Every finding on record at Crystal Heights Care Center

Based on clinical record review, staff interviews, and policy review, the facility failed to follow the physician's orders for one (1) resident (#3) by failing to check the resident's heart rate prior to administering a blood pressure medication. The facility reported a census of 68 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of cancer, bipolar disorder, psychotic disorder, and high blood pressure. It indicated the resident required setup assistance with eating and oral hygiene, moderate assistance with upper body dressing, was dependent with bathing, and required maximal assistance with all other Activities of Daily Living (ADLs). It also revealed he required supervision with all bed and transfer mobility.A Physician's Order dated 7/28/26 directed staff to administer 12.5 milligrams (mg) of metoprolol by mouth twice daily and to hold the medication if the heart rate was less than (<) 60 beats per minute (bpm). The August 2026 Medication Administration Record (MAR) revealed the resident received the medication twice daily at 6:00 AM and 3:00 PM since 8/01/26 but did not include a heart rate prior to the administered medication.An Electronic Health Record (EHR) Pulse Summary included documented one (1) daily pulse (heart rate) on 8/01/26; 8/02/26; 8/04/26; 8/07/26; 8/09/26; 8/11/26; 8/13/26; 8/14/26; 8/15/26; 8/16/26; and 8/19/26. There were no documented pulse checks for 8/17/26 or 8/18/26 and the remaining documented pulse checks did not coincide with the medication administration times.An EHR POC (point of care) Response History did not include any documented pulse checks.The Care Plan revised 8/07/26 did not include specific staff directives regarding the resident's blood pressure medication use.On 8/19/26 at 3:52 PM, the Advanced Registered Nurse Practitioner (ARNP) stated the parameter to hold a cardiac medication is an expectation and she expected staff to check the pulse before giving the medication.On 8/20/26 at 10:15 AM, the Assistant Director of Nursing (ADON) stated the metoprolol order should've been entered to include a pulse assessment with each administered dose when the resident returned from the hospital in July.The facility did not have a policy specific to following physician's orders.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to provide appropriate toileting hygiene assistance to prevent a urinary tract infection (UTI) for 2 of 3 resident (#2, #68). The facility reported a census of 68 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of severe intellectual disabilities, bipolar disorder, diabetes mellitus, seizure disorder, and the need for assistance with personal care. It revealed the resident was frequently incontinent with bladder, required maximal assistance with toileting transfers, and was dependent with toileting hygiene.The Care Plan revised 12/15/25 included frequent bladder incontinence and a history of a urinary tract infection (UTI) as a focus. It indicated the resident alerted staff of the need to toilet and received extensive two (2)-person assistance and mechanical lift with toileting needs.During a continuous observation on 8/19/26 at 7:51 AM, Staff A, Certified Medication Aide (CMA) and Staff B, Certified Nurse Aide (CNA) assisted Resident #2 with toileting in a shower room used by multiple residents. Staff A put on gloves, applied a gait belt to the resident, and assisted the resident to stand using a grab bar. Staff A then removed the resident's briefs while Staff B set up a clean brief. Staff A grabbed several hygiene wipes from a package and placed them on the side of the sink. As Staff B stabilized the resident, Staff A wiped the resident using a front-to-back motion, three times but did not perform hand hygiene or change gloves before performing toileting hygiene. Both staff assisted the resident back to sitting in her wheelchair, removed their gloves and performed hand hygiene. At 7:56 AM, Staff A stated she should've performed hand hygiene and changed her gloves prior to wiping the resident. She also stated she didn't think about the wipes being on the sink as a possible hygiene wipe contamination.Resident #68's MDS assessment dated [DATE] identified a BIMS score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of spinal stenosis (narrowing of the backbone that causes pressure on the spinal cord nerves), osteoarthritis, and muscle weakness. It revealed the resident was frequently incontinent with bladder, required moderate assistance with toileting transfers, and maximal assistance with toileting hygiene.The Care Plan revised 10/30/25 included bladder incontinence related to poor toileting habits. It also indicated she required one (1)-person assistance with toileting needs.During a continuous observation on 8/19/26 at 8:14 AM, Staff C, CNA assisted Resident #68 with toileting in a shower room used by multiple residents. Staff C put on gloves, held the wheelchair in place while the resident used the grab bar to stand, grabbed the hygiene wipes, and wiped the resident using a front-to-back motion, twice. She did not perform hand hygiene or change gloves before wiping the resident.On 8/20/26 at 10:15 AM, the Assistant Director of Nursing (ADON) stated staff shouldn't have removed the wipes from the package unless she had a barrier to place them on. She also should've removed her gloves, performed hand hygiene and donned new gloves prior to wiping the resident.A policy titled Hand Hygiene revised 4/25 indicated It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards.A policy titled Hand Washing revised 5/17 indicated It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.

Based on observation, record review, and interview, the facility failed to ensure staff provided range of motion (ROM) (joint movement exercises) to maintain functional status and prevent joint contractures (permanent tightening of muscles or joints) for 1 of 2 residents reviewed for restorative care (Resident #37). The facility reported a census of 68 residents. Findings included:Resident #37's MDS assessment dated [DATE] listed diagnoses including cancer (malignant growth), age-related debility (weakness from aging), and adult failure to thrive (decline in physical and cognitive function). Resident #37's MDS documented impairment in ROM on both sides of upper and lower extremities and a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The MDS reflected Resident #37 received Hospice services (end-of-life care) during the lookback period. On 7/16/26 at 8:33 AM observed Resident #37 sitting at the nursing station with his left arm held up tightly to his chest with his left wrist bent downwards at a 90-degree angle. When asked to move the wrist up and down, Resident #37 moved the right wrist, but couldn't move the left wrist. Resident #37's Minimum Data Set (MDS) assessment dated [DATE] documented no impairment in ROM in upper or lower extremities (limbs). Resident #37's MDS assessment dated [DATE] documented no impairment in ROM in upper extremities and impairments on both sides of lower extremities. Resident #37's MDS assessment dated [DATE] documented no impairment in ROM in upper extremities and impairments on both sides of lower extremities. Resident #37's MDS assessment dated [DATE] documented no impairment in ROM in upper extremities and impairments on both sides of lower extremities. Resident #37's MDS assessment dated [DATE] documented impairments in ROM on both sides of upper and lower extremities. A Condition Follow-Up Note dated 12/21/26 documented staff noted a contracture to Resident #37's left arm. Resident #37 held the left arm stiffly in place across the abdomen and chest. Resident #37's record review lacked documentation that completed ROM exercises with him. The Restorative Care policy dated July 2021 instructed the facility to provide each resident restorative care according to individual needs. The policy instructed residents receive services to maintain the highest possible functional status and noted restorative care may include ROM. On 7/15/26 at 2:53 PM Staff E, Certified Nursing Assistant (CNA), stated Resident #37 had a stiff-arm which he could move, but it grew stiffer. Staff E stated the arm got worse. On 7/15/26 at 3:08 PM Staff F, CNA, stated Resident #37's left arm became contracted. Staff F stated the arm felt stiff and Resident #37 could pull the arm out some, but it got worse. Staff F stated no one ever assigned Staff F to complete ROM. On 7/15/26 at 3:28 PM Staff D, CNA, stated working at the facility for 2 years without a restorative program existing at the facility. On 7/15/26 at 4:49 PM Staff A, Therapy Director, stated Hospice would carry out ROM as part of hospice services if Resident #37 received Hospice care. On 7/16/26 at 8:39 AM Staff B, Director of Nursing (DON), stated Resident #37 didn't start out as stiff as currently observed and slowly became stiffer. Staff B stated Hospice could bring in therapy if Hospice desired. On 7/16/26 at 9:14 AM Staff G, Hospice Director, stated via phone seeing nothing on Resident #37's Care Plan related to ROM and assumed the facility managed ROM. On 7/16/26 at 12:14 PM Staff H, Assistant Director of Nursing (ADON), stated the facility didn't have a ROM program, but knew a program needed to exist.

Based on observation, record review, and interview, the facility failed to ensure staff served meals in a timely manner for 7 of 7 residents (Resident #3, Resident #55, Resident #58, Resident #64, Resident #68, Resident #38, and Resident #28) reviewed for meal service. The facility reported a census of 68 residents. Findings included:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of heart failure (heart muscle weakness), non-Alzheimer's dementia (memory loss), and anxiety disorder (excessive worry). Resident #3's MDS listed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 7/13/26 at 1:24 PM Staff C, Dietary Aide (DA), delivered Resident #3's lunch to her in her room. 2. Resident #55's MDS assessment tool dated 5/20/26 listed diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression (mood disorder). Resident #55's MDS listed a BIMS score of 15, indicating intact cognition. On 7/13/26 at 12:35 PM Resident #55 stated meals arrived late. 3. Resident #58's MDS assessment tool dated 4/5/26 included diagnoses of depression, high blood pressure (elevated blood pressure), and coronary artery disease (clogged heart arteries). Resident #58's MDS listed a BIMS score of 15, indicating intact cognition. On 7/13/26 at 2:40 PM Resident #58 stated they received lunch that day around 1:30 PM, as usual. The undated facility Mealtimes schedule documented lunch served at 11:30 AM in the Assisted Dining Room and 12:00 PM in the Main Dining Room. The schedule didn't indicate when residents in their rooms received lunches. On 7/13/26 at 3:20 PM Staff D, Dietary Manager (DM), stated staff tried serving room trays before serving the assisted dining room and the main dining room. Staff D stated today wasn't necessarily typical. Staff D stated meal service usually went better than today and tomorrow would go better because they would be present. 4. On 7/13/26 starting at 12:25 PM Resident #64 explained the residents should receive food by 12:30 PM. Resident #64 stated wanting to eat at 12:00 PM, but 12:30 PM was the latest she wanted to eat. Resident #64 stated facility operations felt better organized when she first came compared to now. Resident #64 stated meals usually arrive late and reported she told staff without seeing changes. Resident #64 didn't recall who she told. On 7/13/26 Resident #68 stated meals arrive late sometimes, expressing frustration regarding available options. On 7/13/26 at 1:00 PM witnessed a staff member served the last meal in the main dining room. On 7/13/26 at 1:11 PM observed a staff member bring out the room tray cart. On 7/13/26 at 1:20 PM Resident #38 said she wished staff would bring food as she was hungry and wanted tea. On 7/13/26 at 1:25 PM Staff C, Dietary Aide (DA), stated one staff member usually passes out room trays while another cleaned the dining room. Staff C denied knowing why the meal delivery took so long that day. On 7/13/26 at 1:28 PM witnessed a staff member took room trays to the North Hallway. On 7/13/26 at 1:33 PM saw a staff member served room trays on the East Hall. On 7/13/26 at 1:35 PM Staff H, Dietary Aide (DA), carried an uncovered food tray to Resident #28's room on the [NAME] Hallway. Staff H stated they needed to get drinks for Resident #28, but didn't pass by again with the drinks. On 7/13/26 at 1:41 PM observed Staff C pass by with the food cart and reported they were done.

Based on clinical record review, policy review, staff, and resident interviews, the facility failed to ensure residents had access to their personal funds in a timely manner for 1 of 1 resident reviewed for personal funds (Resident #55) and for 9 of 9 additional residents who did not have access to their funds for their shopping needs. The facility reported a census of 68 residents.Findings included: 1. Resident #55's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of non-Alzheimer's dementia (memory loss), anxiety disorder (excessive worry), and depression (mood disorder). The MDS listed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 7/13/26 at 12:35 PM Resident #55 stated residents lacked access to their money on weekends and she currently waited for items on a shopping list. 2. The Week 1 Resident Shopping List included Resident #55 and 9 additional residents. The Accounts Receivable Policy and Procedure dated 7/7/26 instructed the facility to ensure residents had appropriate access to their funds. On 7/15/26 at 2:09 PM Staff A, Administrative Assistant, stated residents could access their money from 8:00 AM to 4:30 PM on Monday through Friday. Staff A stated they held the only key to the cash box. On 7/15/26 at 3:21 PM Staff B, Activities Assistant, stated she couldn't go shopping the previous week for any residents on the Week 1 Resident Shopping List because she couldn't obtain money from Staff A. On 7/15/26 at 4:57 PM Staff C, Administrator, stated the facility didn't have a plan in place for residents to get money on weekends. Staff C stated moving forward they would place money in the narcotic (controlled medication) box for staff to distribute during off hours. On 7/16/26 at 12:35 PM Staff C stated a breakdown in communication caused staff to not be able to go shopping for residents the previous week. Staff C stated moving forward the staff would go shopping for the residents every Thursday. The previous week, she didn't think money was ready for Staff B to take shopping.

Based on observation, record review, and interview, the facility failed to ensure staff provided planned activities and supervision for 3 of 3 residents (Resident #17, Resident #20, Resident #19) living on the Memory Care Unit. The facility reported a census of 68 residents. Findings include:Resident #17's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Resident #17's MDS documented Resident #17 wandered 4 to 6 days out of the 7-day look-back period. Resident #17's MDS documented medical diagnoses for vascular dementia (brain damage affecting memory), unspecified severity, with agitation (restlessness), anxiety disorder (excessive worry), and depression (mood disorder). Resident #17's Care Plan dated 10/17/25 documented a focus area for dependence on staff to meet emotional, intellectual, physical, and social needs related to vascular dementia with behavioral disturbance, hypertension (HTN) (high blood pressure), recurrent depressive disorder (repeated mood depression), severe vascular dementia with agitation, seizure disorder, and epilepsy (seizure disorder). Resident #17 enjoyed walking around the dementia care unit, visiting with others, helping staff with tasks, and visiting with family including a sister who calls on the phone regularly. Care Plan interventions dated 10/17/25 instructed staff to give step-by-step instructions one at a time as needed to support cognitive function, keep routine consistent, and try providing consistent caregivers as much as possible to decrease confusion. On 7/15/26 at 7:55 AM the Memory Care Unit displayed a white board with the date 7/15/26 and the following activities of the day:10:00 AM: ring toss1:00 PM: movie3:00 PM: coffee time On 7/15/26 at 3:12 PM Resident #17 wandered around the common area/TV room in the Memory Care Unit. Staff A, Certified Nursing Assistant (CNA), asked residents what they wanted for drinks and snacks. On 7/15/26 at 3:20 PM Resident #17 walked over to Resident #19, picked up chocolate milk off Resident #19's wheeled walker seat, and started drinking it. Resident #19 tried to tell Resident #17 no, but Resident #17 continued drinking the milk and walked away. No staff remained in the area to observe residents at this time. On 7/15/26 at 3:23 PM staff entered the unit, walked past the common area, and went down the hallway. On 7/15/26 at 3:28 PM Staff A walked into the area, walked into the kitchen area behind the common/TV area for a few seconds, and exited the unit. Resident #20's Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of 9, indicating moderately impaired cognition. Resident #20's MDS documented a medical diagnosis for Alzheimer's dementia (progressive brain disease causing memory loss), unspecified. Resident #20's Care Plan dated 8/26/25 documented a focus area for potential activity deficit related to a diagnosis of dementia. Resident #20 stayed active and social participating in activities of choice. Care Plan interventions dated 8/26/25 instructed staff to engage Resident #20 in simple, structured activities such as folders club, live entertainment, and watching TV/movies, provide an activity calendar, and notify Resident #20 of calendar changes. On 7/14/26 at 12:53 PM the Memory Care Unit displayed a white board showing 10:00 AM group exercises, 1:00 PM bird watching, and 3:00 PM coffee time. On 7/14/26 at 2:04 PM Staff A brought a picture to Resident #20 to color. On 7/15/26 at 7:55 AM the Memory Care Unit displayed a white board with the date 7/15/26 and the following activities of the day:3:00 PM: coffee time On 7/15/26 at 3:10 PM Resident #20 sat in the TV/common room. Staff A asked what Resident #20 wanted to drink or eat. After Staff A supplied drinks and snacks to residents in the area, Staff A left the area. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of 4, indicating severe cognitive impairment. Resident #19's MDS documented a medical diagnosis for Alzheimer's dementia. Resident #19's Care Plan dated 8/26/25 documented a focus area for little or no activity involvement related to Resident #19 wishing not to participate. Care Plan interventions dated 8/26/25 instructed staff to invite Resident #19 to scheduled activities his wife attended to encourage participation. Care Plan interventions dated 4/1/26 indicated the importance of social interaction and leisure activity time. On 7/14/26 at 12:53 PM the Memory Care Unit displayed a white board showing:10:00 AM group exercises1:00 PM bird watching3:00 PM coffee time. On 7/14/26 at 2:04 PM Staff A brought a picture to Resident #20 to color. Staff A asked Resident #19 if Resident #19 wanted to color something, and Resident #19 declined. On 7/15/26 at 7:55 AM the Memory Care Unit displayed a white board with the date 7/15/26 and the following activities of the day:3:00 PM: coffee time On 7/15/26 at 3:20 PM Resident #19 sat in a chair in the TV/common room, ate a snack, and kept chocolate milk on a wheeled walker seat. After Staff A provided snacks and drinks to residents, Staff A left the area. The TV played a show about Elvis. Residents didn't talk among themselves; they sat, ate snacks, and drank drinks. No staff stayed in the area to engage with residents. On 7/15/26 at 2:18 PM Staff B, Activity Assistant, stated conducting the 1:00 PM activity with residents while CNAs conducted morning and afternoon activities with residents in the Memory Care Unit. Staff B stated providing sensory activities, doing programs with Elvis, and taking residents outside when weather didn't feel too hot. Staff B provided a copy of monthly activities for the Memory Care Unit. The July 2026 Activity Calendar for the Memory Care Unit documented activities planned at 10:00 AM, 1:00 PM or 2:00 PM, and 3:00 PM daily. The Activity Calendar documented coffee time every day at 3:00 PM. Beautiful nails scheduled eight times in the month at 10:00 AM. Group exercise planned eight times at 10:00 AM without noted details. The Memory Care Unit housed 10 residents. On 7/15/26 at 3:33 PM Staff D, Certified Nursing Assistant (CNA), stated activities proved a struggle, but having 2 CNAs on the unit now should make tasks easier. Staff D stated Staff B tried coming back to the unit. Staff D stated 3:00 PM coffee time represented snack and drink distribution between lunch and supper. Staff D stated coffee time meant social time, but residents didn't talk to each other. On 7/16/26 at 12:37 PM Staff B stated walking around with Resident #17 and trying to provide squish toys. Staff B stated spending between 30 to 45 minutes a day on the Memory Care Unit depending on arriving fast enough because meals sometimes ran late. Staff B stated Resident #17 and another resident received the first 15 minutes of time Staff B spent on the unit. On 7/16/26 at 12:48 PM Staff C, Assistant Director of Nursing (ADON), stated activity staff went to the Memory Care Unit for 2 or 3 hours a day. When informed interviews showed activity staff didn't spend more than 45 minutes a day in Memory Care, Staff C agreed and confirmed meal times affected the time activity staff spent on the unit. Staff C confirmed the facility could do more and would promote a new program to implement more activities for the Memory Care Unit.

Based on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance(QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 68 residents.Findings included:The Quality Assurance and Performance Improvement Policy dated April 2025 instructed facility staff to continually assess facility performance using a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety and quality. The Centers for Medicare & Medicaid Services (CMS) Form 2567 dated 6/26/25 listed, in part, the following concerns:F567 related to residents having access to personal fundsF679 related to activity provision Record reviews and interviews conducted from 7/13/26 to 7/16/26 identified the same concerns. On 7/16/26 at 3:56 PM Staff A, Administrator, stated staff didn't discuss personal funds or activities in Quality Assurance (QA). A Performance Improvement Plan (PIP) dated 5/26/26, sent by Staff A on 7/17/26, identified increasing activities in the dementia (memory loss) unit. The PIP documented unit observations of inactivity, increased wandering behaviors, increased falls, and inconsistent participation in structured activities. Objectives included a 25% increase in activities and 1 to 2 hours of daily structured activities offered. Facility records lacked further evaluation of the activity PIP and lacked documentation of QA activities related to resident access to personal funds.

Based on Clinical record review and staff interview, the facility failed to follow medication administration protocol resulting in the wrong medication being administered. (Resident#1). The facility reported census was 70.Findings include: According to a Minimum Data Set (MDS) with a reference date of November 7, 2025, Resident #1 had a Brief Mental Status (BIMS) score of 0 of 15 indicating a severely impaired cognitive status. Resident #1 required moderate to maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included Non-Alzheimer's dementia, cancer, renal insufficiency, arthritis, diabetes mellitus, gastroesophageal reflux disease and malnutrition.According to Resident #1's Care Plan, Resident #1 was diagnosed with diabetes mellitus with risk for hypoglycemia (low blood sugar) and interventions which included fasting serum blood sugars as ordered, monitor for hypoglycemia and provide diabetic medications as ordered.Review of Resident #1's physician orders found an order for blood glucose checks before meals and at bedtime starting 11/4/25.Medication Administration Records (MARS) for November 2025 revealed Resident #1 was admitted on [DATE] with no initial order for insulin. On 11/15/25, Resident #1 was started on Tresiba 26 units at bedtime following blood sugars exceeding 300 days earlier. On 11/18/25 the Tresiba order was changed to 26 units in the morning daily. On 11/27/25 Resident #1's Tresiba 26 units every morning was discontinued following an event in which Resident #1's blood sugars fell below 40.In an interview on 12/8/25 at 7:12 a.m. Staff A, Registered Nurse, stated at around 2:05 a.m. on 11/26/25, staff had reported Resident #1 was experiencing increased confusion and earlier that day had had low blood sugars. Staff A stated he checked her blood sugar and it was 38 mg/dL. (milligrams per deciliter) Staff A stated there was no order for Glucagon and he called the nurse practitioner (ARNP) and received an order. Staff A stated he removed a syringe of medication from the compartment in the ekit labeled Glucagon and administered the contents in the syringe. Staff A stated 5 minutes later he checked the blood sugar again and this time it was 36 mg/dL. Staff A stated he called the ARNP again and received an order to give another dose of Glucagon. Staff A returned to the ekit and removed another syringe from the compartment labeled Glucagon and administered the contents. Five minutes later he checked the blood sugar and it was lower yet, prompting him to call for an ambulance. Within a few minutes, the emergency medical technicians (EMT) arrived and took over care for Resident #1, including administering intravenous 50% dextrose. Staff A returned to his medication cart and began documenting the event. Upon looking at the syringes he had administered, he noted the medication given was not Glucagon, but instead Enoxaparin, an anticoagulant used to prevent or treat dangerous blood clots. Staff A stated the pharmacy had errantly placed the Enoxaparin syringes in the compartment labeled Glucagon. Staff A stated he immediately informed the EMTs and contacted the ARNP of his error. Staff A stated Resident blood sugars returned to 200 mg/dL, but her mental status remained altered (not related to the Enoxaparin) and she was sent to ER for further observation.In an interview on 12/2/25 at 2:14 p.m. the Director of Nursing (DON) was questioned regarding a medication error in which Staff A removed what he believed was Glucagon from the ekit (emergency supply tackle box) and administered two doses of Enoxaparin 100 milligram/1 milliliter to Resident #1. The DON stated Resident #1 was having a hypoglycemic episode with blood sugars critically low in the thirties. The DON stated Resident #1 was not responding and Staff A notified emergency medical services (EMS). Once EMS took over the care of Resident #1, Staff A went to the trash can and removed the packaging, discovering at that time he had given Enoxaparin (anticoagulant) instead of Glucagon (glucose booster). Further investigation revealed the pharmacy had incorrectly placed Enoxaparin syringes in the Glucagon compartment and Glucagon syringes in the Enoxaparin compartment.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the Care Plan identified Hospice services, correct transfer status, activities, and behavioral interventions for Post-Traumatic Stress Disorder (PTSD), and lacked documentation of care conferences conducted for 7 of 19 residents reviewed for Care Plans (Residents #15, #33, #34, #37, #44, #56 #61). The facility reported a census of 62 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #33 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS listed the resident's Brief interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 6/24/25 at 10:27 a.m., Resident #33 stated the facility did not invite her to care conferences. A Care Conference Summary, dated 4/23/25, stated the resident had a care conference in her room with a staff nurse and the Assistant Director of Nursing(ADON). The facility lacked documentation of additional care conferences held during the survey year(8/8/24-6/23/25). On 6/25/25 at 9:17 a.m., the Assistant Director of Nursing(ADON) stated there was a change in personnel and she could not locate any care conferences prior to April 2025. 2. The Annual MDS assessment tool, dated 5/28/25, listed diagnoses for Resident #44 which included anxiety disorder, severe intellectual disability, and depression. The MDS stated the resident required partial to moderate assistance for transfers and listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. A 6/15/22 Care Plan entry stated the resident was independent with transfers. The Care Plan failed to reflect the MDS with the direction that the resident required assistance with transfers. On 6/25/25 at 7:55 a.m. Staff L and M Certified Nursing Assistants(CNAs) transferred the resident from her wheelchair to the toilet using a gait belt. The resident required substantial assistance(lifting and stabilizing) from the CNAs to complete the transfer. On 6/26/25 at 8:17 a.m., Staff G CNA stated Resident #44 required the assistance of two staff to get to the toilet. On 6/26/25 at 12:19 p.m., The ADON stated the Care Plan should reflect correct transfer statuses. 3. The Quarterly MDS assessment dated [DATE] for Resident #15 documented diagnosis, non-Alzheimer's Dementia. The MDS coded Resident #15 received hospice care. The Clinical Census, Electronic Health Record (EHR) revealed Resident #15 hospice care began 10/25/24. The Care Plan for Resident #15 was not updated to reflect that the resident received hospice services. 4. The MDS assessment for Resident #37 dated 5/21/25 revealed diagnosis of Alzheimer's diseases, early onset , no completed BIMS assessment, was coded rarely or never understood. The Clinical Census, Electronic Health Record (EHR) revealed Resident #37 admitted [DATE]. The Care Plan for Resident #37 documented behavior symptoms related to Alzheimer's revision dated 12/10/21 directed encourage group activity, to engage in simple structured activities, did not provide updates or information on resident interest or preference, lacked details, activity options or guidance to support physical mental or psychosocial well-being. 5. The Quarterly MDS assessment for Resident #56 dated 5/7/25 revealed unspecified mild dementia. The BIMS assessment scored 9 out of 15 indicated moderate cognitive decline. The Clinical Census, Electronic Health Record (EHR) revealed Resident #56 admitted [DATE]. The Care Plan for Resident #56 documented inaccurate BIMS score of 4 and did not provide updates or information on resident interest or preference, lacked details, activity options or guidance to support physical mental or psychosocial well-being. 6. The MDS dated [DATE] for Resident #61 revealed diagnosis included Non-Alzheimer's Dementia and BIMS assessment score of 3 indicated severe cognitive impairment. The Care Plan initiated 5/19/25 was not updated to reflect dressing, eating, hygiene, toileting or transfer intervention, areas left blank. The Care Plan did not provide updates or information on resident interest or preference, lacked details, activity options or guidance to support physical mental or psychosocial well-being. On 6/26/25 at 12:15 PM The ADON relayed awareness of need to expand on Care Plans updates, felt the newly hired staff would be helpful. Facility Policy titled Activities, not dated revealed activity interests will be identified in the residents plan of care and reviewed quarterly . The undated facility policy Comprehensive Resident Plan of Care stated resident needs were addressed within the comprehensive plan of care and stated the development of the plan of care included the resident. The policy stated the Care Plan would reflect changes and stated care conferences would occur quarterly.

Based on observations, representative, staff interviews, record review, and facility policy review the facility failed to provide the residents in the Chronic, Confusion, and Dementia Illness (CCDI) unit a activity program built to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Findings include: 1. A Quarterly Minimum Data Set, dated [DATE] for Resident #15 documented diagnosis, non-Alzheimer's dementia and coded wore a wander/elopement alarm. The Brief Interview for Mental Status (BIMS) assessment coded 00 to reflect resident, was not able to take assessment. In an interview on 6/23/25 at 4:34 PM with representative of resident #15 relayed there is nothing at all related to activities and is concerning, had not seen or heard of any activities, never seen anything posted, relayed books are provided but, did not think reading was an option anymore due to dementia progression and Resident #15 no longer wearing her glasses. 2. The MDS assessment dated [DATE] for Resident #61 revealed BIMS assessment of 3 indicated severe cognitive impairment. The diagnosis included Non-Alzheimer's Dementia. In an Interview on 6/23/25 with Resident #61 spouse, relayed would like to see activities in the unit, relayed there are none here, referred to the locked memory care unit. When queried about an activity calendar, resident representative reported not aware of any activity calendar. Representative revealed would have to take spouse outside of the memory care unit to take part in activities and am not always here to do that. 3. The Quarterly MDS assessment dated [DATE] for Resident #56 revealed BIMS score of 9 indicated moderated cognitive impairment. The diagnosis included Non-Alzheimer's unspecified dementia, mild without behavioral, mood or anxiety disorders In an interview on 6/23/25 at 11:57 AM Resident #56 relayed there is nothing to do, not aware of any activities, does own puzzles in her room, was not aware of activities outside of the unit as an option. After discussion, Resident #56 revealed was not aware of church services in the common area outside of the unit on Sunday and is interested, had never seen an activity calendar. 4. The Quarterly MDS assessment for Resident #37 dated 5/21/25 revealed diagnosis of Alzheimer's diseases, early onset and was not unable to conduct the BIMS assessment, was coded rarely or never understood. Observation on 6/25/25 3:00 PM to 4:08 PM Resident #37 walked back and forth in the unit without purpose. During a confidential interview on 6/25/25 at 4:08 PM it was relayed Resident #37 usual behavior is walking back and forth, relayed would like to see staff directed activities for all the residents. 5. The Quarterly MDS assessment dated [DATE] documented Resident #45 was unable to conduct a BIMS assessment. The Clinical diagnosis documented in Resident#45's Electronic Health Record (EHR) included vascular dementia. On 6/23/25 at 4:34 PM the family visiting Resident #45 reported the residents usual behavior of walking back and forth with her head down, was usual daily behavior. The family reported wishing there were activities for the residents in the unit. In an interview on 6/25/25 at 4:40 PM Staff H, Activity Staff relayed last year they did have an activity person that concentrated on the memory care unit, but thought that staff left in December and did not get a replacement. Staff F, Registered Nurse acknowledged there is no activity calendar and the CNA in the unit is expected to fit in activities when they have time. Activity Staff H acknowledged CNA staff may not have time. In an interview on 6/25/25 on 4:41 PM The Business Office Manager (BOM)/Provisional Administrator acknowledged there is no activity calendar for the memory care unit, and thought the residents may join in the common area for activities if desired. A facility email on 6/26/25 at 10:42 AM an email relayed the Certified Activity Coordinator is also the Provisional Administrator (also has the role of BOM) . The email relayed Activity Staff H operates under the Administrator/BOM certification. Facility Policy titled Activities, not dated revealed the objective is to provide a stimulating and fulfilling activity program designed to meet resident individual needs, to achieve satisfaction and contentment. The process included to gather information about interest, share information with staff to ensure meaningful activities aligned with interests and needs in individual and group settings. Activities to be planned related to gathered information and encouraged. Staff to document resident participation. The Activity Director will update the calendar of events. Activity assessments will be completed with the comprehensive assessment, quarterly and as needed in accordance with state and federal regulations. Activity interests will be identified in the resident's plan of care and reviewed quarterly.

3. On 6/25/25 at 8:05 AM, observation of Resident #14 revealed the resident was sitting in the dining room with Staff A, LPN (Licensed Practical Nurse), next to her. Staff A fed the resident a bite of oatmeal. Resident #14 said, That's too hot. Staff A responded that it wasn't too hot and tried to give the resident another bite. Resident #14 stated, If you burned your mouth you would think it was too hot too. Resident #14 refused to eat any more of the oatmeal. Based on observation, clinical record review, and staff interview, the facility failed to treat 2 of 5 residents reviewed for dignity with respect by failing to assist a resident to the bathroom when the need was voiced (Residents #14 and #44) and by failing to acknowledge a resident's food temperature preferences (Resident #14). The facility reported a census of 62 residents. Findings: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 5/28/25, listed diagnoses for Resident #44 which included anxiety disorder, severe intellectual disability, and depression. The MDS stated the resident required partial to moderate assistance for toileting hygiene and toileting transfers and listed the resident's Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating severely impaired cognition. 6/15/22 Care Plan entries stated the resident had a behavior problem and was tearful, had verbal outbursts, and laid on the floor crying due to mild intellectual disabilities. The Care Plan entry directed staff to anticipate the resident's needs. A Care Plan entry, revised 3/16/23, stated the resident called for assistance with incontinence episodes when needed. On 6/26/25 at 10:53 a.m., Staff A Licensed Practical Nurse(LPN) stated Staff D Certified Nursing Assistant(CNA) did not get along with Resident #44. She stated she observed the resident tell Staff D that she had to go to the bathroom and Staff D stated to her that it was not time yet and did not assist her. Staff A stated she talked to the Assistant Director of Nursing(ADON) about it. On 6/26/25 at 11:21 a.m., Staff D CNA stated Resident #44 had a lot of behaviors and asked to go to the bathroom multiple times. She stated they assisted her to the toilet multiple times when she did not end up urinating or defecating. Staff D questioned what they should do when they had other residents to assist to the bathroom who did have to go. She stated they had Resident #44 on a two hour schedule and they tried to keep it consistent. She stated there were times when the resident wanted to go to the bathroom and she(Staff D) told her it was not time yet. 2. The Quarterly MDS assessment tool, dated 5/14/25, listed diagnoses for Resident #14 which included Alzheimer's disease, anxiety disorder, and weakness. The MDS stated the resident required substantial to maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her cognition as severely impaired. A 9/13/23 Care Plan entry stated the resident required the assistance of two staff for toileting needs. On 6/24/25 at 11:36 a.m., Resident #14 sat at a dining room table and drank approximately 240 milliliters(ml) of chocolate milk. Staff then provided her another cup of milk and she drank a portion of this as well. At 11:55 a.m., Staff I CNA fed the resident and the resident stated she had to go to the bathroom. Staff J CNA stated to Staff I that it was hard to tell with Resident #14 and told Staff I that if she said she had to go to the bathroom again, then to take her. Staff I did not take the resident to the bathroom and continued to feed her. The resident remained in the dining room until 12:08 p.m. On 6/26/25 at 10:53 a.m., Staff A LPN stated if Resident #14 stated she had to go to the bathroom, staff should take her. On 6/26/25 at 11:21 a.m. Staff D CNA stated if Resident #14 asked to go to the bathroom, she would take her. She stated the resident did urinate in the toilet. On 6/26/25 at 12:19 p.m., The Assistant Director of Nursing(ADON) stated if Resident #14 stated she had to go to the bathroom, staff should assist her. She stated this also applied to Resident #44. She stated she did not hear of anyone not taking Resident #44 to the bathroom when she had to go. On 6/26/25 at 2:23 p.m., via email, the ADON stated the facility did not have a policy related to dignity.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure residents had ready access to their personal funds for 1 of 1 residents reviewed for personal funds(Resident #33). The facility reported a census of 62 residents. Findings include: The Annual Minimum Data Set (MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #33 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS listed the resident's Brief interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 6/24/25 at 10:27 a.m., Resident #33 stated she requested money on Monday(6/23/25) from the Business Office Manager (BOM) but she told her she would not go to the bank until Thursday(6/26/25). On 6/25/25 at 1:10 p.m., the BOM stated she handled resident funds in the facility. She stated she normally went to the bank on Thursday. She stated on Monday, Resident #33 requested money and she told her she couldn't get to the bank until Thursday. On 6/26/25 at 12:19 p.m., the Assistant Director of Nursing (ADON) stated residents should have access to their money and it was her understanding they did. The undated facility policy admission Agreement-Personal Property, stated the facility would hold and safeguard a small amount of money in accordance with State Resident Fund/Trust Account laws and/or facility policies and would provide (money) upon request.

Based on Code Status Form, observation, record review and interview the facility failed to ensure consistent documentation of code status for 1 of 24 resident reviewed for advanced directives (Resident #15). The facility reported a census of 72 residents. Findings include: The Code Status form signed by Resident #15 on [DATE] directed CPR referring to cardiopulmonary resuscitation. The Care Plan initiated [DATE] for Resident #15 lacked code status and did not indicate hospice services. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 on hospice services. Medical diagnoses included heart disease, renal disease, diabetes and dementia. The Brief Interview for Mental Status (BIMS) exam scored 3 out of 15 indicating severe cognitive deficits. The Pocket Care Plan (condensed Care Plan directing resident cares) undated directed CPR. Observation of the Binder (chart) for Resident #15 directed Do Not Resuscitative (DNR) was wrote on the spine of the binder. The Electronic Census record revealed Resident #15 started hospice services on [DATE]. An interview with Assistant Director of Nursing (ADON) on [DATE] at 9:54 AM relayed was not sure if CPR status had changed with start of hospice services and acknowledged the concern with the code discrepancies. The ADON reported she would look into this immediately to ensure residents wishes are followed. A policy on Advance Directives was not available.

Based on clinical record review, observation and staff interviews, the facility failed to ensure staff completed the assessment of residents to accurately reflect their status for 2 of 19 sampled residents (Resident #18 and #12). The facility reported a census of 62 residents. Findings included: 1. The Quarterly Minimum Data Set (MDS) assessments for Resident #18, dated 3/5/25 and 6/4/25, identified a diagnosis of Alzheimer's and an admission date of 12/7/22. The assessment included documentation that the resident was dependent on staff for toileting, bathing, lower body dressing, transfers and substantial or maximum assistance for personal hygiene and rolling in bed from one side to another. The resident used a wheelchair for mobility and did not walk or stand. Her Brief Interview for Mental Status (BIMS) was documented as severely impaired with no assessed score. The same MDS assessment documented the resident did not have a impairment to upper or lower extremities. On 6/25/25 at 8:18 AM, during an interview, Staff F, Registered Nurse (RN), reported she had worked at the facility for 11 years and knew Resident #18 well. Staff F reported Resident #18 did not walk and had impairments to her bilateral lower extremities. Staff F reported the resident was a Hoyer (type of mechanical lift transfer used for dependent residents who were unable to safely stand). Staff F thought the resident had been a Hoyer transfer for the last year. On 6/25/25 at 8:37 AM, during an observation, Staff K, Certified Nurses Aide (CNA), and Staff L, CNA, transferred the resident with a Hoyer lift. The resident was dependent on staff during the transfer and did not move her lower extremities. In an interview during the same observation, Staff K, CNA, reported that staff had been utilizing the Hoyer lift for transfers with Resident #18 for a couple years. Staff K, CNA explained the resident utilized a standing mechanical lift prior to the Hoyer, but became a Hoyer lift transfer when the resident was no longer able to stand. On 6/25/25 at 2:45 PM, during an interview, Staff A, Licensed Practical Nurse (LPN), reported she was the restorative nurse for all of the residents at the facility. Staff A reported Resident #18 participated in both individual and group range of motion (ROM) activities. Staff A reported the resident did not have real good range of motion in the bilateral lower extremities. Staff A further explained she performed passive (resident did not independently move) ROM on Resident #18's bilateral lower extremities. Staff A explained that she was unable to do full range of motion on the lower extremities due to the resident being stiff. Staff A clarified that the resident had limited ROM and limited impairment to the bilateral lower extremities. Staff A reported the resident was admitted to the facility with a limited impairment to the lower extremities and was limited even when the resident used the EZ stand (type of lift where the resident stands with mechanical support. Facility staff inaccurately coded the MDS to indicate Resident #18 did not have an impairment bilaterally to the lower extremities. On 6/26/25 at 1:29 PM, in an email response, the Assistant Director of Nursing reported the facility did not have an MDS assessment policy. 2. The Quarterly MDS dated [DATE] for Resident #12 documented diagnosis of heart disease, diabetes and lung disease. The MDS coded resident used a invasive mechanical ventilator or respirator within the last 14 day look back period. An observation on 6/23/25 2:01 PM Resident #12 did not use a ventilator, room was not set up for a ventilator/respirator. During an interview on 6/25/25 at 2:52 PM the Advanced Registered Nurse Practitioner (ARNP) reported Resident #12 had not been on a ventilator. During an interview with the Assistant Director of Nurses (ADON) on 6/25/25 at 3:01 PM confirmed resident #12 did not require ventilator/respirator while at the facility and the MDS was coded in error.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to assist 1 of 2 residents reviewed for toileting assistance to the bathroom when the need was voiced(Resident #14). The facility reported a census of 62 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/14/25, listed diagnoses for Resident #14 which included Alzheimer's disease, anxiety disorder, and weakness. The MDS stated the resident required substantial to maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her cognition as severely impaired. A 9/13/23 Care Plan entry stated the resident required the assistance of two staff for toileting needs. On 6/24/25 at 11:36 a.m., Resident #14 sat at a dining room table and drank approximately 240 milliliters(ml) of chocolate milk. Staff then provided her another cup of milk, and she drank a portion of this as well. At 11:55 a.m., Staff I Certified Nursing Assistant(CNA) fed the resident and the resident stated she had to go to the bathroom. Staff J CNA stated to Staff I that it was hard to tell with Resident #14 and told Staff I that if she said she had to go to the bathroom again, then to take her. Staff I did not take the resident to the bathroom and continued to feed her. The resident remained in the dining room until 12:08 p.m. On 6/26/25 at 10:53 a.m., Staff A Licensed Practical Nurse(LPN) stated if Resident #14 stated she had to go to the bathroom, staff should take her. On 6/26/25 at 11:21 a.m. Staff D CNA stated if Resident #14 asked to go to the bathroom, she would take her. She stated the resident did urinate in the toilet. On 6/26/25 at 12:19 p.m., The Assistant Director of Nursing(ADON) stated if Resident #14 stated she had to go to the bathroom, staff should assist her. The undated Toileting and Check and Change Policy directed staff to toilet residents before and after meals and as needed throughout the day.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure 1 of 1 resident reviewed for pain received treatment and care related to pain management(Resident #14). The facility reported a census of 62 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/14/25, listed diagnoses for Resident #14 which included Alzheimer's disease, anxiety disorder, and weakness. The MDS stated the resident was on scheduled pain medication and had no indicators of pain such as vocal complains or non-verbal sounds. The MDS listed her cognition as severely impaired. On 6/24/25 at 8:11 a.m., Resident #14 stated I hurt multiple times throughout out breakfast. Multiple staff were present in the dining room including Staff A Licensed Practical Nurse(LPN). On 6/24/25 at 11:55 a.m., Staff I Certified Nursing Assistant(CNA) fed the resident and Staff J CNA sat with another resident. The resident stated she hurt. Care Plan entries, dated 2/10/20, stated the resident reported frequent pain and discomfort to her right hip and utilized scheduled pain medications/ The entries directed staff to attempt three non-pharmacological pain interventions prior to the initiation of as needed(prn) pain medications, administer medications as ordered, and evaluate the effectiveness of pain interventions. The June 2025 Medication Sheet listed an 8/25/23 order for Acetaminophen(a non-narcotic pain medication) 2 tablets every 6 hours as needed. The record lacked documentation staff administered the medication on 6/24/25. The resident's clinical record lacked documentation of interventions carried out on 6/24/25 aimed at relieving the resident's pain and lacked documentation of an assessment of the resident's pain. On 6/25/25 at 3:11 p.m., Staff F Registered Nurse(RN) stated if a resident had pain she would like the aides to let her know and they could administer something like Tylenol(acetaminophen) or use a muscle rub. On 6/26/25 at 12:19 p.m., The Assistant Director of Nursing(ADON) stated if Resident #14 complained that her head hurt, staff should respond and offer her Tylenol. The undated facility policy Pain Assessment stated the facility would assure that residents were thoroughly assessed for pain and as comfortable as possible. The policy directed staff to carry out interventions to alleviate pain and discomfort.

Based on clinical record review, resident/family interview and staff interview, the facility failed to ensure residents who were trauma survivors received trauma-informed care to eliminate or mitigate triggers that might have caused re-traumatization of the resident for 2 of 2 sampled residents (Resident #1 and #34) identified by either record review or interview as being a trauma survivor. The facility reported a census of 62 residents. Findings included: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #1, dated 5/7/25, revealed the resident was admitted [DATE], scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition, had diagnoses of non traumatic brain dysfunction, heart failure, bipolar disorder, asthma and Post Traumatic Stress Disorder (PTSD). Review of the current Care Plan for Resident #1, last revised on 2/20/25, revealed the resident took anti-anxiety and antidepressant medications and was care planned for potential in alterations in psychosocial well-being related depression and anxiety. The Care Plan included non-pharmacological interventions to provide 1:1 reassurance when the resident felt anxious or down and to allow the resident time to answer questions and to verbalize feelings perceptions, and fears. The Care Plan failed to identify the resident was a trauma surveyor and address the resident's PTSD, triggers and interventions. On 06/23/25 at 03:03 PM, Resident #1 reported she had not been invited to attend a care plan meeting since her admit to the facility. On 6/25/25 at 2:50 PM, Resident #1 reported having abandonment and trust issues related to their PTSD. PTSD episodes were triggered when the resident was upset or felt unsafe. The resident reported having had symptoms of nightmares about past trauma and becoming withdrawn when her PTSD was triggered. On 06/25/25 at 12:18 PM, the Assistant Director of Nursing (ADON) reported she had not realized Resident #1 had PTSD and was a trauma survivor until this week when she saw the trigger on the facility matrix (form that included MDS assessment trigger information for residents). The ADON confirmed they had not included trauma-informed care goals or interventions in the care plan. On 06/26/25 at 8:28 AM, Staff N, CNA, reported she worked days and was familiar with Resident #1. She reported not knowing much about the resident being a trauma survivor. On 6/26/25 at 8:33 AM, Staff F, Registered Nurse (RN), reported she would identify trauma survivors by reading through the admission notes and looking for related diagnoses such as PTSD. Staff F was aware of 2 residents that were trauma survivors, and named Resident #34. Staff F was unaware of Resident #1 being a trauma survivor and reported she had not seen Resident #1 display any mental health issues. On 6/26/25 at 8:42 AM, the Activity Director reported that she relied on the ADON to let her know if a resident was a trauma survivor. The Activity Director explained that if she was aware a resident was a trauma survivor, then she would avoid saying anything that would trigger the resident. The Activity Director was unaware that Resident #1 and Resident #34 were trauma survivors. On 6/26/25 at 11:04 AM, during an interview, Staff A, Licensed Practical Nurse (LPN), confirmed she was the acting social worker for the facility. Staff A reported if a resident was a trauma survivor she would talk with the Medical Director about getting the resident set up with mental health services. Staff A explained that she would talk with the ADON about care planning at the time the resident was admitted . Staff A reported being aware that Resident #34 was a trauma survivor due to talking with the resident's family. Staff A was unaware that Resident #1 was a trauma survivor. Staff A confirmed that she was responsible for completing the BIMS and mood assessments quarterly for Resident #1. Staff A described Resident #1 as a troublemaker and reported the resident had never expressed being traumatized. On 6/26/25 at 2:08 PM, the facility's Advanced Registered Nurse Practitioner (ARNP) reported the main mental health issue for Resident #1 was her PTSD.

Based on clinical record review, policy review, resident/family interview and staff interview, the facility failed to ensure they had sufficient nursing staff to meet the needs of the residents for 3 of 19 sampled residents (Resident #1, #13, and #50). The facility reported a census of 62 residents. Findings included: 1. The MDS assessment for Resident #1, dated 5/7/25, revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition, had diagnoses of non traumatic brain dysfunction, heart failure, bipolar disorder, asthma and Post Traumatic Stress Disorder. The MDS assessment identified the resident required partial to moderate assistance with bathing and personal hygiene. On 6/23/25 at 2:10 PM , Resident #1 explained that the facility had two CNAs working per hall, but there was not enough staff to meet the needs of the residents. Resident #1 reported the facility was always short, but mainly at meals and bath times. Resident #1 reported her shower days were Sundays and Wednesdays. Resident #1 reported that she did not always get her showers two times per week. Resident #1 explained that sometimes the staff were not getting to her shower until 10:00 PM. Resident #1 expressed that this time of night was too late, and she didn't want wet hair at 10:00 at night, so she would refuse her showers at times due to the lateness. Observation of during the interview, revealed the resident to have unkempt hair with a greasy, unwashed appearance. Review of the facility bathing record, titled Resident Cares, for Resident #1, dated February 2025, revealed the resident refused showers on 2/5/25 and 2/16/25 on the 2:00 PM to 10:00 PM shifts. On 2/16/25, Staff C, Certified Nurses Aide (CNA), documented the resident refused the shower and said too late. Review of the facility bathing records, titled Resident Cares, for Resident #1, dated March 2025 through June 2025, revealed the resident refused showers on the 2:00 PM shift to 10:00 PM shift on 3/2/25 and 4/6/25, and refused a shower on the 10:00 PM to 6:00 AM shift on 6/22/25. On 6/24/25 at 3:34 PM, Staff C, CNA, reported she was working 3rd shift (6:00 PM to 6:00 AM) until a couple months ago. Staff C reported Resident #1 normally received her shower on second shift and liked a shower anytime after supper, but before 9:00 PM. Staff C explained that by the time the CNAs got all of the residents out of dining room, the couldn't get to Resident #1's shower until 10:00 PM or 10:30 PM, depending on the night. Staff C reported a couple times they did not enough staff to get all of the residents' showers done. Staff C confirmed Resident #1 had refused a shower a few times due to the lateness. 4. The Payroll Based Journal(PBJ) Staffing Data Report stated the facility triggered for excessively low weekend staffing for the period of 1/1/25 to 3/31/25. The Facility Assessment Tool, updated 5/16/25, stated the facility staffed 4-7 Certified Nursing Assistants(CNAs) on the 1st shift and 4-6 CNAs on the 2nd shift. On 6/26/25 at 8:27 a.m. via phone, Staff G CNA stated on the weekends there was absolutely not enough staff to take care of everyone. She stated sometimes they ran with 2-3 CNAs and stated they sometimes had to complete resident showers as late as 10:00 p.m. On 6/26/25 at 12:19 p.m., The Assistant Director of Nursing(ADON) stated staffing was not good in the last five years. She stated she expected staff to respond to call lights within 15 minutes. The undated facility policy Call Light directed staff to respond to call lights to rule out an emergency situations. 3. The Minimum Data Set (MDS), dated [DATE], revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Diagnoses included Heart Failure, End Stage Renal Disease (ESRD), Diabetes Mellitus, anxiety disorder, depression, history of malignant neoplasm of bronchus and lung, and history of urinary tract infections. The Care Plan, revised on 6/23/25, revealed Resident #50 had an Activities of Daily Living self-care performance deficit and required extensive assistance of 2 staff for toilet use, transferring, and bed mobility. On 6/24/25 at 10:50 AM, Resident #50 reported it can take an hour for staff to answer her call light when pressed, and identified a digital clock on dresser in which she notes the wait time. Resident #50 stated on 6/23/25 evening she waited an hour and a half to use the restroom when staff told her they would return soon. Resident #50 explained that wait times are longest after an evening meal, when requesting assistance to go to bed. The Care Plan, revised 6/23/25, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #13 frequently had bladder incontinence, required toileting assistance approximately every two hours, and extensive assistance of one staff to transfer between surfaces. The Care Plan listed an intervention to encourage Resident #13 to use the call bell for staff assistance. On 6/23/25 at 1:30 PM, Resident #13 reported frequently waiting up to an hour for help after pressing the call light. Resident #13 stated she would watch a digital clock on the night stand when in the bathroom and a 2nd hand clock on the wall in front of the recliner to monitor for staff response time. Resident #13 stated that recently, unable to recall the date, she waited on the toilet for an hour and four minutes.

2. On 6/26/25 at 11:24 AM, Staff B, Registered Nurse (RN), removed Furosemide and Tramadol from the medication cart and put the medications in a cup with applesauce. Staff B approached Resident #5 with the medications, fed the resident the medications with a bite of applesauce. Staff B then touched the resident's shoulder and returned to the medication cart. Staff B threw away the used medication cup, charted, flipped between the residents' Medication Administration Records (MARs), put applesauce in a cup, opened the medication cart with the keys, removed a medication cassette with Acetaminophen from the cart, dropped two tabs in the cup with applesauce, returned the cassette to the medication cart and locked the cart. Staff B then approached Resident #26, touched the resident's wheelchair on the hand hold area, touched the resident's arm, and fed the resident a bite of applesauce with the medication. Staff B returned to the medication cart, threw away the used medication cup and charted. Staff B flipped through the residents' MARs. Staff B then approached Resident #8 about administering scheduled medications, but the resident refused. Staff B returned to the medication cart, flipped through the residents' MARs and reported that she had no further medications to give until 12:00 PM. Staff B walked away from the medication cart. Staff B failed to perform hand hygiene, either hand washing or an alcohol based hand rub, between residents. An undated facility policy, titled Subcutaneous Injections, included instructions for nursing staff to swab the rubber stopper of the insulin medicine container with an alcohol sponge prior to inserting the syringe in the rubber stopper. An undated facility policy, titled Hand Washing, included instructions for staff to thoroughly wash their hands before and after providing resident care. Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to sanitize the rubber stopper of a multiple-use insulin vial when insulin injection was prepared and administered (Resident #50) and further failed to perform hand hygiene before preparing and between administration of oral medications to multiple residents (Resident #5, #8, and #26) for infection prevention during 2 of 2 medication administration times observed. The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) Assessment, dated 6/05/25, revealed Resident #50 had a diagnosis of Diabetes Mellitus and required insulin injections for 7 of the 7 days review period. The Care Plan, revised on 6/23/25, revealed Resident #50 had diagnosis of Diabetes Mellitus and lacked focus area, goals, or interventions for care needs related to Diabetes Mellitus diagnosis. The June 2025 Medication Administration Record (MAR), revealed an order, initiated on 5/20/25, for Novolog Injection 100 units per milliliter (mL), with instructions to inject 25 units subcutaneously three times a day with meals. On 6/25/25 at 11:20 AM, Staff F, Registered Nurse (RN) removed Resident #50's opened vial of Novolog insulin and a packaged insulin syringe from the medication cart. The insulin syringe was removed from packaging and inserted directly into the rubber stopper of Resident #50's Novolog vial. Staff F removed 25 units of insulin from Novolog vial into the syringe and re-sheathed the needle. When queried, Staff F denied sanitizing the stopper of the vial with alcohol wipe to remove potential pathogens before inserting the syringe into the vial. Staff F proceeded to enter Resident #50's room and administered Novolog insulin injection subcutaneously into the resident's right lower quadrant abdomen. On 6/25/25 at 4:18 PM, the Assistant Director of Nursing (ADON), revealed the expectation of nursing staff to sanitize the rubber of an insulin vial when preparing an insulin syringe for infection prevention. The undated facility policy, titled Subcutaneous Injection, revealed procedure step #9, which instructed staff to swab the rubber stopper of the medication container with an alcohol sponge, prior to inserting the needle into the container.

Based on record review, staff interviews, and policy review the facility failed to develop and implement a comprehensive care plan for 2 of 2 residents reviewed (Resident #50 and Resident #54). The facility reported a census of 55 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #50, dated 11/3/23, documented diagnoses of schizophrenia, history of falling, and moderate intellectual disabilities. The MDS identified a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The electronic health record lacked of a comprehensive care plan. An interview with the ADON on 12/6/23 confirmed the care plans had not been developed. She stated they knew it would be an issue and they are working on it. An undated policy titled Comprehensive Resident Plan of Care documented a comprehensive plan of care would be developed for each resident that included measurable objectives and time frames to meet resident medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. 48888 2. The Minimum Data Set (MDS) assessment, dated 10/08/23, revealed Resident #54 diagnoses included: Congestive Heart Failure, anemia, Diabetes Mellitus, anxiety disorder, bipolar disorder, and Schizophrenia. The MDS indicated Resident #54 had disorganized thinking, trouble sleeping, and feeling down or depressed nearly every day of reference period. Resident #54 required the following types of medications: antipsychotic, insulin, and diuretic, on a daily basis. The Baseline Care Plan, dated 10/03/23 for an admitted [DATE], revealed Resident #54 required 1500 milliliter (mL) per day fluid restriction and diabetic ulcer wound care upon admission. On 12/06/23 at 02:00 PM Assistant Director of Nursing (ADON), revealed she was responsible for Care Plans and stated if a Care Plan was not in a resident's Electronic Health Record (EHR), it had not been done. ADON confirmed Resident #54 did not have a Care Plan in place since admission.

Based on record review and staff interviews, the facility failed to implement and monitor an effective screening process for staff and visitors to prevent a Coronavirus Disease 2019 (COVID-19) outbreak for 56 of 74 residents. The lack of effective screening resulted in a staff member being able to work while knowingly ill and failing to report it. The spread of COVID-19, once introduced to the facility, was rampant, and resulted in 9 deaths. The facility reported a census of 68. Findings include: During an interview on 5/29/20 at 11:01 a.m., the Director of Nurses (DON) stated on 3/13/20 they received guidance from the Center for Disease Control and Prevention (CDC) which included an emphasis on keeping COVID-19 out of the facility. As a part of that effort, the CDC recommended restricting visitors and implementing a screening process for anyone entering the facility, including all staff. The DON stated that same day all staff were provided training and education on the screening process which included one entry into the building with a screening area at that entry. Staff were to wash or sanitize their hands upon entering, then review a series of questions related to whether they were having any signs or symptoms of COVID-19 and whether they had worked in other facilities or locations with recognized COVID-19 cases. Based on having any active symptoms or an elevated temperature, staff were to be restricted from entering the facility. The DON stated it was made clear to ALL staff that if they were ill, they were to stay home. The DON stated staff were permitted to self-screen and they did not have anyone at the entry monitoring staff as they arrived. According to the American Health Care Association (AHCA) screening form used by the facility, ALL individuals (staff, other health care workers, family, visitors, government officials, etc.) entering the building must be asked the following questions: 1. Has the individual washed their hands or used alcohol-based hand rub (ABHR) on entry? 2. Ask the individual if they have any of the following respiratory symptoms? Cough, shortness of breath or at least two of these symptoms: Fever, repeated shaking with chills, headache, new loss of taste or smell, diarrhea, chills, muscle pain, sore throat, vomiting. If yes to any, restrict them from entering the building. 3A. Check temperature and document results. Fever present? If yes, restrict from entering the building. 3B. Ask if they have worked in facilities or locations with recognized COVID-19? If yes, ask if they have worked with persons with confirmed COVID-19? If yes, require them to wear personal protective equipment (PPE) including mask, gloves, gown before any contact with residents. 4. Allow entry into the building and remind the individual to: Wash their hands or use ABHR throughout their time in the building. Not shake hands with, touch or hug individuals during their visit. During an interview on 5/27/20 at 9:30 a.m., the Administrator at Facility #2 (Admin 2) stated Staff A worked Facility #2 every other weekend, Friday through Sunday. On 4/24/20, Staff A called in sick at Facility #2 due to a fever. Admin 2 explained to Staff A that she would be restricted from working for 10 days and need to be free of symptoms 72 hours before returning to work. During an interview on 5/26/20 at 1:30 p.m., the Assistant Director of Nurses (ADON) stated on 5/10/20 she received a call from the Administrator at Facility #2 (Admin 2). Admin #2 asked if Staff A worked at Facility #1. Admin 2 stated Staff A, who also worked at Facility #2 had a COVID-19 test on 5/9/20. The ADON reported Staff A had not worked at Facility #1 since 5/4/20 and had not disclosed that she was working at Facility #2. The ADON reported Staff A arrived to a scheduled shift at Facility #1 on 5/11/20. Staff A completed the screening tool and planned to work. The ADON approached Staff A, at the door, and sent her home. On 5/12/20, the COVID-19 test for Staff A returned as confirmed positive. That same day three other staff called in ill, had a COVID-19 test and had confirmed positive results for COVID-19. On 5/15/20, 6 residents developed symptoms. All 6 residents had a test and had confirmed positive results for COVID-19. By 5/20/20, all residents and staff were tested for COVID-19, 49 residents and 13 staff had confirmed positive results for COVID-19. The ADON stated Staff A worked shifts at Facility #1 on 4/24/20, 4/27/20, 4/29/27, 4/30/20, 5/1/20, 5/2/20, 5/3/20 and 5/4/20. Review of screening sign in sheets revealed Staff A indicated she had no symptoms or temperature on 4/24/20, 4/27/20, 4/29/20, 4/30/20, 5/1/20, 5/2/20, 5/3/20 or 5/4/20. During an interview on 6/4/20 at 10:20 a.m., Staff A (Certified Nurse Aide) stated she first started having symptoms, feeling feverish, headaches and weakness on 5/4/20. Staff A stated she had been feeling ill, but felt fine when she arrived to work that day at 2:00 p.m. At 3:30 p.m. Staff A stated she began having a headache, but not unusual for her. She spoke with the Charge Nurse and was given some Tylenol and told her she should get checked out. Staff A stated she finished her shift and over the next several days she was noticeably sick. Staff A stated she was finally tested for COVID-19 on 5/9/20 and was not feeling well, but went to work at Facility #1 on 5/11/20 because she didn't want to call off. Staff A stated she filled out the screening form and didn't have a temperature and at that moment didn't have any symptoms. The ADON met her at the door and they went outside where Staff A was questioned about coming to work after just being tested for COVID-19. Staff A stated she admitted to the ADON that she felt cold and sick. Staff A was then asked about calling into work sick Facility #2 on 4/24/20. Staff A stated she woke up that morning vomiting, with a headache and fever. Staff A stated she called in sick at Facility #2, but didn't remember going into work at Facility #1. Staff A stated she text the Administrator at Facility #2 on 4/25/20 and informed him/her she couldn't work that weekend. Staff A stated she felt fine by Monday, 4/27/20. On 6/1/20 at 3:32 p.m., the State Agency notified the facility of the Immediate Jeopardy. On 6/1/20, the facility abated the Immediate Jeopardy. The facility educated staff on the proper use of the thermometer and implemented a staff person on post to ensure proper screening of staff prior to entering the facility.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 6 residents reviewed. The sample consisted of 6 residents and the facility reported a census of 72 residents. Findings include: Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 10/17/2016. The MDS identified the resident scored an 11 on the BIMS (Brief Interview for Mental Status) test. A score of 11 represented the resident had a moderate cognitive impairment. The MDS indicated the resident required the extensive assistance of two staff members for transfers, dressing, personal hygiene, bathing and toileting. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off toilet, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had one fall with no injury since the prior assessment. Review of the Fall Risk Evaluation, dated 10/15/16 identified the resident scored a total score of 12 which indicated the resident should be considered at high risk for falls. The Resident Care Plan, dated as initiated on 11/15/13 and updated on 8/1/16 identified a potential for injury due to depression, arthritis, intellectual disabilities and diabetes, history of falls, with a goal dated through 11/16 that the resident would not fall and hurt self. The interventions directed the staff the resident required extensive assistance of 2 persons for transfers. The Resident Care Plan identified an actual nursing problem, self-care deficit as evidenced by receiving extensive assistance of 2 staff members with dressing, toileting, and bathing. The goal indicated the resident would help with cares as much as can and directed extensive assist of 2 staff for dressing. On 11/1/16 at 2:35 p.m. the Director of Nursing (DON) provided and identified a document as the Pocket Care Plan effective on 10/19/16. The Pocket Care Plan directed the staff to transfer the resident to the assistance of 2 staff members. The DON clarified all staff are expected to carry and refer to the Pocket Care Plan. A fall incident report dated 10/19 at 5:30 p.m. identified the resident was lowered to the floor during a transfer. Staff B, licensed practical nurse (LPN) assessed the resident and identified no injury, and notified the provider and the family. Review of Focus Nursing Notes revealed on 10/19/16 at 5:30 p.m. Staff B, LPN documented called to the resident ' s room. The Certified Nurse Aide (CNA) reported the resident was lowered to floor during a transfer. The resident complained of right knee discomfort, no redness or swelling noted, range of movement normal. Further review of the Focus Nursing Notes indicated on10/20/16 at 1:30 a.m. Staff C, Registered Nurse (RN) documented the resident screamed in bed, complained of right lower extremity pain. The nurse notified the physician and ordered the resident transferred via ambulance to the emergency room . Review of a Radiology Preliminary Report dated 10/20/16 at 2:12 a.m. documented the reason for the exam was pain on the right side. The report reflected four views of the right knee demonstrated an acute spiral fracture involving the distal right femur. An Operative Report dated 10/20/16 reflected the resident underwent [REDACTED]. The resident was admitted to the hospital until admission orders [REDACTED]. On 11/1/16 at 11:00 a.m. Staff D, CNA was interviewed and stated he was 1 of the 2 CNA ' s assigned to care for residents on that hall on the date of the fall. Staff D stated the Care Plan directed two staff person assistance for transfer. Staff D had left the resident ' s room but was coming back to assist Staff A with the transfer. Staff D, stated it would be unsafe to transfer Resident #1 with one person. Staff D stated he carries a cheat sheet (Pocket Care Plan). During an interview on 11/1/16 at 12:10 p.m. Staff A, certified nursing assistant (CNA), stated on 10/19/16 getting the resident dressed and ready for supper. Staff A, CNA acknowledged that she made a mistake, the resident is a two person assist and she tried to stand her with one person. Clarified that she was not trying to transfer the resident, stated when stood the resident to pull pants up, they lost footing and the resident went down on right knee. Staff A described the resident ' s right leg as bent back and the resident was screaming. Staff A stated that she straightened the leg out. Staff A, CNA stated she is a new CNA and could not recall if had the Pocket Care Plan, typically does carry. Staff A stated she had hot been instructed to carry the pocket care plan, but knows now that she has to have one at all times In an interview on 11/1/16 at 2:35 p.m. the Director of Nursing, DON confirmed the Care Plan had not been followed. On the date of the fall, the Care Plan directed assistance of two staff for dressing and transfer. The DON stated the expectation is for staff to carry a pocket care plan and to follow the Care Plan directives. In an interview on 11/8/16 at 12:40 p.m. the Administrator confirmed expectation that staff carry an updated Pocket Care Plan. The Administrator further clarified if the Pocket Care Plan directed 2 assist that 2 staff would have assisted the resident to stand and transfer.

Based on record review, staff interviews and review of facility policy/procedures, the facility failed to assess and provide interventions to promote healing for an onset of skin problem areas (Resident #2). The facility identified a census of 69 residents. Findings include: 1. Resident #2 had an MDS (Minimum Data Set) with a reference date of 6/4/12 which identified a BIMS (Brief Interview for Mental Status) score of 8. A score of 8-12 identified moderate impairment of interview for mental status (BIMS) score of "8" (moderate cognitive impairment). The resident required extensive staff assistance with transfers, toileting, dressing, personal hygiene, bathing and experienced frequent bladder and bowel incontinence. On 7/10/12 at 2:22 p.m. observation revealed the resident in bed grabbing at the perineal area. The resident voiced " It hurts " . At 3:38 p.m. (on the same day) observation revealed the resident's perineal area, inner thighs and buttocks very red and slightly swollen. At that time Staff J commented the red areas look like it hurts. The staff notified the charge nurse who arrived and applied [MEDICATION NAME] (barrier) to the buttocks and [MEDICATION NAME] (antifungal cream) to the perineal area. Review of the resident's record did not identify the staff assessed the areas. A Record review revealed a lack of skin sheets available for Resident #2 with information identifying the red areas. Review of the resident's July Treatment Administration Record (TAR) identified an order for [REDACTED]. Staff applied [MEDICATION NAME] twice per day on 7/5/12, 7/6/12 and 7/9/12. The resident had an order for [REDACTED]. Review of the focus nursing notes documented the following information: On 5/3/12 at 9 p.m. labia red/tender and [MEDICATION NAME] applied. On 5/5/12 at 6 p.m. to 6 a.m. charting buttocks sore. On 5/6/12 at 8:45 p.m. [MEDICATION NAME] to inner thighs as areas are reddened. On 5/16/12 at 10 p.m. [MEDICATION NAME] applied to pink buttocks. On 5/17/12 at 8 p.m. [MEDICATION NAME] applied to abdominal folds, mons and labia. Areas red. On 5/18/12 at 9 p.m. [MEDICATION NAME] applied to red buttocks and periarea. [MEDICATION NAME] applied to abdominal fold. On 5/19/12 at 9 p.m. [MEDICATION NAME] applied to buttocks light red. On 5/26/12 at 3 a.m. [MEDICATION NAME] applied to buttocks with no open areas. [MEDICATION NAME] applied to periarea Reddened at this time. On 5/27/12 at 9 p.m. [MEDICATION NAME] applied to reddened buttocks and [MEDICATION NAME] applied to reddened periarea. On 5/28/12 at 9 p.m. [MEDICATION NAME] applied to buttocks. Area is reddened with no open areas. The record contained no further documentation regarding red areas and there were no skin sheets for this period of time until 7/11/12 (the day after the surveyor initially observed extreme redness). Review of June 2012 TARs identified staff intermittently continued to apply [MEDICATION NAME] and [MEDICATION NAME] to the resident without any further assessment of the skin until 7/11/12, the day after the surveyor observed it. Non-pressure skin condition reports dated 7/11/12 measured the right buttock red area as 15 centimeters (cm.) by 4 c.m., left periarea red area measured 9 cm. by 6 cm., the right periarea red area measured 7 cm. by 6 cm., under right breast red area measured 6.5 cm. by 4 cm. and left buttock measured 0.9 cm. by 0.3 cm red. Observation revealed on 7/11/12 at 9:15 a.m., the resident sitting up in a wheelchair. At that time the resident told the surveyor, "My butt ' s pretty sore yet". On 7/11/12 at 4:15 p.m. Staff Q (nurse aide) stated she provided care to the resident on 7/8/12 and the resident was red. Staff Q stated it looks better today. Staff Q stated she washed the resident and she applied the periguard and the nurses apply the ointment. The follow up measurements of the red areas identified an increase in size to the right buttock. On 7/18/12 the area measured 15 cm. by 6 cm. The left periarea increased in size and measured 10 cm. by 7 cm. on 7/18/12. The area under the right breast increased in size on 7/18/12 and measured 8 cm. by 3 cm. On 7/25/12 at 3:13 p.m. Staff C (acting Director of Nursing) stated the facility did not notify the physician of the red areas or the increased size of the red areas because the resident already has PRN ointments for the staff to apply. A "skin assessments" policy indicated if staff noted any red areas the charge nurse should assess the area and fill out a skin sheet. If treatment is needed, staff will notify the physician. Staff follows up with weekly assessments and charting on TARs for treatments done.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazard from self and elements in the environment and the written health care plan failed to reassess and plan individualized care to be given when Resident #22 continued and was known to unclip a personal alarm. The facility identified a census of 69 residents. The sample consisted of 4 residents with injury from falls. On 6/25/12 Resident #22 fell without injury in the dining room after multiple occasions of removing the alarm. On 7/13/12, the resident sat in the dining room, restless and removing the clip alarm which staff reapplied. The resident ultimately removed the clip alarm and fell fracturing a hip. The facility failed to provide increased supervision knowing the resident was restless and had removed the clip alarm, which was reapplied. The resident had a history of [REDACTED]. Findings include: 1. Resident #22 had a Minimum Data Set (MDS) assessment with a reference date of 5/11/12 which identified the resident with a BIMS (Brief Interview Mental Status) score of 3. A score of 3 revealed the resident had a severely impaired cognitive status. The resident had delirium with inattention present and disorganized thinking. The MDS reflected the resident required extensive staff assistance with transfers, toileting, personal hygiene, bathing and nonambulatory. The MDS identified the resident as unsteady and only able to stabilize with staff assistance when moving from seated to standing, walking, moving on and off toilet and surface to surface transfers. The MDS did not identify prior falls since the previous assessment. The Care Area Assessment (CAA) dated 5/21/12, documented the resident had a history of [REDACTED]. The resident had long and short term memory loss with decreased safety awareness. The resident used a personal alarm and bed alarm. The resident's fall risk assessment score was 17 (high risk for falls) and the resident transferred with extensive assistance of 2 people. The resident could not stabilize self during balance testing without staff assistance. The resident used a low bed with mat next to the bed. The care plan dated 5/21/2012 identified a potential for injury. The plan of care identified a fall prior to admit which resulted in a right hip fracture and the resident having short and long term memory problems. The interventions included a seat belt to the wheelchair with a drop seat on 6/4/2012 and personal safety alarm, bed alarm (10/14/2011). History of falls per fall assessment and investigation: On 1/3/12 at 1 p.m. staff observed the resident sitting on the floor in front of the resident's bed. An investigation of the fall identified the resident's alarm did not sound when the fall occurred. The investigation did not identify why the alarm did not sound. The intervention after the fall was: Low bed with mat next to bed. On 5/14/12 at 8:30 p.m. staff observed the resident on the floor in the room. The investigation identified the resident's alarm did not sound due to the resident unhooking the alarm from his/her shirt. The intervention after the fall was: Staff educated to have resident in supervised activities and put to bed around 8 p.m. Resident stated that is when he/she likes to lay down in bed. The investigation and care plan did not identify the facility changed alarms or altered where staff placed the alarm clip so it would be more difficult for the resident to reach. On 6/3/12 at 7 p.m. staff observed the resident on the floor of the activity room. The resident's alarm sounded when the fall occurred. The intervention after the fall was: Seatbelt On 6/25/12 at 12:40 p.m. staff observed the resident on floor in the dining room with the alarm disconnected. The resident stated he/she hit head but staff did not identify injury. Focus nursing notes dated 6/25/12 at 12:35 p.m. documented the staff noted the resident to disconnect the clip alarm multiple times. Staff educated the resident on the importance of leaving the alarm on (resident has short term memory problems). At 12:40 p.m. staff heard a "thud" and observed the resident lying on the floor with the alarm disconnected. The intervention after the fall was: Assist resident to toilet or rest following meals. The investigation and care plan did not identify the facility changed alarms or altered where staff placed the alarm clip so it would be more difficult for the resident to reach. Or that the facility reevaluated the risks of the resident in a regular dining room chair with just the clip alarm that the resident could remove, when normally the resident sat in a wheelchair with a seatbelt and a clip alarm. A toileting policy in place since 2010 identified the staff will toilet residents upon arising, before and after meals and during rounds through the night. On 7/25/12 at 11 a.m. the Administrator stated the toileting intervention was already in place when the facility identified it as a new intervention, but resting after meals would be a new intervention. On 7/7/12 at 6:15 a.m. staff observed the resident on the floor at bedside. The alarm sounded. Focus nursing notes of the same date, identified the resident complained of hip pain and transported to the emergency room for evaluation. X-rays did not identify a fracture and the resident returned to the facility at 9:30 a.m. The intervention following the fall was" Staff educated to check resident between 5:45 a.m. and 6 a.m. to see if ready to get up". On 7/13/12 at 12:15 p.m. the resident stood up from a dining room chair in the dining room after previously removing alarm clip from shirt. The resident removed the clip alarm several times and staff replaced it prior to the fall. After the fall, the resident complained of severe pain. The resident was transported to the hospital emergency room and x-rays identified a fracture. A major injury determination form, dated 7/17/12 at 10:30 a.m. identified the physician documented the resident's fracture was not a major injury. A hospital consultation report dated 7/13/12 indicated the resident arrived at the hospital after a recent fall at Crystal Heights Care Center. The resident complained of significant pain in the left hip. The x-rays identified a left intertrochanteric hip fracture. The report indicated the resident would benefit from surgical repair of the left hip and, until surgery, the hospital kept the resident in 5 pounds of Bucks traction, bed rest and ice applied to the hip. A radiology report dated 7/13/12 identified an acute comminuted fracture involving the left femoral intertrochanteric region. Staff Interviews: On 7/25/12 at 2:25 p.m., Staff F (Registered Nurse) stated she was in the other dining room when Staff P (Nurse Aide) came to her and said the resident fell . Staff G (Licensed Practical Nurse) told Staff F the resident stood up and took a step to the left while in the dining room. Staff F checked the resident's legs and hips and the resident complained of pain. Staff F called the ambulance and the facility then transported the resident to the emergency room for an evaluation. Staff F identified the resident's son as angry about the resident's fall and asked why the staff did not have the resident tied down. Staff F explained the resident sat in a regular chair in the dining room so the resident did not have the wheelchair seatbelt in place. Staff F identified staff seated the resident in the dining room chair so the resident could not leave the dining room. Staff F stated the resident self-removed the alarm 2 to 3 times and staff reapplied it, before the resident removed the alarm again and got up from the dining room chair and fell . When asked what could have prevented the fall, Staff F stated if staff could have kept the resident in the wheelchair the fall most likely would not have occurred. When asked if she thought the alarm sounding could have prevented the fall, Staff F stated she did not know if staff could have gotten there that quickly and she was not present. On 7/25/12 at 12:20 p.m., Staff CC (dietary) stated the resident almost fell twice that day. The first time the resident dropped silver ware and bent to pick it up. The nurses got to him/her before the resident fell . The second time the resident still sat at the table and dietary was through serving. Staff CC stood about 5 feet away and didn't see the resident get up. When Staff CC saw the resident, the resident was already in the act of falling. On 7/25/12 at 10:42 a.m. Staff G (Licensed Practical Nurse) stated the resident sat in a regular dining room chair in the assisted dining room. Staff G was 25 feet away doing intakes because the residents finished their meals and staffs were transporting residents back to their rooms. The resident stood up and stepped over to the left and fell down. The resident hit his/her bottom and then the back of his/her head on the floor. Several staff rushed to the resident. One of the staff, Staff E (Nursing Assistant) rushed to the resident. Staff G stated the resident used an alarm and had one on but the resident can be very good at removing it. Staff replaced the alarm at least 5 times during lunch. When staff placed it back on the resident, he/she would say, "I just don't want that". Staff G stated she was sure the resident removed the alarm at different times in the past as well as on 7/13/12. The resident also utilized a seat belt when in the wheelchair but staff places the resident in a regular dining room chair for meals so the resident doesn't wheel away from the table so the seatbelt is not on at meals. At the meal, the resident only used a clip alarm with the box to the alarm kept in a bag on the dining room chair. Staff G stated the incident occurred very quickly and even if an alarm sounded she did not know if staff could have gotten there in time. On 7/25/12 at 1:30 p.m. Staff E (Nursing Assistant) stated he was not there when the resident fell . He stated the resident takes the clip alarm off "a lot". He identified the resident as "jumpy" during the meal because staff walked the resident and the resident was still excited about walking. On 7/25/12 at 12:52 p.m. Staff H (Nursing Assistant) stated she thought the resident finished eating and then the fall occurred. Staff H stated the resident always takes the clip off and tries to get up. Staff H stated, "I wish I had his/her energy". Staff H stated she knew of the resident removing the alarm in the activity room and also in the dining room before. On 7/25/12 at 11:04 a.m. Staff P (Nursing Assistant) stated she took a resident from the dining room and as she came back up the slope to the dining area she looked and saw the resident standing. Staff P yelled for Staff R (Nursing Assistant) who sat at the table beside Resident #22 and by the time Staff P spoke the resident ' s name, the resident started falling back. When asked if a functioning alarm would have made a difference, Staff P stated she thought if the alarm sounded it would have alerted Staff R and she could have "been there". Staff P stated the resident removed the clip four or five times the day of the incident. Staff P stated now they do not remove the resident from the wheelchair and the resident uses a tray on the wheelchair. Staff P stated the resident removed the alarm many times before the day of the incident and "really needs to be watched". On 7/25/12 at 1:50 p.m. Staff R (Nursing Assistant) identified self as "right there" when the resident fell . She stated staff took residents back to their rooms after the meal and they had walked a resident that required the assistance of 2 staff out of the dining room. Staff R came back and sat by another resident and in the blink of an eye Resident #22 fell down. Staff R stated if the alarm functioned she probably couldn't have gotten there any quicker. Staff R stated the resident unhooked the alarm once or twice during that meal. When staff reattached the alarm, the resident would say, "Don't tie me down with it". Staff R stated she reattached the alarm to the middle of the resident's back. Staff R stated before the resident stood and fell , she apparently unhooked the alarm again. Staff R stated staff could prevent the fall if they didn't have to transfer the resident into the regular dining room chair. Resident return to Facility after Surgical Repair of left hip fracture: Observation revealed on 7/18/12 at 4:30 p.m., the resident returned to the facility via ambulance. A skilled daily note dated 7/18/12 at 4:30 p.m. stated the resident returned following surgical repair of the hip. The surgical incision contained 21 staples. Staff administered Tylenol for pain on 7/18/12 at 7:30 p.m. and 7/19/12 at 1:30 p.m. for nonverbal pain cues of grimacing and moaning. Staff documented positive results from the Tylenol. On 7/19/12 at 11:30 a.m. skilled daily notes identified the resident with pain and Tylenol administered. On 7/19/12 at 9 p.m. staff observed the resident tearful and restless so they administered Tylenol and laid the resident in bed. At 9:45 p.m., the resident rested quietly without evidence of pain. On 7/20/12 at 9 a.m. staff obtained an order for [REDACTED]. The order indicated with the TID (three times a day) dosage the resident could not have PRN (when needed) Tylenol. On 7/21/12 at 4 a.m., the resident screamed "help" and complained of pain, moaned and guarded the hip. The facility notified the physician who directed staff to administer Lortab (narcotic) 5/500 mg every 4 hours as needed for pain. Observation on 7/25/12 at 10:30 a.m. revealed 2 staff members transfer the resident from the wheelchair. The resident used a pressure seat alarm in the wheelchair and the alarm sounded when staff transferred the resident. Observation on the same date at 12:45 p.m., revealed the resident in a low bed, resting on a pressure alarm with mat beside the bed. The resident stated he/she did not remember falling.