 that she would be calling the RN supervisor. LPN #1 indicated she walked down to the 400 wing with NA #3 still screaming at her while NA #3 was pushing Resident #99 down the hallway to the 600 wing to go and provide incontinent care to the resident. LPN #1 identified she called RN #6 to report the incident with NA #3. LPN #1 indicated Resident #110 reported to her that NA #3 had been in Resident #92's room and was aggressive with Resident #92 and told the resident to shut up. LPN #1 indicated Resident #110 also reported that NA #3 was yelling and screaming being disrespectful to the nurse, and he/she was going to report NA #3 to the DNS. Interview with NA #3 on 4/9/25 at 11:23 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and was not assigned to Resident #99. NA #3 indicated at the beginning of the shift there were 3 nurse aides, and one of the aides, the agency nurse aide, left and went home which NA #3 indicated is an on-going issue with the agency nurse aides. NA #3 indicated Resident #110 was ambulating on the wing and was in the common area watching television. NA #3 indicated she was upset and probably loud when Resident #99, who was at the nurse's station in a wheelchair, urinated on himself/herself and the floor. NA #3 indicated LPN #1 placed a towel down on the floor and left it there. NA #3 indicated there was only 2 nurse aides overseeing the 400, 500, and 600 wings answering call lights and providing care, and she expected LPN #1 to help. NA #3 indicated she and LPN #1 had words. Interview with RN #6 on 4/9/25 at 11:50 AM identified she worked on 4/7/25 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #6 indicated LPN #1 called her to the [NAME] wing because NA #3 was being disrespectful towards her. RN #6 indicated LPN #1 reported Resident #99 had urinated on the floor and she placed a towel on the floor and NA #3 told her it was everyone's job to provide resident care. RN #6 indicated LPN #1 never informed her that NA #3 was getting very agitated and aggressive with Resident #99 and pulled/yanked Resident #99's wheelchair and said to Resident #99 (act like a damn man you're behaving like a child). Further, RN #6 identified LPN #1 did not report to her that Resident #110 reported NA #3 was verbally abusive to Resident #92. RN #6 indicated she told LPN #1 and NA #3 to work out their issues or take it to Human Resource in the morning. RN #6 indicated she educated LPN #1 not to discuss what took place between her and NA #3. The reportable event form dated 4/10/25 at 11:30 AM identified during another investigation, it was discovered that LPN #1 witnessed NA #3 allegedly yank Resident #99's wheelchair and told the resident to (act like a damn man, you're behaving like a child). LPN #1, and NA #3 remain on administrative leave pending an investigation. Resident #99 was evaluated by psychiatrist and social services. The APRN, Administrator, police, and the resident Power of Attorney were notified. A statement by NA #3 dated 4/10/25 at 11:29 AM identified that she denied the allegations. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home leaving the [NAME] wing with only 2 nurse aides instead of three. LPN #1 indicated NA #3 had an attitude and was upset that Resident #99 was at the nurse's station for monitoring. LPN #1 indicated she observed NA #3 pull/yank Resident #99's wheelchair and said to the resident (act like a damn man and that he/she was acting like a child). LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to (act like a damn man and that he/she was behaving like a child). LPN #1 indicated RN #6 stated that she and NA #3 need to get along and she will address the issue with the DNS in the morning. LPN #1 indicated that was not the first time she has witnessed NA #3 yelling, using profanity, and being argumentative with agency nurse aides or other staff on the 11:00 PM - 7:00 AM shift on the [NAME] wing. Interview with Resident #110 on 4/10/25 at 9:55 AM identified he/she does not sleep throughout the night, so he/she ambulates up and down the hallway and the common areas on the unit. Resident #110 indicated on Monday night he/she overheard NA #3 yelling and arguing with LPN #1 at the nurse's station and the hallway. Resident #110 indicated Resident #99 was sitting in a wheelchair at the nurse's station and NA #3 continued yelling, arguing, and was disrespectful to LPN #1 about who was going to clean Resident #99 and clean the urine off the floor. Resident #110 indicated NA #3 she was yelling, very angry and had an attitude that night. Interview with the DNS on 4/10/25 at 12:22 PM identified she was not aware that NA #3 was witnessed to pull/yank Resident #99's wheelchair and say to the resident (act like a damn man you're acting like a child) because until surveyor inquiry, she had not read LPN #1's statement that was written on 4/8/25. The DNS indicated NA #3 was not removed from the facility after LPN #1 witnessed NA #3 pull/yank Resident #99's wheelchair and say to the resident (act like a damn man, you're acting like a child). The DNS indicated that the expectation of the facility is that when there is an allegation of abuse, the staff member is to be removed off the unit and sent home immediately. The DNS indicated NA #3 should have been removed from the unit and sent home until further notice. The DNS indicated she is not aware if LPN #1 had reported the incident to RN #6. The DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. Review of the facility abuse, neglect, and exploitation policy identified facility to provide protection for 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 resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical arm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility abuse, neglect, and exploitation policy identified the facility will provide protection for 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 resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will have written procedures that include reporting of all alleged violations to the Administrator, State Agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation.

Based on review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #38 and 65) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to ensure a PASARR rescreen was completed upon admission to the facility for a resident with a long-standing history of a serious mental health diagnosis and after a new mental health diagnosis was identified. The findings include: 1. Resident 38 was admitted to the facility in July 2024 with diagnoses that included chronic obstructive pulmonary disease, tracheostomy, and body dysmorphic disorder. Review of a PASARR level 1 screen outcome dated 7/10/24, prior to admission to the facility, identified that Resident #38 had not received any mental health services in the past and did not have any legal intervention due to mental health symptoms or behaviors. The PASARR level 1 outcome determined a level II was not required due to no evidence of a PASARR condition related to an intellectual disability or serious behavioral health condition. Review of the clinical record identified that Resident #38 had court appointed Conservator of Person and Estate in place upon admission to the facility due to bipolar illness and executive deficits. A psychiatric APRN note dated 7/19/24 identified that Resident #38 was seen as a new referral to the facility. The note identified that Resident #38 had a history of delusional disorders, dysthymic disorder, and anxiety disorder. The note identified that Resident #38 had chronic psychiatric illness and required medication that included Abilify (an antipsychotic medication) 5 mg daily. The quarterly MDS dated [DATE] identified Resident #38 had intact cognition, was always continent of bowel and bladder, required moderate staff assistance with toileting, dressing, and set up assistance with bathing. The MDS also identified that Resident #38 required antipsychotics on a routine basis. The care plan dated 2/12/25 identified that Resident #38 was at risk for complications related to the use of antipsychotic and anxiolytic medications for history of depression, dysthymic disorder, and anxiety. Interventions included monitoring for the continued need for medication for behavior and mood, and monitoring for changes in mental status and function and reporting to the physician as indicated. Review of the clinical record failed to identify any documentation related to a PASARR re- screen being initiated or completed following Resident #38's admission to the facility. Interview with the Social Work Director (SW #1) on 4/7/25 at 12:00 PM identified that she was unaware that Resident #38 had a significant psychiatric history. SW #1 identified she was aware that Resident #38 had a Conservator of Person and Estate and had a history of depression and anxiety but was not aware that Resident #38 had a history of bipolar illness or executive deficits, or that Resident #38 had psychiatric treatment prior to admission to the facility. SW #1 identified while it was the responsibility of the social work department to initiate the PASARR re-screen, the psychiatric provider and facility staff did not notify her of the resident's previous psychiatric history. SW #1 identified that Resident #38 should have had a PASARR rescreen completed upon admission to the facility. The facility policy on Resident Assessment- Coordination with PASARR Program directed that the facility coordinated assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder or related condition received care and services in the most integrated setting appropriate to their needs. The policy further directed that any resident with a newly evident or possible serious mental disorder would be referred for a level II review. Examples included: a resident whose related condition was not previously identified through PASARR, and a resident who is behavioral, psychiatric, or mood related symptoms were related to the presence of a mental disorder where dementia was not the primary diagnosis. 2. Resident #65 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, dysthymic disorder, and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, and the resident mood interview identified the following symptoms and frequency: little interest or pleasure in doing things (several days) and feeling down, depressed, or hopeless (several days). The care plan dated 3/27/25 identified Resident #65 was at risk for distressed/fluctuating mood symptoms related to diagnoses of dysthymic disorder, generalized anxiety disorder, and PTSD. Interventions included observing for signs and symptoms of a new psychiatric disorder or worsening symptoms of current psychiatric disorder and encouraging resident to seek staff support for distressed mood. The care plan further identified that Resident #65 used psychotropic medications related to depression and anxiety. Interventions included administering psychotropic medications as ordered by the physician and to monitor, document, and report any adverse reactions to the medications. The Notice of PASRR Level 1 Screen Outcome dated 5/31/22 indicated that a PASARR disability was not present because of the following reason: there is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. No Level II required. Review of the clinical record identified Resident #65 was diagnosed with major depressive disorder on 7/28/23. Interview and clinical record review with the Director of Social Services (SW #1) on 4/07/25 at 10:41 AM identified that at the time Resident #65's major depressive disorder diagnoses was identified, she was not his/her social worker, so she was not aware that Resident #65 had a new mental health diagnosis with no PASARR rescreen submitted, but she would have expected the social worker to have submitted a new Level 1 PASARR upon the identification of a new mental health diagnosis. SW #1 indicated that she would submit another Level 1 PASARR for Resident #65, subsequent to surveyor inquiry. The facility's Resident Assessment-Coordination with PASARR Program policy directs the facility coordinate assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis), a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR, and a resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay, or equally intensive treatment. The social services director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #77) reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the physician's orders. The findings include: Resident #77 was admitted to the facility in November 2024 with diagnoses that included fractures of the left lower leg and patella, anemia, and bipolar disorder. A completed physician's order dated 1/24/25 with an end date of 2/21/25 directed to administer Cefadroxil oral capsule (antibiotic), give 500mg by mouth twice daily for four weeks, for septic arthritis. The quarterly MDS dated [DATE] identified Resident #77 had intact cognition and was currently taking an antibiotic. The care plan dated 3/12/25 identified Resident #77 was at risk for impaired skin integrity due to immobility and presence of cam boot (orthopedic footwear used to immobilize the foot and ankle). Interventions included turning and repositioning 4 times per shift. A physician's order dated 4/3/25 directed to administer Cephalexin oral capsule (antibiotic), give 500mg by mouth four times daily for 14 days, for cellulitis. Medication administration observation of LPN #2 on 4/7/25 at 8:38 AM identified LPN #2 reviewed the orders for Resident #77's morning medication pass which included the administration of the following medications: Ascorbic acid tablet 500mg give 1 tablet by mouth once daily for supplement. Cephalexin oral capsule 500mg by mouth four times daily for 14 days, for cellulitis. Trazadone HCL 50mg give 1 tablet by mouth once daily for bipolar. LPN #2 was observed removing a 500mg capsule of Cefadroxil from Resident #77's bubble pack into a medication cup and returned the bubble pack into the medication cart, then removed Resident #77's Trazadone bubble pack from the medication cart, removed the medication from the package into the medication cup, and returned the package into the medication cart. Subsequent to surveyor inquiry because LPN #2 had removed the incorrect antibiotic and placed it into the cup to be administered, LPN #2 removed the Cefadroxil bubble pack from the medication cart, again, and reviewed the physician's orders, for a second time. LPN #2 went back into the medication cart and identified a bubble pack containing 500mg of Cephalexin for Resident #77. LPN #2 reviewed Resident #77's discontinued and completed medication orders and identified that Resident #77 was no longer taking Cefadroxil. LPN #2 indicated that this was not the usual unit where she was assigned, and she would have expected that a discontinued medication would have been removed from the medication cart. LPN #2 removed the 500mg capsule of Cefadroxil from the medication cup and replaced it with the 500mg Cephalexin capsule. Interview with the DNS on 4/7/25 at 8:55AM identified that she would expect the nurse to adhere to the 5 right of medication administration and to double check the accuracy of the medication and ensure it matches the physician's order. The DNS further indicated that discontinued medications should be removed from the medication cart. The facility's Medication Administration policy directed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with standards of practice. Ensure that the six rights of medication administration are followed: right resident, drug, dosage, route, time, and documentation. Review MAR to identify medication to be administered and compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time. Refer to drug reference material if unfamiliar with the medication.

Based on observation, review of the clinical record, facility policy, and interviews for 4 residents (Resident #39, 69, 81, 268) the facility failed to provide care according to professional standards, facility policy and physician's orders. For 1 of 2 residents, Resident #39) reviewed for falls, the facility failed to ensure the functionality of a remote cardiac transmission device. For 1 resident (Resident #69) the facility failed to administer medications according to the physician's orders. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to follow the physician's orders and complete RN assessments when the resident had multiple episodes of hyperglycemia and hypoglycemia that required additional treatment. For 1 of 5 residents (Resident #268) reviewed for medication administration, the facility failed to ensure medications were administered per the physician's order. The findings include: 1. Resident #39 was admitted to the facility in January 2016 with diagnoses that included the presence of a cardiac pacemaker, paroxysmal atrial fibrillation, and tachycardia. A cardiology consultant study dated 11/8/24 identified Resident #39's routine pacemaker remote transmission was received. Battery voltage and impedance stable, battery longevity 11.8 months, normal pacemaker function, no arrythmias noted, and to continue routine monitoring. The ECG 12 lead tracing document dated 1/13/25 identified AV dual-paced rhythm, abnormal ECG when compared with ECG of 9/25/24, no significant change was found. A physician's order dated 1/16/25 directed for a pacer transmission on 2/8/25 at 8:00 AM with a specialty provider remote card device. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition and was taking an antiplatelet medication. The care plan dated 3/12/25 identified Resident #39 had a pacemaker related to a heart block diagnosis. Interventions included checking the pacemaker per physician's order and documenting in the chart: heart rate, rhythm, and battery check. The care plan further identified Resident #39 was at risk for cardiovascular symptoms or complications related to heart block, hypertension, tachycardia, pacemaker, and receiving aspirin and antiplatelet medications. Interventions included pacer checks as ordered and ensure transmitter is plugged in daily. Resident #39's clinical record December 2024 through April 2025 failed to identify documentation that the cardiac transmitter had been monitored for functionality. Observation on 4/8/25 at 9:55 AM identified a transmitter on the bedside table, with no indicator that the machine had power. Resident #39 indicated that the machine at his/her bedside was a device the heart doctor had given him/her years ago, and it hadn't worked in over a month. Interview with LPN #11 on 4/8/25 at 10:00 AM identified that she was the nurse assigned to Resident #39, but she was an agency nurse and was not familiar with the resident and could not answer questions about Resident #39's cardiac device or the transmitter. Interview with RN #4 on 4/8/25 at 10:05 AM identified that Resident #39 had an internal pacemaker and the device on his/her bedside table was a transmitter for his/her pacemaker. Observation at that time with RN #4 identified that usually a light would illuminate on the front of the device to indicate that it was on, but no light was visible. RN #4 identified that she was unaware that the transmitter was off, and that she would expect the charge nurse to be checking the transmitter daily, to ensure it is on, and to notify the supervisor if the device was not on. Interview with RN #4 and Person #2 (representative from the cardiac transmitter company) on 4/8/25 at 10:11 AM identified that 12/17/24 was the last time there was a connection from Resident #39's transmitter device to the transmitter company. A follow-up interview with RN #4 on 4/8/25 at 11:45 AM identified that a replacement part for the transmitter was ordered and that she was able to schedule an appointment for Resident #39 with the cardiologist on 4/25/25, for an in-person device check. Interview with Person #1 (medical assistant from the cardiology practice) on 4/9/25 at 11:49 AM identified that remote transmissions from Resident #39's device were scheduled for every 3 months however the last transmission reading received from the resident's device was on 11/8/24, 5 months ago. Person #1 indicated that a remote transmission was scheduled for 2/8/25, which was not completed, and that she did not have documentation identifying that the facility or Resident #39's resident representative were alerted that the transmission was missed. Person #1 identified that the medical assistant (Person #4) that would have been responsible for notifying the facility was currently out of the office and not available for an interview. Person #1 further indicated that the facility had reached out to their office on 4/8/25, and Resident #39 was scheduled for an in-person device check on 4/25/25. Interview with the DNS on 4/10/25 at 10:35 AM identified that the manufacturer's manual for the transmitter identified that the device would beep if there was a failed transmission, and that she was not aware that the device had alerted the staff that the transmission had failed. The DNS further indicated that there were no concerns identified with the device during the 11/8/24 transmission, and it was functioning properly during Resident #39's January 2025 hospital admission. The DNS identified that the nursing staff should be checking the device to ensure it is on and further investigate why the device is not on if they discover it is not functioning and report it to the supervisor. Interview with the Cardiology APRN (APRN #4) on 04/10/25 at 11:45 AM identified that Resident #39 had remote transmissions scheduled every 3 months, as a supplement to annual office checks, to monitor the functionality and condition of his/her pacemaker. APRN #4 further identified that Resident #39's last transmission was due in February of 2025 but was not completed and the last transmission completed, in November of 2024, identified that the pacemaker looked good and had approximately 1 year of battery life remaining. APRN #4 indicated that the home monitor would also ping the device daily looking for alert conditions, such as if the battery needed elective replacement or if the automatic measurement parameters were detected. APRN #4 was unable to identify which measurement parameters had been programmed on Resident #39's device, but if he/she had an episode that met that alert criteria it would also ping the system. APRN #4 identified that it is the standard of care for the pacemaker to be evaluated in the office, annually, and by remote transmissions every 3 months, which the transmission device would have to be turned on in order for the transmission to occur. Although attempted, an interview with Person #4 was not obtained. The transmitter user's manual identified the device records and stores heart data. The transmitter will securely send information to the doctor or clinic on a routine basis, typically every three months. It also does a quick check of the device on a nightly basis and will send information only if an event (as defined by your doctor) is detected. The facility's Remote Cardiac Telemetry policy directs the facility staff to notify the ordering provider if the device becomes damaged or does not appear to be working. 2. Resident #69 was admitted to the facility in February 2025 with diagnoses that included leg surgery, chronic kidney disease and dependent on dialysis, hypertension, and gastroparesis. A physician's order dated 2/13/25 directed to give Gabapentin 600 mg by mouth three times a day for phantom pain, Lactobacillus give 1 capsule by mouth one time a day for supplement, and Bumetanide 2 mg give 1 tablet two times a day for hypertension. The care plan dated 2/17/25 identified Resident #69 was at risk for impaired renal function and complications related to hemodialysis. Interventions included providing medications as ordered. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, dressing, and personal hygiene. Additionally, Resident #69 was on antibiotics, diuretics, opioids, and anticonvulsants. Review of the April 2025 MAR dated 4/6/25 at 11:48 PM identified Bumetanide 2 mg due to be administered twice daily for hypertension was not available. Medication observation with RN #4 on 4/7/25 at 9:17 AM indicated she had taken Resident #69's blood pressure earlier and it was 176/84. RN #4 prepared Resident #69's medications then identified she did not have the Gabapentin 600mg, Lactobacillus capsule, or the Bumetanide 2 mg available. RN #5 indicated that she had searched the medication cart and there was not any available and these medications were not in the emergency supply. An interview with RN #4 on 4/7/25 at 9:25 AM indicated that Resident #69 had not received the evening dose of Bumetanide 2 mg the day prior, and the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were not available. RN #4 indicated that the nurses were responsible for reordering medications before the resident ran out of a medication. RN #4 indicated that she would reorder the medications from the pharmacy. Review of the nurses' notes dated 4/6/25 to 4/7/25 failed to reflect the APRN or physician had been notified that the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were unavailable and had not been administered. Review of the MAR dated 4/7/25 at 9:28 AM identified RN #4 documented the scheduled 9:00 AM doses of Gabapentin 600 mg for phantom pain, Lactobacillus capsule for supplement, and Bumetanide 2mg's for hypertension were not available in facility and pharmacy was notified. Review of the MAR dated 4/7/25 identified Resident #69 did not receive the scheduled 1:00 PM dose of Gabapentin 600 mg. Interview with RN #5 (Regional corporate nurse) on 4/8/25 at 11:01 AM indicated that when a nurse does not have a medication available to give a resident per the physician order, he or she is responsible for notifying the pharmacy and the physician to see if there was an alternate medication(s) or could change the time of administration. Interview with APRN #1 on 4/8/25 at 11:18 AM indicated Resident #69 was on Bumetanide for fluid retention because of his/her diagnosis and if Bumetanide was not available nursing must notify her. APRN #1 indicated if Resident #69 misses a dose she would want to find out why and do an intervention and evaluate resident's blood pressures to see if it was elevated and if he/she has sustainable blood pressures with dialysis treatments. APRN #1 indicated that her expectation would be she must be notified if of any resident miss doses of medications. APRN #1 indicated that Resident #69 was on gabapentin for phantom pain due to the BKA. APRN #1 noted Resident #69 came into the facility on a low dose but because Resident #69 has complaints of pain the dose has been going up a couple of times, so it is important to give it and have it available, and the Lactobacillus is because nephrology ordered it from dialysis for the gastrointestinal system. APRN #1 indicated that she was not aware Resident #69 had missed the Bumetanide the evening of 4/6/25 or medications on 4/7/25 in the am or afternoon. APRN #1 indicated it was the nurse's responsibility to reorder the medications timely. APRN #1 indicated that the nurses were responsible for documenting who they notified and when if a resident had missed a scheduled medication. Interview with the DNS on 4/8/25 at 12:52 PM indicated that when a resident does not receive a dose of a scheduled medication the charge nurse is expected to notify the RN supervisor who must notify the APRN or physician and it needed get an order for an alternate medication or any other new orders from the provider and then write a nurses note with who the nurse spoke with and any recommendation or new orders from the provider. After clinical record review, the DNS indicated that from 4/6/to 4/8/24 she did not see the APRN, or physician were notified of the missed doses of medication. The DNS indicated that the Lactobacillus was house stock and if the nurse had asked the supervisor, she would have gotten it for RN #4. An interview with the DNS on 4/9/25 at 12:54 PM indicated her expectation was the nurses follow the physician orders and give the medications at the time they are scheduled within the hour before or hour after window. The DNS indicated the expectation was the nurses will reorder the medications when there are 6 doses left in the blister pack, so the resident does not run out of medications. Review of the facility Unavailable Medications Policy identified mediations may be unavailable for several reasons. Staff should take immediate action when it is known that the medication is unavailable. Notify the physician of inability to obtain medication upon notification or awareness that the medication is not available. Obtain alternate treatment orders and/or specific orders for monitoring residents while medication is on hold. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Review of the Medication Eror Policy identified the facility shall ensure medications will be administered according to the physician's orders. Medication that is administered not in accordance with the prescriber's order, for example a medication omission. 3. Resident # 81 was admitted to the facility in July 2023 with diagnoses that included COPD, diabetes with hyperglycemia, and dementia. The care plan dated 11/17/24 identified Resident #81 has a diagnosis of Insulin dependent diabetes and hyperglycemia. Interventions included monitoring signs and symptoms of hyper/hypoglycemia and report abnormal findings to the physician, assess and record blood glucose levels as ordered, and administer hypoglycemic medications as ordered. A physician's order dated 12/16/24 directed to inject Glucagon 1 mg (a medication used to treat low blood glucose) IM as needed for blood glucose less than 70 if Resident #81 was unable to swallow or was unresponsive, monitor vital signs and stay with the resident, notify the provider and recheck the blood glucose in 15 minutes, repeat protocol if less than 70 and document response in the progress notes. A physician's order dated 12/16/24 directed to administer Glucose oral gel 15 mg/32ml (a medication used to treat low blood glucose) one application by mouth as needed for blood glucose less than 70 if Resident #81 was asymptomatic or symptomatic but responsive with the ability to swallow. The order further directed to repeat the blood glucose level in 15 minutes, document the results, and if still below 70, notify the provider and administer a second dose of the glucose gel. A physician's order dated 12/19/24 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 3 times daily (7:30 AM, 11:30 AM, 4:30 PM) before meals and administered for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The 5 day MDS dated [DATE] identified Resident #81 had intact cognition, was always incontinent of bowel and bladder and dependent on staff to assist with toileting, bathing, and dressing. An APRN note dated 12/28/24 at 11:58 AM identified that a telehealth visit was conducted with RN #7 due to Resident #81's blood glucose result of 480 on that date. The APRN note identified Resident #81 was asymptomatic and the treatment orders included a total of 14 units of Insulin Lispro, recheck blood glucose in one hour, if blood glucose was above 400 in 2 hours to contact telehealth APRN for further instructions, and notify a clinician of any change in condition. A nurse's note dated 12/28/24 at 12:03 PM by LPN #2 identified Resident #81's blood glucose was 480 and 12 units of Insulin Lispro were administered, the supervisor was notified, and the physician would be contacted. Review of the clinical record failed to identify any documentation that Resident #81's resident representative was notified related to Resident #81's hyperglycemic episode requiring treatment visit. A physician's order dated 1/31/25 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 4 times daily (7:30 AM, 11:30 AM, 4:30 PM, and 9 PM) before meals, at bedtime, and administer for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The January 2025 MAR identified LPN #2 documented Resident #81 had a blood glucose of 459 on 1/31/25 at 4:30 PM and received a partial dose of Insulin Lispro. The MAR failed to identify the dose administered. Review of the clinical record failed to identify any additional documentation related to Resident #81's blood glucose of 459 on 1/31/25 including notification to the provider per the physician's order due to the blood glucose level above 450, or that Resident #81's resident representative was notified. The February 2025 MAR identified Resident #81 had a blood glucose of 63 on 2/13/25 at 7:30 AM. The MAR identified that the blood glucose parameters were out of range and no Insulin was administered. Review of the clinical record for 2/13/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 50 obtained by LPN #2 on 2/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 47 obtained by LPN #2 on 2/18/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/18/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 51 obtained by LPN #2 on 2/22/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/22/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. A nurse's note dated 3/3/25 at 10:26 PM by LPN #1 identified that Resident #81 had a blood glucose of 54. The note identified glucose gel was administered. Review the clinical record for 3/3/25 failed to identify any additional documentation that the provider or Resident #81's resident representative was notified. A nurse's note dated 3/14/25 at 8:52 AM by RN #12 identified Resident #81 had a morning blood glucose of 45, that Resident #81 was given juice and breakfast, a repeat blood glucose 15 minutes later was 78, and that the APRN was notified. Further review of the clinical record failed to identify that Resident #81's resident representative was notified of the hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 62 on 3/16/25 at 11:30 AM. Further review of the MAR identified that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/16/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 68 obtained by LPN #2 on 3/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 55 obtained by LPN #2 on 3/20/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/20/25 failed to identify any additional documentation including that the provider or Resident #81's representative were notified. A nurse's note dated 3/21/25 at 3:49 AM by RN #12 identified Resident #81 had a blood glucose of 53 at 3:00 AM. The note also identified that an IM Glucagon injection was given, and Resident #81 had a repeat blood glucose of 112 at 3:45 AM. Further review of the clinical record for 3/21/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified. A nurse's note dated 3/22/25 at 7:54 AM by RN #12 identified that at 3:30 AM, Resident #81 was observed to be alert but lethargic with skin warm to the touch but clammy. The note further identified Resident #81 had a blood glucose of 50 and was administered glucose gel, and a recheck 20 minutes later identified a blood glucose of 69. The note identified Resident #81 reported feeling better and was offered orange juice, and a repeat blood glucose was 112 after an hour. The note also identified Resident #81 received Insulin Glargine 52 units at bedtime and that Resident #81 had a blood glucose of 149 at 7:30 AM. Review of the clinical record for 3/22/25 failed to identify that the provider or Resident #81's resident representative were notified. The March 2025 MAR identified on 3/22/25 at 8:00 PM that 52 units of Insulin Glargine was held by LPN #3 due to Resident #81's blood glucose levels dropping to 50 overnight. The clinical record failed to identify that the provider was notified that Resident #81 did not receive his/her nightly dose of Insulin Glargine on 3/22/25 or that Resident #81's resident representative was notified of the medication hold due to hypoglycemia. Review of the clinical record and MAR for March 2025 identified on 3/23/25 at 1:30 AM, LPN #3 identified Resident #81 had a blood glucose level of 50 and was administered glucose gel. Review of the clinical record identified on 3/23/25 at 2:00 AM, LPN #3 documented Resident #81 had a blood glucose recheck of 63. A nurse's note dated 3/23/25 at 2:32 AM by LPN #3 identified Resident #81 was clammy, cold, and lethargic and glucose gel was administered. Review of the clinical record identified on 3/23/25 at 2:30 AM, RN #12 documented Resident #81 had a blood glucose of 112. Review of the clinical record for 3/23/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. Review of the clinical record identified on 3/25/25 at 2:00 AM LPN #3 documented Resident #81 had a blood glucose of 45. Further review of the clinical record identified a recheck by LPN #3 done at 3:44 AM was 70. Review of the clinical record and March 2025 MAR for 3/25/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. A nurse's note dated 3/26/25 at 1:20 AM by LPN #1 identified she was notified by a nurse aide that Resident #81 was profusely sweating. LPN #1 identified that Resident #81 had blood glucose check of 41, that emergency glucose was given immediately, and that a recheck would be done in a few minutes. The March 2025 MAR identified LPN #1 administered glucose gel on 3/26/25 at 1:20 AM. A nurse's note dated 3/26/25 at 1:45 AM by LPN #6 identified Resident #81 had a repeat blood glucose check of 54. Further review of the nurse's note identified LPN #1 documented a repeat blood glucose check of 131 at 2:14 AM. Review of the clinical record for 3/26/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 67 obtained by LPN #2 on 3/31/25 at 11:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/31/25 failed to identify any documentation that Resident #81's resident representative was notified of Resident #81's hypoglycemic episode. Interview with APRN #1 on 4/8/25 at 11:52 AM identified that she was aware that Resident #81 had variable blood glucose levels but felt these were related to dietary noncompliance and a recent course of antibiotics. APRN #1 identified she could not remember if she was notified that if Resident #81 received IM Glucagon or of all the blood glucose levels under 70 since 2/13/25, but if the resident had a blood glucose above 450 or below 70, she would expect that the nurses would assess the resident to ensure he/she was not symptomatic and that she or the on call provider would be notified if the resident had symptoms. Interview with LPN #1 on 4/9/25 at 10:50 AM identified that she was assigned to Resident #81 on 3/3 and 3/26/25. LPN #1 identified that LPNs in the facility were not allowed to complete an assessment of the residents or contact the physician/APRN and resident representative regarding a change in condition, so that should have been completed by the RN. LPN #1 identified she was unsure who she reported Resident #81's hypoglycemic episodes to and she did not document the information in the clinical record. Interview with RN #12 on 4/9/25 at 11:56 AM identified that she was the nurse assigned to Resident #81 on 3/20/25 on the 11:00 PM - 7:00 AM shift and was the RN supervisor working with LPN #3 on 3/22/25 on the 11:00 PM - 7:00 AM shift. RN #12 identified on 3/21/25 at 3:00 AM a nurse aide notified her that Resident #81 was very lethargic, and she administered IM Glucagon which was the standard order for all diabetics in the facility for hypoglycemia. RN #12 identified she obtained vital signs on Resident #81 and completed a repeat blood glucose check at 3:45 AM and documented a progress note. RN #12 identified that on 3/23/25 Resident #81 had a similar hypoglycemic episode with LPN #3 overnight and required glucose gel and juice. RN #12 identified she did not notify the on-call provider or Resident #81's resident representative regarding Resident #81's hypoglycemic episodes on 3/21 or 3/23/25 and that she would have passed the information on in morning report to the day shift or told APRN #1 in person if she was in the facility at shift change. RN #12 identified that she did not feel that it was necessary to notify the on-call provider but was aware that the physician orders and facility protocol for hypoglycemia directed to contact the physician or APRN for a blood glucose less than 70 Interview with LPN #2 on 4/9/25 at 12:15 PM identified she could not remember any blood glucose issues for Resident #81 from 12/28/24, 1/31/25, 2/2025, or 3/2025. LPN #2 identified that unless she noticed a specific issue or it was listed in her tasks in the MAR or TAR, she did not document a note or assess Resident #81 related to blood glucose issues. LPN #2 identified any documentation would be in a progress note, and that she would notify the RN supervisor. LPN #2 identified LPNs in the facility were not allowed to contact the physician/APRN of any issues with a resident and only the RN supervisor was allowed to contact the provider. LPN #2 also identified that Resident #81 typically had high blood glucose levels due to his/her resident representative bringing in a [NAME] Donuts coffee in daily. Interview with RN #7 on 4/9/25 at 12:54 PM identified that she vaguely remembered Resident #81 having an episode of hyperglycemia on 12/28/24. RN #7 identified that LPN #2 notified her, she then contacted the telehealth APRN and assisted with the visit, and notified LPN #2, who was assigned to Resident #81, of the orders including the additional 2 units of Insulin and rechecks. RN #7 identified that she could not remember any additional information regarding LPN #2, the telehealth orders, or contacting Resident #81's resident representative. Interview with LPN #3 on 4/9/25 at 1:01 PM identified that she was present with RN #12 on 3/20/25 and was assigned to care for Resident #81 on 3/22/25 on the 11:00 PM - 7:00 AM shifts. LPN #3 identified that Resident #81 was very lethargic and not responsive during the 3/21/25 hypoglycemic episode and she went in to assist RN #12. LPN #3 identified it was very hectic and scary, but following the IM Glucagon administration, Resident #81 improved. LPN #3 identified that later in the shift, she reviewed Resident #81's Insulin orders and blood glucose levels and noted that Resident #81 had multiple episodes of hypoglycemia dating back to January or February 2025. LPN #3 identified she printed out all the blood glucose levels and provided them to RN #12 for review. LPN #3 identified she did not know if RN #12 notified the physician, APRN, or Resident #81's resident representative, and that LPNs in the facility had been instructed they were not supposed to contact the providers or assess any of the residents following a change of condition, and that this was only to be done by RNs in the facility. LPN #3 identified that on 3/22/25, she was assigned Resident #81 for the first time, and since she had been present for the hypoglycemic episode on 3/21/25, she decided to hold Resident #81's bedtime Insulin Glargine, but that Resident #81 still had a hypoglycemic episode very similar to the one on 3/21/25. LPN #3 identified that she did notify RN #6 or RN #12 related to holding Resident #81's Insulin but could not remember who. Interview with the DNS and RN #5 (Regional Resource Nurse) on 4/9/25 at 1:35 PM identified that provider notification for blood glucose levels depended on the resident's orders. The DNS identified that for Resident #81, she would expect the nurses to notify the provider for any blood glucose levels under 70 or over 450, and that the nurses would assess the resident for symptoms of hypo or hyperglycemia. The DNS identified that LPNs in the facility did have the authority to notify the provider but to notify the RN. The DNS further identified if an RN assessment of the resident was needed due to a change in condition, the LPNs had been instructed to not bypass the RN and that the RN should be notified that the resident had a change that required an RN assessment. The DNS further identified that provider notification usually took place in person with APRN #1 when she was in the building. The facility policy on Hypoglycemia directed that the purpose of the policy was to a standard care routine for management of episodes of hypoglycemia based on the

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure appropriate care according to professional standards and facility policy when a new pressure ulcer was identified. The findings include: Resident #91 was admitted to the facility on [DATE] and readmission on [DATE] with diagnoses that included fall with left femur fracture, and dementia. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition, was always incontinent of bowel and bladder and required moderate assistance with rolling left to right and transfers chair/bed to chair transfers. Additionally, Resident #91 required maximum assistance with perineal hygiene and dressing. Resident #91 was at risk for developing a pressure ulcer but did not have any pressure ulcers. The readmission nursing assessment dated [DATE] identified Resident #91's skin was intact except for periorbital bruising to the face status post fall. The assessment did not identify any open areas or pressure areas. A physician's order dated 1/31/25 directed for skin prep to bilateral heels daily on evening shift for 14 days last day 2/12/25. The care plan dated 2/13/25 identified Resident #91 was at risk for skin breakdown related to decreased mobility and left hip surgical incision. Interventions included applying barrier cream after each incontinent episode, dietitian consultation as needed, and weekly skin checks by the licensed nurse. The weekly skin check assessment documented by RN #2 dated 2/15/25 identified Resident #91's left heel had a blister with slough measuring 6.0 cm by 6.0 cm intact. (first identified) The weekly skin check assessment documented by LPN #1 dated 2/22/25 at 7:23 PM identified a previously identified wound to the left heel. (second time identified) Interview with LPN #1 on 4/7/25 at 8:55 AM indicated that she did the weekly skin assessment on 2/22/25 for Resident #91. LPN #1 indicated that she thought the left heel was already noted and not new, so she did not call for an RN assessment. An interview with RN #2 on 4/7/25 at 11:11 AM indicated that she was the charge nurse on the unit and was responsible on 2/15/25 to do the weekly body assessment on Resident #91. RN #2 indicated that she had noted an intact 6 cm by 6 cm blister with yellow drainage inside the blister but the skin under the blister was not viable skin. RN #2 indicated that she assumed the DTI to the left heel was old. RN #2 indicated that if it was new she would have told the supervisor so she could have done a change in condition assessment, get a treatment order. RN #2 indicated that because she thought it was old she did not notify the RN supervisor to do the change of condition RN assessment. The APRN note dated 2/24/25 at 1:04 PM identified she was notified by RN #1 and had seen Resident #91 for a deep tissue injury (DTI) to left heel today noted by nursing. Recommended Santyl topically with daily dressing change to facilitate until seen by wound provider later this week. Nursing to off load heels for Resident #91. The Change of Condition Evaluation documented by RN #1 dated 2/24/25 at 1:21 PM identified Resident #91 noted to have a new injury to his/her left heel. RN #1 noted this is the leg affected by his/her broken hip and surgical fixation. Left heel unstageable DTI measuring 2.5 cm by 1.4 cm by 0.1cm. The Wound Integrity Report written by RN #1 dated 2/24/25 identified Resident #91 had a new unstageable DTI to the left heel measuring 2.5 cm by 1.4 cm by 0.1 cm with sloughy appearance in wound bed, moderate amount of serous drainage, macerated surrounding tissue, and wound had no odor. Review of the nurse's and dietitian notes dated 2/15/25 to 4/1/25 identified the dietitian did not evaluate the residents nutritional status in relation to the new pressure ulcer until 4/2/25 (49 days later). The dietitian note dated 4/2/25 identified Resident #91 triggers for significant weight loss times 1 month and pressure ulcer to the left heel, resident was at risk for malnutrition. Resident #91 remains at risk for malnutrition related to unplanned weight loss and need for mechanically altered diet and requires total assistance for feeding. Recommendations included Glucerna once day in the evening to assist with stability and protein supplements to support wound healing in view of pressure injury to left heel. Interview with the Dietitian on 4/9/25 at 11:35 AM identified the wound nurse was responsible to provide her with a weekly wound report for all wounds that would include new wounds and if wounds are getting worse. The Dietitian indicated that she did not receive any wound reports for the month of February 2025 and only 1 report in March 2025. The Dietitian indicated the wound report for the week of 3/7/25 did not include Resident #91. The Dietitian indicated that notified the DNS that she was not receiving the weekly wound reports. The Dietitian indicated that if a resident receives a new facility acquired pressure ulcer and she was notified she would have seen the resident within a week at the most. The Dietitian indicated she would assess the resident and make sure the resident is meeting nutritional needs and would recommend some type of protein supplement based on the stage of the wound. The Dietitian indicated that on 4/2/25 after Resident #91 was readmitted on [DATE] she went to do the nutritional evaluation and noted the documentation of the left heel pressure ulcer. The Dietitian indicated at that time she had recommended the protein supplement (Prostat Advanced Wound Care) and the order was put into place. The Dietitian indicated that if she was aware on 2/15/25 when someone had first found the left heel, she would have seen Resident #91. The Dietitian indicated that it is the protocol for stage 3, stage 4, or unstageable to immediately start the protein supplement to promote wound healing. Interview with RN #1 on 4/7/25 at 9:46 AM indicated that no one had informed her of Resident #91's left heel pressure ulcer and that she had found it when auditing the weekly skin assessments that are completed weekly. RN #1 indicated that on 2/24/25 she noted that the left heel started on 2/15/25 and when she assessed the heel the blister had opened and was unstageable and measured 2.5 cm by 1.4 cm by 0.1 cm. RN #1 indicated that the first complete RN assessment for the left heel pressure area was completed on 2/24/25 that was 9 days after first found. RN #1 indicated that the wound assessment would have included measurements of wound measuring it by length by width by depth, description of wound bed, any drainage noted, if resident had any pain, appearance, undermining, surrounding tissue, or any odor. RN #1 indicated that there was no treatment in place for the left heel from 2/15/25 to 2/24/25. RN #1 indicated that when the wound physician saw the left heel on 2/27/25 he staged it as an unstageable DTI. RN #1 indicated that on 2/15/25 when the left heel pressure ulcer was first identified there should have immediately been an RN change of condition assessment with a complete wound assessment, and the physician should have been notified. Interview with the DNS on 4/7/25 at 11:21 AM indicated Resident #91 had a left heel noted on 2/24/25 by the wound nurse RN #1 on 2/24/25. The DNS indicated that when a pressure ulcer is first identified the charge nurse notifies the RN supervisor to do the initial wound assessment including measurements, description of wound and wound bed, and the surrounding skin. The DNS indicated that she thought Resident #91's left heel started on 2/24/25 and she was first notified about it on 2/24/25. Review of Pressure Injury Prevention and Management Policy identified the facility as committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to promote treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injures. Pressure injury refers to localized damage to skin and/or underlying soft tissue usually over a bony prominence. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be documented with the stage of the pressure injury will be clearly identified. Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate, presence of pain, signs of infection, wound bed, wound edges, and surrounding tissue characteristics. The goals and preferences of the resident and/or resident representative will be included in the care plan. The RN unit manager or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression of wound healing, and compliance at least weekly, and document a summary of findings in the medical record. The attending physician will be notified of the presence of a new pressure injury identification. A review will be performed on each pressure injury that develops in the facility. Findings will be reported in the monthly QAA committee meetings. Review of the Nutritional Management Policy identified the facility promotes care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in his/her overall condition. A comprehensive nutritional assessment will be completed by the dietitian within 72 hours of admission, annually, and upon significant change in condition. Components of the assessment will include, but not limited to residents' general appearance, height, weight, cognitive, physical, and medical conditions, food and fluid intake, poor intake, weight loss, review of medications, and review of labs.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #1) reviewed for aspiration risk, the facility failed to ensure that the resident received the appropriate supervision and assistance while eating, resulting in a choking episode. The findings include: Resident #1's diagnoses included diabetes mellitus, dysphagia, oral pharyngeal phase and dementia. The resident care plan (RCP) dated [DATE] identified Resident #1 required assistance with ADL's related to dementia. Interventions included, monitor for changes in nutritional status and eat in the assisted dining area to provide intermittent assistance/cueing while eating. A significant change Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 had severe cognitive impairment requiring extensive assistance with activities of daily living (ADL), and supervision/one-person assistance with eating. A nurse's note dated [DATE] and timed at 5:13 PM identified a change in the resident's condition. A cough was noted, and lung sounds were decreased at the bases. The physician was notified and ordered a chest x-ray, a speech therapy consult, and a diet down grade to dysphagia puree texture with nectar thick liquids. A speech therapy initial evaluation dated [DATE] identified the resident presented with a significant coughing episode with suspected aspiration. The clinical impression identified mild pharyngeal dysphagia characterized by reduced laryngeal elevation, occasional cough post sips of thin liquids, and reported history of shoveling. The Speech Therapist consulted two nurses regarding upgrading the resident's diet. The nurses reported constant coughing and choking on solids and observations of the resident eating large bites of food in the middle of a coughing episode and then eventually vomiting. Resident #1 was transitioning to hospice care and the therapist recommended the resident remain on a puree diet. A Physician's order dated [DATE] directed one to one feeding of all meals. The Care Plan was revised on [DATE] to include hospice care. A significant change MDS dated [DATE] identified Resident #1 had severe cognitive impairment and required one-person physical assistance with eating. On [DATE] at 11:38 AM Resident #1 was evaluated by a hospice APRN who recommended that when feeding Resident #1, alternate food and fluids and if coughing persists, stop feeding and contact Hospice. The recommendations from Hospice were discussed with the Nursing Supervisor. Review of the facility's reportable event and investigation documentation dated [DATE] identified that licensed staff responded immediately to an overhead page, when the staff entered the room, the resident was cyanotic, diaphoretic and unable to speak. He/she was lowered to the floor, and the [MEDICATION(S)] maneuver was initiated. A sweep of the resident's mouth caused the resident to vomit a thick orange/tan substance. Prior to leaving the facility to go to the hospital, the resident's color had improved, his/her eyes reacted to voice and his/her pulse was weak. The resident was able to squeeze a staff member's hand. A nurse's note dated [DATE] at 6:20 PM identified Resident #1 had an unplanned transfer to the hospital emergency department (ED). The hospital emergency department documentation identified Resident #1 was transferred to the ED following a choking episode. The documentation further noted the resident was provided a thickened puree diet tray by a staff member, but staff did not remain with the resident, after several minutes the staff returned to the room. Resident #1 was noted to be blue with vomit around the mouth. EMS was notified and they reported that despite a non- rebreather oxygen mask, the resident was hypoxic with an oxygen saturation in the 70's. In addition, the documentation noted that the resident was unresponsive during transport. Once at the ED, a chest x-ray identified bilateral infiltrates which indicated possible aspiration with the aspiration resulting in profound [CONDITION(S)]. Although intracranial pathology was possible, the resident's prolonged [CONDITION(S)] likely resulted in a hypoxic [CONDITION(S)]. The documentation further identified that the resident was actively dying. The hospice nurse was consulted and Resident #1 returned to the facility on comfort measures. A nurse's notes dated [DATE] identified Resident #1 was pronounced deceased at 12:10 AM Interview and review of the clinical record and facility documentation on [DATE] at 10:00 AM with the Director of Nurses (DNS) identified that Resident #1 had a recent history of eating too fast, coughing and choking. Subsequently the resident's diet was downgraded to puree with one to one feeding assistance. NA#1 was not aware that the resident was a choking risk or that he had to be supervised/fed all meals. Additionally, the Care Plan/Care Card was never revised after the episode on [DATE] to include the resident's risk, change in required feeding assistance, and the feeding technique that was recommended by Hospice was not included on the card. The DNS identified that it is the responsiblility of the nurses to update the care cards and Resident #1 should not have been left unsupervised while eating. Interview and review of the clinical record on [DATE] at 12:30 PM with the Speech Therapist identified that due to the Resident's risk for aspiration, he/she should not have been left unsupervised while eating. Interview and review of NA#1's written statement on [DATE] at 1:30 PM with NA#1, identified that she left the resident's tray in front of him/her, instructed the resident to eat slowly and proceeded to pass out other trays. Several minutes later the Resident's roommate alerted her that Resident #1 was coughing. When NA#1 entered the room, Resident #1 was grayish blue in color and she immediately called for help. NA #1 was not aware that the resident was a choking risk, required one to one assistance with eating, or that the resident should always be supervised while eating. Additionally, NA #1 was not aware of the feeding technique recommended by Hospice. The Facility failed to ensure Resident #1, who had a diagnosis of Dysphagia and a recent history of swallowing difficulties, was provided with the appropriate supervision and assistance when eating resulting in the need for emergency intervention during a choking episode. The Facility failed to ensure the Care Plan/NA Care Card was revised to reflect the resident's risk for choking/aspiration and required feeding assistance after the choking incident on [DATE] The Facility failed to communicate and implement the Hospice recommended feeding technique. Subsequent to Surveyor inquiry all resident diets, care plans, and tasks were reviewed and updated. The DNS ensured the dietary department continues the early tray delivery for those Residents who require assistance. Additionally, the staff was educated on supervision and assistance levels during meals.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three residents reviewed for mistreatment (Resident #1), the facility failed to keep the resident free from physical mistreatment. The findings include: Resident # 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was without cognitive impairment and required extensive assistance of one person for toileting and dressing. The resident's care plan (RCP) dated 3/4/20 identified that the resident was dependent for dressing and toileting related to weakness and had interventions that included, assist the resident with toileting with the use of grab bars. The nurse's skin assessment dated [DATE] at 2:00 PM identified that the resident had existing bruising to his/her bilateral lower extremities and no new skin injury/wounds. Review of the facility's Reportable Event (RE) dated 3/8/20 at 9:00 PM contained the allegation that NA#1 punched Resident #1 on his/her left arm during care. NA#1 was removed from the facility. The resident was observed with a bruise on his/her left upper arm and the left wrist. The physician, the next of kin, and the Director of Nursing Services were notified. Review of NA#1's statement indicated that she did not hit the resident but that the resident hit her two times during care on 3/8/20 at around 4:00 PM. NA#1 was removed from the facility and the police were notified. The facility began an investigation. An X-ray of the left arm was ordered by the physician and completed on 3/9/20. The X-ray was negative for any fractures. An interview with Resident #1 on 3/11/20 at 1:00 PM identified that on 3/8/20 at around 4:00 PM, NA#1 came into his/her room with a [NAME] gown and told the resident that it was time for bed. Resident #1 indicated that he/she told NA#1 that it was too early for bed and that he/she does not wear [NAME] gowns to bed. Resident #1 further identified that the nurse aide was upset and mumbled something and while the resident was seated in the wheelchair, grabbed his/her left wrist and punched the resident's upper left arm. Resident #1 further indicated that he/she screamed and hit NA#1 back. Resident #1 indicated that a nurse came into the room and that the resident told the nurse immediately that NA#1 had hit him/her. An interview with LPN #1 on 3/11/20 at 2:45 PM identified that on 3/8/20 at around 4:00 PM, NA#1 came out of Resident #1's room and identified that Resident #1 hit her twice and called her a derogatory name. LPN #1 identified that she went into Resident #1's room and the resident was upset and indicated that NA#1 wanted him/her to get ready for bed. LPN#1 indicated that NA#1 did not want to work with the resident any longer and that Resident #1 did not want NA#1 caring for him/her any further. LPN#1 indicated that Resident #1 did not inform her that NA#1 had hit him/her. LPN #1 removed NA#1 from Resident #1's assignment. NA #2 was assigned to Resident #1 for the remainder of the shift. LPN #1 further indicated that at around 8-8:30 PM, NA #2 approached her and informed her that Resident #1 had reported to her that he/she was hit by NA#1 earlier in the evening at around 4:00 PM. LPN#1 indicated that she immediately went into Resident #1's room and assessed the resident because he/she was complaining of left arm pain. The resident identified that he/she was hit earlier by NA #1 in the left arm. LPN #1 assessed the resident's left arm and noted a bruise on the left upper arm. LPN #1 further identified that she informed RN #1 of the incident immediately. Interview with RN#1 on 3/11/20 at 3:00 PM identified that LPN#1 informed her of an allegation of mistreatment at around 8:30-9:00 PM on 3/8/20. She immediately went to speak with Resident #1 and the resident told her that around 4:00 PM, NA#1 came into his/her room with a [NAME] gown and told the resident to put it on for bed. The resident told her that it was too early for bed and that he/she did not wear [NAME] gowns to bed. The resident told her that NA#1 was upset and grabbed his/her left wrist and punched his/her left upper arm. RN#1 indicated that she assessed the resident's left arm and identified a bruise that was purple and blue in color on the resident's upper left arm. RN #1 further noted that she observed two bruises, purple and blue in color on the resident's left wrist. In addition, RN#1 indicated that the resident was upset and stated that he/she was scared. RN #1 identified that she began an investigation and immediately removed NA#1 from the facility. RN#1 called the police, the physician, the Director of Nursing Services and Person #1. RN #1 further indicated that after speaking with Person #1, Person #1 indicated that he/she was visiting Resident #1 on 3/4/20 in the evening and the resident's door was shut. Person #1 indicated to RN #1 that he/she overheard NA #1 speaking to Resident #1 in an undignified manner. RN #1 identified that Person #1 did not tell anyone of the incident but did speak to NA #1 on 3/4/20 and informed her that her behavior was not appropriate. NA#1 was not available for an interview. Interview with Social Worker #1 on 3/11/20 at 12:00 PM identified that she spoke with Resident #1 on 3/9/20 at 11:45AM and the resident remained upset and bothered by the incident which occurred on 3/8/20 with NA#1. Social Worker #1 further indicated that Resident #1 had reported to her the exact same sequence of events which was reported the night before on 3/8/20. She also indicated that Resident #1 was alert and oriented and did not have any history of accusatory behaviors. Interview with The Director of Nursing Services on 3/11/20 at 3:30 PM indicated that the facility has not completed the investigation. She further indicated that the resident had a full body skin assessment done prior to the incident on 3/8/20 at 2:30 PM and the resident did not have any bruising noted on his/her upper left arm and left wrist. She further indicated that the bruising was noted after the incident and indicated that something must have happened. Review of the facility's Abuse Prohibition Policy identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Physical abuse includes hitting, slapping pinching, kicking, as well as controlling behavior through corporal punishment. Based on review of the reportable event, interviews with the staff and resident, the facility failed to keep the resident free from physical mistreatment.

Based on clinical record review, staff interview, review of facility documentation, and review of facility policy and procedure, for the only sampled resident reviewed for a significant medication error (Resident #5), the facility failed to ensure the resident was free from a significant medication error. The findings include: Resident #5's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was without cognitive impairment, required limited to extensive assistance with Activities of Daily Living (ADL's), and received an anticoagulant medication daily. The care plan (RCP) dated 12/21/18 identified a risk for bruising/skin tears as evidenced by poor safety awareness and anticoagulant use. Interventions included anticoagulant to be given as ordered, and to monitor for active bleeding, ie hematuria, bruising, guiac positive stool, and nose bleeds. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Resulting in the resident receiving 9 doses of [MEDICATION NAME] 5 mg instead of the physician's directed order for [MEDICATION NAME] 2 mg. Nurse notes dated 2/18/19 at 2:00 PM noted Resident #5 with excessive bleeding to the right lower extremity, resident with blood soaked ace wrap, kerlix, sock, and shoe, the dressing was changed and a pressure dressing was applied. The physician was notified and directed to send the resident to the emergency room for an evaluation. The Reportable Event dated 2/18/18 identified Resident #5 had multiple bilateral lower leg wounds and the right lower extremity had started bleeding over night. While removing the dressing for a routine dressing change, Resident #5 was noted with blood soaked ace wraps, sock, shoe, and kling wrap. A superficial area continued to seep blood, a pressure dressing was applied and Resident #5 was sent out to the emergency room for an evaluation. The Emergency Department discharge instructions identified a PT ([MEDICATION NAME] timing) level of greater than 89.9 (normal 9.6-11.5) and Resident #5 recieved Vitamin K intramuscularly. Facility documentation identified upon return from the emergency room it was determined that there was a transcription error on 2/6/18. Resident #5 was to receive [MEDICATION NAME] 2mg Monday through Friday and [MEDICATION NAME] 1.5mg Saturday and Sunday. Instead the resident recieved [MEDICATION NAME] 5mg for nine doses. Interview with the Director of Nurses (DNS) on 2/28/19 at 12:15 PM identified on 2/6/18 RN #3 obtained a new [MEDICATION NAME] order for 2mg Monday through Friday and to administer [MEDICATION NAME] 1mg Saturday and Sunday. The facility investigation identified RN #3 transcribed the [MEDICATION NAME] order as [MEDICATION NAME] 5mg Monday through Friday and 1.5mg Saturday and Sunday. Interview and review of the incident with RN #3 on 2/28/19 at 12:35 PM identified that although he/she couldn't recall the incident he/she indicated when he/she receives a new physician's orders [REDACTED]. RN #3 identified he/she was probably distracted at the time. Facility policy and procedure for [MEDICATION NAME] transcription and checking physician's orders [REDACTED]. PT/INR form, and transcribe the order to the MAR. The 11-7 charge nurse will compare the new [MEDICATION NAME] orders to the MAR indicated [REDACTED] The facility failed to ensure the medication was transcribed correctly resulting in a significant medication error requiring transfer and treatment at the acute care hospital.

Based on review of the clinical record, facility documentation and interview for 1 of 3 residents (Resident #88) reviewed for accidents, and/or for 1 of 3 residents (Resident #23) reviewed for facility related events, the facility failed to develop and implement a comprehensive care plan that addressed safe wheelchair transport, to prevent an injury, and/or the facility failed to notify the State Agency when a threat of violence with potential for injury was made toward the facility. The findings include: 1. Resident # 88's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified Resident #88 had severely impaired cognition, required extensive assistance of 2 staff for transfers, required extensive assistance with locomotion on and off unit and was not able to walk. The care plan dated 7/6/17 identified Resident #88 had impaired cognitive function, impaired thought processes, and was at risk for falls due to impaired mobility, cognitive loss, and lack of safety awareness related to dementia. Additionally, Resident #88 was at risk for decreased ability to perform ADL's, including transfers. Interventions included to provide Resident #88 with cueing and sequencing to maximize current level of function, and assist with wheelchair as needed. Nurse's note dated 7/13/17 identified Resident #88 had increased [MEDICAL CONDITION] to both legs, and the residents weight had been slowly increasing. Additionally, the nurse's note indicated a new order was obtained to administer [MEDICATION NAME] 40mg at that time, and administer [MEDICATION NAME] 20mg daily for two days. Nurse's note dated 7/20/17 identified Resident #88 was observed lying on the floor near the bathroom, face down in front of the roommates bed. Resident #88 was observed with blood dripping down his/her face, a laceration was noted on the forehead/mid scalp, the resident's nose was swollen, and a skin tear was noted to the right forearm. Additionally, Resident #88 was unable to follow commands. Review of the reportable event report dated 7/20/17 indicated Resident #88 fell out of the wheelchair while being transported by a NA, and sustained a skin tear to forearm, and a laceration to the forehead and nose which required sutures. Review of hospital documentation dated 7/20/17 identified Resident #88 sustained multiple facial lacerations, which were anesthetized with 1% local [MEDICATION NAME] and followed by 4 sutures to the mid upper forehead, 4 sutures to a [MEDICATION NAME] laceration mid forehead, 3 sutures to vertical laceration in mid lower forehead and 1 suture to superficial laceration over nasal bridge (total of 12 sutures). Additionally, steri-strips were applied to a skin evulsion on right arm. Further review of hospital documentation indicated a nasal bone fracture was suspected, however a CT scan was not completed because Resident #88 was not able to cooperate. Interview with NA #1 on 12/27/17 at 1:30 PM he/she identified that while transporting Resident #88 in the wheelchair from his/her room to the nursing station, the resident placed his/her feet onto the floor and fell face down out of the wheelchair. NA #1 further indicated although Resident #88 did not utilize foot rests while in the wheelchair, he/she was not able to propel him/herself, and often required constant reminders to keep his/her feet off the ground while been pushed in the wheelchair by facility staff. Additionally, NA #1 indicated that he/she usually asks Resident #88 to pick his/her feet up while being pushed in the wheelchair, but the resident does not always understand the direction. In an interview with LPN #1 on 12/27/17 at 1:42 PM he/she indicated that on the morning of 7/20/17 he/she was called to Resident #88's room and upon entering he/she observed Resident #88 bleeding on both sides of his/her face, under eyes and nose. LPN #1 indicated that at that time Resident #88 was yelling at NA #1, however the resident was unable to explain what happen due to cognitive impairment. LPN #1 indicated Resident #88 could follow direction with constant reminders and redirection. LPN #1 further indicated that at the time of incident Resident #88 did not utilize leg rests for his/her wheelchair, but one was applied after the fall. Interview and review of Resident #88's clinical record with OT #1 on 12/27/17 at 2:50 PM identified that an OT screen was conducted 7/28/17, per nursing request, after the resident sustained [REDACTED]. OT recommended leg rests to the wheelchair at all times for safety because Resident #88 was not able to consistently follow commands to lift and/or keep his/her feet up during transport. OT #1 further indicated that due to Resident #88's cognitive impairment, and inability to keep his/her legs up for an extended time, facility staff should have utilized leg rests for the resident during transport, prior to the fall. Although requested, a policy on the use of leg rests was not provided. Based on the investigation, Resident #88 was not able to consistently follow commands without constant reminders and/or redirection. Additionally, the care plan was not comprehensive to address Resident #88's inability to be safely transported in the wheelchair without the use of an assistive device, (leg rests). 2. Review of R # 23's clinical record identified R # 23 had a memory problem, and was not able to recall the current season, location of room, staff names or faces and that he/she was in a nursing home. Additional review identified Person # 10 was the Conservator of Person for R # 23. Review of facility documentation identified Person # 10 signed into the facility on [DATE] at 3:50 PM as a visitor. Review of local newspaper article dated 1/4/17 identified on 1/3/18 Person # 10 told an employee he/she was going to shoot up the nursing home. According to the article Person # 10 went to the nursing home a short time later, he/she did not have a weapon, and Person # 10 was arrested. Interview, review of facility documentation and facility policies review with the Administrator, DON, and Director of Maintenance on 1/8/18 at 10:36 AM identified on 1/3/18 at approximately 3:40 PM LPN # 10 arrived at the facility and reported that while she was at a store in [MEDICATION NAME], and Person # 10 came up behind her and said he/she was glad LPN # 10 was not working because he/she may go there and shoot up the place that night. The DON stated the LPN # 10 stated she felt threatened, and the facility notified the local State Police and were directed that LPN # 10 needed to file a complaint in [MEDICATION NAME]. The DON stated before the entrance doors could be locked, and before LPN # 10 left the facility, Person # 10 was observed walking down the entrance hallway toward R # 23's room. Staff followed Person # 10 while 911 was called. The State Police responded, an Officer stayed with Person # 10 while another took a statement from LPN # 10, and [MEDICATION NAME] Police were called to the facility by the State Police. The DON stated she was told by the State Police that Person # 10 did not have any handguns, and [MEDICATION NAME] Police arrested Person # 10. [MEDICATION NAME] Police told the DON, if Person # 10 was on the property prior to the court hearing it would be trespassing unless he/she had a Police escort. All facility entrance doors were then locked, and the DON stated she told the Nursing Supervisor that the doors would remain locked until 8 AM on 1/4/18. The DON stated that no incident report was completed and the State Agency was not notified of the threat of violence against the facility because she was told by the Corporate office that it was not needed. Review of facility policy with the DON identified an incident report should have been completed and the State Agency should have been notified. Interviews with eight staff on 1/8/18 from 11:50 AM through 12:39 PM identified the Bookkeeper, the Receptionist, LPN # 10, and OTA # 10 were aware of Person # 10's visiting restrictions. NA # 14 stated she assumed there may be restrictions because she saw the newspaper article, and NA # 15 stated she heard a rumor that there may be visitor restrictions for Person # 10. LPN # 11, NA # 13, and NA # 11 all stated they were not aware of any residents with any visitor restrictions. An interview on 1/8/18 at 12:58 AM with Regional Nurse # 1 identified after LPN # 10 notified the facility of the threat of violence, she locked the front entrance door, and only minutes later Person # 10 was observed walking in the hallway. Regional Nurse # 1 stated someone may have unlocked the door to let Person # 10 in the facility. Regional Nurse # 1 stated she heard the police say Person # 10 had no weapons on his/her person, Person # 10 was arrested by [MEDICATION NAME] Police and would have a no trespass for entering the facility unsupervised. Interview with LPN # 10 on 1/8/18 at 1:32 PM identified while she was at a [MEDICATION NAME] store, Person # 10 came up behind her, and while breathing in the back of her hair asked her when she was working. She replied she was not working, and Person # 10 responded to let him/her know when she is not at work so when he/she goes to shoot up the place she will not be there. Then Person # 10 walked away from LPN # 10. LPN # 10 stated she was shocked, and went directly to the facility after the comment was made. LPN # 10 stated after she notified the DON and Regional Nurse # 1, she saw Person # 10 in the hallway near the DON office, walking toward R # 23's room carrying a coffee cup and a large black computer-type bag. LPN # 10 stated she was terrified of Person # 10 and barricaded herself in the office. Interview with the DON and Regional Nurse # 1 on 1/9/18 at 2:40 PM identified the State Agency should have been notified of the incident. Review of facility Accidents/Incidents Policy identified in part an accident is defined as any unexpected incident which may result in injury to a resident. An Incident is defined as any occurrence not consistent with the routine operation of the Center and can involve a visitor. A Risk Management System report will be completed and notification of state reportable events will be made.

Based on clinical record review, review of facility documentation and interviews for one sampled resident (Resident #1) who required assistance with bathing, the facility failed to provide the appropriate supervision and/or safety device to reduce the risk of injury which resulted in immediate jeopardy. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that it was very important for Resident #1 to choose between a tub bath, shower, bed bath or a sponge bath. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #1 had no cognitive impairment and required extensive one person assistance with personal hygiene, bathing, and dressing and limited one person assistance with ambulating. The resident care plan dated 9/25/13 identified that Resident #1 required assistance with activities of daily living. Interventions directed to assure the resident's comfort and privacy, encourage resident participation while providing appropriate care, and assist as needed. The care plan also identified that the resident was at risk for falls due to use of pain and psychotropic medications. The nurse's note dated 10/30/13 at 11:23 PM identified that Resident #1 was found in the whirlpool bath this shift. When found, the resident was hunched forward, very weak, and diaphoretic. Resident #1's blood pressure was 103/58, temperature 101.2 degrees, pulse 87 and respirations 18 and the resident felt very dizzy. The physician's progress note dated 10/30/13 identified that Resident #1 was examined by the attending physician after the incident. The note indicated the resident's temperature was elevated and recommended to not have the bath water as warm given the age and the use of diuretics. The reportable event form dated 10/31/13 identified that on 10/30/13 at 7:30 PM Resident#1 was in the tub and noted to be calling out. Staff responded and Resident #1 was noted to be slumped forward. Review of the facility's investigation identified that Resident #1's preference was for whirlpool tub baths two to three times weekly and the whirlpool tub is located on another unit. On 10/30/13 at approximately 6:45 PM Nurse Aide (NA) #1 assisted Resident #1 with a bath. NA #1 filled the tub, washed Resident #1's back and hair and proceeded to leave the tub room leaving the resident unsupervised. At approximately at 7:30 PM (forty-five minutes later), one of the nurses heard calls for help and upon investigation found Resident #1 in the whirlpool tub. The resident stated that he/she felt hot and wanted to get out. When interviewed by the Administrator, NA #1 indicated that whenever she assisted Resident #1 with a bath, she did not give the resident the call bell because she always checked on him/her numerous times. NA #1 identified that she did not use the security belt to secure Resident #1 in the tub chair and was unable to recall if the safety bar was down on 10/30/13. Review of Operation Instructions for Mastercare Integrity Bathing System dated 12/31/02 directed to secure the resident into the chair with security belts and pads provided. A resident who is not secured with the security belts provided is at risk of falling from chair. Interview with the Unit Manager, Registered Nurse (RN) #1, on 12/3/13 at 9:30 AM identified that the call bell was not within the resident's reach and the safety straps were not utilized. In an interview on 12/3/13 at 10:20 AM, Resident #1 identified that he/she became anxious when NA #1 did not return and had to call out for help. Interview with the charge nurse, Licensed Practical Nurse (LPN) #1, on 12/3/13 at 11:00 AM identified that NA #1 had not reported she was taking Resident #1 off the unit for the tub bath. Interview with the Registered Nurse Educator on 12/3/13 at 12:20 PM identified that the whirlpool tub has been utilized since it was purchased in 2007 or 2008. Review of the inservice training sign-in sheet identified that on 6/13/08 an inservice "operation of new tub" was conducted and twenty-two staff had signed off attending. Interview and review of the facility investigation with the Director of Nurses (DON) on 12/3/13 at 1:20 PM identified that subsequent to the investigation NA #1 was terminated on 11/6/13. The DON indicated that a caregiver must be in attendance while the resident was in the whirlpool tub, and the safety belts must be utilized to secure the resident. Interview with NA #1 was unsuccessful. Subsequent to the incident, the facility implemented an action plan and inserviced all nursing staff on whirlpool tub safety.