Every finding on record at Davis Health Care Center

Based on observations, record review and interviews with staff, Nurse Practitioner and Responsible Party (RP), the facility failed to protect the residents' right to be free of resident-to-resident physical abuse for 2 of 2 residents (Resident #110 and Resident #14) reviewed for abuse. Resident #110 (a female resident with severe cognitive impairment) had a history of following Resident #14 (a male resident with cognitive impairment) around the facility, getting close to him, and entering his room at night. Staff reported Resident #14 would get irritated and try to get away from Resident #110. On 6/5/26 Resident #110 was observed poking Resident #14 in the face with her finger and yelling. Resident #14 grabbed Resident #110's wrist, followed by Resident #110 grabbing Resident #14's left arm digging in her nails, and Resident #14 hitting Resident #110 on her face. Resident #14 had scattered bruising and a small skin tear to the arm and Resident #110 had reddened areas to her face following the 6/5/26 altercation. Two days later on 6/7/26, Nurse #6 heard Resident #14 yelling from his (Resident #14's) room and when the nurse entered the resident's room she saw Resident #110 on the ground with Resident #14 standing over her. Resident #14 was holding Resident #110 by the hair with one hand causing Resident #110's upper body and head to be elevated off the ground as Resident #14 was kicking Resident #110 in the face. Resident #110 was sent to the emergency department for evaluation, was identified with no acute findings, and returned to the facility. A reasonable person expects to be safe from abuse in their home environment. The altercation that occurred on 6/7/26 would have resulted in trauma, fear, and severe anxiety for Resident #110. Immediate Jeopardy began on 6/7/26 when Resident #14 was holding Resident # 110 by the hair and kicking Resident #110 in the face. The immediate jeopardy was removed on 6/19/26 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective.Findings included:Resident #14 and Resident #110 resided in the facility's special care unit (a secure unit designed for residents with dementia or other cognitive impairments at risk of wandering and/or elopement). The residents' rooms were across from each other in the special care unit.Resident #14 was admitted on [DATE] with a diagnosis of dementia with agitation.Review of Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had impaired short- and long-term memory impairment, was usually able to make self-understood and understand others, rejected care 1 to 3 days during the look back period, was independent with transfers and ambulation with no assistive device and received antipsychotic and antidepressant medications. Resident weighed 166 pounds and was 72 inches tall. A review of Resident #14's care plan revealed a behavioral problem initiated on 3/26/25 and updated on 4/3/26 which indicated that the resident had a behavioral problem related to delusions, cognitive impairment and dementia. Interventions indicated to respect Resident #14's need for privacy and space, avoid unnecessary touching of the resident, provide 1 to 1 supervision as needed for behaviors and 15-minute checks as needed for safety. A review of a progress note written by the Psychiatric Nurse Practitioner dated 5/5/26 at 5:09 PM indicated that Resident #14 was hard of hearing, had impaired speech, mumbled and smiled at times and was primarily non-communicative. The note indicated that Resident #14 had moderate dementia with restlessness and agitation with a history of violent outbursts.Resident #110 was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, restlessness, agitation and bipolar disorder. A physician order in Resident #110's electronic health record dated 11/23/25 written by the Nurse Practitioner indicated trazadone 50 mg at bedtime daily. (Trazadone is an antidepressant used to manage restlessness and anxiety and is used as a sleep aid).A pharmacy recommendation dated 2/6/26 indicated that Resident #110 received trazadone 50 milligrams (mg) at bedtime. The recommendation stated to consider dose reduction if appropriate. The recommendation was signed in agreement by the Nurse Practitioner on 2/17/26 with a new order written to decrease trazadone to 25 mg at bedtime. A physician order in Resident #110's electronic health record dated 2/17/26 written by the Nurse Practitioner indicated to discontinue trazadone 50 mg at bedtime and start trazadone 25 mg at bedtime daily. An NP progress note dated 2/24/26 indicated that Resident #110 was evaluated due to staff reports of increased anxiety and insomnia since trazadone was decreased due to pharmacy recommendation for gradual dose reduction. The note indicated that staff requested intervention and that Resident #110 had failed the dose reduction. A physician order in Resident #110's electronic health record dated 2/24/26 written by the Nurse Practitioner indicated trazadone 25 mg at bedtime daily. (same dose as the resident was receiving).A nursing progress note written by Nurse #3 on 3/2/26 at 6:54 PM revealed that Resident #110 was sitting in a reclining chair watching television when the nurse was alerted by staff that Resident (110) had pushed another resident, which caused the other resident to fall. Resident #110 was unable to answer why she pushed the other resident and appears irritated or annoyed by writer's question. Resident #110 is marginally verbal at baseline and seldom completes intelligible sentences.Review of Resident #110's electronic health record revealed a Nurse Practitioner progress note dated 3/3/26 at 5:16 PM that indicated that the resident was evaluated due to agitation with recent agitation toward another resident. Review of Resident #110's care plan last updated on 3/3/26 indicated a problem of behavioral symptoms with restlessness, anxiety, agitation. The care plan indicated that Resident #110 packs her belongings in anticipation of leaving the facility, has a history of exit seeking behaviors, refusing medications, wandering and requiring 1 to 1 supervision. Interventions included to notify and collaborate with the psychiatric service and staff will observe and re-direct as able.A review of Resident #110's annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a severe cognitive impairment, was sometimes able to make herself understood and sometimes understood others. Resident #110 exhibited physical behaviors directed towards others including hitting, kicking, pushing, scratching or grabbing others for 1 to 3 days in the review look back period. Resident #110 exhibited verbal behaviors including threatening, screaming and cursing and other behavioral symptoms including pacing and rummaging in the past 1 to 3 days. Resident #110 ambulated independently and weighed 138 pounds and was 64 inches tall.A review of Resident #110's physician orders revealed an order dated 3/5/26 to obtain a psychiatric service consult.A nursing progress note dated 3/23/26 at 2:25 AM indicated that Resident #110 was found in Resident #14's room. Staff redirected Resident #110 back to her own room. A nursing progress note dated 3/31/26 at 10:24 PM indicated that Resident #110 was found sleeping in Resident #14's bed. Resident #110 became very agitated and combative swinging her arms trying to hit the nurse and NA who redirected her back to her room. Resident #110 eventually returned to her room. NA had to sit outside Resident #110's room to keep her from going back into Resident #14's room.A nursing progress note dated 4/4/26 at 6:24 AM revealed that Resident #110 was seen wandering throughout the shift.A review of Resident #110's electronic health record revealed a Psychotherapy Comprehensive Clinical assessment dated [DATE] which indicated that an assessment was completed for services due to history of agitation, aggressive behaviors and wandering at night. The recommendation indicated that psychotherapy talk therapy was not appropriate due to Resident #110's severe cognitive impairment. Medication management services were indicated to address psychotropic medications. An Initial Psychiatry Visit note written by the Psychiatric NP dated 4/21/26 indicated Resident #110 was seen for mood and medication management. Staff reported Resident #110 was agitated and aggressive with other residents at times. The recommendation indicated to continue to monitor Resident #110's mood and agitation and if resident became unstable, medication will be added to maintain mood.A Psychiatry Follow Up note written by the Psychiatric NP dated 5/19/26 indicated the recommendation was to increase Resident #110's trazodone to 50mg or 75mg nightly for sleep and restlessness. A review of Resident #110's electronic Medication Administration Record for May 2026 revealed that the resident continued to receive trazadone 25mg at bedtime daily and not the 50 to 75mg as ordered. A review of Resident #110's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment, exhibited wandering, verbal symptoms and other behavioral symptoms directed toward others 1 to 3 days in the review period and received an antidepressant. Resident was independent with ambulation. Resident #110 did not receive an anticoagulant (blood thinner).A nursing progress note in Resident #110's medical record note dated 6/5/26 at 2:30 PM written by Clinical Coordinator #3 indicated that Resident #110 was observed poking Resident #14 in the face with her pointer finger yelling. While staff attempted redirection, Resident #14 grabbed resident #110's wrist. Resident #14 let go of Resident #110's wrist. While Resident #110 was being redirected by staff, the resident turned and grabbed Resident #14's left arm digging in her nails. Resident #110 then attempted to bite Resident #14 and bit staff while staff was intervening. Resident #110 still had a hold of Resident #14's left arm when Resident #14 hit her in the face. At that time, Resident #110 let go of Resident #14's arm and staff was able to redirect her to another room. Resident #110 had reddened areas on the right side of her face. The Physician and Responsible Party were notified. Staff will continue to monitor resident for any injuries associated with the event.A nursing progress note in Resident #14's medical record note dated 6/5/26 at 2:35 PM written by Clinical Coordinator #3 indicated that Resident #14 was poked in the face by Resident #110. Resident #14 grabbed Resident #110's wrist. Resident #110 grabbed Resident #14's arm digging her nails in resulting in scattered bruising and a small skin tear to the arm. The Physician and Responsible Party were notified. Staff will continue to monitor resident for any injuries associated with the event.An interview was conducted with Clinical Coordinator #3 on 6/17/26 at 10:00 AM. Clinical Coordinator #3 stated that she walked by the common area on 6/5/26 and observed Resident #110 and Resident #14 sitting together. Resident #110 was poking Resident #14 in the face. Clinical Coordinator #3 stated that she tried to redirect Resident #110 when the resident grabbed Resident #14's arm. Resident #14 hit Resident #110 in the face. Resident #110 attempted to bite Resident #14 and ended up biting the Clinical Coordinator. Clinical Coordinator #3 stated that Resident #110 had redness to her face after being hit by Resident #14. Resident #14 had bruising and scratches to his arm. Clinical Coordinator #3 stated that Resident #14 was very upset, seemed sad and kept pointing at his arm after the incident. Clinical Coordinator #3 stated that after the incident on 6/5/26, the staff tried to monitor the residents and keep an eye on them. Clinical Coordinator #3 stated that the incident did not seem that significant as Resident #110 and Resident #14 were frequently together. Clinical Coordinator #3 indicated that she did not think this was abuse, there was not a plan of correction implemented following this incident and she did not think any other residents were affected by either of the residents, so no skin observations of other residents were completed. Clinical Coordinator #3 stated that she was not instructed by the Director of Nursing or the Administrator to implement any other monitoring or interventions. An interview with the Nurse Aide (NA) #2 on 6/18/26 at 3:00 PM revealed that Resident #14 did not like to be bothered and did not like people getting close to him. NA #2 stated that Resident #110 frequently irritated Resident #14 by getting close to him. Resident #110 exhibited agitation and restlessness and frequently pointed her finger at other residents and staff. Resident #14 would attempt to get away from Resident #110. NA #2 stated that on 6/5/26, she was in a resident room providing personal care when the incident between Resident #110 and Resident #14 occurred. NA #2 stated that after the incident on 6/5/26, neither Resident #14 or Resident #110 had a sitter and there were no interventions implemented that she was aware of. NA #2 indicated that following the incident on 6/5/26, she was instructed by the Clinical Coordinator to keep an eye on Resident #14 and Resident #110. A Physician progress note dated 6/7/26 at 9:55 PM indicated that Resident #110 was seen for a telemedicine visit due to a physical altercation with another resident. Resident #110 has a history of dementia and bipolar disorder. Resident #110 went to a male resident's room (Resident #14) and would not leave his room after being told by him to leave. Resident #14 likely pushed Resident #110 down to the floor. When the staff heard the altercation, they found Resident #14 was pulling Resident #110's hair, kicking her in the face and staff noted that the resident had a raised area to the back of her head. Resident #110 exhibited some discomfort. It seemed that Resident #110 had similar behavior in the past where she chased the male resident (Resident #14) and did not leave him alone. Resident #14 gets upset and aggressive. The assessment and plan indicated Resident #110 had a head strike with the floor and Resident #14 hit her in the face and pulled her hair. Resident #110 to be transferred to the emergency department for evaluation and monitoring.A nursing progress note in Resident #110's electronic health record written by Nurse #6 dated 6/7/26 at 11:34 PM indicated that the nurse was passing medications earlier in the evening when she heard arguing coming from a male resident's room. The nurse quickly went into the room where the arguing was heard. The nurse noticed Resident #110 lying on Resident #14's floor. Resident #14 was standing over Resident #110, holding her by her hair and kicking her in the face. The nurse attempted to separate the residents but was unable to so she called for the Nurse Aide (NA) to help. The NA and nurse separated the residents and was able to get Resident #110 to her room. Resident #110 had a notable knot on the back of her head. The on-call provider was notified, and Resident #110 was sent to the emergency department for evaluation. A nursing progress note in Resident #14's electronic health record written by Nurse #6 dated 6/7/26 at 11:53 PM indicated that the nurse observed Resident #14 standing over Resident #110 and was holding onto her hair while kicking her in the face. Resident #14 and #110 were quickly separated by the nurse and the NA. Resident #14 observed with scratches to the right hand. No other injuries were observed. Staff will continue to monitor. An interview was conducted via phone on 6/17/26 at 4:10 PM with Nurse #6, the nurse that was assigned to Resident #110 and Resident #14 on 6/7/26 from 7:00 PM to 7:00 AM on 6/8/26. Nurse # 6 stated that Resident #110 was always following Resident #14 around and was obsessed with him. Resident #110 was demonstrating agitation and would frequently enter Resident #14's room at night. Resident #14 would get irritated and try to get away from Resident #110. Nurse #6 stated that she heard Resident #14 yelling on 6/7/26 when she was down the hall administering medications. Nurse #6 stated that she entered the room to see Resident #14 standing over Resident #110 who was on the floor with her upper body and head elevated. Resident #14 was holding Resident #110 by the hair with one hand and kicking Resident #110 in the face with his foot. Nurse #6 stated that she called the NA for assistance to separate the residents. Resident #110 was scratching Resident #14 on his arms. Nurse #6 stated that both residents had behaviors and had a history of aggressive behavior and she and the NA tried to keep an eye on them.An interview was conducted via phone with NA #3 on 6/17/26 at 1:50 PM. NA #3 stated that she worked from 7:00 PM to 7:00 AM and was assigned to Resident #110 and Resident #14 frequently. NA #3 stated that Resident #110 had been increasingly agitated and aggressive with a change in her behavior for the past several months. NA #3 stated that Resident#110 had become increasingly agitated and aggressive with other residents, would get upset with other residents and slam doors. NA #3 reported that there had been prior warning signs involving Resident #110 and Resident #14, noting a history of verbal altercations and incidents in which Resident #110 wandered into Resident #14's room at night and was found in his bed. NA #3 stated that she and the other staff had expressed concerns to the nurses and had reported the concern that something bad was going to happen between Resident #110 and Resident #14. NA # 3 stated that she was told by the nurses that they would investigate it. NA #3 stated that Resident #14 typically kept his door closed at night and Resident #110 frequently went into his room and would agitate him. NA #3 explained that Resident #14 was highly protective of his personal space and belongings, and as a result, was unable to share a room with another resident. NA #3 stated that there may have been other incidents between the residents that happened behind closed doors. NA #3 stated there were other nights that she witnessed Resident #110 upset coming out of Resident #14's room. On the night of 6/7/25, NA #3 stated that she was in another resident's room providing personal care when she heard the nurse yelling for help. NA #3 stated when she entered the room, she grabbed Resident #14 and tried to calm him down. NA #3 stated that Resident #14's level of aggression was 100. NA #3 stated that Resident #14 was agitated for several hours after the incident with Resident #110 and was swinging at staff. NA #3 stated that Resident #14 was at the nurse's station after the incident for several hours and then went to his room and went to sleep.An emergency department encounter note dated 6/8/26 at 12:20 AM indicated that Resident #110's chief complaint was assault victim. The note indicated that Resident #110 presented after an assault by another resident. Resident #110 was kicked in the head resulting in a head injury. Resident #110 was evaluated for possible head injury and pelvic fracture. A CT (Computed Tomography) scan was completed with no acute findings. An exam revealed no evidence of a pelvic fracture and Resident #110 was discharged back to the facility on 6/8/26 with instructions to monitor for new symptoms or changes in condition.A Nurse Practitioner progress note dated 6/9/26 at 9:44 AM indicated that X rays were completed to the left wrist for pain. Results of the x ray were negative. Resident #110's left wrist is still swollen and tender today. Resident #110 had 2 altercations over the weekend, one episode when she went into another resident's room and required an emergency room visit for a possible head injury. Resident #110 has a bruise to her wrist as well as a lump to the back left side of the head. Emergency department workup was negative. Resident #110's wrist is still painful.An interview with the Nurse Practitioner on 6/19/26 at 9:00 AM revealed that Resident #110 wandered frequently, often went into other residents' rooms and plundered in their belongings. The NP stated that the psychiatry recommendations should have been addressed by the provider. If the medication had been increased according to the psychiatric recommendation, it would have been expected to aid in her sleep and prevent wandering and plundering in other resident rooms at night. The NP stated that there was potential for Resident #110 to sustain further injuries during the altercation with Resident #14 on 6/7/26. The NP stated that there was a likelihood that Resident #14 could have caused serious bodily harm to Resident #110 if the staff had not intervened when they did. Resident #14 had an increased adrenaline response during the assault, and something could have been triggered in him that caused such a violent response.An interview with Clinical Coordinator #3 was conducted on 6/17/26 at 10:15 AM. Clinical Coordinator #3 stated that Resident #110 had episodes of wandering and that sometimes she (Resident #110) got along with Resident #14 and sometimes she didn't, but they were frequently together during the daytime. Clinical Coordinator #3 stated that she didn't know if Resident #14 reminded Resident 110 of someone she used to know, or why she (Resident #110) always tried to be around Resident #14. Clinical Coordinator #3 stated Resident #14 would become aggravated with Resident #110 always wanting to be around him. Clinical Coordinator #3 stated that on the morning of 6/8/26 she was informed of the incident that occurred on 6/7/26 between Resident #14 and Resident #110. Clinical Coordinator #3 stated that she was informed that Resident #14 was observed pulling Resident #110's hair and kicking the resident. Resident #110 was sent to the emergency department for evaluation and returned in the early morning. Clinical Coordinator #3 stated that on 6/8/26, Resident #110 appeared upset throughout the day but was unable to express why. Clinical Coordinator #3 stated that Resident #110 was moved to another area of the facility later in the day on 6/8/26. Clinical Coordinator #3 stated that there was no additional monitoring or interventions implemented, and a plan of correction was not initiated following this incident. An interview with Nurse #3 on 6/17/26 at 3:40 PM indicated that Resident #14 had episodes of angry outbursts. Nurse #3 stated that Resident #110 was obsessed with Resident #14 and would follow him around. Resident #110 would get agitated and aggressive when staff or other residents interacted with Resident #14. Nurse #3 stated that he was the assigned nurse on 6/5/26 and was in a resident room when the incident between Resident #110 and #14 occurred. No interventions were implemented following the incident on 6/5/26 and the residents continued to sit together. Nurse #3 stated that he had received reports from night shift staff that Resident #110 had been aggressive and agitated at times and had a few episodes of going into Resident #14's room. Nurse #3 stated that the night shift staff reported that they had to monitor Resident #110 closely due to her behaviors and he had instructed the staff to continue to keep an eye on the residents. An interview with Resident #110's Responsible Party (RP) was conducted via phone on 6/17/26 at 6:20 PM. Resident #110's RP stated that she received a telephone call from the facility on 6/5/26 that stated that Resident #110 instigated an altercation with Resident #14 and was informed that staff would keep an eye on the resident. Resident #110's RP stated that she was alarmed when she received a phone call on the night of 6/7/26 stating that Resident #110 had been involved in an incident with Resident #14 in his room. Resident #110's RP stated that she was informed that Resident #110 had an injury to her head and required evaluation at the hospital. Resident #110's RP stated that she immediately went to the hospital emergency department and when she arrived Resident #110 stated that her head and her arm hurt. The Responsible Party stated that if Resident #110 were in her right mind, the incident with Resident #14 and the evaluations at the emergency department would have been upsetting and caused her to be anxious and fearful. Resident #110's RP stated that she was aware that Resident #110 would sit with Resident #14 in the common areas on the unit during the daytime. Resident #110's RP stated that she was unaware that Resident #110 wandered into Resident #14's room at night and was observed in his bed. An interview with the Administrator on 6/17/26 at 12:30 PM revealed that the resident-to-resident altercations between Resident #110 and Resident #14 should not have occurred and the facility was responsible for keeping the residents free from abuse. The Administrator stated that if interventions were implemented following the first incident on 6/5/26 between Resident #110 and Resident #14, then the second incident may not have occurred. The facility Administrator was notified of immediate jeopardy on 6/17/26 at 7:09 PM.The facility Administrator provided the following credible allegation of immediate jeopardy removal plan.Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 2/17/2026, Medical Director decreased trazadone from 50 mg to 25 mg for gradual dose reduction. On 5/19/2026, psychiatry saw Resident #110 during regular visit. Resident #110 was ordered Trazadone 50 mg. The order was sent via encrypted email to the Clinical Coordinator. The Clinical Coordinator missed the order as an oversight. On 6/16/2026 a new process was implemented that encrypted emails will be printed when they are received, given to Director of Nursing of designee for review then order highlighted prior to being given to physician for review. The order will then be given back to Director of Nursing or designee for final review before being scanned into resident chart. The Director of Nursing educated the nursing team of this process on 6/16/2026. On 6/5/2026, Resident #14 and Resident #110 were sitting next to each other in living room when Resident #110 poked Resident #14 in the face and began yelling. Resident #14 grabbed Resident #110's wrist. Nurse redirected Resident's #110 and #14. Resident # 14 let go of Resident #110's wrist however Resident #110 grabbed Resident # 14's left arm and dug her nails in his arm. Resident #14 then hit Resident #110 in the face. Resident # 110 had reddened area on her face. Staff who did not implement effective interventions were educated on Abuse Prevention Program on 6/18/2026 by Nursing Leadership Team. On 6/7/2026, nurse witnessed Resident #14 was found in his room by nurse standing over Resident #110 on the floor. Resident #14 was holding the hair of Resident # 110 and kicking her in the face. Nurse attempted to separate residents and called the nurse aide for help. Nurse and certified nurse's assistant separated Resident #14 and Resident #110 and Resident #110 went to her room. Nurse assessed Resident #110 who had a knot on the back of her head. Nurse placed an ice pack on the back of Resident #110's head then called the on-call provider. Nurse called emergency management services to send Resident #110 to hospital for evaluation. Nurse then called Resident #110's daughter, Director of Nursing and Nursing Supervisor. Nurse assessed Resident #14 for injury who had scratches on his right hand. Nurse notified on call provider who did not give any new orders. Nurse notified Resident #110's daughter, Director of Nursing and Nursing Supervisor. One on one caregiver was initiated for Resident #14 on 6/7/2026 at 11:53 PM. On 6/7, after the incident was reported, the nurse notified the DON. The DON directed staff to separate the residents, contact law enforcement, and place Resident #14 on 1:1 supervision.Following the incident, the Nurse Supervisor educated the nurses on duty regarding the facility's policy and procedures for resident-to-resident altercations.On 6/18, the DON provided education to the nurse leadership team on the facility's incident reporting policy and procedures related to resident-to-resident altercations, including resident safety interventions, notification requirements, and documentation expectations.Nursing Supervisor reported event to Police Deputy [NAME] at 9:53 PM on 6/7/2026. [NAME]'s department came to the facility and spoke to Nursing Supervisor about incident. [NAME]'s department completed police report.Resident #110 was transported to emergency department and assessed for head trauma, wrist pain and assault. Resident #110 had x-ray completed for left wrist and CT of spine with no abnormalities. Resident #110 was offered Tylenol but refused administration. Neurology assessment was completed for Resident #110 with no abnormalities. Resident #110 discharged back facility on 6/8/2026 at approximately 1 AM. Resident #110 remained in the facility.Resident #110 was moved to another room in a separate wing on 6/8/2026. Resident #110's daughter was notified and agreeable. Resident #110's physician evaluated resident on 6/8/2026 and ordered Olanzapine to treat Resident #110 for bipolar disorder with behavioral disturbances. Resident #14 was evaluated by physician on 6/8/2026 who ordered increased Zyprexa and continue one to one staff supervision.Residents were assessed by the Clinical Coordinator for injury of unknown origin with a skin audit on 6/18/2026. No injuries were noted on any residents. Each resident has a weekly body audit completed by the nurse which would show any deficient practice. This body audit is reviewed at weekly Interdisciplinary Team meetings. The Interdisciplinary team consists of Compliance Administrator, Director of Nursing, Nursing Home Administrator, Assisted Living Administrator, Clinical Coordinators and the Staff Educator/Infection Control Nurse.Resident's behavior monitoring logs were reviewed by Director of Nursing on 6/18/2026 which did not identify any significant behavior changes that required intervention. Behavior monitoring logs are completed each shift by staff nurse. These logs will be reviewed at weekly Interdisciplinary Team meetings. The Interdisciplinary team consists of Compliance Administrator, Director of Nursing, Nursing Home Administrator, Clinical Coordinators and the Staff Educator/Infection Control Nurse. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 6/5/2026, the facility utilized an internal investigation guide to respond to the incident. This was in error, as the facility should have utilized the Reportable Event Checklist, which includes required interventions such as separating residents involved in an altercation and implementing 1:1 supervision of the aggressor when an injury has occurred.On 6/18/2026, the facility implemented the Reportable Event Checklist and nursing leadership provided education to all nurses and nurse's assistants regarding its use and the required interventions outlined within the process. The Reportable Event Checklist has been posted at each nurses' station to ensure staff have immediate access to the procedure and can consistently implement the required actions during future reportable events.The Nursing Leadership team meets weekly to review status changes of any resident. This process was implemented on 11/1/2025, nurses and nurse's assistants were reeducated by Leadership on 6/18/2026. This review includes the following: I. Resident Risk AssessmentUpon admission, quarterly, annually, and with any significant change in condition, the interdisciplinary team will assess residents for risk factors including: Cognitive impairment or dementia History of aggression, assaultive behavior, or threatening behavior Wandering or intrusive behaviors Delusions, paranoia, or psychosis Behavioral symptoms associated with mental illness History of resident-to-resident altercations Communication deficits Exit-seeking behaviorsResidents i[TRUNCATED]

Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to ensure two cognitively impaired residents were free from the use of physical restraints. A staff member applied gait belts around the residents' abdomen and secured the belts to the back frames of their wheelchairs, restricting their freedom of movement and preventing them from independently rising from the chairs. The residents were unable to remove the belts on their own. There was no physician's order, assessment, care plan or clinical justification for restraint use. This deficient practice occurred for 2 of 2 residents (Resident #3 and Resident #95) reviewed for restraint use. A reasonable person would have felt fear, loss of autonomy, helplessness, and a loss of dignity when physically restrained in a wheelchair without the ability to remove the device or move freely.Findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia and generalized anxiety. Resident #3's care plan revised 12/19/25 revealed no plan of care regarding the use of restraints. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 had moderately impaired cognition. The assessment revealed no physical or verbal behaviors directed toward others. No restraints were noted on the assessment. Resident #95 was admitted to the facility on [DATE] with diagnoses including dementia. Resident #95's care plan revised 3/1/26 revealed no plan of care regarding the use of restraints. The MDS annual assessment dated [DATE] revealed Resident #95 had severe cognitive impairment. The assessment revealed no physical or verbal behaviors directed toward others. No restraints were noted on the assessment. A 5-day investigation report submitted to the State Agency revealed: the date of the incident was 3/17/26, the facility became aware 4/22/26 at 5:15 PM. An employee reported that two residents (Resident #3 and Resident #95) had their rights violated by having gait belts around them and their wheelchairs. Resident #3 and Resident #95 were able to self-propel in their wheelchairs independently. There were no injuries reported. During an investigation it was discovered that the assigned nurse (Nurse #24) was aware of the gait belts around the residents, however Nurse #24 denied ever having knowledge of this. Nurse Aide #1 (the assigned nurse aide) reported that she informed Nurse #24 that gait belts were in place. Nurse Aide #1 was told that the Clinical Coordinator (#2) placed the gait belts on the residents. The Activity Assistant also questioned Nurse Aide #1 and Nurse #24. Later Nurse #24 messaged the Activity Assistant asking her not to say anything to anyone and that she had removed the gait belts from the residents. The Clinical Coordinator (#2) and Nurse #24 were both terminated on 4/23/2026.Review of Resident #3 and Resident #95's electronic medical records from 3/17/26 through 6/16/26 revealed no documentation of the incident, no physical assessments, or monitoring following the incident, and no physician's order in place indicating a medical symptom for the use of restraints. During an interview on 6/16/26 at 1:40 PM, the Activities Director stated that during a St. Patrick's Day (3/17/26) activity in the locked unit, she overheard Activity Assistant #1 and Nurse #24 arguing about the gait belts being on the residents. The Activity Director stated she observed Resident #3 and Resident #95 wearing gait belts secured around their abdomens and strapped around the back of their wheelchairs. She stated she reported the concern to the Administrator, and the Director of Nursing but could not recall if she went to them the day of the incident or the following day. During an interview on 6/16/26 at 2:00 PM, Activity Assistant #1 stated she was no longer the Activity Assistant and now currently worked in Housekeeping. She stated on St Patrick's Day (3/17/26) during an activity she observed gait belts around Resident #3 and Resident #95 that were around their abdomen and strapped to the back of their wheelchairs. She indicated both residents were cognitively impaired. Resident #95 kept pulling at her shirt during that time as if something was bothering her. She questioned Nurse Aide #1 who stated she did not know why the belts were on the residents and Nurse Aide #1 stated to her that the Clinical Coordinator (#2) put the gait belts on them. The Activity Assistant stated she reported the gait belts to Nurse #24 who told her, You let me worry about my own house. The Activity Assistant stated Nurse #24 later sent her a text message asking her not to say anything about the gait belts to anyone and that she had removed them from the residents. The Activity Assistant stated she reported this immediately to the Activity Director who reported it to the Administrator. She stated Resident #3 and Resident #95 remained with the gait belts on them during the activity which lasted approximately 30-45 minutes, and she did not know how long the gait belts had been on the residents prior to her entering the locked unit or how long they were on after she left the unit. The Activity Assistant stated she never heard anything else about the incident so a few weeks later she asked Human Resources what the outcome of the incident was, and an investigation was started. During a phone interview on 6/16/26 at 2:30 PM, Nurse Aide #1 stated that the Clinical Coordinator (#2) placed gait belts on Resident #3 and Resident #95 while they were in the dining room. Nurse Aide #1 stated after lunch she observed the gait belts wrapped around the residents and strapped to the back of their wheelchairs. She asked Nurse #24 about the gait belts and why they were being used because she had never seen the gait belts used like that before. Nurse Aide #1 stated Nurse #24 looked at the belts but did not take any action. Nurse Aide #1 stated the gait belts were on the residents for at least an hour before Nurse #24 removed them. Nurse Aide #1 stated she denied seeing gait belts on Resident #3 and Resident #95 following the incident because it was the Clinical Coordinator (#2) who put the gait belts on the residents and indicated she feared retaliation from the Clinical Coordinator and Nurse #24. During observations on 6/15/26 at 12:00 PM Resident #3 and Resident #95 were observed sitting in the dining area of the locked unit. There were no signs of distress. During an interview on 6/16/26 at 3:30 PM, the Director of Nursing (DON) stated she was alerted of the incident with the gait belts on Resident #3 and Resident #95 by the Activity Assistant following the incident. She and the Administrator went to the locked unit but did not observe gait belts on the residents at that time. The DON stated she questioned the Clinical Coordinator (#2) and Nurse #24 and both denied using the gait belts on the residents. The DON stated she assessed both residents for skin issues at that time with no injuries found but did not document her assessments. The DON stated Human Resources received additional information a few weeks later when the Activity Assistant provided a copy of the text message that was sent to her by Nurse #24 asking her not to say anything about the gait belts being used on the residents. The DON questioned Nurse Aide #1 again and she confirmed the device used was a gait belt. She stated the Clinical Coordinator and Nurse #24 continued to deny involvement and were suspended and later terminated. During an interview on 6/16/26 at 3:50 PM, the Administrator stated following the incident she was informed by the Activity Director that her activity staff observed the two residents (Resident #3 and Resident #95) in their wheelchairs with gait belts around the abdominal area and attached to the back of their wheelchair. The Administrator and the Director of Nursing went to the locked unit to ask about the gait belts. She spoke with the Clinical Coordinator (#2), the assigned nurse (Nurse #24), and the assigned nurse aide (Nurse Aide#1) , and all three denied the allegation, and at that time the residents did not have the gait belts on them. The Administrator stated that based on those denials, no further investigation was completed at that time. On 4/15/26, the Activity Assistant contacted Human Resources to ask about the outcome of the initial investigation, which prompted further review. The Activity Assistant then provided a text message from Nurse #24 asking her not to say anything about the gait belts and that she had removed them. The Administrator stated that additional interviews were conducted, and staff reported that the Clinical Coordinator (#2) had placed the gait belts on the residents. Following the investigation, both the Clinical Coordinator (#2) and Nurse #24 were suspended and then terminated. Multiple attempts to contact the Clinical Coordinator (#2) and Nurse #24 during the investigation from 6/16/26 through 6/19/26 were unsuccessful.During a phone interview on 6/17/26 at 3:00 PM Resident #95's Responsible Party stated (Resident #95) had severe dementia, poor safety awareness, and would not have wanted to be restrained.During a phone interview on 6/17/26 at 3:15 PM Resident #3's Responsible Party stated (Resident #3) had severe dementia and would have been angry and scared if restrained.During an interview on 6/19/26 at 9:00 AM the Nurse Practitioner stated she was aware of the incident with the gait belts regarding Resident #3 and Resident #95. She indicated both residents remained at their baseline and there had been no reported change in condition following the incident from the use of the gait belts.

Based on record review, and staff and resident interviews, the facility failed to communicate the efforts to address and resolve concerns that were reported during Resident Council Meetings for 6 of 8 months of Resident Council Meeting minutes reviewed (October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, April 2026, May 2026).Finding included:a. The Resident Council Minutes dated 10/23/25 indicated in the notes section of the form that the following concerns were voiced: the laundry was not being put away after being washed and the food was cold. Staff in attendance at the meeting were the Activities Director, Activities Assistant, Administrator, Director of Nursing (DON), Dietitian, Environmental Services Supervisor (EVS), and Food Services Director. b The Resident Council Minutes dated 11/20/25 did not indicate that a response was provided to the council regarding the concerns that were voiced on 10/23/25 or any follow-up that the facility completed. Staff in attendance were the Activities Assistant, Administrator, Dietitian, EVS, and Food Services Director. Cold food was listed as a concern again. c. The Resident Council Minutes dated 12/18/25 did not indicate that a response was provided to the council regarding the food being cold. Cold food was listed as a concern again. Staff in attendance were the Activities Assistants, Administrator, Dietitian, and EVS. d. The Resident Council Minutes dated 1/15/26 did not indicate that a response was provided to the council regarding the concerns that were voiced on 12/18/25 or any follow-up that the facility completed. The following concerns were listed cold food, and the use of plastic silverware and plates, and having to ask for desserts, and employees were on their cell phones and wearing ear buds during resident care. Staff in attendance were the Activities Director and the Activities Assistants. A Grievance Report dated 1/16/26 was filed by the Resident Council regarding the use of plastic silver ware and paper plates for meals. The Corrective Action Taken was the Dining Director ordered more silverware on 1/17/26 and it was signed by the Administrator on 1/19/26. e. The Resident Council Minutes dated 2/19/26 did not indicate that a response was provided to the council regarding cold food and employees being on their cell phones and wearing ear buds during resident care. Staff in attendance were the Activities Director and the Activities Assistant. Ongoing concerns were regarding cold food and residents not receiving assistance with eating such as cutting food and opening containers. f. The Resident Council Minutes dated 3/19/26 through 3/23/26 (individual meetings were held during resident infection quarantine) did not indicate a response was provided to the council regarding the concerns that were voiced on 2/19/26 or follow-up the facility completed. There were ongoing complaints regarding the laundry not being returned timely, folded and put away, not getting help opening foods, having to ask for desserts and salads. Staff in attendance were listed as the Activities Director and the Activities Assistants. g. The Resident Council Minutes dated 4/28/26 did not indicate that a response was provided to the council regarding the concerns that were voiced on 3/19-3/23/26 or any follow-up that the facility completed. The following concerns were listed receiving plastic ware and paper plates for meals, cold food, and staff being on their cell phone during resident care activities. Staff in attendance were the Activities Director and the Activities Assistants. A Grievance Form was filed on 4/29/26 by the Resident Council regarding cold food and having to ask for dessert. The Response was Dining Director was to review concerns and address with dining staff. It was reviewed and signed by the Administrator on 6/8/26 due to ongoing issues at Resident Council. A Grievance Form was filed on 4/29/26 by the Resident Council regarding staff talking on their phones during patient care and other concerns. The Corrective Action Taken was Review of dining concerns with dining staff. Repeat concerns from Resident Council. Call bell reports review call bell reports daily and it was signed by the Administrator on 6/8/26. There was no mention of staff being on phones during resident care. h. The Resident Council Minutes dated 5/26/26 did not indicate that a response was provided regarding the cold food and staff being on cell phones during resident care. The following concerns were listed: staff on their phone when providing resident care, and cold food. Staff in attendance were the Activities Director and the Activities Assistants. A Grievance Form was filed on 5/28/26 by the Resident Council regarding dietary and cold food. The Corrective Action Taken: Review of issues given to dining team Director and it was signed by the Administrator on 6/8/26. A Grievance Form dated 5/28/26 was filed by the Resident Council regarding staff being on the phone during care and having to ask for dessert during meals. The Corrective Action Taken: was reviewed findings discussed with Clinical Staff. Staff reeducated on resident requests and Clinical Coordinators to follow up with meal and it was signed by the Administrator on 6/8/26. An interview was conducted with Resident #75 on 6/16/26 at 9:14 AM. Resident #75 stated that the Resident Council met monthly and the Activities Director and Activities Assistants recorded the concerns that were expressed. Resident #75 indicated that nothing was done about the concerns that were expressed during the meetings. Resident #75 stated she attended all the Resident Council meetings and she was getting frustrated with the lack of follow-up because she felt administration did not address the concerns of the council. She stated the council was not provided with a resolution to their concerns each month, especially the ones regarding the laundry and cold food. During an interview with the Resident Council on 6/16/26 at 1:30 PM the residents stated Resident Council meetings were held regularly but their concerns were not addressed. The residents stated they felt like no one listened to them. The residents stated they were told the issues were being reviewed, when they expressed their concerns, but nothing was ever done, and this made them feel like they did not make any difference. An interview was conducted with the Activities Director on 6/16/26 at 2:31 PM. The Activities Director stated she was responsible for documenting the grievances and concerns that were voiced during the Resident Council Meeting. She stated that the process was for her to give a copy to the Social Worker and the Administrator. An interview with the Social Worker was completed on 6/16/26 at 2:46 PM. The Social Worker stated she was the Grievance Coordinator and was responsible for recording the grievances in the logbook and keeping the logbook with the forms. The Social Worker stated that she reviewed each grievance and then gave them to the Department Director responsible for the concern. She stated that she knew there were ongoing concerns with the food being cold and plastic silverware and paper plates. An interview with the Administrator on 6/18/26 at 2:10 PM revealed that the process for addressing the Resident Council grievances was that The Activities Director records the grievances and gives a copy to the Social Worker and to her. She stated the Social Worker was responsible for making sure the grievance was distributed to the proper department director and then they were supposed to address the grievance. The Administrator indicated that both she and the Social Worker were responsible for ensuring the concerns were addressed. She stated that there were some issues that were not addressed appropriately. The Administrator confirmed there were multiple grievances filed by the Resident Council regarding cold food and the use of plastic silverware and paper plates. She stated that she had ordered more silverware but that it still didn't seem to solve the problem. The Administrator indicated that the process that they had in place to address the Resident Council grievances was not working well. She stated that they should address the grievances and provide a resolution at next month's meeting.

Based on record review, and resident, staff, the Pharmacy Quality Assurance Representative, Pharmacy Nurse Consultant and Nurse Practitioner interviews, the facility failed to protect resident's right to be free from misappropriation of narcotic pain medications (oxycodone). This deficient practice occurred for 2 of 2 residents reviewed for misappropriation of controlled medications (Resident #125 and Resident #87). Findings included: a.) Resident # 125 was admitted to the facility on [DATE] with diagnoses including lower lumbar radiculopathy (any pinched nerve root in the lower back). A physician's order for Resident #125 dated 3/3/26 revealed oxycodone 10 milligram (mg) tablets, to give one tablet by mouth three times a day for lumbago/sciatic pain, (a specific presentation of lower lumbar radiculopathy) with a start date of 3/3/26 and an end date of 4/1/26. A packing slip and delivery receipt from the dispensing pharmacy revealed on 3/3/26 that a total of 90 oxycodone 10 mg tablets (3 cards of 30 tablets each) were delivered for Resident #125. The delivery receipt was signed as received by Nurse #13. During a phone interview on 6/18/26 at 12:50 PM the dispensing Pharmacy's Quality Assurance Representative confirmed the delivery of 3 cards with 30 tablets each (90 tablets) of oxycodone 10 mgs on 3/3/26 for Resident #125. She confirmed no medication was returned to the pharmacy. During a phone interview on 6/18/26 at 3:03 PM Nurse #13 who signed the delivery receipt on 3/3/26 stated she was made aware there were missing oxycodone tablets for Resident #125. Nurse #13 stated that if she signed for 90 tablets of oxycodone 10 mg tablets for Resident #125 on 3/3/26, then that amount was received.The facility's investigation report dated 3/23/26 revealed Nurse #9 attempted to reorder oxycodone 10 milligram tablets for Resident #125 on 3/23/26. The pharmacy denied the refill and stated Resident #125 had 90 tablets dispensed on 3/3/26 and should have 30 oxycodone tablets remaining from the 3/3/26 delivery. Nurse #9 immediately notified the Director of Nursing (DON). An investigation was initiated and all medication carts in the facility were searched. The Administrator, Medical Director, and pharmacy were notified. The DON counted all narcotics on the medication carts, and card counts matched the narcotic count sheets. All staff were interviewed, with the exception of one nurse who did not respond after multiple attempts. State agencies, the police, and the Drug Enforcement Agency (DEA) were notified. The investigation identified multiple discrepancies during narcotic counts, including mathematical counting errors, lack of staff visually confirming counted narcotics, and missing signatures on end of shift count sheets. Education was provided to all nurses on proper narcotic count procedures. A new form was implemented for signing in and removing narcotics from the count. The facility determined Resident #125 did not miss any scheduled doses. Review of the Medication Administration Record (MAR) from 3/3/26 through 4/1/26 revealed Resident #125 received oxycodone 10 mg three times daily, as documented by nurse signatures. During an interview on 6/17/26 at 4:30 PM, Nurse #9 confirmed that she called the pharmacy on 3/23/26 to refill Resident #125's oxycodone 10 mg tablets. The pharmacy denied the refill because oxycodone should have remained from the 3/3/26 delivery. She stated that 30 tablets were unaccounted for and were never found During an interview on 6/19/26 at 9:10 AM, the Nurse Practitioner stated she monitored narcotic refill requests and reviewed order histories if requests appeared early. She reported that at the time, Resident #125's medications were being adjusted but the resident had no complaints of unrelieved pain during that time. b.)Resident # 87 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome. A physician's order dated 11/30/25 for Resident #87 which remained active at the time of review, revealed oxycodone 15 milligrams (mg) take one tablet by mouth every four hours for chronic pain. A packing slip and delivery receipt from the dispensing pharmacy revealed that on 3/4/26 a total of 180 oxycodone 15 mg tablets ( 6 cards of 30 tablets each) were delivered to the facility for Resident #87. The delivery receipt was signed off as received by Nurse #10. During a phone interview on 6/18/26 at 12:50 PM the dispensing Pharmacy's Quality Assurance Representative confirmed that 6 cards with 30 tablets per card of oxycodone 15 mgs were delivered to the facility on 3/4/26 for Resident #87. She confirmed no medication was returned to the pharmacy. During an interview on 6/18/26 at 4:00 PM the Director of Nursing (DON) stated only 4 of the 6 declining count sheets for the 3/4/26 delivery were located. The DON stated two cards (60 tablets) along with the corresponding declining count sheets were missing from the medication cart for Resident #87 and were never found. During a phone interview on 6/19/26 at 1:40 PM Nurse #10 who signed the delivery receipt on 3/4/26 stated she was aware there were missing oxycodone tablets for Resident #87. She stated that at the time of delivery, the process required nurses to initiate a declining count sheet for each card of 30 tablets. A new sheet was started after each card was completed. She indicated the facility later updated the process to number each sheet (e.g., 1 of 6) to improve tracking. Nurse #10 stated that if she signed for 180 tablets on 3/4/26, then that amount was received.A pharmacy packing slip and delivery receipt dated 3/23/26 documented another delivery of 180 oxycodone 15 mg tablets (6 cards of 30 tablets each) for Resident #87. The signature on the receipt was illegible. During a phone interview on 6/18/26 at 12:50 PM the dispensing Pharmacy's Quality Assurance Representative confirmed that 6 cards with 30 tablets per card of oxycodone 15 mgs was delivered to the facility on 3/23/26 for Resident #87. She confirmed no medication was returned to the pharmacy. The facility's investigation report dated 4/8/26 revealed only 3 of the 6 declining count sheets for the 3/23/26 delivery were accounted for. Three cards (90 tablets) were missing from the medication cart for Resident #87. Review of the Medication Administration Record (MAR) from 11/30/25 through 6/18/26 revealed Resident #87 received oxycodone 15 mgs every 4 hours, as documented by nurse signatures. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #87 was cognitively intact and received opioid medications. During an interview on 6/19/26 at 8:15 AM Resident #87 reported she consistently received her pain medication, and her pain was well controlled.During an interview on 6/18/26 at 12:00 PM the Director of Nursing (DON) stated on 3/23/26 Nurse #9 reported to her that Resident #125 had missing oxycodone. She stated all medication carts were checked, and staff were interviewed and they determined 30 oxycodone 10 mg tablets were unaccounted for and were never found. She stated the resident was notified and also the Medical Director, pharmacy, the police, Drug Enforcement Agency (DEA), and the state agencies. The DON stated on 4/8/26 Nurse #12 reported missing oxycodone cards for Resident #87 after the pharmacy declined a refill request due to it being too soon. The DON stated an investigation determined that several declining count sheets and medication cards were missing. Resident #87 was assessed and confirmed she had not missed any medication doses. The DON stated oxycodone was kept in the pyxis (in house medication dispenser) so oxycodone was available for the residents during that time. The DON stated all medication carts were checked, staff were interviewed, and staff drug screens were completed except for one nurse who refused testing and was no longer employed. The DON reported they found discrepancies on the end of shift narcotic count sheets and implemented new procedures requiring nurses to log all delivered narcotic cards in a notebook, numbering each card (1 through 6), numbering the declining count sheets accordingly, and verifying empty cards with signatures from both outgoing and incoming nurses. The DON stated they had not identified any concerns with controlled medications until this occurred with Resident #125. The DON indicated she conducted periodic cart audits and the pharmacy conducted random cart audits and the missing medication cards were not identified during the audits. During an interview on 6/19/26 at 8:15 AM, Nurse #12 stated she routinely worked on the hall where Resident #87 resided. She stated that during the morning shift count (on 4/8/26), Nurse #11 questioned whether Resident #87 should have had more oxycodone 15 mg medication cards on the cart than were present, even though the total number of narcotic cards on the cart matched the narcotic count sheet. Nurse #12 contacted the pharmacy to request a refill, and the pharmacy informed her it was too soon for a refill for Resident #87. Nurse #12 reported this to the Director of Nursing, and an investigation was started. She stated that medication cards containing oxycodone 15 mg tablets, along with the associated declining count sheets, were missing. Nurse #12 reported the missing medication cards were never located. During a phone interview on 6/19/26 at 3:00 PM Nurse #11 stated she returned from being off work from 4/2/26 through 4/7/26 and noted that Resident #87 had only one oxycodone card remaining, and she had four cards before leaving. Nurse #11 calculated Resident #87 should have used only one card during her time off work. She stated Nurse #12 reported this to the DON and an investigation was done and staff had to have urine drug screens. Nurse #11 stated the missing medication cards, and count sheets were never located. During a phone interview on 6/18/26 at 4:00 PM the Pharmacy Nurse Consultant stated she conducted random medication cart audits during her visits to the facility. She stated she would review a random selection of medications, but it was not her process to conduct a full narcotic count of each controlled medication during her audits. During an interview on 6/19/26 at 9:10 AM the Nurse Practitioner stated there had been no concerns brought to her regarding Resident #87's oxycodone until the missing medication issue was discovered. She stated Resident #87 has had no complaints of unrelieved pain. During an interview on 6/19/26 at 4:00 PM the Administrator stated the DON conducted an investigation after missing oxycodone was identified for Resident #125 on 3/23/26 and then again on 4/8/26 for Resident #87. The medications were reported to the state agencies and the DEA. The Administrator reported that the missing oxycodone was never found. The facility did not provide a fully implemented corrective action plan therefore, corrective actions could not be validated.

Based on record review, and staff and Nurse Practitioner interviews the facility failed to implement its abuse policy and procedures in the areas of reporting to the Administrator, reporting to the regulatory agency, law enforcement and Department of Social Services Adult Protective Services and provide protection for: 1.) An injury of unknown origin in a cognitively impaired resident (Resident #14) who sustained fractures of the left radius and ulna without any documented or reported fall, and was not reported to the Administrator. 2.) Two (2) separate incidents of resident-to-resident abuse between Resident #14 and Resident #110 in a special care unit that resulted in injuries to both residents and a hospital evaluation for Resident #110. None of these 3 incidents were reported to the North Carolina Division of Health Service Regulation or Adult Protective Services (APS as required), and 3.) failed to thoroughly investigate a reported incident of resident abuse involving improper restraint use at the time of the initial allegation. The staff member continued to work with the affected residents from 3/17/26 until termination on 4/22/26 with no protective measures in place during this period to ensure resident safety. This failure occurred with 4 of 4 residents reviewed for injuries of unknown origin, abuse, and improper restraint use (Resident #14, Resident #110, Resident #3 and Resident #95). Findings included: The facility's abuse policy revised in 2026 stated that all alleged incidents of resident abuse, including an injury of unknown source which is defined as an injury that the source was not observed or could not be explained, shall be promptly reported to the Administrator and investigated by the Administrator or designee. Should a resident be observed or accused of abusing another resident, the facility will remove the resident from the situation and develop a plan of care to protect the resident and prevent recurrence. All allegations related to abuse or neglect shall be reported to the appropriate state agency, law enforcement and the Department of Social Services Adult Protective Services within 24 hours or as soon as practicable. The Administrator or designee will report the investigation findings of allegations of abuse including injuries of unknown origin within 5 working days of the allegation of abuse to the Division of Health Service Regulation. The investigation report will include the name of the resident or residents, names of witnesses, and the corrective actions and protection that was implemented. 1).Resident #14 was admitted to the facility in a special care unit on 3/13/24 with a diagnosis of dementia with agitation. Review of Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had impaired short- and long-term memory impairment, had impaired communication, rejected care 1 to 3 days during the look back period, was independent with transfers and ambulation and received antipsychotic and antidepressant medications. A review of Resident #14's electronic health record from 3/25/26 through 3/31/26 revealed no reported falls or injury with no pain or swelling to the left hand and wrist observed. Review of a skin audit dated 3/28/26 indicated that Resident #14 had no new skin issues and no open areas on the skin were noted. Review of a nursing progress note dated 4/1/26 at 10:54 AM written by Nurse #8 indicated Resident #14 had new left hand and wrist edema (swelling) extending to the forearm. Pain and tenderness as well as generalized purplish discoloration were observed over the resident's left hand, index finger, thumb and wrist. Unknown source of the injury. Resident #14's Responsible Party was in the facility and was updated. The provider was notified and an order was received to obtain an x ray. The resident cannot verbalize what occurred. An interview with Nurse Aide (NA) #2 on 6/18/26 at 3:00 PM indicated that she was assigned to Resident #14 from 7:00 AM to 7:00 PM on 4/1/26. NA #2 stated that on 4/1/26, Resident #14's left arm and hand appeared significantly swollen and painful. NA #2 stated she did not know what the cause was. NA #2 reported that Resident#14 had not experienced any falls in the week prior to the X ray being obtained which indicated he had an acute fractured wrist. An interview with NA #1 on 6/18/26 at 3:10 PM revealed that on 4/1/26 from 7:00 AM to 7:00 PM she was assigned to the area that Resident #14 resided in. NA #1 indicated that Resident #14 had swelling and pain in his left arm and hand on 4/1/26. NA #1 stated that she did not know what the cause of the injury was and was unaware of the resident having had any falls. NA #1 stated that Resident #14 had dementia with behaviors, was ambulatory and could have had an unwitnessed fall. NA #1 stated that Resident #14 liked his privacy and preferred to have his door closed at night. An x ray report in Resident #14's electronic health record dated 4/2/26 at 10:12 AM indicated a result of acute fractures of the left radius and ulna (the long bones in the forearm). A nursing progress note dated 4/2/26 at 3:46 PM written by Nurse #7 indicated that Resident #14's left hand and wrist swelling was first observed on the previous day, at which time an x-ray was ordered. The mobile x-ray was completed today. X-ray results were received and revealed acute fractures of the left hand involving the radius and ulna. The physician was immediately updated with these findings and provided a new order to send the resident to the emergency department for further evaluation and management. A review of an emergency department visit note dated 4/2/26 indicated that Resident #14 was diagnosed with a closed left wrist fracture with no falls or injuries reported. Resident #14 presented to the emergency department with swelling of the left hand and forearm with fractures identified and the recommendation was for the resident to follow up with an orthopedic doctor. An interview was conducted with the Administrator on 6/18/26 at 12:25 PM. The Administrator stated that she had no information regarding Resident #14's injury of unknown origin and she had no incident report regarding this. The Administrator stated that a facility initial allegation report was not submitted to the North Carolina Division of Health Service Regulation, Law enforcement was not notified and Resident #14's injury was not investigated. The Administrator stated that she was not aware of the reporting and investigation requirements for an injury of unknown origin. The Administrator acknowledged that she was the abuse coordinator for the facility and stated that she expected that reports of abuse including injuries of unknown origin would be reported timely and that the appropriate authorities would be informed. The Administrator stated that she was not aware that she was required to notify Adult Protective Services of incidents of alleged abuse. An interview was conducted with the Director of Nursing (DON) on 6/18/26 at 2:00 PM. The DON stated that she reviewed Resident #14's electronic health record and noted that the resident had an injury of unknown origin documented on 4/1/26. The DON stated that she advised the nursing staff to obtain an order for an x ray. The DON stated that she did not submit an initial allegation report to the North Carolina Division of Health Service Regulation, did not inform law enforcement or other agencies and did not complete an investigation of Resident #14's injury of unknown origin. The DON stated that she was new to the position and was not aware of the requirements. Attempts were made on 6/17/26 at 11:11 AM, 6/18/26 at 8:42 AM, and 6/19/26 at 10:05 AM to interview Clinical Coordinator #2. Voicemail and text messages were sent with no return call received. Clinical Coordinator #2 was the coordinator at the time of this incident but is no longer employed at the facility. An interview with the Nurse Practitioner on 6/19/26 at 9:00 AM revealed that any incident of unknown origin or changes in condition should be reported and investigated as soon as possible. The NP stated that a delay in the treatment of an injury could cause further complications and increased pain. 2)a. Resident #110 was admitted to the facility in a special care unit on 2/29/24 with diagnoses which included dementia, anxiety, restlessness and agitation. A review of Resident #110's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a severe cognitive impairment, exhibited wandering, verbal symptoms and other behavioral symptoms 1 to 3 days in the review period and received an antidepressant. A nursing progress note dated 6/5/26 at 2:30 PM written by Clinical Coordinator #3 indicated that Resident #110 was observed poking Resident #14 in the face with her pointer finger yelling. While staff attempted redirection, Resident #14 grabbed resident #110's wrist. Resident #14 let go of Resident #110's wrist. While Resident #110 was being redirected by staff, the resident turned and grabbed Resident #14's left arm digging in her nails. Resident #110 then attempted to bite Resident #14 and bit staff while staff were intervening. Resident #110 still had a hold of Resident #14's left arm when Resident #14 hit her in the face. Resident #110 let go of Resident #14's arm and the staff were able to redirect her to another room. Resident #110 had reddened areas on the right side of her face. A review of an Initial Allegation Report provided by the facility revealed that the report was prepared by the Administrator. The Report indicated that the facility became aware of an incident on 6/5/26 at 12:00 AM with the allegation details listed as an altercation between Resident #110 and Resident #14 in which Resident #14 sustained bruising to the left arm and a skin tear and Resident #110 had a reddened area to the right side of the face. Law enforcement was notified at 1:30 PM on 6/5/26. There was no evidence that the Initial Allegation Report was received by the North Carolina Division of Health Service Regulation and the Department of Social Services Adult Protective Services was not notified. A review of an Investigation Report completed by Clinical Coordinator #3 on 6/9/26 indicated that Resident #110 and Resident #14 were involved in an altercation on 6/5/26. The summary of the facility investigation indicated that Resident #110 and Resident #14 were cognitively impaired and required redirection. Corrective action indicated that staff were present to redirect the residents when needed. The Investigation Report indicated that the County Department of Social Services Adult Protective Services (APS) was not notified. There was no evidence that the Investigation Report was sent or received by the North Carolina Division of Health Service Regulation and the Department of Social Services APS was notified. An interview with the Administrator on 6/17/26 at 12:30 PM revealed that she was in the position since April 2025 and had never verified that Initial Allegation Reports or Investigation Reports were received by the North Carolina Division of Health Service Regulation. The Administrator stated that the reports were sent via an electronic fax system and she had not verified that the reports went through the system. The Administrator further indicated that she had never notified the Department of Social Services APS of allegations of abuse and was not aware of this requirement. 2)b. A nursing progress note written by Nurse #6 dated 6/7/26 at 11:34 PM indicated that the nurse was passing medications earlier in the evening when she heard arguing coming from a male resident's room. The nurse quickly went into the room where the arguing was heard. The nurse noticed Resident #110 lying on Resident #14's floor. Resident #14 was standing over Resident #110, holding her by her hair and kicking her in the face. The nurse attempted to separate the residents but was unable to so she called for the Nurse Aide (NA) to help. The NA and nurse separated the residents and was able to get Resident #110 to her room. Resident #110 had a notable knot on the back of her head. The on-call provider was notified, and Resident #110 was sent to the emergency department for evaluation. A review of a facility Initial Allegation Report revealed a report which indicated an incident occurred on 6/7/26 between Resident #110 and Resident #14. The Report indicated Resident #110 entered Resident #14's room. The nurse heard yelling and witnessed Resident #14 holding Resident #110's hair and kicking her in the head. Resident #110 sustained a moderate sized raised area to the back of her head and Resident #14 sustained scratches to the right hand. Law enforcement was notified at 9:53 PM on 6/7/26. A review of an Investigation Report dated 6/12/26 completed by Clinical Coordinator #3 indicated that an incident occurred on 6/7/26 between Resident #110 and Resident #14. The Investigation Report indicated that the nurse witnessed Resident #14 holding Resident #110's hair and kicking her in the head. The incident resulted in physical injury or harm. The report indicated that Resident #110 and Resident #14 were unable to get along and Resident #110 was moved to another area. The Investigation Report indicated that the County Department of Social Services Adult Protective Services (APS) was not notified. An interview with Clinical Coordinator #3 was conducted on 6/17/26 at 10:15 AM. Clinical Coordinator #3 stated that she was new to the position and was not familiar with how to complete the investigation reports for abuse and was not aware that it was required to report incidents of abuse to the County Department of Social Services APS. An interview with the Administrator on 6/18/26 at 12:30 PM revealed that there was no investigation completed regarding the incident between Resident #110 and Resident #14 that occurred on 6/7/26. The Administrator stated she had no further information regarding the incident. The Administrator acknowledged that the facility policy indicated that an investigation of all incidents of abuse was to be completed. The Administrator stated that she had never notified the Department of Social Services APS of allegations of abuse and was not aware of this requirement. 3.) Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia and generalized anxiety. Resident #95 was admitted to the facility on [DATE] with diagnoses including dementia. A 5-day investigation report submitted to the State Agency revealed: the date of the incident was 3/17/26, the facility became aware 4/22/26 at 5:15 PM, and the investigation end date 4/27/26. An employee reported that two residents (Resident #3 and Resident #95) had their rights violated by having gait belts around them and their wheelchairs. Resident #3 and Resident #95 were able to self-propel in their wheelchairs independently. There were no injuries reported. During an investigation it was discovered that the assigned nurse (Nurse #24) was aware of the gait belts around the residents, however Nurse #24 denied ever having knowledge of this. Nurse Aide #1 (the assigned nurse aide) reported that she informed Nurse #24 that gait belts were in place. Nurse Aide #1 was told that the Clinical Coordinator (#2) placed the gait belts on the residents. The Activity Assistant also questioned Nurse Aide #1 and Nurse #24. Later Nurse #24 messaged the Activity Assistant asking her not to say anything to anyone and that she had removed the gait belts from the residents. The Clinical Coordinator (#2) and Nurse #24 were both terminated on 4/22/2026. A handwritten facility investigation report with a timeline of the events revealed the following: On 3/18/26 the Activity Director reported to the Administrator and Director of Nursing (DON) that activity staff saw two residents in wheelchairs with gait belts on them. The Administrator and DON went to the unit and questioned Clinical Coordinator #2, who denied that gait belts had been used. Nurse #24 was also questioned and stated that she had heard about it. Both denied knowledge of the gait belts. On 4/15/26 the Activity Assistant went to Human Resources to get an update on the incident with the gait belts. The Administrator and DON spoke with Human Resources and reported that nothing was found. On 4/17/26 new information was received from the Activity Assistant that she reported the gait belts to Nurse #24. Nurse Aide #1 now states that she saw the gait belts and questioned Nurse #24. A text message was sent by Nurse #24 to the Activity Assistant saying that she had removed the gait belts and not to say anything. The Activity Assistant reported that Clinical Coordinator #2 stopped speaking to her. On 4/22/26 the reports were submitted to administration. Clinical Coordinator #2 and Nurse #24 were terminated. Review of the employee timecard revealed that Clinical Coordinator #2 continued to work his regular full time schedule, Monday through Friday from 8:30 AM to 5:00 PM, from 3/17/26 until his termination on 4/22/26, and no protective measures were implemented by the facility to prevent potential further abuse during this time. During an interview on 6/16/26 at 1:40 PM, the Activities Director stated she observed Resident #3 and Resident #95 wearing gait belts secured around their abdomens and strapped around the back of their wheelchairs on the day of the incident (3/17/26). She stated she reported the concern to the Administrator, and the Director of Nursing but could not recall if she went to them the day of the incident or the following day. During an interview on 6/16/26 at 2:00 PM, Activity Assistant #1 stated she was no longer the Activity Assistant and now currently worked in Housekeeping. She stated on St Patrick's Day (3/17/26) during an activity she observed gait belts around Resident #3 and Resident #95 that were around their abdomen and strapped to the back of their wheelchairs. The Activity Assistant stated she reported this immediately to the Activity Director who reported it to the Administrator. The Activity Assistant stated she never heard anything else about the incident so a few weeks later she asked Human Resources what the outcome of the incident was, and an investigation was started. During a phone interview on 6/16/26 at 2:30 PM, Nurse Aide #1 stated on the day of the incident (3/17/26) she observed the gait belts wrapped around the residents and strapped to the back of their wheelchairs. Nurse Aide #1 stated she denied seeing gait belts on Resident #3 and Resident #95 following the incident because it was the Clinical Coordinator (#2) who put the gait belts on the residents and indicated she feared retaliation from the Clinical Coordinator and Nurse #24, and she was scared to say anything. During an interview on 6/16/26 at 3:30 PM, the Director of Nursing (DON) stated she was alerted of the incident with the gait belts on Resident #3 and Resident #95 by the Activity Assistant following the incident on 3/17/26. She and the Administrator went to the locked unit but did not observe gait belts on the residents at that time. The DON stated she questioned the Clinical Coordinator (#2) and Nurse #24 and both denied using the gait belts on the residents. The DON stated she assessed both residents for skin issues at that time with no injuries found but did not document her assessments. During an interview on 6/16/26 at 3:50 PM, the Administrator stated she did not initiate a full investigation on 3/17/26 because the staff involved denied the allegations, and as a result, the facility's abuse investigation protocols were not implemented. She acknowledged that a thorough investigation was not initiated until 4/15/26 and the required reporting to the State Agency until 4/22/26.

Based on record review, Psychiatric Nurse Practitioner interview, and staff interviews, the facility failed to permit a resident to return to the facility after being transferred to the hospital for a psychiatric evaluation due to aggressive behaviors toward other residents for 1 of 2 residents reviewed for hospitalization (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with cumulative diagnoses that included generalized anxiety, Alzheimer's disease, dementia with behavioral disturbance, restlessness and agitation, recurrent moderate major depressive disorder, disorientation and insomnia.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severely impaired cognition. No mood issues were identified. Other behavioral symptoms not directed toward others and wandering occurred on 1 to 3 days and the resident was noted with no change in behavior or other symptoms compared to a prior assessment. The resident had functional impairment with range of motion in one upper and one lower extremity, used a walker and a wheelchair, and required supervision for all activities of daily living. He had received antidepressant medication during the assessment look back period.A progress note written on 11/24/25 at 5:36 PM by Nurse #3 documented Resident #1 was found in another resident's room, room [ROOM NUMBER]. Another staff member told Nurse #3 that she saw Resident #1 shake the resident in Bed 2 to wake her. Nurse #3 did not observe this. Both residents were assessed and there were no injuries to either one. Nurse #3 was able to redirect Resident #1 away from room [ROOM NUMBER].An interview was conducted with Nurse Aide (NA) #1 on 06/18/26 at 4:55 PM. She stated she was familiar with Resident #1 and had cared for him during his stay. She stated that Resident #1 always thought his room was in a different location (room [ROOM NUMBER]). NA #1 recalled that on 11/24/25 Resident #1 was seen by herself shaking the resident who resided in Bed 2 trying to wake her so she would move out of what he thought was his bed. Resident #1 often had to be redirected back to his own room. NA #1 stated Resident #1 had never struck a staff member or another resident.Review of the care plan updated on 11/24/25 for Resident #1 documented he had behaviors directed toward others. He often wandered hallways, disrobed and urinated/defecated in his room, packed up his belongings and entered other resident's rooms. The goal for Resident #1 was to not exhibit socially inappropriate or disruptive behavior. Interventions included: one to one (1:1) supervision (created 11/24/25); avoidance of over-stimulation, maintain a calm environment and approach to the resident; provide activities and a daily schedule that resembles the resident's prior lifestyle, and when resident begins to become socially inappropriate or disruptive, provide comfort measures for basic needs such as pain, hunger, toileting, too hot or cold, etc. A progress note written on 12/10/25 at 2:31 AM by Nurse #6 documented Resident #1 hit his roommate with a laminated piece of paper witnessed by staff. Nurse #6 was able to redirect Resident #1. Nurse #6 documented she had administered an as needed (PRN) dose of lorazepam (a benzodiazepine) 0.5 milligrams (mg) to Resident #1 for agitation and the medication was effective. There were no injuries identified upon assessment. Resident was on 1:1 observation.Attempts to contact Nurse #6 by phone on 06/19/26 at 8:58 AM and 1:30 PM were unsuccessful.An interview was conducted with Nurse #3 on 06/17/25 at 3:55 PM via telephone. He stated he cared for Resident #1 and remembered him. He indicated the resident was hard to care for because Resident #1 always felt his room was in a different location (room [ROOM NUMBER]) that was occupied by another resident and it was difficult to redirect him when he went into that room. He explained that the different interventions used to manage the resident's behaviors were medication administration, 1:1 sitter, verbal redirection, and pain assessments. He stated the family was aware of the resident's behaviors because he had been in constant contact with the family.A psychiatry note by Psychiatric Nurse Practitioner #2 on 12/11/25 recommended that Resident #1 be sent to the hospital for a full psychological evaluation. It was her hope that once the evaluation was completed staff could appropriately manage and maintain Resident #1's behaviors with adjusted medications and repeated nonpharmacological interventions.An interview was conducted with the Psychiatric Nurse Practitioner #2 on 06/23/26 at 10:01 AM. She explained Resident #1 was newer to her when she saw him on 12/11/25 and she had planned on doing an in depth assessment on him when he returned to the facility after a psychiatric evaluation at the hospital to assess his medications. She noted that when she interviewed Resident #1 via telehealth on 12/11/25 that he was sweet as pie. She indicated that Resident #1 was agitated at times by his roommate's constant humming and had previously suggested that he be moved to another room but understood that room availability was a barrier.Nurse #3 documented on 12/12/2025 at 2:32 PM that Resident #1 departed the facility via EMS (Emergency Medical Services) and was enroute to the hospital for a psychiatric evaluation for acute episodic behaviors.In an additional in person interview with Nurse #3 on 06/19/26 at 11:50 AM he stated he was caring for Resident #1 on 12/12/25 when he was sent to the hospital for evaluation. He explained that on 12/12/25 Resident #1 had not had any behaviors out of the ordinary and had not required PRN lorazepam. Nurse #3 stated he was sure that if the resident had behaviors that were out of the ordinary on the day he was discharged he would have administered the PRN lorazepam.Review of the hospital emergency room records dated 12/12/2025 revealed Resident #1 was assessed by the psychiatric team who documented they did not feel the patient needed a psychiatric admission, but rather a medicine admission. In the emergency room Resident #1 was assessed as resting comfortably, answered to his name, and denied any complaints. He was pleasantly confused and followed commands. He did not know where he was or what year it was. The resident was admitted to the hospital on [DATE] for a medical admission with psychiatric consultation. The listed diagnosis was dementia with behavioral disturbance.Review of the hospital discharge record dated 12/15/25 revealed a Case Manager at the hospital documented that on 12/15/25 the facility was contacted and advised by Clinical Coordinator #2 that the facility was unable to accept Resident #1 back to the facility due to his aggressive behaviors. The Case Manager documented that Resident #1 was not exhibiting aggressive behavior at the hospital. The family chose to have Resident #1 discharged from the hospital to a community Hospice House.Three attempts to contact the hospital Case Manager by phone were made on 06/19/26 with no success. Voicemail messages were left on each attempt with no response.During an interview with Psychiatric Nurse Practitioner #2 on 06/23/26 at 10:01 AM she stated she was very surprised when she learned Resident #1 had been denied admission back to the facility as it was never her intention when he was sent to the hospital for a psychiatric evaluation.During an interview with NA #1 on 6/18/26 at 4:55 PM she stated Resident #1 was difficult to care for, but she considered his behaviors to be the same at discharge as they were when he was admitted .An interview was conducted with the Administrator on 06/17/26 at 4:00 PM. She stated Clinical Coordinator #2 handled Resident #1's discharge in coordination with herself and Director of Nursing (DON) #2 . She reported that it was decided by all 3 of them that Resident #1 would not be accepted back to the facility because they felt other residents were unsafe due to Resident #1's behaviors. The Administrator stated she was under the impression that the hospital had called to return Resident #1 to the facility, and Clinical Coordinator #2 refused his readmission because Resident #1 had thrown a laminated paper at his roommate.In a follow up interview on 06/19/26 at 3:00 PM the Administrator retracted her previous statement that she was involved in the decision to deny Resident #1 readmission and clarified that she was not involved in the decision to deny Resident #1 readmission. She explained that she was informed by Clinical Coordinator #2 that he refused to take Resident #1 back for readmission. Multiple attempts were made to contact Clinical Coordinator #2 by phone during the survey with no success. He was no longer employed by the facility.An interview was conducted with the DON #1 on 06/19/26 at 11:30 AM. DON #1 stated she was not involved with any decisions that were made regarding Resident #1's care. She stated she knew nothing about the situation and that Clinical Coordinator #2 had made the decision not to readmit Resident #1.A phone interview was conducted with a former DON, DON #2, on 06/18/26 at 1:24 PM. She indicated she was not an employee at the facility on 12/12/25 when Resident #1 was transferred to the hospital for psychiatric evaluation. She stated she had separated from employment at the facility in October 2025. An interview was conducted with NA #2 on 06/18/26 at 5:20 PM. She stated she had had taken care of Resident #1 during his stay at the facility. She was aware that Resident #1 always felt his room was in a different location that was occupied by another resident and it was difficult to redirect him when he went into that room. He often had to be redirected out of the room because he was confused. NA #2 explained that it was often difficult to redirect Resident #1, but she would let him cool down and when reapproached he could then be redirected. She had known Resident #1 was frustrated with his roommate humming all the time and he would ask his roommate to stop. She thought his behaviors remained the same throughout his stay. She stated he wasn't really difficult to care for and felt his behaviors were ordinary for a resident with dementia.

Based on observations, staff and Nurse Practitioner (NP) interviews, and record review, the facility failed to ensure a safe environment free of accident hazards for 1 of 5 residents reviewed for accidents (Resident #25), when a can of WD-40 (a penetrating oil used to lubricate metal surfaces and highly flammable) was observed in Resident #25's room in an area easily accessible to other cognitively impaired residents, creating the potential for accidental ingestion, misuse, or exposure. This deficient practice had the potential to affect all residents on the unit.Findings included:Resident #25 was admitted to the facility on [DATE] with bilateral below the knee (BKA) amputations.Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and used an electric wheelchair for mobility.The label on the can of WD-40 read in part to keep the product out of reach of children. The contents are, flammable and to keep it away from heat, sparks, flames, etc. It further read that it was a breathing hazard and to use only in well-ventilated area and that deliberate or direct inhalation of vapor or mist may be harmful or fatal.An observation and interview with Resident #25 were completed on 6/17/2026 at 2:04 PM. Resident #25 was observed in the first bed of a semi-private room. A 2.75 ounce (oz) can of WD-40 was observed on top of his dresser on the left side of the doorway entrance. Resident #25 stated that he used the WD-40 on his electric wheelchair as needed. He further stated that he had ordered the WD-40 and had it delivered to the facility. Resident #25 indicated he was unaware he was not supposed to have WD-40 in his room. He stated he had not considered that other residents were able to access it.An interview with Clinical Coordinator was completed on 6/17/26 at 2:06 PM. Clinical Coordinator #3 indicated she was the nurse working on the unit that day. She stated she was not sure if Resident #25 was supposed to have WD-40 in his room. She further stated she was going to remove it and check with the Director of Nursing (DON) regarding facility policy. Clinical Coordinator #3 stated that there were several cognitively impaired residents on the unit that wandered in and out of rooms and sometimes they took other residents' belongings. She stated it could be dangerous if a cognitively impaired resident sprayed themselves or other residents with it. An interview with the Social Worker (SW)was conducted on 6/18/26 at 11:23 AM. The SW stated that residents were not allowed to keep dangerous products in their rooms where other residents could access it. She further stated there were several residents on that unit that wandered in other residents' rooms and could accidentally misuse it and harm themselves or others.An interview with Nurse Aide (NA) #4 was completed on 6/18/26 at 11:29 AM. NA #4 stated she had not noticed the WD-40 in Resident #25's room. She further stated there was a new resident on the unit that frequently wandered in other residents' rooms and they would have to redirect her attention out of the room.An interview with NA #5 was completed on 6/18/26 at 11:35 AM. NA #5 stated there were usually two NAs and one nurse on the unit. She indicated there were several residents that frequently wandered in other residents' rooms. She stated she didn't know Resident #25 was keeping WD-40 in his room.An interview with Nurse #5 was completed on 6/18/26 at 11:37 AM. Nurse #5 stated she had worked at the facility for approximately a year and floated or worked wherever she was needed. She indicated Resident #25 should not have WD-40 in his room because it could be dangerous for other residents.An interview with the Administrator was completed on 6/18/26 at 2:00 PM. The Administrator stated that WD-40 should not be kept in a resident's room because there were residents that wander on that unit and they could get a hold of it. She indicated that it was dangerous for other residents if they were accidentally exposed to it.An interview with the Director of Nursing (DON) was completed on 6/18/26 at 2:15 PM. The DON stated that WD-40 was not to be kept in residents' rooms because it was a hazardous substance. She indicated that it could be harmful if a cognitively impaired resident got a hold of it and was accidentally exposed.An interview with the Nurse Practitioner (NP) #2 was conducted on 6/19/26 at 9:32 AM. The NP stated that Resident #25 was not supposed to have WD-40 in his room. She further stated that it was aerosol petroleum product that could be dangerous if inhaled or ingested. NP #2 indicated an accidental exposure could cause aspiration or chemical pneumonia or other serious issues.

Based on record review, and interviews with staff, Nurse Practitioner and Psychiatric Nurse Practitioner, the facility failed to address a psychiatric Nurse Practitioner recommendation to increase the medication trazadone (an antidepressant used to manage restlessness and anxiety and is used as a sleep aid) for a resident (Resident # 110) diagnosed with dementia who had a known pattern of wandering behaviors and nighttime sleep disturbance. This deficient practice was for 1 of 1 resident (Resident # 110) sampled for dementia care.Findings included:Resident #110 was admitted on [DATE] with diagnoses which included dementia, anxiety, restlessness, and agitation.A physician order in Resident #110's electronic health record dated 11/23/25 written by the Nurse Practitioner indicated trazadone 50 mg at bedtime daily. A pharmacy recommendation dated 2/6/26 indicated that Resident #110 received trazadone 50 milligrams (mg) at bedtime. The recommendation stated to consider dose reduction if appropriate. The recommendation was signed in agreement by the Nurse Practitioner on 2/17/26 with a new order written to decrease trazadone to 25 mg at bedtime. A Nurse Practitioner (NP) progress note dated 2/17/26 indicated that Resident #110 was evaluated regarding a pharmacy review and recommendation for a gradual dose reduction of trazadone from 50 mg to 25 mg.A physician order in Resident #110's electronic health record dated 2/17/26 written by the Nurse Practitioner indicated to discontinue trazadone 50 mg at bedtime and start trazadone 25 mg at bedtime daily. An NP progress note dated 2/24/26 indicated that Resident #110 was evaluated due to a pharmacy recommendation for a gradual dose reduction of trazadone. Staff reported increased anxiety and insomnia since trazadone was decreased. The note indicated that staff requested intervention and that Resident #110 had failed the dose reduction. A physician order in Resident #110's electronic health record dated 2/24/26 written by the Nurse Practitioner indicated trazadone 25 mg at bedtime daily. (same dose as the resident was receiving).A review of Resident #110's electronic health record revealed no new order dated 2/24/26 to increase trazadone to 50 mg. A review of Resident #110's electronic Medication Administration Record (MAR) for February 2026 indicated that from 2/1/26 through 2/16/26 the resident received trazadone 50 mg daily at bedtime. The MAR indicated from 2/17/26 through 2/28/26 Resident #110 received 25 mg trazadone daily at bedtime. A nursing progress note written by Nurse #3 on 3/2/26 at 6:54 PM revealed that Resident #110 was sitting in reclining chair watching television when the nurse was alerted by staff that resident had pushed another resident, which caused the other resident to fall. Review of Resident #110's electronic health record revealed a Nurse Practitioner (NP) progress note dated 3/3/26 at 5:16 PM that indicated that the resident was evaluated due to agitation with a recent incident of agitation toward another resident. The assessment and plan indicated to consult with the psychiatric service for possible increase in trazadone. Review of Resident #110's care plan last reviewed on 3/3/26 indicated a problem of behavioral symptoms with restlessness, anxiety, agitation. Resident #110 packs belongings in anticipation of leaving facility, has a history of exit seeking behaviors, refusing medications, wandering and requiring 1:1. Interventions included to notify and collaborate with the psychiatric service for behavioral review and recommendations as indicated and staff will observe and re-direct as able; attempt to engage in activities or phone call with family to encourage acceptance of placement. A review of Resident #110's physician orders revealed an order dated 3/5/26 to obtain a psychiatric service consult.A review of Resident #110's electronic Medication Administration Record (MAR) for March 2026 revealed the resident received trazadone 25 mg daily at bedtime daily from March 1, 2026 through March 31, 2026.A nursing progress note dated 3/16/26 at 6:30 AM indicated that Resident #110 was seen wandering throughout the shift. A nursing progress note dated 3/23/26 at 2:25 AM indicated that Resident #110 was in Resident #14's room. Resident #110 was redirected to her room. A nursing progress note dated 3/31/26 at 6:24 AM revealed that Resident #110 was found in Resident #14's bed. Resident #110 became very agitated and combative swinging her arms at the nurse and Nurse Aide. Eventually Resident #110 was redirected back to her room. Nurse Aide had to sit outside Resident #110's room to keep her from going back into Resident #14's room.A nursing progress note dated 4/4/26 at 6:24 AM revealed that Resident #110 was seen wandering throughout the shift. Staff attempted to redirect Resident #110. Review of Resident #110's electronic health record revealed a Psychotherapy Comprehensive Clinical assessment dated [DATE] which indicated that an assessment was completed for services due to the resident's history of agitation, aggressive behaviors and wandering at night. The assessment indicated that Resident #110 presented with guarded and suspicious behavior with agitation. The assessment highlighted Resident #110's significant cognitive and behavioral challenges suggesting a need for further interventions. Resident #110 became agitated with peers, easily frustrated and angry and staff reported a history of violent behavior. The assessment indicated that psychotherapy talk therapy was not appropriate due to Resident #110's severe cognitive impairment. Medication management services were indicated to address psychotropic medications.A review of Resident #110's electronic health record revealed a pharmacy evaluation for April 2026 which indicated no new recommendations and no information regarding the behaviors of wandering at night and agitation documented in the nursing progress notes. A Psychiatric Initial Visit note dated 4/22/26 indicated that an initial visit was completed with Resident #110. The plan indicated to monitor and document the side effects of medications, mood changes, and changes in behavior with no current medication changes recommended. A review of Resident #110's electronic MAR for April 2026 revealed that the resident received trazadone 25 mg nightly from 4/1/26 through 4/30/26. A nursing progress note dated 5/2/26 at 6:00 AM indicated that Resident #110 was seen wandering throughout the night. Plan of care was continued. No new interventions were implemented. A Psychiatry Follow Up note dated 5/19/26 indicated the recommendation was to increase Resident #110's trazodone to 50mg or 75mg nightly for sleep and restlessness. A review of Resident #110's electronic health revealed there was no order dated 5/19/26 to increase trazadone from 25 mg to 50 mg or 75 mg.A review of Resident #110's electronic MAR for May 2026 revealed that the resident received trazadone 25 mg nightly from 5/1/26 through 5/31/26.A review of Resident #110's electronic MAR for June 2026 revealed that the resident received trazadone 25 mg nightly from 6/1/26 through 6/16/26. Resident #110 received 50 mg trazadone starting on 6/17/26.A review of Resident #110's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a severe cognitive impairment, exhibited wandering, verbal symptoms and other behavioral symptoms 1 to 3 days in the review period and received an antidepressant.An interview with Clinical Coordinator #3 on 6/18/26 at 2:50 PM revealed that she began her role in May, 2026. In this position, she serves as the nursing manager responsible for overseeing patient care coordination for the special care unit where Resident #110 resided. She stated the Director of Nursing received the psychiatry recommendations and either presented them to the provider for orders or delegated that task to the staff nurse assigned to the resident. Clinical Coordinator #3 stated that she was unaware there was a recommendation from psychiatry to increase Resident #110's trazadone to 50 mg or 75 mg. An interview with Nurse Practitioner (NP) on 6/19/26 at 9:00 AM revealed Resident #110 exhibited behaviors including wandering frequently, often entering other residents' rooms and plundering in their belongings. The NP revealed on 2/24/26, Resident #110's dose of trazadone should have been increased back to the previous dose of 50 mg at bedtime. The NP stated it was her error and that she thought Resident #110's trazadone was discontinued completely on 2/17/26. The NP stated the psychiatry recommendations should have been addressed. The NP indicated she was unaware of the process for how psychiatric recommendations were handled in the facility. If the medication had been increased according to the psychiatric recommendation, it would have been expected to aid in her sleep and prevent wandering and plundering in other resident rooms at night. An interview was conducted with the Psychiatric Nurse Practitioner (NP) via telephone on 6/19/26 at 5:00 PM. The Psychiatric NP explained that trazodone is an antidepressant commonly used to assist with sleep. She stated that she had recommended increasing Resident #110's dose of trazadone to help address nighttime sleep disturbances and wandering behaviors. The Psychiatric NP further indicated that the dosage adjustment should have been implemented and that a breakdown occurred in the process of carrying out the recommendations she documented.An interview with the Director of Nursing (DON) on 6/17/26 at 1:10 PM revealed the facility's established process was that the clinical coordinator received recommendations from the psychiatric service via email, print the recommendations, and provide them to the staff nurse to submit to the provider for review, approval, and new orders if in agreement. The DON stated that she did not recall whether the Clinical Coordinator received the psychiatric recommendation written on 5/19/26 which recommended to increase Resident #110's trazadone. The DON stated that the psychiatry recommendation for Resident #110 to increase the trazadone was missed and was not addressed and assumed it was due to human error.

Based on observations, record review, and staff interviews, the facility failed to record the opened date on an insulin pen and discard an expired bottle of an ophthalmic solution (eye drops), according to the manufacturer's guidelines, and discard an expired bottle of a proton pump inhibitor (a medication that decreases the amount of acid produced in the stomach). This was observed on 1 of 3 medication carts (200 hall medication cart) reviewed for medication storage. Findings Included: Review of the manufacturer's guidelines for Insulin Glargine (Lantus) pens instructed to discard 28 days after opening. Review of the manufacturer's guidelines for Polyvinyl 1.4 % ophthalmic solution instructed to discard 90 days after opening. An observation of the 200-hall medication cart on 6/17/26 at 10:30 AM along with Nurse #10 revealed the following: - One Insulin Glargine (Lantus) pen with no opened date and the insulin pen had been used, - One bottle of Polyvinyl 1.4 % ophthalmic solution with an open date of 3/4/26, - One bottle (house stock) of Omeprazole (proton pump inhibitor) opened and used with a manufacturer's expiration date on the bottle of April 2026. During an interview on 6/17/26 at 10:30 AM Nurse #10 stated that the nurses were required to check medication carts for expired medications and to record the date insulin pens were opened. She stated she had not administered Lantus, the eye drops, or omeprazole that morning and therefore had not noticed the expiration dates. During an interview on 6/19/26 at 4:00 PM the Administrator indicated all nurses were responsible for checking medication carts for expired medications and insulin pens should be checked daily and opened dates recorded. She stated the expired medications on the 200-hall cart should have been discarded and an open date labeled on the Lantus pen.

Based on observations, record review, and staff interviews, the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when two staff members (Nurse #9 and NA #7) were observed providing direct care activities to Resident #42 who had a Stage IV pressure ulcer on her sacrum and Nurse #9 was observed not changing her gloves and hand sanitizing prior to going from a dirty area to a clean area during wound care. This occurred for 2 of 3 staff members observed for infection control practices. Findings included: The Infection Control Policy dated 11/2/25 revealed Enhanced Barrier Precautions referred to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms by requiring the use of gown and gloves during high contact resident care activities. During an observation on 6/17/26 at 10:11 AM Resident #42 was observed lying in bed. There was no Enhanced Barrier Precaution sign observed on the door of Resident #42's room and there was no Personal Protective Equipment (PPE) on the door or the outside of the room. Nurse #9 and Nurse Aide #7 were observed washing their hands and applying gloves and they did not apply gowns. Nurse Aide #7 assisted Resident #42 to roll over on her right side to expose her sacral area. Nurse #9 then removed the dirty sacral dressing. Nurse #9 was not observed removing her dirty gloves and hand sanitizing prior to cleaning the wound with Normal Saline and applying calcium alginate with silver and covering with a dry self-adhesive dressing. An interview with Nurse #9 was completed on 6/17/26 at 10:19 AM. Nurse #9 stated she was provided education by the facility regarding EBP. She indicated she should have been wearing a gown and gloves during Resident #42's dressing change. She stated she was not aware that the EBP was not posted outside the door. Nurse #9 explained she was just real nervous because she was being observed and just forgot to apply the PPE gown. She stated she just forgot to change her gloves and sanitize her hands after removing the dirty dressing and applying the clean dressing. Nurse #9 indicated she usually carried an extra pair of gloves with her supplies, but she was just nervous and forgot.An interview was completed with the Director of Nursing (DON) on 6/17/26 at 10:25 AM. The DON stated she was the interim Infection Control Preventionist (ICP) since the ICP resigned in May. She indicated she was the staff member responsible for initiating EBP by placing a sign and PPE supplies outside the identified resident's door. The DON explained she was aware of Resident #42's Stage IV pressure ulcer and she just missed putting the supplies out and the sign for EBP. The DON confirmed that Nurse #9 should have changed her gloves and sanitized her hands and applied clean gloves prior to applying the clean dressing.An interview was conducted with NA #7 on 6/17/26 at 12:47 PM. NA #7 stated she was aware of EBP, but there was never a sign or PPE outside Resident #42's room. She stated she should have been wearing a gown and gloves when assisting with wound care for Resident #42.An interview was completed with the Administrator on 6/18/26 at 2:05 PM. The Administrator stated she expected the nursing staff to follow EBP when providing direct patient care for residents, including wound care.

Based on observation, record review, and interviews with staff, resident, Physician and Wound Care Specialist, the facility failed to identify an environmental hazard and supervise Resident #1. Resident #1 was newly admitted to the nursing home, severely cognitively impaired and blind. On 10/11/25, Nurse Aide (NA) #1 placed Resident #1, who was seated in his wheelchair, in front of the lit fireplace in the dining room after he expressed feeling cold. NA #1 then left to assist another nurse aide, leaving Resident #1 unsupervised. While unattended, Resident #1 tipped his wheelchair over backward, falling against the fireplace. His head, back, and shoulders came into contact with the hot mesh grate. Resident #1 yelled out. Resident #2 was on the other side of the fireplace and yelled for help from staff. NA#1 responded and alerted Nurse #1. Resident #1 told NA #1 his head was burning. Nurse #1 responded, and moved Resident #1 away from the fireplace. Emergency Medical Services (EMS) were contacted. Upon arrival, EMS assessed the resident's pain level at 10 out of 10 and administered three doses of narcotic pain medication during transport to the hospital. At the hospital, Resident #1 was diagnosed with second-degree burns (damage to the outer layer of skin and part of the underlying layer caused by contact with a hot object with redness, swelling, blisters and pain which may be severe) with blistering to the back of his scalp (approximately palm-sized), right shoulder, upper back, and left index finger. He also sustained a hematoma to the back of his head. A burn center consultation determined that acute intervention or transfer was not required, and topical antibiotic ointment was recommended. Resident #1 remained hospitalized until 10/13/25 and required additional narcotic pain medication during his stay. On 10/15/25, the Wound Care Specialist performed a sharp selective debridement procedure to remove the necrotic or dead tissue from the wounds to the scalp and shoulder. Additionally, the facility lacked safety precautions to prevent residents from accessing or activating the fireplaces or coming into contact with the hot mesh grates. turning on the fireplace or touching the mesh grate of the fireplace. This deficient practice affected 1 of 4 residents reviewed for supervision to prevent accidents (Resident #1). There were six households in the nursing home and two of which had free-standing, double-sided fireplaces in the middle of the common area dividing the living and dining room. The other four households had single-sided wall fireplaces in the common living room areas with no precautions in place to prevent residents access to touching the grates in front. Immediate jeopardy began on 10/11/25 when staff left Resident #1 without staff supervision in the dining room with a lit fireplace that had no physical barrier to restrict access from the hot surfaces. Immediate jeopardy was removed on 10/18/25 when the facility implemented an acceptable plan of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that education is completed and monitoring systems are in place and are effective. Findings included:The owner's manual for the gas fireplace indicated that children and other individuals may be susceptible to accidental contact burns. The fireplace consisted of tempered glass and a decorative mesh grate barrier in front of the decorative logs and heating elements. Important safety and operating information indicated that the tempered glass will become hot and the hot glass will cause burns. Safety information further indicated to not touch the glass until cooled and keep a clear space of 3 feet in front of the fireplace. A physical barrier is recommended if there are individuals at risk in the area. To restrict access to the fireplace an adjustable safety gate should be installed to keep individuals at risk away from the hot surfaces of the fireplace. A switch lock or wall remote control with a child protection lockout feature should be installed. Never leave children or at-risk adults alone near a hot fireplace whether it is operating or cooling down. High temperatures may ignite clothing or other flammable materials. Clothing, furniture, draperies and other flammable materials must not be placed on or near the fireplace. Children and adults should be alerted to the hazard of high surface temperatures and should be kept away to avoid burns or clothing ignition. The manual further indicated that when the wall switch is turned to the on position the fireplace will ignite and run continuously at the high flame setting with no adjustment of the flame height or temperature setting possible. Resident #1 was admitted on [DATE] with diagnoses of vascular dementia, history of falls and glaucoma. Resident #1's care plan, dated 10/8/25, identified a problem of highly impaired vision related to glaucoma. Interventions included adapting the environment to resident's needs, assessing loss of vision on resident's functional status, orienting to changes in environment and providing an environment that is free of clutter. The care card dated 10/8/25 used by the Nurse Aides revealed Resident #1 had a diagnosis of vascular dementia with confusion at times, was blind, used a wheelchair and transferred with stand pivot assistance. The care card indicated that Resident #1 was a fall risk and fall interventions indicated to ensure stable transfer support, keep pathway clear of obstacles, and someone was to be present to assist with stand and pivot transfers. A fall risk assessment dated [DATE] indicated Resident #1 was legally blind, required the use of an assistive device for mobility, had three or more falls in the past three months, had cognitive decline and was at high risk for falls. A care plan, dated 10/11/25, identified a problem with falls due to dementia with a history of frequent falls and cognitive impairment. Interventions included keeping the call bell within reach and non-skid footwear. A facility investigation of the incident dated 10/13/25 completed by the Clinical Coordinator revealed that Resident #1 sustained injuries resulting from an accidental fall that occurred on 10/11/25. Resident #1 expressed that he was feeling cold and the Nursing Aide (NA) #1 positioned the resident in front of the fireplace to warm up while they attended to other care duties. At the time of the incident, the staff were assisting another resident that required a mechanical lift for transfers. While staff were occupied with the other resident, Resident #1 tipped his wheelchair backwards. Resident #1 fell against the fireplace screen, sustaining burns to the posterior scalp and right shoulder. The resident was sent to the emergency department for evaluation and treatment. A witness statement dated 10/13/25 written by NA #1 revealed that on 10/11/25, she was assigned to Resident #1 and got him up for breakfast. The statement indicated that she transferred Resident #1 to his wheelchair and sat him at the table closest to the fireplace in the dining room. The statement indicated that she informed Resident #1 that she would be back shortly and went to assist another NA. The statement indicated that she and the other NA were assisting another resident and as they were coming out of the room, they heard a loud scream. The statement indicated that she went to the dining room and observed that Resident #1 fell backwards in his wheelchair and was on the floor. The statement indicated that the NA moved the resident then waited for the nurse to assist him. An interview with NA #1 was conducted on 10/15/25 at 1:14 PM. NA #1 indicated that she was an agency NA that had worked at the facility for the past two years as needed. NA #1 indicated that she was assigned to Resident #1 on 10/11/25 from 7:00 AM to 3:00 PM. NA #1 stated that Resident #1 stated that he was cold, so she brought the resident to the dining room in his wheelchair and placed him in front of the lit fireplace with his back towards the fireplace and locked the brakes of his wheelchair. NA #1 stated her colleague NA #2 requested her assistance with another resident down the hall. NA #1 stated she and NA #2 left the dining room area where Resident #1 was seated in his wheelchair and went to provide personal care to the other resident. A few minutes later, NA #1 could not recall exactly how long, as they were finishing assisting the other resident, she and NA #2 heard Resident #2 screaming that another resident [Resident #1] was on the floor. NA #1 stated that she immediately went to the dining room area where she heard the screaming and observed Resident #1 on the floor with his wheelchair tipped over backwards. The wheelchair was underneath the resident and his head was on the fireplace when she arrived in the dining room. Resident #1 was hollering in pain. NA #1 stated that she immediately pulled the resident a few inches away from the fireplace as the resident was saying his head was burning and he was yelling. NA #1 recalled that it was hot in the area surrounding the fireplace. NA #1 stated that she knew that Resident #1 was new to the facility and he was blind but other than that she did not know much else about him. NA #1 stated that often the fireplace was turned on when she came in to work at 7:00 AM and that it was turned on by the 11:00 PM to 7:00 AM staff. NA #1 indicated that she had not received any instructions or in-service education regarding the fireplace prior to this incident. A follow up interview with NA #1 on 10/16/25 at 3:15 PM revealed that she positioned Resident #1 at the table with his back towards the fireplace. NA #1 was unsure of the distance between Resident #1 and the fireplace but indicated that he was close enough to hit his head on it when he fell backwards. NA #1 stated that she frequently observed other residents turn on the fireplace. NA #1 stated on the morning of 10/11/25, the fireplace was already turned on and that she had not turned it on when she placed Resident #1 in front of it. NA #1 stated that she was not instructed that the residents and objects should be kept at least three feet away from the fireplace and she was not aware that the outside of the fireplace unit was hot when it was turned on. NA #1 stated that she was surprised that Resident #1 sustained burns from contact with the outside of the fireplace.A witness statement dated 10/13/25 written by NA #2 revealed that on 10/11/25, Resident #1 was in the dining room in his wheelchair near the fireplace. After breakfast, NA #2 requested NA #1 assist her with another resident that required 2 person assist. Both NAs left the dining room area and went to assist the other resident. At the time they left the dining room, Resident #1 was seated in his wheelchair. While NA #1 and NA #2 were in the room assisting the other resident, they heard yelling. NA #2 stated that the other NA went to check to see who was yelling first and then she came out to the dining room a few a minutes later after she finished with the resident they were assisting. NA #2 stated when she came out to the dining room, she observed Resident #1's wheelchair turned over, and he was on the floor by the fireplace. An interview with NA #2 on 10/15/25 at 2:15 PM revealed that Resident #1 was in the dining room in front of the fireplace when she and the other NA left the dining room and went to assist another resident in their room leaving the resident unsupervised in the area. NA #2 stated they had just finished the other resident's care when they heard a resident screaming loudly. NA #2 stated NA #1 immediately went to the dining room to see what happened. NA #2 stated she went to the dining room a few minutes later after she finished in the other resident's room. NA #2 stated when she went out to the dining room, Resident #1 was lying on the floor with his head a few inches from the fireplace with the wheelchair beneath him and he was hollering and was agitated. NA #2 stated that she had not received any in-service training regarding the incident. NA #2 stated that they always used the fireplace and had not had any issues with it before. NA #2 indicated that she had not received any safety instructions regarding the fireplace prior to this incident. An interview was conducted on 10/15/25 at 2:30 PM with Resident #2, who was alert and oriented to person, place and time. Resident #2 stated that he was on the other side of the fireplace on 10/11/25 when Resident #1 fell. Resident #2 stated that he heard Resident #1 yell and went to see what happened. Resident #2 stated that he observed Resident #1 on the floor with his head and shoulders against the fireplace screen. Resident #2 stated that he felt the metal frame around the fireplace screen and noted it was hot, and the fireplace was on for a while that morning. Resident #2 stated he was the first person on the scene to respond when he heard Resident #1 hollering, so he yelled for help. Resident #2 indicated that after he yelled for help, NA #1 quickly responded and came over to assist Resident #1. Resident #2 stated that he was aware of how to turn the fireplace on and off using the switch on the wall and that he enjoyed having the fireplace on. Resident #2 stated that after this incident there was now a box over the switch, so he and the other residents were no longer able to turn the fireplace on and off. A witness statement dated 10/13/25 written by Nurse #1 who was assigned to Resident #1 on 10/11/25 from 7:00 AM to 7:00 PM revealed that she was passing medications when the incident occurred. The statement indicated that while preparing medications for another resident, NA #1 and NA #2 notified her that there was a fall. The two NAs were assisting another resident and after they finished, they went to the dining room and observed Resident #1 on his back in his wheelchair in front of the fireplace on the floor. The witness statement indicated that the nurse and the NA moved Resident #1 a little further away from the fireplace. The resident stated he hit his head. The nurse indicated that she observed redness to the back of Resident #1's head. The nurse called the ambulance to transfer the resident to the hospital for evaluation. A nursing progress note dated 10/11/25 written at 2:05 PM by Nurse #1 revealed that Resident #1 was sitting in the dining room and had just finished eating breakfast when the nurse was notified that the resident was on the floor having fallen backwards out of his wheelchair close to the fireplace. The note stated that the nurse moved the resident away from the fireplace. The resident complained of pain to the back of the head and a reddened area was noted. 911 was called and Resident #1 was transported to the hospital for evaluation. An interview was conducted on 10/15/25 at 11:00 AM Nurse #1 who was assigned to Resident #1 on 10/11/25 from 7:00 AM to 7:00 PM. Nurse #1 stated she was passing medications when NA #1 alerted her that a resident fell in the dining room. The nurse stated she observed Resident #1 on the floor close to the fireplace and that he had flipped his wheelchair over and was lying on his back on the floor with his head towards the fireplace about 2 inches from the metal grate that was in front of it. Nurse #1 stated she thought Resident #1 must have forcefully pushed backwards in his wheelchair not realizing that the brakes were locked and flipped backwards. The resident stated he hit his head. The nurse stated she moved Resident #1 a small amount away from the fireplace and called 911. She observed the back of Resident #1's head and noted that it was red with a hematoma, the resident was hollering in pain and was agitated. Nurse #1 stated that she did not observe Resident #1's index finger as she was more concerned about the resident injuring his head. Nurse #1 stated that Resident #1 was agitated and because of this she was unable to obtain vital signs. The nurse stated that she turned off the fireplace, and she noted that the area in front of the fireplace was hot as it had been on for a while that morning. The nurse stated that the NA #1 and NA #2, the only other staff assigned to the area, were in another resident's room when the incident occurred. Nurse #1 stated that Resident #2 was the only resident in the area when the incident occurred. The nurse stated that she was new to the facility and 10/11/25 was the first day that she worked in that area and that she had not received in-service education or training regarding the fireplace or safety hazards prior to this incident. An Emergency Medical Services (EMS) record dated 10/11/25 indicated that EMS arrived at the facility at 9:53 AM and observed Resident #1 with burns to the back of his head, right shoulder and upper back with redness, blisters and pain noted. Vital signs were temperature 98.0, respirations 20 per minute, pulse 117 beats per minute (normal pulse rate is generally 60-100), blood pressure 202/94 (normal blood pressure is generally less than 120/80 millimeters of mercury), and a pain level of 10 (a pain scale of 0-10 with 0 being no pain and 10 the worst pain ever). The record indicated that EMS administered fentanyl (a narcotic medication for pain) 50 micrograms (mcg) at 10:06 AM, 25 mcg. at 10:18 AM and 25 mcg at 10:35 AM. The hospital Discharge summary dated [DATE] indicated that Resident #1 was transferred to the hospital on [DATE] for evaluation following an unwitnessed fall near the lit fireplace where he was identified with second degree burns (damage to the outer layer of skin and part of the underlying layer caused by contact with a hot object with redness, swelling, blisters and pain which may be severe) with blistering to the back of his scalp (approximately palm-sized), right shoulder, upper back, and left index finger in addition to a hematoma to the back of his head. A skin assessment on presentation in the emergency department indicated Resident #1 had a large thermal burn with sloughing and blistering of the skin to the posterior scalp and the wound was extremely tender. The resident had large burns with sloughing and blistering to the right shoulder and upper back. Resident #1 was admitted to the hospital and a consultation with the local Burn Center indicated the resident's condition did not necessitate acute action or transfer and recommended an antibiotic ointment. An order was included in the discharge orders for oxycodone 5 milligrams (mg) every 6 hours as needed for pain management. Resident #1's electronic health record revealed a physician order from the hospital discharge orders dated 10/13/25 which indicated to administer oxycodone 5 milligrams (mg) every 6 hours as needed for pain. Resident #1's electronic Medication Administration Record (MAR) indicated that Resident #1 was assessed for pain using a 0-10 rating scale with 0 being no pain and 10 the worst pain ever, and was administered as needed oxycodone 5 mg on the following dates:10/13/25 at 4:58 PM due to a pain level of 9. The medication was documented as effective.10/13/25 at 10:30 PM due to a pain level of 8 and the medication was documented as effective.10/14/25 at 3:18 PM due to a pain level of 6 and the medication was documented as effective. 10/15/25 at 11:55 AM due to a pain of 6 and the medication was documented as effective.10/16/25 at 11:25 AM with no pain level documented and the medication was documented as effective.A physician order dated 10/16/25 indicated to clean the posterior scalp, upper back and shoulder with normal saline, apply silver sulfadiazine (a cream used to prevent and treat infections of second- and third-degree burns) and cover with foam silicone border dressing daily and as needed for soilage, saturation or dislodgement. A Wound Care Specialist initial wound evaluation and management summary dated 10/15/25 indicated Resident #1 was evaluated due to wounds on his scalp, upper back and shoulder. The evaluation indicated Resident #1 presented with a full thickness burn wound to the posterior scalp measuring 10.5 centimeters (cm.) in length by 5.7 cm width and 0.1 cm. depth. Resident #1 had a full thickness burn wound to the right shoulder that measured 4.5 cm. length by 10.5 cm. width with 0.1 cm depth. A burn wound of undetermined thickness was observed to the upper back that measured 3.5 cm. length and 4 cm width. The wound summary indicated that the Wound Care Specialist performed a sharp selective debridement procedure to remove the necrotic or dead tissue from the wounds to the scalp and shoulder. A wound care observation was conducted on 10/15/25 at 1:30 PM with the Wound Care Specialist and the Clinical Coordinator. The right shoulder wound measured 4.5 centimeters (cm) length by 10.5 cm width with a depth of 0.1 cm. with serous drainage noted. The wound was a full thickness wound. The upper back wound measured 3.5 cm. length by 4.0 cm. width with no depth and slight blistering. The scalp wound measured 10.5 cm length by 5.7 cm width with a depth of 0.1 cm. The areas were cleansed, and the Wound Care Specialist performed the sharp selective debridement procedure in which he removed the blistered tissue from the wounds and applied dressings to the wounds. The resident complained of pain and tenderness to the wounds during the evaluation and treatment of the wounds. An interview was conducted with the Wound Care Specialist on 10/15/25 at 1:43 PM. The Wound Care Specialist stated that Resident #1's wounds were consistent with burns with full thickness wounds (severe burns that destroy all layers of the skin and require pain management and wound care with the removal of the dead tissue) to the right shoulder and the scalp. The Wound Care Specialist stated that he removed the blistered tissue to promote wound healing and Resident #1 tolerated the procedure well. The Wound Care Specialist stated that he would change the wound care treatment to silver sulfadiazine ointment daily to promote wound healing and prevent infection. An interview was conducted on 10/15/25 at 3:08 PM with the Nursing Supervisor that was on duty on 10/11/25 from 7:00 AM to 7:00 PM. The Nursing Supervisor stated that she called the Director of Nursing (DON) to report the incident and was instructed by the DON to be sure that the fireplace was off. The Nursing Supervisor stated that she did not know how to turn the fireplace off other than checking that the operating switch on the wall was not turned to the on position, however she stated that the switch was accessible to the residents. The Nursing Supervisor stated that she did not put anything over the operational switch for the fireplace to prevent it from being turned on and that she was not informed to call the Maintenance Director. The Nursing Supervisor stated that the Administrator was out of town at the time of the incident and was unavailable. The Nursing Supervisor stated that several times during the day after the incident occurred on 10/11/25, she observed that the fireplace was on and when she asked the staff, they stated that the residents turned it on because they were cold. The Nursing Supervisor stated that the switch on the wall that operated the fireplace was accessible to the residents and the residents were aware of how to turn on the fireplace. The Nursing Supervisor stated that the staff that worked the 11:00 PM to 7:00 AM shift often turned the fireplace on, and it was often observed on in the morning when the 7:00 AM to 3:00 PM staff reported for duty. The Nursing Supervisor stated that prior to the incident, she had not received any training or education regarding the fireplace, safety considerations or how to turn the fireplace off in an emergency. An interview with the Clinical Compliance Coordinator and the Administrator on 10/16/25 at 9:30 AM revealed that prior to the incident on 10/11/25 there was no protocol regarding the fireplace or any safety considerations. The Clinical Compliance Coordinator stated that the fireplace was in the common area of the facility and was part of the household/homelike model and therefore had not been considered a hazard prior to this incident. The Clinical Compliance Coordinator stated that there was no training or education provided to the staff regarding the safety and use of the fireplace prior to this incident. The Clinical Compliance Coordinator and the Administrator stated that on 10/13/25 they were informed of the incident with Resident #1 and the fireplace. The Clinical Compliance Coordinator stated that she did not think that the fireplace was used very often, and she never thought that it presented a safety hazard. She further stated that she was not aware that residents turned the fireplace on and off. An interview with the Physician on 10/16/25 at 3:05 PM revealed that burns had the potential for infection and were quite painful. The Physician stated that Resident #1 required wound care to the burns, close monitoring for signs of infection and evaluation by the Wound Care Specialist.An observation was conducted on 10/15/25 at 10:30 AM in the small household cottage in which Resident #1 resided. The facility consisted of 6 separate household cottages that feature a large kitchen, dining area and living room common area with a fireplace. In the household cottage that Resident #1 resided in a free-standing, double-sided fireplace with a metal mesh grate and glass in front of it was observed in the common area with residents in wheelchairs seated in the area. One side of the fireplace faced the living room portion of the common area and the other side of the fireplace faced the dining room portion of the common area. The fireplace was flush with the floor and did not have an adjustable safety gate or any type of physical barrier to prevent access to the metal grate and glass in front of the fireplace. The fireplace did not have a wall remote control with a child protection lockout feature. During the observation, cognitively impaired residents were observed propelling their wheelchairs and ambulating near the fireplace. A staff member was observed sitting in a chair along the wall in the common area approximately six feet away from the residents that were in the area. The fireplace was turned off at the time of the observation. The operational switch which resembled a light switch was observed on the wall beside the fireplace in the living room area at a height of approximately five feet and a locked clear plastic box was covering the switch. An observation was conducted on 10/17/25 at 10:15 AM of the second household cottage which was designated as an area for residents with that require specialized care due to dementia. A free-standing double-sided fireplace with a metal mesh grate and glass was observed. One side of the fireplace faced the living room area, and the other side faced the dining room portion of the common area. The fireplace did not have a safety gate or physical barrier preventing access to the metal grate and glass and the fireplace was flush with the floor surrounding it. During the observation, cognitively impaired residents were observed propelling their wheelchairs and ambulating near the fireplace. The assigned nurse and NA were observed in the area supervising the residents. The operational switch was observed on the wall in the living room area at a height of approximately five feet with a clear plastic box covering the switch. An observation of the other four of six household cottages on 10/17/25 at 10:45 AM revealed single sided wall fireplaces flush with the floor with metal grates and glass in front were present in the common living room areas. The operational switches were observed on the wall beside the fireplaces with clear plastic boxes covering the switches. An interview with the Maintenance Director on 10/15/25 at 11:30 AM revealed that he was in the process of shutting off the gas and electricity to all the fireplaces. The Maintenance Director stated that he was just informed on 10/15/25 of the incident that occurred with Resident #1 on 10/11/25. The Maintenance Director stated that the fireplace was gas and electric and it generated heat and had a blower that emitted the heat. The Maintenance Director stated that an operational switch on the wall turned the fireplace on, and it heated up. The Maintenance Director stated that the glass and decorative mesh grate were in place in front of the fireplace and he was not sure if they got hot. The Maintenance Director stated that the fireplace was a hazard due to being accessible to the residents. The Maintenance Director stated that he was in the position for a few months, and he had not thought about initiating any safety interventions around the fireplace. A follow-up interview with the Maintenance Director on 10/16/25 at 3:30 PM revealed that he had been in the position since March and was not aware that there was an issue with the fireplace until this incident occurred. The Maintenance Director stated that he was aware of the safety and operating instructions for the fireplace and was aware that the area in front of the fireplace should have been kept clear for 3 feet with no residents or objects placed in that area. The Maintenance Director stated that there were products available to purchase to ensure that the residents did not have access to the outside of the fireplace, but they were not in place at the time of the incident. The Maintenance Director stated that the fireplace was operable all the time and that the fuel source was not turned off at different times of the year. The Maintenance Director stated that he installed the covers over the switches that controlled the fireplaces on 10/15/25 when he was informed of the incident. An interview was conducted with the DON on 10/17/25 at 11:45 AM. The DON stated that she was an interim DON and just started in the position the week of the incident. The DON stated she received a call from the Nursing Supervisor on 10/11/25 and was informed that Resident #1 fell backwards and had sores on the back of his head due to the fall near the fireplace. The DON stated that Resident #1 was not supervised when he was placed close to the fireplace and then tipped his wheelchair over backwards striking the back of his head and shoulders on the fireplace. The DON stated she instructed the Nursing Supervisor to turn the fireplace off and that she did not know what else to tell her. The DON stated that she did not instruct the Nursing Supervisor to call the Maintenance Director to turn the heat source off for the fireplace at the time as she had not thought about it nor did she instruct her to ensure that all fireplaces in the facility were turned off. The DON stated the following day, 10/12/25, she received a call from the Admissions Coordinator who informed her that Resident #1 had sustained second degree burns when he fell. The Admissions Coordinator visited Resident #1 at the hospital on [DATE] and received the information regarding his condition and the burns. The DON stated that on 10/12/25 after receiving the information that Resident #1 sustained second degree burns, she did not call the Nursing Supervisor or Maintenance Director to follow up with further interventions regarding the fireplace. The Administrator was notified of the immediate jeopardy on 10/16/25 at 2:05 PM.The facility provided the following credible allegation of immediate jeopardy removal:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 10/11/2025, it was identified that Resident #1, was placed at dining room table in his wheelchair with his back facing the lit fireplace due to Resident #1 stating he was cold. It is unknown how long the fireplace had been on. Resident #1 was eating a breakfast sandwich and drinking coffee at the dining room table. Resident #1 is able move around in his wheelchair; however, his mobility varies from day to day. Shortly thereafter, NA #1 left the dining room area to assist a colleague with resident care regarding a transfer. NA #1 informed the resident she would return shortly after assisting another resident. Nursing Home Administrator re-interviewed NA #1 and nurse on 10/17/2025 for clarification regarding positioning of Resident #1. Resident #1 tipped his wheelchair over, landing on the ground while remain[TRUNCATED]

Based on observations, and staff, Ombudsman, Director of Dining Services, Certified Dietary Manager, Club Cook, Compliance Coordinator, and Registered Dietitian (RD) interviews, and record review, the facility failed to have no greater than a 14-hour lapse between the provision of a substantial evening meal and breakfast the following day for residents served their meals on 5 of 8 meal carts (Club area Cart-1&2; Pavilion area Cart; Haven area Cart, and River Bend area Cart) utilized for meal service. This practice had the potential to affect all the residents (91 of 91) in the facility for meal delivery. The findings included: An interview with the Ombudsman on 04/11/25 at 9:43 AM indicated that there were problems with the meal service times. The Ombudsman stated lunch and dinner meals were served early and breakfast was late. A schedule of the Dining Service Times was provided by the facility on 04/15/25. A review of this schedule indicated the meal cart delivery times allowed as much as 15 - 16 hours to lapse between the last meal of the day and first meal of the following day. An observation was conducted at the Rehabilitation Hall on 04/17/25 at 8:47 AM and indicated the breakfast trays were being served. An interview with Nursing Assistant (NA#1) on 04/17/25 at 8:47 AM revealed that they started serving breakfast between 8:15 AM and 8:45 AM. An observation in the Club Dining Room on 04/17/25 at 8:49 AM revealed the residents were being served breakfast. An interview with the Hospitality Aide (HA#1) 04/17/25 at 8:49 AM revealed they started serving the breakfast meal at 8:30 AM. An interview and observation with Resident #14 on 04/17/25 at 8:50 AM revealed the resident sitting in the Club dining room eating breakfast. Resident #14 stated breakfast was good, but anything would taste good when you were really hungry. The resident stated that it was a long time between dinner and breakfast, and she was hungry in the morning at breakfast. An observation on 04/17/25 at 8:55 AM revealed residents on the Riverbend Hall were being served breakfast trays. An observation in the Club Dining Room on 04/17/25 at 8:59 AM revealed meal trays were being plated to be served. On 04/17/24 at 9:30 AM, Director of Dining Services provided a copy of the facility's current Dining Service Times. A review of the facility's current Dining Service Times (not dated) were scheduled as follows: Breakfast 8:00 AM, Lunch 12:00 PM, and Dinner 5:00 PM. -The Club area Cart #1 delivered at 4:30 PM for dinner and 9:30 AM for Breakfast, indicative of a 17-hour and time span between the two meals. -The Club area Cart #2 was delivered at 4:30 PM for dinner and 9:30 AM for Breakfast, indicative of a 17-hour time span between the two meals. -The Pavilion area Cart was delivered at 4:30 PM for dinner and 8:30 AM for Breakfast, indicating a 16-hour time span between the two meals. -The Haven Hall meal cart was delivered at 4:30 PM for dinner and 8:30 AM for Breakfast, indicative of a 16-hour time span between the two meals. -The River Bend Hall meal cart was delivered at 4:30 PM for dinner and 8:30 AM for Breakfast, indicative of a 16-hour time span between the two meals. An interview with the Compliance Coordinator on 04/17/25 at 9:35 AM revealed the interdisciplinary team had discussed mealtimes in recent Quality Assurance (QA) meetings but had not come up with a conclusion as to how to ensure that meals are served timely and within the appropriate time frames. The Compliance Coordinator stated that there needs to be a process in place to ensure that meals are served within the appropriate time frames. An interview conducted on 04/17/25 at 9:40 AM with the Director of Dining Services and the Certified Dietary Manager revealed that residents' breakfast and dinner meals were currently served 15 hours or greater between the dinner meal and breakfast meal service times, which should be less than 14 hours. An interview conducted on 04/17/25 at 12:40 PM with the facility's Registered Dietitian (RD). During the interview, the RD was shown the facility's Dining Service Times schedule provided and asked what her thoughts were with regards to the time lapse between the evening meal and breakfast the following day. The RD stated, 15 hours or more, is not okay. The RD acknowledged that the facility would need to offer a nourishing snack to everyone if greater than 14 hours elapsed between Dinner and Breakfast the next day. She reported that to her knowledge, the facility did not meet these requirements. An interview was conducted on 04/17/25 at 12:50 PM with Club [NAME] #1. She said breakfast in the Club Dining Room was served usually between 9 AM - 9:30 AM. She said the facility staff does not pass out evening snacks to residents. She said facility staff used to go around with carts of substantial snack carts in the evenings, but no more. The [NAME] said dinner to breakfast meals from 5:00 PM to 9:00AM (16 hours) was way too long between meals, without a substantial evening snack. She said if they had the snack carts back, they would be able to go around and offer residents an evening substantial snack like a peanut butter or ham sandwich, like they used to, which according to her would be a great idea. Upon review, the [NAME] stated she was not sure why the dinner carts were delivered from the main kitchen around 4:30 PM or why breakfast was ready around 9:00 AM, which was over 15 hours between dinner and breakfast meals. The [NAME] also said she was not sure why the facility stopped using the snack carts or stopped offering residents a significant evening snack, like sandwiches, and now if the residents ask, they offer them a package of crackers or maybe a small plastic fruit cup.

Based on record review, and staff and resident interviews, the facility failed to provide a resolution and communicate the efforts to address grievances reported during Resident Council meetings for 10 of 12 months reviewed (June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, January 2025 February 2025, March 2025). Findings included. The Resident Council meeting minutes were reviewed for the period of April 2024 through March 2025. The meeting minutes did not include resolutions to the concerns expressed by the residents for the following months: 6/26/24: The Resident Council minutes noted concerns regarding not getting evening showers that were scheduled. Staff wearing headphones during their shift and having snacks available. 7/10/24: The Resident Council minutes did not include a discussion regarding resolution of old business including the concerns that were reported. Concerns were reported again regarding receiving scheduled showers and staff being on their phones and having ear buds in during resident care. 8/10/24: The Resident Council minutes did not include a discussion regarding resolution of old business including the concerns that were reported during the July meeting. No new concerns were reported. 9/4/24: The Resident Council minutes did not include a discussion regarding resolution of old business including concerns reported during July 2024 meeting. New concerns were reported regarding short staffing and answering call lights. 10/16/24: The Resident Council minutes did not include a discussion regarding resolution of old business. Concerns were reported regarding timeliness of medications, answering call lights, and getting breakfast served late. 11/13/24: The Resident Council minutes did not include a discussion regarding resolution of old business. Concerns were reported regarding timeliness of medications, answering call lights, and Nurse Aides being disrespectful, and staff using headphones and cell phones during shift. 12/11/24: The Resident Council minutes did not include a discussion regarding resolution of old business. Concerns were reported regarding shower schedules not being adhered to, and getting breakfast served to late and earlier than 10:00 AM. 1/29/25: The Resident Council minutes did not include a discussion regarding resolution of old business. No new concerns were reported in the meeting minutes. 2/12/25: The Resident Council minutes did not include a discussion regarding resolution of old business from previous months meetings. Concerns were voiced regarding shower schedules not being followed. 3/5/25: The Resident Council minutes did not include a discussion regarding resolution of old business. No repeat concerns were reported during the meeting. During the Resident Council meeting interviews on 4/16/25 at 10:05 AM residents in attendance stated that they had ongoing concerns that had been voiced for months during the Resident Council meetings. Residents stated their concerns were not being addressed and there was no discussion held at the beginning of each monthly meeting to address any resolutions regarding concerns voiced from the previous month. Residents reported breakfast continued to be served late on one of the units. Shower schedules continued to not be adhered to. Call lights were not being responded to within a reasonable time, and staff continued to use headphones or ear buds during care. During an interview with the Activity Director on 4/16/25 at 11:00 AM she stated she was recently hired two weeks ago and was now the full-time Activities Director. She stated she did not know how the meetings were being conducted prior to her taking on this role. She stated she would be including a discussion regarding resolution of any concerns at the beginning of each meeting moving forward. She indicated she had been instructed to notify the appropriate department of any concerns voiced during the monthly Resident Council meetings and would ensure that the concerns were being addressed. During an interview on 04/16/25 at 2:42 PM the Administrator stated she became the Administrator in January 2025. She stated she did not know how the previous Administrator and Activities Director handled the concerns voiced during the Resident Council meetings. She stated she had no documentation that could show the grievances reported during the monthly meetings had been addressed. She stated the process now included that the department managers typically attend the monthly Resident Council meetings, and the concerns voiced were sent to each department to address. She stated moving forward she would ensure that Resident Council minutes were being addressed each month. She indicated staff education would be held on Resident Rights and resolving and following up on grievances reported during the monthly Resident Council meetings.

Based on record review, and staff interviews, the facility failed to coordinate a plan of care with the Hospice provider for 2 of 2 residents (Resident #54 and #21) reviewed for Hospice care. The findings included: a. Resident #54 was admitted to the facility on [DATE] with medical diagnoses which included in part: Hospice, senile degeneration of the brain, influenza, malnutrition, abnormal weight loss, and dementia. An Election of Hospice Benefit form was signed by Resident #54's Responsible Party (RP) on 02/07/25. Review of the 02/20/25 significant change Minimum Data Set (MDS) assessment revealed Resident #54 had severe cognitive impairments, and Hospice care was indicated. Review of the care plan dated 04/10/25 included activities for daily living (ADL) self-deficit related to dementia, chronic pain related to the history of fractures, and a nutritional deficit problem. No facility care plan problems indicated that Resident #54 received Hospice services. A review of Resident #54's electronic care plan record did not reveal a current hospice plan of care, only Hospice progress notes. b. Resident #21 was admitted to the facility on [DATE] with medical diagnoses which included in part: encephalopathy (brain dysfunction or damage), polymyalgia (widespread muscle pain and stiffness), anorexia, depression, pleural effusion, dementia, pain, hypertension, and heart disease. Review of the 04/03/25 Minimum Data Set (MDS) assessment revealed Resident #21 had severe cognitive impairments, and Hospice care was indicated. An Election of Hospice benefit was signed by the resident and resident's power of attorney (POA) on 04/04/25. Review of the care plan dated 04/10/25 included activities for daily living (ADL) self-deficit related to dementia, acute and chronic pain related to the history of fractures, and a nutritional deficit problem due to diagnosis of dementia and weight loss. No facility care plan problems indicated that Resident #21 received Hospice services. An interview was conducted with the MDS Nurse Instructor/Director of Nursing (DON) on 04/15/25 at 1:15 PM. She confirmed that Residents #54 elected Hospice benefit on 02/07/25, and Resident #21 elected Hospice benefit on 04/04/25, and that the Hospice benefit services were ongoing. The MDS Nurse/DON stated that the facility care plan should contain information regarding Hospice services and interventions provided for the two residents but did not. The DON could not locate any documentation to show that the facility's care plan had been collaborated with the Hospice staff for either Resident #54 or Resident #21. She further indicated that she was training two new MDS Nurses, and that the two new MDS Nurses must have overlooked updating the facility's care plans for Resident #54 and Resident #21to include a Hospice section. The DON said she was ultimately responsible for not following up with Hospice as she should have, and for the facility of not having a clear process in place to obtain and coordinate a Hospice care plan. She said after the MDS Nurse received resident's complete Hospice admission documentation, including a Hospice care plan, the nurse would collaborate with the Hospice Nurse, to develop a facility Hospice care plan. The care plan should be developed and entered into the resident's electronic medical record within 3 to 5 days after receiving the Hospice documentation and care plan, which the MDS Nurse failed to do. An interview was conducted with the Clinical Compliance Administrator on 04/17/25 at 10:20 AM. She said it was her expectation that the MDS Nurses to incorporate Hospice documentation and care plan into their care plan, which they did not do. An interview was conducted with the Hospice Nurse on 04/17/25 at 10:30 AM. She stated that she kept most of Resident #54 and Resident #21's Hosice orders, assessments, and notes in her computer, which were scanned to the facility timely. The Hospice Nurse stated she was not aware that Resident #54 and Resident #21's Hospice care plans were not added to the facility's care plans by the facility's MDS nurses. She said the MDS nurses should have updated the facility's care plan to include her Hospice care plan, so that all facility and Hospice staff were all on the same page regarding residents' plan of care. An interview was conducted with the Administrator and Director of Nursing (DON) on 04/17/25 at 10:00 AM. The DON and Administrator revealed that there should have been Hospice information included in the facility's care plan for Resident #54 or #21 and there was not. An interview was conducted with the Administrator on 04/17/25 at 10:05 AM. She indicated it was her expectation that the Hospice section be available in the facility's care plan for all residents receiving Hospice services. She further explained that her expectation was for Hospice care plan to have been developed and available in the facility's care plan for Resident #54 and Resident #21, which there wasn't.

Based on record review and staff interviews, the facility failed to transmit Annual Minimum Data Set (MDS) assessments (Resident #14, Resident #58, and Resident #27) and a Discharge MDS assessment (Resident #80) to the Centers for Medicare and Medicaid Services (CMS) system 14 days after completion of the assessment for 4 of 23 residents reviewed for MDS assessments. Findings included: a.Resident #14 was admitted on [DATE]. Resident #14's Annual MDS assessment with an assessment reference date (ARD) of 1/31/25 was listed as production batch. The Annual MDS assessment had not been transmitted to CMS within the required timeframe. b. Resident #58 was admitted on [DATE]. Resident #58's Annual MDS assessment dated [DATE] status indicated finalized. The Annual MDS assessment had not been transmitted to CMS within the required timeframe. c. Resident 27 was admitted on [DATE]. Resident #27's Annual MDS assessment dated [DATE] status was listed as production batch. The Annual MDS assessment had not been transmitted to CMS within the required timeframe. d. Resident #80 was admitted on [DATE]. Review of Resident #80's MDS assessments indicated a discharge return not anticipated MDS assessment dated [DATE] had a status listed as finalized. This discharge MDS assessment had not been transmitted to CMS within the required timeframe. An interview was conducted with the Director of Nursing (DON) on 4/15/25 at 1:15 PM. The DON stated she was new to the position, the MDS nurses were all new and she oversaw the MDS calendar of assessments. The DON stated she was responsible for the management and coordination of the assessments. The DON stated there were 3 new nurses that had not worked in MDS previously and they were being trained but were not functioning yet in the role of MDS. The DON stated the term finalized indicated that the MDS assessment was completed but not transmitted and the term production batch indicated the MDS assessment was not sent. The DON indicated that the assessments were to be transmitted within the regulatory time frame which was 14 calendar days after the completion date. The DON stated the assessments were not transmitted within the required time frame due to changes in personnel in the MDS department.

Based on observations, record review and staff interviews the facility failed to treat a resident with dignity and respect when Nurse #3 spoke to a resident (Resident #41) in a demeaning way when she demanded the cognitively impaired resident to pick up food and dishes that the resident had thrown on the floor for 1 of 2 residents observed for dignity. This action would have caused a reasonable person psychosocial harm such as feelings of shame, humiliation, agitation, and degradation. Findings included: Resident #41 was admitted to the facility on [DATE]. Diagnoses included, in part, vascular dementia with behavioral disturbance, restlessness and agitation, Alzheimer's Disease, mild intellectual disabilities, and anxiety. A review of Resident #41's care plan written on 11/30/21 and last reviewed on 01/30/24 revealed a plan of care for the ability to self-propel in wheelchair with approaches to include that staff will allow resident to self-propel wheelchair as desired. Resident has episodes of verbal outbursts/verbal abuse toward staff at times with approaches to include staff will redirect resident with snack, stuffed bear, TV shows or drink when verbal outbursts occur. Staff should try to listen carefully to her requests when she displays outbursts. Resident displays behaviors related to particular dining habits, wants, needs, including pushing plates, food, and glassware when she determines she is finished. Approaches include remove dinner ware when resident requests or yells that she is finished. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #41 was moderately cognitively impaired and demonstrated no behaviors during this assessment. Resident #41 was coded as having adequate hearing. Resident #41 required supervision with one staff physical assistance with bed mobility and was dependent with one staff physical assistance with transfers, independent with locomotion on the unit requiring no assistance, and independent with set up with meals. She had impairment to both sides to lower extremities and used a wheelchair. She was always continent of bowel and bladder and on hospice care. A written statement by the Hospice Social Worker (no date) revealed During a visit with a hospice resident in the [memory care household], I witnessed an event that occurred in the dining room while I was seated in the TV area facing the dining room. I heard a very loud clatter come from the dining room, and when I looked up I saw [Resident #41] in front of the kitchen counter waving her hands towards the kitchen staff member. The kitchen staff member spoke loudly back at [Resident #41] regarding her behavior and accusing the resident of being rude/mean/not nice. The kitchen staff member went to go around the counter and the Social Worker could then see a bowl and spoon on the floor along with some cake realizing [Resident #41] had thrown these items on the floor. [Resident #41] turned her chair and went back towards her room out of sight from me. I heard the [kitchen staff member] speaking loudly at someone else out of sight and then saw [Nurse #3] come towards the kitchen staff member asking her what happened. The staff member spoke to [Nurse #3] who then turned around out of site and returned quickly with [Resident #41) and pushed wheelchair up to where the dish was on the floor. [Nurse #3] proceeded to speak in a very loud voice to [Resident #41] that she needed to get out of her chair and pick up the items from the floor. [Nurse #3] stood next to [Resident #41] pointing at the items and repeatedly telling [Resident #41] to get up out of her chair and pick up her mess. I then started to stand and head toward them to see if I could help. [Nurse #3] looked up at me and then stopped what she was doing, turned [Resident #41]'s chair around back towards the resident's room stating loudly that she would be calling the resident's family. A phone interview was conducted with the Hospice Social Worker on 02/08/24 at 9:45 AM. The Hospice Social Worker stated she remembered she was in the common area and Resident #41 was in her wheelchair by the dining area and Resident #41 threw her dessert on the floor. The Hospice Social Worker stated she heard Nurse #3 yelling at Resident #41 and recalled that Nurse #3 was being insensitive and rude. The Hospice Social Worker added, Nurse #3 was telling Resident #41 she needed pick up the mess she made which Resident #41 would not have been able to do because she was in a wheelchair. The Hospice Social Worker stated, Nurse #3 said loudly to Resident #41, pick it up! Pick it up, now! The Hospice Social Worker stated she proceeded to the dining area to see if she could help and Nurse #3 took Resident #41 to her room in her wheelchair. The Hospice Social Worker stated Resident #41 was not crying or yelling out and she could not recall if she said anything back to Nurse #3, but she mumbled. The Hospice Social Worker stated Resident #41 would mumble when she spoke and it was difficult to understand what she was saying. The Hospice Social Worker stated a dietary cook was in the kitchen serving food but she could not remember if the dietary cook said anything or not. She added, I remember awful person being said but I do not recall who said it. She stated if I put it in my statement, then she [the dietary cook] must have said it. A written statement by Nurse #3 dated 03/15/23 revealed at approximately 12:30 PM, this nurse was asked by Resident [#41] for a spoon. I gave her a fork because I did not hear her ask for a spoon. I walked off from dining room and was walking back toward office when the resident threw her cake on the floor. Resident stated that she wanted a spoon. Resident started to leave. I pushed the resident back in her wheelchair toward the food on the floor and said I should make you get down and clean it up. The resident looked at me and I pushed her in her wheelchair toward her room as I cleaned cake off of the floor. When I entered the resident's room she proceeded to spit food from her mouth on the floor which I then picked up. I told the resident that was unacceptable behavior. Resident apologized to this nurse and asked for a hug. An interview with Nurse #3 on 02/07/24 at 2:30 PM revealed Resident #41 had behaviors and would get agitated very easily. Nurse #3 stated Resident #41 could stand and pivot from her wheelchair with assistance. Nurse #3 reported on 03/15/23 shortly after lunch, Resident #41 was having a piece of cake and she asked for a utensil to eat her cake with. Nurse #3 reported she got a fork from the kitchenette and that was not what Resident #41 wanted so she threw the cake that was in the bowl and the fork and yelled she wanted a spoon. Nurse #3 stated she informed Resident #41 that she did not hear her ask for a spoon and that it was unacceptable for her to be throwing dishes and food. Nurse #3 stated she had elevated her voice because Resident #41 was hard of hearing and stated to the resident that she should make her pick up the bowl and spoon, but added, she was not yelling she was just speaking loudly due to her hearing loss. Nurse #3 stated Resident #41 did not cry or seem upset, but there was no excuse for speaking to Resident #41 that way and she asked to be removed from the household due to burn out. Nurse #3 stated she received education regarding treating dementia residents with dignity and respect and obtained additional training through human resources on more effective ways to manage dementia residents with behaviors. A written statement by Dietary Cook #1 dated 03/16/23 revealed yesterday 03/15/23 after lunch Resident [#41] was at the bar area and wanted a piece of chocolate cake. I put it in a bowl and Resident [#41] asked for a spoon. I was about to give her a spoon but nurse [Nurse #3] gave her a fork. I asked her why she did not give her a spoon and [Nurse #3] said she could use a fork. [Resident #41] then threw the bowl with the cake and fork. I was behind the bar in the kitchenette and asked [Resident #41] why she threw the bowl and said, that was not very nice. At that time, [Nurse #3] took the resident in wheelchair to bowl and told her to pick it up. Resident was about to stand up from wheelchair and pick it up and nurse looked like she changed her mind and wheeled resident to her room. I am not sure where the nursing aides were at this time. An interview with the Dietary Cook #1 on 02/07/24 at 10:30 AM revealed someone reported her about a violation and what they said happened was not what happened. Dietary Cook #1 stated Resident #41 had behaviors and would throw stuff sometimes and was aggressive with staff. She added, as she could recall, Resident #41 did not want a fork to eat her cake and Nurse #3 gave her a fork and she got mad and violently threw everything on the floor in the dining room. Dietary Cook #1 stated she recalled telling Resident #41 not to throw things because that was not nice and someone said she yelled at Resident #41 and that was not true. Dietary Cook #1 stated she was from another country and she did not speak English very well and when she spoke she spoke loudly, but she was not yelling. She stated she was on the other side of the counter when she saw Resident #41 throw the cake and she was speaking loudly so Resident #41 could hear her. Dietary Cook #1 stated she never said to Resident #41 she was an awful or mean person. Dietary Cook #1 stated she could not remember what Nurse #3's reaction was. She stated if she wrote in her statement Nurse #3 told Resident #41 to pick up the cake, then that is what she must have said. Review of a 5 day investigation report submitted to the Department of Health and Human Services dated 03/22/23 by the Administrator revealed the following investigation was conducted regarding Resident #41: Resident #41 was admitted to the memory support household in November 2021 with diagnoses to include vascular dementia with behavioral disturbance, anxiety disorder, and mild intellectual disabilities with a history of verbal and physical outbursts. Resident [#41] threw cake in a bowl in the dining room as she asked a fork rather than a spoon to eat the cake and nurse [#3] and household cook [Dietary Cook #1] spoke sharply to the resident. It was reported the nurse [#3] pushed resident in wheelchair to the cake and stated that she should have to clean it up. Resident then wheeled herself back to her room and staff cleaned up the cake. During an interview with Nurse [#3], she stated she felt she could have handled the situation better and she had had a particularly rough weekend in the household as some of the residents' behaviors were increased. The nurse [#3] voiced that she felt like she had become very burnt out and hit the wall. During this investigation, it became apparent that Nurse [#3] had been experiencing caregiver burn out. While interviewing the [Dietary] cook, it became apparent that related to her cultural back ground she is naturally a bit louder and animated than some of our other staff. This cook did state that after the resident threw the cake, she did ask the resident why she threw the cake and stated, that was mean. She was behind the kitchen counter during this interaction. The facility determined that this incident was not a willful act to harm a resident in any way but rather a cultural difference. An interview was conducted with the Administrator on 02/08/24 at 2:30 PM. The Administrator reported she expected any staff that was providing care for residents with cognitive impairments with behaviors needed to step away from situations that were escalating and reapproach. The Administrator added if a nurse or staff member was demonstrating burn out and was having challenges she would expect to be notified so that she would take steps to help support them and protect the residents.

Based on observations, record review, and staff interviews the facility failed to ensure perishable food items were labeled with a date when stored in 1 of 1 walk in refrigerator, and 1 of 1 reach in refrigerator. These practices had the potential to affect food served to residents. Findings included. During the initial tour of the kitchen conducted on 02/05/24 at 10:00 AM along with the Head Chef and the Director of Kitchen Services the following perishable food items were observed: a.) A cardboard box containing 3 large bags of raw chicken thighs that were not labeled with a date to show when the chicken was placed into the walk-in refrigerator. b.) A plastic sealed raw pork roast that was not labeled with a date to show when the pork was placed into the walk-in refrigerator. c.) Three plastic sealed tubes of raw hamburger meat that were not labeled with a date to show when the hamburger was placed into the walk-in refrigerator. d.) A container of liquid eggs was observed along with the Director of Kitchen Services in the reach in refrigerator located in the kitchen on the 300 hall. The container was not labeled with an opened date. The container read that it was recommended to discard the eggs 3 days after opening. During an interview on 02/05/24 at 10:30 AM the Head Chef stated the chicken thighs were placed in the walk-in refrigerator on 02/02/24, and the pork shoulder was placed in the walk-in refrigerator on 02/03/24. He stated both the chicken, and the pork were fresh and not frozen when they were placed in the refrigerator. He stated the 3 packs of hamburger meat were frozen and were placed in the walk-in refrigerator that morning on 02/05/24 to thaw. He stated he should have dated the meat when it was placed in the refrigerator, and it was an oversight. During an interview on 02/05/24 at 10:30 AM the Director of Kitchen Services stated the perishable meat was good to stay in the refrigerator for up to 7 days. He stated the meats should have been labeled with the date of when it was placed in the walk-in refrigerator. He stated the liquid eggs should have also been labeled with an opened date and agreed that the eggs were to be discarded 3 days after opening. He indicated additional education would be provided to the Kitchen staff regarding food storage. During an interview with the Administrator on 02/08/24 at 1:44 PM she indicated food should be labeled and dated when placed in the refrigerators for use according to the recommended guidelines.

Based on record review, observations, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 6/21/21 and the recertification and complaint investigation survey of 8/9/22. This was for one recited deficiency on the current recertification and complaint investigation survey of 2/8/24 in the area of food preparation and storage (F812). The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program. Findings included: This tag is cross referenced to: F812 Based on observations, record review, and staff interviews the facility failed to ensure perishable food items were labeled with a date when stored in the walk in and reach in refrigerators. These practices had the potential to affect food served to residents. During the recertification and complaint investigation survey of 6/21/21 the facility failed to ensure frozen items were sealed. Additionally, the facility failed to allow stainless steel pans and glasses to dry prior to stacking or placing the items in a cupboard. During the recertification and complaint investigation survey of 8/9/22 the facility failed to store handheld plastic scoops outside of dry food storage bins. An interview on 2/8/24 at 3:30 PM with the Administrator revealed ongoing monitoring and education was required to ensure that food was properly labeled and stored. The Administrator indicated the facility had changed to a corporate food service company to staff the dietary department. The Administrator stated that she would be working closely with the corporate food service company to ensure that regulations were followed and staff were properly trained.

Based on record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) admission assessment within the regulatory time frame as specified in the Resident Assessment Instrument (RAI) manual for 1 of 1 resident reviewed for completion of a comprehensive MDS assessment (Resident # 219). Findings included. Resident #219 was admitted to the facility on [DATE] with diagnoses of a fractured wrist and respiratory disease. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the assessment was signed as completed on 01/18/23. During an interview on 02/07/24 at 12:45 PM MDS Coordinator #1 stated many of the MDS assessments were behind. She stated she and MDS Coordinator #2 were trying to get the MDS assessments up to date. She indicated she was aware of the time frame to complete the admission assessments. She stated the assessments were late getting completed due to both MDS nurses having medical issues and due to a change in staff. During an interview on 02/08/24 at 9:29 AM the Director of Nursing (DON) stated she was aware the MDS assessments were behind. She stated the MDS nurses were going to start attending Interdisciplinary Team (IDT) meetings to help with their process in gathering information to complete the assessments. She indicated the assessments should have been completed in full and completed in a timely manner according to the regulations. During an interview on 02/08/24 at 3:45 PM the Administrator indicated she was aware the MDS assessments were behind. She stated MDS assessments were to be completed within the regulatory timeframe.

Based on observations and staff interviews, the facility failed to dispose of an expired box of acetaminophen 650 milligram suppositories (Rehab medication storage room) and an expired bottle of tuberculin solution (Riverbend medication storage room) for 2 of 3 medication storage rooms observed. Findings included: Observation of the Rehab medication storage room on 2/7/24 at 10:10 AM was made with Nurse #2 in attendance. Observation revealed a box of acetaminophen 650 milligram suppositories with a printed expiration date of 12/23. Interview on 2/7/24 at 10:10 AM with Nurse #2 revealed she did not know why the expired suppositories were in the cabinet and that they should have been removed. Observation of the Riverbend medication storage room on 2/7/24 at 10:15 AM with Nurse #3 in attendance revealed an opened bottle of tuberculin solution with a label which indicated an opened date of 12/6/23 and an expiration date of 1/6/24. An interview with Nurse #3 was conducted on 2/7/24 at 10:15 AM. Nurse #3 revealed the nurses try to check the medication expiration dates but they must have missed the bottle of tuberculin solution. An interview was conducted on 2/8/24 at 9:23 AM with the Director of Nursing (DON). The DON revealed she expected there would not be any expired medications in the facility. The DON further indicated she expected that expired medications would be discarded.

Based on record review and interviews with facility staff, Physician, Psychiatric Physician's Assistant (Psych PA), and observations, the facility failed to protect a resident with severe cognitive impairment from a hazardous environment when a resident wrapped a call light cord around her neck and tied the cord in a knot on three separate occasions (04/29/22, 07/12/22 and 07/22/22) for 1 of 7 residents reviewed for accidents (Resident #11). This deficient practice placed Resident #11 at risk for asphyxiation (deprivation of oxygen) which can result in loss of consciousness, [CONDITION(S)], or death. Immediate Jeopardy began on 7/12/22 when Resident #11 was observed with the call bell cord wrapped loosely around her neck and tied in a knot. The Immediate Jeopardy was removed on 8/6/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring systems are education put into place are effective. The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, mild intellectual disabilities, and depression. Review of the electronic medical record (EMR) for Resident #11 revealed she was admitted to Hospice services on 4/11/22 with a diagnosis of senile dementia. Further review of Resident #11's EMR revealed she had a fall on 4/19/22 and was diagnosed with a left and right sinus fracture. Review of Resident #11's quarterly Minimum Data Set assessment dated [DATE] revealed she was severely cognitively impaired. She required extensive assist of 1 staff with activities of daily living (ADL). Resident #11 required extensive assistance of 1 staff with bed mobility, and toilet use. She required limited assistance of 1 staff for mobility and was occasionally incontinent of urine. a. A nurse progress note dated 4/29/22 at 5:01 PM by Nurse #1 revealed she was called to Resident #11's room by a nurse aide (NA). She observed Resident #11 with the call bell cord loosely wrapped around her neck with 2 knots in it. The call bell cord was removed from the room and an alternate call bell was provided. Review of the electronic medical record (EMR) revealed a physician's order dated 5/4/22 to obtain a psych consult. A psychiatric evaluation for Resident #11 was conducted on 5/5/22 by the Psych PA. The Psych PA assessment revealed Resident #11's suicidal ideation was now resolved however had suicide attempt over the weekend without true intention to harm herself. She indicated Resident #11 was in a secured nursing facility, with licensed clinical staff so no safety concerns were identified. The Psychiatric PA recommended antidepressant, antianxiety medication, and antipsychotic medication changes and she would follow-up in 2-4 weeks as needed. Review of the care plan (last reviewed on 7/30/22) for Resident #11, revealed a plan of care dated 5/10/22 for resident unsafe with call bell, wraps cord around neck at times with one intervention: to provide resident with manual bell for call bell usage and ensure manual bell is within reach. A psychiatric periodic evaluation for Resident #11 was conducted on 5/19/22 by the Psych PA. The Psych PA indicated the call bell cord was still removed from Resident #11's room. The Psych PA's mental status examination revealed Resident #11 had poor judgement and was no longer having suicidal ideations. The Psych PA indicated in the recommendations that she would allow Resident #11 to have her call bell cord back at this time. A psychiatric periodic examination was conducted on 5/31/22 by the Psych PA. The Psych PA indicated Resident #11 was very happy to have her call bell cord back. The Psych PA revealed that the facility nursing staff reported Resident #11 used her call bell frequently and there had been no issues with it. The Psych PA indicated Resident #11 was not experiencing suicidal ideations anymore. The Psych PA revealed in the recommendations that she would allow Resident #11 to have her call bell back at this time. b. A nurse progress note dated 7/12/22 at 6:50 AM by Nurse #2 revealed she had observed the call bell was wrapped loosely around Resident #11's neck and tied in a knot when she entered the room. Nurse #2 indicated she had telephoned the Psych PA and they agreed Resident #11 was displaying attention-seeking behaviors and was not at risk of self-harm at this time. The call bell cord was not removed from Resident #11's room by Nurse #2. There were no new interventions initiated to monitor Resident #11 more closely by the facility or the Psych PA. A psychiatric periodic evaluation was conducted by the Psych PA on 7/12/22. The Psych PA's history of present illness indicated Resident #11 had placed the call bell cord around her neck that morning. The Psych PA revealed Resident #11 denied any suicidal ideations and denied she had made any attempts on taking her own life. The Psych PA further revealed that Resident #11 continued to have very loose and vague suicidal threats, that she uses for attention seeking. The Psych PA indicated in the recommendations that she did not feel that Resident #11 needed any suicide monitoring or precautions at this time, and she felt these were attention seeking behaviors and there was no danger to self at the time. c. A nursing progress noted dated 7/22/22 at 6:27 PM by Nurse #1 revealed Resident #11 was observed with the call bell cord loosely wrapped around her neck with a knot in it. Resident #11 was also observed with the bathroom call cords wrapped around her neck. Nurse #1 revealed she had received a telephone order from the Hospice Physician to administer Resident #11 an antianxiety medication by injection. Nurse #1 indicated in the progress note that Resident #11 had been inconsolable all day and needed to see someone about her trying to kill herself. The call bell cord was removed by the Director of Nursing (DON) and replaced with a manual call bell. An interview with the DON on occurred on 8/4/22 at 8:55 Am. She stated that she had removed the call bell cord from Resident #11's room on 7/22/22. She stated that she had removed the call bell cord from the room because it was on a Friday, and she thought that was the best thing to do over the weekend. A psychiatric periodic evaluation was conducted by the Psych PA on 7/26/22. The Psych PA indicated she had once again been asked to see Resident #11 due to continued behaviors that appear to be suicide attempts. The Psych PA indicated Resident #11 was continuing to wrap the call bell cord around her neck, and then remove when staff entered the room. The Psych PA notes revealed Resident #11 at first denied that she was trying to kill herself by wrapping the call bell cord around her head, but later made a comment that she wished she was dead. The Psych PA indicated that Resident #11 reported she no longer plans to use the cord, and was told if she does, it will be taken away. The Psychiatric PA's assessment revealed Resident #11 continues to make suicidal comments, but no plan, for attention mostly. The Psych PA's recommendation for Resident #11 indicated that she did not need any suicide monitoring or precautions at this time because she felt this was attention seeking behavior and there was no danger to herself at this time. The DON removed the call bell from Resident #11's room and replaced it with a manual bell. An observation of Resident #11 on 8/3/22 at 8:55 AM revealed an approximately 6-foot-long call bell cord in her bed within reach. The cord for the electric bed control was noted beside bed and within reach of Resident #11. Resident #11's bathroom was observed to have an emergency cord in it and a shower cord. An interview with Nurse #1 was conducted on 8/3/22 at 09:20 AM. She stated she knew Resident #11 and her family and that these behaviors were attention seeking. She stated Resident #11 had other attention seeking behaviors such as hollering and shaking the bed rails. She stated the call bell cord had been removed from the room on 4/29/22 and 7/22/22 and replaced with a manual call bell. She further stated she didn't know who had given Resident #11 the call bell cord back. She indicated on 7/22/22, Resident #11 was saying she wanted to die, and she wished the place would burn down or she would have a [CONDITION(S)]. She stated Resident #11 was able to wheel herself into the bathroom and transfer on to the toilet. She further stated Resident #11 required assistance with transferring back to the wheelchair. A telephone interview was conducted the Psych PA on 8/3/22 at 10:50 AM. She stated she had not given Resident #11 her call bell cord back. She stated when she saw Resident #11 on 7/26/22 the call bell cord was already back in her room. She further stated Resident #11 was not suicidal when she interviewed her. The Psych PA indicated Resident #11 was attention seeking and she didn't think she would harm herself. She stated it was up to the facility to decide if the call bell cord should remain in Resident #11's room. A telephone interview was conducted on 8/3/22 at 11: 10 AM with a Physician in Resident #11's primary care physician's office. The Physician stated Resident #11's primary care physician was on vacation this week. The Physician indicated she was familiar with Resident #11 and had seen her twice. She stated she had been on call for one of the incidents involving the call bell cord. She stated that Resident #11 had severe dementia and poor judgement. She further stated the facility and Psych PA should not have depended on the Resident to make good decisions or trusted her judgment. She further stated that removing the call bell cords from the room was the facility's decision because they knew Resident #11 the best. An observation and interview with Resident #11 on 8/3/22 at 11:32 revealed she was sitting on the toilet in the bathroom with the wheelchair beside her. Resident #11's speech was difficult to understand because she has had a stroke and she is edentulous (no teeth). She indicated that she had gotten herself to the bathroom and transferred to the toilet by herself. An interview with Nurse #2 occurred on 08/4/22 at 11:55 AM. She stated that she had observed Resident #11 with a call bell cord wrapped loosely around her neck with a knot in it. She further stated that she had immediately untied the cord and removed it from her neck. She indicated that Resident #11 had not had any bruising or red marks on her neck. She stated that she just had a feeling these behaviors were just attention seeking. She further stated that she had not removed the call bell cord from Resident #11's room on July 12, 2022. The Administrator, DON, and the Clinical Services Administrator were notified of the Immediate Jeopardy on 8/4/22. F689 On 8/6/22 the facility provided the following credible allegation of Immediate Jeopardy Removal 1. Identify those recipients who have suffered, are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to protect a resident from a hazardous situation when the resident wrapped a call light cord around her neck on three separate occasions (Resident #11). The residents at risk are those with severe cognitive impairment. There were 73 residents identified on the most recent 802. The 802 is a roster sample matrix used to identify pertinent care categories for all residents. 2.Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action is complete. Resident #11 was in a private room. The call bell was immediately removed by the Social Worker upon identification by the surveyor on 8/3/22. Room assessment was completed on 8/4/22 at 1:15 pm to identify any other potential accident hazards in room. This included modification of all other cords in the room (bathroom cord and bed control cord) to ensure ability to use with a length short enough to prevent ability to wrap around neck. No other hazard beyond the cords were observed during the assessment. This task was completed on 8/4/22 at 1:30 pm. An audit was conducted on 8/4/22 to identify residents who triggered for severe cognitive impairment on the current MDS 802 (Resident Roster). Their environments are to be assessed to identify and remove any potential hazards. The audit was conducted by the Administrator and Director of Nursing. The resident environments will be assessed by the Nurse Educator, staff (MDS) nurse, and the Social Worker to be completed by the end of business day 8/5/22. Training: On 8/4/22 the facility Nurse educator-initiated training on identifying and removing hazards in the environment of cognitively impaired residents. Education will include supervision of residents to avoid accidents and hazards and will extend to 100% against payroll. The majority of work will be completed by end of business day 8/5/22 and all other staff including contract prior to or at the beginning of the next work shift. Completion date: 08/06/22 The Licensed Nursing Home Administrator is responsible for ensuring the removal plan had been implemented and completed. The facility alleges Immediate Jeopardy was removed 08/06/22. On 8/9/22 the Immediate Jeopardy removal plan was verified by onsite validation. A sample of staff that included nurses, nursing assistants, and housekeeping staff were interviewed regarding in-servicing related to the deficient practice. All staff interviewed stated they received Inservice training including in person education and written materials regarding identifying and removing hazards in the environment of cognitively impaired residents. All staff verbalized understanding of the in-services that were presented. A review of all documents developed to correct the deficient practice was completed. Facility policies and procedures that were revised to address the deficient practice were reviewed. The audit forms that were developed to monitor that the systems put in place were effective were also reviewed. An observation of Resident #11's room revealed: that there was a manual call bell; the bed cord was zip tied under the bed where she could not reach it; and the bathroom emergency call bell cord was shortened to a length that would not wrap around her neck. The facility's Immediate Jeopardy removal date was validated to be 8/6/22.

Based on staff interviews, physician interview and record review the facility neglected to identify the urgency for the need for medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #240). Resident #240 was sent to the hospital for evaluation at approximately 8:20 AM on [DATE] by the on-coming shift. He expired the next day ([DATE]) at the hospital with discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Immediate Jeopardy began on [DATE] when Resident #240 experienced falls with a head injury at 2:45 AM and again at 6:00 AM and the facility neglected to initiate immediate medical attention. 911 was not called until 7:54 AM. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #240 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #240 had mildly impaired cognition. He had trouble sleeping and concentrating on ,d+[DATE] days during the assessment period with hallucinations. He required limited assistance with bed mobility, dressing and personal hygiene. He was not steady and was only able to stabilize with staff assistance for moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfers. He had no impairment of his upper or lower extremities. No mobility device was selected. At the time of the assessment, he had falls prior to admission and one fall since admission with no injury. He received Physical Therapy on 5 days during the assessment look back period. The following care plan was dated [DATE]. Falls: Resident #240 was at risk for falls related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal target date was [DATE] for Resident #240 not to sustain serious injury related to falls through the next review. Approach start date of [DATE]: Assess fall risk upon admission, quarterly and as needed; encourage resident to call for assistance prior to transferring or ambulating; keep call bell within reach and answer promptly; keep frequently used items within reach; keep pathways free from clutter and provide adequate lighting; non-skid footwear when out of bed; Physical Therapy for balance, gait, transfers and safety as indicated; resident to be in common area for frequent observation when possible. A nursing note written on [DATE] at 3:45 AM by Nurse #1 documented, CNA reported to this writer that resident was sitting on the floor in his bedroom. This writer observed resident sitting on the floor at the foot of his bed legs crossed in front of him holding his head with both hands. Resident unable to recall how he got on the floor. States he hit his head this writer noticed a hematoma to resident forehead and blood from a straight line laceration across his nose. Resident assessed for further injury. No other injury noted at this time. Assisted resident to bed with some resistance by resident. Asked resident if he felt he needed to go to the hospital and resident declined and said he would be ok. Resident was pleasant but did not appear to want much help from staff. Gave resident wash cloth to wipe blood off his nose. Attempted to assist resident declined. Stated he is ok and wanted to rest in bed. Neuro checks initiated and WNL (within normal limits). VSS (vital signs stable) ,d+[DATE]-97.[DATE]-99% (blood pressure, temperature, heart rate, respirations, oxygen saturation) on room air. Called RP (Responsible Party) and left voicemail message. Facility Neurological Check Sheets generated for Resident #240 were reviewed. The first set of neurological check sheets began at 2:45 AM on [DATE] after the first fall with no abnormal findings documented. The second set of neurological check sheets began on [DATE] after the second fall with no abnormal findings documented. Assessments were documented as completed every 15 minutes x 4, then every 30 minutes x 4 after the first fall and every 15 minutes x 4 after the second fall before the resident was transferred to the emergency room . The last neurological check was completed at 7:15 AM. A second nursing note written on [DATE] at 7:29 AM by Nurse #1 documented, CNA reported to this writer that resident was sitting on the floor at bedside and has small amount of blood on the back of his head. This writer observed resident sitting beside his bed feet in front and legs crossed with his shoes on. Resident has a 2.5 x 0.5 abrasion to the back of his head. Resident unable to recall events that led him to be on the floor. Assessed for further injury with none noted at this time. VSS ,d+[DATE]-97.[DATE]-98% RA (room air). Neuro checks WNL. During a telephone interview with Nurse Aide #1 on [DATE] at 10:45 AM she stated at approximately 2:30 AM on [DATE] she did rounds and found Resident #240 sitting on the floor and at approximately 6:00 AM she went back and again and he was sitting on the floor. She reported both incidents to the nurse immediately. She remembered she noticed a hematoma on his forehead after the first fall and a bruise on the back of his head after the second fall. She recalled the resident was confused but alert. She remembered the nurse asked him if he wanted to go to the hospital after the first fall and he declined. He told her he was ok when she asked him. During a telephone interview with Nurse #1 on [DATE] at 6:57 PM she stated she remembered Resident #240. She recalled he was usually quiet and sat with his head down. She recalled the first fall occurred around 3:00 AM. She stated he had responded appropriately to questions and did not want to be bothered. She felt he was capable of making the decision not to go to the hospital and that it was normal for him to resist care. She stated she started neuro checks after the first fall. She could not remember how often she completed the neuro checks. She did not remember calling the physician. She stated she did not know the resident was on a blood thinning medication. She noted that because his vital signs were normal and he had stated he did not want to go out she had not sent him to the emergency room . She stated she had called the family and left a voice message. She could not recall what time the second fall had occurred but remembered it was toward the end of her shift in the morning. She stated if she had known Resident #240 was on a blood thinner she would have called the physician after the first fall for instructions. She could not remember how often the resident was checked during the night between the first and second fall. She believed she saw Resident #240 right before she left her shift in the morning and he may have been lying in bed but stated she didn't really remember. During a second telephone interview with Nurse #1 on [DATE] at 4:20 PM she stated she could not remember how many times she assessed Resident #240. She recalled when she had completed the neurological assessments she used a little flash light pen thingy to assess his pupils, and checked his movement by having the resident squeeze her hands. She could not recall which questions she had asked him to determine his level of alertness. She did recall he was awake most of the night with his light on but could not remember if he had a roommate. She stated after Resident #240 fell at approximately 6:00 AM she was also completing other tasks that included passing medications to other residents, giving report to the oncoming shift and completing the narcotic count. She could not remember how many times staff checked on the resident after the second fall. She stated she had not called the physician or sought emergency medical attention for the resident. A nursing note written on [DATE] at 8:00 AM by Nurse #3 documented, Resident observed sitting on edge of bed with large hematoma on his forehead and a large hematoma on the back of his head. Resident complains of headache, dizziness and back pain. Phoned on call provider, no answer. Notified Supervisor (Nurse #2) and called 911. EMS arrived and took resident out of facility via stretcher. Notified (family member) of injury and transfer to hospital. During a telephone interview with Nurse #3 on [DATE] at 7:52 PM she stated she had came on shift the morning of [DATE] and in report from Nurse #1 she learned Resident #240 had fallen twice during the night so she went to check on him as soon as she got out of report. She commented he was sitting on the edge of his bed trying to put his pants on. He was holding his head, so she asked him if his head hurt. He replied his head hurt and he was dizzy. She recalled he was determined he was getting up so she helped him put his pants on and got him up to a wheelchair. Nurse #1 was leaving and she asked her if she had called the provider. She remembered Nurse #1 told her she had sent the provider an email. The supervisor, Nurse #2, came through at that time and she asked her to assess the resident. They both decided he needed to go to the emergency room . She stated she called the provider and did not get an answer so they sent the resident out, sometime between 7:30 and 8:00 AM. She recalled the physician called back later and she told her she had sent the resident to the emergency room . She commented she knew immediately that he needed to go to the emergency room because he had a headache and was dizzy after falling twice. She indicated she would have called the provider after the first fall and obtained orders because Resident #240 was on a blood thinner and had a hematoma on his head. During an interview with Nurse #2, Clinical Coordinator and Weekend Supervisor, at 12:40 PM on [DATE] she stated she was familiar with Resident #240. She had gone to make rounds the morning of [DATE]. She discovered Resident #240 had fallen in the early morning and then again toward the end of third shift. She recalled he was up in a wheelchair when she arrived. The day nurse asked her to look at him because she didn't think he looked right. She assessed the resident and agreed. She remembered he was not talking like he normally did and his pupils were not equal. She stated she told Nurse #3 to send him out for evaluation. She noted he declined rapidly and in a few seconds time he was not responding and hung his head down. She commented she looked at the neuro checks that had been completed during the night and they looked normal. She explained he had been on a fall protocol that included an optimal low bed (when sitting on edge feet touched the ground), frequent checks, call bell within reach, when ambulating used his walker, and reminders not to get up alone. She stated he had intermittent confusion. She said staff had met after the falls and talked about what staff could have done differently to prevent the falls and decided staff had done everything to prevent him from falling. She learned after the first fall he went back to sleep then woke up and fell again. She said staff later went into his room to try to determine where he had fallen and look for evidence of blood where he might have hit his head on but couldn't find any clues. She reiterated when she initially encountered him he was talking to staff and then he hung his head and stopped talking. Review of the EMS (Emergency Medical System) records documented a 911 call was received at 7:54 AM on [DATE]. EMS arrived at the facility at 8:00 AM. At 8:07 AM EMS recorded the following vital signs for Resident #240: Blood pressure ,d+[DATE], heart rate 76, respirations 20, oxygen saturation 88%, pain level 10. EMS documented he had a hematoma to the forehead, dried blood on the bridge of his nose and a fresh abrasion and hematoma to the back of his head. He was on a blood thinner. Resident #240 complained of head and neck pain and was placed in a cervical collar. He was transported to the emergency room and arrived at the hospital at 8:45 AM. Review of the hospital record dated [DATE] documented the patient (Resident #240) was evaluated in the Emergency Department after a fall and documented: He had apparently fell and hit the back of his head and there was also a contusion on the anterior (front) side. The patient was on [MEDICATION(S)]. A scan was performed and revealed an acute right cerebral (brain) convexity hematoma measuring up to 3.2 CM (Centimeters) in thickness over the frontal lobe (of the brain). There was a 9 MM (Millimeter) leftward midline shift. There was also a posterior (back of the head) scalp hematoma. He was evaluated by Neurosurgery and found to not be an operative candidate, thus making his injury not survivable. He expired on [DATE] at 7:06 PM. The hospital documented his discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the on-call physician on [DATE] at 4:15 PM she stated she was familiar with the incident and confirmed she had been the physician on-call that weekend. She said staff first called her around 8:00 AM on [DATE] after they had sent the resident out to the emergency room . She stated she had not been called in the middle of the night when Resident #240 first fell . She explained she would have expected staff to call her the first time he fell . She noted she would have sent him out at that time knowing he had hit his head and that he was on a blood thinner ([MEDICATION(S)]). She commented that not all residents who fell and hit their head were sent out if they had not had any symptoms but because he was on [MEDICATION(S)] she would have ordered him to be sent for evaluation. She further explained she knew the resident fell twice but said she could not determine which fall was fatal. She stated Resident #240 would have been able to tell staff if he had a headache, which was the first sign of a subdural hematoma, but also knew the resident had some confusion and was not sure if he was able to determine on that night if he needed to go to the hospital or not. She stated she would have sent him out had she been called. The Executive Administrator and the Clinical Services Administrator were notified of Immediate Jeopardy on [DATE] at 5:52 PM. Immediate Jeopardy Removal Plan Davis Health Care Center [DATE] 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance a. Resident #240 is no longer in the facility. Resident admitted to Davis Health Center [DATE] with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident chart documentation reflects at approximately 2:45 a.m. on [DATE], resident observed sitting on floor at foot of bed. Nurse assessment reveals hematoma to forehead with small straight line laceration to nose. Nurse and resident clean resident face, resident assisted back to bed. Nurse initiates neuro checks, (rule of 4's) retrieves Vital Signs (,d+[DATE]-97.,d+[DATE]- 17. 99% RA). Nurse documents per chart, called and left message with responsible party following first event. The nurse did not notify the physician that the resident fell and hit his head, as nurse documents resident remained at baseline for Range of Motion, cognition and denying pain. Nurse stated reviewed medications at time of fall, however, did not see blood thinning agent. Later in same shift resident observed sitting on floor side of bed with shoes on. Nurse documented assessment reveals 2.5 x 0.5 abrasion to back of head with small amount of blood. Resident unable to recall event. Vital Signs retrieved (,d+[DATE]-97.[DATE]-98% RA). Neuro checks continue to be normal. At change of shift, day shift nurse enters room observes resident sitting on bed. Nurse denotes hematoma to both forehead and back of head. Resident voices headache, back pain and dizziness. Nurse immediately calls on-call provider and notifies supervisor. Both nurses assessing resident, stating condition deteriorating rapidly. EMS is activated and resident is sent via stretcher to hospital. Wife is notified of falls and transfer to hospital. Later in day Clinical Coordinator has follow-up conversation with family. Hospital reports CT reveals subdural hematoma, resident unresponsive, code status changed to DNR with palliative consult. Per hospital record, resident was admitted on [DATE] and expired on [DATE] with discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] b. 39 residents have been identified as ordered and receiving blood thinners. 4 of the 39 residents identified as receiving blood thinners have had a fall in the past 60 days. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. a. The facility policy regarding intervention for residents experiencing a fall and on blood thinner was revised [DATE]. The Physician will be contacted for instruction on how to care for residents who have fallen and are on blood thinner even in the absence of apparent injury. b. Care plans for the identified residents were reviewed [DATE] by Clinical Coordinator Nurses and DON to ensure blood thinner is noted on the care plan. c. Training: i. Facility nurse education initiated on [DATE] on the revised protocol for intervention for residents experiencing a fall and on blood thinner. Education was provided by Clinical Coordinator Nurses and RN Staff Educator in person and with written materials. 11 Nurses received the education on [DATE]. Education continues for other nurses by Clinical Coordinator nurses/RN Staff Educator or designee prior to the start of their next worked shift. Any staff from Agencies will receive the same education prior to any worked shift by the Clinical Coordinator/ RN Staff Educator or designee. The training is recorded on a training log with staff signature. ii. Facility nursing staff education initiated [DATE] on the Falls Risk Assessment and Prevention Policy. Education was provided by Clinical Coordinator Nurses/RN Staff Educator in-person with written materials. 11 Nurses received the education on [DATE]. Education continues for other staff by Clinical Coordinator nurses/RN Staff Educator or designee prior to the start of their next worked shift. Any staff from agencies will receive the same education prior to any worked shift by the Clinical Coordinator nurses/RN Staff Educator or designee. The training is recorded on a training log with staff signature. d. All nurses, both staff and agencies, will receive training regarding immediate medication review for all fall events to see if blood thinning agent is being used. This training is being provided by Clinical Coordinator nurses/RN Staff Educator or designee and will begin promptly. Person Responsible for implementing the Removal Plan: Clinical Coordinator Nurses/RN Staff Educator or designee. Facility alleges Immediate jeopardy was removed [DATE]. The Removal Plan of Immediate Jeopardy was validated on [DATE] at 5:15 PM. A sample of staff that included nurses, nurse aides, medication aides and a case manager were interviewed regarding in-servicing related to the deficient practice. Three staff members were in the process of being in-serviced during the validation process and all other nursing staff interviewed stated they had been in-serviced regarding the facility policy and procedure related to Fall Risk Assessment and Prevention and Post Fall Protocol including in-person education and written materials. Training included all nurses, both staff and agencies. A review of all documents developed to correct the deficient practice was completed. All facility policies and procedures that were revised to address the deficient practice were reviewed. A review of audit forms that were developed to ensure that in-services presented to all staff were understood and allowed an opportunity for staff to interact with dialogue were also reviewed. Immediate Jeopardy was removed on [DATE] at 5:40 PM.

Based on observation, staff interviews and record review, the facility failed to use a mechanical lift for transfers for 1 of 3 sampled residents (Resident #1) reviewed for transfers, resulting in three left lower extremity fractures. Findings included: Resident #1 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of resident ' s most recent comprehensive MDS (Minimum Data Set) dated 2/21/14 revealed the resident was severely cognitively impaired and required extensive assistance with the physical assistance of two people for transfers. Resident ' s quarterly MDS dated [DATE] had documentation that the resident continued to need extensive assistance with the physical assistance of two people for transfers. During review of the medical record on 9/17/14 there was not a formal care plan written regarding resident ' s ADLs (Activities of Daily Living) or how she was to be transferred. A review of Resident #1 care card (A card that is in each resident ' s closet stated the care needed for the resident) revealed documentation that the resident was to be lifted with a mechanical lift and with the assistance of two people. The care card wasn ' t dated; however it was revised after the incident that that the resident was to be lifted with a mechanical lift with the assistance of three people. Further review of the resident ' s medical record it was noted that on 8/25/14 at 12:31pm the NP (Nurse Practioner) documented that the resident had been seen today at nursing request due to sudden onset of left knee pain after being transferred today by staff. The NP assessed the resident ' s knew the and documented her assessment as the resident was having pain with when her leg was moved, swelling to the resident ' s knee and that is was warm to the touch. The assessment/plan was documented as acute knee pain: x-ray and pain meds as needed. Further interventions based upon findings. Review of mobile x-ray report dated 8/25/14 revealed the resident had acute fractures of the tibia and the fibula. A nursing note was written on 8/25/14 at 6:21pm stated earlier in the shift, resident ' s left knee was observed swollen, warm and painful to touch. NP in facility and assessed (resident ' s name) left knee. Orders received for x-ray of left knee. X-ray results showed acute fracture at the proximal tibia. Results called to NP. Orders to send to emergency room to evaluate and treat left knee. Hospital records for the resident ' s emergency room visit on 8/25/14 were reviewed. A form from the emergency department had documentation of [DIAGNOSES REDACTED]. The discharge directions were for the resident to wear an immobilizer and see an orthopedist. On 9/17/14 at 12:25pm, an observation was made of staff transferring resident to the bed from a chair. Three staff members were present for the transfer. Two staff members used a mechanical lift and the other staff member held the residents left leg during the transfer. The resident ' s left leg had an immobilizer in place. Her left foot appeared to be rotated towards the left and edema was visible. The resident did grimace during the transfer. During an interview with the administrator on 9/17/14 at 10:30 am, the administrator indicated Resident #1 was transferred by a nursing assistant and the hair stylist on 8/25/14 and did not use a mechanical lift. She stated the facility did investigate the incident and that both employees were suspended during the investigation. She further stated that neither staff member still worked at the facility; that both resigned while the facility was conducting the investigation. The administrator provided the facility's investigation which included statements from both the nursing assistant and the hair stylist. She also stated that once determined an incident occurred from an improper transfer that all staff were inserviced about using mechanical lifts as well as safety during transfers. During an interview with Nurse #1 on 9/17/14 at 2:00pm, the nurse indicated that she was working the day the resident was injured. She stated that she is the resident ' s usual nurse on days. She stated that on 8/25/14, NA #1 came and got her to report the resident was yelling and that her leg was hurting. She further stated that once she was in the room she noticed the resident did not have a mechanical lift pad under her. Nurse #1 said that she asked the nursing assistant at that time if she used the lift for the transfer and the nursing assistant said no. She further indicated there are care cards in every resident's closet that communicates the resident's specific care needs to the care givers and that Resident #1 care card states that the resident is to be transferred using a mechanical lift. She explained that once she was in the room the resident was assessed and it was noted that the resident's left knee was warm and swollen. She indicated she immediately notified the Nurse Practioner and orders were given for x-rays. During a telephone interview with NA #1 on 9/17/14 at 3:02pm, the nursing assistant stated she was assigned to resident #1 on 8/25/14. She indicated she got the resident up that morning after providing morning care and with the assistance of another nursing assistant transferred her to her recliner using a mechanical lift. She stated the resident was ok when she left the room. The nursing assistant further stated that later in the morning the hair stylist had requested the resident be brought to the beauty shop to have her hair done. The nursing assistant stated she asked the stylist if he was comfortable helping her lift the resident from the recliner to a wheelchair and he said yes. She explained that she was on one side of the resident and the stylist was on the other side. She indicated that she put one arm under the resident ' s arm and one under her thigh and that the stylist did the same on the resident ' s other side. She further stated they lifted the resident from the recliner to the wheelchair and the resident yelled out. She stated she did not notice anything specific about the resident but did report to the nurse that she thought the resident was in pain. The nursing assistant continued to explain the incident by saying she was providing care for another resident in the shower room and was using one of the facility ' s mechanical lifts. She stated she could not find another lift and knew the resident needed to get her hair done and " obviously used poor judgment in asking the stylist to help her lift the resident because now her leg is broken. " Additionally she stated she knew the resident was supposed to be transferred with the use of a mechanical lift and this was not new information. She indicated she was aware of the resident ' s care needs and had taken care of her frequently. She added every resident has a care card in their closet to communicate resident specific information and that the care card did have that resident was to be transferred with a mechanical lift and two people at all times. On 9/17/14 at 3:25pm and attempt was made to interview the hair stylist via telephone, but there was no answer for either phone number provided. An interview was conducted with a MDS nurse on 9/17/14 at 4:00pm. The MDS nurse stated that a care plan would not be written for the resident ' s ADL ' s if it did not trigger on the MDS to be considered for care planning. She further stated resident specific care needs are communicated to the staff on care cards that are kept in each resident ' s closet. An interview with the DON (Director of Nursing) on 9/17/14 at 4:15 pm was conducted related to Resident #1. The DON stated that it had been more than a year since Resident #1 had been determined that she should be transferred by mechanical lift. She indicated that she expected all nursing assistants to transfer residents with mechanical lifts if the resident had been identified as requiring transfer with a mechanical lift. She explained that all care needs are kept in each resident ' s closet with specific information related to the resident ' s care needs.