Every finding on record at Desert Haven Care Center

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#87, and #37) to be free from physical abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: -Resident #87 (alleged victim, AV) was admitted to the facility on [DATE] with diagnoses that included Schizophrenia, social pragmatic communication disorder, anxiety disorder, autistic disorder, difficulty walking, cognitive communication deficit, generalized muscle weakness and other comorbid conditions. A behavioral care plan revised April 21, 2026 indicated that the resident #87 has a behavioral problem as evidenced by being intrusive to others, and verbally aggressive toward others. Interventions include discussing the behaviors with the resident and explaining and/or reinforce why behavior is unacceptable. Also included in the interventions is to approach calmly, divert attention and remove from the situation and take to another location to protect the rights and safety of others. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a BIMS score of 15 indicating intact cognition. The MDS also indicated that the resident wanders at the hallway for one to three days during the assessment period. An incident note dated May 16, 2026 at 6:07 pm documented that the resident #87 bit the hand of resident #37 and stated that she pulled my hair and I bit her hand. An additional situation, background, assessment and recommendation (SBAR) note on May 16, 2026 at 6:46 pm stated that the staff came to help resident #87 after she called out for help. The SBAR note also stated that at the scene, resident #37 was holding hairs on her hand and the staff separated both residents and one of the staff took resident #37 to the dining room, while other staff stayed with resident #87. Resident #87 stated during that time that I was passing by resident #37, and she pulled my hair, that is why I had to bite her on her hand. The SBAR note further stated that the nurse noticed a bore spot on the top of resident #87's head. A health status note in May 17, 2026 at 1:43 pm stated that resident #87 complained of soreness on top of her scalp, which she was given Tylenol for pain relief. -Resident #37 (alleged perpetrator, AP) was admitted to the facility on [DATE] with diagnoses that included Schizoaffective disorder bipolar type, difficulty walking, delusion related to Schizophrenia, Insomnia, and other comorbid conditions. A cognition care plan initiated on July 22, 2021 and revised on February 4, 2024 revealed that resident #37 has impaired cognitive function related to Schizophrenia, dementia with behavioral disturbances, insomnia and bipolar disorders. Some of the interventions from this cognition care plan included passive approach and stay in control when resident #37 is agitated and constantly reminding her (resident #37) that she is in a safe environment. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a BIMS score of 7 indicating severe cognitive impairment. The MDS also indicated that the resident wanders at the hallway for four to six days during the assessment period. A behavioral care plan initiated on July 22, 2021 and revised on May 4, 2026 indicated that resident #37 displays behavioral symptoms related to her diagnoses. Resident #37 exhibits care refusal, disruptive yelling, physical and verbal aggression, placing herself on the floor and wandering, delusion, and hallucination. Some of the interventions identified in this care plan included staff's attempts to communicate using creative refocusing to alter behavior patterns when behavioral signs such as yelling, cussing, and inappropriate behaviors arise. Based on previous behavioral notes on May 14, 2026 at 4:54 pm resident #37 was observed to be in the hallway pacing while swinging her hands, restless and was redirected to her room. On May 16, 2026 at 2:29 pm prior to the incident, the resident was also observed ambulating along the hallway and was also redirected. An additional behavioral note dated May 16, 2026 at 5:52 pm stated that staff heard other residents screamed for help, upon checking the scene, resident #37 was observed holding a bunch of hair on her hand, after pulling it from the other resident's hair. An additional behavioral Note on May 16, 2026 at 5:49 pm stated that the nurse heard someone yelling for help, the staff came to witness resident #37 holding a bunch of hairs on her hand, with resident stated I pulled resident #87's hair and she bit my hand. However, the staff intervened and took resident #37 to the dining room while the other staff stayed with resident #87. The same behavior note stated that resident #37 was assessed and a bite mark was observed on her left wrist. Resident #37 was moved to a different room, farther from resident #87. Review of the facility's final investigation (5 day) report dated May 16, 2026 indicated that resident #37 was admitted to the facility on [DATE]. Resident #37 was at baseline cognitive status, was alert and oriented with a BIMS score of 7. Resident #37 also used a walker at times but could ambulate independently and swing her arms when ambulating. On the same 5 day report, Resident #87 was admitted to the facility on [DATE] with baseline cognitive status, alert and oriented with a BIMS score of 15. Resident #87 could ambulate independently with a slow, steady gait. The facility's 5 day report noted that the incident was a reaction on both residents. Resident #37 reacted to verbal words that resident #87 had started at breakfast and possibly carried through when she was trying to get out her door. The report also stated that resident #87 biting resident #37 was a reaction to resident #37 pulling her hair. An interview with a certified nursing aide (CNA), staff #127, was conducted on June 9, 2026. Staff #127 stated that resident #37 is a little confused and wanders a lot in the hallway daily. Staff #127 also stated that resident #37 needed a lot of redirection because she is forgetful and confused on what to do next. Staff #127 stated that based on her experience resident #87 is expressive in nature and very interactive with other residents' daily routine, which was consistent with what found on the resident #7's care plan. Staff #127 reiterated that resident #37 always moving and pacing around and resident #87 constantly reminding or redirecting resident #37 which can cause friction at the behavioral unit. An additional interview with the nurse at the floor staff #82 was conducted on June 9, 2026 at 10:00 am. The staff #82 stated that they have to constantly remind resident #37 her daily routine because she easily forgets time, place and her routine. However, staff #82 stated that resident #87 is a young resident who is always interactive with other people's conversation which most of the staff always have to remind her (resident #87) not to interfere with other people's conversation. Staff #82 also reiterated that resident #87 can be verbal at times with a bold voice towards staff, residents and sometimes yelling at the nurses. Another interview with a nurse staff #49 who was at the scene on May 16, 2026 was conducted on June 9, 2026 at 12:30 p.m. Staff #49 stated that she was called to the scene on that day and saw resident #87 sitting down and a bunch of hairs was on the floor and some on resident #37's hand. Staff #49 stated that she separated the two residents with assistance from another staff member. Resident #37 had a bite mark on her left hand. Staff #49 also provided skin assessment and stated that there was no skin torn, break or wound, however, it was just a red mark. Staff #49 also provided a head to toe check on resident #87 and found part of resident #87 scalp with no hairs but there was no skin injury or wound. Staff #49 also stated that resident #87 complained that the affected scalp area was painful, and was given Tylenol that day. Staff #49 related that resident #87 told her that when she (resident #87) passed by resident #37, resident #37 pulled her hair and she (resident #87) bit her hand. Staff #49 stated that resident #87 did not elaborate more on the reason why she bit resident #37's hand. An interview with the social services staff #500 was conducted on June 9, 2026 at 1:30 p.m. Staff #500 stated that he knew about the altercation and the two residents are safe at this time. Staff #500 also stated that the abuse response team worked collaboratively to address further incidents by separating the two residents as further away from each other. The two residents were neighbors prior to the date of the incident. The staff #500 also reiterated that this type of incident is chronic in the behavioral units where the two residents are housed, however, the facility is providing necessary measures to mitigate abusive occurrences such as separating females and males in different units, anticipate possible hikes in resident altercations, and proper staff development skills to address and control these problems from happening. An interview with the Director of Nursing services (DON/ staff #501) was conducted on June 9, 2026 at 1:20 p.m. The staff #501 stated that their Abuse response team treated these incidents very seriously and anticipated mitigation measures especially dealing with residents diagnosed with behavioral issues. Staff #501 also stated that she reported the incident to the respective authorities within the required time frame and conducted an internal investigation and was submitted to the authorities on time. The staff #501 reiterated that her staff undergoes Abuse training on certain time i.e., upon hiring, annually, and during their annual skill fairs and monthly staff meetings. She (staff #501) reported that she has adequate staff at the behavioral units. Staff #501 defined abuse as doing something to someone with an intention to harm them however, staff #501 willingly consented that when a resident hits another resident, hitting their head, pulling their hair, biting or even slapping other residents is a form of physical abuse which echoed similar responses from all the staff that was interviewed during the survey. A review of the facility policy titled Abuse Guidelines reviewed on February 3, 2026, revealed that it is the responsibility of the employees, facility consultants, attending physicians, family members, and visitors to promptly report any incident or suspected incident of resident abuse to the facility management. The Policy also reiterated that the facility will not condone any form of resident abuse or neglect, and that all personnel are to report any signs and symptoms of abuse and neglect to their supervisor or to the director of nursing services immediately.

Based on clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one (#16) of three sampled residents to be free from physical abuse by another resident (#22). The deficient practice could result in further abuse of residents.Findings include:-Regarding Resident #16:Resident #16 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with other behavioral disturbance, anxiety disorder, delusional disorder, reduced mobility, weakness, homicidal ideations, personal history of traumatic brain injury, drug-induced subacute dyskinesia, and depression.The care plan for Resident #16 revealed a focus initiated on June 26, 2025, for a behavior problem related to physical aggression, hallucinations, and intrusive behaviors. Interventions included to protect the rights and safety of others, diverting attention, and removal of Resident #16 from situations and taking him to another location as needed.The Quarterly Minimum Data Set (MDS), dated [DATE], revealed that Resident #16 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The assessment further revealed that Resident #16 exhibited physical and verbal behaviors directed toward others for 1 to 3 days during the assessment period.An incident progress note dated April 15, 2026, revealed Resident #16 was attending an activity that afternoon and attempted to intervene during a verbal disagreement between two residents. The note revealed that one of the arguing residents, who was in a wheelchair, stood up, approached Resident #16, and struck resident #16 in the head, neck, and arms with the resident's prosthetic hand and arm. No injuries were noted; however, Resident #16 complained of minor pain all over. The note further revealed Resident #16 declined to go to the hospital for evaluation.Review of a skin assessment for Resident #16, dated April 15, 2026, revealed no visible injuries.A Situation, Background, Assessment, and Recommendation (SBAR) report for Resident #16, dated April 15, 2026, revealed that an altercation with Resident #22 occurred while Resident #22 was in the activity room. The SBAR report further revealed that Resident #16 reported that he heard Resident #22 yelling, stood up, and attempted to approach him before Resident #22 turned toward him and attempted to hit him, swinging his arm. The SBAR form also revealed that resident #16 stated that he raised his hands to cover his head.A behavior progress note dated April 16, 2026, revealed that Resident #16 told staff that the previous day Resident #22 was swinging at him, and Resident #16 put his hands in the air to protect himself, not to hit Resident #22. The note further revealed that resident #16 was again assessed to have no skin injuries and was observed pacing the hallways.-Regarding Resident #22:Resident #22 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic stimulant abuse, acquired absence of the right upper limb below the elbow, complete traumatic amputation of the right shoulder and upper arm, complete traumatic metacarpophalangeal amputation of the left thumb, complete traumatic metacarpophalangeal amputation of an unspecified finger, skin transplant, other specified mental disorders due to a known physiological condition, and bipolar disorder.Resident #22's care plan revealed a focus initiated May 21, 2025, for displays of socially inappropriate and manipulative behaviors as evidenced by physical aggression and self-isolation. Interventions included if Resident #22 displays harmful behaviors, approach in a calm manner, divert attention, and take the resident to another location as needed.Resident #22's most recent completed quarterly MDS, dated [DATE], revealed that Resident #22 had a BIMS score of 15, indicating that Resident #22 was cognitively intact. The assessment further revealed that Resident #22 exhibited verbal behaviors directed toward others for 1 to 3 days during the assessment period.A health status progress note dated April 15, 2026, revealed that at approximately 2:00 p.m., Resident #22 was verbally and physically aggressive, threw a pitcher of water and other items, and during activities, punched another resident multiple times, according to staff. The police were called, and the other resident wanted to press charges. Resident #22 was escorted out of the facility by police at 2:54 p.m. As Resident #22 was being escorted from the facility by police, he was observed to be verbally threatening and using profanity.Review of the clinical record for Resident #22 revealed an admission summary progress note dated April 24, 2026. This note indicated that Resident #22 was readmitted to the facility.Review of the facility's 5-day investigation report indicated that the facility interviewed residents and staff and concluded that it was uncertain whether Resident #22 made contact with Resident #16. The facility investigation did not verify the abuse allegation.An interview was conducted on May 1, 2026, at 10:20 a.m., with Resident #16, who stated that he was recently in a physical altercation with Resident #22. He stated that on the day of the incident, he heard Resident #22 speaking loudly, and Resident #22 approached him and hit him in the right temple.An interview was conducted on May 1, 2026, at 10:43 a.m., with a licensed practical nurse (LPN/Staff #85) who stated that he was on duty on April 15, 2026, observed Resident #22 exhibiting verbal behaviors, and made several attempts to de-escalate the situation. Staff #85 stated he did not witness the altercation during activities, but heard yelling coming from the activity room and rushed over to assist. Staff #85 further noted that he called 911, and police interviewed both residents and arrested Resident #22.An interview was conducted on May 1, 2026, at 10:58 a.m., with the activities assistant (Staff #104), who stated that on April 15, 2026, he was assisting with activities and passing out snacks to residents. He stated that Resident #22 came into the room and appeared upset. He observed Resident #22 charge toward Resident #16 and begin taking swings, making contact with Resident #16. During the incident, Staff #104 stated that Resident #22's prosthetic arm fell off. Staff #104 noted that staff rushed into the room to assist with separating the residents.An interview was conducted on May 1, 2026, at 12:25 p.m., with Resident #22, who stated that Resident #16 often provokes him and that both residents regularly exchange tense words and gestures. Resident #22 stated that on April 15, 2026, he approached and slapped Resident #16 during activities.An interview was conducted on May 1, 2026, at 12:33 p.m., with the Director of Nursing (DON/Staff #79), who stated that abuse would be defined as unwanted contact, such as hitting or slapping a resident, and would fail to meet expectations for the facility. Staff #79 stated that the incident between Resident #16 and Resident #22 on April 15, 2026, failed to meet expectations and placed residents at risk for injury or psychosocial harm.Review of the facility policy titled Abuse Guidelines, with a review date of February 3, 2026, revealed that abuse was defined as the willful infliction of injury resulting in physical harm, pain, or mental anguish. The policy further revealed that the facility would assess residents exhibiting signs and symptoms of behavioral problems and develop and implement care plans to address behavioral issues.

Based on clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one (#5) of three sampled residents to be free from abuse by another resident (#19). This failure resulted in Resident #5 sustaining facial trauma, including bilateral nasal bone fractures and a laceration to the left ear after being repeatedly struck by Resident #19. The deficient practice could result in further abuse of residents.Findings include:-Resident #5 (alleged victim) was admitted to the facility on [DATE], with diagnoses including dementia with other behavioral disturbance, dementia in other diseases classified elsewhere with agitation, essential (primary) hypertension, major depressive disorder, recurrent severe without psychotic features, unsteadiness on feet, history of falling, weakness, brief psychotic disorder, and hearing loss.The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The assessment also included that Resident #5 exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others for four to six days, but less than daily during the assessment period.The care plan revised on December 12, 2025 revealed the resident had behavior problems as evidenced by placing himself on the floor, banging his head, yelling, paranoid thoughts, refusing care, verbal and physical aggression, refusing medications, being territorial over his table in the dining room, and making false accusations. Interventions included anticipating his care needs and providing care before Resident #5 became overly stressed, and implementing interventions as needed to protect the rights and safety of others.The psychiatric reevaluation assessment dated [DATE], revealed that Resident #5 displayed relative stability on his current treatment regimen for management of neurocognitive impairment with behavioral disturbances and depression. The provider documented that no medication changes were indicated and recommended adherence to care planned therapeutic interventions in response to episodes of distress and behavioral disturbance.A health status note dated February 11, 2026 included the nurse heard a CNA (Certified Nursing Assistant) scream in the dining room; and that, the resident was found sitting in his wheelchair with blood dripping from his nose, blood coming out of his left ear and a hematoma to the side of his left eyebrow. The documentation also included that the resident had his hearing aids in his hand and there was blood on the surrounding area of his wheelchair. Per the documentation, the provider was notified and the resident was transported to the hospital.The Situation, Background, Assessment, and Recommendation (SBAR) progress note dated February 11, 2026 included that at approximately 3:59 p.m., the registered nurse (RN/Staff #26) heard a CNA yelling in the dining room. Per the documentation the RN ran to the dining room and found Resident #5 sitting in his wheelchair with blood dripping from his nose; and, there was blood present on the floor surrounding the wheelchair. The documentation included that Resident #5 was holding his hearing aids in his hand, there was blood was coming from his left ear and a hematoma to the left eyebrow area. According to the documentation, first aid was administered but the RN was unable to obtain vital signs due to Resident #5's combativeness; and that, the provider was notified and Resident #5 was transferred to the hospital by ambulance at approximately 4:30 p.m.Review of hospital discharge documentation dated February 11, 2026, revealed that Resident #5 was admitted to the emergency department at 4:47 p.m. for facial trauma; and had computed tomography (CT) imaging and treatment for a 1.5 cm laceration to the left ear. Per the documentation, CT imaging revealed mildly displaced bilateral nasal bone fractures; and that, suture repair was performed to the left ear. A health status note dated February 12, 2026 revealed resident returned to the facility and was noted to have a swollen nose and one stitch to his left ear.Another health status note dated February 12, 2026 revealed the resident visible bruising surrounding nose and left eye related to a recent altercation.A health status note dated February 13, 2026 included that Resident #5 had two black eyes from prior attack by fellow peer, repeatedly made mention of him getting into a fight with a peer and reported that his hearing aids were damaged by his attacker. Review of weekly skin observation assessments dated February 16 and 23, 2026 included bruising and discoloration remained present to the nose and eye area related to the recent incident.-Resident #19 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including schizophrenia, mild neurocognitive disorder due to a known physiological condition with behavioral disturbance, psychoactive substance use disorder, anxiety disorder, insomnia, suicidal ideations, homicidal ideations, schizoaffective disorder bipolar type, and drug-induced subacute dyskinesia.The care plan revealed a focus initiated December 10, 2025, for behavioral problems as evidenced by self-isolation, aggression, and a history of suicidal and homicidal ideation. Interventions included intervening as needed to protect the rights and safety of others, approaching the resident in a calm manner, diverting attention, and removing the resident from situations and taking him to another location as needed.The admission MDS assessment dated [DATE], revealed that Resident #19 had a BIMS score of 15, indicating the resident was cognitively intact. The MDS also included that Resident #19 exhibited other behavioral symptoms not directed toward others one to three days during the assessment period.Review of a psychiatry assessment dated [DATE], revealed additional diagnoses of mild neurocognitive disorder due to a known physiological condition with behavioral disturbance and psychoactive substance use disorder. Recommendations included maintaining firm boundaries regarding appropriate and acceptable communication and behavior between patients and staff and consideration of a two-person assist for safety and accountability. No medication changes were recommended.The care plan dated January 14, 2026 revealed the resident had impaired thought processes related to schizoaffective disorder. Intervention included cuing, reorienting and supervising the resident as needed.A behavioral progress note dated February 11, 2026, indicates that at approximately 4:00 p.m., Resident #19 passed by the nurse's station and asked to speak with the unit manager. and he was informed that the unit manager had already left for the day. The documentation included that staff asked if he needed anything, and Resident #19 stated that he was fine and did not need assistance. Further, the documentation revealed Resident #19 then walked into the dining room; and, shortly afterward, a physical altercation was heard, and the CNA (Staff #96) separated the two residents. Per the documentation, Resident #19 was redirected to the hallway to calm down and discuss the incident, and was later escorted to his room.A behavior note dated February 12, 2026 included that at approximately 10:00 p.m. on February 11, 2026, Resident #19 had stated that he wanted to leave the facility; and, at 1:37 a.m. on February 12, 2026, Resident #19 broke a door and left the facility. The documentation included that the guardian was notified and guardian told facility to call the police and have Resident #19 arrested for earlier assault on another resident. The documentation included police arrived at the facility shortly after Resident #19 broke out. Another behavior note dated February 12, 2026 included that resident was presented with risk and benefits of leaving the facility AMA (against medical advice) but the resident refused to sign it. The facility follow-up report dated February 16, 2026 included that the incident was witnessed by one CNA who reported that Resident #19 walked over to Resident #5 and asked Resident #5 a question. Per the documentation, Resident #5 was hard of hearing and responded what; and that, Resident #19 then started hitting Resident #5. It also included that Resident #19 could not remember what happened; and, the police refused to arrest Resident #19 due to cognitive disability. The facility investigation concluded that the allegation was verified by evidence collected during their investigation. Interviews were conducted on March 2, 2026, regarding the February 11, 2026 incident:During a telephone interview a registered nurse (RN/staff #26) conducted on March 2, 2026 at 10:39 a.m. the RN stated that on February 11, 2026, she was the nurse assigned to Resident #5; and, at approximately 4:00 p.m., she was called to the dining room by two CNAs (Staff #96 and Staff #37). She stated that when she got in the dining room, the two residents had already been separated, and she provided first aid to Resident #5. The RN said that Resident #5 was bleeding from the ear and was subsequently transferred to the hospital; and that, Resident #5 did not return to the facility prior to her leaving her shift at 6:15 p.m.An interview with Resident #5 was conducted on March 2, 2026 at 11:03 a.m. Resident #5 stated that he had recently been beat up by another resident; but, he could not recall the specific day, time, or the name of the other resident. Resident #5 stated that he had spoken with the police about the incident and told the police that he wanted to pursue criminal charges against the resident who hit him. Resident #5 stated that he worried about being assaulted again at the facility but was grateful that he was able to receive treatment at the hospital and that the police arrested the other resident.An interview with another RN (staff #31) was conducted on March 2, 2026 at 11:14 a.m. The RN (Staff #31) stated that on February 11, 2026, she was the nurse assigned to Resident #19 who had not exhibited any behaviors earlier in the day prior to the incident. The RN said that at approximately 4:00 p.m., while she was working at the medication cart, Resident #19 approached her asking to speak with the unit manager regarding paperwork he believed the manager was holding. The RN informed him that the unit manager had left for the day and asked if he needed assistance The RN said that Resident #19 responded he did not and then walked into the dining room. The RN said that shortly thereafter, she heard a commotion and when she arrived the residents (#19 and #5) had already been separated by the CNAs (Staffs #37 and #96). The RN stated that Resident #19 was speaking aggressively and accused Resident #5 of holding his paperwork. Further, the RN said that after Resident #5 was transported to the hospital, police arrived at approximately 5:30 p.m. to speak with Resident #19 and staff.In an interview with a CNA (staff #37) conducted on March 2, 2026 at 11:21 a.m., The CNA stated that on February 11, 2026, at approximately 4:00 p.m., she was in the dining room and saw Resident #19 walk in calmly. She stated that Resident #19 approached Resident #5 and asked him for a blue folder; and that, resident #5 responded and told Resident #19 that he did not have the folder. The CNA said that Resident #19 then became agitated and struck Resident #5 with a closed fist; and that, she and another CNA (Staff #96) ran to separate the residents. The CNA further stated that due to the size and strength of Resident #19, it required significant effort to separate them, and Resident #19 was able to strike Resident #5 several additional times before both residents were separated.A telephone interview with another CNA (staff #96) was conducted on March 2, 2026 at 11:32 a.m. The CNA (staff #96) stated that on February 11, 2026, at approximately 4:00 p.m., he was in the dining room while Resident #5 was seated watching television. He stated that Resident #19 walked into the room and initially did not appear agitated; and, Resident #19 approached Resident #5 and began discussing a blue folder. The CNA said that the conversation quickly became confrontational and that he stood up to intervene; and that, as he stood up, he saw Resident #19 strike Resident #5 with a closed fist. The CNA said that Resident #19 struck Resident #5 approximately five times before staff were able to fully separate the residents. The CNA further stated that he continued to monitor Resident #19 for the remainder of his shift, which ended at approximately 10:00 p.m.During an interview with the Director of Nursing (DON/Staff #10) conducted on March 2, 2026 at 12:37 p.m., the DON stated that the incident between Resident #5 and Resident #19 that occurred on February 11, 2026, met the definition of physical abuse. She stated that this incident did not meet the expectations of the facility; and that, when physical abuse occurs, residents were at risk for both physical injuries and psychosocial harm. The DON further stated that Resident #19 had already left the facility before Resident #5 returned from the hospital and that Resident #5's care and needs had been closely monitored since the incident.Review of the facility policy titled Abuse Guidelines, reviewed February 3, 2026, revealed that abuse was defined as the willful infliction of injury resulting in physical harm, pain, or mental anguish. The policy further stated that the facility would assess residents exhibiting signs and symptoms of behavioral problems and develop and implement care plans to address behavioral issues. The policy included that they will not condone resident abuse by anyone, including staff members, physician, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardian, sponsors, other residents, friends and other individuals.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#78) was free from abuse by another resident (#89). The deficient practice could result in residents being physically and emotionally harmed.Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights and safety of others.A care plan focus initiated on September 13, 2024, revealed the resident had shown behaviors of verbal aggression towards activity staff and other residents in group activities, with interventions to provide social visits to the resident throughout the week and offering independent leisure materials.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days and other behavioral symptoms for 4-6 days. A behavior progress note dated December 15, 2025, at 8:01 p.m. revealed that the resident was sitting in the hallway when he noticed a peer by the nurses' station. The note also revealed that the resident yelled, Get away from there, you're just bothering them. You need to take your a** back to your room, and staff intervened by trying to redirect the resident. A behavior progress note dated December 19, 2025, at 5:28 p.m. revealed that the resident was observed becoming verbally aggressive and cursing profanities at another resident and activities staff at 3 p.m. The note further revealed that the resident was redirected and monitored during a smoke break, and 30 minutes later, the resident was yelling at another resident for clogging his toilet. The note also revealed that the resident was observed threatening to fight another resident and cursing, and he was redirected and de-escalated. A behavior progress note dated December 21, 2025, at 3:25 p.m. revealed that the resident was observed attempting to redirect one of his closest peers to his room and informed the peer he would assist with cleaning his toilet seat when Resident #89 put his hands on the outside of the peer's bilateral arms to redirect towards his room. The note revealed that the peer was not ready to leave the nurses' station, and so an argument ensued. The note further revealed that staff separated the residents. A behavior progress note dated January 11, 2026, at 10:09 p.m. revealed that a nurse approached the resident regarding a statement he made to a CNA (Certified Nursing Assistant) that seemed threatening, and the resident became upset with the nurse, approached the nurse in a threatening and menacing manner, and stated they should not be approaching or talking to him at all or else he would f*** with them.A behavior progress note dated January 13, 2026, at 11:23 p.m. revealed that the resident was observed to be yelling and cursing at peers and threatening to put his hands on one peer, and the nurse was able to redirect and administer as-needed medication to aid with increased anxiety.There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. -Regarding Resident #78:Resident #78 was admitted [DATE], with diagnoses that included vascular dementia, depression, chronic kidney disease, hypertension, cerebral infarction, chronic viral hepatitis C, pure hypercholesterolemia, chronic obstructive pulmonary disease, hyperlipidemia, aphasia, dysphagia, basal cell carcinoma, adjustment mood disorder, anxiety disorder, and dysphagia.A care plan focus initiated on January 19, 2024, revealed the resident displayed behavioral symptoms related to dementia, including physical aggression like hitting, kicking, and pushing, verbal symptoms like yelling, cursing, and other threatening behaviors, as well as hallucinations, wandering, and refusal of care with interventions to give psychoactive medications as orders, record behavioral symptoms, and educate the resident on appropriate behaviors when on the patio with peers.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days. There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. A request was made for the facility's self-reports, grievances, and investigations for the last 4 months, and the facility documented that they had not reported any incidents or had any grievances in the last 4 months. An interview was conducted on January 26, 2026, at 3:27 p.m. with a Certified Nursing Assistant (CNA/Staff #34), who stated that Resident #89 was an aggressive resident who would try to intimidate people. The CNA stated that Resident #89 had behaviors mostly when women were around because he would try to impress them by getting aggressive, yelling, and being rough with staff. The CNA stated that Resident #89 had made threats to residents before, and that within the last week, Resident #89 made a cardboard gun, covered his face with a bandana, and went into Resident #78's room to tell the resident, if you don't be quiet, I'll teach you a lesson. The CNA stated that staff made efforts to get Resident #89 out of the room and calm him down, and that he would consider the incident a resident-to-resident abuse. The CNA also stated that the two nurses who were present at the time of the incident took charge of the situation and reported it to their supervisor. The CNA stated that the cardboard gun appeared to be a long handgun, and he was not sure where the cardboard gun went after the incident. An interview was conducted on January 26, 2026, at 3:50 p.m. with a Licensed Practical Nurse (LPN/Staff #17), who stated that reportable incidents would be considered any form of abuse or what you are seeing such as physical, emotional, and the poor treatment of residents, and that he would report incidents to the unit manager or the Director of Nursing (DON). The LPN stated that Resident #89 was a resident who would get aggressive with other residents, and that he would get upset with Resident #78 sometimes if he was loud.A telephonic interview was conducted on January 26, 2026, at 4:39 p.m. with an LPN, Staff #80, who stated that abuse incidents should have been recorded in the progress notes within the clinical record, and that the timeframe for reporting abuse was immediately to the designated person, the DON, or the administrator. The LPN stated that reportable abuse incidents could be physical, verbal, or resident-to-resident, and that she had a resident-to-resident emotional abuse incident on January 20, 2026, that she had to report. The LPN stated that the incident involved Resident #89 and Resident #78, and that Resident #89 entered Resident #78's room and was holding a pretend gun made out of cardboard. The LPN stated that she witnessed the entire event and that Resident #89 told Resident #78 that he would shoot him if he did not quiet down. The LPN stated she heard Resident #89 say, go to sleep, or I am going to shoot you, and that Resident #78 felt intimidated after the incident. The LPN stated that in the hours following the incident, Resident #78 got into his bed and did not want to do anything, which was not like him. The LPN stated that the cardboard gun was flat, and one side was colored with art supplies to look more realistic, to show a handle on the gun. The LPN stated that at one point, the gun fell from Resident #89's hands, and she picked it up to see it, but gave it back to him because she was scared of what he might do to her. The LPN further stated that she spoke with the LPN unit nurse manager (unit manager/Staff #56) to report the incident and asked her to take the cardboard gun from the resident. Staff #80 further stated that she protected Resident #78 for the rest of her shift by staying at his door because he was intimidated and very frightened. The LPN stated that she reported the incident to the unit manager, and the unit manager told her to write a statement about the incident on paper. The LPN stated that she did not know if the unit manager reported the incident further. A telephonic interview was attempted on January 26, 2026, at 4:50 p.m. with an LPN, Staff #23, with no success.An interview was conducted on January 26, 2026, at 4:57 p.m. with the Director of Nursing (DON/Staff #67), who stated that she expected that nursing staff document allegations of abuse in the clinical record in an incident report and progress note, and that the timeframe for reporting an allegation of abuse was two hours to all applicable state agencies, physicians, case managers, and family. The DON stated that she does the abuse coordination, investigating, and reporting for the facility, and that a resident-to-resident physical or verbal abuse would be considered a reportable abuse. The DON stated that she did not know anything about a recent abuse incident between Resident #89 and Resident #78, but she did know that Resident #89 had a bad weekend where he was verbally aggressive to staff. The DON stated that her process for investigating allegations of abuse was to interview staff and residents, look at the charting, and then report to the applicable state agencies. An interview was conducted on January 26, 2026, at 5:07 p.m. with the LPN unit nurse manager (unit manager/Staff #56), who stated that nursing staff were expected to document all progress notes, including incidents of abuse or allegations. The LPN unit manager stated that the timeframe for reporting an allegation was immediately, but no longer than two hours, and that she would report abuse incidents or allegations to the DON. The LPN unit manager stated that she had not reported anything recently, but she found out just 5-10 minutes before the interview that Resident #89 was really bad, and that he made a cardboard gun and was playing with staff and Resident #78. The LPN unit manager stated that she had no idea who was involved, she did not recall the incident being reported to her, and that she would immediately let the DON know so she could investigate. The LPN unit manager stated that she did not investigate the incident with the cardboard gun.A follow-up telephonic interview was conducted on January 26, 2026, at 5:14 p.m. with the LPN, Staff #80, who stated that the unit manager she reported the abuse incident to was Staff #56, and that there was a camera pointing at the office where they discussed the incident. The LPN also stated that there was another woman present in the office when she reported the incident to the unit manager, but she could not recall the woman's identity. Review of a policy titled, Abuse Guidelines, had a review date of July 2022 and revealed that it was the responsibility of the employees, facility consultants, attending physicians, family members, and visitors to promptly report any incident or suspected incident of resident abuse to facility management. The policy defined abuse as being the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also revealed that the facility would not condone resident abuse by anyone, including other residents, and all personnel were encouraged to report incidents of resident abuse or suspected incidents of abuse without fear of retaliation from the facility or its staff. The policy further revealed that employees, consultants, and physicians must immediately report any suspected abuse to the DON, and in their absence, reports may be made to the nurse supervisor on duty. The policy revealed that the administrator must be immediately notified of suspected abuse or incidents of abuse.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident involving resident-to-resident abuse between two residents (#89 and #78). The deficient practice could result in continued abuse of residents and physical or emotional harm to residents. Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights and safety of others.A care plan focus initiated on September 13, 2024, revealed the resident had shown behaviors of verbal aggression towards activity staff and other residents in group activities, with interventions to provide social visits to the resident throughout the week and offering independent leisure materials.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days and other behavioral symptoms for 4-6 days. A behavior progress note dated December 15, 2025, at 8:01 p.m. revealed that the resident was sitting in the hallway when he noticed a peer by the nurses' station. The note also revealed that the resident yelled, Get away from there, you're just bothering them. You need to take your a** back to your room, and staff intervened by trying to redirect the resident. A behavior progress note dated December 19, 2025, at 5:28 p.m. revealed that the resident was observed becoming verbally aggressive and cursing profanities at another resident and activities staff at 3 p.m. The note further revealed that the resident was redirected and monitored during a smoke break, and 30 minutes later, the resident was yelling at another resident for clogging his toilet. The note also revealed that the resident was observed threatening to fight another resident and cursing, and he was redirected and de-escalated. A behavior progress note dated December 21, 2025, at 3:25 p.m. revealed that the resident was observed attempting to redirect one of his closest peers to his room and informed the peer he would assist with cleaning his toilet seat when Resident #89 put his hands on the outside of the peer's bilateral arms to redirect towards his room. The note revealed that the peer was not ready to leave the nurses' station, and so an argument ensued. The note further revealed that staff separated the residents. A behavior progress note dated January 11, 2026, at 10:09 p.m. revealed that the resident became upset when the nurse asked him what he said to the CNAs because it sounded like a threat, and he approached the nurse threateningly and menacingly while leaving verbal threats that they should not be approaching or talking to him at all or else he would f*** with them.A behavior progress note dated January 13, 2026, at 11:23 p.m. revealed that the resident was observed to be yelling and cursing at peers and threatening to put his hands on one peer, and the nurse was able to redirect and administer as-needed medication to aid with increased anxiety.There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. -Regarding Resident #78Resident #78 was admitted [DATE], with diagnoses that included vascular dementia, depression, chronic kidney disease, hypertension, cerebral infarction, chronic viral hepatitis C, pure hypercholesterolemia, chronic obstructive pulmonary disease, hyperlipidemia, aphasia, dysphagia, basal cell carcinoma, adjustment mood disorder, anxiety disorder, and dysphagia.A care plan focus initiated on January 19, 2024, revealed the resident displayed behavioral symptoms related to dementia, including physical aggression like hitting, kicking, and pushing, verbal symptoms like yelling, cursing, and other threatening behaviors, as well as hallucinations, wandering, and refusal of care with interventions to give psychoactive medications as orders, record behavioral symptoms, and educate the resident on appropriate behaviors when on the patio with peers. A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days. There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. A request was made for the facility's self-reports, grievances, and investigations for the last 4 months, and the facility documented that they had not reported any incidents or had any grievances in the last 4 months. An interview was conducted on January 26, 2026, at 3:27 p.m. with a Certified Nursing Assistant (CNA/Staff #34), who stated that Resident #89 was an aggressive resident who would try to intimidate people. The CNA stated that Resident #89 had behaviors mostly when women were around because he would try to impress them by getting aggressive, yelling, and being rough with staff. The CNA stated that Resident #89 had made threats to residents before, and that within the last week, Resident #89 made a cardboard gun, covered his face with a bandana, and went into Resident #78's room to tell the resident, if you don't be quiet, I'll teach you a lesson. The CNA stated that staff made efforts to get Resident #89 out of the room and calm him down, and that he would consider the incident a resident-to-resident abuse. The CNA also stated that the two nurses who were present at the time of the incident took charge of the situation and reported it to their supervisor. The CNA stated that the cardboard gun appeared to be a long handgun, and he was not sure where the cardboard gun went after the incident. An interview was conducted on January 26, 2026, at 3:50 p.m. with a Licensed Practical Nurse (LPN/Staff #17), who stated that reportable incidents would be considered any form of abuse or what you are seeing such as physical, emotional, and the poor treatment of residents, and that he would report incidents to the unit manager or the Director of Nursing (DON). The LPN stated that Resident #89 was a resident who would get aggressive with other residents, and that he would get upset with Resident #78 sometimes if he was loud.A telephonic interview was conducted on January 26, 2026, at 4:39 p.m. with an LPN, Staff #80, who stated that abuse incidents should have been recorded in the progress notes within the clinical record, and that the timeframe for reporting abuse was immediately to the designated person, the DON, or the administrator. The LPN stated that reportable abuse incidents could be physical, verbal, or resident-to-resident, and that she had a resident-to-resident emotional abuse incident on January 20, 2026, that she had to report. The LPN stated that the incident involved Resident #89 and Resident #78, and that Resident #89 entered Resident #78's room and was holding a pretend gun made out of cardboard. The LPN stated that she witnessed the entire event and that Resident #89 told Resident #78 that he would shoot him if he did not quiet down. The LPN stated she heard Resident #89 say, go to sleep, or I am going to shoot you, and that Resident #78 felt intimidated after the incident. The LPN stated that in the hours following the incident, Resident #78 got into his bed and did not want to do anything, which was not like him. The LPN stated that the cardboard gun was flat, and one side was colored with art supplies to look more realistic, to show a handle on the gun. The LPN stated that at one point, the gun fell from Resident #89's hands, and she picked it up to see it, but gave it back to him because she was scared of what he might do to her. The LPN further stated that she spoke with the LPN unit nurse manager (unit manager/Staff #56) to report the incident and asked her to take the cardboard gun from the resident. Staff #80 further stated that she protected Resident #78 for the rest of her shift by staying at his door because he was intimidated and very frightened. The LPN stated that she reported the incident to the unit manager, and the unit manager told her to write a statement about the incident on paper. The LPN stated that she did not know if the unit manager reported the incident further. A telephonic interview was attempted on January 26, 2026, at 4:50 p.m. with an LPN, Staff #23, with no success.An interview was conducted on January 26, 2026, at 4:57 p.m. with the Director of Nursing (DON/Staff #67), who stated that she expected that nursing staff document allegations of abuse in the clinical record in an incident report and progress note, and that the timeframe for reporting an allegation of abuse was two hours to all applicable state agencies, physicians, case managers, and family. The DON stated that she does the abuse coordination, investigating, and reporting for the facility, and that a resident-to-resident physical or verbal abuse would be considered a reportable abuse. The DON stated that she did not know anything about a recent abuse incident between Resident #89 and Resident #78, but she did know that Resident #89 had a bad weekend where he was verbally aggressive to staff. The DON stated that her process for investigating allegations of abuse was to interview staff and residents, look at the charting, and then report to the applicable state agencies. An interview was conducted on January 26, 2026, at 5:07 p.m. with the LPN unit nurse manager (unit manager/Staff #56), who stated that nursing staff were expected to document all progress notes, including abuse incidents or allegations. The LPN unit manager stated that the timeframe for reporting an allegation was immediately, but no longer than two hours, and that she would report abuse incidents or allegations to the DON. The LPN unit manager stated that she had not reported anything recently, but she found out just 5-10 minutes before the interview that Resident #89 was really bad, and that he made a cardboard gun and was playing with staff and Resident #78. The LPN unit manager stated that she had no idea who was involved, she did not recall the incident being reported to her, and that she would immediately let the DON know so she could investigate. The LPN unit manager stated that she did not investigate the incident with the cardboard gun.A follow-up telephonic interview was conducted on January 26, 2026, at 5:14 p.m. with the LPN, Staff #80, who stated that the unit manager she reported the abuse incident to was Staff #56, and that there was a camera pointing at the office where they discussed the incident. The LPN also stated that there was another woman present in the office when she reported the incident to the unit manager, but she could not recall the woman's identity. Review of a policy titled, Abuse Guidelines, had a review date of July 2022 and revealed that it was the responsibility of the employees, facility consultants, attending physicians, family members, and visitors to promptly report any incident or suspected incident of resident abuse to facility management. The policy defined abuse as being the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also revealed that the facility would not condone resident abuse by anyone, including other residents, and all personnel were encouraged to report incidents of resident abuse or suspected incidents of abuse without fear of retaliation from the facility or its staff. The policy further revealed that employees, consultants, and physicians must immediately report any suspected abuse to the DON, and in their absence, reports may be made to the nurse supervisor on duty. The policy revealed that the administrator must be immediately notified of suspected abuse or incidents of abuse. The policy titled, Abuse Guidelines, also revealed that when an allegation or suspected case of mistreatment or abuse was reported, the administrator or his/her designee would immediately notify the state licensing agency, the local/state ombudsman, the resident representative, adult protective services, and the resident's physician. The policy further revealed that the notifications would need to include the name of the resident, the number of the room the resident resided in, the type of abuse that was alleged, the date and time the incident occurred, the names of the persons involved, and what immediate action was taken by the facility. The policy also revealed that the physician or licensed nurse would immediately need to examine the resident, record findings in the medical record, complete an unusual occurrence form with written statements from witnesses, and an immediate investigation would be made, and a copy of the investigation would be provided to the administrator. The policy revealed that when an incident of resident abuse was suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. The policy also revealed that failure to report an incident may result in legal or criminal action being filed against the individuals for withholding such information.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was reported. The deficient practice could result in continued abuse and physical or emotional harm to residents.-Regarding Resident #89Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights and safety of others.A care plan focus initiated on September 13, 2024, revealed the resident had shown behaviors of verbal aggression towards activity staff and other residents in group activities, with interventions to provide social visits to the resident throughout the week and offering independent leisure materials.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days and other behavioral symptoms for 4-6 days. A behavior progress note dated December 15, 2025, at 8:01 p.m. revealed that the resident was sitting in the hallway when he noticed a peer by the nurses' station. The note also revealed that the resident yelled, Get away from there, you're just bothering them. You need to take your a** back to your room, and staff intervened by trying to redirect the resident. A behavior progress note dated December 19, 2025, at 5:28 p.m. revealed that the resident was observed becoming verbally aggressive and cursing profanities at another resident and activities staff at 3 p.m. The note further revealed that the resident was redirected and monitored during a smoke break, and 30 minutes later, the resident was yelling at another resident for clogging his toilet. The note also revealed that the resident was observed threatening to fight another resident and cursing, and he was redirected and de-escalated. A behavior progress note dated December 21, 2025, at 3:25 p.m. revealed that the resident was observed attempting to redirect one of his closest peers to his room and informed the peer he would assist with cleaning his toilet seat when Resident #89 put his hands on the outside of the peer's bilateral arms to redirect towards his room. The note revealed that the peer was not ready to leave the nurses' station, and so an argument ensued. The note further revealed that staff separated the residents. A behavior progress note dated January 11, 2026, at 10:09 p.m. revealed that the resident became upset when the nurse asked him what he said to the CNAs because it sounded like a threat, and he approached the nurse threateningly and menacingly while leaving verbal threats that they should not be approaching or talking to him at all or else he would f*** with them.A behavior progress note dated January 13, 2026, at 11:23 p.m. revealed that the resident was observed to be yelling and cursing at peers and threatening to put his hands on one peer, and the nurse was able to redirect and administer as-needed medication to aid with increased anxiety.There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. -Regarding Resident #78Resident #78 was admitted [DATE], with diagnoses that included vascular dementia, depression, chronic kidney disease, hypertension, cerebral infarction, chronic viral hepatitis C, pure hypercholesterolemia, chronic obstructive pulmonary disease, hyperlipidemia, aphasia, dysphagia, basal cell carcinoma, adjustment mood disorder, anxiety disorder, and dysphagia.A care plan focus initiated on January 19, 2024, revealed the resident displayed behavioral symptoms related to dementia, including physical aggression like hitting, kicking, and pushing, verbal symptoms like yelling, cursing, and other threatening behaviors, as well as hallucinations, wandering, and refusal of care with interventions to give psychoactive medications as orders, record behavioral symptoms, and educate the resident on appropriate behaviors when on the patio with peers.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days. There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. A request was made for the facility's self-reports, grievances, and investigations for the last 4 months, and the facility documented that they had not reported any incidents or had any grievances in the last 4 months.Review of State Agency (SA) complaint database through the date of the survey revealed no evidence that the facility reported the resident-to-resident incident between Resident #89 and Resident #78 on January 20, 2026.An interview was conducted on January 26, 2026, at 3:27 p.m. with a Certified Nursing Assistant (CNA/Staff #34), who stated that Resident #89 was an aggressive resident who would try to intimidate people. The CNA stated that Resident #89 had made threats to residents before, and that within the last week, Resident #89 made a cardboard gun, covered his face with a bandana, and went into Resident #78's room to tell the resident, if you don't be quiet, I'll teach you a lesson. The CNA stated that he would consider the incident a resident-to-resident abuse and that it should have been reported. The CNA also stated that the two nurses who were present at the time of the incident took charge of the situation and reported it to their supervisor. An interview was conducted on January 26, 2026, at 3:50 p.m. with a Licensed Practical Nurse (LPN/Staff #17), who stated that reportable incidents would be considered any form of abuse or what you are seeing such as physical, emotional, and the poor treatment of residents, and that he would report incidents to the unit manager or the Director of Nursing (DON). The LPN stated that the timeframe for reporting an abuse incident or allegation would be immediate. A telephonic interview was conducted on January 26, 2026, at 4:39 p.m. with an LPN, Staff #80, who stated that abuse incidents should have been recorded in the progress notes within the clinical record, and that the timeframe for reporting abuse was immediately to the designated person, the DON, or the administrator. The LPN stated that reportable abuse incidents could be physical, verbal, or resident-to-resident, and that she recently had a resident-to-resident emotional abuse incident that she had to report. The LPN stated that the incident involved Resident #89 and Resident #78, and that Resident #89 entered Resident #78's room and was holding a pretend gun made out of cardboard. The LPN stated that she witnessed the entire event and that Resident #89 told Resident #78 that he would shoot him if he did not quiet down. The LPN stated she heard Resident #89 say go to sleep, or I am going to shoot you, and that Resident #78 felt intimidated after the incident. The LPN stated that in the hours following the incident, Resident #78 got into his bed and did not want to do anything, which was not like him. The LPN stated that at one point, the gun fell from Resident #89's hands, and she picked it up to see it, but gave it back to him because she was scared of what he might do to her. The LPN further stated that she spoke with the LPN unit nurse manager (unit manager/Staff #56) to report the incident and asked her to take the cardboard gun from the resident. The LPN stated that she reported the incident to the unit manager, and the unit manager told her to write a statement about the incident on paper. The LPN stated that she did not know if the unit manager reported the incident further. A telephonic interview was attempted on January 26, 2026, at 4:50 p.m. with an LPN, Staff #23, with no success.An interview was conducted on January 26, 2026, at 4:57 p.m. with the Director of Nursing (DON/Staff #67), who stated that she expected that nursing staff document allegations of abuse in the clinical record in an incident report and progress note, and that the timeframe for reporting an allegation of abuse was two hours to all applicable state agencies, physicians, case managers, and family. The DON stated that she does the abuse coordination, investigating, and reporting for the facility, and that a resident-to-resident physical or verbal abuse would be considered a reportable abuse. The DON stated that she did not know anything about a recent abuse incident between Resident #89 and Resident #78, but she did know that Resident #89 had a bad weekend where he was verbally aggressive to staff. An interview was conducted on January 26, 2026, at 5:07 p.m. with the LPN unit nurse manager (unit manager/Staff #56), who stated that it was expected of nursing staff to document everything in the progress notes, including abuse incidents or allegations. The LPN unit manager stated that the timeframe for reporting an allegation was immediately, but no longer than two hours, and that she would report abuse incidents or allegations to the DON. The LPN unit manager stated that she had not reported anything recently, but she found out just 5-10 minutes before the interview that Resident #89 was really bad, and that he made a cardboard gun and was playing with staff and Resident #78. The LPN unit manager stated that she had no idea who was involved, she did not recall the incident being reported to her, and that she would immediately let the DON know so she could investigate. The LPN unit manager stated that she did not investigate or report the incident with the cardboard gun.A follow-up telephonic interview was conducted on January 26, 2026, at 5:14 p.m. with the LPN, Staff #80, who stated that the unit manager she reported the abuse incident to was Staff #56, and that there was a camera pointing at the office where they discussed the incident. The LPN also stated that there was another woman present in the office when she reported the incident to the unit manager, but she could not recall the woman's identity. Review of a policy titled, Abuse Guidelines, had a review date of July 2022 and revealed that it was the responsibility of the employees, facility consultants, attending physicians, family members, and visitors to promptly report any incident or suspected incident of resident abuse to facility management. The policy defined abuse as being the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also revealed that the facility would not condone resident abuse by anyone, including other residents, and all personnel were encouraged to report incidents of resident abuse or suspected incidents of abuse without fear of retaliation from the facility or its staff. The policy further revealed that employees, consultants, and physicians must immediately report any suspected abuse to the DON, and in their absence, reports may be made to the nurse supervisor on duty. The policy revealed that the administrator must be immediately notified of suspected abuse or incidents of abuse. The policy titled, Abuse Guidelines, also revealed that when an allegation or suspected case of mistreatment or abuse was reported, the administrator or his/her designee would immediately notify the state licensing agency, the local/state ombudsman, the resident representative, adult protective services, and the resident's physician. The policy further revealed that the notifications would need to include the name of the resident, the number of the room the resident resided in, the type of abuse that was alleged, the date and time the incident occurred, the names of the persons involved, and what immediate action was taken by the facility. The policy further revealed that when an incident of resident abuse was suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. The policy also revealed that failure to report an incident may result in legal or criminal action being filed against the individuals for withholding such information.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was investigated. The deficient practice could result in continued abuse and physical or emotional harm to residents.Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights and safety of others.A care plan focus initiated on September 13, 2024, revealed the resident had shown behaviors of verbal aggression towards activity staff and other residents in group activities, with interventions to provide social visits to the resident throughout the week and offering independent leisure materials.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days and other behavioral symptoms for 4-6 days. A behavior progress note dated December 15, 2025, at 8:01 p.m. revealed that the resident was sitting in the hallway when he noticed a peer by the nurses' station. The note also revealed that the resident yelled, Get away from there, you're just bothering them. You need to take your a** back to your room, and staff intervened by trying to redirect the resident. A behavior progress note dated December 19, 2025, at 5:28 p.m. revealed that the resident was observed becoming verbally aggressive and cursing profanities at another resident and activities staff at 3 p.m. The note further revealed that the resident was redirected and monitored during a smoke break, and 30 minutes later, the resident was yelling at another resident for clogging his toilet. The note also revealed that the resident was observed threatening to fight another resident and cursing, and he was redirected and de-escalated. A behavior progress note dated December 21, 2025, at 3:25 p.m. revealed that the resident was observed attempting to redirect one of his closest peers to his room and informed the peer he would assist with cleaning his toilet seat when Resident #89 put his hands on the outside of the peer's bilateral arms to redirect towards his room. The note revealed that the peer was not ready to leave the nurses' station, and so an argument ensued. The note further revealed that staff separated the residents. A behavior progress note dated January 11, 2026, at 10:09 p.m. revealed that the resident became upset when the nurse asked him what he said to the CNAs because it sounded like a threat, and he approached the nurse threateningly and menacingly while leaving verbal threats that they should not be approaching or talking to him at all or else he would f*** with them.A behavior progress note dated January 13, 2026, at 11:23 p.m. revealed that the resident was observed to be yelling and cursing at peers and threatening to put his hands on one peer, and the nurse was able to redirect and administer as-needed medication to aid with increased anxiety.There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. -Regarding Resident #78Resident #78 was admitted [DATE], with diagnoses that included vascular dementia, depression, chronic kidney disease, hypertension, cerebral infarction, chronic viral hepatitis C, pure hypercholesterolemia, chronic obstructive pulmonary disease, hyperlipidemia, aphasia, dysphagia, basal cell carcinoma, adjustment mood disorder, anxiety disorder, and dysphagia.A care plan focus initiated on January 19, 2024, revealed the resident displayed behavioral symptoms related to dementia, including physical aggression like hitting, kicking, and pushing, verbal symptoms like yelling, cursing, and other threatening behaviors, as well as hallucinations, wandering, and refusal of care with interventions to give psychoactive medications as orders, record behavioral symptoms, and educate the resident on appropriate behaviors when on the patio with peers.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS also revealed that the resident exhibited verbal behaviors for 4-6 days. There was no evidence of documentation completed in the resident's clinical record regarding the resident-to-resident incident on January 20, 2026. A request was made for the facility's self-reports, grievances, and investigations for the last 4 months, and the facility documented that they had not reported any incidents or had any grievances in the last 4 months. An interview was conducted on January 26, 2026, at 3:27 p.m. with a Certified Nursing Assistant (CNA/Staff #34), who stated that Resident #89 was an aggressive resident who would try to intimidate people. The CNA stated that Resident #89 had behaviors mostly when women were around because he would try to impress them by getting aggressive, yelling, and being rough with staff. The CNA stated that Resident #89 had made threats to residents before, and that within the last week, Resident #89 made a cardboard gun, covered his face with a bandana, and went into Resident #78's room to tell the resident, if you don't be quiet, I'll teach you a lesson. The CNA stated that staff made efforts to get Resident #89 out of the room and calm him down, and that he would consider the incident a resident-to-resident abuse. The CNA also stated that the two nurses who were present at the time of the incident took charge of the situation and reported it to their supervisor. An interview was conducted on January 26, 2026, at 3:50 p.m. with a Licensed Practical Nurse (LPN/Staff #17), who stated that reportable incidents would be considered any form of abuse or what you are seeing such as physical, emotional, and the poor treatment of residents, and that he would report incidents to the unit manager or the Director of Nursing (DON) for them to investigate. The LPN stated that Resident #89 was a resident who would get aggressive with other residents, and that he would get upset with Resident #78 sometimes if he was loud.A telephonic interview was conducted on January 26, 2026, at 4:39 p.m. with an LPN, Staff #80, who stated that abuse incidents should have been recorded in the progress notes within the clinical record, and that the timeframe for reporting abuse was immediately to the designated person, the DON, or the administrator for further investigation. The LPN stated that reportable abuse incidents that needed to be investigated could be physical, verbal, or resident-to-resident, and that she had a resident-to-resident emotional abuse incident on January 20, 2026, that she had to report. The LPN stated that the incident involved Resident #89 and Resident #78, and that Resident #89 entered Resident #78's room and was holding a pretend gun made out of cardboard. The LPN stated that she witnessed the entire event and that Resident #89 told Resident #78 that he would shoot him if he did not quiet down. The LPN stated she heard Resident #89 say, go to sleep, or I am going to shoot you, and that Resident #78 felt intimidated after the incident. The LPN further stated that she spoke with the LPN unit nurse manager (unit manager/Staff #56) to report the incident, and the unit manager told her to write a statement about the incident on paper. The LPN stated that she did not know if the unit manager reported the incident to the DON or management, or if it was investigated. A telephonic interview was attempted on January 26, 2026, at 4:50 p.m. with an LPN, Staff #23, with no success.An interview was conducted on January 26, 2026, at 4:57 p.m. with the Director of Nursing (DON/Staff #67), who stated that she was responsible for the abuse coordination, investigating, and reporting for the facility, and that a resident-to-resident physical or verbal abuse would be considered a reportable abuse. The DON stated that she did not know anything about a recent abuse incident between Resident #89 and Resident #78, but she did know that Resident #89 had a bad weekend where he was verbally aggressive to staff. The DON stated that her process for investigating allegations of abuse was to interview staff and residents, look at the charting, and then report to the applicable state agencies. An interview was conducted on January 26, 2026, at 5:07 p.m. with the LPN unit nurse manager (unit manager/Staff #56), who stated that she had not reported anything recently, but she found out just 5-10 minutes before the interview that Resident #89 was really bad, and that he made a cardboard gun and was playing with staff and Resident #78. The LPN unit manager stated that she had no idea who was involved, she did not recall the incident being reported to her, and that she would immediately let the DON know so she could investigate. The LPN unit manager stated that she did not investigate the incident with the cardboard gun.A follow-up telephonic interview was conducted on January 26, 2026, at 5:14 p.m. with the LPN, Staff #80, who stated that the unit manager she reported the abuse incident to was Staff #56, and that there was a camera pointing at the office where they discussed the incident. The LPN also stated that there was another woman present in the office when she reported the incident to the unit manager, but she could not recall the woman's identity. Review of a policy titled, Abuse Guidelines, had a review date of July 2022 and revealed that it was the responsibility of the employees, facility consultants, attending physicians, family members, and visitors to promptly report any incident or suspected incident of resident abuse to facility management. The policy defined abuse as being the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also revealed that the facility would not condone resident abuse by anyone, including other residents, and all personnel were encouraged to report incidents of resident abuse or suspected incidents of abuse without fear of retaliation from the facility or its staff. The policy further revealed that employees, consultants, and physicians must immediately report any suspected abuse to the DON, and in their absence, reports may be made to the nurse supervisor on duty. The policy revealed that the administrator must be immediately notified of suspected abuse or incidents of abuse. The policy titled, Abuse Guidelines, also revealed that when an allegation or suspected case of mistreatment or abuse was reported, the administrator or his/her designee would immediately notify the state licensing agency, the local/state ombudsman, the resident representative, adult protective services, and the resident's physician. The policy further revealed that the physician or licensed nurse would immediately need to examine the resident, record findings in the medical record, complete an unusual occurrence form with written statements from witnesses, and an immediate investigation would be made, and a copy of the investigation would be provided to the administrator.

Based on clinical record review, interviews and review of facility policy and procedure, the facility failed to ensure physician orders were followed regarding blood glucose monitoring; and, failed to ensure a healthcare provider was notified of abnormal blood glucose reading for one of 3 sampled resident (#44). The deficient practice led to the resident being admitted to the intensive care unit of a hospital with hyperglycemia and treatment for diabetic ketoacidosis.Findings Include: Resident #44 was admitted on [DATE], and re-admitted on [DATE], with diagnoses of type 1 diabetes mellitus, cerebral infarction, long term use of insulin, unspecified dementia, unspecified psychosis, and other sequelae of cerebral infarction.A care plan dated June 7, 2024, revealed Resident #44 had diabetes mellitus. Interventions included: diabetic medication and fasting serum blood sugar as ordered by physician; to educate resident regarding medications and importance of compliance and have resident verbally state an understanding; monitor/document/report as needed any signs and symptoms of hyperglycemia (increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, pain, Kussmaul breathing, acetone breath, stupor, and coma) and hypoglycemia (sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait). The care plan did not include monitoring of BS (blood sugar) with either accuchecks (fingerstick BS monitoring device) or Dexcom device (continuous glucose system sensor). A physician order dated August 28, 2024 included for the following:Dexcom G7 Sensor to inject 1 dose (sensor) subcutaneously one time a day every 10 day(s) for type 1 diabetes mellitus, and to install on upper arm and alternate arms each dose, and to remove per schedule; and,Keep Dexcom G7 sensor charged at all times.A physician order dated June 26, 2025, included to change Dexcom G7 Sensor every 10 days.A physician order dated September 3, 2025, included for Humalog Injection Solution 100 unit/ml (Insulin Lispro), to inject 8 units subcutaneously every 4 hours as needed for hyperglycemia, and may give additional 8 units if BS >300.A quarterly minimum data set (MDS) assessment dated [DATE] a BIMS (brief interview for mental status) score of 10, indicating resident #44 had moderate cognitive impairment. Active diagnoses of diabetes mellitus and psychotic disorder. The documentation revealed a discrepancy in Section N, which showed that Resident #44 received insulin injections 7 out of 7 days or since admission, and that the documentation was not check/marked in the box to indicate that the resident was taking a hypoglycemic medication (insulin) during the last 7 days or since admission.The behavior note dated September 16, 2025 revealed resident was alert and oriented x 2 with confusion and frequently refusing cares. The documentation also included glucose monitoring as ordered with no signs/symptoms of hypo or hyperglycemia.A behavior note dated September 17, 2025 included the resident demanded his insulin that morning and the nurse explained that insulin was held because resident's BS was 89. The documentation also included that the resident took his medications and his insulin needed from Accucheck.A care plan revised on September 18, 2025 included the resident exhibited maladaptive behaviors as evidence by refusing medication and care, and repetitively asking for Accuchecks to be done and demanding insulin multiple times per day. Interventions included to conduct an evaluation of the behavioral symptoms to determine what strengths or needs are communicated via the behavior; to emphasize soothing, kind, slow and compassionate speech, do not rush or hurry, and use body language that communicates patience; to give psychoactive medication as ordered; and, to record behaviors/medication side effects, report changes to facility psychiatric practitioner.The behavior note dated September 19, 2025 revealed the resident was alert and oriented, tolerated medication administration as well; and that, the resident will come to the nurse's station to get his blood sugar checked and short acting was given.A behavior note dated September 30, 2025 included the resident was compliant with medication administration; and, will come to the nurse's station to ask to get his blood sugar checked. The order administration note dated October 4, 2025 revealed BS of 102 mg/dl (milligrams/deciliter).The order administration note dated October 5, 2025 revealed BS of 113 mg/dl.The order administration note dated October 6, 2025 revealed BS of 90 mg/dl.The order administration note dated October 7, 2025 revealed BS of 65 mg/dl.The order administration note dated October 8, 2025 revealed BS of 96 mg/dl.Despite documentation of low BS readings, there was no evidence the resident was monitored for sign/symptoms of hypoglycemia, actions were taken to address the low blood sugar; and that, the physician was notified.The blood sugar summary record for October 8, 2025 revealed the resident had a BS reading of 216 mg/dl.A physician order dated October 15, 2025, included for Insulin Glargine Solution 100 unit/ml, to inject 17 units subcutaneously one time a day, at 10:00 p.m., for type 1 diabetes mellitus.The blood sugar summary record dated October 16, 2025 revealed a BS reading of 260 mg/dl.The behavior note dated October 20, 2025 included that the resident refused midday insulin and became aggressive.The order administration notes dated October 20 and 22, 2025 revealed the resident refused Humalog insulin.The orders administration note dated October 20, 2025 revealed resident #44 refused the insulin medication.The clinical record revealed no documentation that the physician was notified of the resident's refusal of insulin.A physician order dated and signed by a Nurse Practitioner (NP / Staff #27) on October 24, 2025, included to check BS four times a day, at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. Another physician order dated October 24, 2025, included for Humalog Injection Solution 100 unit/ml (Insulin Lispro), to inject 6 units subcutaneously before meals and at bedtime (7:30 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.) for diabetes, and to hold if BS <120, and to scan Dexcom G7 Sensor, and keep it charged.The orders for Decom G7 sensor and to inject 1 dose every 10 days were transcribed onto the MAR (medication administration record) for October 2025. The documentation in the MAR included that removed on October 2 and 12, was applied on October 12 and was refused by the resident to be applied on October 9 and to be removed on October 22, 2025.The order administration note dated October 24, 2025 included that the resident refused Insulin twice and reported that he did not want it.The order administration note dated October 26, 2025 revealed that resident's BS was 63 mg/dl which was outside of the parameters and no insulin was administered.A behavior note dated October 26, 2026 included that the resident ate all meals in dining room, was compliant with BS checks and insulin administration. However, the documentation did not include that BS was rechecked and what the BS readings were.The order administration note dated October 27, 2025 revealed BS was 52 mg/dl which was outside of the parameters and no insulin was administered.The order administration note dated October 28, 2025 included Humalog insulin was held because the resident's BS was 69 mg/dl.The order administration note dated October 29, 2025 revealed the resident's BS was 53 which was outside of the parameters and no insulin was administered.Despite documentation of low BS readings from October 26 through 29, 2025, there was no evidence the resident was monitored for sign/symptoms of hypoglycemia, BS was retaken, actions were taken to address the low blood sugar; and that, the physician was notified.The order administration notes dated October 30 and 31, 2025 included that the resident refused, after multiple witnessed attempts, to allow staff to check his Dexcom device or to check his blood sugar manually, and no insulin was given.There was no evidence found that the resident was monitored for sign/symptoms of hyper- or hypoglycemia; and that, the physician was notified.Review of the MAR for October 2025 revealed that the order for Humalog insulin and to hold if BS was <120 was transcribed and was documented as administered as ordered except on the following dates when the resident refused: October 15, 13, 19, 20, 22, 24, 30 and 31.Continued review of the documentation in the October 2025 MAR included that Humalog insulin was coded as 14 indicating vital/lab outside of the parameter on the following dates: October 4, 5, 6, 7, 8, 21, 26, 27, 28 and 29. The physician order to check blood glucose 4x a day at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. was not transcribed onto the MAR or the TAR (treatment administration record) for October 2025.Further, the clinical record revealed no evidence that resident's BS was checked four times a day, at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. as ordered by the physician from October 24 through October 31, 2025. There was also no documentation found in the clinical record of what the resident's BS readings on the dates that were coded as 14 in the October 2025 MAR.The order administration note dated November 1, 2025 revealed the resident refused the placement of the Dexcom G7 sensor.However, the behavior note dated revealed the resident was compliant with BS checks and insulin administration.Review of the MAR for November 2025 included that Humalog insulin 6 units subcutaneously was administered to the resident on November 1, 2025 at 7:30 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m.However, the clinical record revealed no evidence that resident's BS was checked and recorded; and, what the BS readings were prior to the administration of Humalog insulin on November 1, 2025 at 7:30 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m.The blood sugar summary revealed that on November 2, 2025 the resident's BS reading was 329 mg/dl.A behavior note dated November 2, 2025 revealed the resident was compliant with BS check and insulin injection.The MAR for November 2025 revealed Humalog insulin was administered as ordered on November 2, 2025.The order administration notes dated November 4, 2025, the resident refused accucheck.The MAR for November 2025 included resident refused insulin administration on November 4, 2025 scheduled at 4:00 p.m.; and on November 5, 2025.Despite documentation that resident refused accuchecks and insulin administration, the clinical record revealed no documentation the resident was monitored for sign/symptoms of hyper- or hypoglycemia; and that, the physician was notified on November 4 and 5, 2025.The order administration note dated November 6, 2025 revealed resident refused accucheck; and that, resident had no signs/symptoms of hyper-/hypoglycemia.Review of the MAR documentation for November 6, 2025 included that the resident refused insulin administration on November 6, 2025 scheduled at 11:00 a.m. and 4:00 p.m.; and, insulin was documented as administered on November 6 scheduled at 7:30 a.m. and 8:00 p.m.The behavior note dated November 7, 2025 revealed the resident continued to self-isolate in room, refused bedtime medications and blood sugar checks with no signs and symptoms of distress noted.The November 2025 MAR revealed that the resident was administered with insulin on November 7, 2025 except the scheduled dose at 8:00 a.m. which was coded as 2 indicating resident refusal.However, the clinical record revealed no evidence that the resident's BS was taken on November 6 and 7, 2025; and that, the physician was notified of missed insulin doses because of resident refusal.The behavior note dated November 8, 2025 included the resident was alert & oriented x 3 and refused his scheduled bedtime medications and accuchecks.The order administration note dated November 8, 2025 at 7:45 a.m. revealed the resident's BS was 87 which was outside of the parameters; and that, no insulin was administered.The clinical record revealed no documentation that the resident was monitored for sign/symptoms of hypoglycemia, or actions were taken to address the resident's low BS and the physician was notified of the resident's low BS reading.Review of the MAR revealed that resident was administered insulin on November 8, 2025 scheduled at 11:00 a.m., 4:00 p.m. and 8:00 p.m.However, the clinical record revealed no documentation that the resident's BS was rechecked and recorded; and BS readings were taken prior to administration of insulin on November 8 at 11:00 a.m., 4:00 p.m. and 8:00 p.m.The medical provider note dated November 9, 2025 revealed the resident continued on his insulin for diabetes. Past medical history included type 1 brittle diabetes and history of diabetic ketoacidosis. Assessment included type 1 diabetes; and that, current diabetic interventions were reasonable.The order administration note dated November 10, 2025 at 8:24 a.m. revealed the resident's BS was 63 which was outside of the parameters; and that, no insulin was administered.There was no evidence found that the resident was placed on a change in condition or was monitored for signs/symptoms of hypoglycemia, or actions taken to address the low BS; and that, the physician was notified.Review of the MAR revealed that resident was not administered with insulin on November 10, 2025 scheduled at 7:30 a.m. because of vitals outside the parameter and at 8:00 a.m. because resident refused.Continued review of the MAR documentation on November 10, 2025 revealed that insulin was documented as administered on November 10 scheduled at 11:00 a.m. and 4:00 p.m.However, the clinical record revealed no documentation that the resident's BS was rechecked and recorded; and BS readings were taken prior to administration of insulin on November 10 at 11:00 a.m. and 4:00 p.m.The order administration note dated November 11, 2025 revealed the resident refused the scheduled Dexcom dose.The behavior note dated November 11, 2025 included that the resident initially refused blood sugar checks and insulin administration, but on the second attempt, allowed both before meals.The MAR revealed that insulin was documented either coded as a 5 indicating to see progress note or as 2 indicating drug was refused.The behavior note dated November 12, 2025 revealed the resident refused any medications; had self-isolated in his room for most of the day and had no discomforts noted at the time.The blood sugar summary included that on November 12, 2025 at 7:43 a.m. the resident had a BS reading of 85 mg/dl.The clinical record revealed no documentation that the resident was placed on a change in condition or was monitored for sign/symptoms of hypoglycemia or actions taken to address the resident's low BS; and, the physician was notified.The order administration note dated November 14, 2025 revealed the resident refused accucheck and his insulin; and, there were no signs/symptoms of distress noted.The MAR included that insulin was administered to the resident on November 14, 2025 except at the scheduled 8:00 p.m. dose.A behavior note dated November 14, 2025 included the resident refused all bedtime medications and accucheck.However, the clinical record revealed no documentation that the resident's BS was rechecked and recorded; and, BS readings were taken prior to administration of insulin on November 14 at 7:30 a.m., 11:00 a.m. and 4:00 p.m.The behavior note dated November 16, 2025 revealed resident refused all night oral medications; but, allowed accucheck and insulin injection.The blood sugar summary dated November 16, 2025 at 8:10 p.m. included the resident had BS reading of 345 mg/dl.Despite documentation of a high BS reading, the clinical record revealed no documentation that the resident's BS was rechecked and recorded after insulin was administered or the resident was placed on change in condition or the resident was monitored for signs/symptoms of hyperglycemia; and that, the physician was notified.The order administration note dated November 17, 2025 at 9:52 p.m. revealed the resident refused insulin 3x.The behavior note dated November 18, 2025 included resident refused daytime insulin checks.The blood sugar summary revealed that on November 18, 2025 at 7:53 p.m., the resident's BS reading was 561 mg/dl.The order administration note dated November 18, 2025 at 9:23 p.m. revealed resident was very combative, threw punches and kicked at the staff when 2 kinds of insulin were injected. The documentation also included the resident's BS reading was 516 mg/dl.There was no evidence found that the resident was monitored for sign/symptoms of hyperglycemia or the resident was placed on a change in condition; and that, the physician was notified.The order administration notes dated November 19, 2025 revealed the resident refused multiple attempts by the nurse to administer insulin and refused accucheck.Review of the MAR revealed that on November 19, 2025 insulin was administered to the resident scheduled at 7:30 a.m. The documentation also included that the insulin was documented as code 2 indicating the resident refused insulin scheduled for 11:00 a.m., 4:00 p.m. and 8:00 p.m.There was no evidence that the resident's BS was checked and recorded on November 19, 2025; and that, the physician was notified of the missed doses of insulin.An order administration notes dated November 20, 2025 revealed the resident refused 3 attempts at insulin administration.The behavior note dated November 20, 2025 included the resident's BS was within normal limits (WNL); however, the documentation did not include what the BS reading was.Another order administration note dated November 20, 2025 at 9:00 p.m., revealed the resident refused accucheck.Despite documentation of continued resident refusal of accuchecks and insulin, there was no evidence found that the resident was monitored for sign/symptoms of hyper- or hypoglycemia or the resident was placed on a change in condition; and that, the physician was notified of the missed doses.The MAR revealed that on November 21, 2025, the scheduled dose of Dexcom was documented as code 14 indicating vital/lab outside of parameter.The health status note dated November 21, 2025 included that resident felt dizzy and laid himself on the floor outside of the room door. Per the documentation, BS was monitored and maintained per physician's ordered; and that, monitoring will continue.A behavior note dated November 21, 2025 revealed that the resident's BS was monitored and maintained. The documentation did not include what the resident's BS reading was.The order administration note dated November 21, 2025 included that the resident refused accucheck and had no signs/symptoms of distress.There was no evidence found in the clinical record that the resident's BS was checked on November 21, 2025.Despite the lack of BS readings, the MAR revealed that on November 21, 2025, the resident was administered insulin as scheduled at 7:30 a.m., 11:00 a.m., and 4:00 p.m. The documentation in the MAR also included that insulin was documented as not administered at the scheduled 8:00 p.m. dose.There was no evidence found in the clinical record that the physician was notified of the missed insulin dose; and that, the resident was monitored for signs/symptoms of hyper- or hypoglycemia.A behavior note dated November 22, 2025 at 12:36 a.m. revealed Resident #44 continued to refuse scheduled accuchecks and bedtime medications.An order administration note dated November 22, 2025 at 2:11 a.m. revealed staff reported Resident #44 was vomiting and that BS was checked and read high. According to the documentation, the PRN (as needed) insulin was administered as ordered by the PCP (primary care physician). The documentation did include the what BS reading was.There was also no evidence found in the clinical record that the provider was notified of the resident's high BS reading, or that the resident was placed on COC monitoring or was monitored for signs/symptoms of hyperglycemia.An order administration note dated November 22, 2025 at 5:29 a.m., revealed Resident #44 refused to allow nurse to recheck BS.The MAR revealed that insulin was administered on November 22, 2025 as scheduled on 7:30 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. However, there was no evidence that BS was checked and recorded prior to the administration of insulin on these scheduled times.The blood sugar summary revealed that the BS reading on November 23, 2025 was 222 mg/dl.The November 2025 MAR revealed that insulin was documented as administered on November 23, 2025 except on the 8:00 p.m. scheduled dose.The clinical record revealed no evidence that the resident's BS was checked and recorded prior to insulin administration at the scheduled times on November 22 and 23, 2025. A medical provider note dated November 26, 2025 revealed the reason for visit was for follow-up on insulin dependence. The documentation revealed the resident was frequently refusing insulin dosing approximately 50% of the time. Plan included to encourage adherence to insulin administration and to notify the provider if BS value was <60 or >400.The blood sugar summary dated November 27, 2025 at 7:53 a.m. revealed that the resident had a BS reading of 467 mg/dl.An order administration notes dated November 27, 2025 revealed the resident refused insulin and accucheck.Despite documentation of resident refusing accucheck and insulin and a high BS reading, there was no evidence that the resident was placed on change in condition or monitored for signs/symptoms of hyper- or hypoglycemia; and that, the physician was notified.The clinical record revealed documentation that the resident continued to refuse accuchecks and his medications including scheduled insulin on November 28 and 29, 2025.A behavior note dated November 29, 2025 revealed the resident was compliant with BS check before breakfast; and that, BS reading was 450 mg/dl and 6 units of insulin was administered. The documentation also included the resident refused the 11:30 a.m. accucheck, and that, at 3:00 p.m., the nurse was notified that the resident vomited and reported that he was not feeling well. It also included that the resident's BS reading was 491 mg/dl and 6 units of insulin were administered.Another behavior note dated November 29, 2025 revealed that at 3:00 p.m., the resident's accucheck was completed twice and that on both times the readings read high. The MAR included that on November 29, 2025, insulin was documented as administered to the on the 7:30 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. scheduled dose.Despite the documentation of a high BS, there was no evidence found in the clinical record that the physician was notified or that the resident was placed on any change in condition monitoring on November 29, 2025. The physician order to check blood glucose 4x a day at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. was not transcribed onto the MAR/TAR for November 2025.The clinical record revealed no evidence that resident's BS was checked 4x/day at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. as ordered by the physician from November 1 through November 29, 2025.An order administration note dated November 30, 2025 revealed the BS is high.A health status note dated November 30, 2025 revealed that at 4:30 a.m., the resident was vomiting during rounds; and, BS was checked which showed as high. The documentation also included that the PRN insulin coverage was administered to the resident; and, BS was re-checked 15 minutes later and the results was still high. According to the documentation, the provider was notified and new orders were received to re-check BS in 2 hours, and if BS was still high, the NP would provide new orders.The blood sugar summary included a BS reading of 575 mg/dl on November 30, 2025 at 7:15 a.m.The SBAR (Situation-Background-Assessment-Recommendation) note dated November 30, 2025 included the resident had a BS of 575 mg/dl, the provider was notified and orders to send the resident to the hospital was received.A physician order dated November 30, 2025, included to send the resident out through 911 for high BS.A Transfer to Hospital Summary dated November 30, 2025, revealed the NP ordered to send Resident #44 to the hospital emergently via 911.An order administration note dated November 30, 2025, revealed the resident was hospitalized .The admission summary note dated December 1, 2025 included that Resident #44 re-admitted to the facility and had BS reading of 222.A medical provider note dated December 2, 2025 revealed the resident was sent to the ER (emergency room) on November 30, 2025 for hyperglycemia. The documentation included that the resident had been refusing insulin since his return to the facility; and that, the resident was on 17 units long acting insulin and 18 units short acting insulin with hold parameters and PRN insulin available for BS > 300 mg/dl. Plan included to encourage adherence to insulin regimen, titrate insulin to optimize BS, and to call the provider for BS of <60 mg/dl or >400 mg/dl.The blood sugar summary included that on December 2, 2025 at 7:59 p.m., the resident's BS reading was 377 mg/dl.The documentation un the MAR for December 2, 2025 revealed that the resident was administered with insulin.Review of the clinical record from December 2 through 5, 2025 revealed that the resident continued to refuse medications including insulin and accuchecks.A behavior note dated December 6, 2025 included the resident refused morning oral medications but allowed an accucheck and insulin. Per the documentation, the resident's blood sugar was 475 mg/dL, and 6 units of insulin were given. The note also included that the resident refused accuchecks at 11:30 a.m. and 4:00 p.m. after two attempts by staff; and that, the resident was educated on the risks of high and low blood sugar. However, the documentation did not include that the provider was notified of the residents BS reading.The order administration note dated December 8, 2025 at 8:16 a.m. revealed Resident #44 had a BS value of 51 and was not administered insulin.A behavior note dated December 8, 2025 included the resident was compliant with the 7:30 a.m. accucheck and had a BS of 51 mg/dl so no insulin was administered. The documentation also included that the resident refused his 12:00 p.m. accucheck, insulin administration and lunch despite two attempts by staff. It also included the resident was compliant with the 4:00 p.m. accucheck and insulin administration. Per the documentation, the resident's BS at 4:00 p.m. was 456 mg/dl. Further, the documentation included that the resident refused his dinner but accepted glucose control boost with evening medication mixed in.There was no evidence that the resident was placed on change in condition monitoring or was monitored for signs/symptoms of hypo- or hyperglycemia and that the physician was notified of the resident low BS readings and the missed insulin doses.The behavior note dated December 9, 2025 revealed Resident #44 refused accuchecks four times; but, the documentation did not indicate specific times the resident refused. Per the documentation, the nurse returned 10 minutes later and the resident agreed o have his BS checked, and the BS reading was 177, and insulin was administered.Another behavior note dated December 9, 2025 revealed the resident's BS was checked and insulin given; however, the documentation did not include the BS reading. Per the documentation, the resident picked which medications he wanted to take, and that the provider and unit manager were aware.A behavior note dated December 10, 2025 included the resident's BS was low, and the unit manager was notified. However, the documentation did not include the BS reading; and that the provider was notified of the resident's low BS.The clinical record also revealed no evidence that the resident was placed on change in condition monitoring or was monitored for signs/symptoms of hypoglycemia.The order administration note dated December 11, 2025 included the resident's Dexcom device indicated BS value of 278.An alert note dated December 12, 2025 at 3:38 a.m. revealed that after midnight the resident's Dexcom device read high. The documentation did not include how high the BS reading was.The order administration note dated December 12, 2025 at 7:44 p.m., included the resident's Dexcom device read high; and that, the resident refused insulin. The documentation did not include how high the BS reading was.A behavior note dated December 12, 2025 at 11:04 pm. P.M. revealed that Resident #44 was observed lying in bed since the beginning of shift, had refused medications and accuchecks; and that, the Dexcom device read high. However, the documentation did not indicate how high the BS reading was. There was no evidence that the provider was notified of the resident high BS reading, resident's refusal to have accucheck and insulin.There was also no evidence that the resident was placed on change in condition monitoring or was monitored for sign/symptoms of hyperglycemia.A review of the physician order summary from October 24 through December 12, 2025 revealed an active order since October 24, 2025 for checking of BS 4x a day at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m.However, this order was not transcribed onto the MAR/TAR for October, November and December 2025.The clinical record continued to reveal no evidence that resident's BS was checked 4x/day at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. as ordered by the physician from October 24 through December 12, 2025. The order administration note dated December 13, 2025 at 9:01 a.m. revealed that the resident's BS was high and 8 units of PRN insulin was administered. The documentation also included that the resident was symptomatic.The MAR for December 2025 revealed that 8 units of PRN insulin were administered on December 13, 2025 at 9:01 a.m.An SBAR note dated December 13, 2025 revealed the nurse went to wake the resident up for breakfast, BS check, and insulin administration at 7:50 a.m.; and that, the resident had dried dark brown vomit around the mouth, with tachypnea (abnormally rapid and shallow breathing), diaphoresis (excessive sweating or perspiration), and was responsive to painful stimuli with occasional grunting. Per the documentation, both the accucheck and the Dexcom device read high when assessed. The documentation did not indicate the BS readings. Vital signs included BP (blood pressure) of 115/77 mmHg (millimeters Mercury) in left arm and BP of 87/59 mmHg in right arm, pulse 50 beats per minute, temperature 98.5 degrees Fahrenheit, respirations 44 per minute, and oxygen saturation 85% on room air. According to the documentation, 8 units of PRN insulin were administered, the provider was notified and orders to start the resident on supplemental oxygen and send the resident to the hospital via emergency medical services (EMS) for hyperglycemia was received. Further, the documentation included that at 8:25 a.m., EMS arrived and transported the resident to the hospital.The order administration note dated December 13, 2025 at 9:02 a.m. revealed the resident was sent to the hospital this morning before oral medications were given, due to hyperglycemia.A behavior note dated December 13, 2025 included Resident #44 was admitted to the hospital.A hospital admission history and physical note dated December 13, 2025 revealed Resident #44 presented to the emergency room from the skilled nursing facility on December 13, 2025, with altered mental status and was found to be in diabetic ketoacidosis. The note also included that the resident was deemed critically ill with ongoing threat to life or limb secondary to metabolic acidosis, necessitating ICU (intensive care unit)-level care.The hospital critical care admission history and physical note dated December 13, 2025 included Resident #44 had a principal problem of type 1 diabetic ketoacidosis. Per the documentation, the resident presented to the emergency department from the facility for altered mental status after the BS was thought to be high, and reports of seizure-like activity. The assessment revealed the resident was admitted for acute encephalopathy and diabetic ketoacidosis and hyperosmolar hyperglycemic state

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate regarding blood glucose monitoring for one resident (#44). The deficient practice could lead to incomplete and inaccurate medical record.-Findings Include:Resident #44 was admitted on [DATE], and re-admitted on [DATE], with diagnoses of type 1 diabetes mellitus, cerebral infarction, long term use of insulin, unspecified dementia, unspecified psychosis, and other sequelae of cerebral infarction.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #44 had a brief interview for mental status (BIMS) assessment score of 10, indicating moderate cognitive impairment. Section I revealed Resident #44 had active diagnoses of diabetes mellitus and psychotic disorder.A care plan dated June 7, 2024, revealed Resident #44 had diabetes mellitus, with interventions that included:-Diabetic medication as ordered by physician-Fasting serum blood sugar as ordered by physicianNo evidence was found in the care plan regarding monitoring blood glucose (blood sugar / BS) with either accucheck (fingerstick BS monitoring device) or dexcom device (continuous glucose system sensor). Additionally, the care plan revealed the most recent revision was on June 25, 2025.A physician order dated May 24, 2024, included for vital signs per facility policy.Physician orders dated August 28, 2024, included:-Dexcom G7 Sensor (continuous glucose system sensor), to inject 1 dose (sensor) subcutaneously one time a day every 10 days for type 1 diabetes mellitus, and to install on upper arm and alternate arms each dose, and to remove per schedule.-Keep Dexcom G7 sensor charged at all times.A physician order dated June 26, 2025, included to change Dexcom G7 Sensor every 10 days.A physician order dated and signed by a Nurse Practitioner (NP / Staff #27) on October 24, 2025, included to check BS four times a day, at 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.Another physician order dated October 24, 2025, included for Humalog Injection Solution 100 unit/ml (Insulin Lispro), to inject 6 units subcutaneously before meals and at bedtime (7:30 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.) for diabetes, and to hold if BS <120, and to scan Dexcom G7 Sensor, and keep it charged. The clinical record was reviewed and revealed the following regarding BS readings (values / numerical data) for Resident #44:October 24, 2025:-An Orders Administration Note revealed the resident refused insulin administration 2 times.-There was no evidence of any BS readings. October 25, 2025:No evidence of any BS readings. October 26, 2025:-An Orders Administration Note at 7:23 A.M. revealed no insulin was administered due to BS reading 63 and outside of parameters.-A Behavior Note revealed Resident #44 was compliant with BS checks and insulin administration, however there was no evidence of how many readings were taken, or what the BS values were. October 27, 2025:-An Orders Administration Note at 7:23 A.M. revealed no insulin was administered due to BS reading of 52, and outside of parameters.-There was no evidence of any other BS readings. October 28, 2025:-An Orders Administration Note revealed insulin was held due to BS reading 69.-There no evidence of any other BS readings. October 29, 2025:-An Orders Administration Note at 7:53 A.M. revealed no insulin was administered due to BS reading 53, outside of parameters.-There was no evidence of any other BS readings. October 30, 2025:-Orders Administration Notes at 9:45 P.M. and 9:47 P.M. revealed the resident refused to allow the nurse to check BS with dexcom device or check BS manually (fingerstick), and no insulin was administered.-There was no evidence of any other BS readings. October 31, 2025:-A Behavior Note at 12:16 A.M. revealed the resident refused to allow the nurse to check dexcom or check BS manually, and no insulin administered.-An Orders Administration Note at 8:41 P.M. revealed the resident refused multiple attempts of insulin administration.-There was no evidence of any other BS readings. November 1, 2025:-An Orders Administration Note revealed Resident #44 refused the dexcom sensor placement.-A Behavior Note revealed the resident was compliant with BS checks and insulin administration. -There was no evidence of how many BS readings were taken and when, nor what the BS values were. November 2, 2025:-A Vitals Log at 7:06 P.M. revealed a BS reading of 329-A Behavior Note at 9:37 P.M. revealed the resident was compliant with BS check and insulin injection.-There was no evidence of any other BS readings. November 3, 2025:-Orders Administration Notes at 7:37 A.M. and 4:09 P.M. both revealed no insulin was administered due to BS reading of 120, outside of parameters, and at 9:35 P.M. the resident refused the insulin for two attempts.-There was no evidence of any other BS readings. November 4, 2025:-A Behavior Note revealed the resident tolerated medication administration well and self-isolated in his room all day other than meal times and insulin administration. The note revealed no evidence of a BS reading.-An Orders Administration Note at 5:13 P.M. revealed the resident refused accucheck.-There was no evidence of any other BS readings. November 5, 2025:-Orders Administration Notes at 8:04 A.M., 11:53 A.M., and 5:04 P.M. revealed Resident #44 refused insulin administration.-There was no evidence of any BS readings. November 6, 2025:-An Orders Administration Note at 11:59 A.M. revealed the resident refused accucheck, and was observed without signs and symptoms of hyper/hypoglycemia.-Orders Administration Notes at 5:07 P.M. and 9:09 P.M. revealed the resident refused insulin administration.-There was no evidence of any other BS readings. November 7, 2025:-A Behavior Note at 2:58 P.M. revealed the resident refused his medications and BS checks.-Orders Administration Notes at 8:31 P.M. and 8:32 P.M. revealed the resident refused scheduled insulin and BS check.-There was no evidence of any other BS readings. November 8, 2025:-A Behavior Note at 5:48 A.M. revealed Resident #44 refused accucheck and refused his scheduled medication. There was no evidence that the dexcom device was attempted, nor that education was provided to the resident.-An Orders Administration Note at 7:45 A.M. revealed no insulin administered due to BS reading 87, outside parameters.-A Behavior Note at 2:51 P.M. revealed Resident #44 was compliant with BS checks, however no evidence of a BS value.-There was no evidence of any other BS readings. November 9, 2025:-There was no evidence of any BS readings. November 10, 2025:-An Orders Administration Note at 8:24 A.M. revealed no insulin administered due to BS reading 63, outside of parameters.-Orders Administration Notes at 9:10 P.M. and 9:11 P.M. revealed the resident refused multiple attempts of insulin administration and accucheck. There was no evidence of attempts to use the dexcom device, nor education provided to the resident.-There was no evidence of any other BS readings. November 11, 2025:-Orders Administration Notes at 8:33 A.M. revealed the resident refused insulin administration and refused the dexcom sensor.- A Behavior Note at 4:29 P.M. revealed the resident refused the first attempt at BS check, then allowed a second attempt for a BS check. There was no evidence what the BS value was.-There was no evidence of any other BS readings. November 12, 2025:-A Vitals Log at 7:43 A.M. revealed a BS reading of 85.-There was no evidence of any other BS readings. November 13, 2025:-Orders Administration Notes at 8:27 and 8:28 P.M. revealed the resident refused insulin administration.-There was no evidence of any BS readings. November 14, 2025:-A Behavior Note at 5:35 A.M. revealed Resident #44 refused medications and accucheck.-Orders Administration Notes at 8:21 P.M. and 8:22 P.M. revealed the resident refused insulin administration and accucheck.-There was no evidence of any BS readings. November 15, 2025:-A Behavior Note at 12:52 A.M. revealed the resident refused medications and accucheck.-There was no evidence of any BS readings. November 16, 2025:-A Vitals Log at 8:10 P.M. revealed a BS reading of 345.-A Behavior Note at 8:49 P.M. revealed the resident allowed accucheck and insulin injection.-There was no evidence of any other BS readings. November 17, 2025:-An Orders Administration Note at 9:52 P.M. revealed the resident refused 3 attempts to administer insulin.-There was no evidence of any BS readings. November 18, 2025:-A Behavior Note at 2:47 P.M. revealed the resident took morning medications, but refused daytime insulin check. There was no evidence of any BS readings.-An Orders Administration Note at 5:04 P.M. revealed the resident refused accucheck.-A Vitals Log at 7:53 P.M. revealed a BS reading of 561.-A Behavior Note at 9:21 P.M. revealed the resident's BS reading was 516.-There was no evidence of any other BS readings. November 19, 2025:-An Orders Administration Note at 10:38 A.M. revealed the resident refused insulin multiple attempts. There was no evidence of a BS reading.-An Orders Administration Note at 3:07 P.M. revealed the resident refused accucheck.-An Orders Administration Note at 8:00 P.M. revealed that the resident refused the insulin administration. There was no evidence of a BS reading.-There was no evidence of any other BS readings. November 20, 2025:-An Orders Administration Note at 8:09 A.M. revealed the resident refused 3 attempts at insulin administration. There was no evidence of a BS reading.-A Behavior Note at 2:30 P.M. revealed the resident's BS was within normal limits (WNL), however no evidence of what the BS value was.-An Orders Administration Note at 5:16 P.M. revealed the resident refused 3 attempts at insulin administration. There was no evidence of evidence of a BS reading.-Orders Administration Notes at 9:00 P.M. and 9:01 P.M. revealed the resident refused accucheck.-There was no evidence of any other BS readings. November 21, 2025:-A Health Status Note at 11:54 A.M. revealed the resident was coming to the dining room for lunch and stated he felt dizzy and laid himself on the floor outside the room door. The documentation revealed BS was monitored and maintained per physician orders. There was no evidence what the BS value was, or that the provider was notified of the incident, or that the resident was placed on COC monitoring.-A Behavior Note at 4:02 P.M. revealed Resident #44's BS was monitored. There was no evidence what the BS value was.-An Orders Administration Note at 8:23 P.M. revealed the resident refused accucheck. There was no evidence the dexcom device was attempted, or that education was provided to the resident.-There was no evidence of any other BS readings. November 22, 2025:-A Behavior Note at 12:36 A.M. revealed Resident #44 refused scheduled accuchecks.-An Orders Administration Note at 2:11 A.M. revealed staff reported Resident #44 was vomiting, and that BS was checked and read high, and that as-needed (PRN) insulin was administered.-An Orders Administration Note at 5:29 A.M. revealed Resident #44 refused to allow nurse to recheck BS.-There was no evidence of any other BS readings. November 23, 2025:-A Vitals Log at 4:59 P.M. revealed a BS reading of 222.-There was no evidence of any other BS readings. November 24, 2025:-A Behavior Note at 10:29 A.M. revealed Resident #44 was compliant with insulin administration and accucheck today. There was no evidence of a BS reading.-An Orders Administration Note at 9:32 P.M. revealed the resident refused 3 attempts at insulin administration. There was no evidence that the resident was provided education, nor any evidence of BS reading.-There was no evidence of any other BS readings. November 25, 2025:-An Orders Administration Note at 11:58 A.M. revealed the resident refused accucheck for 3 attempts.-A Behavior Note at 2:12 P.M. revealed the resident refused medications except his insulin. There was no evidence of a BS reading.-An Orders Administration Note at 4:32 P.M. revealed the resident refused accuchecks.-There was no evidence of any other BS readings. November 26, 2025:-An Orders Administration Note at 10:25 A.M. revealed the resident refused insulin administration and refused accucheck.-A Behavior Note at 2:14 P.M. revealed the resident approached the nurses station this morning asking for his insulin.-An Orders Administration Note at 3:51 P.M. revealed the resident refused accucheck and insulin.-There was no evidence of any BS values. November 27, 2025:-A Vitals Log at 7:53 A.M. revealed a BS reading of 467.-An Orders Administration Note at 11:48 A.M. revealed the resident refused insulin for 3 attempts.-An Orders Administration Note at 12:00 P.M. revealed the resident refused insulin.-AN Orders Administration Note at 8:07 P.M. revealed the resident refused accucheck.-There was no evidence of any other BS readings. November 28, 2025:-A Behavior Note at 1:56 A.M. revealed the resident continued to refuse medications and accuchecks for multiple attempts.-An Orders Administration Note at 2:45 P.M. revealed the resident refused to get his BS checked.-A Behavior Note at 5:08 P.M. revealed Resident #44 continued to refuse his medication and accuchecks for multiple attempts.-An Orders Administration Note at 8:29 P.M. revealed the resident refused accucheck.-There was no evidence of any BS readings. November 29, 2025:-A Behavior Note at 5:00 A.M. revealed Resident #44 was non-compliant with medications, accuchecks, and scheduled insulin.-An Orders Administration Note at 1:11 P.M. revealed the resident refused BS check.-A Behavior Note at 4:37 P.M. revealed the resident was compliant with BS check before breakfast, that revealed BS of 450, and that 6 units of insulin were administered. The documentation revealed the resident refused 11:30 A.M. accucheck, and at 3:00 P.M., the nurse was notified that the resident vomited, and the BS reading was 491, and 6 units of insulin were administered.-A Behavior Note at 5:08 P.M. revealed at 3:00 P.M., the accucheck was completed twice and that both times, the monitor read high.-There was no evidence of any other BS readings. November 30, 2025:-An Orders Administration Note at 4:30 A.M. revealed the BS is high.-A Health Status Note at 4:57 A.M. revealed that at 4:30 A.M., the resident was vomiting during rounds. The resident's BS was checked and shows high, and PRN insulin coverage was provided. The resident's BS was re-checked 15 minutes later and still is high. The documentation revealed the provider was called at 4:45 A.M. and new orders were received to re-check BS in 2 hours, and if BS was still high, the NP would provide new orders.-A Vitals Log at 7:15 A.M. revealed a BS reading of 575. A Transfer to Hospital Summary dated November 30, 2025, revealed the NP ordered to send Resident #44 to the hospital emergently via 911.An Orders Administration Note dated November 30, 2025, revealed the resident was hospitalized .An admission Summary note dated December 1, 2025, revealed Resident #44 re-admitted to the facility and had BS reading of 222.The clinical record revealed the following regarding BS readings for Resident #44 after re-admitting from the hospital: December 2, 2025:-A Behavior Note at 3:17 A.M. revealed the resident was refusing all medication in the evening.-An Orders Administration Note at 1:22 P.M. revealed the resident refused insulin administration, and there was no evidence of a BS reading.-A Behavior Note at 3:06 P.M. revealed the resident would not allow BS check at 4:00 P.M.-A Behavior Note at 10:59 P.M revealed the resident initially refused medications and BS check, however the nurse provided the resident a diet coke and then the resident agreed to take medications and BS check. The note revealed no evidence of a BS value.-There was no evidence of any other BS readings. December 3, 2025:-An Orders Administration Note at 12:16 P.M. revealed the resident refused to get BS checked.-A Behaviors Note at 6:41 P.M. revealed accucheck was initiated and insulin administered. There was no evidence of a BS value.-There was no evidence of any other BS readings. December 4, 2025:-An Orders Administration Note at 12:19 P.M. revealed the resident refused insulin administration two times. The documentation revealed that education was provided to the resident.-A Behavior Note at 5:09 P.M. revealed the resident was compliant with morning accucheck, however there was no evidence of a BS value, and that the resident refused afternoon and evening accucheck, and education was provided to the resident.-An Orders Administration Note at 9:06 P.M. revealed the resident refused accucheck.-There was no evidence of any other BS readings. December 5, 2025:-A Behavior Note at 12:36 A.M. revealed the resident refused accucheck and medications.-A Behavior Note at 12:26 p.m. revealed the resident's BS was checked and he received insulin. There was no evidence of a BS value.-An Orders Administration Note at 8:28 P.M. revealed the resident refused accucheck.-There was no evidence of any other BS readings. December 6, 2025:-An Orders Administration Note at 1:20 P.M. revealed the resident refused accucheck for 2 attempts.-An Orders Administration Note at 5:25 P.M. revealed the resident again refused accucheck for 2 attempts.-A Behavior Note at 5:27 P.M. revealed the resident tolerated accucheck and insulin administration in the morning, and that the BS reading revealed 475. The documentation also revealed that the resident refused 11:30 A.M. and 4:00 P.M. accuchecks.-There was no evidence of any other BS readings. December 7, 2025:-A Behavior Note at 5:25 P.M. revealed Resident #44 was compliant with morning accucheck and insulin administration, however there was no evidence of a BS value. The documentation revealed that the resident initially refused 11:30 A.M. accucheck, but allowed accucheck after a second second attempt, however there was no evidence of a BS value. The note also revealed the resident refused 4:00 P.M. accucheck.-There was no evidence of any other BS readings. December 8, 2025:-An Orders Administration Note at 8:16 A.M. revealed Resident #44 had a BS value of 51 and was not administered insulin.-An Orders Administration Note at 12:53 P.M. revealed the resident refused accucheck.-A Behavior Note at 5:13 P.M. revealed the resident was compliant with 4:00 P.M. accucheck, with a value of 456, and that insulin was administered.-An Orders Administration Note at 10:15 P.M. revealed the resident refused insulin administration for 3 attempts.-There was no evidence of any other BS readings. December 9, 2025:-A Behavior Note at 5:23 P.M. revealed Resident #44 refused accuchecks four times, but did not specify which times. The note revealed that the nurse returned 10 minutes later and the resident did agree to have his BS checked, and the value was 177, and insulin was administered.-A Behavior Note at 6:18 P.M. revealed the resident's BS was checked and insulin given, however there was no evidence of a BS value.-There was no evidence of any other BS readings. December 10, 2025:-A Behavior Note at 1:52 P.M. revealed the resident's BS was low, and the unit manager was notified. There was no evidence the provider was notified of the low BS or that the resident was placed on COC monitoring.-An Orders Administration Note at 7:53 P.M. revealed the resident refused BS check.-There was no evidence of any other BS readings. December 11, 2025:-A Behavior Note at 5:03 P.M. revealed Resident #44 was compliant with 7:30 A.M. accucheck and insulin administration, however there was no evidence of a BS value. The note revealed the resident was compliant with administration of the dexcom sensor on the resident's left deltoid, and compliant with 11:30 A.M. and 4:00 P.M. accuchecks and insulin administrations. There was no evidence of the BS values.-An Orders Administration Note at 8:25 P.M. revealed the dexcom indicated BS value of 278.-There was no evidence of any other BS readings. December 12, 2025:-An Alert Note at 3:38 A.M. revealed after midnight the dexcom read high.-An Orders Administration Note at 12:20 P.M. revealed the resident refused accucheck and insulin administration two attempts.-An Orders Administration Note at 7:44 P.M. revealed the dexcom read High.-A Behavior Note at 11:04 P.M. revealed that Resident #44 was observed lying in bed since the beginning of shift, and refused medications and accuchecks, and that the dexcom device read high.-There was no evidence of any other BS readings. December 13, 2025:-An Orders Administration Note at 9:01 A.M. revealed that the resident's BS was high and the resident was symptomatic, and that 8 units of PRN insulin was administered.-The Medication Administration Record (MAR) for December 2025 revealed 8 units of PRN insulin were administered on December 13, 2025 at 9:01 A.M.-An Orders Administration Note at 9:02 A.M. revealed the resident was sent to the hospital in the morning before oral medications were given, due to hyperglycemia.-An SBAR note at 9:34 A.M. revealed the nurse went to wake the resident up for breakfast, BS check, and insulin administration at 7:50 A.M., and that the resident was observed with dried dark brown vomit around the mouth and with tachypnea and diaphoresis, and that the resident was responsive to painful stimuli with occasional grunting. The note revealed that both the accucheck and the dexcom device read high when assessed. The note revealed vital signs were assessed as follows: blood pressure 115/77 in left arm and 87/59 in right arm, pulse 50 beats per minute, temperature 98.5 degrees, respirations 44 per minute, and oxygen saturation 85% on room air. The documentation revealed that 8 units of PRN insulin were administered, and that the provider was notified and ordered to send the resident to the hospital via emergency medical services (EMS) for hyperglycemia. The note revealed at 8:25 A.M. EMS arrived and transported the resident to the hospital.-There was no evidence of any other BS readings. Review of the MAR and treatment administration record (TAR) for October, November, and December 2025 revealed no evidence of documentation of any BS values.A signed statement from the Director of Nursing (DON / Staff #59) dated December 17, 2025, revealed the facility had no specific policy for vitals assessment, and no specific policy for BS monitoring. The statement revealed the staff follow physician orders for BS monitoring.An interview was conducted with a Licensed Practical Nurse (LPN / Staff #90) on December 17, 2025, at approximately 10:45 A.M. Staff #90 stated that the facility protocol for assessing vital signs for residents was to assess vital signs once a month, during the first week of the month, and to document the vital sign data in the Vitals Log in the electronic medical record (EMR). Staff #90 stated that for residents who require daily BS checks, that only the nurses check BS, not the certified nursing assistants (CNAs), and then log the BS on the MAR. Staff #90 stated that the BS value could also be documented in a progress note or in the vitals log in the EHR, and that there were no paper logs for BS or vital signs. Staff #90 stated that staff follow physician orders for monitoring BS and administering insulin, and that if not followed, a resident could experience blood sugar too low or too high (hypoglycemia or hyperglycemia). Staff #90 stated that a dexcom device was an electronic device that could read the BS of a resident anytime, once the sensor was placed on the resident's arm. Staff #90 said he was aware that Resident #44 had a dexcom device. The clinical record of Resident #44 was reviewed together and Staff #90 stated that the resident had a physician order to assess BS four times a day, scheduled at specific times of 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M., and that those BS values should be recorded on the MAR. The MAR for December 2025 was reviewed together, and Staff #90 stated that no BS values were on the MAR. Staff #90 then reviewed the physician order for assessing BS four times a day, and stated that the nurse practitioner who entered the order did not check a box that would include the BS monitoring on the MAR, and that it was likely oversight on the provider's part.An interview was conducted with a unit manager / LPN (Staff #31) on December 17, 2025, at approximately 11:00 A.M. Staff #31 stated that the importance of monitoring blood sugars for a diabetic resident was that the nurses would be able to determine when to administer insulin based on the physician orders. Staff #31 stated that she was sure that for Resident #44, the BS values were recorded on the MAR. Staff #31 reviewed Resident #44's physician order for BS to be checked four times a day, and stated that the scheduled times were 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M, and then Staff #31 reviewed the MAR for December 2025, and stated that she could not find any BS values recorded on the MAR. Staff #31 stated that some BS values could be documented in the progress notes, however when Staff #31 reviewed the progress notes, Staff #31 stated there were multiple days in December 2025 where there were not BS values or attempts documented four times a day. Staff #31 stated that a dexcom device was a device that monitored a resident's BS, and that the dexcom device would display the word high or low when the BS value was above or below certain values, but that Staff #31 did not know what those specific values were. A telephonic interview was conducted with a nurse practitioner (NP / Staff #27) on December 17, 2025, at 11:29 A.M. Staff #27 stated that her expectation for managing insulin for residents with type 1 diabetes, was for staff to check the resident's BS 3-4 times per day, certainly before meals and before bedtime before the insulin was administered, and that she would expect staff to record the value of the BS in the medical record. Staff #27 stated that she checks the EMR for BS values, and that the BS values are recorded sometimes in the progress notes and sometimes in the MAR or vitals log, but that the BS values are always recorded in the chart somewhere.An interview was conducted with a CNA (Staff #45) on December 17, 2025, at 12:30 P.M. Staff #45 stated that the facility's protocol for assessing vital signs was once a month, during the first week of the month, and that nurses check vital signs for residents needing daily BS checks prior to administering medications. Staff #45 stated that only nurses check BS and that data is entered into the EMR and there were no paper logs.A telephonic interview was conducted on December 17, 2025, at 12:36 P.M. with a Registered Nurse (RN / Staff #77), who stated that staff monitor residents' vital signs once a month during the first week of the month, however for specific residents, staff follow physician orders and take BS readings before administering medications, and record the data on the MAR. Staff #77 stated that only the nurses assess BS, not the CNAs.Regarding Resident #44, Staff #77 stated that the resident needed his BS checked, and that she normally attempted 3 or 4 times a day, and that the resident refused the BS checks often. Staff #77 stated that Resident #44's BS could be checked with either the dexcom device or an accucheck device. Staff #77 said that the dexcom device was a small electronic device that read a sensor that was placed in the resident's arm and remained there, and that the dexcom could give a BS reading at any time, as long as the device was within 20 feet of the resident. Staff #77 stated that even though the dexcom device was available, that certain nurses on the unit would not use the dexcom, that they would only attempt to check the resident's BS using a fingerstick device (accucheck). Staff #77 stated that when the Dexcom read high that she did not know what it indicated as far as a BS value.A telephone interview was conducted with the manufacturer's support for the Dexcom G7 device on December 17, 2025, at 1:30 P.M. The support personnel stated that if the dexcom device displays the word high then that would indicate that the patient's BS value was over 400, and if the dexcom device displays low, then the BS value was under 40.An interview was conducted with an RN (Staff #6) on December 17, 2025, at 1:55 P.M. who stated that vital signs were checked every month unless the resident was on antibiotics or on a change of condition monitoring status, which would indicate to check vitals signs every shift. Staff #6 stated that there were no paper logs for vital signs, that the vital signs would be recorded in the EMR, either in the vitals log, or progress noted, or MAR. Staff #6 stated that facility staff would know when and how often to check a resident's BS because it would be indicated in the physician orders, and would be triggered to document the BS values on the MAR.An interview was conducted with the Director of Nursing (DON / Staff #59) on December 17, 2025, at 2:17 P.M., who stated that staff monitor resident vital signs to ensure they were within safe parameters and that residents were medically stable. Staff #59 stated vital signs were assessed once a month, unless the resident was on antibiotic medication or on a change of condition monitoring status, then the vitals were assessed regularly for 72 hours or whatever the physician orders indicated. Staff #59 stated that vital signs were documented in the EMR, in the vitals log, or progress notes, or MAR. Staff #59 stated it was her expectation that staff would follow physician orders and attempt to get BS readings and document the values in the EMR if there was a physician order indicating to monitor BS multiple times per day. Staff #59 said if a resident had a physician order to check BS four times a day, then the order should carry over to the MAR, and have specific times indicated. Staff #59 stated she expected staff to notify a provider when vitals signs were abnormal and to document that the provider was notified in the medical record.In regard the dexcom system, Staff #59 stated that there was a small adhesive patch with a very small needle sensor that was applied to a resident's arm and remained there for a period of time, and that a nurse holding the small handheld dexcom reader could easily electronically connect with the sensor in the resident's arm anytime to receive a current BS value. Staff #59 stated that if the dexcom device displayed a reading of the word low that indicated the resident's BS was less that 60, and if the dexcom device read high that meant the BS value was higher than 500. In either situation high or low, Staff #59 stated that she would expect staff to contact the provider and attempt to provide a resident insulin.Regarding Resident #44, Staff #59 stated that she believed the resident was on a sliding scale of insulin, and that his BS was monitored with a dexcom device because he historically refused the accucheck (fingerstick) monitoring. The clinical record was reviewed, and Staff #59 stated that Resident #44 had a physician order to check BS four times a day, and that it was scheduled for 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. Staff #59 stated that the BS values were assessed using the dexcom device after midnight on night shift of December 11-12, 2025, and again in the evening (7:44 P.M.) of December 12, 2025, which indicated high both times, and that Staff #59 could not find evidence in the clinical record that the provider was notified either instance. Additionally, Staff #59 reviewed the clinical record, and stated she could not find evidence on December 11, 2025, that the BS checks conducted in the morning, were recorded as numerical values anywhere in the clinical record, and that the only BS value that was recorded that date was at 8:25 P.M. which indicated a BS value of 278. The physician order for BS checks was reviewed again, and Staff #59 stated that the NP who entered the order put the scheduled times in the order, but failed to click boxes to add required supplemental documentation on the MAR, which would have triggered the nurses to automatically document the resident's BS values on the MAR four times a day. Staff #59 stated that this was oversight on the NP's part.Review of the facility policy titled Charting and Documentation, revised July 15, 2022, revealed that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Documentation of procedu

Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#3) was provided wound care in accordance with physician orders and professional standards. The deficient practice could result in wounds worsening or becoming infected. Findings include:Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia with mood disturbance, muscle weakness, and type two diabetes mellitus.Review of the care plan focus, initiated December 12, 2024, revealed that Resident #3 had pressure ulcers. The entry listed an unstageable right ischium wound with a date of November 25, 2024, and an unstageable sacral wound with a date of July 14, 2025. Interventions in place included to provide wound care as ordered by the physician.Review of physician orders revealed the following active wound care orders:Right Ischium: Cleanse with wound cleanser, pat dry, apply skin prep to surrounding wound, pack with Dakin's soaked gauze, cover with dry dressing daily and PRN.Sacrum: Cleanse with wound cleanser, pat dry, apply skin prep to surrounding wound, pack with Dakin's soaked gauze, cover with dry dressing daily and PRN.Observation of wound care was conducted on September 3, 2025 at 1:31PM with a Licensed Practical Nurse (LPN/Staff #124) who served as the wound care nurse for the facility. When preparing the supplies for the wound care, the LPN soaked gauze with Dakin's Half Strength Solution and placed it into a cup. While doing this, the LPN stated that she was told by the wound provider to not clean the wound, but to instead only put the Dakin's soaked gauze into the wound. The LPN stated that she was unsure if this was right, but that this was how she was instructed to do it.During the wound care observation, the surveyor observed the LPN remove the previous wound dressings. After discarding soiled dressings, the LPN performed hand hygiene and donned new clean gloves. The LPN proceeded to pack the sacral wound with the Dakin's soaked gauze. The LPN did not cleanse the wound site prior to packing. A 6x6 dressing was then applied over the wound. After changing gloves, the LPN then applied skin prep around the right ischial wound. The wound was then packed with the Dakin's soaked gauze. Again, the LPN did not cleanse the right ischial wound prior to packing. The LPN applied a 4x4 dressing over the right ischium.Interview was conducted on September 4, 2025 at 10:47AM with a LPN (Staff # 32), who stated that floor nurses and the wound care nurse can do wound care for residents. The LPN explained that the nurses should reference the physician orders to understand how to complete the wound treatments. She also stated that the wound nurse trains the floor nurses on how to complete wound care.Interview was conducted on September 5, 2025 at 9:48AM with the Director of Nursing (DON/Staff #72), who stated that she expected her nurses to look at provider orders when doing wound care and to do the ordered treatment. The DON stated that she knew the surveyor had questions about the wound care observation conducted, and produced a typed statement, which she stated was from the wound care nurse (LPN #124). The statement was not signed or dated. The DON, referencing the statement, stated that Dakin's solution did not require a wound to be cleansed prior, unless the wound was visibly soiled, as the Dakin's should stay on the wound. The statement also indicated that it was important to follow manufacturer recommendations for use. Despite the statement, the DON explained that every nurse gets education from the wound care nurse on how to complete the treatments.Upon directing to the link provided on the wound care nurse's written statement, it was discovered that the link led to the Dakin's website on an article titled, Using Dakin's Solution During the Wound Healing Process: 3 Methods for Safe, Effective Healing. Review of this article revealed no evidence that the manufacturer suggested omitting cleansing a wound prior to packing the wound.Interview was conducted on September 5, 2025 at 11:15AM with the Wound Physician (MD/ Staff #320), who stated that nurses should follow the physician orders for wound care. The MD also explained that he would expect wounds to be cleansed at the time of assessment and treatment. He stated that he had told nurses that it is okay to use Dakin's solution instead of wound cleanser when cleansing a wound, but that wounds should definitely be cleansed prior to packing the wound. He further explained that he would expect the nurses to use one set of Dakin's soaked gauze to clean a wound, which would be discarded, and then use a separate set of Dakin's soaked gauze to pack the wound. The wound Physician felt that there may have been miscommunication with the wound nurse regarding the use of Dakin's solution.Review of the facility policy, Administering Medications revealed that all medications must be administered in accordance with the orders.

Based on observations, staff interview, and policy review, the facility failed to ensure staff were maintaining proper sanitary conditions by not wearing hair nets and facial hair guards during food preparation. The deficient practice could result in infection and or contamination of food.Findings include:A kitchen observation was conducted on September 02, 2025 at 8:10 a.m. Staff #107, cook, was observed in the kitchen without a hair net. Further, Staff #51, cook, was observed in the kitchen without a hair net and with facial hair present without wearing a beard guard/net. A small pot of a green substance resembling vegetables was observed to be boiling on the stove during this time.An interview was conducted on September 02, 2025 at 2:32 p.m. with Staff #125 (Food Service Director). Staff #125 stated that while working in the kitchen staff were required to wear hair nets and facial hair guards. Staff # 125 stated that failure to wear hair nets and facial guards can cause a risk of hair in the food. Regarding staff not wearing hair nets or facial hair guards during food preparation food service director stated, Yeah, they know better.An interview was conducted with Staff #5 (Administrator). Staff #5 stated that the expectations were that the facility policy are followed in order to prevent cross contamination in the kitchen. Further, Staff #5 stated he wanted staff to be safe and follow policy and procedure. Staff #5 stated that the expectations were to have staff follow policy and procedure, wash hands, keep everything clean. Food clean, storage clean, preparation of food orderly. Hand washing protocols followed. During food prep, the proper PPE should be donned including hair nets and facial hair covers are expected to be used while preparing food in the kitchen for the residents, cleanliness, and cross contamination purposes. Staff #5 stated that the risks included cross contamination of bacteria or any other substance that is unhealthy for the resident to consume.An interview was conducted September 05, 2025 at 11:08 a.m. with Staff #125 (Food Service Director). Staff #125 was informed that during the initial kitchen observation, a boiling pot of green vegetables was observed on the stove. He was asked what was in the pot. He replied that it was buttered spinach. It is started early in the day for slow cook or else it would burn. Buttered spinach was then verified on the menu as a lunch time item for service on September 02, 2025.A review of policy titled Personal Hygiene and Health Reporting from Chapter 4: Sanitation and Infection Control 4-7 from Nutrition Alliance, LLC revealed that all food and nutrition services employees will be trained on appropriate personal hygiene and health reporting. Further, Procedure 2.B states that hair should be kept neat and clean. Hair restraints must be worn around exposed foods, in the kitchen or food service areas and dining areas. Further, Procedure 2.C states that beards and mustaches should be closely cropped and neatly trimmed. When around exposed foods, beards must be restrained using beard covers.

Based on observation, staff interviews, and review of facility documentation, the facility failed to ensure call light was within reach for one resident (#27). The deficient practice could result in a preventable accident and resident not able to meet the resident's needs. Findings include: Resident #27 was admitted to the facility May 17, 2024 with two discharges to the hospital on July 22, 2024 and October 21, 24. Resident was readmitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, encephalopathy, unspecified, and bipolar disorder. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 06 indicating severe cognitive impairment. Further review of the MDS revealed the resident has both upper and lower impairment on both sides. A care plan dated May 29, 2024 revealed resident had activities of daily living (ADL) self-care deficit and needed assistance with bed mobility, transfer, locomotion, eating, toilet use, personal hygiene, bathing related to spinal stenosis, impaired mobility and behavioral episodes. The care plan also revealed interventions which included positioning rail(s) as an enabler: 1/4 rails; Assist and/or guard position rails and soft touch call light. The physician order report revealed an order dated October 31, 2023 for opiod medication monitoring for nausea, vomiting, sedation, slowed reaction, respiratory depression. An observation was conducted on November 06, 2024 at 9:20 A.M. The soft touch call light was in the resident's top dresser drawer, approximately two feet out of reach from the resident. A follow up observation on November 06, 2024 at 12:36 P.M. revealed the resident's soft touch call light pinned on the resident's lap at her hip -- out of reach for the resident. The resident was screaming for help. This surveyor entered the resident's room and the resident immediately asked if this surveyor could have the call light placed where she is able to reach it. Review of the providers progress note dated August 27, 2024 revealed resident was seen for follow-up due to altered mental status. The note stated, Since last week her delirium and screaming is nearly constant. She is up all night and then naps during the day. Recently did a GDR on Seroquel and she is somewhat worse with behaviors, continues to see things on wall but this is no different that prior to her hospitalization . This morning she was napping but opened her eyes. Says the oxygen does not stay on, this provider adjusted the NC. She requires 1:1 assist with eating, bed positioning, hygiene and other ADL's. An interview was conducted on November 06, 2024 at 12:53 P.M with certified nursing assistant (CNA#12/Staff) CNA #12 stated that resident #27 was dependent for total care and dependent for eating. Stated the resident requires a pad call light due to limited movement. She stated the resident had limited movement with her right arm; and that, she did not recall whether she had placed the call light within reach for the resident after her rounds at 6:30am. CNA #12 stated she assisted the resident with her breakfast at approximately 7:40 a.m. and following breakfast at approximately 9:15 a.m. had placed the call light on the resident's gown. She stated no one else had entered the resident's room, since she was the one assigned to the resident for the day. CNA #12 stated when the resident needs assistance she will use her call light or start yelling. In an interview with the Director of Nursing (DON/Staff#12) November 06, 2024 at 1:07 P.M. she stated resident #27 uses a touch call light and it should be placed on her upper chest. The DON stated the resident does not have the ability to reach her call light at her hip and had noticed this when in the resident's room. The DON stated she had to reposition the resident's call light to where it was within reach; and that, the risk of not having the call light within reach is the resident would be unable to call for help if needed and could fall. A request was made for the facility Call Light Policy. DON/Staff#12 stated the facility does not have a Call Light Policy and signed a statement indicating the facility does not have a Call Light policy.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent elopement. The deficient practice could result in injury or harm to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, aphasia following cerebral infarction, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, anoxic brain damage, vascular dementia, mild, with agitation, dysphagia, epilepsy, intractable without status epilepticus. The minimum data set (MDS) assessment was currently in progress for new admission to facility and had not been completed. The elopement risk assessment dated [DATE] revealed a score of 14 indicating the resident was a high risk to wander. Review of the care plan dated August 21, 2024 revealed the resident has a history of eloping. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation and television, identify pattern of wandering, is wandering purposeful, aimless or escapist? Does it indicate the need for more exercise? and to intervene as appropriate. A progress note dated August 16, 2024 at 22:51 stated that the resident#1 was alert, wondering about unit and exit seeking at times. Another progress note dated August 18, 2024 at 17:21 stated that the resident #1 continue on 1:1 monitoring with aide staff on the shift. The note further stated that the resident was noted pushing on the exit doors attempting to leave the facility. A progress note dated August 20, 2024 at 20:30 stated approximately at 1830 the nurse heard alarm for exit door. The note stated the medication delivery had just came through door, the nurse then accepted medications and went to turn off alarm. The nurse found alarm to be door by oak dining room. The note stated the nurse immediately went out the door looking to see if anyone had gotten out the door. The note further stated upon coming back inside, another resident stated he saw resident #1 push on this exit door getting it opened and walked out. A progress note dated August 21, 2024 at 15:55 stated that the resident #1 had returned to the facility from a hospital with only clothing that the resident was wearing and no other personal belongings. The note state blisters were present to resident #1's sole of left foot near heel and ball of left foot. The note stated one additional blister was present to sole of right foot near ball of foot. An interview was conducted on August, 23, 2024 at 10:54 AM with Unit Manager(UM)/ Licensed Practical Nurse (LPN/staff #2) who stated that resident #1 was new and they did not know his behaviors. Staff #2 stated resident #1 was on 1 to 1 (one staff member to one resident) monitoring over the weekend and was currently on 1 to 1, for 24 hours and an aide will monitor the resident. Staff #2 stated the facility also has video to help monitor and stated the facility will watch all the time. Staff #2 stated resident #1's feet is doing better and the blisters are drying up. An interview was conducted on August 23, 2024 at 10:58 AM with a certified nursing assistant (CNA/staff #3), who stated that the staffs were familiar with this resident and is currently overseeing the care of the resident while the main CNA scheduled to be on 1 to 1 care is at lunch. Staff #3 stated that the staff was told resident #1 is a 1 to 1, because he had an elopement. Staff #3 stated the way to keep the resident safe is good communication, face forward, stay side by side, try not to leave the room, give them space and always make sure staff have replacement to watch them. An interview was conducted on August 23, 2024 at 1:11 PM with the Director of Nursing (DON/staff #1), who stated that she was not in the facility when the elopement occurred but was told by the nurse that was working that evening, what had occurred. The medication guy came with a delivery. The nurse went to turn the alarm off and noted that the door next to Oak dining room alarm was going off. She stated the nurse then went out and did not see anyone, came back and another resident said they saw the resident push on the door and go out. That is when the search started. The resident was originally on a 1 to 1 and that was removed on Monday morning (August 19, 2024). She stated there are many consequences if a resident elopes and resident could get lost. The resident was found by his sister the next morning and was taken to a local hospital to be assessed. The resident returned to the facility later in the day with blisters on the bottom of both feet. The facility's policy, Elopement Guidelines last reviewed on November 30, 2022, states that all Nursing personnel shall report and investigate all reports of missing residents.

Based on observations, staff and resident interviews, the facility failed to ensure that residents were were treated with dignity while dining by using disposable cutlery and dishware. The deficient practice could result in residents not able to exercise their right to be treated with respect and dignity. Findings include: During dining observation conducted on Monday, April 15, 2024 at 5:07 p.m., there were seven residents in the dining room eating dinner. The food, drinks and dessert for the seven residents were served in Styrofoam containers, cups, and bowls. The residents were also using plastic ware for utensils. In an interview One of the resident's (#80) stated that Styrofoam is used sometimes, but not all the time. An interview was conducted on April 16, 2024 at 12:35 p.m. with the dietary director (staff #85), who stated that meals were served on Styrofoam when there is an emergency situation and when the dishwasher staff calls off. He stated that the dishwashing staff (#135) called off on Monday, April 15, 2024, so he did not have anyone to wash the dinner dishes. The dietary director then said that staff #135 was not scheduled to work on Mondays and he was not always able to get a staff to stay to do the dishes on Monday nights, so they use Styrofoam dishware. He stated that the use of Styrofoam dishware, cups and bowls and plastic utensils usually occurs on a monthly basis; and that, the Administrator was aware that he did not have a dishwashing staff coverage on Monday nights and the facility was using Styrofoam dishware cups and bowls and plastic utensils occasionally to serve food/drinks to the residents. Further, the dietary director said that the residents have a right to a home-like environment, which included using proper dishware, cups, and utensils. An interview with the Executive Director (ED/staff #18) was conducted on April 16, 2024 at 1:07 p.m. The ED stated that he supervises the dietary manager/director (staff #85) who informs him when the kitchen needs staff. The ED said he does not review the schedule for the kitchen staff, so he was not aware of a dishwasher being needed on Monday nights; and that, he was just informed by staff #85 five minutes before this interview. The ED said that Styrofoam dishware cups and bowls and plastic utensils had not been used in the facility since the outbreak of COVID-19; and, it was his expectation for staff provide a homelike environment in dining room. The ED further stated it was his expectation that Styrofoam dishware, cups and bowls and plastic utensils would not be used. He stated that it was also his expectation that staff working the Monday night shift wash the dishes if there was not a dishwashing staff scheduled. The facility policy, Dining Room Service dated 2018 included that that individuals will be encouraged to receive their meals in the dining room. A comfortable, attractive atmosphere will be maintained in the dining room area.

Based on observations , staff interviews and review of facility policy and procedure, the facility failed to ensure that the living space, interior and fixtures were maintained in good repair/condition; and, failed to ensure clean and sanitary environment. The deficient practice could result in residents not being afforded a home-like environment. Findings include: During an observation of a resident (#63) room on April 15, 2024 at 11:12 a.m., the window blinds in the were observed broken on both sides in multiple places. There was a light brown substance that had run down the walls and was now dry and there was a strong odor of urine. The plaster and paint were chipped off from the wall by the mirror; and, there were multiple small holes and plaster chipped off on the wall just under the toilet paper holder. The vents located in the bathroom ceiling was covered in brown dust/dirt. In an observation of another room (#22) conducted on April 15, 2024 at 1:14 p.m., the window blinds were broken in multiple places. An interview was conducted on April 17, 2024 at 10:44 a.m. with a certified nursing assistant (CNA/staff #32), who stated that if there was something broken or damaged in the room, staff were to notify maintenance by informing the nurse who would then contact the maintenance staff. During the interview, and observation of the resident (#63) room was conducted with the CNA who stated that the window blinds appeared to have been replaced. Another observation of another resident room next door was conducted with the CNA who stated that the window blinds were broken and should be fixed. In an interview with the licensed practical nurse (LPN/staff #4) conducted on April 17, 2024 at 10:49 a.m., the LPN stated that anything that was broken, including walls and blinds, the nurses would notify maintenance staff. The LPN said that it was an expectation that blinds were replaced immediately, the walls were checked right away and wall repair was planned/scheduled. Further, the LPN said that if things were broken and/or not cleaned, it affects the residents' homelike environment. An interview was conducted on April 17, 2024 at 11:02 a.m. with the Central Supply Manager (staff #63) who stated that his job duties included facility maintenance. He stated that anyone including nurses, CNAs, housekeeping staff and the residents can report or enter a report order when repairs were needed. He stated that the Maintenance Director (staff #20) supervised the housekeepers and does a walk-through of the building daily; and that, the housekeepers should report any damage when they see it. He stated that blinds can be replaced the next day unless they need to be ordered; and, even then, they usually get them by the next day. He said he can also go to the store to purchase blinds and other supplies. The central supply manager stated that he has not noticed any broken blinds in the building. At the end of the interview, the central supply manager walked across the hall from the central supply room and saw that the blinds in room [ROOM NUMBER] were broken in multiple areas. 50026 -An observation of the bathroom of a room (#30) conducted on April 16, 2024 at 3:28 p.m. with the maintenance director who stated that housekeeping was expected to clean bathrooms, including the walls, sink, and vents. He then poked a white substance on the bathroom vent and there was a puff of white and brown substance that came out from the vent. The maintenance director said that the white and brown substance that came out of the vent was dust and should have been cleaned. Another observation of bathroom between two different rooms was conducted with the maintenance director. The bathroom wall was stained with brown substance; and, the maintenance director stated that he would call a pest control company and have them assess the stain because he does not know what the brown stain was. He then grabbed a paper towel and touched the substance, and it crumbled under his touch. The ventilation in the bathroom had dark brown flecks; and the maintenance director stated he expected housekeeping to clean vents and walls. The facility policy, Maintenance Services states that maintenance services shall be provided to all areas of the building, grounds, and equipment. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on clinical record reviews, staff interviews and review of facility policy, the facility failed to ensure that Preadmission Screening and Resident Review (PASRR) was updated for two residents (#73 and #22); and failed to ensure level II determination was submitted for one resident (#22). The deficient practice could result in residents not receiving the care and services they needed. Findings include: -Resident #73 was admitted on [DATE] with diagnoses of bipolar disorder, major depressive disorder, severe intellectual disability. Review of the clinical record revealed that the resident had a new diagnoses of anxiety disorder on January 24, 2024. However, further review of the clinical record revealed no evidence that the PASSR Level I screening was completed after January 24, 2024. An interview was conducted on April 16, 2024 at 3:28 p.m. with the Social Services Director (staff #29), who stated that if a resident had a new psychiatric diagnosis, the PASRR needs to be updated. During the interview, a review of the clinical record was conducted with staff #29 who stated that the PASRR for resident #73 should have been updated when the resident had a new diagnosis of anxiety. She also stated that there was documentation that the resident had an intellectual disability, but there were no details regarding how the intellectual disability affected the resident's ability to complete activities of daily living, but this could have been assessed by observation and included on the PASRR. During an interview with the Director of Nursing (DON/staff #14) conducted on April 16, 2024 at 3:43 p.m., she stated that the PASRR needs to updated if the resident has a new psychiatric diagnosis. 46606 Regarding Resident #22 -Resident #22 was initially admitted to the facility on [DATE] with diagnoses that included cerebral infarction, adjustment disorder with mixed disturbance of emotions and conduct, mental disorder, adjustment disorder with depressed mod, major depressive disorder, and bipolar disorder. A Pre-Admission Screening and Resident Review of (PASRR) Level 1 screening dated September 21, 2021 included diagnoses of major depression, and bipolar disorder. The documentation also included that this was submitted for a PASRR level II determination. Review of the clinical record revealed a new diagnosis of schizoaffective disorder on January 7, 2022. A psychiatric evaluation dated January 11, 2022 revealed the resident had schizoaffective disorder. However, there was no evidence that an updated PASRR I was completed to reflect the new diagnoses of schizoaffective disorder; and there was no evidence that the resident was referred to PASRR level II determination. Review of clinical noted dated October 3, 2023 through January 9, 2024, revealed evidence that the resident had episodes of yelling, using inappropriate language, inappropriate sexual behavior, and being verbally aggressive with staff. A behavioral care plan revised March 29, 2024 indicated that the resident displays behavioral symptoms which included delusions, inappropriate sexual behavior, yelling, and aggression. Interventions included to intervene when any inappropriate behavior is observed, use creative refocusing to alter behavior, and medication adjustment. An interview was conducted on April 16, 2024 at 2:08 p.m., with the Director of Social Services (staff #200), who stated that if a resident has a new mental disorder diagnoses after they have been admitted , a new PASRR should be re-accomplished and a referral for level II determination has to be submitted. Staff #200 noted that if a PASRR is not updated and level II determination is not completed, then there is a chance that the resident is not getting the treatment they need. Staff #200 also stated that when there is no outcome, it is hard to say why a PASRR is important other than it is a routine requirement. He also noted that he is not sure what the value of the PASRR is. Resident # 22's record was reviewed with staff #200 on April 16, 2024 at approximately 2:08 p.m. During the review, staff #200 confirmed that the resident's PASRR is from September 21, 2021. He noted that with a new diagnosis of schizoaffective disorder back in January 7, 2022, it should have triggered a new PASRR and a level II determination. Staff #200 agreed that an updated PASRR should have been accomplished and submitted for level II determination. An interview with the Director of Nursing (DON/staff #14) was conducted on April 16, 2024 at 2:42 p.m. Staff #14 stated that her expectation is that PASRR is completed for each resident. She noted that if there are changes in diagnoses then it should be updated. Staff #14 stated that the impact of not having an updated PASRR is that the care might not be according to the care plan and what they only know about. The DON further noted that she does not know what the impact of the PASRR but knows it is required. She indicated that the PASRR tells you what the diagnoses or any mental illness but that it is already available via reports. The DON noted that with regards to resident #22 having a new mental disorder diagnoses after admission, she stated there should have been an updated PASRR since the facility did a sweep on PASRR. Review of the facility's policy titled PASRR Guideline reviewed July 15, 2022 stated that Preadmission Screening and Resident Review (PASRR) is required for all individuals being considered for admission to a Medicaid-certified nursing facility be screened to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition. The facility's policy on PASRR Guideline included that the Preadmission Screening and Resident Review (PASRR) is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition. PASRR helps to ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that all applicants to a Medicaid-certified nursing facility be evaluated for mental illness (Ml) and/ intellectual disability (ID).

Based on observations, staff interviews and review of facility policy and procedure, the facility failed to ensure food items were labeled and dated when opened; and, failed to ensure that open food item was stored to maintain freshness and prevent contamination. Findings included: The initial tour of the kitchen was conducted on April 15, 2024 at 8:35 a.m. with the Dietary Director (staff #85). There was a 15-pound box of bacon, which was approximately half full in the large refrigerator. A white sheet of paper lay over the top of the bacon, but the bacon was not in a sealed bag/container. There was also approximately one fourth of shredded lettuce remaining in a two pound plastic bag that was not sealed, and the bag had no open date. The bread was located on a tray in the kitchen. A half a loaf of wheat bread was observed and there was no open date, six hamburger buns were in a plastic bag with no open date, and an open bag of twenty-three [NAME] Hawaiian Sweet Rolls did not have an open date. Staff #85 stated he thought that about half the bacon remained in the box and he was not sure if the bacon needed to be stored in a sealed container to maintain freshness. He agreed that the shredded lettuce should have been sealed. He stated that the bread is supposed to be thrown away after 6 days, but he did not know when the wheat bread, hamburger buns, or Hawaiian rolls had been opened. Staff #85 tested the Quat in a small red cleaning bucket with Quat test strip and stated that it should test around 200 parts per million (ppm) and tested at 400 ppm. Staff #85 stated that if the ppm is not accurate, the solution should be adjusted and tested again. He stated that the solution was too strong and needed more water. An interview was conducted on April 17, 2024 at 11:44 a.m. with the Executive Director (staff #18), who stated that open products should be dated and if refrigerated, the products should be sealed with a lid or stretch wrap. He stated that when products are not sealed, oxidation could occur, which creates and issue, and can effect nutritive value and quality. Staff #18 also stated that the Quat should be tested with the testing strips to ensure the correct potency for contaminants. The facility policy, Food Storage and Date Marking states that sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled (if not easily identifiable) and dated if stored for over 24 hours. Leftover food is used within seven (7) days or discarded. The facility Quaternary Sanitizer Test Strip directions states to dip the test strip in the quat solution for ten seconds and it should test at 200 ppm.

Based on observations, clinical record review, staff interviews, review of facility documentation and policy, the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare and Medicaid Services) guidance, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for one resident (#72). The deficient practice could result in transmission of multi-drug resistant organisms. Findings include: Resident #72 was admitted on [DATE] with diagnosis of hemiplegia, diabetes mellitus type 2, cerebral infarction, dementia, and gastrostomy status. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed BIMS (brief interview of mental status) score of 03, indicating the resident had severe cognitive impairment. The MDS also included that the resident had a gastrostomy tube. The physician order dated August 25, 2022 included for PEG (Percutaneous endoscopic gastrostomy) tube placement 18fr x 45cm. for nutritional support. The care plan dated August 28, 2022 revealed that the resident required tube feedings related to a swallowing problem. Interventions included to monitor, document, and report any signs or symptoms of aspiration, fever, infection, tube dysfunction or malfunction, and abnormal breathing sounds. An observation was conducted on April 17, 2024 at 9:25 a.m. There were no signs related to EBP posted outside of the room of resident #18; and, there were no PPE (personal protective equipment) visible outside of the resident's room. An interview was conducted on April 17, 2024 at 9:40 a.m. with a licensed practical nurse (LPN/Staff #9) who stated that there were no precautions in use anywhere in the building. The LPN also stated that this made it easier for staff to take care of the residents as staff did not have to gown up. Further, the LPN said that EBP were only used for leaking wounds and major infections. During an interview with the Director of Nursing, (DON) conducted on April 17, 2024 at 10:30 a.m., the DON stated that there were no precautions in use in the building right now. The DON stated that she had reviewed the notice about EBP and she did not agree with it because it does not maintain a homelike environment. Further, the DON also stated that none of her residents meet the criteria for contact precautions. A review of the facility assessment revealed the services provided by the facility include infection prevention and control, including the identification and containment of infections, and the prevention of infections. The CDC website on healthcare acquired infections revealed that the enhanced barrier precautions are an infection control intervention designed to reduce the transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. The CDC website further showed examples of high-contact resident care activities includes device care or use: central line, urinary catheter, feeding tube, or tracheostomy/ventilator. The CDC website further stated that the use of gown and glove for high-contact resident care activities is indicated when contact precautions do not otherwise apply. Updated July 12, 2022. https://cdc.gov/hai/containment/PPE-Nursing-Homes.html; however, enhanced barrier precautions were not noted for resident #72 who has a PEG tube and receives regular tube feedings. The CMS QSO-24-08-NH Memo dated March 20, 2024 included that EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical device during high-contact resident care activities regardless of their multidrug-resistant organism (MDRO) status, in addition to resident who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. Indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheostomies. EBP should be used for any residents who meet the above criteria, wherever they resident in the facility. The effective date of this memo was April 1, 2024.

Based on staff interviews and facility documentation, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The deficient practice has the potential to affect resident care. Findings include: Review of the facility's staffing documentation revealed there was not a registered nurse on duty for 8 consecutive hours for the month of April and May 2022 on the following dates: April 8 April 20 April 22 April 27 April 29 An interview was conducted on November 30, 2022 at 2:23 p.m. with the Executive Director (ED/staff #79), who stated that the facility was using registry staff during the month of May 2022. The ED stated that he would try to identify the RNs that worked on the above dates and provide invoices to show the numbers of hours worked. An interview was conducted on December 1, 2022 at 9:30 a.m. with the Director of Training and Development (staff #92). She stated that she reviewed the time cards/invoices and that she did not have any documentation of an RN working on April 8, 20, 27, and 29, 2022. She also stated that a Registered Nurse (RN/staff #98) did not work an 8-hour shift on April 22, 2022. An interview was conducted on December 1, 2022 at 10:52 a.m. with the Director of Nursing (DON/staff #63), who stated that the facility does not have a policy regarding staffing and RN coverage, but follows the federal guidelines.

Based on clinical record review, facility documentation, resident and staff interviews, and facility policy and procedure, the facility failed to assist one resident (#4) with a request to transfer to another facility within a timely manner. The sample size was 3. The deficient practice could result in residents being denied the right to make their own choices. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included Psoriatic Arthritis Mutilans, contracture of muscle, and chronic pain syndrome. The initial psychiatric evaluation dated August 4, 2022 revealed the resident plan was to look for another place to live. The resident endorses anxiety over the future. The resident reported a desire to leave this facility and find a new place to live. Coordinated and consulted with nursing staff, and social services regarding assessment. Review of the occupational therapy discharge summary dated August 31, 2022 revealed the resident was to discharge to long-term care. Review of the physical therapy discharge summary dated September 1, 2022 revealed a discharge plan for the resident to currently stay in the facility and there may be another place that the resident could be moving to. The physician's discharge order for physical therapy dated September 1, 2022 did not specify discharge instructions and was not signed or dated by the physician. The care plan dated September 8, 2022 stated the resident expressed a discharge goal to discharge to an assisted living setting. No active discharge plan is indicated at this time. The resident remains long-term care for 24-hour staff available for custodial care and medication management. Interventions included encouraging the resident to discuss feelings and concerns with impending discharge, evaluating and discussing with the resident/family/caregivers the prognosis for independent or assisted living, evaluating the resident's motivation to return to the community; preparing and giving the resident contact numbers for all community referrals, and sending packets with the resident's information to assisted living facilities of the resident choice for consideration of admission to that community. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Facility documentation revealed that the Social Services Assistant (staff #56) faxed a submission packet to one long-term care facility on August 8, 2022 and emailed a submission packet to the same facility and one other long-term care facility on November 7, 2022. A 30-day notice of transfer or discharge date d November 15, 2022 was issued to the resident for failure to pay for residency. An interview was conducted on November 29, 2022 at 10:52 a.m. with a licensed practical nurse/Unit Manager (LPN/staff #27), who stated that she notifies social services when a resident is requesting to leave/transfer to another facility and staff #56 sends submission packets out to other facilities. The LPN stated that staff #56 notifies her when a placement is found. An interview was conducted on November 29, 2022 at 11:16 a.m. with the Social Services Assistant (staff #56), who stated that he sent out submission packets to a bunch of assisted living facilities, but he was not able to provide documentation of these submissions, but believed that the first submissions were sent out the first week of November 2022. Then, he stated that he thinks that he sent out applications for a handful of skilled nursing facilities (SNFs), but did not remember which ones. He stated that the resident was admitted in July 2022 and never wanted to be there. He stated that the policy/facility process is to begin looking for placement immediately, as soon as the resident requests it. Staff #56 stated he knew the resident wanted to leave approximately two months ago when there was an issue regarding the resident paying the share of cost. Staff #56 stated that the resident did not want to pay because the resident did not want to be there. During an interview conducted with resident #4 on November 29, 2022 at 1:26 p.m., resident #4 stated that nobody explained to him that he could not live in a place where he can go out and that he never thought this would be permanent. The resident stated that about two months ago, staff #56 told him that this was his permanent place/home. The resident stated that he did not file a complaint because he did not know that he could. The resident stated he refused to pay his portion of rent because he does not want to be there. On November 30, 2022 at 8:35 a.m., staff #56 and the Executive Director (ED/staff #79) were observed checking the memory on the fax machine. Staff #79 stated that the memory did not go back to August 2022, so there was no way to show that staff #56 had faxed submission packets to other facilities during that time. On November 29, 2022 at 11:44 a.m., an interview was conducted with the Director of Nursing (DON/staff #63), who stated that staff #56 has been responsible for sending out the submission packets to find appropriate placements for residents. She stated that if a resident wants to leave, the facility should begin looking for placement as soon as it is expressed to staff. She confirmed that she reviews the psych notes and the unit manager would be responsible for reviewing the notes. The DON reviewed the psych notes and stated that the resident wanted to go to an assisted living facility. The DON stated that she only became aware of the resident wanting to leave in the last month, and submission packets were sent out to other facilities. The facility's Residents Bill of Rights policy stated the resident has a right to dignified existence, self-determination and communication with access to persons and services inside and outside the facility. A facility shall protect and promote the rights of each resident, including the following right to exercise the resident's rights as a resident of the facility and as a citizen or resident of the United States. The resident has a right to participate in planning his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise found to be incapacitated under the Law of the State.

Based on closed clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#30) had an assistive device in place as ordered to prevent accidents. Findings include: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk Evaluation dated July 13, 2015 revealed the resident was identified to have been at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had memory problems and had moderate cognitive impairment. The MDS also identified that the resident required extensive assistance with transfers and needed limited assistance to self propel in the wheelchair. A physician's orders [REDACTED]. Review of a behavior care plan revealed an intervention dated October 6, 2015 that a lap buddy was to be used at all times when the resident was up in wheelchair, due to poor safety awareness. A fall care plan identified the resident was at risk for injury from falls, due to weakness in his legs and side effects of medications. Interventions included the following: call light within reach, room free of clutter, remind resident and reinforce safety awareness such as; when rising from a lying position sit on the side of bed for a few minutes before transferring or standing, and reinforce importance of requesting staff assistance for transfers. According to the nurse's notes the consent for the lap buddy was obtained from the resident's POA (power of attorney) on October 7, 2015. Review of the nurse's notes dated October 11, 2015 revealed the resident fell from his wheelchair in the hallway and hit his face on a Hoyer lift. The resident sustained [REDACTED]. Review of the facility's investigative report revealed that on October 11, 2015 a CNA had gotten the resident up and in his wheelchair and had placed the resident right outside of his room in the hallway. The CNA was assisting the resident's roommate and had the door closed, when the resident fell out of his wheelchair around 6:30 a.m. The resident hit his head on the base of a Hoyer lift which was being stored in the hallway. The fall was not witnessed. When asked what happened the resident said, I fell and was going. The resident sustained [REDACTED]. The resident was transferred to the hospital at 7:50 a.m. and was admitted for a UTI and required stitches. The resident did not returned to the facility. Further review of the facility's investigative report revealed that the resident had been observed leaning forward in his chair during the past week, which caused a concern for his safety. As a result, a physicians order was obtained for a lap buddy. However, the report included that the lap buddy had not been in place at the time of the fall. The report included that this fall would likely not have occurred if the Lap Buddy (Assistive Device) had been on the resident. Per the report, the CNA did see the lap buddy in the room, but was unsure who it belonged too. The report further included that the failure to utilize the lap buddy was due to poor communication between the Supervising Nurse and the CNA assigned to the resident and that both staff failed to be proactive in sharing information at the change of shift regarding the lap buddy. An interview was conducted on January 6, 2016, at 8:30 a.m., with the LPN on duty at the time of the fall. The LPN reported she was not aware that there was an order for [REDACTED]. She stated staff did not inform her of the order in report. An interview was conducted on January 6, 2016 at 9 a.m., with the resident's assigned CNA at the time of the fall. The CNA stated she finished helping the resident get dressed and then wheeled him to the hallway, in order to get his roommate ready. She stated she heard the resident fall. She stated the resident fell out of his wheelchair and hit his head on a Hoyer lift. She stated she did not know that the resident was to use a lap buddy. She stated she was not informed in report that the resident was to wear a lab buddy in the wheelchair. An interview was conducted on January 7, 2016, with a LPN. She stated when the resident was at the facility, the Hoyer lift was kept outside of his room. She reported that the hoyer lift was kept on the same side of the hall, with the rest of the equipment. She stated the Hoyer lift is usually kept outside of a resident's room who needs it. An interview was conducted on January 7, 2016 with the Director of Nursing (DON). She stated it is not documented on the MAR or TAR, whether a resident is using a lap buddy. Review of a policy regarding Falls and Clinical Protocol revealed the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The policy regarding Managing Falls and Fall Risk included, Based on previous evaluations and current data, the staff will identify appropriate interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy further noted that the staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls and will implement relevant interventions.

Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure the environment was free of accident hazards, by failing to ensure one resident (#47) was provided adequate supervision, per the plan of care and sustained a fall with a fracture. Findings include: Resident #47 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident had moderate cognitive impairment and had delusions. The assessment included that the resident had behavioral symptoms, which were directed toward self and not others. The assessment further included the resident required assistance with part of bathing and had two falls previously. A review of the resident's Behavioral Care Plan revealed that all care was to be provided in pairs. A fall risk assessment dated [DATE], identified that the resident was at high risk for falls. Risk factors included intermittent confusion, three or more falls in the past three months, a drop in blood pressure between lying and standing, and taking multiple medications that cause lethargy or confusion. According to the facility's investigation, the resident was given a shower with the help of a certified nursing assistant (CNA) on December 23, 2013. The CNA assisted the resident in the shower, and then asked a second CNA to watch the resident, while he went to the restroom. When he returned, he finished rinsing off the resident and the second CNA left. He then told the resident to start drying himself off, and that he would be close. The CNA went to check the shower sheet next to the towels in the shower room. Seconds later he saw the resident with soap all over his body fall, while walking out of the stall. Per the supervising nurse's statement, when she entered the shower room, the resident was lying on the floor on his back, holding his right shoulder. The investigation also included the resident was transferred to the hospital and had a right shoulder fracture. During an interview conducted on December 2, 2014 at 1:10 p.m., with the CNA who assisted the resident with his shower stated that the CNA's get information from the Care Sheets that tells CNA's what kind of care the resident's you are assigned to need. He explained care with pairs means you have to have two people with you, while caring for that resident. When asked about the resident's fall in the shower, he stated the other CNA had to leave the room. He said that he left the resident alone, walked around the wall to get more towels and came around the wall and the resident had fallen on the shower floor. During an interview conducted with the Director of Nursing (DON) on December 2, 2014 at 1:48 p.m., the DON stated the CNA's have a book which includes the resident care plans, and they have a care planner that gives them information on what the resident's needs are. The DON stated they would expect the CNA's would follow the Care Plans and Care Sheets.

Based on observations, a clinical record review, resident and staff interviews, and review facility investigative documentation and policies, the facility failed to ensure adequate supervision and interventions to prevent the choking and subsequent death of one resident (# 22), failed to maintain safe water temperatures in residents' rooms, failed to ensure hand rail were free of raised nails and screws and failed to ensure wheelchairs were in safe working conditions. Findings include: Issue regarding supervision: Resident #22 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a behavior care plan dated February 12, 2012, that documented that the resident would sneak food and fluids. The care plan interventions were to monitor the fluid seeking behavior and to follow the resident's personalized behavior plan. No interventions specifically for food seeking. Further review of the clinical record revealed a behavioral care plan dated [DATE], that identified the resident was NPO (nothing by mouth) with a history of choking and hospitalization . The care plan documented that the resident did not have dentures due to choking risk and that the resident was fluid seeking and an aspiration risk. The care plan documented interventions to redirect the resident from fluid sources and supervise resident at snack time for drinking of fluids. There was no documentation of interventions regarding the resident's behavior of sneaking food. A review of a barium swallow study dated [DATE], documented that the resident had been assessed with [REDACTED]. A physician's orders [REDACTED]. A review of nurses' notes from [DATE] through [DATE], revealed documentation of numerous occasions of the resident obtaining fluids and going into other resident's room and taking food. The nurses' notes documented that the resident was easily redirected and reminded of the NPO status. On [DATE], the facility reported to the State Agency (SA) that the resident had been found, in the unit dining room and non-responsive. The report stated that the resident was pronounced dead at the scene and that the resident had choked on a grilled cheese sandwich. A telephone interview was conducted with staff #1, on [DATE]. Staff #1 stated he was a CNA (certified nursing assistant) and that he was working on the unit where resident #22 resided on [DATE]. Staff #1 stated that at approximately 7:55 p.m., on [DATE], he and staff #2 were working in the unit dining room assisting residents to their rooms to use the toilet, assisting residents for bed, and preparing the evening snack. Staff #1 stated that resident #22 was in the dining room, watching a moving with other residents. Staff #1 stated the resident was alert and had laughed at staff #1 when he tripped over her foot as he was assisting another resident out of the dining room. Staff #1 stated he assisted the resident to their room and went to the vending machine and returned to the unit in less than five minutes. Upon returning to the unit, staff #1 stated that staff #2 called out that he needed help in the dining room. At that time, he stated he went into the dining room and found the resident seated at the table with her eyes opened, not verbally responsive, and appeared to be choking. Staff #1 stated the nurses came in and the resident was found to have food lodged in her mouth and throat. Staff #1 stated that he was able to remove some food from the resident's mouth and that the resident was not breathing. Staff #1 stated that he and staff #3, the licensed practical nurse (LPN) started CPR (cardio pulmonary resuscitation) and chest compressions. The paramedics arrived and continued with CPR and stomach thrusts that caused a large amount of food to be expelled, however the resident was pronounced dead. Staff #1 stated that resident #22 had a history of [REDACTED]. eating. Staff #1 stated he thought the trash had been removed from the dining room but thought the resident probably reached into the trash and found a grilled cheese sandwich that had been discarded from dinner. Staff #1 stated that none of the staff were instructed to ensure a staff were in the dining room with residents at all times. He stated that staff were in and out of the room assisting other residents. A telephone interview was conducted on [DATE], with staff #2. Staff #2 stated he was a CNA and had been assigned to work on the unit where resident #22 resided, on [DATE]. Staff #2 stated he was attending to the residents by assisting them from the dining room to their room to use the toilet or get ready for bed. Staff #2 also stated he was getting the snacks ready. He stated it was about 8:00 p.m. Staff #2 stated that he had seen resident #22 earlier in the evening up and about the unit but did not notice her in the dining room until he found her in the dining room slumped over at the table and non-responsive. Staff #2 stated he called for staff #1 and the nurses (staff #3 and #4.) Staff #2 stated that staff #1 and the nurses started CPR and the paramedics arrived and continued the CPR. Staff #2 stated that the resident choked on a grilled cheese sandwich, that he assumed she had gotten it out of the thrash. Staff #2 stated that no one had been assigned to stay in the dining room and that staff usually just were in an out of the dining room assisting the residents. A telephone interview was conducted on [DATE], with staff #3, the LPN (licensed practical nurse) assigned to the resident's unit on [DATE]. Staff #3 stated he was in the hallway administering medications when staff #1 and #2 called out for help. Staff #3 stated he instructed staff #1 and #2 to put the resident on the floor at which time CPR was begun. Staff #3 stated he had staff call the paramedics but when the paramedics arrived the resident still was not breathing. Staff #3 stated that the resident appeared to have choked on a grilled cheese sandwich. Staff #3 stated he did not see the resident get the food from the trash but stated he believed the resident was capable of reaching into the trash to get it. Staff #3 stated that no staff were assigned to the dining room to watch the residents. On [DATE], an interview was conducted with staff #5, a CNA assigned to the resident's unit on [DATE]. Staff #5 stated she was on a break when the incident occurred with the resident choking. She stated she returned to the unit and was directed to watch the doors to let the paramedics in. Staff #5 stated that she had been assigned to remove the trash on [DATE]. She stated that the dinner trash had not been removed that she was going to wait until the residents had finished with their evening snacks. Staff #5 stated that none of the staff were specifically assigned to watch the residents in the dining room. Staff #5 stated that staff were to monitor resident #22 because the resident would go into other resident's rooms to get food or fluids. A review of the facility's policy for routine unit rounds on the secured unit documented that nursing staff on the behavior units must assign staff to conduct and document unit rounds and that rounds would be conducted, at a minimum of every 15 minutes. The policy documented that each resident must be observed during each round and at a minimum ensure that the resident's needs were being met, if there were any changes in the resident's condition, ask the resident about complaints or requests, and to assist with toileting needs. The policy documented that the purpose of rounds was to ensure the health, welfare, and safety of each resident. Issue regarding environmental hazards: -During a tour of the facility, conducted with the Maintenance Director present, at 12:15 p.m. on [DATE], the hot water temperatures in multiple resident bathrooms exceeded 120 degrees Fahrenheit. The hot water temperature in the resident bathroom between room #s 5 and 6 was 125 degrees Fahrenheit. The hot water temperature in the resident bathroom between room #s 8 and 10 was 122 degrees Fahrenheit. The hot water temperature in the resident bathroom between room #s 30 and 32 was 123 degrees Fahrenheit. The hot water temperature in the resident bathroom for room #35 was 125 degrees Fahrenheit. The hot water temperature in the resident bathroom between room #s 2 and 3 was 125 degrees Fahrenheit. Additional water temperatures were tested at 1:25 p.m. on [DATE], the following were observed. The hot water temperature in the resident bathroom between room #s 32 and 33 was 122 degrees Fahrenheit. The hot water temperature in the resident bathroom adjacent to room # 4 was 122 degrees Fahrenheit. During an interview conducted on [DATE], the Maintenance Director stated that the previous week the facility had work done to replace some of the hot water pipes in the facility. He also stated that the hot water temperatures in the resident rooms should not exceed 120 degrees Fahrenheit. He further stated that the last time he checked the hot water temperatures was on [DATE]. During an interview conducted on [DATE], a licensed practical nurse stated that water temperatures that exceeded 120 degrees Fahrenheit were too hot and could burn a resident's skin. -During the environmental tour one handrail across the hall from the dining room on the Pine Unit was observed to have one nail and one screw that were raised from the surface of the handrail. A second handrail next to the men's restroom on the Pine Unit was observed to have a nail head that was raised from the surface of the wood. During an interview conducted at 4:00 p.m. on [DATE], a licensed practical nurse stated that the raised nail/screw heads were unsafe, because residents could harm themselves if they brushed up against the handrail with the raised nail/ screw heads. -During dining observations conducted on the Pine Unit at 8:00 a.m. on [DATE]. 2012, the following were observed. One male resident was observed sitting in a wheelchair with a blue frame. The sling backrest was torn and a metal slat was exposed attached to the frame. The left arm rest was torn and approximately 1-,[DATE] inches of padding and vinyl at the end of the armrest was missing. A second male resident was observed sitting in a wheelchair with a two inch rip in the right Vinyl arm rest from the front end. The armrest also had a rip on the back end approximately one inch long. A female resident was observed to have a five inch tear in the left arm rest of her wheelchair. A third male resident was observed sitting in a wheelchair with multiple cracks and up in the vinyl arm rest. A second female resident was observed sitting in a wheelchair that was missing the left arm rest. A fourth male resident was observed sitting in a wheelchair. The right armrest had a network of cracks in the vinyl cover and a rip in the vinyl where the blue foam under the vinyl was exposed. A fifth male resident's wheelchair was missing the hand gripped on the back of the wheelchair. The resident was observed standing up behind his wheelchair with his hands on the bare metal where the hand grips would have been. One resident interviewed stated that the torn and cracked vinyl on the arm rest of his wheelchair irritated the skin on his forearms. During an interview conducted at 8:41 a.m. on [DATE], a certified nursing assist stated that it was the CNA 's responsibility to notify maintenance when the residents arm rest are ripped or cracked. During an interview conducted on [DATE], the Maintenance Director stated that he had no work orders requesting any repairs for resident's wheelchairs. -A review of the facility Monitoring Water Temperatures policy and procedure revealed the procedure was "Resident use areas 1. Check hot water temperatures at both individual and common resident use areas. 2. Schedule sampling to cover the entire building every 3 days and sample problems areas daily." The policy and procedure also revealed that acceptable temperature range for hot tap water is 100 to 120 degrees Fahrenheit in resident use areas.

Based on clinical record review, resident interview, staff interviews, and review of facility policies and procedures, the facility failed to prevent the development of an avoidable pressure sore for one resident (#71). The resident sustained [REDACTED]. Findings include: Resident #71 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's significant change MDS (Minimum Data Set) assessment dated [DATE], revealed the resident did not have a pressure sore. A review of the resident's clinical record revealed Nurse's Notes dated January 23, 2011, which documented "Noted right knee swollen, red, warm to touch...new orders for xray." The resident's clinical record revealed Nurse's Notes dated January 24, 2011, which documented "Notified MD of undisplaced tibial fracture." Nurse's Notes dated January 30, 2011, documented "Splint to right leg for fractured tibia." The resident's clinical record revealed Physician's Progress Notes dated February 3, 2011, which documented "Dx (diagnosis): Right proximal tibia fracture. Application of right long leg splint. May remove daily to inspect and clean skin evaluate for skin breakdown. The resident's clinical record revealed Nurse's Notes dated February 3, 2011, which documented "Returned from doctor's office with splint noted to right leg...New orders: May remove dressing every day to inspect and clean skin and evaluate for skin breakdown." Nurse's Notes dated February 5, 2011, documented "Splint to right lower leg clean, dry, and intact." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 6, 2011, documented "Splint intact to right lower leg." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 7, 2011, documented "Splint intact to right lower leg." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 8, 2011, documented "Splint intact." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 9, 2011, documented "Splint to right leg is clean dry and intact." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 10, 2011, documented "Splint to right leg clean dry and intact." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 11, 2011, documented "Resident stated 'I took a shower and this got wet' and resident pointed to splint on right leg. Splint wrapped in towel...Splint clean and intact." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes dated February 11, 2011, documented "Splint clean and intact with noted dampness." There was no documentation that the splint was removed to evaluate for skin breakdown. Nurse's Notes Dated February 11, 2011, documented "Took off ace wrap around splint to check skin. Skin intact." There was no documentation that the splint was removed to evaluate for skin breakdown. There was no documentation in the resident's clinical record that the resident's leg splint was removed from February 3 until February 26, 2011, to evaluate for skin breakdown. A review of the resident's clinical record revealed Nurse's Notes dated February 26, 2011 which documented "Splint right leg removed, noted 3.3 cm (centimeter) x 2 cm. irregular shaped necrotic pressure area to right heel. An interview was conducted with the resident on April 27, 2011. The resident stated that licensed nursing staff only removed the ace bandage on her splint but never removed the splint until February 26, 2011, when the pressure sore was observed. The resident further stated that CNA's (certified nursing assistant) put a bag over her splint when she had a shower and never removed the splint. An interview was conducted with an LPN (licensed practical nurse) on April 27, 2011. The LPN stated that the resident's splint should have been removed daily to evaluate for skin breakdown. The LPN further stated that CNA's should have checked the resident's skin during her shower. The LPN stated that she was unable to find documentation in the resident's clinical record that the resident's leg splint was removed from February 3 until February 26, 2011. An interview was conducted with the DON (director of nursing) on April 27, 2011. The DON stated that the resident's clinical record revealed that the splint was intact but should have documented whether or not the resident's skin was intact. A review of the facility's policy Skin Integrity Protocol documented "To immediately and aggressively treat resident skin problems as identified during skin assessment." I

Based on observation, clinical record review and staff and resident interviews, the facility failed to provide adequate supervision for one resident (#75) to prevent a fall which resulted in actual harm. Findings include: Resident #75 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan was updated on August 24, 2010, that documented that the resident was to be on a low bed and mat, along with a concave mattress. Clinical record review revealed a Pre-Restraining assessment dated [DATE], that documented the resident was disoriented with a short attention span and had a history of [REDACTED]. Further clinical record review revealed a Fall Risk assessment dated [DATE], which revealed the resident's total score of 10 or high risk. Nurse's notes dated March 31, 2011, that revealed the certified nursing assistant (CNA) attempted to transfer the resident to the geri chair. The CNA then went to the door to call for another CNA and when the CNA turned around the resident had fallen out of bed. Additional documentation revealed the resident sustained [REDACTED]. Further clinical record review revealed a physician's telephone order dated March 31, 2011, for a stat right elbow x-ray. Additional documentation revealed an x-ray report of the right elbow dated March 31, 2011, with findings that included an acute appearing elbow fracture of the ulnar olecranon process with modest displacement. Additional clinical record review revealed subsequent nurse's note documentation dated March 31, 2011, to include heavy sanguinous fluid to the right elbow when the elbow was bent with no complaints of pain or discomfort. Continued review of the clinical record revealed a physician's telephone order dated March 31, 2011, to send to the hospital for right elbow bleeding. Additional clinical record review revealed a care plan titled "Fall" that documented the resident had a history of [REDACTED]. The care plan additionally documented interventions to include low bed and mattress, bed/chair alarm, concave mattress and geri chair. Continued clinical record review revealed the recapitulation of physician's orders [REDACTED]. Random observations made on April 27 and 28, 2011, revealed the placement of a concave mattress to the resident's bed, the bed in a low position with a floor mat next to the bed when the resident was in bed and the use of a chair/bed alarm and geri chair with tray. In an interview conducted on April 27, 2011, licensed staff stated that the resident was not in her bed at the time of the fall but she was unsure as to why that had occurred. She additionally stated she did not witness the resident fall but when she entered the room the resident was observed lying on her right side on the floor next to the other bed in the room. In an interview conducted on April 27, 2011, the unit manager stated that he was aware that the resident was in the other bed in the room at the time of the fall. He additionally stated that the CNAs stated that it was easier to work with the resident in the other bed. In an interview conducted on April 27, 2011, the CNA stated that she had placed the resident in the other bed in the room because there were items on the resident's bed. She stated that she had just finished changing the resident and went to the door to call for another CNA to assist her with transferring the resident into the geri chair. She stated that as she turned back around the resident rolled off the bed and onto the floor. She stated that she should have changed the resident in her own bed.

Based on clinical record review, staff interview and facility policy review the facility failed to supervise and maintain a safe environment for one resident (#1), with suicidal ideations, that resulted in his death by suicide. The resident sample size was two. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of resident #1's clinical record review revealed a physician's orders [REDACTED]. Place the resident on 15 minute room checks to continue until discontinued by the physician. Remove all sharp objects and check for any medication. Remove all trash cans from the resident's room, bathroom and adjoining room Contact the psychiatric physician if any further behavior occurs. Further clinical record review documented a psychiatric consultation/follow up form dated [DATE], revealed that the resident had a recent suicidal gesture by placing a trash bag over his head. Continued clinical record review revealed a behavioral care plan dated [DATE]. The behavior care plan noted that in the event the resident talks in a suicidal fashion or exhibits any sort of suicidal behavior, suicide precautions were to be implemented to that included: To search the resident and resident's room. To remove any objects that could be used for self harm and staff were to focus on sharp objects and potential medication stashes. To place the resident on 15 minute checks. Finally, to notify the psychiatric physician. Review of the recapitulation of physician's orders [REDACTED]. Clinical record review revealed a daily behavior note completed by direct care staff for the evening shift on [DATE], that documented a suicidal comment made by the resident. Additionally a behavior documentation form, completed by direct care staff for [DATE], consisted of a list of resident target behaviors as reflected in the resident's behavioral care plan revealed one occurrence of suicidal ideation for the evening shift on [DATE]. Clinical record review revealed no documentation to reflect the resident's verbalization of suicidal ideations nor as to the initiation of suicide precautions per the resident's behavioral plan. Clinical record review revealed that on [DATE], the resident was found deceased in his bed with a plastic bag over his head. In an interview conducted on [DATE], a housekeeping staff stated that licensed staff would typically inform the housekeepers of any restriction of items in a resident's room, which would also include plastic bags. She additionally stated that she was unaware of any restrictions in place for the resident. In an interview conducted on [DATE], a licensed staff stated that she observed a trash can with plastic bags next to the resident's bedside at the time of the incident. She additionally reported that she was unaware of any precautions that restricted plastic bags for the resident. The facility did not present policies and procedures on the supervision of a resident who had suicidal ideations and environmental factors that might contribute to possible harm.