Every finding on record at Copper Ridge Health and Rehabilitation Center

Based on observation, interview, and record review, the facility had a policy, but failed to implement a process to ensure food safety, including checking food expiration dates and monitoring refrigerator temperatures of resident personal refrigerators for 3 (#s 4, 14, and 51) of 34 sampled and supplemental residents. Findings include:During an observation on 4/20/26 at 2:48 p.m., resident #4's personal refrigerator did not have a temperature gauge on the inside of the refrigerator or a temperature log to record the temperature. On the inside of the refrigerator, there was a cup of cauliflower and carrots wrapped in a bag in the back of the refrigerator that had a noticeable odor when the refrigerator door was opened. There was no date on the vegetables. There was also no date on the [NAME] syrup. During a follow up interview on 4/20/26 at 4:12 p.m., resident #4 stated she checked her own fridge for spoiled food. She stated staff did check the temperature, but would not use a thermometer.During an observation and interview on 4/20/26 at 2:58 p.m., resident #14 stated no staff members checked her refrigerator for temperature or for spoiled food. There was no temperature log located in resident #14's room.During an observation on 4/20/26 at 3:00 p.m., resident #51 had a personal refrigerator with no temperature log or temperature gauge. Inside of resident #51's refrigerator there were three Crustable sandwiches individually packaged, but all located in a Ziploc bag with the date of 3-4 written on the bag.During an interview on 4/22/26 at 8:20 a.m., staff member M stated nursing staff was not responsible for checking the residents' personal refrigerators.During an interview on 4/22/26 at 9:01 a.m., staff member C stated the facility was noncompliant with personal refrigerator temperatures and have started a Performance Improvement Plan.Review of a facility policy, titled Resident Refrigerators, dated 4/11/25, showed: . A thermometer shall remain in the refrigerator. staff shall clean the refrigerator weekly and discard any foods that are out of compliance .

Based on interview and record review, the facility failed to accurately complete an Annual and Significant Change in Status Minimum Data Set (MDS) assessment for a resident's pre-admission screening and resident review (PASARR), for 2 (#s 7 and 11) of 34 sampled and supplemental residents. Findings include:During an interview on 4/23/26 at 8:54 a.m., staff member F stated resident #7's PASARR Level One was completed on 1/15/24, and PASARR Level Two was completed on 1/22/24. Staff member F stated that when she completed section A of resident #7's MDS submission on 12/29/25, she did not think to look at the resident's PASARR information because the system pre-populated the resident's demographic information. Staff member F stated the same thing occurred with resident #11's Significant Change in Status assessment, which was completed on 3/18/26. Staff member F stated, I will need to start double-checking section A of the MDS assessment. Staff member F stated resident #7 and #11 did not have any disruption in service due to the incorrect coding on the residents' MDS assessments submitted on 12/29/25 for resident #7 and 3/18/26 for resident #11.1. Review of resident #7's electronic medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder and Schizoaffective Disorder. A Level One PASARR was completed on 1/15/24, and the resident qualified for a Level Two screening, which was completed on 1/22/24 with recommended service for resident #7.Review of resident #7's Annual MDS assessment dated [DATE], with an Assessment Reference Date of 12/10/25, section A, showed the facility documented the resident was not considered by the state Level Two PASARR process to have serious mental illness and or intellectual disability or a related condition by answering no.2. Review of resident 11's electronic medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder, Schizophrenia, and Post Traumatic Stress Disorder. A Level One PASRR was completed on 3/11/24, and the resident qualified for a Level Two screening, which was completed on 4/2/24 with recommended service for resident #11.Review of resident #11's Significant Change in Status MDS assessment dated [DATE], with an Assessment Reference Date of 3/8/26, section A, showed the facility documented the resident was not considered by the state Level Two PASARR process to have serious mental illness and or intellectual disability or a related condition by answering no.

Based on interview and record review, the facility failed to revise resident care plans to reflect the Provider Orders for Life Sustaining Treatment (POLST) status for 2 (#s 50 and 74) of 34 sampled and supplemental residents. Findings include:During an interview on [DATE] at 8:21 a.m., staff member J stated resident care plans were updated weekly by the interdisciplinary team. Staff member J stated the nurse can also update the resident's care plan if an immediate update was necessary. Staff member J stated she was not sure why resident #50 and #74's care plan did not reflect their code status.1. Review of resident #50's POLST dated [DATE] showed, section A No CPR.During a review of resident #50's care plan on [DATE], the following entries were documented: Focus: [Resident #50] has an advance Directive as evidenced by: Full codeGoal [Resident #50's] wishes will be honoredIntervention: Will review POLST every 3 months, and upon [Resident #50's] request, to ensure wishes are being followed .2. Review of resident #74's POLST dated [DATE], showed, section A, Do not Attempt Resuscitation (DNR).Review of resident #74's care plan revised on [DATE], showed: Focus: Advance Directive as evidenced by: Full code .Goal: Wishes will be honored through next review date .Intervention: Full Code. Will review POLST every 3 months, and upon [Resident #74's] request, to ensure wishes are being followed .Review of a facility Document titled, Care Plan Revisions Upon Status Change, revised [DATE], showed: Policy:The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy Explanation and Compliance Guidelines:. d. The care plan will be updated with the new or modified interventions.

Based on interview and record review, the facility failed to provide notification to a physician regarding a resident's severe weight loss, resulting in a lack of physician assessment and involvement, which did not allow the physician the opportunity to recommend or implement interventions for 1 (#3) of 16 sampled residents. Findings include:Review of resident #3's weight record showed a severe weight loss of 9.73% from the resident's admission date of 3/10/26 to 4/21/26. The resident's weight on admission was 182 pounds and declined to 164.3 pounds.During an interview on 4/21/26 at 3:56 p.m., staff member G stated she had been following resident #3 closely since admission. Staff member G stated she had been making ongoing changes to accommodate the resident's nutritional needs and did not notify the medical provider of the resident's weight loss but would do so today (4/21/26).During an interview on 4/23/26 at 10:28 a.m., staff member B stated the dietician is responsible for reporting a resident's weight loss to the medical provider. Staff member B stated resident #3's weight loss was not reported to the medical provider until 4/21/26.Review of resident #3's EHR showed no documentation that the physician was notified or involved in resident #3's weight loss until 4/21/26.Review of a facility Document titled Weight Monitoring, not dated, showed: . 7. Documentation:The Physician should be informed of a significant change in weight.

Based on interview and record review, the facility failed to ensure a physician personally conducted an initial comprehensive visit within the first 30 days after admission for 1 (#3) of 16 sampled residents. The failure increased the risk of missed resident care needs. Findings include:During an interview on 4/22/26 at 3:00 p.m., staff member A stated resident #3 was seen by a physician assistant at the facility on 4/21/26. Staff member A stated there was 10-day slippage for provider visits and the visit on 4/21/26 would meet the deadline for resident #3's 30-day physician visit. Staff member A stated the facility had contracted with a new physician; however, the physician's state license was still pending.During an interview on 4/23/26 at 10:28 a.m., staff member B stated she thought resident #3 was seen by the provider the week of 4/8/26. Staff member B stated she would look for the physician's note.Review of resident #3's hospital discharge noted dated 3/10/26, showed resident #3 had several chronic medical conditions which would require monitoring and medical management, including insulin dependent diabetes, atrial fibrillation on anti-coagulation therapy, congestive heart failure, chronic obstructive pulmonary disease on nasal oxygen, land left leg hematoma with progressive skin changes.Review of resident #3's progress notes from 3/10/26 to 4/23/26, showed no physician visit note that resident #3 was seen by a medical doctor at the facility.A request was made on 4/23/26 for a physician visit note for resident #3. No documentation was received from the facility by the end of the survey.Review of a facility Document titled, Physician Visits and Physician Delegation, revised 1/1/26 showed: Policy:It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.2. The physician should:a. See resident within 30 days of initial admission to the facility .

Based on observation, interview, and record review, the facility failed to ensure there was not a 5% or greater medication error rate. The observed medication error rate was 10.34% for 2 (#s 13 and 38) of 34 sampled and supplemental residents. Findings include:1. During an observation and interview on 4/21/26 at 8:15 a.m., staff member K prepared the medications for resident #38 (amlodipine, clopidogrel, aspirin, multivitamin, norco, Senna Plus, and pantoprazole). The pantoprazole administration time shown on the MAR was 7:00 a.m. and was shown to be late. Staff member K stated the pantoprazole should have been given before resident #38 ate breakfast for the medication to have the best efficacy. Staff member K stated they often had to give this medication at the same time as the other medications (at 8:00 a.m.) if staff member K was running late on morning tasks. Staff member K stated resident #38 was currently in the dining room. Staff member K also put one tablet of Senna Plus in the medication cup and then continued to prepare the norco (hydrocodone/acetaminophen). The surveyor asked staff member K why two tablets of Senna Plus was not going to be administered, and staff member K stated, Oh yup, and added an additional Senna Plus tablet to the medication cup.Review of resident #38's EHR showed the physician orders: Senna Plus . Give 2 tablets .2. During an observation and interview on 4/21/26 at 9:50 a.m., staff member L prepared the medications for resident #13 (vitamin b complex, folic acid, coenzyme Q10, vitamin b12, potassium chloride powder, lorazepam, and magnesium oxide). Before pouring out the 400 mg magnesium oxide tablet, staff member L stated the MAR did not match the medication bottle. Staff member L showed the surveyor that the physician order was 420 mg of magnesium oxide (on the MAR), but showed the magnesium oxide medication label was 400 mg. When asked how long the incorrect dose had been given to resident #13, staff member L stated paused and stated, for a while. Staff member L then administered the magnesium oxide to resident #13.

Based on interview and record review, the facility failed to promptly obtain a new PASARR (Preadmission Screening and Resident Review) Level One screen, upon re-admission from the hospital for a resident who had a significant change in mental status, for 1 (#68) of 16 sampled residents. Findings include:A review of a facility document in resident #68's EHR showed a request for a PASARR Level One review, dated 11/4/22.A review of a progress note for resident #68 in the facility's EHR, dated 4/8/26 at 10:35 a.m., showed, [Resident #68] reported to charge nurse and to myself that she had awakened hearing voices and that she was frightened. She reported that the voices were repeating 'Knife, knife, and kill, kill, kill.' [Resident #68] verbalized being afraid that she may act on the hallucinations . [sic]A review of a progress note for resident #68 in the facility's EHR, dated 4/8/26 at 10:45 a.m., showed, . This writer sat with [Resident #68] until EMS arrived to transport [Resident #68] to the Emergency Department for evaluation. [sic]A review of a telemedicine consult for resident #68, with a creation time of 4/9/26 10:28 a.m., for a Hospital Emergency Department encounter on 4/8/26, showed: Psychiatry Follow-up Evaluation .Summary[AGE] year old female with history of Bipolar II disorder, fetal alcohol syndrome, PTSD present in ED for evaluation of AH that started yesterday morning.Working Diagnoses .Severe depressed bipolar II disorder with psychotic features. [sic]A review of resident #68's diagnoses in the facility's EHR, showed, Altered Mental Status, Unspecified . 3/20/26. The date of the diagnosis was almost three and half years since the last Level One PASARR was completed for resident #68. A review of a facility document in resident #68's EHR showed a new request for a PASARR Level One review, dated 4/22/26.During an interview on 4/23/26 at 9:55 a.m., staff member C stated a new PASARR Level One review should have been requested when there was a new psychiatric or mental health diagnosis. Staff member C further stated a new PASARR Level One should be requested for a resident in the instance of like if we sent them out for psych clearance.A review of a facility policy titled, Resident Assessment-Coordination with PASARR Program, with a copyright date of 2025, showed, Policy:This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.Policy Explanation and Compliance Guidelines:1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screeninga. PASARR Level I - initial pre-screening that is completed prior to admission . [sic]

Based on interview and record review, the facility failed to ensure the designated infection preventionist had completed specialized training in infection prevention. The failure placed residents at risk for inconsistent infection prevention and control practices due to the lack of specialized training for the infection preventionist. Findings include:During an interview on 4/21/26 at 9:50 a.m., staff member C stated staff member D was the facility's infection preventionist. Staff member C stated staff member D had completed infection preventionist coursework in 2021 but was unable to retrieve a certificate of completion from the CDC (Centers for Disease Control and Prevention) website.During an interview on 4/22/26 at 11:45 a.m., staff member D stated she worked in infection control since approximately 2019 and completed the first 12 (of 23) modules in the CDC infection preventionist training between 2020 and 2021, but did not complete the training and did not have an infection preventionist certification.Review of a facility policy titled Infection Prevention and Control Program, revised January 2026, showed: The infection preventionist is responsible for oversight of the program, including infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of infectious diseases.Review of an online article from the Centers for Disease Control and Prevention titled, Infection Prevention Training for Long-Term Care, located at https://www.cdc.gov/longtermcare/training.html, and accessed on 4/22/26, showed: .nursing homes are required to have a designated infection preventionist who has received specialized training in infection prevention and control.

Based on observations, interviews, and record reviews, the facility staff failed to ensure each resident had access to call lights for 4 (#s 16, 24, 49, and 54); and failed to prevent elopements for 1 (#54) of 22 sampled residents. These deficient practices placed residents at risk of falls, injuries, elopements, or a negative outcome if a medical crisis occurred, and the resident could not call for assistance. Findings include: 1. Call lights not in reach a. During an observation on 4/7/25 at 10:00 a.m., resident #16 was attempting to access his call light. Resident #16 had left-sided weakness from a stroke and was unable to maneuver his wheelchair to the call light hanging off the wall tied to his bed. Resident #16 continued to attempt to reach his call light for three minutes and then called for help by yelling at a staff member walking by. b. During an observation and interview on 4/7/25 at 2:29 p.m., resident #24 stated he needed help, and no one would help him. Resident #24 stated, I can't breathe. Resident #24's call light was not within reach. This surveyor pushed the call button for the resident, and staff member H arrived and assessed resident #24. c. During an observation and interview on 4/7/25 at 1:14 p.m., resident #49 stated she fell this morning. Resident #49 stated she fell because she did not call for help before getting up from bed. Resident #49 pointed to the signs around her room reminding her to call for help before getting up. Resident #49's call light was not in reach to use for calling for assistance. d. During an observation on 4/7/25 at 10:37 a.m., resident #54 was walking around in his room looking for something with the door closed. Resident #54 was unable to verbalize his needs. The call light was wound up in a circle and taped to the wall. The call light was not able to be pulled to call for help. During an interview on 4/7/25 at 10:47 a.m., staff member F stated resident #54's call light should be in reach and the door should be partially open so the staff could keep an eye on him. Staff member F stated she did not know who taped the call light to the wall. During an interview on 4/9/25 at 1:16 p.m., staff member A stated the facility did not have a policy related to call lights. 2. Elopement Risk a. During an observation on 4/7/25 at 10:37 a.m., resident #54 was walking around in his room looking for something with the door closed. During an observation on 4/8/25 at 12:01 p.m., resident #54 was wandering the hallway and exit seeking, pushing on the door to exit the building. Staff member O redirected resident away from the door and resident #54 continued to walk. At 12:11 p.m., resident #54 was attempting to enter other resident's rooms. At 12:21 p.m., resident #54 entered another resident's room requiring redirection from staff. During an observation on 4/9/25 at 7:23 a.m., resident #54 was up walking alone in the hallways, unsupervised. No staff members were present on the unit to observe resident #54 while he walked. Staff members were in rooms, providing care to other residents. During an observation on 4/9/25 at 1:32 p.m., resident #54 was in his room with the door closed. During an interview on 4/9/25 at 1:41 p.m., staff member F stated resident #54's door should be open so the staff could see him. Staff member F stated she did not know why the door was closed. During an interview on 4/9/25 at 1:45 p.m., staff member I stated the CNAs should have ensured resident #54's door was open for safety. Staff member I stated resident #54 had eloped twice as far as she was aware. During an observation on 4/9/25 at 2:45 p.m., resident #54 was exiting his room carrying clothes, entered another resident's room, who was not in the room, and placed the items on the dresser. Resident #54 went over to the bed, moved the bedding around and exited the room. Resident #54 then entered another resident's room. Resident #54 exited the room and went back to his room. Resident #54 then exited his room and entered resident #56's room, moving items around on the chair and then going over to the bed and touching resident #56's leg. Resident #56 was sleeping and resident #54 started to exit as staff entered and found resident #54, redirecting him back to his room. Review of a Facility Reported Incident, dated 8/26/25, reflected, . [Resident #54] was found outside, across the street by van driver and was escorted back to the facility safely and without incident.It was found that [Resident #54] had removed the window and the screen from his private room and exited the facility by the window. [sic] Review of resident #54's EHR Nurse Progress Note, dated 3/16/25, reflected, nurse alerted by housekeeping that resident was seen outside another resident room walking on the sidewalk. housekeeping and CNA went outside front door to encourage resident to come back inside. resident was standing in parking area near main front entrance when approached. resident redirected and assisted to room, toileted and given snacks. resident continues to actively exit seek after redirection. [sic] During an interview on 4/9/25 at 11:30 a.m., staff member M stated resident #54 pulled the full window out on 8/26/25 and set it inside his room. Staff member M stated resident #54 eloped straight out the window and was a very smart man with construction work in his background. Staff member M stated resident #54 was on 15-minute checks and there was nothing to prevent him from going out a window in another resident's room. Review of resident #54's EHR attached Visual checks reflected no visual check sheets for 4/4/25 through 4/6/25. Visual Checks sheet dated 4/9/25 reflected missing checks from 12:30 p.m. to 2:00 p.m. Review of resident #54's active Nursing Care Plan, revision date 3/20/25, reflected: - . resident #54 was at risk for injury related to wandering. Interventions for this focus included 15-minute to 1:1 checks for safety and elopement risk (revised on 3/17/25). - DX of UNSPECIFIED DEMENTIA, MILD, W/AGITATION, is an elopement risk/wanderer as evidenced by impaired orientation and impaired safety awareness, decision making, and judgement(i.e., changes in behavior to include wandering, throwing away clothing, wandering into other residents rooms etc.), dining room wandering with tendencies of grabbing food off plates and grazing, undressing tendencies in public areas, urination elimination in inappropriate places, and inappropriate communication/language towards others. (revised on 3/20/25). Interventions included: Monitor for psychosocial changes, new or increase in behaviors and or agitation. 30-minute checks, 1:1 engagement/supervision. [sic] Review of the facility's policy, Elopements, dated Qrt 3, 2018, did not reflect what the process would be after the incident report was filed.

Based on observation, interview, and record review, the facility failed to ensure staff were educated on policies and procedures for the use of personal protective equipment, for a resident on enhanced barrier precautions, for 1 (#57) of 16 sampled residents for enhanced barrier precautions. This deficient practice increased the risk of infection for all residents related to staff not adhering to proper EBPs. Findings include: During an observation and interview on 4/7/25 at 10:22 a.m., staff member P was exiting a resident's room with trash. A sign was on the door reflecting the resident was on EBP precautions. Staff member P stated she did not know what EBP stood for or what the precautions were for the resident. Staff member P stated she was in orientation, but she was currently working the floor by herself. Staff member P stated her trainer went to lunch. During an interview on 4/9/25 at 11:24 a.m., staff member Q stated, I don't know what EBP is . I think Enhanced Barrier Precautions are used when someone has an infection or C-Diff; we (staff) would then wear a gown and gloves when we go into the residents' room. We should also use PPE if the resident has pneumonia or some other illness. During an interview on 4/9/25 at 3:27 p.m., staff member C stated the facility tried to highlight Enhanced Barrier Precautions at their annual skills fair and upon hire. Staff member C stated, I know EBP is an ongoing issue with staff. During an observation on 4/10/25 at 7:49 a.m., two unidentified staff were observed assisting resident #57 to get up from his bed. Neither of the unidentified staff were wearing PPE while assisting resident #57. There was an Enhanced Barrier Precaution sign on #57's door and PPE hanging on the back of the door. During an interview on 4/10/25 at 8:35 a.m., staff member F stated, We (staff) should wear PPE when doing catheter care and peri-care if the resident is on Enhanced Barrier Precautions. I think we are supposed to wear gowns while doing baths as well, but they get all wet, and it makes us feel like we need a shower. The gowns don't work well when doing showers . Wow, we must use PPE for all those areas of care? Review of resident #57's care plan showed: Focus: Enhanced barrier precautions r/t an indwelling medical device. Interventions: [NAME] gown and gloves during high-contact personal care activities, Enhanced Barrier Precautions . Review of a facility document titled Enhanced Barrier Precautions, dated August 2022, showed: .1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply . 3. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. Changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . [sic] 48261

Based on observation, interview, and record review, the facility failed to maintain areas of the building in need of repair for 3 (#s 11, 19, and 27) of 22 sampled residents; and, failed to maintain a clean environment related to housekeeping services, for 1 (#57) of 22 sampled residents. Residents were concerned about lack of repairs and unclean areas identified. Findings include: 1. Wall repairs a. During an observation and interview, on 4/7/25 at 12:30 p.m., resident #19's room had 13 circular shaped holes, approximately one centimeter each in diameter, in the wall next to a grab bar. Resident #19 stated she told staff member M a while ago, I guess he just forgot, it would be nice if he fixed it soon, someday I guess he will. b. During an observation and interview on 4/8/25 at 10:08 a.m., in resident #11's room, there was long vertical jagged gouges, in the wall and above the head of her bed, all approximately twelve to twenty inches in length and one inch in width. Resident #11 stated, My wall has been really banged up for a while. I'm not sure if there are plans to fix it. c. During an observation on 4/7/25 at 10:21 a.m., in resident #27's room, there was an area of wall damage, approximately two feet tall by two inches wide, with the plaster and paint missing. The baseboards below the damaged wall were hanging from the wall, at the corners, appearing to have come unglued from the wall. During an interview on 4/8/25 at 9:53 a.m., staff member L stated the wall gouges in resident #11's room was from having the bed pushed up against the wall repeatedly. Staff member L stated she would normally put room repairs needed in a maintenance log, but had not done so yet. During an interview on 4/8/25 at 11:16 a.m., staff member K stated for room repairs she would fill out a request on the computer. Staff member K stated it took a long time to enter information into the computer, it was easier to just ask staff member M if he could do a room repair. Staff member K did not inform staff member M or enter into the computer needed wall repairs for residents #11 or #19. During an interview on 4/8/25 at 1:25 p.m., staff member J stated for room repairs she would tell staff member M or let the Director of Nursing know what needed fixed. During an interview on 4/8/25 at 1:30 p.m., staff member A stated the Direct Supply TELS electronic system was used for maintenance requests. Staff member A stated any employee could log in and enter a maintenance request. Staff member A stated there were no work orders in the TELS system for resident #11 or #19 for needed wall repairs. During an interview on 4/8/25 at 8:11 a.m., staff member M stated he would find out about resident room repairs needed from the TELS system. Staff member M stated he was not aware of the wall repairs needed for residents #s 11, 19, and 27 until yesterday. Staff member M stated he fixed all three walls yesterday after finding out they needed repairs. Review of the facility's policy titled, Maintenance Inspection, dated 2025, showed, Policy: It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents . 49554 2. During an observation on 4/7/25 at 10:19 a.m., there was a thick brown substance smeared on the commode seat, smeared on the handrail next to the toilet, and on the roll of toilet paper next to the toilet. There was a sticky substance spilled on the floor next to the bed and a plastic urinal full of a yellow substance on the bedside table. During an observation and interview on 4/8/25 at 9:14 a.m., resident #57 stated, They (housekeeping staff) come in and clean every day or so. I know the bathroom is a mess. It bothers me, but they (staff) will get to it. The bathroom still had a thick brown substance smeared on the commode seat and on the handrail next to the toilet. There was still a sticky substance spilled on the floor next to the bed and a full urinal on the bedside table. During an observation and interview on 4/8/25 at 3:48 p.m., resident #57 stated, They (staff) have not been in yet to clean. A thick brown substance was still on the commode seat and on the handrail next to the toilet. During an interview on 4/9/25 at 9:11 a.m., staff member N stated, We (staff) have a daily routine we follow while cleaning the rooms . The bathrooms should be cleaned daily, but I have been on another hall for a while, and staffing can be hit and miss. I'm not sure about this hall and if the bathrooms have been cleaned thoroughly. Review of a facility document titled, Daily Resident Room Cleaning, undated, showed: .8. Toilet W/Cloroxtoilet cleaner and wand or green scrubbie. 9. Wipe down all handrails and door nobs w/T. E. T or lemon cleaner. [sic] Review of a facility document titled, Toilet Care, undated, showed: Purpose: Daily cleaning of toilets for basic sanitary conditions. Control of bacteria and odor. 5. Wipe down entire toilet with Clorox disinfectant.

Based on interview and record review, the facility failed to collect and act on admission information necessary to provide a safe, comfortable, and homelike environment accommodating a resident's physical size, for 1 (#1) of 6 residents sampled. Findings include: Review of resident #1's hospital history and physical, dated 2/5/25, listed the resident's height and weight. Review of facility admission paperwork, not dated, showed a handwritten nurse handoff report between the hospital and the facility. At the top of this report showed resident #1's weight, which was 337 pounds, and a height of 6 feet and 8 inches tall. In addition, his diagnosis, code status, allergies, and medications were noted. Review of a photo, taken on 2/10/25, showed a standard resident bed, with the head of the bed tilted, at a slight downward angle. At the foot of the bed was a bench to extend the length of the bed by several feet. This bench was kept in place by a chair wedged between the edge of the bench and the wall. During an interview on 3/11/25 at 1:30 p.m., resident #1 stated they told him to sleep in the recliner in the room. When he declined, staff modified the bed present by taking the foot board off, using straps, and then the staff strapped a piano bench to the foot of the bed. They then slid the mattress down and filled in the gap at the head of the bed with pillows. During an interview on 3/11/25 at 3:15 p.m., staff member H stated the facility had a wide bed extension prepared, but not an extension piece for adding length, when the resident arrived on 2/10/25. Staff member H stated this extension was immediately fixed the next morning when maintenance arrived 2/11/25. During an interview on 3/12/25 at 8:30 a.m., staff member C stated the admission process would have gone differently had they known about the resident's uncommon height. The facility failed to have the necessary bed/equipment on hand for the resident's admission to accommodate the resident's height.

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided for a new resident admitted on a high rate of oxygen, and this the oxygen was removed by a staff member, which resulted in signs of hypoxia for 1 (#5). The facility also failed to ensure physician orders were followed for 3 (#s 1, 2, and 4) of 5 sampled residents receiving oxygen. This deficient practice showed a potential concern for neglect and serious adverse effects to residents receiving oxygen services. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. 1. Review of resident #5's EHR showed an admitted [DATE]. Review of resident #5's EHR showed no oxygen saturation reading was entered into PCC until 2/1/25. Review of resident #5's EHR showed no admission nursing note was entered into PCC when resident #5 was admitted on [DATE]. During an interview on 2/24/25 at 9:03 a.m., staff member C stated they would never take a resident to get a weight without their required oxygen. Staff member C stated during an admission, they were instructed to obtain a weight first and then vitals on a resident. Staff member C stated the nurse would then come in the room to do their assessment. During an interview and record review on 2/24/25 at 10:32 a.m., staff member A stated the situation that occurred with resident #5 was wrong. Staff member A stated staff member E had taken resident #5's oxygen off to obtain a weight down the hall. Staff member A stated the oxygen had been removed for a few minutes. Staff member A stated they thought an admission note had been completed by staff member G summarizing the situation that occurred on 1/31/25 with resident #5, but was unable to find it. Staff member A was able to attain a typed statement from staff member G and a document titled Admission & Baseline Care Plan/Summary that was filled out by staff member G. Review of the document, Admission & Baseline Care Plan/Summary, dated 1/31/25, showed no record of the incident that occurred with resident #5's oxygen being taken off. The document showed: Does the resident currently have altered respiratory status? Yes . No oxygen saturation, no overall events, no summary, no interventions, or note contacting the physician/hospice/administration were documented. Review of the signed and typed personal statement from staff member G, dated 1/31/25, showed: . the CNA had taken his (resident #5's) Oxygen cannula off to get his weight and brought him back to the room. The resident's family was present and then [staff member G] was called to the room because the family thought he was having a seizure. When [staff member G] arrived, [resident #5] was in his w/c, the oxygen cannula was in place under his nose, and he looked kind of gray. [Staff member G] checked his SpO2 and it was low, so [staff member G] started to turn up the oxygen. He was throwing up and [staff member G] grabbed gloves and a tow-el (towel), and the CNA went to get a basin. One of the CNA's suggested we get him to the bed so he could be turned on his side and supported in case he got weaker, the family insisted that he not be moved from the w/c. [Staff member G] was notified that [entity name] was on the way .so [staff member G] stepped out of the room to count with the oncoming shift and give over keys and report what was going on with him. [Staff member G] asked [a staff member] to give him an oxy mask (type of oxygen mask), now that he was no longer vomiting, since she had the keys . By this time, [entity name] was in the room with the resident and his family. [sic] During an interview on 2/24/25 at 11:30 a.m., staff member D stated the process of an admission for them was to get a weight and then obtain vitals. Staff member D stated the process of obtaining a weight and the total distance to the spa room where the scale was located would usually take a couple of minutes depending on where the resident's room was located. During an interview and observation on 2/24/25 at 12:13 p.m., staff member E stated on 1/31/25, they were floated to another hall. Staff member E stated that day had felt busy and was a cluster. Staff member E stated they had known nothing about resident #5, but had been instructed to obtain a weight and vitals. They stated they had trouble getting a reading on resident #5's oxygen saturation. Staff member E stated the family said this was not an uncommon problem, so staff member E tried some other interventions regarding the oxygen saturation but was unsuccessful and eventually gave up moving on to the weight. Staff member E stated usually for an admission, the room was set up with the needed supplies (such as a portable oxygen cylinder). Staff member E stated on 1/31/25 and with resident #5's incident, the room had not been set up and there was not a portable oxygen cylinder in the room. Staff member E stated they noticed resident #5 had originally been on five liters of oxygen when staff member E had first walked into the room. Staff member E stated they did go look for a portable oxygen cylinder in the clean utility storage room, but there were none. Staff member E stated this was unusual. Staff member E then stated even if they would have found a portable cylinder that day it still would not have gone high enough for resident #5's seven liter oxygen requirement as the maximum liters was six liters. Staff member E stated they were unaware of any oxygen cylinders or tanks with a regulator that could have gone up high enough to accompany for the seven liter requirement. Staff member E stated prior to this incident, they knew it was wrong to take a resident's oxygen off. Staff member E stated they felt they had been in a sticky situation. During an interview and observation on 2/24/25 at 12:51 p.m., staff member C stated, I don't know what I would do, when they referred to if a resident had been admitted to the facility on a high amount of oxygen such as 10 liters. Staff member C stated they would ask their nurse or use a bunch of tubing down the hall to obtain the weight. They stated this would not be the ideal solution. Staff member C then opened the door near the nurse's station that was labeled 'Oxygen,' which showed about 15 unopened tanks of oxygen with approximately two regulators. Staff member C stated they were unaware of these oxygen tanks because they never had to use them, but stated these would work in a situation where a resident needed 10 liters of oxygen. During an interview on 2/24/25 at 1:06 p.m., staff member F stated anything over four or five liters of oxygen they would consider a high amount in this facility. Staff member F stated signs of hypoxia were gasping, low oxygen saturations, and physical signs such as a resident's face turning blue. They stated if a resident had a low oxygen saturation, it was important that they called the physician and notified administration. During an interview on 2/24/25 at 2:18 p.m., staff member G stated the day of 1/31/25 was really chaotic. They stated resident #5 arrived at the facility at around 1:45 p.m., and they had sent staff member E to get a weight and vitals. They stated quickly after that time, staff member E reported resident #5 was physically grey and was vomiting. Staff member G stated, Oh my god, it's (resident #5's oxygen was) low. Staff member G stated they could not remember the exact number or even an estimate from the pulse oximeter reading on 1/31/25, but remembered thinking it was low and turned the oxygen up for resident #5. Staff member G stated they told staff member H because staff member G had no orders in PCC as resident #5 was a new admission. Staff member G stated when they got back to resident #5's room, they felt resident #5 was more stable and was no longer vomiting. Staff member G stated they did not receive a report from the hospital so knew almost nothing about resident #5. Staff member G stated, It depends, if the hospital would call for report or not. They stated, the facility would hand out a green admission paper that showed general admission information such as diagnosis and oxygen needs. Staff member G stated this was the only information they had known about resident #5 during this incident. Staff member G stated they had received the green admission paper right before the incident happened. Staff member G stated they highly discouraged taking off a resident's oxygen to do any cares for a resident. Staff member G stated they thought this was basic knowledge for all staff members in the facility. Staff member G stated they would not know what to do if a resident was admitted and required a high amount of oxygen such as 10 liters. Staff member G stated they would go to management for guidance. Staff member G stated they were so busy the day of resident #5's incident that they had forgotten to write an admission progress note. Staff member G stated they thought this issue happened with resident #5 because of a combination of communication and staffing. During a return call interview on 2/24/25 at 3:18 p.m., NF1 stated during the admission resident #5's family member was very frustrated. When NF1 had walked in the door, resident #5 was vomiting but did have his oxygen on. NF1 stated, That first day he looked so bad. I thought he might die that day. NF1 stated resident #5 had gotten pretty sick during the admission process. NF1 stated resident #5 was frail, thin, short of breath while at rest and with oxygen, so the smallest thing could throw him off. NF1 stated, It was a sad unfortunate situation, and, A big oops. NF1 stated employees make stupid mistakes sometimes. Review of a facility policy, titled Oxygen Administration, revised 10/2010, showed: . Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e., blue tone to the skin .) . 2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion) . Review of a facility policy, titled Admission Criteria, revised 3/2019, showed: Our facility admits only residents whose medical and nursing care needs can be met . 1.Our objectives of our admission criteria policy are to: . c. address concerns of residents and families during the admission process . Review of a facility policy, titled Resident Rights, dated 2/2021, showed: . These rights include the resident's rights to: . c. be free from abuse, neglect, misappropriation of property, and exploitation . 2. During an observation on 2/24/25 at 9:06 a.m., resident #2's oxygen concentrator was set at three liters. Review of resident #2's EHR showed the physician order: Oxygen at 1-2 LPM per NC. During an observation on 2/24/25 at 11:25 a.m., resident #1's oxygen concentrator was set to four liters. Review of resident #1's EHR showed two liters of oxygen were ordered by the physician. During an observation and interview on 2/24/25 at 12:10 p.m., resident #4's oxygen concentrator was set at five liters. Resident #4 stated she was on three liters of oxygen when she was wearing her nasal cannula. Review of resident #4's EHR showed the physician orders: Bi-PAP . with Oxygen bled in at 2-4 LPM . and Oxygen at 2.5 LPM per NC .

Based on observation, interview, and record review, a staff member removed a resident's oxygen for the provision of care, knowing it was necessary to maintain the resident's oxygen levels, and the resident showed signs of signs of hypoxia prior to being placed back on the oxygen, for 1 (#5) of 5 sampled residents. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. Review of the signed and typed personal statement from staff member G, dated 1/31/25, showed: . the CNA had taken his (resident #5's) Oxygen cannula off to get his weight and brought him back to the room. The resident's family was present and then [staff member G] was called to the room because the family thought he was having a seizure. Review of a facility grievance, dated 1/31/25, showed: . Patient became hypoxic and took time to recover. Complainant remarks: I just want to ensure this doesn't happen again. During an interview on 2/24/25 at 9:03 a.m., staff member C stated they would never take a resident to get a weight without their required oxygen. During an interview on 2/24/25 at 12:13 p.m., staff member E stated they reported any concerns about neglect to their nurse. Staff member E stated the situation with resident #5 vomiting after seven liters of oxygen had been removed, was reported to staff member G on 1/31/25. Staff member E stated on 1/31/25, they were floated to another hall. Staff member E stated that day had felt busy and was a cluster. Staff member E stated they had known nothing about resident #5, but had been instructed to obtain a weight and vitals. Staff member E stated she had trouble getting an oxygen reading from the pulse oximeter for resident #5. Staff member E stated usually for an admission, the room was set up with the needed supplies (such as a portable oxygen cylinder). Staff member E stated on 1/31/25 and with resident #5's incident, the room had not been set up and there was not a portable oxygen cylinder in the room. Staff member E noticed resident #5 had originally been on five liters of oxygen with a concentrator when staff member E had first walked into the room. Staff member E stated they did go look for a portable oxygen cylinder in the clean utility storage room, but there were none. Staff member E stated this was unusual. Staff member E also stated even if they would have found a portable cylinder that day, it still would not have gone high enough for resident #5's seven liter requirement. Staff member E explained and showed the surveyor that the portable oxygen cylinders went to a maximum of six liters. Staff member E stated they were unaware of any oxygen cylinders or tanks with a regulator that could have gone up high enough to accompany for the seven liter requirement for the resident. Staff member E stated prior to this incident, they voiced knowing it was wrong to take a resident's oxygen off during cares, and felt they had been in a sticky situation. During an interview on 2/24/25 at 2:18 p.m., staff member G stated they highly discouraged taking off a resident's oxygen to do any cares for a resident. Staff member G stated they thought this was basic knowledge for all staff members in the facility. During an interview on 2/24/25 with staff member A and B at 2:38 p.m., both staff members A and B stated they did not think this was a willful act of abuse. Review of a facility policy, titled Abuse and Neglect - Clinical Protocol, dated March 2018, showed: . 2. Neglect, as defined at S483.5 means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on interview and record review, the facility failed to report an incident of neglect where a resident's oxygen was removed for care, which resulted in the resident exhibiting symptoms of hypoxia during the admission process. The facility did not report the incident to the State Survey Agency within 24 hours, and failed to report a follow up investigation within 5 working days, as required, for 1 (#5) of 5 sampled residents. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. Review of the Facility Reported Events for the facility, submitted to the State Survey Agency, showed the event was not entered into the the reporting system for resident #5. During an interview on 2/24/25 at 12:13 p.m., staff member E stated they reported any concerns about neglect to their nurse. Staff member E stated the situation with resident #5 vomiting had been reported to staff member G on 1/31/25. During an interview on 2/24/25 at 1:06 p.m., staff member F stated they would first notify the physician of abuse, neglect, or misappropriation if it occurred and then notify a manager. Staff member F stated they would also call directly to the State Survey Agency if an abuse or neglect concern occurred. During an interview on 2/24/25 at 2:18 p.m., staff member G stated if they had a concern about abuse, neglect, or misappropriation, they would notify staff member A or H. Concerning the incident on 1/31/25, with resident #5's oxygen being removed. Staff member G stated they had told staff member H about the situation. During an interview on 2/24/25, with staff member A and B at 2:38 p.m., both staff members A and B stated they did not think this event needed to be reported to the State Survey Agency as it was not a willful act of abuse. Review of a facility policy, titled Abuse and Neglect - Clinical Protocol, dated March 2018, showed: . 2. Neglect, as defined at S483.5 means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on interview and record review, the facility failed to ensure 1 (#5) of 5 sampled residents received appropriate respiratory services on admission, and failed to have physician orders and necessary equipment on hand, and staff were not aware of or educated on the resident's respiratory care needs or risks related to them, and this resulted in neglect of care when a staff member removed the resident's oxygen, and then the resident showed signs of hypoxia. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. During an interview and observation on 2/24/25 at 12:13 p.m., staff member E stated on 1/31/25, they were floated to another hall to work. Staff member E stated that day had felt busy and was a cluster. Staff member E stated they had known nothing about resident #5, but had been instructed to obtain a weight and vitals and then staff member E had trouble getting a reading on resident #5's oxygen saturation. Staff member E stated the family said this was not an uncommon problem, so staff member E tried some other interventions regarding the oxygen saturation but was unsuccessful and eventually gave up moving on to the weight. Staff member E stated usually for an admission, the room was set up with the needed supplies (such as a portable oxygen cylinder). Staff member E stated on 1/31/25 and with resident #5's incident, the room had not been set up and there was not a portable oxygen cylinder in the room. Staff member E stated they noticed resident #5 had originally been on five liters of oxygen when staff member E had first walked into the room. Staff member E stated they knew resident #5 required seven liters of oxygen. Staff member E stated they did go look for a portable oxygen cylinder in the clean utility storage room, but there were none. Staff member E stated this was unusual. Staff member E then stated even if they would have found a portable oxygen cylinder that day it still would not have gone high enough for resident #5's seven liter oxygen requirement. Staff member E demonstrated with a portable oxygen cylinder to show the maximum was six liters. Staff member E stated they were unaware of any oxygen cylinders or tanks with a regulator that could have gone up high enough to accompany for the seven liter requirement for resident #5. Staff member E stated they had taken off resident #5's oxygen for a few minutes while the weight was obtained because they felt they had been in a sticky situation. During an interview on 2/24/25 at 2:18 p.m., staff member G stated the day of 1/31/25 was really chaotic and resident #5 arrived at the facility at around 1:45 p.m. Staff member G stated they had received two admissions around the same time and still had medications to pass before the end of the shift. Staff member G stated the timing of the admissions could have been better in their opinion. Staff member G stated they sent staff member E to get resident #5's weight and vitals, and then quickly after that time, staff member E reported resident #5 was physically grey and was vomiting. Staff member G stated, Oh my god, it's (resident #5's oxygen was) low. Staff member G stated they turned up the oxygen, and left the room to notify staff member H because staff member G had no physician orders as resident #5 was a new admission. Staff member G stated when they got back to resident #5's room, they felt resident #5 was more stable and was no longer vomiting. Staff member G stated they did not receive a report from the hospital so knew almost nothing about resident #5. Staff member G stated this was not a new problem and, It depends, if the hospital would call to give report or not, and the facility would hand out a green admission paper that showed general admission information such as diagnosis and oxygen needs. Staff member G stated this was the only information they had known about resident #5 during this incident. Staff member G stated they had received the green admission paper right before the incident happened. Staff member G stated they were so busy the day of resident #5's incident that they had forgotten to write an admission progress note. Staff member G stated they thought this issue happened with resident #5 because of a combination of communication and staffing. During a return call interview on 2/24/25 at 3:18 p.m., NF1 stated during the admission, resident #5's family member was very frustrated and upset with the facility. When NF1 had walked in the door, resident #5 was vomiting but did have his oxygen on. NF1 stated, That first day he looked so bad. I thought he might die that day. NF1 stated resident #5 had gotten pretty sick during the admission process. NF1 stated resident #5 was frail, thin, short of breath while at rest and with oxygen, so the smallest thing could throw him off. NF1 stated, It was a sad unfortunate situation, and, A big oops. NF1 stated employees make stupid mistakes sometimes. NF1 stated resident #5 looked uncomfortable and did eventually get morphine while NF1 was there. Review of a facility policy, titled Admission Criteria, dated 3/2019, showed: . 5. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: ., b. medication orders, including (as necessary) a medical condition or problem associated with each condition; and, c. routine care orders to maintain or improve the residents function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. 6. Residents are admitted to this facility as long as their needs can be met adequately by the facility. Examples of conditions that can be treated adequately in this facility include: . b. COPD. Review of resident #5's EHR showed a primary diagnosis of COPD.

Based on interview and record review, the facility failed to care plan interventions to keep a resident safe from unwanted sexual advances or abuse from another resident, for 1 (#3) of 7 sampled residents for abuse. Findings include: During an interview on 11/21/24 at 10:26 a.m., staff member A said resident #3 had been the subject of another resident's sexual advances on 5/13/24 and on 11/3/24. Staff member A said the first incident was just a quick touch of her (#3's) breast on 5/13/24, but the most recent incident on 11/3/24, the same male resident was found in resident #3's room with his hand under her bed covers. Resident #3 told staff the male resident had touched her breasts and her vagina. During an interview on 11/21/24 at 1:35 p.m., staff member A stated there had not been any changes made to resident #3's care plan after the 5/13/24 incident, or after the 11/3/24 incident, to protect resident #3 from the male resident. Staff member A said they made multiple changes to the male resident's care plan but not resident #3's. Review of resident #3's care plan, revised on 11/3/24, showed she experienced an adverse event with another resident in facility. There were no interventions related to the entry documented on the care plan related to keeping resident #3 safe from the specific male resident or how staff were to ensure she was monitored closely or removed from his vicinity.

Based on observation of a facility security video, interview, and record review, the facility failed to protect 1 resident (#3) who could not consent to sexual contact from 1 resident (#2), of 7 sampled residents for abuse. Findings include: During an interview on 11/21/24 at 10:26 a.m., staff member A stated there had been an incident on 11/3/24 between resident #2 and resident #3. Staff member A stated resident #2 was witnessed by a staff member in resident #3's room with his hands under her covers touching her. Staff member A said resident #3 was not capable of consenting to sexual contact. Staff member A stated resident #2 was capable of understanding what he was doing but had impulse control issues. Staff member A stated she interviewed both residents after the incident, and resident #3 told her resident #2 had touched her breasts and vagina. Staff member A stated resident #2 told her he had touched resident #3's breasts and her vagina. Staff member A stated the police were called, and they arrived and interviewed the residents. Staff member A said resident #3 could not tell the police what happened and resident #2 stated he would not talk to the police without an attorney. Staff member A said the CNA who witnessed the residents together said resident #3's brief was intact, and the velcro was still attached on both sides of the brief. They could not determine if resident 2's hand was actually inside resident #3's brief, or if his hand was just under the blanket. Staff member A stated there had been an earlier incident, on 5/13/24, between the two residents, in which resident #2 put his hand on resident #3's breast in the hallway. The interviews staff member A did with witnesses from that incident said it looked like resident #2 just placed his hand on her breast but was not groping her. Staff member A stated the facility put resident #2 on medication to decrease libido and increased staff supervision of resident #2. Since resident #2 had some other hypersexual behaviors. They felt it was appropriate to put resident #2 on one to one observation to make sure he was not targeting female residents. Staff member A said they took resident #2 off of one to one observation, after the May incident, after he was placed on the medication, and because he had not shown any more hypersexual behaviors. Staff member A stated since the 11/3/24 incident, the facility placed resident #2 back on one to one monitoring any time he was out of his bed, and he would continue to be on the one to one until the facility could find other placement for resident #2. The resident was unable to get out of bed alone, but needed staff assistance. Staff member A said the facility had been working with mental health, and the state mental health nursing home, in an attempt to place the resident there since the state mental health nursing home had better facilities for him, and also because his family lived near the state mental health nursing home. During an observation of a facility security video, dated 11/3/24, resident #2 was observed wheeling himself down the hallway in his wheelchair. There were two other residents in the hallway. Resident #2 turned his wheelchair and backed into resident #3's room. The time stamp on the video showed 1 minute and 30 seconds elapsed between the time resident #3 backed through the threshold of resident #3's doorway until staff member J entered resident #3's room, to separate the two residents. During an interview on 12/3/24 at 1:00 p.m., NF1 stated he was disappointed resident #2 was able to get to [Resident #3] for a second time. He stated he has asked [Resident #3] about the incident on 11/3/24, but she did not seem to remember it, and she didn't have any changes in her behavior after or since either incident occurred. NF1 stated he really would like to see resident #2 find alternate placement in another facility to meet his needs. During an interview on 12/4/24 at 9:49 a.m., staff member J stated she was working on 11/3/24, when the incident between resident #2 and 3, occurred. She said she entered resident #3's room immediately upon seeing resident #2 was in the room. Staff member J stated she knew those two residents needed to be kept separated. Staff member J stated she observed resident #2 had his hand under resident #3's blanket, and resident #3 was laying in her bed. Staff member J stated it did not appear that resident #2's hand was inside of resident #3's brief, and the velco on the brief was still attached securely on both sides. She did not believe resident #2 was able to get his hand inside of resident #3's brief. Staff member J stated she asked resident #3 what happened and resident #3 verbalized resident #2 touched her, and then resident #3 pointed to her breasts and peri area, to show staff member J where resident #2 touched her. Staff member J was also present during the incident on 5/13/24. Staff member J stated it looked like resident #2's hand just brushed up against resident #3's breast, and then resident #3 swatted her hand at him. Staff member J said that was when the facility put resident #2 on a one to one the first time. Staff member J stated she had not seen resident #2 try to touch any other female resident in a sexual manner nor had she seen him behave inappropriately in a sexual nature to other staff or herself. During an interview on 12/4/24 at 11:47 a.m., staff member E stated she was a travel nurse, and she worked at the facility occasionally. Staff member E stated the facility had a great method of communicating changes in resident Care Plans, and she was aware resident #2 needed increased supervision. She stated the facility had been trying to get resident #2 into a facility with a higher level of care and oversight, so the facility was documenting any encounters with other residents. Staff member E stated she wrote a nursing note on 6/6/24 showing resident #2 reached out towards resident #3, and resident #3 attempted to slap resident #2. Staff member E said neither resident made physical contact, and she stated it did not appear sexual in nature at all. Staff member E contacted the administrator on call and wrote a note. She stated she would have done a risk assessment had there been actual physical contact but there had not been. Staff member E stated she only wrote the note in this case because the communication from the facility was to document any behaviors for resident #2. Review of a facility provided document, not titled, dated 11/3/24, showed resident #3 stated the following during the facility investigation into the incident, He touched my head, breasts, and privates. The same document showed resident #2 stated, Yeah, I did, she is telling the truth. I pulled her blankets down and touched her chest and her vagina. Review of resident #3's EMR (electronic medical record) showed a nurse note, dated 11/3/24 at 2:53 p.m., which reflected resident #3 was observed in her bed with a male resident in her room, with his hand underneath her blanket, touching her. Resident #3's care plan showed she experienced an adverse event with another resident in facility. Resident #3's comprehensive care plan reflected resident #3 had dementia and exhibited cognitive impairments as evidenced by impaired orientation, forgetfulness/confusion, poor recall, impaired decision making, and judgement. Review of resident #2's EMR, showed his care plan included a one-to-one observer (a staff member dedicated to observing resident #2) initiated on 11/3/24, for inappropriate sexual behavior. A one-to-one was also initiated on 5/14/24 for inappropriate sexual behavior, and was discontinued on 5/22/24. Resident #2's care plan revealed resident #2, . has a behavioral complex care plan due to behavioral presentations, to include socially inappropriate behaviors, physical behavioral presentations towards others, and hypersexuality/inappropriate sexual behaviors towards staff and others at times. It also showed resident #2 would engage in self-masturbation at times, and staff were to ensure a safe and private place for this behavior, which was identified, with the date of initiation on 10/12/22, and revised on 5/20/24. Resident #2's chart showed: - A nursing note, dated 5/14/24 at 10:52 a.m., showed resident #2 had been involved in an incident involving a female resident (resident #3), and he would be put on one-to-one observation anytime he was out of his bed. -A social service note, dated 5/22/24 at 6:34 p.m., showed one-to-one observation had been discontinued. - A progress note, dated 5/29/24, showed, . has been exhibiting some inappropriate sexual behavior towards fell ow female residents. Several months ago, he had a demented female resident walk into his room, and he encouraged her to fondle his genitals. More recently he touched another female resident's breasts (found not to be the case). We have chosen to place him on a low dose of estradiol and monitor his behaviors. - A progress note, dated 11/20/24, showed He is currently on one-to-one observational status secondary to some inappropriate sexual advances towards a female resident. This is actually his second offense. Review of a facility policy titled, Abuse and Neglect, revised 2022, showed: . 3. 'Sexual abuse' is defined at 483.5 as non-consensual sexual contact of any type with a resident . Review of a facility policy titled, Identifying Types of Abuse, revised 2022, showed: . 1. Abuse of any kind against residents is strictly prohibited . Sexual Abuse. 1. Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to: a. unwanted intimate touching of any kind especially of breasts or perineal area . 2. Generally, sexual contact is nonconsensual if: a. The resident appears to want the contact to occur, but lacks the cognitive ability to consent .

Based on observations, interviews, and record review, the facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart; and, failed to properly store medical supplies, keeping the supplies off the floor in one medication room. These failures increased the risk of expired medications and medical supplies being used for any resident at the facility. Findings include: During an observation on 3/26/24 at 8:10 a.m., with staff member G, the following was found in the 400-hall medication room and cart: - Wound vac supplies on the floor, including open cases of canisters with gel, Grandufoam dressings, unopened cases of Whitefoam dressings, and canisters with gel. - Expired medications, and medical supplies with expired dates, included: 1 box Pen needles box open 100, with dated expiration of 4/30/23 1 Sharp debridement tray, dated 11/20/23 2 Natural Dermal Templates, dated 1/31/24 1 box of anti-diarrheal, dated 8/16 1 bottle of nasal decongestant, dated 5/23 2 bottles of ear drops, dated 5/23 1 bottle of Xyzal allergy, dated 11/23 2 bottles of Oyster shell calcium, dated 4/23 1 bottle of prenatal vitamins, dated 6/23 1 bottle of Geri-dryl, dated 6/23 1 bottle of vitamin D-3, dated 11/23 1 bottle of gentle laxative, dated 2/23 1 bottle of Thimamin, dated 2/23 10 pills of Loperamide HCL anti-diarrheal, dated 2/24 1 package of Promogran prism, dated 4/30/23 During an observation on 3/26/24 at 9:45 a.m., with staff member B, the following was found in the 300-hall medication room and cart: -Expired items with expiration dates included: 1 bottle of ear drops, dated 1/24 1 bottle of Preservision AREDS, dated 2/24 1 bottle of Potassium 99 mg, dated 1/24 1 bottle of folic acid, dated 9/23 1 bottle of stool softener, dated 12/23 5 tubes of sterile water, dated 3/23 1 full box of albuterol sulfate 2.5 mg, dated 1/24 24 pills of acid reducer, dated 12/23 1 tube of hydrocortisone cream, dated 2/24 24 blue top blood collection tubes, dated 1/31/24 During an observation on 3/26/24 at 10:20 a.m., with staff member B, the following was found in the 200-hall medication room, wound supply cart, and medication cart: -Expired items with expiration dates included: 1 tube of Glutose 15 oral gel, dated 12/23 1 bottle of Oyster shell calcium, dated 1/24 1 bottle of Folic acid, dated 9/23 1 bottle of Potassium 99 mg, dated 1/24 3 bags of Vancomycin 1.5g/300mL, dated 12/23 1 bag of Vancomycin 1g/200mL, dated 12/23 51 bluetop blood collection tubes, dated 1/24 12 gold top blood collection tubes, dated 12/23 1 tube of antifungal cream, dated 11/23 1 bottle of nasal decongestant, dated 5/23 1 foley catheter 22 F, expiration date 11/28/21 3 catheter secure devices, dated 7/19/23 5 Dermafilm clear hydrocolloid dressings, dated 3/19/22 1 Unna Boot, dated 7/23 3 Promogran prisms, dated 4/23 1 tube of hydrogel amorphous dressing, dated 12/22 2 tubes of Muscle rub, dated 1/24 118 DermaView II Films, dated 2/24 1 open tube of Aspercreme, dated 6/23 1 povidone iodine swab, dated 3/23 During an interview on 3/27/24 at 10:25 a.m., after a second request for the audit forms from night shift medication room checks, staff member B stated, They were probably not done since the changeover in management. During an interview on 3/27/24 at 11:45 a.m., staff member A stated the facility did not have the audit forms for night shift medication room and cart checks because the audits were not done. A review of the facility's policy, Medication Labeling and Storage, revised February 2023, reflected: -Medication Storage . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these medications.

Based on observations, interviews, and record review, the facility failed to administer respiratory treatments in accordance with professional standards of practice for 4 (#s 22, 33, 36, & 49) of 6 sampled residents for respiratory services. Findings include: During an observation on 3/27/24 at 11:01 a.m., staff member K entered the room of resident #49 to administer a nebulizer treatment of albuterol 0.5-2.5. The nebulizer machine canister already had a full dose of liquid in the chamber, the mask was soiled with a white film, and white chunks of an unknown substance was on the inside of the mask. Staff member K added the additional dose of albuterol to the dose already in the chamber and went to hand it to resident #49. When asked by the surveyor, what the liquid was that was already in the chamber, resident #49 stated it was an earlier nebulizer treatment dose, which he had forgotten to take. Staff member K then stopped and said, Oops, I should clean it out then. Staff member K cleansed the mask and chamber and went to get another dose of the albuterol nebulizer treatment. Staff member K put the new dose in the chamber. Staff member K offered the nebulizer mask to resident #49 who stated he would complete the treatment, in a bit. Staff member K left the room, returned to her cart, and proceeded to complete medication administrations for other residents. During an interview on 3/27/24 at 1:28 p.m., NF1 stated, [Resident #49]does not have orders to self-administer any medications. I saw him on Monday, and I'm not sure he is appropriate for self-administration. During an interview on 3/27/24 at 1:54 p.m., staff member K stated, [Resident #49] starts and stops the nebulizer himself when he wants to administer his nebulizer treatment. [Resident #33] also does his own nebulizer treatment and medications, we just put them in a cup, and he takes them when he's ready. Most other residents who had nebulizer treatments, we setup the nebulizer treatment and start it, then come back and turn it off in 10-15 minutes. We don't do vitals with nebulizers but the CNAs do vitals on their shifts. Staff member K stated resident #'s 22 and 36 also recieved nebulizer treatments. During an interview on 3/27/24 at 3:40 p.m., staff member A stated the facility did not have physician orders for self-administration for resident #s 22, 33, 36, and 49. Staff member A stated the facility did not have self-administration assessments for resident #s 36 and 49 and resident #22's self administration evaluation showed she is not capable of self-administration of medications. During an interview on 3/28/24 at 9:15 a.m., staff member L stated she was trained to be in view of the residents, except resident #33, and go back and shut off the nebulizer when the residents are done. During an interview on 3/28/24 at 9:25 a.m., staff member G stated, We are supposed to stay in the room with residents and assess their respiratory throughout the nebulizer treatment and watch them (the resident). During an interview on 3/28/24 at 9:30 a.m., staff member C stated, They should stay close, cart in doorway is fine because they can still watch them. They know better than moving on. Record review of resident #22's Self-Administration of Medication Evaluation, dated 4/13/20, reflected resident #22 was not capable of independent self-administration of medication. Record review of resident #36's EHR reflected no assessment was completed for self-administration of medication. Record review of resident #49's EHR reflected no assessment was completed for self-administration of medication. Record review of resident #s 22, 33, 36, and 49's EHR reflected no documentation of pulses, respiratory rates, or lung sounds before and after nebulizer treatments. A review of the facility's policy, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, reflected: -Steps In Procedure . 15. Instruct the resident to take a deep breath, pause briefly and then exhale normally. 16. Encourage the resident to repeat the above breathing pattern until the medication is completely nebulized, or until the designated time of treatment has been reached. 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement dictates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness, and nervousness throughout the treatment . - .21. Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup . - .23. Administer therapy until medication is gone . - .Documentation . 5. Pulse, respiratory rate, and lung sounds before and after the treatment. 6. Pulse during treatment.

Based on observation, interview, and record review, a licensed staff member failed to properly administer enteral tube feedings, for 1 (#1) of 2 sampled residents; and the facility nursing staff failed to have the enteral tube feeding order clarified further on receipt. The failure resulted in the resident being given the incorrect amount of tube feeding formula and the resident had a decline in status. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency, dated 7/13/23, At 20:00 (8:00 p.m.) [Resident #1] was receiving her bedtime bolus via her feeding tube. [Resident #1] requested her feeding be stopped. This was done per her request. [Resident #1] was left sitting up in her recliner. At 21:30 (9:30 p.m.) [Resident #1] had audible congestion and an oxygen saturation of 46. Oxy mask was placed bringing her O2 sat to 77. At this time son requested transfer to ER for evaluation. This was done and [Resident #1] was transported via ambulance to ER. At 21:50 (9:50 p.m.) son called facility to report [Resident #1] has passed away. Investigation initiated to rule out tube feeding as causative factor. Review of [Resident #1] code status completed, she was DNR. [sic] The facility investigation findings, submitted on 7/19/23, showed: Per investigation, nursing staff entered into patient room to administer bolus feeding per feeding tube orders, procedure discussed with patient and administration occurred. During administration, patient had a small emesis and patient and nursing staff discussed and agreed to stop feeding. Following cessation of feeding, son presented in the facility to visit with patient and notified nursing of a decline in patient presentation. Nursing assessment completed and notification to physician of patient presentation per assessment completed. Discussion completed with family regarding patient presentation and recommendation to transfer to hospital, family present agreed to hospital transfer. Order obtained to transfer to hospital, . ambulance contacted and transport to hospital occurred. Nursing staff notified post transfer of patient expiration. Investigation ongoing pending cause of death. [sic] During an interview on 9/20/23 at 1:22 p.m., staff member A stated resident #1 was transferred from the 200 hall of the facility to the 400 hall on 7/13/23. Staff member A relayed staff member C had not cared for resident #1 before. Staff member A stated she got a call around 9:00 p.m., that night, that resident #1 was being sent to the ED for emesis and her O2 saturation was in the 40's. Staff member A further stated that resident #1's son called the facility 20 minutes after resident #1 was transported to the ED, and said that she had passed away. Staff member A stated staff member C administered four cartons of formula to resident #1 during his shift on 7/13/23. He (staff member C) put four cartons of formula into a graduate (cylinder) and the fifth carton wouldn't fit. He was supposed to put one carton in the gravity bag at each feeding. The order was one bag every four hours, 8:00 a.m., noon, 1600 (4:00 p.m.), 1600 (8:00 p.m.), and midnight. Staff member A stated, The breakdown was the order itself, how it was written, because it says five cartons a day. During an interview on 9/20/23 at 1:35 p.m., staff member A stated when tube feeding was administered for resident #1, multiple staff reported the tube feeding formula would not always flow with gravity. On 4/11/23, resident #1 was sent out for an evaluation to determine if the enteral tube placement was compromised. Resident #1 returned to the facility with no findings or reason for the intermittent flow restriction that facility staff were reporting. Staff member A further stated, the formula flow seemed to be positional and if staff would sit the resident upright while administering the feeding, there was less complications with the feeding. Staff member A stated staff member F reported this in the 24-hour handoff to staff member C. During an interview on 9/20/23 at 2:00 p.m., staff member E stated she would have questioned an order of five cartons of tube feeding formula in one administration and ask another nurse before administering it. During an interview on 9/20/23 at 2:30 p.m., staff member C stated he had worked at the facility going on five years, and had not had any training on enteral feeding while working at the facility. Staff member C stated resident #1 was the first resident he had administered an enteral feeding to while working at the facility. Staff member C stated he did not receive a report for tube feeding administration (for resident #1) from any of the nurses that had taken care of resident #1, while she was on the 200 hall of the facility. He was working the 400 hall, where she was moved to, prior to his shift. Staff member C stated the fill in nurse he received report from, relayed to him, that the formula had to be pushed when it does not flow with gravity. Staff member C further stated the order on the MAR was to give five cartons at 4:00 p.m. and five cartons at 8:00 p.m. Staff member C stated when administering one carton at a time at the 4:00 p.m. feeding, when the resident spit up a little, a CNA told him that it was normal for resident #1 to spit up some while receiving the formula. Staff member C said at the 8:00 p.m. feeding, he administered four cartons and resident #1 threw up and he immediately stopped the feeding. Staff member C further stated I followed the order, and I think she likely aspirated, the order was not clearly written. During an observation and interview on 9/20/23 at 3:15 p.m., staff member D stated it was demonstrated to her the tube feeding administration for resident #1 before she performed it by herself. Staff member D stated the physician orders on the MAR are sometimes misleading, but she would have questioned administering five cartons of formula and displayed a carton of [Brand Name] tube feeing formula that was 250 ml., stating the stomach only holds 750 ml of liquid, there is no way a stomach could hold five cartons. During an interview on 9/20/23 at 3:45 p.m., Staff member A stated the nurses should have gave a good handoff report, and, things they did specific to her (resident #1), I think he (staff member C) was told the enteral feeding for her was different. A review of resident #1's physician orders in the EHR, showed, Order: [enteral formula brand name] 1.5 x 5 cartons daily. Administer as a bolus. FREE WATER FLUSES OF 50ML BEFORE AND AFTER EACH FORMULA BOLUS[sic] Directions: 5 times a day. Start Date: 3/8/23. Order: have dietician review feeding amount to be sure it is appropriate and the free water amount to be sure shes getting enough fluids. [sic] . A review of a progress note in resident #1's EHR, with a created date of 7/14/2023 at 17:41:44 (5:41 p.m.), and authored by staff member NF2, showed: Son came and got this nurse at 200 hall. Said something was wrong with his mom. I went to her room and heard her (the resident) gurggling. She was in her recliner. I leaned her forward she had vomit on her gown. patted her on back told her to cough or throw up the fluid. she had fluid come out her mouth and out her nose. I had [CAN name] get me a bag mask to help bring her o2 up. She was 74% when I first checked she dropped down to 46. Moved the o2 up as much as we could on concentrator. [sic] A review of a progress note in resident #1's EHR, with a created date of 7/14/2023 at 21:40:23 (9:40 p.m.), and authored by staff member C, showed: 1600 (4:00 p.m.) - Bolus [Brand name] via G-tube as ordered. Resident tolerated ok. Resident up in recliner. 1745 (6:45 p.m.) - Resident noted to have emesis x1. 2000 (8:00 p.m.) - Bolus [Brand name] via G-Tube as ordered - resident noted to have emesis after 4th carton - stopped feeding per resident request. Resident sitting in recliner. [sic] A review of a progress note in resident #1's EHR, with a created date of 7/14/2023 at 21:41:33 (9:41 p.m.), and authored by staff member C, showed: Late Entry for 7/13/23 @ 2100.1600 (9:00 p.m. and 4:00 p.m.) - In to do Bolus tube feeding as ordered - Resident appears withdrawn - Bolus TF procedure explained prior to administration. She is in her recliner sitting up at 90 degree angle. Water given as ordered via G-tube. Attempt to instill bolus tube feeding via gravity not working. Was told via nursing report that tube feeding had to be pushed thru tube. Resident received 5 cartons. [sic] A review of a progress note in resident #1's EHR, with a created date of 7/15/2023 at 16:15:16 (4:15 p.m.), and authored by staff member C, showed: Late Entry for 7/13/23 1400 (2:00 p.m.) No specific instructions was given on bolus tube feeding dosage orders in nursing report other than it had to be pushed. [sic] A review of a progress note in resident #1's EHR, listing type, as IDT Event Review, with a created date of 7/17/2023 10:20:05 (10:20 a.m.), and authored by staff member B, showed: Resident had emesis post TF on 7/12/23, and an emesis post 1600 (4:00 p.m.) feeding, at 1745 (5:45 p.m.) on 7/13/2023. At 1900 (7:00 p.m.), resident appeared withdrawn, nurse was in and out of room to monitor and slowly administer the next scheduled feeding. After the 4th carton of formula, she again had a small emesis, and the nurse stopped the feeding after making direct eye contact and ensuring that was what she wanted. Resident's son requested suctioning and nurse called the on-call provider. [sic] A review of a hospital emergency department document, with no title, listing NF1, with a Creation Time of 7/13/2023 at 9:33 p.m., showed: Chief Complaint: Patient presents with Cardiac Arrest. HPI: [Resident #1's name] is a 86yr female who presents to emergency department with complaints of aspiration, difficulty breathing. Nursing home staff reported that patient appeared to aspirate with her tube feeding and had difficulty breathing. EMS states that she had oxygen saturation in the mid 50s and was placed on oxygen with some improvement in saturations to the 60s. On presenting to the emergency department patient was pulseless with asystole on the monitor and without spontaneous respirations. REVIEW OF SYSTEMS: Review of Systems, Unable to perform ROS: Patient unresponsive. ED COURSE & MEDICAL DECISION MAKING Patient presents to [hospital name] to the emergency department for evaluation of aspiration, difficulty breathing. On arriving to the emergency department patient without spontaneous respirations, no heart tones auscultated and no palpable peripheral pulses. Patient has POLST form accompanying her that indicates DNR/DNI, therefore resuscitative measures not initiated. Time of death called 2132 (9:32 p.m.). CLINICAL IMPRESSION 1. Respiratory arrest. [sic] A review of a facility document, titled [Facility Name] Inservice Attendance Roster dated 7/14/23, with a topic of Education on Tube Feeding, listed eight staff members attended, Staff member C's name was on the list. A review of a facility document titled, Enteral Tube Feeding via Gravity Bag, with a revision date of 11/2018, showed: Purpose The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Preparation I. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and provide for any special needs of the resident. Steps in the Procedure 2. Check the order to verify the type, amount, method and rate of administration. 3. Pour prescribed amount of enteral feeding into enteral feeding bag and prime tubing. Clamp tubing. 4. Verify placement of feeding tube. 5. If anything suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. Reporting I. Report complications promptly to the supervisor and the Attending Physician .

Based on observation, interview, and record review, a licensed staff member failed to seek out necessary education or guidance to ensure competency for the skills and knowledge necessary for the administration of enteral tube feedings for a resident who was new to the unit, and who had complications with tube feedings, for 1 (#1) of 7 sampled residents. This deficiency resulted in the resident having a decline in status, and the resident was sent to the emergency room for further evaluation. Findings include: During an interview on 9/20/23 at 1:22 p.m., staff member A stated resident #1 was transferred from the 200 hall of the facility to the 400 hall on 7/13/23. Staff member A relayed staff member C had not cared for resident #1 before. Staff member A stated she got a call around 9:00 p.m., that night, that resident #1 was being sent to the ED for emesis and her O2 saturation was in the 40's. Staff member A stated staff member C administered four cartons of formula to resident #1 during his shift on 7/13/23. He (staff member C) put four cartons of formula into a graduate (cylinder) and the fifth carton wouldn't fit. He was supposed to put one carton in the gravity bag at each feeding. During an interview on 9/20/23 at 1:35 p.m., staff member A stated, the formula flow for resident #1 seemed to be positional, and if staff would sit the resident upright while administering the feeding, there were less complications with the feeding. Staff member A stated staff member F reported this in the 24-hour handoff to staff member C. During an interview on 9/20/23 at 2:00 p.m., staff member E stated she would have questioned an order of five cartons of tube feeding formula in one administration and ask another nurse before administering it. During an interview on 9/20/23 at 2:30 p.m., staff member C stated he did not receive a report for tube feeding administration (for resident #1) from any of the nurses that had taken care of resident #1, while she was on the 200 hall of the facility. He was working the 400 hall, where she was moved to, prior to his shift. Staff member C stated the fill in nurse he received report from, relayed to him, that the formula had to be pushed when it does not flow with gravity. Staff member C further stated the order on the MAR was to give five cartons at 4:00 p.m. and five cartons at 8:00 p.m. Staff member C stated when administering one carton at a time at the 4:00 p.m. feeding, when the resident spit up a little, a CNA told him that it was normal for resident #1 to spit up some while receiving the formula. Staff member C said at the 8:00 p.m. feeding, he administered four cartons and resident #1 threw up, and he immediately stopped the feeding. Staff member C further stated I followed the order, and I think she likely aspirated, the order was not clearly written. Staff member C stated he had worked at the facility going on five years, and had not had any training on enteral feeding while working at the facility. Staff member C stated resident #1 was the first resident he had administered an enteral feeding to while working at the facility, but had administered them in the past. During an observation and interview on 9/20/23 at 3:15 p.m., staff member D stated she would have questioned administering five cartons of formula. She showed a carton of [Brand Name] tube feeing formula that was 250 ml., and explained how the stomach holds 750 ml of liquid, so there was no way the resident's stomach could have taken the five cartons. During an interview on 9/20/23 at 3:45 p.m., Staff member A stated the nurses should have gave a good handoff report, and, things they did specific to her (resident #1), I think he (staff member C) was told the enteral feeding for her was different. A review of resident #1's physician orders in the EHR, showed, Order: [enteral formula brand name] 1.5 x 5 cartons daily. Administer as a bolus. FREE WATER FLUSES OF 50ML BEFORE AND AFTER EACH FORMULA BOLUS[sic] Directions: 5 times a day. Start Date: 3/8/23. Order: have dietician review feeding amount to be sure it is appropriate and the free water amount to be sure shes getting enough fluids. [sic] . A review of a progress note in resident #1's EHR, with a created date of 7/14/2023 at 17:41:44 (5:41 p.m.), and authored by staff member NF2, showed: Son came and got this nurse at 200 hall. Said something was wrong with his mom. I went to her room and heard her (the resident) gurggling. She was in her recliner. I leaned her forward she had vomit on her gown. patted her on back told her to cough or throw up the fluid. she had fluid come out her mouth and out her nose. I had [CAN name] get me a bag mask to help bring her o2 up. She was 74% when I first checked she dropped down to 46. Moved the o2 up as much as we could on concentrator. [sic] A review of a progress note in resident #1's EHR, with a created date of 7/14/2023 at 21:40:23 (9:40 p.m.), and authored by staff member C, showed: 1600 (4:00 p.m.) - Bolus [Brand name] via G-tube as ordered. Resident tolerated ok. Resident up in recliner. 1745 (6:45 p.m.) - Resident noted to have emesis x1. 2000 (8:00 p.m.) - Bolus [Brand name] via G-Tube as ordered - resident noted to have emesis after 4th carton - stopped feeding per resident request. Resident sitting in recliner. [sic] A review of a progress note in resident #1's EHR, with a created date of 7/14/2023 at 21:41:33 (9:41 p.m.), and authored by staff member C, showed: Late Entry for 7/13/23 @ 2100.1600 (9:00 p.m. and 4:00 p.m.) - In to do Bolus tube feeding as ordered - Resident appears withdrawn - Bolus TF procedure explained prior to administration. She is in her recliner sitting up at 90 degree angle. Water given as ordered via G-tube. Attempt to instill bolus tube feeding via gravity not working. Was told via nursing report that tube feeding had to be pushed thru tube. Resident received 5 cartons. [sic] A review of a progress note in resident #1's EHR, with a created date of 7/15/2023 at 16:15:16 (4:15 p.m.), and authored by staff member C, showed: Late Entry for 7/13/23 1400 (2:00 p.m.) No specific instructions was given on bolus tube feeding dosage orders in nursing report other than it had to be pushed. [sic] A review of a progress note in resident #1's EHR, listing type, as IDT Event Review, with a created date of 7/17/2023 10:20:05 (10:20 a.m.), and authored by staff member B, showed: Resident had emesis post TF on 7/12/23, and an emesis post 1600 (4:00 p.m.) feeding, at 1745 (5:45 p.m.) on 7/13/2023. At 1900 (7:00 p.m.), resident appeared withdrawn, nurse was in and out of room to monitor and slowly administer the next scheduled feeding. After the 4th carton of formula, she again had a small emesis, and the nurse stopped the feeding after making direct eye contact and ensuring that was what she wanted. Resident's son requested suctioning and nurse called the on-call provider. [sic] A review of a facility document titled, Enteral Tube Feeding via Gravity Bag, with a revision date of 11/2018, showed: Steps in the Procedure 2. Check the order to verify the type, amount, method and rate of administration. 3. Pour prescribed amount of enteral feeding into enteral feeding bag and prime tubing. Clamp tubing. 4. Verify placement of feeding tube. 5. If anything suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician.

Based on interview and record review, the facility failed to prevent the development of three Stage II pressure ulcers, after a resident had a fracture and became more dependent on staff for assistance, and the pressure ulcers were avoidable, for 1 (#1) of 2 sampled residents. Findings include: During an interview on 4/11/23 at 10:50 a.m., staff member H stated resident #1 had a pressure ulcer on her bottom. Staff member H stated resident #1 developed the pressure ulcer after she broke her femur in March 2023. Staff member H stated resident #1 became a lot less mobile after the fall and could not move as easily to reposition herself. Staff member H stated resident #1 was incontinent of bowels and staff repositioned resident #1 when staff provided incontinence care. During an interview on 4/11/23 at 1:03 p.m., staff member I stated resident #1 had a few pressure ulcers at one time. One on her right lateral buttocks, one on her right buttock near her rectum, and one on her sacrum. All the pressure ulcers had healed except the pressure ulcer on her right buttocks. Staff member I stated resident #1 had a current Stage II pressure ulcer on her right buttock that she developed at the facility. Staff member I stated she believed the pressure ulcer developed due to the resident scooting around in bed and refusing to be repositioned after her femur fracture. Staff member I stated resident #1 broke her femur on 3/7/23 and developed Stage II pressure ulcers that were identified on 3/16/23 during a skin assessment. Staff member I stated staff were to turn and reposition resident #1 a few times a shift, but she was unsure if CNAs documented the turning and repositioning of the residents. During an interview on 4/11/23 at 2:08 p.m., staff member G stated turning and repositioning was documented in the 'tasks' section of the resident's electronic medical record. Staff member G stated staff were to document there every time they turned and repositioned the resident. Staff member G stated if a resident refused to be turned and repositioned, they were to document this as 'refused.' Staff member G stated she was unsure why resident #1 did not have a 'task' in her electronic medical record for turning and repositioning. Staff member G stated it should have been added (generated) to the resident's electronic medical record. Turning and repositioning documentation for resident #1 was requested on 4/11/23 at 4:45 p.m., and was not received by the end of survey. Review of resident #1's Wound/Skin Note in the resident's EHR nursing progress notes, dated 3/16/23, showed, .Right buttock SDTI near rectum 1x1.4 cm Shearing right lower buttocks, Stage 2 right lateral buttocks 2x2(x)0.1 cm, Stage 2 sacral area 0.25x0.25x0.1 cm and superficial shearing left buttocks .Educated staff on importance of offloading frequently. Due to frequent incontinent stools foam dressing is not indicated. Covered SDTI as a trial - will re-evaluate next week. Will use zinc for now . [sic] Review of resident #1's Wound/Skin Note in the EHR nursing progress notes, dated 3/23/23, showed, .Right buttock SDTI near rectum healed. Stage 2 right buttocks 2x2x0.1 cm, Stage 2 sacral area 1x1x0.1 cm .Will change treatment to medi honey and foam dressings ad resident continues to scoot in wheelchair seat. Staff educated on importance of replacement when soiled or compromised. [sic] Review of resident #1's Wound/Skin Note in the EHR nursing progress notes, dated 3/30/23, showed, .Stage 2 right buttocks has a cluster of two open areas 2x2x0.1 cm, Stage 2 sacral area healed .Staff continue with off loading. [sic] Review of resident #1's Wound/Skin Note in the EHR nursing progress notes, dated 4/11/23, showed, .Pressure area on right buttocks continues to improve. 1x0.5x0.1 cm. Will continue with current treatment. Review of resident #1's Care Plan Original Care Plan Item, dated 3/2/23, showed, Preventative Care as follows: turn and reposition q 2 hours and PRN, assess positioning in bed and wheelchair .thorough peri care after each episode of incontinence . Review of resident #1's Care Plan, Changes Prior to Completion of Last Review, dated 3/2/23, showed, Preventative Care as follows: encourage . assist to change position 3-4 times a shift and PRN, assess positioning in bed and wheelchair .thorough peri care after each episode of incontinence . [sic]

Based on interview and record review, the facility failed to assess and monitor 1 (#1) of 5 sampled residents when there was a change in condition. Resident #1 experienced increased weakness, nausea, vomiting, and diarrhea, however there was not documentation in the medical record showing the resident was assessed and monitored for worsening of condition in the 14 hours prior to the resident being sent to the hospital. Findings include: During an interview on [DATE] at 10:37 a.m., NF1 stated resident #1 had been experiencing increased nausea and diarrhea in the week prior to being sent to the ER. NF1 stated resident #1 would just lay in bed with the blinds closed. NF1 stated she inquired on [DATE] regarding a [MEDICATION NAME] level but did not get a response from the staff. NF1 stated resident #1's nausea had gotten worse and by [DATE] the resident had required transport to the hospital for weakness, nausea, vomiting, and diarrhea. NF1 stated by the time the resident got to the ER her diarrhea was horrible. NF1 stated resident #1 had expired on [DATE], at the hospital from [MEDICATION NAME] toxicity. During an interview on [DATE] at 3:28 p.m., staff member G stated the signs and symptoms for [MEDICATION NAME] toxicity were blood pressure changes, disorientation, and confusion. Staff member G stated she would contact the physician by fax or phone, depending on the acuity. Staff member G stated she would wait 30 minutes for the physician to respond and then attempt to contact again. Staff member G stated if it was in the evening she would wait 20 minutes. Staff member G stated if the physician still did not respond, she would call the DON and the administrator. Staff member G stated she would monitor vital signs, alertness, neurological status, cardiac status, lungs and abdominal condition when a resident had a change in condition. During an interview on [DATE] at 3:35 p.m., staff member H stated the signs and symptoms of [MEDICATION NAME] toxicity were irregular heartbeat, anxiety, sweats, vision changes, pain, nausea, and vomiting. Staff member H stated she would notify the physician right away of any change in condition and get a full set of vitals. Staff member H stated she would monitor the resident closely. Staff member H stated the method in which she would contact the physician depended on the acuity of the resident. Staff member H stated she would document the attempts to contact the physician. During an interview on [DATE] at 4:00 p.m., staff member B stated the expectation for a change in condition was to assess the resident, chart for 72 hours following the change, contact the physician, notify the DON and the administrator, and if need be, contact the medical director. Staff member B stated she would expect a head to toe assessment of the resident. Staff member B stated if it was in the evening, the staff were to contact the management on call. Staff member B stated all the above depended on the acuity of the resident. Staff member B stated she would expect to see more assessments during the shift for a change in condition. During an interview on [DATE] at 4:15 p.m., staff member A stated resident #1 had refused to eat or drink during her admission to the facility, stating she would go on a hunger strike. Staff member A stated resident #1 did not want to be at the facility and had expressed wishes to return home. Staff member A stated the resident had only wanted comfort care until the daughter came in and then the resident agreed to go to the ER. Staff member A stated nursing staff should always call the physician when there is a change in condition. Staff member A stated the only reason the nurse called the physician on [DATE] was because the daughter wanted her to. Staff member A stated the physician was aware of the nausea and that was why the facility got an order for [REDACTED]. Staff member A stated the protocol was to attempt to contact the physician. If unable to contact the resident's physician, staff were to call the on call-provider or the medical director. Staff member A stated neither the on-call physician or the medical director had been contacted in this case as the nurse did not feel the situation was dire. Staff member A stated a set of vital signs were taken on [DATE] at 7:00 p.m. The medical record failed to show further assessments or monitoring of the resident. Review of resident #1's progress notes showed the following: -[DATE] at 1:37 p.m.: complaining of nausea, refused to eat, No emesis. Remained in bed all day. Assist with transfers. -[DATE] at 2:26 p.m.: Complained of nausea after breakfast. Had a few sips of beef broth and peppermint tea for lunch and reported feeling some better. -[DATE] at 11:05 a.m.: has had some nausea and dihhea (sic) last couple of days felt good this am but then loose stool after breakfast. -[DATE] at 2:53 p.m.: Has had no nausea complaints today. Daughters asking to have nausea med if she needs it. Placed call to physician. -[DATE] at 10:48 a.m.: No nausea yesterday or today on this shift. The resident went to a physician appointment and the plan was for family to pick her up at 4 p.m. for discharge to home. -[DATE] at 2:56 p.m.: The resident came back from physician appointment and the physician did not feel the resident was safe to discharge home. Received an order for [REDACTED]. -[DATE] at 10:31 a.m.: No nausea today -[DATE] at 3:42 p.m.: Dietician note; resident not eating d/t nausea. [MEDICATION NAME] order received .At risk for wt loss secondary to no intake/poor intake. -[DATE] at 3:40 a.m.: Episodes of anxiousness three times a day very anxious and upset over leg requesting frequent meds and ice. -[DATE] at 1:09 p.m.: Resident alert. Makes needs known. Denied pain this shift. Medicated for nausea x's 1 with adequate results . -[DATE] at 9:56 a.m.: Late entry-physician messaging service called at 1800 (6:00 p.m.) on [DATE]-no response-pt with increased weakness, nausea, vomiting, and diarrhea, [DATE] at 0900 (9:00 a.m.) pt c/o not feeling well, nausea, weakness. (physician's name) here and notified-he went in and saw pt, order received to send pt to the ER. Family notified and here prior to transferring via ambulance to (hospital name) for eval. Daughter riding on ambulance with pt, ER notified and report given to nurse. Review of resident #1's medical record did not show interventions for diarrhea. Documentation showed the nursing staff failed to recognize the signs and symptoms of [MEDICATION NAME] toxicity and failed to assess and monitor the residents weakness, nausea, and diarrhea for 14 hours prior to admission to the hospital. Review of resident #1's Daily Skilled Notes, from [DATE] through [DATE], showed diarrhea daily, and showed nausea on two days. Progress notes, from [DATE] through [DATE] showed frequent nausea and some diarrhea. The resident's Daily Skilled Notes showed the resident was only assessed one time per day from [DATE]-[DATE]. Review of resident #1's Physical Therapy note, dated [DATE], showed .participates well and is improving with independence with transfers and bed mobility, improved strength . Review of resident #1's Physical Therapy note, dated [DATE], showed .Pt has been sick the last couple days and feeling weaker each day. CNA reports pt is not eating well . Review of resident #1's Weights and Vitals Summary showed the following: -blood pressure was assessed two times per day from [DATE]-[DATE], -oxygen saturation was checked one time on [DATE] -temperature was assessed two times on [DATE] and [DATE], -heart rate was checked four times from [DATE]-[DATE], -respirations were checked two times on [DATE] and [DATE]. Review of resident #1's physician progress notes [REDACTED]. 3 days n/v/d (nausea/vomiting/diarrhea). pt. feels terrible mouth dry lungs (decreased) Heart rate 60 regular abd-flat slightly tender diffuse (no) [MEDICAL CONDITION] skin dry family arrived. pt DNR pt wants to go to ER for comfort care, maybe IV family agrees-daughter is a nurse. Transported by ambulance. Review of resident #1's hospital IP Encounter Report showed, under labs, a [MEDICATION NAME] level of 4.4. Normal reference range was 0XXX,[DATE].0. Under the section Final Impression showed poisoning by [MEDICATION NAME]-glycoside, accidental or unintentional, initial encounter. Review of resident #1's hospital Discharge Summary, dated [DATE], under cause of death, showed [MEDICAL CONDITION] secondary to [MEDICATION NAME] toxicity.

Based on interview and record review, the facility staff failed to ensure a resident who had a fall with a significant head injury received thorough and ongoing medical assessments and monitoring for the analysis of post fall assessment data to be used for the purpose of identifying resident changes; and staff failed to effectively identify, document, and communicate the fall details, to include notifying the physician of the change of status and head injury for the resident, and allow the physician the opportunity to determine if a higher level of care or treatment was necessary; and failed to address interventions for safety related to accidents and hazards for the fall, which included the resident's transfer to the emergency room in a private vehicle, for 1 (#2) of 7 sampled residents. Findings include: Family Interview During a family interview on [DATE] at 9:32 a.m., NF3 stated she received a call from the facility that her mother had a fall. She stated her sister came in to see their mom in the morning around 7:45 a.m. and she came a little later. NF3 stated her mother had bruising to the right side of her face, from the top of her head to her cheek and between her eye socket and her ear. NF3 stated she noticed a cut on the top right side of her head above her forehead and to her right shoulder and arm. NF3 stated she told staff member B she wanted her mom to go to the hospital. NF3 stated her mom's eyes were rolling back in her head and she couldn't stand. NF3 stated she and her sister took resident #2 to the hospital. She stated the hospital did a CT scan and found her mom had bleeding in the back of her brain. NF3 stated resident #2 lingered for a week and died at the hospital. NF3 stated the situation could have been different if her mother would have gotten treatment sooner to stop the bleeding by being administered vitamin K right away. NF3 stated, They took away her chance to live by delaying treatment. 1. Resident Transfer and Admission to the Hospital During an interview on [DATE] at 2:05 p.m., staff member E stated just before she and another nurse found resident #2 on the floor she heard a ting of metal sound. She stated they had concerns for resident #2 regarding her medications and her confusion. She stated they found resident #2 laying on the floor, on her back, with her walker in her hands. She stated they assessed resident #2 and then stood her up. She stated resident #2 had normal range of motion to her extremities and there were no signs of blood. She stated if there was an injury bruising would not be noticed for 72 hours unless there had been a tremendously hard impact. Review of resident #2's emergency department notes, dated [DATE] at 10:27 p.m., showed resident #2 presented with a chief complaint of a fall. The physician review of systems showed resident #2 had right sided facial contusions. The emergency department course and medical decision making showed resident #2 was Comfort Care per her POLST, and was diagnosed with [REDACTED]. The note showed a neurosurgeon was consulted and stated there was no surgical indication for the current brain bleed. Resident #2 was admitted to the hospital as an inpatient under Comfort Care. 2. Review of the facility policy and procedure titled, Physician Notification, showed, .All communication verbal or written must be documented in the permanent medical record. 1. Emergent: Post fall with injury or suspected injury, change in mental status, new onset pain, [MEDICAL CONDITION] (no void in 8 hours), no response to bowel protocol, chest pain, shortness of breath with desaturation require a phone call to the physician or on call physician in less than 1 hour from initial occurrence. 3. A review of resident #2's medical record showed the following: a. Initial Assessments Review of resident #2's 5 day admission MDS, with and ARD of [DATE], showed she had severe cognitive impairment, had disorganized thinking, hallucinations and delusions, required extensive assistance from two staff members for transfers toileting, and bed mobility, and extensive assistance of one staff member for walking in her room. Review of resident #2's bladder evaluation dated [DATE] showed the resident was confused and disoriented, required extensive assistance from staff to transfer, had decreased manual dexterity and pain with movement, and had decreased upper and lower extremity muscle strength. The evaluation showed resident #2 had a perception of needing to void, and a pattern of voiding upon arising and after meals. The evaluations showed resident #2 required the assistance of one person and the use of a FWW to facilitate her toileting ability. b. Review of resident #2's fall risk assessment, dated [DATE], showed a score of 20 which represented a high risk for falls. Review of resident #2's care plan, with an initiation date of [DATE], showed a focus area for a self-care deficit due to cognitive impairment. The goal was for resident #2 to be able to safely perform self-care activities. Interventions listed included that staff would assist resident #2 with dressing, ambulation with a walker, closely monitor for loss of balance or fall, monitor for the assistance needed to eat, and provide one person limited assistance to extensive assistance with bed mobility, transfers and toileting. Review of resident #2's Medication Administration Record [REDACTED]. c. Fall Investigation Review of the facility Occurrence Report showed resident #2 had a fall in her room on [DATE] at 11:30 p.m. The report showed staff found her laying on her back on the floor with her FWW in her hands. The report showed resident #2 had been confused and had been yelling out and had been given a [MEDICATION NAME] 5 mg at 9:00 a.m. The report showed items that were on the bedside table had been knocked off onto the floor. The follow-up report for the Occurrence Report showed changes to the resident status as facial bruising. Review of resident #2's Neurological Assessment Flow Sheet, showed staff started the assessment at the time of her fall at 11:30 p.m. The form showed both eyes were dilated from 11:30 p.m. through the last check on [DATE] at 4:15 p.m. Observation entries on [DATE] at 8:15 a.m., 12:15 p.m., and 4:15 p.m. showed the resident was drowsy. Review of a resident #2's Nursing Fax Sheet, sent to the resident's physician, on [DATE] at 11:30 p.m., showed the resident was found on the floor on her back. The fax showed resident #2 had no apparent injury, no complaints of pain, no redness or abrasions, and was assisted to her wheelchair and then to bed. d. Nursing Documentation After the Fall Review of resident #2's nurse's note, dated [DATE] at 11:30 p.m., showed resident #2 was found on the floor, supine with feet under the sink and near the bathroom. The nurse's note showed no apparent injuries and the resident was assisted to her wheelchair then to bed. The note showed the family was notified and a fax was sent to resident #2's provider. Review of resident #2's nurse's note titled Late entry for [DATE] at 8:00 a.m. by staff member C, was entered AFTER the nurse's notes dated [DATE] at 3:00 p.m. and [DATE] at 4:30 p.m. The late entry showed resident #2's pupils were equal and reactive and hand grasps were equal. It included the sentence, no request for transfer. There was no documentation that showed resident #2 had bruising to her face. The entry on the Neurological Assessment Flow Sheet on [DATE] at 8:15 showed resident #2's right and left pupils were dilated. No other assessments were documented in resident #2's medical record from 8:00 a.m. through 3:00 p.m. that reflected if any injuries were noted to include bruising to the face until the note dated [DATE] at 3:00 p.m. Review of resident #2's nurse's note, dated [DATE] at 3:00 p.m., showed resident #2 was confused and not talking much. The nurse's note showed resident #2's eye was dilated and had strong grips, and was groggy. The nurse's note showed resident #2 had bruising over and on the side of her right eye. The note showed resident #2's family had been with her all day. The note did not contain documentation that showed resident #2's provider has been notified of the dilated eye and the bruising over and on the side of her right eye. Review of resident #2's nurse's note, dated [DATE] at 4:30 p.m., by staff member B, showed resident #2's family requested a transfer to the emergency room . The note showed an order to transfer was received from resident #2's provider. The note showed staff was unable to reach the ambulance service and dispatch was notified of the need for a non-emergency transfer. The note showed the family transported resident #2 to the emergency department. Staff member B documented the ER nurse was notified resident #2's family was bringing her to be examined and gave report. The medication list and POLST were faxed to the ER. Review of resident #2's nurse's note, dated [DATE] at 4:30 p.m., by staff member G, showed at 3:00 p.m. family members called her into resident #2's room. The note showed staff member G was asked by the family if they would send resident #2 to the ER. The note showed resident #2's family told staff member G that resident #2 had been found on the floor. Staff member G noted the family had asked that resident #2 be sent to the ER. Staff member G wrote in the note that resident #2's family decided to take their mom to the ER in their care since the ambulance was not able to at that time. Review of resident #2's nurse's note, dated [DATE] at 5:30 p.m., by staff member G, showed the hospital called and reported that resident #2 had a brain bleed, the [MEDICATION NAME] was stopped, and thanked staff member G for sending resident #2 to the ER. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a fall in her room on [DATE] at 11:30 p.m. Resident #2's provider was notified of the fall via fax and that there was no injury. Facility staff failed to notify resident #2's provider of changes in her condition and the facial bruising the following morning. Resident #2's daughters took her to the emergency department on [DATE] for an evaluation, rather than the facility identifying the need for further evaluation and treatment at the local hospital. Resident #2 was diagnosed at the hospital with a midline focal tentorial subdural hematoma. The intra-cranial hemorrhage was non-operable. Resident #2 was admitted as an in-patient at the hospital and transitioned to comfort care on [DATE]. She passed away on [DATE].

Based on interview and record review, the facility failed to notify the physician of a change in physical condition after a resident's fall with injury, for 1 (#2) of 7 sampled residents, and the resident was found to have a significant injury. Findings include: Family Interview During a family interview on [DATE] at 9:32 a.m., NF3 stated she received a call from the facility that her mother had a fall. She stated her sister came in to see their mom in the morning around 7:45 a.m. and she came a little later. NF3 stated her mother had bruising to the right side of her face, from the top of her head to her cheek and between her eye socket and her ear. NF3 stated she noticed a cut on the top right side of her head above her forehead and to her right shoulder and arm. NF3 stated she told staff member B she wanted her mom to go to the hospital. NF3 stated her mom's eyes were rolling back in her head and she couldn't stand. NF3 stated she and her sister took resident #2 to the hospital. She stated the hospital did a CT scan and found her mom had bleeding in the back of her brain. NF3 stated resident #2 lingered for a week and died at the hospital. NF3 stated the situation could have been different if her mother would have gotten treatment sooner to stop the bleeding by being administered vitamin K right away. NF3 stated, They took away her chance to live by delaying treatment. Resident Fall Detail Review of the facility Occurrence Report for the resident's fall showed resident #2 had a fall in her room on [DATE] at 11:30 p.m. The report showed staff found her laying on her back on the floor with her FWW in her hands. The report showed resident #2 had been confused and had been yelling out and had been given a [MEDICATION NAME] 5 mg at 9:00 a.m. The report showed items that were on the bedside table had been knocked off onto the floor. The follow-up report for the Occurrence Report showed changes to the resident status as facial bruising. Review of resident #2's Neurological Assessment Flow Sheet, showed staff started the assessment at the time of her fall at 11:30 p.m. The form showed both eyes were dilated from 11:30 p.m. through the last check on [DATE] at 4:15 p.m. Observation entries on [DATE] at 8:15 a.m., 12:15 p.m., and 4:15 p.m. showed the resident was drowsy. Review of resident #2's Fax Sheet, showed staff sent a fax to the resident's provider on [DATE] at 11:30 p.m. The fax notified the provider that resident #2 was found on the floor on her back. The fax showed resident #2 had no apparent injury, no complaints of pain, no redness or abrasions, and was assisted to her wheelchair and then to bed. Review of resident #2's nurse's note, dated [DATE] at 11:30 p.m., showed resident #2 had no apparent injuries and the resident was assisted to her wheelchair then to bed. The note showed the family was notified and a fax was sent to resident #2's provider, which did not address a change in condition Review of resident #2's nurse's note titled Late entry for [DATE] at 8:00 a.m. by staff member C, was entered AFTER the nurse's notes dated [DATE] at 3:00 p.m. and [DATE] at 4:30 p.m. The late entry showed resident #2's pupils were equal and reactive and hand grasps were equal. It included the sentence, no request for transfer. There was no documentation that showed resident #2 had bruising to her face. The entry on the Neurological Assessment Flow Sheet on [DATE] at 8:15 showed resident #2's right and left pupils were dilated. No other assessments were documented in resident #2's medical record from 8:00 a.m. through 3:00 p.m. that reflected if any injuries were noted to include bruising to the face until the note dated [DATE] at 3:00 p.m. Review of the nurse's note, dated [DATE] at 3:00 p.m., showed resident #2 was confused and not talking much. The nurse's note showed resident #2's eye was dilated and had strong grips, and was groggy. The nurse's note showed resident #2 had bruising over and on the side of her right eye. The note showed resident #2's family had been with her all day. The note did not contain documentation that showed resident #2's provider has been notified of the dilated eye and the bruising over and on the side of her right eye. Review of resident #2's nurse's note, dated [DATE] at 4:30 p.m., by staff member B, showed resident #2's family requested a transfer to the emergency room . The note showed an order to transfer was received from resident #2's provider, based on the family's request, rather than the facility's. The note showed the family transported resident #2 to the emergency department. Review of resident #2's emergency department notes, dated [DATE] at 10:27 p.m., showed resident #2 presented with a chief complaint of a fall. The physician review of systems showed resident #2 had right sided facial contusions. The emergency department course and medical decision making showed resident #2 was Comfort Care per her POLST, and was diagnosed with [REDACTED]. The note showed a neurosurgeon was consulted and stated there was no surgical indication for the current brain bleed. Resident #2 was admitted to the hospital as an inpatient under Comfort Care. Review of the facility policy and procedure titled, Physician Notification, showed, .All communication verbal or written must be documented in the permanent medical record. 1. Emergent: Post fall with injury or suspected injury, change in mental status, new onset pain, [MEDICAL CONDITION] (no void in 8 hours), no response to bowel protocol, chest pain, shortness of breath with desaturation require a phone call to the physician or on call physician in less than 1 hour from initial occurrence. In summary, resident #2 had a fall in her room on [DATE] at 11:30 p.m. Resident #2's provider was notified of the fall via fax and that there was no injury. Facility staff failed to notify resident #2's provider of changes in her condition, to include facial bruising, the following morning. Resident #2's daughters requested a higher level of care for further assessment of the resident, and transferred her to the emergency department on [DATE] for an evaluation. Resident #2 was diagnosed at the hospital with a midline focal tentorial subdural hematoma. The intra-cranial hemorrhage was non-operable. Resident #2 was admitted as an in-patient at the hospital and transitioned to comfort care on [DATE]. She passed away on [DATE]. Further investigation showed:

Based on record reviews and staff interview the facility failed to ensure 3 (#'s 1, 22, and 23) of 23 sampled and supplemental residents received appropriate treatment and services to restore as much normal bladder function as possible. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/6/14 at 10:45 a.m., the medical record lacked documentation that resident #1 had been assessed for bladder status and the resident's ability to participate in a toileting program in the previous 2 months. Review of the ADL flowsheet for 3/2014 showed that resident #1 was incontinent daily. Review of the medical record's 7 day observation tool dated 3/4-3/10/14 indicated that resident #1 was an extensive assist by 2 staff for toileting needs during the day and totally dependent on staff for toileting needs at night. 2. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 12/26/13, section H, showed resident #22 always continent of urine. Review of the ADL flowsheet for 1/2014 showed 7 urinary incontinent episodes. The medical record, on 3/6/14 at 2:00 p.m., lacked evidence of a bladder assessment, reason for the decline from always continent to occasionaly incontinent in urinary function or the ability to participate in a bladder training program. 3. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the14 day MDS with an ARD of 2/18/14, section H showed that resident #23 was always continent. Review of the 30 day MDS with an ARD of 3/4/14, section H, showed resident #23 was occasionally incontinent of urine. Review of the ADL flow sheet for 1/2014 showed 8 episodes of urinary incontinence. Review of the medical record on 3/6/14 at 3:30 p.m., did not show evidence of bladder status, reason for decline from always continent to occasionally incontinent or the ability to participate in a bladder training program. On 3/6/14 at 10:45 a.m., staff member A reported to the surveyor that the facility had not begun assessing residents for their ability to participate in a toileting program and that the facility had not implemented a toileting program as of the date of the interview. Staff member A further reported that the facility had not begun to audit the effectiveness of the bladder control program because it had not been implemented yet. The facility provided the surveyor with a form titled "Bladder Assessments." The form was blank showing no evidence that bladder assessments were completed on any residents.

Based on record review, and resident, family, and staff interviews, the facility failed to ensure 2 (#1 and #12 ) of 16 sampled residents received appropriate treatment and services to maintain as much normal bladder function as possible. Resident #1 and #12 were continent of urine upon admission; they both declined and became incontinent. The facility failed to assess for patterns, causes and types of incontinence and develop interventions to maintain or improve continence. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On admission, the facility staff documented on the Resident-Data Collection form, dated 08/23/13, that the resident was continent of bladder, used the toilet and was able to participate in bladder training. An admission Bladder Incontinence Evaluation was started by the facility on 8/23/13; several sections were incomplete. The evaluation indicated the resident was alert/oriented, and required extensive assistance with transfers and standing ability was impaired. The resident's voiding pattern was marked "upon rising"; however, the evaluation of the resident's voiding patterns was not completed. The environmental factors/assistive devices which would restrict or facilitate the resident's toileting ability were not completed. The section with types of programs available at the facility which the resident could have participated in to assist in her continuation to remain continent was not completed. The section with the resident's choice or ability to participate in the available programs was not completed. Documentation in the interdisciplinary progress notes dated 8/24/13 at 2:00 a.m. reflected the nursing staff were offering toileting every two hours. The resident's initial MDS with an ARD of 9/6/13 documented the resident required extensive assist with toileting. The resident was documented as being continent of urine. The CAA summary, dated 9/5/13, triggered for cognition loss, identified the resident exhibited "some dementia, inattentive often" with periods of confusion documented. The CAA summary for urinary incontinence reflected the resident was continent and the facility would proceed to care plan. The facility addressed toileting in the resident's plan of care, dated 9/5/13. The facility goal was to have the resident's toileting needs met. The interventions included; providing hygiene after voiding, to remind the resident to call for assistance before toileting, to select easily removable clothing, and change continence brief/pad. It was unclear why the resident wore a continence brief/pad when she was documented as being continent (9/5/13 CAA summary). The next MDS assessment showed a decline in the resident's continence. The resident's quarterly MDS with an ARD of 11/22/13 documented the resident was occasionally incontinent of urine. During the family interview on 12/29/13 at 4:10 p.m. with the resident and her son, the resident's son stated since resident #1's stroke, staff had to assist the resident with ADLs. The resident said during the last outing, her daughter assisted her to the bathroom when she needed to go, indicating she could be continent if she received assistance. Staff member T, the restorative CNA was interviewed on 12/31/13 at 11:30 a.m. She stated resident #1 usually told her when she needed to use the toilet. When the resident told her she needed to void, it was urgent so she usually tried to take her to the restroom after meals if she walked with the resident. When the resident was in restorative dining, the staff member stated she took the resident to the bathroom after meals. She was not sure what the CNAs did as far as toileting the resident. Staff member H, an LPN, was interviewed on 12/30/13 at 3:45 p.m. She stated resident #1 was toileted, but at times, it was too late. She stated if the staff could anticipate resident #1's need for assistance with toileting, resident #1 could remain continent. Staff member U, a CNA, was interviewed on 12/31/13 at 11:35 a.m. She stated resident #1 told the staff if she needed to use the restroom. The staff member said the resident didn't always make it in time to the restroom. At times, "She (resident#1) gets up on her own. She thinks she can do it by herself." Staff member I, a CNA, was interviewed on 12/31/13 at 11:38 a.m. She stated, "She (resident #1) lets us know" when she needed to use the toilet. "She knows when she has to go." The staff member stated she watched and reminded the resident throughout her shift for toileting as the resident would try getting up by herself if she felt the need to void. The resident declined in her ability to remain continent. The resident's ADL performance form for December 2013 was reviewed. For 31 out of 84 shifts (36% of the time), the resident was charted as being incontinent of urine. The ADL Flowsheet for December 2013 included evidence that the resident was incontinent of urine on 26 out of 29 days. Two of the 29 days, the resident was out of the facility and one day, staff did not chart. The incontinence episodes were mainly during the evening and night shifts. These records showed the resident was incontinent most days. There was a lack of evidence the facility identified the decline, assessed for patterns, types and causes of the incontinence and implemented interventions to address the incontinence. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 7/8/13 indicated that resident #12 was independent with toileting, personal hygiene, mobility, dressing, and eating. Further review indicated that resident #12 had moderately impaired cognitive skills. Under section H0300, the resident scored 0 for always being continent of urine. Review of the MDS with an ARD of 9/25/13 indicated that resident #12 was independent with toileting, personal hygiene, mobility, dressing, and eating. Further review indicated that resident #12 had moderately impaired cognitive skills. Under section H0300, the resident scored 0 for always being continent of urine. Review of the MDS with an ARD of 12/13/13 indicated that resident #12 required extensive assistance with toileting, personal hygiene, mobility, dressing, and eating and required assistance of 2 staff to meet the resident's needs. Further review indicated that resident #12 had moderately impaired cognitive skills. Under section H0300, the resident scored 2 for being frequently incontinent of urine. Under section H0200 no trial toileting program had been implemented even though the incontinence represented a change from the previous assessments. The review of the ADL flowsheet dated November, 2013 indicated that the resident had 9 episodes of urinary incontinence within a 30 day period. Review of the ADL flowsheet for December, 2013 indicated that the resident had 1 or more urinary incontinence episodes per day for 29 out of 31 days. Review of the facility form labeled bladder incontinence evaluation dated 9/24/13 documented that the evaluation was incomplete with no assessment of bladder status. A review of the bladder incontinence evaluation with a date in the notes section dated 12/8/13 was incomplete with no assessment of bladder status, functional status or evaluation for bladder program potential. Review of the care plan dated 12/18/13 identified the following interventions in place for urinary incontinence and toileting needs: provide good hygiene and peri-care, remind resident to ask for assistance, when resident is wandering ask if the resident needs to go to the bathroom, select clothing that is easily removed, change incontinence pad/brief PRN, check for incontinence, ask to toilet before/after meals, morning, bedtime and PRN, and keep path to bathroom clear and well lit. There was no evidence the facility assessed resident #12 for her bladder incontinence, reason for decline in urinary continence, and appropriate treatment and services to restore normal bladder function.

Based on clinical record review and staff interview, the facility failed to identify and care plan immediate needs for 2 (#s 1 and 13) of 16 sampled residents. Findings included: 1. Resident #1 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Following admission, an interim nursing plan of care was not developed to address the resident's immediate needs. On 1/19/10 at 5:00 a.m., the resident sustained [REDACTED]. An admission MDS assessment was completed with an ARD of 1/14/11. The licensed nurse documented the resident required assistance to stabilize his balance during transitions and walking (G0300 A-E, 2), mobility devices included a walker and wheelchair (G0600 A, B), and the resident had a fall history prior to admission (J1700 B, 1). The CAA's (care area assessments) and plan of care were still in progress. A Fall Risk assessment was completed on 1/7/11. A score of 14 identified the resident as high risk for falls. Prescribed medications on admission included [MEDICATION NAME] 20 mg BID for pain and [MEDICATION NAME] 30 mg at hs prn. On 1/17/11 a licensed nurse obtained a physician order [REDACTED]. The resident was scheduled for a blood glucose evaluation at 9:00 p.m. and insulin coverage if necessary. On 1/18/11, the licensed nurse failed to document a blood glucose value and insulin dose for 9:00 p.m. Based on an Interdisciplinary Progress Note dated 1/19/10 at 5:00 a.m., the resident sustained [REDACTED]. The licensed nurse documented the resident sustained [REDACTED]. On 1/19/11 at 6:20 a.m., the resident was transported to an acute care hospital and remained for two days in an intensive care unit with [DIAGNOSES REDACTED]. On 1/31/11 at 2:00 p.m., the plan of care notebook on the unit was reviewed and did not include a plan of care for resident #1. On 2/2/11 at 9:30 a.m., staff members A, C, and D, the administrator and two DONs, were interviewed. The temporary plan of care was requested and post fall assessment. On 2/3/11 at 10:10 a.m., staff member K, the MDS coordinator, provided a plan of care with an effective date of 1/13/11 and a print date of 2/2/11 at 10:20 a.m. Staff member K stated she was unable to locate a plan of care. 2. Resident #13 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Based on clinical record documentation, on 11/21/10 the resident threw herself on the floor and sustained a fractured pelvis. A significant change MDS assessment was completed with an ARD of 12/7/10. As a result of the injury, the resident had increased pain and decreased mobility. (CAA #s 5, 6, 9, and 19, completed 12/9/10). Based on the MDS assessment dated [DATE], the resident exhibited constipation (H0600, 1). The CAA #14 findings included the following statement, "newly constipated dt (due to) increase of pain meds and immobility." On 11/30/10, the physician prescribed [MEDICATION NAME] 325/5 mg, one tablet QID by mouth. On the recapitulation of orders dated February 2010, in an order dated 1/20/09, the physician authorized the facility staff to use their bowel protocol. On 2/2/11 at 4:30 p.m., the bowel management protocol was requested. As of the exit on 2/3/11, the bowel management protocol was not provided. On 12/8/10, the physician prescribed Deficol 10 mg suppository, to be administered every 4th day, if the resident did not have a bowel movement. The January 2011 bowel monitor was reviewed. The resident had 3, 5-day periods where a bowel movement did not occur. The time frames without a bowel movement were: 1/2/11 through 1/6/11, 1/8/11 through 1/12/11, and 1/21/11 through 1/25/11. According to the January 2011 MAR, Deficol was not administered during the month of January. On 2/2/11 at 4:30 p.m., the lack of bowel management documentation was discussed with staff members A, C, and D. On 2/3/11 at 9:00 a.m., staff member C, the DON, provided a nurse's note dated 1/13/11. The licensed nurse documented that a suppository had been given for constipation.