Every finding on record at Douglas Manor

Based on clinical record review, facility documentation/policies and interviews for one (1) of two (2) sampled residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was treated with dignity and respect when a staff member caused repeated discomfort when repositioning the resident and did not respect the resident's right to refuse care. The findings include:Resident #2's diagnoses included Parkinson's Disease, dysphagia, and depression.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 as moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), required maximum assistance with bed mobility, hygiene and dressing, and was bed bound.The Resident Care Plan (RCP) dated 2/17/26 identified Resident #2 required assistance for hygiene, bathing, dressing, toileting, bed mobility, and transfers. A BIMS score of fourteen (14) dated 3/20/26 identified Resident #2 as cognitively intact.The Social Service note dated 3/20/26 at 9:15 AM identified Resident #2 asked to see the Director of Social Services (DSS) due to a concern regarding care. The DSS met with Resident #2 along with the supervisor and identified Resident #2's concern was going to be investigated.Th facility incident report dated 3/20/26 at 10:45 AM by RN #2 identified on the night of 3/18/26 during the 11:00 PM to 7:00 AM shift, NA #1 picked up Resident #2's right leg to place it back in bed and hit the leg on the bedside table. Resident #2 further identified NA #1 did the same thing on 3/19/26 while Resident #2 was asleep causing Resident #2's leg to hit the bedside table and shifting the laptop which was seated on top of the bedside table.The nurses note dated 3/20/26 at 11:15 AM by RN #2 identified that a skin check to both legs was completed and there were no redness or signs of trauma to the legs.Interview with the DSS on 4/8/26 at 11:20 AM identified on 3/18/26 while in the process of moving Resident #2's right leg back into the bed, NA #1 hit Resident #2's leg on the bedside table. Resident #2 did not feel that was done maliciously. On 3/19/26, NA #1 woke Resident #2 while she was in the process of moving Resident #2's right leg back into bed and hit it on the bedside table. Resident #2 voiced that he/she was angry because NA #1 woke him up when doing this. Resident #2 further identified to the DSS that NA #1 was abrupt and always seemed to be in a hurry. The DSS identified other residents in the past had voiced concerns over the approach NA #1 took when providing care and had identified NA #1 was abrupt and made them feel like they were a burden.Interview with Resident #2 on 4/8/26 at 12:10 PM identified Resident #2 recalled the events of 3/18/26 and 3/19/26 as they had been described previously. Resident #2 identified on 3/18/26 when NA #1 informed him/her that she was going to move Resident #2's right leg back on the bed, Resident #2 told NA #1 not to move the leg, but she proceeded to anyways and, in the process, hit Resident #2's leg on the bedside table. Resident #2 told NA #1 to leave the room. On 3/19/26 while Resident #2 was asleep, NA #1 came into his/her room and woke Resident #2 who was in a sound sleep, while NA #1 was moving Resident #2's leg back into bed. NA #1 hit Resident #2's leg on the bedside table again so hard that his/her lap top and camera equipment on the table moved. Resident #2 told NA #1 to leave his/her room again and requested a new NA. Upon observation and interview with Resident #2, he/she could move his/her right leg on and off the mattress, and he/she indicated it is easier to have help, however, often preferred the right leg to hang slightly off the bed for comfort. Resident #2, who was primarily bed-bound, kept two overbed tables positioned directly over the bed. One table had a laptop and camera on it and the other had personal items and was used at mealtimes. This set up was purposeful for Resident #2 so he/she had the ability to access whatever is needed.Interview with the Director of Nursing on 4/8/26 at 1:00 PM identified the facility had prior patient care concerns brought to their attention regarding NA #1. NA #1 would often provide care to residents without first informing them or asking for their permission. The DON identified NA #1 failed to provide care in a dignified manner and failed to respect Resident #2's rights when he/she asked NA #1 to stop performing a certain duty and NA #1 continued the care. The facility subsequently terminated NA #1.Although attempted, an interview with NA #1 was not obtained.Review of the facility Resident's [NAME] of Rights identified that residents have the right to be treated with consideration, respect and dignity, recognizing each resident's individuality, wishes, and preferences.

Based on review of the clinical record, facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of abuse, the facility failed to ensure concerns reported by a resident representative were identified, documented, and investigated through the grievance process in accordance with facility policy. The findings include:Resident #1's diagnoses included intramedullary nailing following left intertrochanteric femur fracture, intellectual disability, and legal blindness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), independent with bed mobility, touching assistance with transfers, and required moderate assistance with toileting hygiene and dressing.The Resident Care Plan (RCP) dated 1/29/26 identified Resident #1 was at risk for safety due to cognitive deficits and was legally blind. Interventions directed to introduce self when providing care, approach in a calm manner, explain what is being done, anticipate needs, maintain privacy and dignity, orient resident to room, tv remote, bed remote, and call bell.Review of the facilities grievance log for the prior six (6) months failed to identify grievances filed on behalf of Resident #1.Interview with Person #2 (resident representative) on 4/8/26 at 10:20 AM identified she visited Resident #1 on several occasions while Resident #1 was at the facility. Person #2 identified during one visit she was in Resident #1's room and Resident #1 was screaming, two facility staff members went into the room and one of them said, yell, yell, yell. That's all we have to listen to. Person #2 informed the two staff members that Resident #1 was in a lot of pain, which was the reason he/she was yelling.Person #2 identified during another visit, two (2) staff members where with Resident #1 and one staff member began to wheel Resident #1 down the hall to obtain a weight but there were no leg rests on the wheel chair so when they pushed the wheel chair, Resident #1's legs were dragging on the floor and Resident #1 was yelling. One of the staff members said to Resident #1, here you go yelling and screaming at which Person #2 responded to the staff member that Resident #1 was in a lot of pain following the recent femur surgery. Person #2 further identified one of the staff members asked her who she was and when she identified which family member she was, the staff member stopped talking, retrieved leg rests and took the resident to the room. Person #2 further identified she reported to the Director of Social Services (DSS) that she did not like the way staff spoke to Resident #1and felt it was inappropriate. The DSS agreed with Person #2. Person #2 was unable to identify dates, times or who the specific staff members were that were involved in these instances but identified she brought her concerns to the DSS immediately.Interview with the DSS on 4/8/26 at 11:09 AM identified she recalled during a meeting with Person #2 that Person #2 reported comments staff made to Resident #1. The DSS acknowledged replying that the comments were not appropriate. The DSS did not file a grievance because she thought the comments were going to be included in a separate allegation of abuse that was being investigated. The DSS further identified the concern brought to her by Person #2 was not investigated and it should have been investigated.Interview with the Director of Nursing (DON) on 4/8/26 at 12:45 PM identified she was never informed by the DSS of the concern from Person #2 regarding how facility staff members spoke to Resident #2. The DON identified a grievance should have been filed and an investigation should have immediately been initiated. The DON further identified the facility did not follow its grievance policy.Although an interview with Resident #1 was attempted, he/she could not recall specific events during his/her stay at the facility.The facility Resident Rights Policy identified the resident had the right to have the facility resolve their grievance.The facility Grievance Policy identified the facility supports the right for residents or family members to voice grievances and would actively work toward resolution of the grievance. The Policy further identified grievances may be filed verbally to a staff member and the staff member receiving the grievance will file the grievance form.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for falls, the facility failed to adherence to the care plan-specifically by ignoring repeated observations of the resident's forward leaning and rocking and leaving a roommate's wheelchair as an obstruction and to ensure a wheelchair that was not in use was positioned in a way to maintain a clutter-free environment and prevent the resident from sustaining a laceration to left eyelid when the resident leaned forward and fell out of the wheelchair resulting in transfer to the ED for the treatment and evaluation. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, anxiety, muscle weakness, history of falls and macular degeneration (an eye disease that affects central vision). The Fall Risk Evaluation dated 6/4/25 identified that Resident #1 was at risk for falls. The Resident Care Plan dated 7/29/25 identified Resident #1 was at risk for falls related to cognitive impairment, generalized weakness, previous history of falls, and use of an antidepressant. Interventions included instructing the resident to request assistance prior to attempting to transfer or walk within his/her capacity to understand, keeping the area clutter free and well-lit, offering the resident periods of rest in bed and therapy evaluation as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero (0) out of fifteen (15) indicating Resident #1 was not able to make decisions regarding tasks of daily life, had difficulty focusing and disorganized thinking, required substantial assistance with transfers, was independent with wheelchair mobility and had sustained a fall since the prior assessment. The Post Fall Evaluation dated 10/5/25 at 3:23 PM identified Resident #1 sustained an unwitnessed fall at 2:40 PM in his/her room. Resident #1 was leaning forward in the wheelchair and fell out of the wheelchair hitting his/her forehead against another wheelchair in the room. A moderate amount of bleeding was noted. The note identified pressure, and a dressing were applied, the physician was notified, and a new order was obtained to transfer Resident #1 to the Emergency Department (ED) for evaluation. The hospital documentation dated 10/5/25 identified Resident #1 was seen in the ED post head injury, reporting Resident #1 sustained a left eyelid laceration requiring repair with seven (7) sutures. The note indicated imaging of the head was completed and the results reported a soft tissue injury of the left frontal region and there was no acute intracranial hemorrhage (bleeding within the skull). The Reportable Event Summary dated 10/10/25 identified the investigation following the fall, noted that a travel wheelchair belonging to Resident #1's roommate had been left in the room following an appointment earlier that morning. Education was provided to staff regarding proper storage of equipment to maintain a safe environment and prevent clutter in resident rooms and high traffic areas. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/15/25 at 11:03 AM identified she noticed Resident #1 would rock his/her knees, cross his/her arms and lean forward while in the wheelchair. LPN #1 indicated Resident #1 was transferred to her unit several months ago (6/27/25) and thought the behavior was Resident #1's baseline so she did not report the behavior to anyone. Interview with the Occupational Therapy Assistant (Rehab Director) on 10/15/25 at 11:14 AM identified Resident #1 had been on Physical Therapy (PT) services at the time of the fall, she had not observed Resident #1 leaning forward in the wheelchair or rocking. The Rehab Director indicated if the nursing staff observed this behavior, they should have encouraged Resident #1 to lean back and/or put Resident #1 back to bed if he/she appeared fatigued. The Rehab Director identified if Resident #1 was not fatigued and the behavior was ongoing, therapy should have been notified for possible positioning changes, and the therapy department had not been notified. The Rehab Director identified Resident #1 was safe to self-propel in the wheelchair independently. The Rehab Director identified the travel wheelchair belonging to Resident #1's roommate should not have been stored in the room, impeding Resident #1's path of mobility and Resident #1 required verbal cues to navigate around obstacles. Interviews with Nurse Aides (NA) #1, #2 and #4 on 10/15/25 identified that Resident #1 frequently crossed his/her arms, rocked back and forth and would lean forward while in the wheelchair. NA #1 reported she was unsure why the travel wheelchair was just inside the doorway of the Resident #1's room on 10/5/25 and the wheelchair should have been removed from the room. Interview with the 7AM-3PM nursing supervisor, Registered Nurse (RN) #2, on 10/15/25 at 12:20 PM identified although she did not witness Resident #1's fall, Resident #2 reported to her Resident #1 was leaning forward in the wheelchair and then fell forward out of the wheelchair, hitting his/her head on the brake handle of the travel wheelchair. RN #2 identified the travel wheelchair should not have been stored in the doorway of Resident #1's room. Interview with the Director of Nursing (DON) on 10/15/25 at 1:52 PM identified she was unaware Resident #1 had ongoing behaviors of leaning forward in the wheelchair and rocking, and the nursing staff should have notified her and therapy, so they could work with therapy to develop an appropriate plan to ensure Resident #1's safety. The DON explained the travel wheelchair should not have been left in the doorway and stored appropriately, so not to impede Resident #1's path of mobility. Review of the Fall Risk Assessment policy (undated) directed, in part, that the nursing staff, in conjunction with the Interdisciplinary Team (IDT), will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The IDT will evaluate functional and psychosocial factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, ADL capabilities, activity tolerance, continence and cognition. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The IDT will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Although requested, facility policies for wheelchair storage and clutter-free environments were not provided.

Based on clinical record reviews, facility documentation, policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were at risk for falls, the facility failed to ensure a Fall Risk Evaluation was completed quarterly. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, anxiety, muscle weakness, history of falls and macular degeneration (an eye disease that affects central vision). A Fall Risk Evaluation dated 6/4/25 identified Resident #1 was at risk for falls. The Resident Care Plan dated 07/29/25 identified Resident #1 was at risk for falls related to cognitive impairment, generalized weakness, previous history of falls, use of an antidepressant and a history of vertigo (a sensation that the environment around you is off balance and spinning in circles). Interventions included instructing the resident to request assistance prior to attempting to transfer or walk within his/her capacity to understand, keeping the area clutter free and well-lit, offering the resident periods of rest in bed and therapy evaluation as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero (0) out of fifteen (15) indicating Resident #1 was not able to make decisions regarding tasks of daily life, had difficulty focusing and disorganized thinking, required substantial assistance with transfers, was independent with wheelchair mobility and had sustained a fall since the prior assessment. The Post Fall Evaluation dated 10/5/25 at 3:23 PM identified Resident #1 sustained an unwitnessed fall at 2:40 PM in his/her room. Resident #1 was leaning forward in the wheelchair, fell out of the wheelchair, hitting his/her forehead against another wheelchair that was in the room and a moderate amount of bleeding was noted. The note identified pressure and a dressing were applied, the physician was notified, and a new order was obtained to transfer Resident #1 to the Emergency Department (ED) for evaluation. Review of the clinical record from 6/5/25 through 10/4/25 failed to identify a Fall Risk Evaluation was completed within those four (4) months, coinciding with the 9/23/25 comprehensive assessment. Interview with the Director of Nursing (DON) on 10/15/25 at 1:52 PM identified fall risk evaluations are to be completed by nursing on admission, quarterly, after each fall and with any change in condition. The DON explained Fall Risk Evaluations should have been completed around the 7/25/25 and 9/23/25 resident assessments and she was unsure why they were not completed. Review of the Fall Risk Assessment policy (undated) directed, in part, that a fall risk assessment is to be completed on admission, quarterly, after falls and with any health changes.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who were reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to complete a PASRR Level 2 screening when the initial screen expired causing a delay in Resident #1's transfer to another long term care facility. The findings include:Resident #1's diagnoses included congestive heart failure, chronic obstructive pulmonary disease, depression, post-traumatic stress disorder, and bipolar disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory deficits and received anti-anxiety and anti-depressant medications. The PASRR Level 1 notice of action dated [DATE] identified Resident #1 received his/her approval for a period of seven (7) days and a Level 2 referral was not needed with this screening. The notice identified the admitting nursing facility was responsible for submitting the updated Level I/PASRR and LOC at admission so a Level 2 referral may be initiated. The social service note dated [DATE] at 10:28 AM identified Resident #1 was issued a Notice of Medicare Non-Coverage (NOMNC) on [DATE] and an appeal form was completed. The social service note dated [DATE] at 4:35 PM identified Resident #1 lost the appeal and was considered private pay. The note indicated the family was attempting to get Resident #1 into a facility that was Veteran Affairs (VA) connected. The PASRR Level 1 review dated [DATE] identified a previous PASRR short term approval for nursing facility stay is expiring or has expired, a PASRR Level 2 should have been conducted upon expiration of the PASSR Level 1 on [DATE]. The Grievance/Concern Form dated [DATE] identified Resident #1 and family members alleged social service was not assisting with transfers to another facility. The notice of the PASRR Level 2 dated [DATE] identified Resident #1 required the level of services provided in a nursing facility, did not need special services for serious mental health issues and was approved, therefore Resident #1 could choose the nursing facility. The social service note dated [DATE] at 10:19 AM identified Resident #1 was discharged to another long-term care facility. Interview with the Director of Social Services on [DATE] at 2:25 PM identified the process at the facility for PASRR screenings was, upon admission the Director of Social Services was responsible for looking at the PASSR Level 1 screening to determine if further screening was required. The Director of Social Services identified she failed to recognize Resident #1's PASRR Level 1 was approved for seven (7) days and due to Resident #1's psychiatric diagnoses a PASSR Level 2 screening was required. The Director of Social Services explained she did not discover this error until Resident #1's notice of Medicare non-coverage was issued and Resident #1's family requested to transfer Resident #1 to a facility with VA benefits. The Director of Social Services identified she contacted several VA facilities and one facility identified they were able to accept Resident #1 and requested a copy of the PASRR Level 2. The Director of Social Services explained the receiving facility was unable to accept Resident #1 until the PASRR Level 2 was completed, Resident #1 had to remain at the current facility as private pay from [DATE] to [DATE] for a total of fifteen (15) days until the process was completed. The Director of Social Services identified the facility failed to follow the requirements for filing a PASRR Level 2 when due. Interview with the Administrator on [DATE] at 2:55 PM identified the facility failed to follow the requirements for filing a PASRR Level 2 for Resident #1 which caused Resident #1 to have to pay privately until Resident #1 was able to be accepted at a VA facility. The facility Resident Rights policy identified residents have the right to a safe transfer or discharge through sufficient preparation by the nursing home.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who were reviewed for coordination of the plan of care, the facility failed provide the baseline and comprehensive care plans to the resident or the resident's family within forty-eight hours of admission to promote continuity of care and communication with the staff. The findings include:Resident #1's diagnoses included congestive heart failure, chronic obstructive pulmonary disease, depression, and bipolar disorder. The baseline Resident Care Plan dated 5/28/25 identified Resident #1 had a colostomy, was incontinent of bladder, had bipolar disorder, and had a self-care deficit. Interventions directed to toilet the resident every two (2) hours, provide incontinent care, apply barrier protection after care, obtain lab work as ordered, administer medications as ordered, monitor behaviors, psychiatric consults as needed, and assist with daily living skills. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory deficits, required moderate assistance with personal hygiene and bed mobility, maximum assistance for dressing, was dependent on toileting, showers, transfers, and ambulation, had a colostomy, and was always incontinent of bladder. Review of the clinical record from 5/28/25 when the baseline care plan was developed through 7/28/25 failed to reflect documentation a meeting was held with Resident #1 and the family to discuss Resident #1's care or a copy of the care plans were provided until the 7/28/25 meeting. The Care Plan Meeting Invitation form identified the facility had a meeting with Resident #1 and family members on 7/28/25 and addressed concerns Resident #1 and his/her family had. Interview with the Director of Social Services on 8/18/25 at 2:25 PM identified she thought a meeting was held; however, she could not be sure because she did not document in the clinical record that a meeting occurred. The Director of Social Services checked further with the therapy department as they attended all care plan meetings, and the therapy department had no record of the meeting being held. Review of the facility Resident Rights policy identified the resident had the right to participate in their own care-planning and treatment. Review of the facility Care Plan policy identified the resident had the right to participate in the development and implementation of his/her plan of care.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #1) who was symptomatic for a urinary tract infection and had an order to collect a urine specimen, the facility failed to collect the urine at the time of the order or notify the physician of the delay with obtaining the specimen. The findings include:Resident #1's diagnoses included chronic kidney disease, congestive heart failure, and diabetes mellitus. The baseline Resident Care Plan dated 5/28/25 identified Resident #1 had a colostomy, was incontinent of bladder, and had a self-care deficit. Interventions directed to toilet the resident every two (2) hours, provide incontinent care, apply barrier protection after care, obtain lab work as ordered, and assist with daily living skills as needed. A physician's order dated 5/28/25 directed staff may straight catheterize Resident #1 if unable to obtain a urine specimen for urinalysis or culture and sensitivity as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory deficits, required moderate assistance with personal hygiene, maximum assistance for dressing, was dependent on toileting, and was always incontinent of bladder. The nurse's note dated 6/4/25 at 9:19 PM identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, noted Resident #1 was very lethargic and hard to arouse around 9:00 PM during the medication pass. The note indicated when the nurse aide attempted to provide care Resident #1 became agitated and attempted to strike the nurse aide. The note identified Resident #1 was approached a second time and refused all medications. The plan was to continue to monitor Resident #1. The nurse's note dated 6/5/25 at 5:15 PM identified the 7AM-3PM charge nurse, LPN #2, noticed Resident #1 was listless throughout the day with a flat affect, responded appropriately to questions, complained of dysuria when being toileted in the morning, and was encouraged to increase fluid intake. The note identified the Advanced Practice Registered Nurse (APRN) was notified and directed labs and urine specimens to be done in the morning. The nurse's note dated 6/5/25 at 11:16 PM identified Resident #1 was lethargic during the shift and was found a couple of times with his/her feet dangling out of the bed. Review of the nurse's notes for 6/6/25 and 6/7/25 failed to identify attempts were made to collect a urine sample or there was notification to the APRN regarding the status. The nurse's note dated 6/8/25 at 2:24 PM by the 7AM-3PM floor nurse, LPN #4, identified a family member was in to visit and voiced concerns over Resident #1's increased confusion. The note indicated there was still the need to obtain a urine specimen. A physician's progress note dated 6/9/25 at 11:15 AM identified the urinalysis was positive for bacteria, and the culture and sensitivity were pending. The physician directed to continue to monitor and appropriate antibiotic treatment would be initiated once the culture and sensitivity results were back. The nurse's note dated 6/9/25 at 4:54 PM identified Resident #1 complained of dysuria and required extensive assistance for morning care. A urine specimen was obtained and sent to the lab, four (4) days after the initial order. The lab result dated 6/9/25 identified a positive urinary tract infection. The nurse's note dated 6/10/25 at 9:51 AM identified Resident #1's culture was rejected by the lab and the facility received an order to obtain another urine. The nurse's note dated 6/11/25 at 3:59 PM identified Resident #1 had periods of confusion during the shift and family member had also reported Resident #1 was having more confusion. A physician's progress note dated 6/12/25 at 8:30 AM identified the facility received the results of the urine culture and sensitivity and the APRN directed to administer Rocephin IM for four (4) days. The urine culture and sensitivity lab results dated 6/13/25 identified multiple gram-positive bacteria was noted in the urine. The Grievance/Concern Form dated 7/28/25 identified family members alleged when a urinalysis test was requested there was a delay in obtaining the specimen. Interview with LPN #2 on 8/18/25 at 1:40 PM identified the length of time from the urinalysis being ordered on 6/5/25 until treatment was ordered on 6/12/25 was longer than usual. Interview with LPN #1 on 8/18/25 at 2:00 PM identified she could not recall if she attempted to get a urine sample and noted if she had and was unsuccessful, she would have documented that in the clinical record. Interview with the Infection Control Nurse, Registered Nurse (RN) #1, on 8/18/25 at 2:18 PM identified the facility expectation to collect a urine sample once ordered was within twenty-four (24) hours. RN #1 indicated the physician should have been notified of the delay and inquire if the physician wanted Resident #1 to be straight cathed due to Resident #1's incontinence. RN #1 identified failure to follow proper protocol caused a delay in treating Resident #1. Review of the facility policy Resident Rights identified the resident had the right to receive adequate and appropriate care.

Based on interviews, record review, and facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to include a resident in the development and implementation of a person-centered Resident Care Plan. The findings included: Resident #37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene, and was dependent on staff for toileting and transfers. The Resident Care Plan (RCP) dated 2/4/25 failed to include resident discharge planning. Interview with the Director of Nurses (DNS) on 4/17/25 at 9:35 AM identified the facility does not currently have an MDS coordinator and the care planning and care plan schedules are created by the DNS, Rehabilitation Department, and social worker. Interview with Resident #37 on 4/17/25 at 9:45 AM identified staff had not discussed discharge home or invited him/her to a RCP meeting or discharge planning meeting even though he/she was ready to be discharged . The April 2025 and May 2025 RCP calendars provided identified care plan meetings scheduled on 4/24/25 and after but failed to identify prior calendars or care plan meeting dates. Interview and review of the Resident Care Conference attendance sheet with the DNS on 4/17/25 at 12:39 PM identified residents were involved in the care planning process by being invited to the quarterly care plan meetings. A review of the care conference signature sheet for Resident #37 failed to identify signatures or meetings after 10/24/24. During an interview with the Administrator on 4/22/25 at 10:33 AM he was unable to identify who was ultimately responsible for care plans and care plan meetings since there was no Director of Social Work and no MDS Coordinator in-house, stating it was a team effort. Interview and care conference calendar schedule review with the MDS coordinator, Licensed Practical Nurse (LPN) #5 on 4/22/25 at 11:47 AM identified his last day as the MDS coordinator was 3/16/25, and he had not trained anyone for the position. LPN #5 identified he was in charge of the care plan conference calendars but could not provide copies of calendars prior to 4/24/25 as there was an issue with the computer, and neither he nor the receptionist had hard copies. Additionally, LPN #5 identified residents had documentation in their progress notes reflecting the invitation to the resident care conference. A review of the progress note dated 10/24/24 at 12:04 PM identified a quarterly care plan meeting was held with Resident #37, Nursing Department and social services. The electronic health record failed to identify any progress notes reflecting Resident #37 had a RCP meeting after 10/24/24. The Comprehensive Person-Centered Care Plan Policy directed, in part, that each resident's care plan will be consistent with the residents right to participate in the development and implementation of the care plan.

Based on interview, review of facility documentation, and facility policy during a Resident Council meeting and review of Resident Council minutes, the facility failed to resolve ongoing issues with dietary, extended call bell wait times, locating staff for assistance, and inappropriate language used by staff. The findings include: Review of the Resident Council minutes for March 2024 through March 2025 identified that residents had dietary concerns in March 2024, May 2024, June 2024, July 2024, September 2024, October 2024, November 2024, December 2024, February 2025, and March 2025. Residents had concerns with staff using foul language in June 2024 and December 2024. Additionally, Residents had concerns with Nurse Aides for answering call bells, cell phone use on the units, breaks being taken at the same time, and the inability to locate staff when needed. During a Resident Council meeting conducted on 4/16/25 at 1:35 PM it was identified that the residents have been complaining about food issues for the past 2 years. Issues included taste, ability to get some items regularly (eggs), temperature, and liquid from vegetables not being drained and running into other items served on the same plate. Further residents identified that call bells were being answered timely while the surveyors were in the building, however 1 resident waited 20 minutes and almost fell, and several residents complained that the call bells were being shut off at the nurses stations. Residents indicated that staff members were using foul language, often could not be found, (indicating a staff member was found sleeping in a cubby) and that the noise level by staff was loud. Interview with the Administrator on 4/22/2025 at 2:48 PM identified that although in-services and monitoring occurred by staff management, he would possibly look into a food committee and that resident concerns should not occur on a continuing basis. Interview with the DNS on 4/22/2025 at 3:10 PM identified that she had conducted observations and had in-services, however, she would look into further measures to assist with resident satisfaction. Review of the Concern, Complaint and/or Grievance policy dated 11/25/2016, directed, in part, that it is the facility's intention to actively seek a resolution to a concern, complaint/grievance.

Based on review of the facility's Personal Funds Account, review of facility policy, and interviews, the facility failed to provide access to personal funds outside of the facilities posted banking hours. The findings include: Observation on 4/22/2025 at 11:00 AM identified a sign posted at the reception desk indicating banking hours were Monday through Friday from 8:00 AM to 7:00 PM, and Saturday and Sunday from 9:30 AM to 3:30 PM. Interview with the Business Office Manager on 4/22/2025 at 11:21 AM identified that residents had access to their personal bank account funds daily from 8:00 AM to 7:00 PM. The Business Office Manager reported that a petty cash lock box was kept at the reception desk to allow residents access to their funds when she was not available. She noted that, aside from herself, three facility receptionists had keys to the petty cash box. The Business Office Manager identified residents were unable to access their personal funds outside of the designated banking hours. Interview with Receptionist #1 on 4/22/2025 at 1:07 PM identified that the facility maintains a petty cash lock box for residents to access funds when the Business Office Manager was unavailable. She indicated that banking hours were Monday through Friday from 8:00 AM to 7:00 PM and Saturday and Sunday from 9:30 AM to 3:30 PM. Any resident requesting funds outside if this timeframe would have to wait until the following day when the receptionist or Business Office Manager were onsite. Interview with the Facility Administrator on 4/22/2025 at 2:57 PM identified that the only staff members who had access to the petty cash lock box were the receptionist and the Business Office Manager. Review of the Statement of Resident's Rights Regarding Personal Funds dated 7/2018 failed to indicate how residents get access to funds after their posted banking hours.

Based on record review, interviews, and review of facility policy for 5 of 5 residents, (Resident #26, #30, #50, and #70), reviewed for Resident Care Planning (RCP), the facility failed to provide documentation that quarterly Resident Care Conferences (RCCs) were held and failed to ensure revisions to the Resident Care Plan (RCP) within 7 days after completion of the resident's comprehensive assessment. The findings include: 1. Resident #26's diagnoses included Parkinson's Disease, dementia, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was dependent with personal hygiene, dressing, and rolling left and right. Review of the MDS assessment dated [DATE] identified Resident #25 required substantial assistance with personal hygiene and dressing, and moderate assistance with rolling left and right. a. The RCP in effect from 11/12/2024 through 4/17/2025 failed to reflect the changes in the amount of assistance Resident #26 required with Activities of Daily Living (ADL). b. A review of the RCC sign in sheet failed to identify that a Resident Care Conference (RCC) was held following the 1/29/25 MDS assessment. An interview with Social Worker #1 on 4/16/2025 at 10:43 AM identified Resident #26's RCP was last completed on 12/10/2024 and he/she should have received a quarterly RCP in March, 3 months from the 12/10/2024 date. She further identified that the MDS coordinator was responsible for scheduling RCP updates. Social Worker #1 failed to identify why an RCP was not completed for Resident #26 in 2025. Attempts to schedule an interview with the MDS coordinator were unsuccessful as the facility had only remote MDS Coordinators, and no permanent MDS Coordinator in the facility. An interview with the Director of Nursing Services (DNS) on 4/16/2025 at 1:56 PM identified that Resident #26's last care plan meeting was 11/12/2024 and his/her care plan meetings were not being held on a quarterly basis. The DNS further identified no care plan had been completed for Resident #26 after 12/10/2024. The DNS failed to identify why RCCs were not being held on a quarterly basis and why no RCP had been completed in 2025. 2. Resident #30's diagnoses included epilepsy, left sided hemiplegia, and chronic obstructive pulmonary disease. a. The admission MDS assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment, required moderate assistance with upper body dressing and moving from a sitting to lying position, and was dependent with transfers. The quarterly MDS assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment, required maximal assistance with upper body dressing and moving from a sitting to lying position, and was dependent with transfers. a. The RCP in effect from 7/7/2023 through 4/17/2025 failed to reflect the RCP had been revised to include the changes in the amount of assistance Resident #30 required with Activities of Daily Living (ADL). b. A review of the RCC sign in sheets failed to identify that although Resident #30 had MDS assessments on 12/20/2024 and 3/21/2025 that a meeting was held following the assessment or anytime during 2025. An interview with Social Worker #1 on 4/16/2025 at 10:43 AM identified Resident #30's did not have an RCP completed in 2025 and prior RCPs were not consistently completed within 7 days of his/her MDS submission. Further, she identified the MDS coordinator was responsible for scheduling RCP updates. Social Worker #1 failed to identify why an RCP was not completed for Resident #30 in 2025. 3. Resident #50's diagnoses included atherosclerotic heart disease with angina pectoris, chronic obstructive pulmonary disease, and major depressive disorder. a. The quarterly MDS assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with upper and lower body dressing, moving from a sitting to lying position, and wheeling 150 feet in a manual wheelchair. The quarterly MDS assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required touching assistance with upper body dressing and moving from a sitting lying position, required moderate assistance with lower body dressing. The RCP in effect from 2/28/2023 through 4/17/2025 failed to reflect the RCP had been revised to include a review and revision to cardiac status and failed to include changes in the amount of assistance Resident #50 required with Activities of Daily Living (ADL). b. A review of the RCC sign in sheets for the time period of 1/1/2024 through 4/17/2025 identified RCP meetings for Resident #50 were held on 2/1/2024, 7/26/2024, 11/4/2024, and 2/20/2025. A review of MDS submissions for Resident #50 identified that MDSs were completed on 2/21/2024, 3/29/2024, 4/25/2024, 7/24/2024, 10/21/2024, and 1/27/2025. An interview on 4/22/2025 at 3:08 PM with Social Worker #2 identified that RCPs should be completed between 7 to 10 days after the MDS was completed. She further identified that although an RCP was completed on 5/9/24 (not within the allotted time), the facility failed to meet the requirement for RCP meetings for 6 out of 7 opportunities (2/21/2024, 03/29/2024, 4/25/2024, 7/24/2024, 10/21/2024, and 1/27/2025). 4. Resident #70's diagnoses included multiple sclerosis, depression, and chronic pain. a. The admission MDS assessment dated [DATE] identified Resident #70 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with lower body dressing, and was dependent on staff wheeling 150 feet in a manual wheelchair. The quarterly MDS assessment dated [DATE] identified Resident #70 had a BIMS score of 15 indicating no cognitive impairment, required substantial assistance with lower body dressing, and required partial assistance with wheeling 150 feet in a manual wheelchair. The RCP in effect from 4/9/2024 through 4/17/2025 failed to identify that a review and revision of the care plan related to multiple sclerosis and changes in the amount of ADL assistance required by Resident #70 had been completed since admission. b. A review of MDS submissions for Resident #70 identified that MDSs were completed on 6/6/2024, 9/12/2024, 10/3/2024, and 12/31/24. A review of social service progress notes for the time period of 4/1/2024 through 4/17/25 identified RCP meetings for Resident #70 were held on 7/17/2024, 9/12/2024, and 12/6/2024 but failed to meet the time requirement for RCP meetings. The RCC sign in sheets for the time period of 4/1/2024 through 4/17/2025 were requested, however, the facility failed to provide the requested sign-in sheets. An interview on 4/22/25 at 11:47 AM with the former MDS coordinator LPN #5 identified he was responsible for sending a list of Residents needing an RCC and RCP to the social worker and receptionist for scheduling off of a calendar he created. LPN #5 failed to produce a copy of any past calendar for RCC and RCP scheduling and indicated he erased the calendar from his computer at the end of every month. An interview with Social Worker #2 on 4/22/2024 at 3:08 PM identified that there was a facility expectation for RCPs to be revised the same day a resident has a RCC, although quarterly revisions instead are often made the same week, no later than 10 days, but should be completed between 7 to 10 days after a MDS was completed. She further identified RCPs were completed for Resident #70 on 4/9/2024, 7/19/2024, 10/16/2024, and 1/4/2025 and that the facility failed to meet 3 out of 4 opportunities (6/6/2024, 9/12/2024, 10/3/2024) for timely RCP completions. Review of the Facility's Comprehensive Person-Centered Care Plan Policy identified in part that care plans should incorporate identified problem areas, and aid in preventing or decline in a Resident's functional status and/or functional levels. The policy further identified that comprehensive person-centered care plans should be developed within 7 days of a Resident's completed MDS.

Based on record review, interviews, and review of facility policy for 2 of 2 residents (Resident#37 and #50) reviewed for choices, the facility failed to provide medically related social services to facilitate discharge. The findings included: 1. Resident # 37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene and was dependent on staff for toileting, and transfers. Additionally, the MDS identified Resident #37's overall goal was to return to the community and active discharge planning already occurred. The Resident Care Plan dated 2/4/25 failed to identify a discharge plan. Interview with Resident #37 on 4/14/25 at 9:53 AM identified that he/she was waiting for a representative from Money Follows the Person (MFP), (a federal Medicaid program designed to help individuals transition out of nursing homes into home and community-based settings), to see him/her tomorrow so he/she could get back to the community. Interview with Social Worker #1 on 4/16/25 at 12:38 PM identified she was not versed in Money Follows the Person (MFP) because her supervisor oversaw that process. Social Worker #1 indicated that since her supervisor left, [the previous social workers last day was 3/28/25], the facility did not have a Director of Social Work. Additionally, she identified the Rehabilitation Department was helping with discharges since she was only in the facility for 8 hours a week. Social Worker #1 could not identify any discharge plans for Resident #37, or if he/she had MFP. Interview with the Administrator on 4/16/25 at 12:42 PM identified the facility policy for residents with MFP was to have the social worker follow them and assist with the process. Additionally, he identified the new social worker was starting 4/24/25 and until then the facility was pulling it together between the different departments, and he was not aware of any discharge plans for Resident #37. Interview with the Director of Rehabilitation on 4/16/25 at 1:48 PM identified Resident #37 was waiting for MFP, and was highly motivated to be discharged into the community but could not identify if a discharge plan was initiated since the facility did not have a social worker. Interview with Resident #37 on 4/17/25 at 9:45 AM identified no one had spoken to him/her about going home or invited him/her to meetings about discharge planning even though he/she was ready to go bacl to the community, and aside from setting up housing there was nothing keeping him/her in the facility. Additionally, Resident #37 identified that the case worker from MFP was supposed to come see him/her on 4/15/25 but never showed up for the meeting. Interview with the Community Care Case Manager for MFP on 4/17/25 at 12:19 PM identified Resident #37's application was started 3/9/25, a case worker was supposed to come out 4/15/25, for the initial assessment but rescheduled to 4/24/25 and a message had been left with the receptionist due to the facility's lack of a social worker. Interview with the DNS on 4/17/25 at 12:39 PM identified she was not aware Resident #37 was highly motivated to be discharged , not aware of any MFP visits set up or rescheduled visits, identifying it was the responsibility of the social worker to follow up and it was missed due to lack of communication. Interview with the Administrator on 4/22/25 at 10:33 AM identified that in the absence of a Director of Social Work he was stepping in, even though he had a bachelor's degree in business administration and not in social work. Additionally, he identified there was a social worker in the facility one day a week but residents with MFP were falling through the cracks. Follow up interview with Resident #37 on 4/22/25 at 12:06 PM identified that although the MFP case worker had notified the facility that Resident #37's meeting was to be rescheduled, he/she had never been notified about the rescheduled MFP appointment, and no one in the facility had been speaking to him/her regarding discharge. 2. Resident #50's diagnoses included atherosclerotic heart disease with angina, chronic obstructive pulmonary disease, and major depressive disorder. The Resident Care Plan (RCP) dated 7/15/2024 identified Resident #50's discharge planning included working with Money Follows the Person (MFP) to return to the community. Interventions included collaborating with the Interdisciplinary Team (IDT), resident, and family to collaborate on a plan, goals, and progress, and to set up home care as ordered. The quarterly MDS assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with upper and lower body dressing and chair/bed to chair transfers and required touching assistance when walking 150 feet. An interview with Resident #50 on 4/14/2025 at 10:42 AM identified he/she wanted to discharge from the facility using the MFP program and was informed by the facility there was no one that could assist with his/her request. An interview on 4/16/2025 at 2:15 PM with the Director of Nursing Services identified she was not aware Resident #50 wanted to use the MFP program and stated she would look into Resident #50's request. Subsequent to surveyor inquiry, on 4/19/2025 at 11:56 AM, a facility representative spoke with Resident #50, and he/she relayed the location to where he/she wished to be discharged . An interview on 4/22/2025 at 1:43 PM with the Regional Clinical Registered Nurse (RN) #6 identified she was not aware of what the process was when a Resident had an MFP request but identified Social Work should be responsible for all MFP requests. RN #6 further indicated the facility had no MFP policy. An interview with the Administrator on 4/22/25 at 10:33 AM identified he was aware that staff was not assisting residents with MFP requests due to being short staffed, and stated it is falling through the gap. An interview with Social Worker #2 on 4/22/2025 at 1:45 PM confirmed there was no MFP policy and identified social workers would assist residents with identifying if they would benefit from MFP and assisting them with filling out the paperwork. Further she identified that once social work mailed a resident's paperwork to MFP a scheduler would call within a couple of days to arrange a meeting, after which the social worker met with the MFP Case Manager. Social Worker #2 identified the facility received notification in November of 2024 that Resident #50 needed to submit a voucher to MFP, but the facility failed to assist him/her in sending the voucher and instead informed the resident there was no housing manager at the facility to help him with MFP. Social Worker #2 failed to identify why social work had not assisted Resident #50 with his/her discharge request. The facility did not have a policy on Money Follows the Person discharges. The Process for Discharge policy directed, in part, that social services set up services and developed a discharge care plan (in the absence of social services, nursing, or MDS was to fill in). The social worker job description identified duties and responsibilities included in part, participating in discharge planning, development of social care plans and resident assessments.

Based on observation, staff interview, and facility policy for medication storage and labeling, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include: 1. An observation on 4/14/2025 at 10:00 AM identified an unattended and unlocked medication cart outside the door of room [ROOM NUMBER] in the hallway. Two unsupervised residents were in the hallway, 1 resident rolled past the unlocked cart in his/her wheelchair. An interview with Licensed Practical Nurse (LPN) #1 on 4/14/25 at 10:13 AM identified that she forgot to lock the medication cart before entering a different room to provide routine care for a resident because she was rushing. She indicated she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. 2. An observation on 4/14/2025 at 11:22 AM identified an unattended and unlocked medication cart and an unattended and unlocked treatment cart in the Frog Lane hallway. An observation of the treatment cart with LPN #1 identified that multiple Resident prescription and non-prescription medications were in the unlocked treatment cart. An interview with LPN #1 on 4/14/2025 at 11:22 AM identified that she forgot to lock both carts after use. She further identified that she was aware of the facility policy to lock medication carts and treatment carts when not in use, not in view, and unattended. 3. An observation on 4/15/2025 at 8:04 AM identified the Frog Lane treatment cart was unlocked. One resident was present in the hallway. An inspection of the Frog Lane treatment cart drawers with LPN #2 identified nystatin and other resident medications present in the cart but there were no narcotics. An interview with LPN #2 on 4/15/2025 at 8:04 AM identified that she just got to the facility and should have locked the cart. She further identified that she was aware of the facility policy to lock medication carts and treatment carts when not in use, not in view, and unattended. 4. An observation on 4/16/2025 at 5:15 AM identified the Frog Lane medication cart was unlocked. One resident was watching tv in the activity room and there were no residents in the hallway. An interview with LPN #6 identified that she forgot to lock the cart. She further identified that she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. 5. An observation on 4/16/2025 at 5:23 AM identified the second floor [NAME] medication cart was unlocked. There were no residents in the hallway. An interview with Registered Nurse (RN) #5 identified that many nurses don't lock the carts and [although this was not observed by the surveyor], indicated nurses keep keys to the medication carts in the cart itself. She further stated that there had not been a recent in-service provided to nurses locking medication carts when leaving them unattended. She identified that she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. RN #5 failed to identify a reason why the second floor medication cart was left unattended and unlocked. 6. An observation on 4/16/2025 at 5:41 AM identified the [NAME] Road medication cart was unattended and unlocked. Four unidentified pills were on top of the cart in a white medication cup. No residents were near the [NAME] Road medication cart. An interview with RN #5 identified that the cart was unlocked and should be locked per policy. Subsequent to surveyor inquiry the medication cup with the unidentified medications was placed into the medication cart and locked. 7. An interview with the Director of Nursing Services (DNS) on 4/16/2025 at 2:18 PM identified that it was permissible for medication carts to be unlocked if a nurse has visual contact with the cart, but once a nurse walked away, the cart should have been locked. The DNS indicated that nurses do receive education on locking medication carts. Subsequent to surveyor inquiry the DNS stated she will add the issue of unlocked medication carts to a QAPI plan and perform audits. Review of the facility's Medication Administration Policy identified in part that keys to the medication carts should be in the possession of the nurse at all times, carts are never to be left unattended in resident care areas, and when not in full view and in control of the nurse the cart, must remain locked.

Based on review of facility documentation, facility policy and interviews for 4 of 5 employee files, the facility failed to ensure that the mandatory employee training/in-services were completed. The findings include: 1. LPN #1's date of hire was 11/11/2021. Review of facility documentation for LPN #1 identified that she worked in the facility between 11/11/2021 and 4/22/25. Review of the employee file for LPN #1 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 2. NA #1's date of hire was 8/8/2019. Review of facility documentation for NA #1 identified that she worked in the facility between 8/8/2019 and 4/22/25. Review of the employee file for NA #1 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 3. NA #3's date of hire was 10/11/2023. Review of facility documentation for NA #3 identified that she worked in the facility between 10/11/2023 and 4/22/25. Review of the employee file for NA #3 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 4. NA #4's date of hire was 11/23/2020. Review of facility documentation for NA #4 identified that she worked in the facility between 11/2020 and 4/22/25. Review of the employee file for NA #4 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. Although requested, the facility could not provide documentation that current required trainings (mandatory inservices) had been completed for LPN#1, NA#1, NA#3 and NA#4. Interview and review of facility documentation with the Staff Development RN (RN #2) on 4/22/25 at 1:20 PM identified that required in-service trainings are provided upon hire and annually. RN#2 was unable to provide current documentation for the mandatoryt annual in-service training for LPN #1, NA #1, NA #3 and NA #4. RN #2 indicated that it was his responsibility to ensure the required in-service trainings were completed, documented, and placed in the employees' files for review. Interview and review of facility documentation with the Director of Nurses (DNS) on 4/22/25 at 2:30 PM identified that she was unable to locate the current mandatory annual in-service training documentation for LPN #1, NA#1, NA#3 and NA#4 and identified that RN#2 was responsible for ensuring that employees required in-service trainings were completed, documented, and placed in the employees' files. The DNS identified it is facility policy that staff complete the required in-service trainings upon hire and annually and that she and RN #2 would work on them. Although requested, facility's policy on employees' in-service trainings was not provided.

Based on observations, interviews, clinical record review, and review of facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to ensure the resident's wheelchair of choice was able to be utilized. The findings include: Resident #37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene, and was dependent on staff for toileting and transfers. The Resident Care Plan dated 2/5/25 identified Resident #37 required modified wheelchair positioning for proper body alignment. Interventions included referral to therapy as needed for change in wheelchair positioning, monitor for complaints of pain or evidence for skin breakdown, and transfer out of bed into the modified wheelchair as ordered. A physician's order dated 4/14/25 directed Resident #37 was to be out of bed to the adapted tilt in space wheelchair up to 1 hour to facilitate quality of life. Interview with Resident #37 on 4/14/25 at 9:53 AM identified he/she received an electric wheelchair (currently in the room) from a family member about a year ago, but he/she was unable to use it as the facility prohibited its use. Interview with the Director of Rehabilitation on 4/15/25 at 1:13 PM identified she was aware of Resident #37's desire to use the electric wheelchair, and he/she was evaluated when they first received the electric wheelchair, but did he/she not need an electric wheelchair. Additionally, to maintain function, the decision was made by staff to keep Resident #37 in the customized wheelchair (CWC) to deconditioniong. Review of the summary of skilled services (rehabilitation therapy) dated 6/24/24 at 2:58 PM identified, in part, that Resident #37 had received the electric wheelchair from his/her family, utilized the wheelchair over that weekend but lacked therapy approval or knowledge. Resident #37 was provided educated on inspection, education, and training for any new equipment brought into the facility, as well as extensive education on safety risks associated with the use of an electric wheelchair within a skilled nursing facility due to other residents. Additionally, therapy had concerns that the resident would develop muscle atrophy of the bilateral upper extremities, and he/she had a high risk for impairments, risk for joint deformity, pain and injury due to a lack of positioning devices. Resident #37 was receptive to all education provided and was educated on the need for further assessments to determine if the device was safe for him/her and other residents as well as further education on risk for impairments and injury making the electric wheelchair inappropriate for that environment. (Although multiple requests were made, the facility was unable to provide a screen, evaluation, or assessment of Resident #37 in the electric wheelchair). Interview with Nursing Assistant (NA) #1 on 4/16/25 at 9:22 AM identified she took care of Resident #37 on a regular basis, and he/she used to bring up using the electric wheelchair all the time when the wheelchair was first received. She identified it was always in Resident #37's room, but she did not believe he/she was ever evaluated by therapy for its use and questioned if electric wheelchairs were even allowed in the facility. Follow up interview Director of Rehabilitation on 4/16/25 at 1:48 PM identified Resident #37 was currently receiving therapy for strengthening, and although she was aware of Resident #37's desire to use the electric wheelchair, the facility wanted him/her to keep his/her independence. Additionally, she identified for a resident receiving a muscle relaxant and pain medication might not be appropriate to use an electric wheelchair, because he/she might fall asleep, and the facility needed to think about the safety of other residents. The Director of Rehabilitation identified Resident #37 was highly motivated to be discharged and could use the electric wheelchair in the community. Observation of Resident #37 on 4/15/25 at 2:11 PM identified him/her alert and conversing with staff in the hallway utilizing the wall railing to self-propel in the non-electric wheelchair. Additional observations on 4/16/25 at 11:05 AM identified Resident #37 alert and oriented during a wound treatment change and on 4/16/25 at 2:10 PM he/she was self-propelling in the hallway in his/her non-electric wheelchair. Observations failed to identify Resident #37 dozing off or sleeping any point. Follow up interview with Resident #37 on 4/17/25 at 9:45 AM identified he/she got the electric wheelchair because it was more comfortable than the wheelchair the facility was providing. He/she also identified no one assessed him in the chair, just explained that it was not appropriate due to his leaning, but he/she did not understand that because both the current wheelchair and the electric wheelchair reclined. Review of occupational therapy summaries of daily skilled services notes failed to identify that Resident #37 was assessed in the electric wheelchair after the initial education provided on 6/24/24. Review of the Americans with Disabilities Act (ADA) Requirements: indicated that Wheelchairs, mobility aids, and other power-driven mobility devices directed, in part, that people with disabilities have the right to choose whatever mobility device best suits their needs. Review of the Resident's [NAME] of Rights directed, in part, that residents can store and use their personal possessions and have the right to receive quality care and services with reasonable accommodations of individual needs and preferences.

Based on interviews and record review for 1 of 3 residents, (Resident #19), sampled for advanced directives, the facility failed to identify a code status in the electronic health record. The findings included: Resident #19's diagnoses included chronic obstructive pulmonary disease, anemia and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was moderately cognitively impaired, and required substantial/ maximal assistance with dressing, eating and repositioning in bed. The Resident Care Plan dated 2/10/25 identified Resident #19's advance care planning code status was DNR/DNI/RNP (do not resuscitate, do not in tubate, Registered Nurse may pronounce). Interventions included a physician's order and documentation of the resident's code status and advance care planning in the resident's clinical record. The Resident Advance Directives form signed 3/7/24 identified Resident #19 had a code status of do not resuscitate (DNR). The physicians' orders failed to identify a code status. Interview and record review with Licensed Practical Nurse (LPN) #4 on 4/15/25 at 1:29 PM identified it is facility policy for advance directives to be in the electronic health record, entered by the charge nurse upon admission and passed on in report verbally. LPN #4 further identified in an emergency the protocol would be to check the electronic health record first. Resident #19's electronic record failed to identify code status. Interview and record review with the Director of Nursing (DNS) on 04/15/25 at 1:33 PM identified it is facility policy for advance directives to be in the chart and in the electronic health record, input by the RN supervisor within 24 hours of admission without exception. The DNS could not identify Resident #19's code status in the electronic health record, stating in an emergency, the nurse would have to check the physical chart. The Advance Directives Policy directed in part that an advance directive shall be displayed prominently in the medical record.

Based on review of clinical records, facility documentation, facility policy, and interviews for 2 of 3 sampled residents, (Resident #28 and Resident #63), reviewed for abuse, for Resident #28, the facility failed to report an allegation of misappropriation of funds, and for Resident #63, the facility failed to report an allegation of neglect in a timely manner. The findings include: 1. Resident #28's diagnosis included depression, stroke, and spinal cord dysfunction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact, was independent with eating after set up, was dependent on staff for dressing and transfers, and used a wheelchair for mobility. The Resident Care Plan dated 9/10/2024 identified Resident #28 had impaired Activities of Daily Living (ADL's) requiring assistance related to a history of a stroke. Interventions directed staff to assist with bathing, dressing, and personal hygiene. Interview with Resident #28 on 4/14/2025 at 11:07 AM identified that he/she had $40.00 missing from the bedside table that was going to be used to pay the hairdresser. Resident #28 indicated that due to the missing money, he/she was unable to attend the appointment. Further the missing money had been reported NA #5 approximately 6 months ago, but the facility had taken no action. Interview with Nurse Aide (NA) #5 on 4/16/2025 at 2:44 PM identified that Resident #28 requested her help to get his/her money from inside a cell phone case. When NA #5 opened the case, she explained to Resident #28 that there was no money inside. Resident #28 stated he/she was sure the money had been stored in the cell phone case. NA #5 indicated that she searched for the money in the resident's room, but no money was found. NA #5 stated she reported the incident to either the charge nurse or nursing supervisor, though she could not recall exactly to whom she reported the incident. Additionally, NA #5 stated that she had also completed a written statement and gave it to the nursing supervisor. Interview with LPN #7 on 4/16/2025 at 2:57 PM identified she did not recall being informed about the missing money. Interview with RN #1 on 4/16/2025 at 3:16 PM identified she did not recall NA #5 reporting the missing money. Re-interview with RN #1 on 4/17/2025 3:04 PM identified that the facility failed to provide any written documentation for the missing money being reported or investigated. An interview with the Administrator on 4/17/2025 at 3:08 PM identified that he was unaware of Resident #28's allegation of misappropriation so he would not have reported it to the state agency. Interview with the Director of Nursing Services (DNS) on 4/17/2025 at 5:51 PM identified that she could not explain why the policy for misappropriation [abuse] was not followed and the allegation was not immediately reported to the state agency. Subsequent to Surveyor inquiry, a reportable event was reported to the Department of Public Health (state agency) on 4/16/2025 and the police were notified. 2. Resident #63's diagnoses included dementia, adjustment disorder with anxiety, depressed mood and irritable bowel syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #63 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impaired and required partial moderate assistance with transfers, substantial maximum assistance with bed mobility, and was totally dependent on staff for toileting. Additionally, Resident #63 was frequently incontinent of bowel and bladder. The elimination Resident Care Plan in effect on 9/26/2023 identified Resident #63 was incontinent of bowel and bladder related to impaired cognition and mobility. Interventions included toileting and incontinent care every 2 hours and as needed, disposable adult incontinence brief, and applying barrier skin protection following incontinent care. Review of the grievance concern form dated 10/6/2023 identified that on 9/26/2023 a family member had reported to LPN #3 (the day of the incident) that Resident #63 was neglected for many hours and lacked incontinence care, position changes, or hygiene. When Resident #63's brief was changed, it was noted to have a foul odor, was saturated through to his/her clothes and seat cushion, and a new irritation and open areas were noted. Further review of the grievance form identified that the incident had been reported to the Supervising Registered Nurse, (RN #1) on 9/29/23 (3 days after the initial allegation) and to the Director of Nursing (DNS) on 10/3/23 (7 days after the initial allegation). Review of the Reportable Event form dated 10/6/2023 identified a family member reported to the social worker that there was a delay in providing incontinence care to Resident #63 on 9/26/23. Further, the incident had already been reported to a staff member on 9/26/2023. The Reportable Event form indicated that although the incident had been reported on 9/26/2023, the allegation had not been reported to the state agency until 10/6/23 (3 days after the grievance form was completed on 10/6/2023 and 10 days following the initial allegation on 9/26/2023). An interview with the DNS on 4/17/25 at 10:28 AM identified she could not explain why the allegation of neglect had not been reported to the state agency, per the facility policy, within the requirement of 2 hours following when the neglect was first known by staff. Review of the abuse policy directed, in part, an allegation must be reported immediately to the administrator/DNS and will be entered into the DPH (state agency) reporting system (FLIS) within 2 hours.

Based on review of clinical records, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #28) reviewed for personal property, the facility failed to investigate an allegation of misappropriation of funds, and for the only sampled resident (Resident #63) reviewed for abuse, the facility failed to thoroughly investigate an allegation of neglect, investigate an allegation of neglect in a timely manner, and prevent access to the resident by the staff member following the allegation of neglect. The findings include: 1. Resident #28's diagnosis included depression, stroke, and spinal cord dysfunction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact, was independent with eating after set up, was dependent on staff for dressing and transfers, and used a wheelchair for mobility. The Resident Care Plan dated 9/10/2024 identified Resident #28 had impaired Activities of Daily Living (ADL's) requiring assistance related to a history of a stroke. Interventions directed staff to assist with bathing, dressing, and personal hygiene. Interview with Resident #28 on 4/14/2025 at 11:07 AM identified that he/she had $40.00 missing from the bedside table that was going to be used to pay for a hairdresser appointment. Resident #28 indicated that due to the missing money, he/she was unable to attend the appointment. Further the missing money had been reported NA #5 approximately 6 months ago, but the facility had taken no action. Interview with Nurse Aide (NA) #5 on 4/16/2025 at 2:44 PM identified that Resident #28 requested her help to get his/her money from inside a cell phone case. When NA #5 opened the case, she explained to Resident #28 that there was no money inside. Resident #28 stated he/she was sure the money had been stored in the cell phone case. NA #5 indicated that she searched for the money in the resident's room, but no money was found. NA #5 stated she reported the incident to either the charge nurse or nursing supervisor, though she could not recall exactly to whom she reported the incident. Additionally, NA #5 stated that she had also completed a written statement and gave it to the nursing supervisor. Interview with LPN #7 on 4/16/2025 at 2:57 PM identified she did not recall being informed about the missing money. Interview with RN #1 on 4/16/2025 at 3:16 PM identified she did not recall NA #5 reporting the missing money. Re-interview with RN #1 on 4/17/2025 3:04 PM identified that the facility failed to have any written documentation for Resident #28's missing money being reported or investigated. An interview with the Administrator on 4/17/2025 at 3:08 PM identified that he was unaware of Resident #28's allegation of misappropriation so the facility would not have investigated the circumstances surrounding the missing money. Interview with the Director of Nursing Services (DNS) on 4/17/2025 at 5:51 PM identified that she could not explain why the policy was not followed and the allegation was not immediately investigated. Subsequent to Surveyor inquiry, a reportable event form was completed, and the facility began their investigation into the missing money. 2. Resident #63's diagnoses included dementia, adjustment disorder with anxiety, depressed mood and irritable bowel syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #63 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impaired and required partial moderate assistance with transfers, substantial maximum assistance with bed mobility, and was totally dependent on staff for toileting. Additionally, Resident #63 was frequently incontinent of bowel and bladder. The elimination Resident Care Plan in effect on 9/26/23 identified Resident #63 was incontinent of bowel and bladder related to impaired cognition and mobility. Interventions included toileting and incontinent care every 2 hours and as needed, disposable adult incontinence brief, and applying barrier skin protection following incontinent care. Review of the grievance concern form dated 10/6/23 identified that on 9/26/23 a family member had reported to LPN #3 (the day of the incident) that Resident #63 was neglected for many hours and lacked incontinence care, position changes, or hygiene. When Resident #63's brief was changed, it was noted to have a foul odor, was saturated through to his/her clothes and seat cushion, and a new irritation and open areas were noted. Further review of the grievance form identified that the incident had been reported to the Supervising Registered Nurse, (RN #1) on 9/29/23 (3 days after the initial allegation) and to the Director of Nursing (DNS) on 10/3/23 (7 days after the initial allegation). Review of the Reportable Event form dated 10/6/23 identified a family member reported to the social worker that there was a delay in providing incontinence care to Resident #63 on 9/26/23. Further, the incident had already been reported to a staff member on 9/26/23. The Reportable Event form indicated that although the incident had been reported on 9/26/23, the allegation had not been reported to the state agency until 10/6/23 (3 days after the grievance form was completed and 10 days following the initial allegation). Review of the facility investigation attached with the Reportable Event, conducted by the DNS included written statements. Review of the written statements identified NA #6's statement was dated 10/4/25, LPN #3's statement was dated 10/4/25, RN #1's statement was dated 10/6/25, NA #7's statement was dated 10/10/25, and NA #8's statement was dated 10/10/25. None of the statements reviewed indicated that the investigation had been started until 8 days after the allegation had been reported to staff. RN #1's written statement dated 10/6/23 identified that on 9/26/23 Resident #63's family member mentioned a delay in care a day in the last week, a skin check was performed on 9/27/23, and an order was entered to treat redness of the skin. An interview with the DNS on 4/16/25 at 2:24 PM identified that NA #6 had not been immediately suspended at the time of the allegation, per the facility policy, and had subsequently been suspended on 10/7/23, 10/8/23, and 10/9/25 (10 days after the allegation was reported and allowing access to the resident prior to determining an outcome). The DNS further indicated that on 10/9/23 the family member of Resident #63 called the facility and stated they felt the NA involved could continue to work with Resident #63 and the incident was caused by a lack of communication. Resident #63's care plan was updated to include a toileting plan and rest time during the day. The DNS identified that the alleged neglect was unsubstantiated. Re-interview with the DNS on 4/17/25 at 10:28AM identified that the investigation consisted of incomplete investigation areas for a psychosocial service summary of interview with residents, summary of interviews with staff, summary of interview with resident's roommate, summary of interview with resident's family member, summary of interview with the alleged perpetrator, summary of interview with other resident's/family members care for by the alleged perpetrator and the conclusion of the event. Additionally, a summary of the investigation and the root cause/conclusion and corrective actions was missing on the investigation form. The DNS failed to identify a summary of the investigation or a conclusion that determined whether the allegation of neglect was or was not substantiated. The DNS indicated because the family member changed their mind about the allegation and felt comfortable with the alleged NA working with Resident #63 there was no neglect and no reason to continue the investigation. The DNS could not identify why care was not given. Review of the abuse policy directed, in part, all reports of abuse, neglect, misappropriations of resident's property and injuries of known or unknown source shall be promptly and thoroughly investigated by facility management. An incident of abuse neglect, misappropriation of resident's property or injury of known or unknown source, the Administrator or designee will appoint a member of management to investigate the alleged incident. Employees of this facility who have been accused of the alleged resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator.

Based on observations, review of clinical records, facility policy, and interviews for the only sampled resident, (Resident #28), reviewed for urinary catheter care, the facility failed to perform weekly skin assessments; for the only sampled resident, (Resident #35), reviewed for positioning, the facility failed to ensure a positioning plan for a resident in a customized wheelchair was followed, for the only sampled resident, (Resident #42), reviewed for a non-pressure skin related condition, the facility failed to report a change in a resident's skin condition to a licensed nurse, and for 2 of 2 sampled residents, (Resident #28 and #63) reviewed for abuse, the facility failed to provide timely incontinent care. The findings included: 1. Resident #28's diagnosis included stroke, spinal cord dysfunction, and hemiplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The Resident required a wheelchair for mobility, was dependent with dressing and all transfers. The Resident Care Plan dated 1/15/2025 identified that Resident #28 was at risk for impaired skin integrity related to a history of skin tears and moisture-associated skin damage. Interventions included the use of a low air loss mattress, repositioning to meet the resident's needs, application of a pressure redistribution device, and staff were to report any new skin changes to the physician or nurse. A physician's order dated 3/17/2025 directed staff to perform weekly skin checks, complete the weekly skin evaluation form, and notify the Registered (RN) of any new findings. Review of clinical record from 3/19/2025 through 4/17/2025 identified staff did not complete weekly skin checks for Resident #28 on 3/26/2025 and 4/16/2025. The Treatment Administration Record (TAR) dated 4/1/2025 through 4/22/2025 identified that LPN #7 had signed that a skin check had been completed on 4/16/2025. Interview and review of clinical record on 4/17/2025 at 9:37 AM with RN #2 identified that the last fully documented weekly skin check for Resident #28 was performed on 4/9/2025 and that LPN #7 had not documented the completion of a Skin Check Evaluation form on 4/16/2025 as signed. Additionally, the skin check scheduled for 3/26/2025 had not been completed. RN #2 failed to identify why the weekly skin checks had not been completed per the physician order. RN #2 indicated that charge nurses were responsible for performing weekly skin assessments and if an assessment could not be completed on the day shift, communication through shift to shift handoff procedure was expected to ensure completion by the subsequent shift. An interview and review of the clinical record with LPN #7 on 4/17/2025 at 10:18 AM identified that she was responsible for the 4/16/2025 weekly skin check but did not complete the skin check. LPN #7 indicated that she had signed the skin check as complete on 4/16/25 but had not completed the skin check evaluation. She reported that she had intended to complete the skin check but was likely interrupted and failed to return to Resident #28 to complete the task. Interview on 4/17/2025 at 5:37 PM with the Director of Nursing (DNS) stated that weekly skin checks must be performed by the charge nurse and stated it was unacceptable to document a task as completed without performing the actual task. The DNS identified that a communication breakdown had occurred. Review of the facility's Weekly Skin Audit Policy dated 7/2020 directed, in part, that licensed nurses were required to perform weekly full-body skin audits. Nurses were instructed to initial the TAR to indicate task completion and to complete the Skin Evaluation Assessment. 2. Resident #35's diagnoses included abnormal posture, repeated falls, and end stage renal disease. A Wheeled Mobility Letter of Medical Necessity dated 12/13/24 identified a pelvic belt was provided to Resident #35 for pelvic stabilization and safety while in the wheelchair to reduce any risk of sliding. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 had a BIMS score of 3 indicating severe cognitive impairment and required substantial/maximal assistance from staff with transfers, set up clean up assistance with bed mobility, and was unable to walk. The Resident Care Plan dated 2/11/25 identified Resident #35 required modified wheelchair positioning for proper body alignment when out of bed. Interventions included out of bed to a modified wheelchair every morning, and referral to therapy as needed for changes in wheelchair positioning, complaints of pain, or evidence for skin breakdown. The Custom Wheelchair (CWC) Positioning Plan dated 3/21/25 directed the pelvic positioning belt be fastened snug across the resident's hips for proper skeletal alignment, leg rests on during periods of fatigue or being mobilized by a caregiver, and that leg rests could be removed during periods of alertness for wheelchair mobility and tilt the CWC as tolerated. The Nursing Assistant (NA) Care Card dated 3/24/25 identified Resident #35 was to be up out of bed to a CWC, pelvic positioning belt to be placed snug across the resident's hips at all times, and the positioning plan was to be followed. A physician's order dated 4/14/25 directed Resident #35 to be out of bed to a CWC according to the 24-hour positioning plan, head rest in place at all times, place a pelvic positioning belt fastened snug across the hips for proper pelvic positioning and alignment, provide leg rests during periods of fatigue/caregiver assistance for mobility, and remove leg rests during periods of alertness to facilitate use of bilateral lower extremities for wheelchair mobility every shift. Observation on 4/14/25 at 9:47 AM and 4/14/25 at 11:38 AM identified Resident #35 out of bed in the CWC, sitting on a transfer sling, self-propelling in the hallway without the benefit of the positioning belt being fastened and with both leg rests in place and not removed for independent wheelchair mobility. Observation on 4/14/25 at 12:03 PM identified Resident #35 self-propelling the CWC in the dining room, sitting on a transfer sling, with the trunk of his/her body in a slouched position, his/her head was approximately 2 inches below the headrest, and without the benefit of a seat belt worn. At 12:08 PM and 12:17 PM Nursing Assistant (NA) #2 approached Resident #35 and with the help of a second NA boosted him/her to a more upright position by utilizing the transfer sling, no belt was noted to be worn or removed for repositioning. Interview and observation with Person #1 on 4/16/25 at 9:50 AM identified Resident #35 in his/her room, out of bed to the CWC, the seatbelt was unbuckled and hanging on the outside of the wheelchair. Person #1 stated he/she pulled the belt out from under the transfer sling that was left under Resident #35 but was unable to fasten it him/herself, and now the seatbelt kept getting caught in the wheelchair wheels. Interview with Licensed Practical Nurse (LPN) #2 on 4/16/25 at 9:59 AM identified NA #2 was responsible for applying Resident #35's seatbelt per the NA Care Card located inside the closet, LPN #2 subsequently applied the seatbelt snugly across Resident #35's lap. Interview and review of the NA Care Card with NA #2 on 4/16/25 at 10:05 AM identified she worked at the facility for about a year, was the regular NA for Resident #35, and never applied Resident #35's seatbelt because it would be a restriction. Additionally, she identified that resident care information was inside the resident's closet. Review of Resident #35's NA Care Card with NA #2 identified a positing plan directing the resident be out of bed to the customized wheelchair, a pelvic positioning belt was to be placed snug across his/her hips at all times, and the positioning plan was to be followed. Additionally, a copy of the physician's order for the pelvic positioning belt was with the NA Care Cark. NA #2 could not identify why she did not follow the Care Card as instructed. Interview with the Director of Rehabilitation on 4/16/25 at 10:41 AM identified Resident #35 had a 24-hour positioning plan that included the belt to be on snug across the lap and failure to follow the plan of care would impede optimal body alignment. Additionally, nursing was responsible to ensure the application of the belt and education was still ongoing. The Customized Wheelchairs Policy directed, in part, the purpose of a CWC was to promote proper body alignment for resident's who are unable to be positioned in a standard wheelchair. 3. Resident #42's diagnosis included osteoporosis with a right arm humerus fracture, muscle weakness, and difficulty walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #42 was moderately cognitively impaired. The Resident required a wheelchair for mobility, was dependent with dressing, bathing, and toileting, and required maximal assistance with bed mobility including sit to stand and chair to bed transfers. The Resident Care plan dated 3/17/2025 identified Resident #42 was at risk for alteration in skin integrity. Interventions included the use of a pressure reduction cushion in the wheelchair, float heels off bed, apply moisture barrier per protocol, and perform a daily skin inspection during morning and evening care; staff were to report any changes in skin integrity. A physician's order currently in effect directed staff to perform weekly skin checks, complete the weekly skin evaluation, and notify the RN of any new findings. Observation and interview with Resident #42 on 4/14/2025 at 9:47 AM identified Resident #42 awake, in bed, and complaining of redness and inflammation to the buttocks and genital region. Resident #42 reported nursing staff had applied powder to the affected areas twice in one day a few weeks ago, but no further treatment had been provided. Resident #42 reported telling the nurse that the issue still remained, but nothing had been done. Interview with Licensed Practical Nurse (LPN) #7 on 4/16/2025 at 11:13 AM identified that LPN #7 was unaware Resident #42 was experiencing discomfort in the groin and buttocks region. LPN #7 stated she would follow up with Nursing Assistant (NA) #4, who had provided care to the resident earlier that morning. Interview with NA #4 on 4/16/2025 at 11:22 AM identified she had provided bathroom assistance to Resident #42 that morning. NA #4 stated she did not observe redness to the resident's genital area but noted the buttocks were red and raw. NA #4 did not report any skin integrity issues to the LPN or RN. Although NA #4 was aware of the requirement to escalate these types of findings to licensed nursing staff, NA #4 stated she forgot to do so in this instance. Subsequent to surveyor interview, a nurses note dated 4/21/2025, identified genital irritation requiring antifungal treatment and the left buttock wound would be followed by Wound primary care physician. Review of the Incontinent Care Policy dated 3/2021 directed, in part, that staff who are providing incontinent care were expected to immediately report any reddened, abraded, or broken skin areas to the nurse. 4. Resident #63's diagnoses included dementia, adjustment disorder with anxiety, depressed mood and irritable bowel syndrome. A physician's order dated 3/1/25 directed to apply Triad (protective) ointment to the sacral area every day and evening with skin care until seen by the wound nurse. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS score of 0) and required substantial maximum assistance for personal hygiene, dressing, toileting, bed mobility, and transfers. The Resident Care Plan (RCP) dated 4/5/23 identified Resident #63 had impaired Activities of Daily Living (ADL's). Interventions included to assist Resident #63 with bathing, dressing, hygiene, and transfers, Constant observations by the surveyors on 4/16/25 from 8:46 AM until 12:16 PM identified Resident #63 lying in bed, on his/her back, with the head of the bed raised approximately 90 degrees. Staff failed to provide incontinence care or turning and repositioning, and Resident #63 remained in the same position throughout the observation (3 and ½ hours). During an interview with LPN #3 on 4/16/25 at 12:16 PM she was informed that Resident #63 had not received incontinent care or turning and repositioning since the 8:46 AM constant surveyor's observations began. LPN #3 identified that NA #3 was assigned to Resident #63. Interview with NA #3 on 4/16/25 at 12:20 PM identified that she provided Resident #63 with morning care as soon as she came in at 7:00 AM and Resident # 63 was ready for breakfast. Although the surveyors had constant observations of Resident #63, NA #3 stated she had checked Resident #63 at 9:30 AM. During an observation of incontinence care being performed on Resident #63 by NA #3 on 4/16/25 at 12:22 PM an orange color could be seen through the outside of the resident's brief. When Resident #63's brief was removed, it was noted to be saturated and slight redness was noted to the resident's genitals and groin area. Re-interview with NA #3 on 4/16/25 at 2:00 PM identified that incontinent care should be provided to residents every 2-3 hours, but she did not have a chance to go back in to check Resident #63 after the initial incontinence care she had provided at 7:00 AM, and that this was an oversight on her part. NA #3 indicated that staffing was at a normal level as written on the schedule. Review of the Incontinence Care policy revised on 3/21 directed, in part, incontinence care will be provided at a minimum of every 2-3 hours and as soon as possible after episodes of incontinence.

Based on observations, interviews, and record review for 1 of 3 sampled residents, (Resident #68), reviewed for accidents, the facility failed to follow a post fall care plan for safety interventions. The findings included: Resident # 68 diagnoses included dementia, lack of coordination, and Parkinsonism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was moderately cognitively impaired, and required partial/moderate assistance with transfers, toileting, and changing position in bed. The Resident Care Plan dated 3/15/25 identified that Resident #68 was a fall/safety risk. Interventions included keeping the bed at the lowest position and place floor pads to each side of bed. The Accident and Incident Reportable Event dated 12/21/24 identified Resident #68 was found on the floor next to the bed on 12/21/24 at 7:30 AM positioned on her/his right shoulder, stating she/he was getting out of bed and slipped due to a tissue that was on the floor. Observations on 4/15/25 at 9:14 AM and 4/16/25 at 5:45 AM identified Resident #68 in bed with a floor mat on the curtain side of the bed, but without the benefit of a floor mat by the window side of the bed. Interview with Registered Nurse (RN) Supervisor #1 on 4/16/25 at 9:33 AM identified the facility policy was for the supervisor to immediately put a post fall intervention in place. The interdisciplinary team would review the supervisors intervention and decide to implement that intervention or come up with a different permanent intervention. Additionally, following a fall, the new intervention was placed on the Nurse Aide (NA) Resident Care Card (inside the resident's closet) so the NA could implement the intervention. The charge nurse was also responsible for checking that interventions which had been put in place were being utilized. Subsequent to surveyor inquiry a second floor mat was placed in Resident #68's room, on the floor, at the bedside by the window. Interview and review of the clinical record on 4/16/25 at 12:23 PM with Licensed Practical Nurse (LPN) #2 identified that she was unaware of what the facility policy was regarding floor mats. On review of the clinical record, LPN #2 indicated she was unsure of what was in the Resident Care Plan but stated interventions were placed in the physicians order. During a record review of Resident #68's physicians orders LPN #2 indicated there was no order for floor mats. Follow up interview with RN #1 on 4/16/25 at 1:32 PM identified there should have been a physicians order for Resident #68's floor mats. Upon clinical record review RN #1 was unable to locate a physicians order. RN #1 indicated, that per the facility policy, a physicians order for floor mats for Resident #63 should have been in place to alert staff of the need to implement the fall intervention. Subsequent to surveyor inquiry a physician's order was put in place on 4/16/25 for bilateral floor mats on the floor next to the bed when the patient was in bed, every shift for safety. Review of the Assessing Falls and Their Cause policy directed, in part, documentation in the resident's medical record should include appropriate interventions taken to prevent future falls.

Based on clinical record reviews, review of facility documentation, policies and procedures and interviews for two of three sampled residents (Resident #1 and #2) who had sustained a fall during the provision of care, the facility failed to ensure the siderails were secured prior to turning and repositioning the resident while in bed and the correct number of staff were present in accordance with the assessment and failed to ensure an assistive device, gait belt, was utilized when ambulating the resident in accordance with the plan of care. The findings include: 1. Resident #1's diagnoses included [CONDITION(S)], arthritis, liver [CONDITION(S)], and anxiety. The fall risk assessment dated [DATE] identified Resident #1 was a high risk for falls. The significant change Minimum Data Set assessment dated [DATE] identified Resident #1 as alert and oriented, exhibited no behavioral symptoms, required extensive two (2) person assistance with turning and repositioning from side to side while in the bed, personal hygiene and dressing, was non-ambulatory, and had functional limitations in range of motion on one (1) side of the lower extremities. The assessment indicated Resident #1 was always incontinent of urine, frequently incontinent of bowel, received a scheduled pain medication daily and as needed, was 4 feet 9 inches tall and weighed 321 pounds. The Resident Care Plan dated 5/9/20 identified Resident #1 was resistance with care at times. Interventions directed to monitor the behaviors, explain the importance of grooming, use a calm gentle approach and two (2) people for care if needed. Review of the June 2020 activities of daily living flow record identified that on the 11PM-7AM Resident #1 was a two (2) person extensive or total assistance for bed mobility. The record identified on 6/10/20 Resident #1 was a total two (2) person assistance with bed mobility. The nurse's note dated 6/10/20 at 2:31 AM identified the charge nurse was called to Resident #1's room by the nurse aide and Resident #1 was noted to be lying on the floor on the left side of bed. The note identified the posterior left leg and knee were bleeding and the Nursing Supervisor was made aware. The nurse's note, written by the Nursing Supervisor dated 6/10/20 at 3:42 AM identified Resident #1 was receiving care when the resident rolled over to their left using the side rail and rolled off the bed which was in the elevated position. The note identified Resident #1 was lying on this/her right side and had large lacerations over previous surgical sites that were bleeding, 911 was called and Resident #1 was transferred to the hospital. The Reportable Event Form dated 6/10/20 identified during care at 1:30 AM Resident #1 rolled to their left side holding onto the siderail which was in the up position and rolled out of bed onto the floor, sustaining two (2) large lacerations to the left lower leg. The documentation identified as the nurse aide was changing the occupied bed, Resident #1 turned him/herself to the left side using the side rail and rolled out of bed. The report indicated the nurse aide was performing a complete bed linen change and she had the resident roll to the left away from her to change the linens. The report identified the side rail was either not in a locked position or failed due to the resident's weight. The investigation identified the oversized mattress interferred with the siderail function making it difficult to lock the siderail. Interview with the 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/4/21 at 8:55 AM identified she went in to provide care to Resident #1 and noted that the entire bed was soiled with urine and feces. NA #1 stated she told Resident #1 to roll to the left side away from her, and while changing the linens the bed rail went down and Resident #1 rolled off the bed. NA #1 stated that before she had the resident roll over, she did not move the resident closer to her, so the resident was not in the center of the bed. NA #1 indicated that it was easier to have Resident #1 roll away from her to change the bed linens because of the resident's size she would not be able to reach over the resident and change the linens. NA #1 identified that after the incident she did receive education regarding while providing care for resident in bed to roll the resident towards self instead of away. Interview with the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #2, on 3/5/21 at 2:00 PM identified she was called to the room and found the resident on the floor and the bed was in the high position. RN #2 stated that she assessed Resident #1 and noted two (2) large lacerations to the lower left leg and wrapped the area. RN #2 identified she notified the physician, 911 was called and Resident #1 was transferred to the hospital. RN #2 stated that she spoke to the nurse aide after the incident about what happened, the nurse aide told her that she rolled Resident #1 away from her to provide care and change linens, when the resident rolled over the side rail and fell . RN #2 indicated that the bed was not in the lowest position and that when she checked the side rail, she found it hard to lock the siderail in place because the mattress was an oversized mattress and she had to really pull the siderail up to lock it in place. Interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 3/5/21 at 1:40 PM identified she was called to room by the nurse aide and when she entered the room Resident #1 was on the floor. LPN #1 stated she notified the RN Supervisor and assisted in the assessment. LPN #1 identified Resident #1 required an assist of two (2) people during care due to a history of accusatory behaviors and for safety because the resident was large in size. LPN #1 indicated she does help the nurse aides with resident care and repositioning and on 6/10/20 NA #1 did not ask her to assist with the care of Resident #1. Interview with the Director of Nursing (DON) on 3/5/21 at 1:50 PM identified according to Resident #1's Minimum Data Set assessment, the resident was an assist of two (2) for turning and repositioning while in the bed. The DON stated that some staff are able to care for the resident alone because the resident will allow that. The DON identified the expectation when caring for the resident with one (1) person is to roll the resident towards you when caring for or changing linens for the safety of the resident. The DON indicated that if the nurse aide could not reach over the resident to provide care or change linens, she should have the assistance of another staff member. The DON identified that after the incident the nurse aide was provided education on accident and safety prevention. 2. Resident #2's diagnoses included dementia, history of transient ischemic attacks, and abnormalities of gait and mobility. The fall risk assessment dated [DATE] identified Resident #2 was a high risk for falls related to confusion, chair bound, required assist with elimination and balance problems with standing. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was not able to make decisions regarding tasks of daily life, required extensive one (1) person assistance with getting in and out of the bed and chair and toilet use, the resident's balance during walking and transitions was not steady and the resident was only able to stabilize with staff assistance, utilized a wheelchair for mobility and had no history of fall in the past ninety (90) days. The Resident Care Plan dated 11/3/20 identified the resident had a self-care deficit related to impaired mobility and incontinence. Interventions directed to transfer with the assist of one (1) using the gait belt and to ensure proper footwear. The nurse's note dated 12/20/20 at 9:40 AM identified Resident #2 was lowered to the floor after the resident's knee buckled during a transfer in the bathroom. The note indicated Resident #2 was noted to be lying on their back in the bathroom, and when the resident's range of motion was assessed, Resident #2 complained of pain to the right knee and hip. The note indicated the physician was made aware and an X-rays of the hip and knee were obtained. Review of the right hip and knee X-ray results dated 12/20/20 identified the areas were negative for fracture. The Reportable Event Form dated 12/20/20 at 10:00 AM identified while Resident #2 was being transferred from the toilet to the wheelchair, the resident's knees buckled, and Resident #2 had to be lowered to the floor. The report noted Resident #2 was assessed and complained of pain to the right hip and knee area, the physician was notified, X-rays of the right knee and hip were obtained and were negative for fractures. The investigation identified the nurse aide did not use a gait belt while transferring Resident #2 off the toilet. The nurse's note dated 12/21/20 at 7:59 PM identified staff reported Resident #2 was having right ankle pain, the area was swollen and tender to touch, the APRN was made aware and an X-ray was obtained which identified an acute nondisplaced fracture of the distal fibula. The APRN directed bedrest, an ace wrap to the ankle, Extra Strength Tylenol 1000 milligrams every six (6) hours, to elevate the right leg and apply ice four (4) times a day until an orthopedic consult. The orthopedic consultation report identified a diagnosis of a right ankle fracture. The recommendation was to continue with conservative treatment with a Controlled Ankle Motion (CAM) boot for immobilization, non-weight bearing on the right lower extremity, may remove the boot for showers and hygiene and a follow up visit in two (2) weeks. Interview with the 7AM-3PM Nursing Supervisor Registered Nurse (RN) #1, on 3/4/21 at 10:50 AM identified she was called to Resident #2's room and when she entered the bathroom, she found Resident #2 lying on their back on the floor. RN #1 stated that she completed a range of motion assessment of the Resident #2's lower extremities and feet and the resident complained on right knee and hip pain. RN #1 stated that they log rolled the resident onto a Hoyer pad and lifted him/her back to bed, she notified the physician who ordered X-rays of the right hip and knee. RN #1 identified that at that time she placed Resident #2 on bedrest until the X-ray results came back and after the X-rays identified no fracture, she changed Resident #2's transfer status to an assist of two (2) people until the resident could be evaluated by therapy. RN #1 stated after the incident she spoke to the nurse aide who told her she went to stand and pivot Resident #2 from the toilet to the wheelchair when the resident's knee buckled, and she had to lower Resident #2 to the floor. RN #1identified when she asked the nurse aide where her gait belt was, the nurse aide stated she did not use the gait belt during the transfer. Interview with the Director of Nursing (DON) on 3/5/21 at 2:00 PM identified the facility's policy was to use a gait belt when transferring a resident. The DON stated during the investigation the nurse aide reported she did not use the gait belt to transfer Resident #2, and during the transfer Resident #2 tilted sideways, and the nurse aide lowered the resident to the floor. The DON identified the nurse aide received education on transfers and the use of a gait belt. Several attempts made to contact the nurse aide, Nurse Aide (NA) #2 were unsuccessful.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #72 and 18) reviewed for pressure ulcers, the facility failed to complete treatments and monitoring according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin risk assessment on admission, dated 9/5/18, identified Resident #72 was at high risk for skin breakdown. The admission care plan dated 9/5/18 identified Resident #72 had a stage IV pressure ulcer to the right buttocks (ischial tuberosity). Interventions included to utilize a pressure relieving support to the bed, complete wound assessments and documentation weekly, and notify the physician of no progress or deterioration of the wound. Additionally, the care plan identified to consult dietary, use a draw sheet to move Resident #72 in bed to prevent sheering, encourage the resident to consume fluids, check the dressing every shift, and provide treatments as ordered. Review of a wound progress note dated 9/6/18 identified Resident #72 had a stage IV pressure ulcer to the right ischial tuberosity that measured 1.5cm by 1.5cm by 0.2cm. The note further identified a small amount of serosanguinous drainage was noted, and the wound bed had 76% - 100% pink granulation tissue, no slough, no eschar and no epithelialization present. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility documentation dated 9/13/18 at 11:00 AM identified Resident #72 reported to LPN #2 that that the dressings to the right ischial tuberosity stage IV pressure ulcer, and the left metatarsal amputation site were not changed for 3 days (9/10, 9/11, and 9/12/18). The documentation further noted the dressing on the right gluteal area was saturated with serosanguinous drainage, the wound edges were macerated, and the wound bed had a small amount of a yellow coating. Additionally, the wound measured 2.0cm by 1.5cm by 0.4cm (was larger) and the wound bed had 50% red granulation tissue, and 50% light yellow slough. Subsequent to physician notification, the treatment was changed. Additionally, the documentation noted that although the treatment had been signed by licensed staff as being completed 2 of the 3 days, the investigation concluded that the treatment had not been done as ordered. Interview with the ADNS on 12/4/18 at 2:15 PM identified that he/she was made aware that the dressing to Resident #72's right ischial tuberosity was not completed for 3 days and went to speak to the resident. The ADNS stated that the resident reported to him/her that the dressing to the right ischial tuberosity, and to the left amputation site had not been done for 3 days. The ADNS indicated that he/she notified the agency where 1 of the nurses were from and reported that the nurse hadn't done the dressing on 9/10, and 9/11/18. The ADNS indicated he/she spoke to LPN #4 who admitted that he/she did not do it (the dressing change to the right ischial tuberosity on 9/12/18. Interview with LPN #2 on 12/4/18 at 2:30 PM identified that someone (didn't recall who) reported to him/her that Resident #72 complained the dressing to the right ischial tuberosity hadn't been changed in 3 days. LPN #2 indicated he/she went to Resident #72, who also told him/her that staff had not changed the dressing to the right ischial tuberosity. LPN #2 indicated he/she looked at the dressing to the right ischial tuberosity and noted it was saturated with serosanguinous drainage, and when she removed the dressing the wound bed had a small amount of yellow drainage in it, and the edges were macerated. LPN #2 stated that she immediately reported this to the wound nurse. Interview with LPN #4 on 12/4/18 at 2:45 PM identified that he/she was told by the 1st shift staff when receiving report that Resident #72's dressing changes weren't done, but didn't ask anyone if they had done them. LPN #4 identified that he/she didn't do the dressing because she was busy and doesn't remember if she told anyone. Interview with the wound nurse, RN #3 on 12/6/18 at 10:45 AM identified that it was reported to him/her that Resident #72's wound treatment had not been completed for 3 days. RN #3 assessed the wound (right ischial tuberosity) which looked worse, was larger in size, had macerated edges, and yellow serosanguinous drainage in the wound bed. RN #3 indicated that he/she notified the wound doctor and the treatment was changed. RN #3 further indicated that after the incident, he/she spoke to the agency nurse who had worked on 9/10, 9/11, and 9/12/18. who indicated he/she did not complete the treatments but did not offer an explanation as to why the treatments were not done. Interview with the former DNS on 12/6/18 at 11:00 AM identified that he/she spoke to Resident #72 who was alert and oriented and reported that his/her treatment had not been done for 3 days. The former DNS indicated that he/she spoke to the agency nurse who worked on 9/10 and 9/11/18. The agency nurse reported that he/she did Resident #72's dressing changes, but when questioned further about the wound, the agency nurse answered with a different resident and a different area of the resident's body. The former DNS further indicated that through the investigation it was determined that a 2nd nurse (LPN #4) also did not do the treatments to Resident #72's right ischial tuberosity on 9/12/18 after Resident #72 reported to him/her that the dressings had not been changed in 3 days. Additionally, the former DNS indicated that the agency nurse was no longer allowed to work for the facility, and that LPN #4 received disciplinary action. Additionally, all staff were re-educated on ensuring treatments are completed according to physician orders. The facility policy for wound care and documentation identified that treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure that physician ordered dressing changes to the residents left metatarsal amputation site and stage IV pressure ulcer on the right ischial tuberosity were completed as ordered on 3 days, (9/10, 9/11, and 9/12/18). Additionally, on 9/13/18, when Resident #72 dressing to the stage IV pressure ulcer was removed, it was saturated, the wound edges were macerated, the wound bed had deteriorated, and the wound was larger. Further, subsequent to physician notification, the treatment was changed. 2. Resident #18 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission assessment dated [DATE] identified Resident #18 was cognitively impaired, required extensive assistance for all care, and had intact skin with bilateral pitting [CONDITION(S)] to the ankles. A body audit dated 9/24/18 at 8:20 PM identified Resident #18's heels were boggy. The care plan dated 9/26/18 identified Resident #18 was at risk for alteration in skin integrity. Interventions included daily skin inspection during care, weekly skin checks on shower day, turning and positioning every 2 hours, and pressure reducing cushion in the wheelchair/chair. The 5 day PPS MDS dated [DATE] identified Resident #18 had severely impaired cognition, required extensive 2 person assistance with bed mobility, transfers dressing and toilet use and, did not walk, was dependent on staff for personal hygiene, was at risk for developing pressure ulcers and had no current unhealed pressure ulcers. A nurse's note dated 10/4/18 identified Resident #18 was identified with a 3.0cm by 1.5cm non-blanchable redness to the right heel with a discolored darker area in center. Subsequent to APRN notification, a new order was obtained to apply skin prep to the area, a low air loss mattress to the bed, and offload the heels. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview and review of the clinical record with RN #2 on 12/5/18 at 12:31 PM identified Resident #18 was admitted with boggy heels and interventions should have been put in place including elevation of heels for pressure relief, and/or skin prep to help prevent the development of a pressure ulcer to the heel. RN #2 further identified although there were 3 occurrences documented in the nurses notes 9/24/18 - 10/4/18 of elevating the resident's legs on pillows for lower extremity [CONDITION(S)], the facility did not implement offloading of the heels until the pressure ulcer was identified on 10/4/18. Review of the facility pressure ulcer prevention policy identified residents unable to change position independently will be turned and repositioned off pressure lying areas every 2 hours, elevate heels off mattress with heel protectors or pillows, and do not position residents on pressure effected areas. Although Resident #18 was admitted on [DATE] with bilateral boggy heels, required extensive 2-person assistance with bed mobility and was at risk for skin breakdown, the facility failed to implement interventions to prevent the development of a pressure ulcer to the heel. Subsequent to the lack of interventions, Resident #18 developed a 3.0cm by 1.5cm non-blanchable red area to the right heel with a discolored darker area in center. Additionally, 10/4/18 after APRN notification, an order to offload the heels at all times was written.

Based on clinical record review, review of facility documentation, review of policy and procedures and interviews for 2 of 2 residents (Resident #222 and #64), the facility failed to ensure the resident was free from neglect and/or mistreatment. The findings include: a. Resident #222 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] identified Resident #222 was severely cognitively impaired (BIMS 7) and required total assistance of 2 staff with transfers, extensive assistance of 2 staff with bed mobility, bathing, dressing and grooming, and toilet use, and was independent with eating after set up. Resident #222 did not ambulate. The care plan dated 9/26/17 identified a problem with incontinence of bowel and bladder with interventions including to offer toileting and check for incontinence every 2 hours. The NA care card identified Resident #222 was incontinent, required incontinent care every 2 hours, to check skin integrity and required assistance of 2 staff for transfers with hoyer. Review of the reportable event written by Licensed Practical Nurse (LPN) #1 dated 10/13/17 at 10:30PM identified that NA #1 found Resident #222 left on the bedpan from 5:30PM until 10:30PM. Injury was identified as indentation of bedpan on buttocks with red areas. The report indicated that Resident #222 was alert with some confusion and required total assistance for all activities of daily living, was a hoyer transfer, set up for meals, and was incontinent of bowel and bladder. The report further identified that an investigation was initiated. Review of the reportable event investigation and summary including interviews and statements, identified that Nurse Aide (NA) #1 (who was not the assigned NA for Resident #222) placed Resident #222 on the bedpan at 5:30PM and did not notify anyone including NA#2 (NA assigned to Resident #222) or LPN #1. Additionally, NA#1 did not return to remove the bedpan from underneath the resident. NA #2, who was assigned to the resident, identified that he/she had provided care for Resident #222 at approximately 8:00PM but only readjusted the bedding and checked the bed pads between resident's legs, indicating they were dry, indicating he/she did not see a bedpan. NA#2 did not turn and position resident at that time indicating Resident #22 requested to be left alone and to not be bothered. At approximately 10:30PM, NA#1 and another NA were doing last rounds and discovered Resident #222 was still on the bedpan. It was identified that there was an indentation of the bedpan on resident's buttocks and redness in the area. LPN #1 was immediately notified by NA #1. Further review of the investigation and statements identified that LPN #1 indicated he/she had gone into resident's room at 9:00PM to administer medications however Resident #222 did not say anything and/or indicate being in any pain or discomfort at that time. At 10:30PM LPN #1 was informed by NA #1 that he/she had forgotten to take Resident #222 off of the bedpan (which was placed 5 hours prior at 5:30PM) and that the resident's bottom should be checked. LPN#1 further identified that NA#1 had laughed and said do what you have to do. LPN #1 immediately assessed Resident #222 who was identified as having an outline of and indentation from the bedpan on his/her buttocks. Further review of the nurse's note dated 10/13/17 written by LPN #1 identified Resident #222 had fluid filled blisters on the right and left upper inner thighs. LPN #1 notified RN #1 of the incident and was instructed to complete the reportable event form, notify the physician and obtain statements from NA #1 and NA #2. Review of the wound monitoring forms dated 10/13/17 identified the onset of a fluid filled blister on both the right and left upper inner thigh. An interview with the Director of Nursing Services (DNS) on 1/11/17 at 9:00AM identified that the allegation of neglect by NA #1 was substantiated, identifying that although NA#1 had no prior infractions pertaining to neglecting resident care, the DNS was disturbed by NA #1's reaction to the incident, indicating he/she did not seem to comprehend the seriousness of his/her actions. Additionally, that NA #1 was terminated following the investigation. Review of the facility's accident/incident policy identified that it is the policy of this facility to maintain a work and living environment that is professional and free from threat and occurrences of harassment, abuse (physical, verbal, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Definitions included neglect, which means the failure to provide services for a resident unable to provide for him or herself the services necessary to maintain physical and mental health. b. Resident #64's [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] identified Resident #64 as mildly cognitively impaired being alert and forgetful and requiring assistance of two persons for all Activities of daily living (ADL's) and any transfers. The physician's orders [REDACTED].#64 with assist of 2 staff with a gait belt for transfers, assist of one staff for self-feeding, extensive assistance of 1 staff for Activities of Daily Living, and assist of 2 staff for toileting. The nurses' note dated 12/20/17 at 1:45, entered by the Director of Nursing Services (DNS), identified the incident of Resident #64 requesting a bedpan and NA #5 discovering that Resident #64 had been on the bedpan for an extended time as evidenced by the redden ring indentation size and shape of the bedpan on the buttocks of Resident #64. The DNS assessed Resident #64, and notified the Administrator and the daughter of Resident #64. An interview on 1/10/18 at 11:15 am with Licensed Practical Nurse (LPN) #2, identified that on 12/20/17 he/she was called to the room of Resident #64 by NA's #5 and #6 to examine the redden indentation on the buttocks of Resident #64. LPN # 2 identified him/she immediately notified the DNS of the situation. LPN #2 identified that the indentation on the buttocks of R #64 was the size and shape of the bedpan and redden and there was no open area of skin. Review of Reportable Event form identified that the DNS immediately began an investigation and reported the incident to the Department. The investigation identified that NA #9 had placed resident #64 on the bed pan at approimately 12:30pm (1 hour and 15 minutes earlier) and had told NA #8 he/she had done so. The facility completed a Post Accident/Incident Assessment on Resident #64. The DNS identified the area on the buttocks of Resident #64 as a reddened indentation of perimeter of bedpan and was blanchable. The DNS notified the physician of the occurrence.

Based on clinical record reviews, review of facility documentation and interviews for two of five sampled residents (Resident #1 and #4) who were reviewed for falls, the facility failed to ensure staff assistance and an assistive device, a gait belt, were utilized during a transfer from one surface area to another to prevent a fall with a significant injury. The findings include: 1. Resident #1 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified Resident #1's vision was highly impaired, the resident was alert and oriented with no memory deficits, required full staff performance of two plus for transfers in and/or out of the bed and chair, and utilized a wheelchair for mobility. The Resident Care Plan dated 5/25/17 identified the resident was at risk for falling due to impaired mobility, pain and weakness. Interventions directed to maintain call bell within reach, nonskid footwear and rehabilitation therapies as needed. A physician's orders [REDACTED]. The order directed assist of one person with a gait belt and oxygen from the bed to the wheelchair and/or recliner, and from the wheelchair to the toilet, if the resident has difficulties standing, notify the nurse and use an assist of two person and to monitor the oxygen saturation levels with mobility and move slowly. Review of the Situation Background Assessment Recommendation Communication Form dated 6/4/17 identified the resident fell from a standing position to his/her knees in the bathroom. The note identified the resident sustained [REDACTED]. The note identified although Resident #1 was slow to respond to questions, the resident answered them appropriately. The 7AM-3PM nurse's note dated 6/4/17 identified the Registered Nurse (RN) Supervisor was called to resident's bathroom, the resident was on floor, the resident reported his/her knees buckled and he/she went down to the floor. The note identified there was a large laceration noted just below the left knee, a pressure dressing was applied, 911 was called and the resident was transferred to the hospital. The Reportable Event Form dated 6/4/17 at 11:00 AM identified that while being transferred to the bathroom by two (2) staff members, without the use of a gait belt and no oxygen, the resident's knees buckled and he/she fell to the floor. Statements completed by the two (2) nurse aides, Nurse Aide (NA) #1 and NA #2, identified that they did not use a gait belt during the transfer and had removed the resident's oxygen prior to the transfer. Review of the emergency room report dated 6/4/17 noted laceration present-extensive inferior to the left knee with a sixteen (16) cm laceration down to the bone across the entire length of anterior leg with active bleeding. The report identified the resident was transferred to another acute care facility related to the necessities the resident required were available at the receiving hospital. Review of the hospital discharge report dated 6/13/17 identified the resident sustained [REDACTED]. An addendum investigation note dated 6/16/17 identified that during an interview, Resident #1, stated that he/she was wheeled into the bathroom facing the grab bar and was told by the nurse aides to go ahead and get on the toilet. Resident #1 reported one nurse aide was leaning against the sink and the other was leaning up against the wall to the resident's left and both nurse aides were talking about their personal lives. The documentation noted that the resident took a step and fell landing on his/her knees. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 7/6/17 at 9:50 AM identified that she was told Resident #1 was on the floor. LPN #1 stated that she and the Nursing Supervisor, Registered Nurse (RN) #1, went into the room and she saw the resident lying on the floor on his/her back and the resident's left knee was bleeding. LPN #1 stated that the resident did not have a gait belt on. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #2 on 7/6/17 at 10:55 AM identified that NA #1 asked her for assistance with transferring the resident into the bathroom. NA #2 stated when she entered the room the resident was sitting on the edge of the bed and did not have a gait belt on. NA #2 stated they wheeled the resident into the bathroom, the resident stood and fell landing on his/her knees, they rolled the resident onto his/her buttocks with the left leg under and they assisted the resident to lie on the floor. NA #2 stated that although the facility policy is to transfer residents using a gait belt, she did not place one around the resident because she felt not my resident, not my problem. NA #2 stated that she did not assist the resident in standing and/or transferring onto the toilet. Interview with Resident #1 on 7/6/17 at 11:40 AM identified she needed to use the restroom and two (2) nurse aides wheeled him/her into the bathroom in front of the grab bar. Resident #1 stated that NA #1 was leaning against the sink and NA #2 was leaning against the wall to his/her left. The resident stated that he/she said to the nurse aides come on girls and the nurse aides said go ahead, get up. Resident #1 stated he/she put his/her hands on the grab bar, stood up and fell . The resident stated that the nurse aide did not use a gait belt and neither aide assisted him/her in standing. Interview with NA #1 on 7/6/17 at 3:05 PM identified she and NA #2 wheeled the resident into the bathroom in front of the grab bar, the resident stood up, the resident's legs buckled, the resident fell on to his/her knees with the lower leg area under the buttocks and they then lowered the resident to the floor. NA #1 stated she did not use a gait belt because she was in a rush and just wanted to get the resident into the bathroom because another resident also needed the toilet. Interview with the 7AM-3PM Nursing Supervisor, RN #1, on 7/6/17 at 3:30 PM identified she was called to the resident's bathroom after the nurse aides said they lowered the resident to the floor. RN #1 stated when she entered the bathroom the resident was lying on his/her back with the right leg caught by the leg of the commode, the left leg was profusely bleeding and she was able to visualize a lot of fatty tissue. RN #1 stated that she moved the leg of the commode and the resident slowly slid the leg somewhat straight. RN #1 identified she applied pressure to the wound and log rolled the resident onto the Hoyer pad and transferred the resident back to bed. Interview with the Director of Nursing (DON) on 7/6/17 12:00 PM identified that the facility policy is to use a gait belt with all transfers and that the nurse aides admitted during the investigation to not using the gait belt. The DON stated that after the resident returned from the hospital and was interviewed, NA #1, and NA #2 were suspended related to not following the plan of care for using gait belts and after the investigation was completed both nurse aides were terminated. 2. Resident #4's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was alert and oriented, required one person extensive assistance with transfers and toilet use and utilized a wheelchair and/or walker for mobility. The resident care plan dated 4/13/17 identified the resident was at risk for falls related to impaired mobility and poor eye sight. Interventions directed proper foot wear, assist of one with all transfers and to utilize a gait belt. The Reportable Event Form dated 6/13/17 at 7:30 AM identified three (3) bruises, purple in color were noted on the resident's inner left forearm. The documentation identified that when an 11PM-7AM nurse aide was assisting Resident #4 to the toilet, the nurse aide pulled the resident's arm up to the grab bar. The nurse's note dated 6/13/17 at 2:00 PM identified a bruise to the left forearm. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #2, on 7/18/17 at 10:30 AM identified on 6/13/17 a nurse aide reported to her in the morning that the resident had a bruise on the forearm. LPN #2 stated she went to assess the resident and noted a purple bruise approximately six (6) centimeters (cm) on the left forearm. LPN #2 stated the resident said the bruise occurred when the nurse aide on nights grabbed his/her arm to place a hand on the grab bar when toileting the resident. Interview with Resident #4 on 7/18/17 at 11:20 AM identified that he/she needed to use the bathroom and the male aide came in to assist. Resident #4 stated that the aide wheeled him/her into the bathroom put his hands on his/her forearm and stood him/her up. Resident #4 stated that the nurse aide did not use the gait belt during the transfer. Interview with the 11PM-7AM nurse aide, Nurse Aide (NA) #3, on 7/18/17 at 11:30 AM identified he lifted the resident's left arm with his hand and placed the resident's hand on the grab bar. NA #3 stated he did not use the gait belt because the resident said the belt hurt. NA #3 identified he did not report the resident not wanting the belt used to the charge nurse before he transferred the resident. Interview with the Director of Nursing (DON) on 7/18/17 at 11:50 AM identified that all residents are to be transferred using a gait belt. The DON stated that if the resident did not want the gait belt on then the nurse aide should have went to the nurse for direction prior to transferring the resident. Facility policy and procedure for gait belts identified gait belts are provided to assist staff to safely transfer residents.