Every finding on record at Grimes Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for abuse, the facility failed to protect Resident #7 from verbal abuse and intimidation by Resident #6 after Resident #6 (who resides on a different unit), sat outside Resident #7's room and was verbally aggressive, intimidating and used sexually explicit profanity towards Resident #7. The findings include: a. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, and anxiety disorder.The annual MDS dated [DATE] identified Resident #6 had intact cognition, was independent with transfers and used a walker and a wheelchair for mobility. The care plan dated 8/14/25 identified Resident #6 was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions included to monitor behavior episodes, attempt to determine the underlying cause, and document the behavior and potential causes. Review of the census list identified Resident #6 resided on the 3rd floor unit on 9/7/25.A nurse's note dated 9/7/25 at 5:37 PM written by RN #8 identified that Resident #6 had an incident that morning when he/she was verbally aggressive and used profanity towards another resident. RN #8 identified she counseled and reminded Resident #6 about the behavior and redirected Resident #6 back to his/her room. RN #8 identified that she placed a note in the psychiatric communication book and updated the ADNS. A social work note dated 9/8/25 at 5:11 PM identified she had spoken to Resident #6 that morning related to the incident that Resident #6 provoked on 9/7/25 at 8:00 AM on 2nd floor unit. SW #1 identified that Resident #6 used vulgar and aggressive language and was resistant to leave the unit when staff approached him/her. The note further identified that SW #1 and the ADNS informed Resident #6 that the language used and behaviors were not acceptable. Further, Resident #6 does not respond well to boundaries and tries to be intimidating. The note further identified that Resident #6 again attempted behaviors on 9/8/25 in the evening when he/she thought staff were not present and was taken off the unit. Staff aware if resident resists or is intimidating or aggressive to contact security.Resident #6's care plan, revision dated 9/8/25, identified the resident was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions added included to encourage Resident #6 to avoid other units.A psychiatric note dated 9/11/25 by APRN #1 identified she was asked to see Resident #6 due to use of profanity towards another resident. Nurse interviewed and reports resident was upset and told another resident to (sexually inappropriate profanity). APRN #1 identified there were no other outbursts or physical aggression and that she advised Resident #6 was counseled on treating others with respect. A referral was placed for talk therapy. Further review of the clinical record failed to identify additional documentation related to the incidents involving Resident #6 and another resident, including the identity of the other resident involved. Review of the state agency reportable events portal failed to identify incidents related to Resident #6 and any other residents of the facility for 2025.Review of the facility accident and incident reports failed to identify incidents involving Resident #6 and any other residents of the facility for 2025. b. Resident #7 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, anxiety disorder, and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition, was independent with transfers and required use of a walker and a wheelchair for mobility. The care plan dated 8/20/25 identified Resident #7 was at risk for alteration in psychosocial wellbeing due to history of depression, anxiety, psychosis, PTSD, and borderline personality disorder. Interventions included providing the opportunity to verbalize feelings and concerns.Review of the census list identified that Resident #7 resided on the 2nd floor unit on 9/7/25.A social work note dated 9/8/25 at 5:17 PM by SW #1 identified that she and the ADNS approached Resident #7 regarding an incident that occurred on 9/7/25. The note identified Resident #7 had a verbal altercation with another resident and the other resident made a vulgar comment, intimidated Resident #7 and facility staff had to remove the other resident. The note further identified that Resident #7 came to the social work office on 9/8/25 at 5:00 PM to report that the other resident was attempting to retaliate against him/her (Resident #7). The note identified that SW #1 and Resident #7 returned to Resident #7's floor and a supervisor was removing the other resident from a room. Further review of the clinical record failed to identify additional documentation related to the incident involving Resident #7 and another resident, including the identity of the other resident involved. A psychiatric note dated 9/11/25 by APRN #1 identified she was asked to see Resident #7 urgently due to Resident #7 requesting to restart Risperdal (an antipsychotic medication). The note identified Resident #7 had a history of suicide attempts, suicidal ideations, and homicidal ideations that included pushing strangers into traffic. The note further identified Resident #7 requested to restart Risperdal due to having increased feelings of anger and delusions. Resident #7 also reported increased anxiety and paranoia, and felt people were staring through his/her room window. APRN #1 identified the treatment plan included a restart of Risperdal and monitoring of target behaviors which included paranoia, delusions, hallucinations, and physical/verbal aggression. A psychiatric note dated 9/12/25 by Psychologist #1 identified Resident #7 reported struggling with affective dysregulation and intrusive negative thoughts following events on his/her unit. The note further identified that Resident #7 met with the APRN to discuss medication management and identified the treatment plan included to identify feeling triggers associated with social boundaries. Interview with the DNS on 1/30/26 at 8:40 AM regarding the incidents with Resident #6 and Resident #7 identified she was not aware of any incidents including verbal altercations that occurred between the residents, and she did not have reportable event reports regarding the incidents. The DNS identified that SW #1 and the ADNS would have addressed the issues and completed the reports as the ADNS was acting DNS at that time. Interview with SW #1 on 1/30/26 at 8:50 AM identified she was aware of the incidents involving Resident #6 and Resident #7. SW #1 identified that Resident #6 resided on the 3rd floor unit and had a significant history of antagonizing and being verbally aggressive with other residents. SW #1 identified that Resident #6 had bullying behavior and a history of specifically targeting Resident #7 by pushing his/her buttons but failed to provide any specifics regarding this. SW #1 identified she recalled one incident that occurred between Resident #6 and Resident #7 on 9/7/25 in the afternoon. SW #1 identified that Resident #7 came down to her office on 9/8/25 in the afternoon to report the incident and reported the following: The evening of 9/7/25 (a Sunday), Resident #6 was playing loud music on a smartphone while in his/her wheelchair directly outside of Resident #7's room. Resident #7 told Resident #6 to turn the music off, and Resident #6 started yelling and using profanity towards Resident #7. Resident #7 then yelled back and shortly after facility nursing staff attempted to remove Resident #6 from the hallway and return him/her back to the 3rd floor. SW #1 identified that the incident on 9/7/25 was the only issue that occurred between the residents and that the facility staff had been able to separate the residents, and that Resident #7 had identified when speaking with SW #1 in her office that he/she just wanted to make sure SW #1 was aware of the incident. SW #1 identified that she did not complete an incident report since the issue was addressed and did not complete any investigation or documentation related to the incident. SW #1 further identified that while she was aware she identified in Resident #7's clinical record that Resident #6's behavior included attempts to intimidate and retaliate against Resident #7, SW #1 felt that the behaviors were not abusive towards Resident #7 and did not report the incident to the state agency. SW #1 further identified she did not report any incidents that she was notified of between residents, specifically incidents between Resident #7 and other residents, because I would be reporting every day. But I guess going forward I will report all of them within 2 hours. SW #1 declined to provide any additional information regarding specific incidents that would have required reporting. SW #1 also identified that she was not aware of any additional incidents between the residents, and that facility staff was able to successfully redirect Resident #6 from going to Resident #7's unit.Interview with the ADNS on 1/30/26 at 9:28 AM identified she was aware of one incident that occurred on 9/7/25 during breakfast between Resident #6 and Resident #7. The DNS identified that she was initially notified of the incident by the 7:00 AM - 3:00 PM weekend nursing supervisor, RN #8. The ADNS identified that she and SW #1 went to Resident #7's room on 9/8/25 in the afternoon to speak with him/her regarding the incident and that Resident #7 reported the following: ADNS identified that she did not inquire or ask any follow up questions regarding any additional incidents between the residents and did not complete an investigation or an incident report related to the incident on 9/7/25. The ADNS further identified that since Resident #7 did not identify any additional issues, she did not feel that the incident required any investigation or reporting to the state agency. The ADNS also identified that on 9/8/25 she did recall checking with Resident #7, but it was not specific to follow up for the 9/7/25 incident and did not attempt any additional follow up.Interview with APRN #1 on 1/30/26 at 9:45 AM identified she did not recall any incidents related to Resident #7 having altercations with Resident #6 in 9/2025. APRN #1 identified that she did remember verbal incidents with Resident #7 and another resident of the facility but identified a resident who was not Resident #6. APRN #1 identified she did see Resident #7 on 9/11/25 due to a request by Psychologist #1 for medication management but did not recall any incidents reported during those visits involving any other residents. APRN #1 also identified she only handled medication management for Resident #7 and did not discuss any specific issues or incidents with Resident #7, and that Psychologist #1 might have more information. Interview with Psychologist #1 on 1/30/26 at 10 AM identified that Resident #7 had reported multiple incidents with Resident #6 that included verbal altercations and attempts to intimidate but was unable to provide specific information. Psychologist #1 identified that Resident #6 had a long psychiatric history that included paranoia and fear of others. Psychologist #1 identified that due to his/her history, Resident #7 had avoidant behaviors with others due to fear that he/she might be harmed, and further identified Resident #7 had a history of physical aggression and was triggered when he/she was in fear or worried for his/her safety. Psychologist #1 identified that Resident #7 was seen by her on 9/12/25 and had reported the incidents on 9/7 and 9/8/25 with Resident #6 and identified Resident #7 reported struggling with his/her reactions subsequently. Psychologist #1 identified that Resident #7 has requested to restart Risperdal due to ongoing issues with paranoia and delusions, and while these issues were longstanding, the incidents with Resident #6 did contribute to Resident #7's exacerbation in symptoms. Interview with RN #8 on 1/30/26 at 10:50 AM identified she was the nursing supervisor for the facility on 9/7/25 when the incident between Resident #6 and Resident #7 occurred. RN #8 identified she was notified by a staff member on Resident #7's unit that Resident #6 was on the unit yelling and using profanity towards Resident #7. RN #8 identified she arrived on the 2nd floor and by the time she arrived, the incident was over and Resident #6 had been removed from the unit. RN #8 identified she spoke with Resident #7, who identified he/she had told Resident #6 that the music he/she was playing was too loud. Resident #7 reported Resident #6 then got mad and began to yell at him/her and use profanity. RN #8 identified that she apologized for the incident to Resident #7, identified she would address the issue, and offered Resident #7 a room change, but he/she declined. RN #8 identified she spoke with Resident #6 and documented the note regarding that discussion in the clinical record. RN #8 also identified she placed a note in the psychiatric APRN communication book for APRN #1 to see Resident #6 and notified the ADNS via text message on 9/7/25 regarding the incident. RN #8 identified that when she spoke with Resident #7 following the 9/7/25 incident, he/she reported no issues and that he/she was okay but also identified that there had been ongoing issues with Resident #6 yelling and antagonizing Resident #7 both before and after the 9/7/25 incident, and Resident #6 would often come to Resident #7's unit and yell at him/her and staff often had to redirect Resident #6 to leave the unit. RN #8 identified that Resident #6 would travel to the 2 other units of the facility at least daily, often multiple times a day, and that she had seen him/her on the 4th floor unit prior to this interview. Although attempted, an interview with Resident #7 was not obtained. The facility policy on abuse directed that residents had the right to be free from mental and verbal abuse, and abuse or mistreatment of any kind towards a resident was strictly prohibited. The policy defined abuse as the willful infliction of injury, intimidation, or mental anguish, and instances of abuse, irrespective of any mental condition, cause pain or mental anguish. The policy further defined that willful was used in the definition of abuse to mean that an individual acted deliberately. The policy defined verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to the resident and examples of verbal abuse included saying things to frighten a resident. The policy defined mental abuse included but was not limited to humiliation, harassment, threats of punishment, or deprivation. The policy directed that anyone witnessing or having knowledge of abuse or mistreatment of any kind towards a resident would report the incident immediately to a supervisor and an accident/incident report would be completed for each resident involved. The policy also directed that a description of the incident would be documented in each resident's clinical record as a nurse's note. The policy also directed the Administrator and DNS to be notified, and the DNS or designee would notify the resident's responsible party, physician, the state agency, and law enforcement, and the Administrator/DNS or designee would conduct an investigation immediately upon submission of the report. The policy further directed the investigation would include interviewing all witnesses, including the person accused of abuse; all other parties who may have knowledge useful to the investigation; and dated and signed statements of all involved staff. The policy also directed that the conclusion of the investigation should be documented along with actions taken on the internal investigation form and reporting of the incident should occur immediately, but not less than 2 hours for allegations that involve abuse. The facility policy on accident/incident reports directed that accidents/incident reports were completed for allegations of abuse and resident to resident altercations. The policy further directed that Class B reportable events included a complaint of abuse or an event that involved an abusive act to a resident by any person and for the purpose of a Class B classification, abuse included the willful infliction of injury, intimidation, or mental anguish, and willful was defined as an individual acting deliberately. The facility policy on resident rights directed that residents of the facility had the right to be free from verbal, sexual, physical, and mental abuse.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for abuse, the facility failed to immediately report when Resident #6 (who resides on a different unit), sat outside Resident #7's room and was verbally aggressive, intimidating and used sexually explicit profanity towards Resident #7. The findings include:a. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, and anxiety disorder.The annual MDS dated [DATE] identified Resident #6 had intact cognition. The care plan dated 8/14/25 identified Resident #6 was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions included to monitor behavior episodes, attempt to determine the underlying cause, and document the behavior and potential causes. Review of the census list identified Resident #6 resided on the 3rd floor unit on 9/7/25.A nurse's note dated 9/7/25 at 5:37 PM written by RN #8 identified that Resident #6 had an incident that morning when he/she was verbally aggressive and used profanity towards another resident. RN #8 identified she counseled and reminded Resident #6 about the behavior and redirected Resident #6 back to his/her room. RN #8 identified that she placed a note in the psychiatric communication book and updated the ADNS. A social work note dated 9/8/25 at 5:11 PM identified she had spoken to Resident #6 that morning related to the incident that Resident #6 provoked on 9/7/25 at 8:00 AM on 2nd floor unit. SW #1 identified that Resident #6 used vulgar and aggressive language and was resistant to leave the unit when staff approached him/her. The note further identified that SW #1 and the ADNS informed Resident #6 that the language used and behaviors were not acceptable. Further, Resident #6 does not respond well to boundaries and tries to be intimidating. The note further identified that Resident #6 again attempted behaviors on 9/8/25 in the evening when he/she thought staff were not present and was taken off the unit. Staff aware if resident resists or is intimidating or aggressive to contact security.Resident #6's care plan, revision dated 9/8/25, identified the resident was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions added included to encourage Resident #6 to avoid other units.A psychiatric note dated 9/11/25 by APRN #1 identified she was asked to see Resident #6 due to use of profanity towards another resident. Nurse interviewed and reports resident was upset and told another resident to (sexually inappropriate profanity). APRN #1 identified there were no other outbursts or physical aggression and that she advised Resident #6 was counseled on treating others with respect. A referral was placed for talk therapy. b. Resident #7 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, anxiety disorder, and bipolar disorder.The quarterly MDS dated [DATE] identified Resident #7 had intact cognition, was independent with transfers and required use of a walker and a wheelchair for mobility. The care plan dated 8/20/25 identified Resident #7 was at risk for alteration in psychosocial wellbeing due to history of depression, anxiety, psychosis, PTSD, and borderline personality disorder. Interventions included providing the opportunity to verbalize feelings and concerns.Review of the census list identified that Resident #7 resided on the 2nd floor unit on 9/7/25.A social work note dated 9/8/25 at 5:17 PM by SW #1 identified that she and the ADNS approached Resident #7 regarding an incident that occurred on 9/7/25. The note identified Resident #7 had a verbal altercation with another resident and the other resident made a vulgar comment, intimidated Resident #7 and facility staff had to remove the other resident. The note further identified that Resident #7 came to the social work office on 9/8/25 at 5:00 PM to report that the other resident was attempting to retaliate against him/her (Resident #7). The note identified that SW #1 and Resident #7 returned to Resident #7's floor and a supervisor was removing the other resident from a room. A psychiatric note dated 9/11/25 by APRN #1 identified she was asked to see Resident #7 urgently due to Resident #7 requesting to restart Risperdal (an antipsychotic medication). The note identified Resident #7 had a history of suicide attempts, suicidal ideations, and homicidal ideations that included pushing strangers into traffic. The note further identified Resident #7 requested to restart Risperdal due to having increased feelings of anger and delusions. Resident #7 also reported increased anxiety and paranoia, and felt people were staring through his/her room window. APRN #1 identified the treatment plan included a restart of Risperdal and monitoring of target behaviors which included paranoia, delusions, hallucinations, and physical/verbal aggression. A psychiatric note dated 9/12/25 by Psychologist #1 identified Resident #7 reported struggling with affective dysregulation and intrusive negative thoughts following events on his/her unit. The note further identified that Resident #7 met with the APRN to discuss medication management and identified the treatment plan included to identify feeling triggers associated with social boundaries. Review of the state agency reportable events portal failed to identify the 9/7/25 incident when Resident #6 was verbally aggressive and used profanity towards Resident #7 had been reported. Interview with the DNS on 1/30/26 at 8:40 AM regarding the incidents with Resident #6 and Resident #7 identified she was not aware of any incidents including verbal altercations that occurred between the residents, and she did not have reportable event reports regarding the incident. The DNS identified that SW #1 and the ADNS would have addressed the issues and completed the reports as the ADNS was acting DNS at that time. Interview with SW #1 on 1/30/26 at 8:50 AM identified she was aware of the incident involving Resident #6 and Resident #7. SW #1 identified that Resident #6 resided on the 3rd floor unit and had a significant history of antagonizing and being verbally aggressive with other residents. SW #1 identified that Resident #6 had bullying behaviors and a history of specifically targeting Resident #7 by pushing his/her buttons but failed to provide any specifics. SW #1 identified she recalled one incident that occurred between Resident #6 and Resident #7 on 9/7/25 in the afternoon. SW #1 identified that Resident #7 came down to her office on 9/8/25 in the afternoon to report the incident and reported the following: The evening of 9/7/25 (a Sunday), Resident #6 was playing loud music on a smartphone while in his/her wheelchair directly outside of Resident #7's room. Resident #7 told Resident #6 to turn the music off, and Resident #6 started yelling and using profanity towards Resident #7. Resident #7 yelled back and shortly after facility nursing staff attempted to remove Resident #6 from the hallway and return him/her back to the 3rd floor. SW #1 identified that the incident on 9/7/25 was the only issue that occurred between the residents and that the facility staff had been able to separate the residents, and that Resident #7 had identified when speaking with SW #1 in her office that he/she just wanted to make sure SW #1 was aware of the incident. SW #1 identified that she did not complete an incident report since the issue was addressed and did not complete any investigation or documentation related to the incident. SW #1 further identified that while she was aware she identified in Resident #7's clinical record that Resident #6's behavior included attempts to intimidate and retaliate against Resident #7, SW #1 felt that the behaviors were not abusive towards Resident #7. SW #1 further identified she did not report any incidents that she was notified of between residents, specifically incidents between Resident #7 and other residents, because I would be reporting every day. But I guess going forward I will report all of them within 2 hours. SW #1 declined to provide any additional information regarding specific incidents that would have required reporting. Interview with the ADNS on 1/30/26 at 9:28 AM identified she was aware of one incident that occurred on 9/7/25 during breakfast between Resident #6 and Resident #7. The DNS identified that she was initially notified of the incident by the 7:00 AM - 3:00 PM weekend nursing supervisor, RN #8. The ADNS identified that she and SW #1 went to Resident #7's room on 9/8/25 in the afternoon to speak with him/her regarding the incident and that Resident #7 reported the following: ADNS identified that she did not inquire or ask any follow up questions regarding any additional incidents between the residents and did not complete an investigation or an incident report related to the incident on 9/7/25. The ADNS further identified that since Resident #7 did not identify any additional issues, she did not feel that the incident required any investigation or reporting to the state agency. The ADNS also identified that on 9/8/25 she did recall checking with Resident #7, but it was not specific to follow up for the 9/7/25 incident and did not attempt any additional follow up.Interview with APRN #1 on 1/30/26 at 9:45 AM identified she did not recall any incidents related to Resident #7 having altercations with Resident #6 in 9/2025. APRN #1 identified that she did remember verbal incidents with Resident #7 and another resident of the facility but identified a resident who was not Resident #6. APRN #1 identified she did see Resident #7 on 9/11/25 due to a request by Psychologist #1 for medication management but did not recall any incidents reported during those visits involving any other residents. APRN #1 also identified she only handled medication management for Resident #7 and did not discuss any specific issues or incidents with Resident #7, and that Psychologist #1 might have more information. Interview with Psychologist #1 on 1/30/26 at 10 AM identified that Resident #7 had reported multiple incidents with Resident #6 that included verbal altercations and attempts to intimidate but was unable to provide specific information. Psychologist #1 identified that Resident #6 had a long psychiatric history that included paranoia and fear of others. Psychologist #1 identified that due to his/her history, Resident #7 had avoidant behaviors with others due to fear that he/she might be harmed, and further identified Resident #7 had a history of physical aggression and was triggered when he/she was in fear or worried for his/her safety. Psychologist #1 identified that Resident #7 was seen by her on 9/12/25 and had reported the incidents on 9/7 and 9/8/25 with Resident #6 and identified Resident #7 reported struggling with his/her reactions subsequently. Psychologist #1 identified that Resident #7 has requested to restart Risperdal due to ongoing issues with paranoia and delusions, and while these issues were longstanding, the incidents with Resident #6 did contribute to Resident #7's exacerbation in symptoms. Interview with RN #8 on 1/30/26 at 10:50 AM identified she was the nursing supervisor for the facility on 9/7/25 when the incident between Resident #6 and Resident #7 occurred. RN #8 identified she was notified by a staff member on Resident #7's unit that Resident #6 was on the unit yelling and using profanity towards Resident #7. RN #8 identified she arrived on the 2nd floor and by the time she arrived, the incident was over and Resident #6 had been removed from the unit. RN #8 identified she spoke with Resident #7, who identified he/she had told Resident #6 that the music he/she was playing was too loud. Resident #7 reported Resident #6 then got mad and began to yell at him/her and use profanity. RN #8 identified that she apologized for the incident to Resident #7, identified she would address the issue, and offered Resident #7 a room change, but he/she declined. RN #8 identified she spoke with Resident #6 and documented the note regarding that discussion in the clinical record. RN #8 also identified she placed a note in the psychiatric APRN communication book for APRN #1 to see Resident #6 and notified the ADNS via text message on 9/7/25 regarding the incident. RN #8 identified that when she spoke with Resident #7 following the 9/7/25 incident, he/she reported no issues and that he/she was okay but also identified that there had been ongoing issues with Resident #6 yelling and antagonizing Resident #7 both before and after the 9/7/25 incident, and Resident #6 would often come to Resident #7's unit and yell at him/her and staff often had to redirect Resident #6 to leave the unit. RN #8 identified that Resident #6 would travel to the 2 other units of the facility at least daily, often multiple times a day, and that she had seen him/her on the 4th floor unit prior to this interview. Although attempted, an interview with Resident #7 was not obtained. The facility policy on abuse directed that residents had the right to be free from mental and verbal abuse, and abuse or mistreatment of any kind towards a resident was strictly prohibited. The policy defined abuse as the willful infliction of injury, intimidation, or mental anguish, and instances of abuse, irrespective of any mental condition, cause pain or mental anguish. The policy further defined that willful was used in the definition of abuse to mean that an individual acted deliberately. The policy defined verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to the resident and examples of verbal abuse included saying things to frighten a resident. The policy defined mental abuse included but was not limited to humiliation, harassment, threats of punishment, or deprivation. The policy directed that anyone witnessing or having knowledge of abuse or mistreatment of any kind towards a resident would report the incident immediately to a supervisor and an accident/incident report would be completed for each resident involved. The policy also directed that a description of the incident would be documented in each resident's clinical record as a nurse's note. The policy also directed the Administrator and DNS to be notified, and the DNS or designee would notify the resident's responsible party, physician, the state agency, and law enforcement, and the Administrator/DNS or designee would conduct an investigation immediately upon submission of the report. The policy further directed the investigation would include interviewing all witnesses, including the person accused of abuse; all other parties who may have knowledge useful to the investigation; and dated and signed statements of all involved staff. The policy also directed that the conclusion of the investigation should be documented along with actions taken on the internal investigation form and reporting of the incident should occur immediately, but not less than 2 hours for allegations that involve abuse. The facility policy on accident/incident reports directed that accidents/incident reports were completed for allegations of abuse and resident to resident altercations. The policy further directed that Class B reportable events included a complaint of abuse or an event that involved an abusive act to a resident by any person and for the purpose of a Class B classification, abuse included the willful infliction of injury, intimidation, or mental anguish, and willful was defined as an individual acting deliberately. The policy further directed that immediate notice but not later than 2 hours would be provided to the state agency, and a written report would be provided within 72 hours of the event. The policy also directed that an incident was defined as any happening, not consistent with the routine operation of a long-term care facility, that does not result in bodily injury or property damage, and physical or mental mistreatment of a resident (abuse, actual or suspected) was considered an incident. The policy also directed that for situations of resident abuse, an accident/incident report would be completed, and the police would be notified for cases of confirmed abuse and for resident-to-resident altercations (if the perpetrator was cognitively intact and intended to cause harm).

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for abuse, the facility failed to complete a thorough investigation and protect Resident #7 from further potential abuse by Resident #6 after Resident #6 (who resides on a different unit), sat outside Resident #7's room and was verbally aggressive, intimidating and used sexually explicit profanity towards Resident #7. The findings include:a. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, and anxiety disorder.The annual MDS dated [DATE] identified Resident #6 had intact cognition, was independent with transfers and used a walker and a wheelchair for mobility. The care plan dated 8/14/25 identified Resident #6 was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions included to monitor behavior episodes, attempt to determine the underlying cause, and document the behavior and potential causes. Review of the census list identified Resident #6 resided on the 3rd floor unit on 9/7/25.A nurse's note dated 9/7/25 at 5:37 PM written by RN #8 identified that Resident #6 had an incident that morning when he/she was verbally aggressive and used profanity towards another resident. RN #8 identified she counseled and reminded Resident #6 about the behavior and redirected Resident #6 back to his/her room. RN #8 identified that she placed a note in the psychiatric communication book and updated the ADNS. A social work note dated 9/8/25 at 5:11 PM identified she had spoken to Resident #6 that morning related to the incident that Resident #6 provoked on 9/7/25 at 8:00 AM on 2nd floor unit. SW #1 identified that Resident #6 used vulgar and aggressive language and was resistant to leave the unit when staff approached him/her. The note further identified that SW #1 and the ADNS informed Resident #6 that the language used and behaviors were not acceptable. Further, Resident #6 does not respond well to boundaries and tries to be intimidating. The note further identified that Resident #6 again attempted behaviors on 9/8/25 in the evening when he/she thought staff were not present and was taken off the unit. Staff aware if resident resists or is intimidating or aggressive to contact security.Resident #6's care plan, revision dated 9/8/25, identified the resident was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions added included to encourage Resident #6 to avoid other units.A psychiatric note dated 9/11/25 by APRN #1 identified she was asked to see Resident #6 due to use of profanity towards another resident. Nurse interviewed and reports resident was upset and told another resident to (sexually inappropriate profanity). APRN #1 identified there were no other outbursts or physical aggression and that she advised Resident #6 was counseled on treating others with respect. A referral was placed for talk therapy. Further review of the clinical record failed to identify additional documentation related to the incidents involving Resident #6 and another resident, including the identity of the other resident involved. Review of the state agency reportable events portal failed to identify incidents related to Resident #6 and any other residents of the facility for 2025.Review of the facility accident and incident reports failed to identify incidents involving Resident #6 and any other residents of the facility for 2025. b. Resident #7 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, anxiety disorder, and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition, was independent with transfers and required use of a walker and a wheelchair for mobility. The care plan dated 8/20/25 identified Resident #7 was at risk for alteration in psychosocial wellbeing due to history of depression, anxiety, psychosis, PTSD, and borderline personality disorder. Interventions included providing the opportunity to verbalize feelings and concerns.Review of the census list identified that Resident #7 resided on the 2nd floor unit on 9/7/25.A social work note dated 9/8/25 at 5:17 PM by SW #1 identified that she and the ADNS approached Resident #7 regarding an incident that occurred on 9/7/25. The note identified Resident #7 had a verbal altercation with another resident and the other resident made a vulgar comment, intimidated Resident #7 and facility staff had to remove the other resident. The note further identified that Resident #7 came to the social work office on 9/8/25 at 5:00 PM to report that the other resident was attempting to retaliate against him/her (Resident #7). The note identified that SW #1 and Resident #7 returned to Resident #7's floor and a supervisor was removing the other resident from a room. Further review of the clinical record failed to identify additional documentation related to the incident involving Resident #7 and another resident, including the identity of the other resident involved. A psychiatric note dated 9/11/25 by APRN #1 identified she was asked to see Resident #7 urgently due to Resident #7 requesting to restart Risperdal (an antipsychotic medication). The note identified Resident #7 had a history of suicide attempts, suicidal ideations, and homicidal ideations that included pushing strangers into traffic. The note further identified Resident #7 requested to restart Risperdal due to having increased feelings of anger and delusions. Resident #7 also reported increased anxiety and paranoia, and felt people were staring through his/her room window. APRN #1 identified the treatment plan included a restart of Risperdal and monitoring of target behaviors which included paranoia, delusions, hallucinations, and physical/verbal aggression. A psychiatric note dated 9/12/25 by Psychologist #1 identified Resident #7 reported struggling with affective dysregulation and intrusive negative thoughts following events on his/her unit. The note further identified that Resident #7 met with the APRN to discuss medication management and identified the treatment plan included to identify feeling triggers associated with social boundaries. Interview with the DNS on 1/30/26 at 8:40 AM regarding the incidents with Resident #6 and Resident #7 identified she was not aware of any incidents including verbal altercations that occurred between the residents, and she did not have reportable event reports regarding the incidents. The DNS identified that SW #1 and the ADNS would have addressed the issues and completed the reports as the ADNS was acting DNS at that time. Interview with SW #1 on 1/30/26 at 8:50 AM identified she was aware of the incidents involving Resident #6 and Resident #7. SW #1 identified that Resident #6 resided on the 3rd floor unit and had a significant history of antagonizing and being verbally aggressive with other residents. SW #1 identified that Resident #6 had bullying behavior and a history of specifically targeting Resident #7 by pushing his/her buttons but failed to provide any specifics regarding this. SW #1 identified she recalled one incident that occurred between Resident #6 and Resident #7 on 9/7/25 in the afternoon. SW #1 identified that Resident #7 came down to her office on 9/8/25 in the afternoon to report the incident and reported the following: The evening of 9/7/25 (a Sunday), Resident #6 was playing loud music on a smartphone while in his/her wheelchair directly outside of Resident #7's room. Resident #7 told Resident #6 to turn the music off, and Resident #6 started yelling and using profanity towards Resident #7. Resident #7 then yelled back and shortly after facility nursing staff attempted to remove Resident #6 from the hallway and return him/her back to the 3rd floor. SW #1 identified that the incident on 9/7/25 was the only issue that occurred between the residents and that the facility staff had been able to separate the residents, and that Resident #7 had identified when speaking with SW #1 in her office that he/she just wanted to make sure SW #1 was aware of the incident. SW #1 identified that she did not complete an incident report since the issue was addressed and did not complete any investigation or documentation related to the incident. SW #1 further identified that while she was aware she identified in Resident #7's clinical record that Resident #6's behavior included attempts to intimidate and retaliate against Resident #7, SW #1 felt that the behaviors were not abusive towards Resident #7 and did not report the incident to the state agency. SW #1 further identified she did not report any incidents that she was notified of between residents, specifically incidents between Resident #7 and other residents, because I would be reporting every day. But I guess going forward I will report all of them within 2 hours. SW #1 declined to provide any additional information regarding specific incidents that would have required reporting. SW #1 also identified that she was not aware of any additional incidents between the residents, and that facility staff was able to successfully redirect Resident #6 from going to Resident #7's unit.Interview with the ADNS on 1/30/26 at 9:28 AM identified she was aware of one incident that occurred on 9/7/25 during breakfast between Resident #6 and Resident #7. The DNS identified that she was initially notified of the incident by the 7:00 AM - 3:00 PM weekend nursing supervisor, RN #8. The ADNS identified that she and SW #1 went to Resident #7's room on 9/8/25 in the afternoon to speak with him/her regarding the incident and that Resident #7 reported the following: ADNS identified that she did not inquire or ask any follow up questions regarding any additional incidents between the residents and did not complete an investigation or an incident report related to the incident on 9/7/25. The ADNS further identified that since Resident #7 did not identify any additional issues, she did not feel that the incident required any investigation or reporting to the state agency. The ADNS also identified that on 9/8/25 she did recall checking with Resident #7, but it was not specific to follow up for the 9/7/25 incident and did not attempt any additional follow up.Interview with APRN #1 on 1/30/26 at 9:45 AM identified she did not recall any incidents related to Resident #7 having altercations with Resident #6 in 9/2025. APRN #1 identified that she did remember verbal incidents with Resident #7 and another resident of the facility but identified a resident who was not Resident #6. APRN #1 identified she did see Resident #7 on 9/11/25 due to a request by Psychologist #1 for medication management but did not recall any incidents reported during those visits involving any other residents. APRN #1 also identified she only handled medication management for Resident #7 and did not discuss any specific issues or incidents with Resident #7, and that Psychologist #1 might have more information. Interview with Psychologist #1 on 1/30/26 at 10 AM identified that Resident #7 had reported multiple incidents with Resident #6 that included verbal altercations and attempts to intimidate but was unable to provide specific information. Psychologist #1 identified that Resident #6 had a long psychiatric history that included paranoia and fear of others. Psychologist #1 identified that due to his/her history, Resident #7 had avoidant behaviors with others due to fear that he/she might be harmed, and further identified Resident #7 had a history of physical aggression and was triggered when he/she was in fear or worried for his/her safety. Psychologist #1 identified that Resident #7 was seen by her on 9/12/25 and had reported the incidents on 9/7 and 9/8/25 with Resident #6 and identified Resident #7 reported struggling with his/her reactions subsequently. Psychologist #1 identified that Resident #7 has requested to restart Risperdal due to ongoing issues with paranoia and delusions, and while these issues were longstanding, the incidents with Resident #6 did contribute to Resident #7's exacerbation in symptoms. Interview with RN #8 on 1/30/26 at 10:50 AM identified she was the nursing supervisor for the facility on 9/7/25 when the incident between Resident #6 and Resident #7 occurred. RN #8 identified she was notified by a staff member on Resident #7's unit that Resident #6 was on the unit yelling and using profanity towards Resident #7. RN #8 identified she arrived on the 2nd floor and by the time she arrived, the incident was over and Resident #6 had been removed from the unit. RN #8 identified she spoke with Resident #7, who identified he/she had told Resident #6 that the music he/she was playing was too loud. Resident #7 reported Resident #6 then got mad and began to yell at him/her and use profanity. RN #8 identified that she apologized for the incident to Resident #7, identified she would address the issue, and offered Resident #7 a room change, but he/she declined. RN #8 identified she spoke with Resident #6 and documented the note regarding that discussion in the clinical record. RN #8 also identified she placed a note in the psychiatric APRN communication book for APRN #1 to see Resident #6 and notified the ADNS via text message on 9/7/25 regarding the incident. RN #8 identified that when she spoke with Resident #7 following the 9/7/25 incident, he/she reported no issues and that he/she was okay but also identified that there had been ongoing issues with Resident #6 yelling and antagonizing Resident #7 both before and after the 9/7/25 incident, and Resident #6 would often come to Resident #7's unit and yell at him/her and staff often had to redirect Resident #6 to leave the unit. RN #8 identified that Resident #6 would travel to the 2 other units of the facility at least daily, often multiple times a day, and that she had seen him/her on the 4th floor unit prior to this interview. Although attempted, an interview with Resident #7 was not obtained. The facility policy on abuse directed that residents had the right to be free from mental and verbal abuse, and abuse or mistreatment of any kind towards a resident was strictly prohibited. The policy defined abuse as the willful infliction of injury, intimidation, or mental anguish, and instances of abuse, irrespective of any mental condition, cause pain or mental anguish. The policy further defined that willful was used in the definition of abuse to mean that an individual acted deliberately. The policy defined verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to the resident and examples of verbal abuse included saying things to frighten a resident. The policy defined mental abuse included but was not limited to humiliation, harassment, threats of punishment, or deprivation. The policy directed that anyone witnessing or having knowledge of abuse or mistreatment of any kind towards a resident would report the incident immediately to a supervisor and an accident/incident report would be completed for each resident involved. The policy also directed that a description of the incident would be documented in each resident's clinical record as a nurse's note. The policy also directed the Administrator and DNS to be notified, and the DNS or designee would notify the resident's responsible party, physician, the state agency, and law enforcement, and the Administrator/DNS or designee would conduct an investigation immediately upon submission of the report. The policy further directed the investigation would include interviewing all witnesses, including the person accused of abuse; all other parties who may have knowledge useful to the investigation; and dated and signed statements of all involved staff. The policy also directed that the conclusion of the investigation should be documented along with actions taken on the internal investigation form and reporting of the incident should occur immediately, but not less than 2 hours for allegations that involve abuse. The facility policy on resident rights directed that residents of the facility had the right to be free from verbal, sexual, physical, and mental abuse.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #7) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to incorporate the recommendations from the PASARR level II determination into the resident assessment and care plan for a resident with a history of harm directed behaviors and substance abuse. The findings include:Resident #7 was admitted to the facility in November 2024 with diagnoses that included borderline personality disorder, anxiety disorder, and bipolar disorder. The annual MDS dated [DATE] identified Resident #7 had intact cognition, was always continent of bowel and bladder, required set up with bathing, and was independent with toileting and transfers. The MDS further identified Resident #7 had active diagnosis that included bipolar disorder and psychotic disorder and required anti-psychotic medication daily. The MDS failed to identify the resident had a serious mental illness according to the state Level II PASARR process. The care plan dated 10/29/25 identified Resident #7 was at risk for alteration in psychosocial well being due to history of depression, anxiety, psychosis, PTSD, and borderline personality disorder. Interventions included providing the opportunity to verbalize feelings and concerns.a. Review of the clinical record identified a positive Level II PASARR dated 11/26/25 which identified Resident #7 had additional diagnoses which included cocaine use, opioid use, alcohol abuse, suicide attempts, and attempts at harming others by pistol whipping and pushing people into oncoming traffic. The PASARR recommended services and supports that included crisis intervention and a safety plan due to the resident's history of attempting to harm self and others, and the plan should include monitoring for an increase in symptoms or changes in behaviors and steps for the resident and facility staff to take when this happened. Review of the clinical record failed to identify that the Level II PASARR recommendations, including those related to crisis intervention and safety planning, had been reviewed, addressed, or implemented. b. Review of the clinical record identified that Resident #7's history of suicidal ideation, suicide attempts, homicidal ideations, and substance abuse were documented in the treatment notes by both APRN #1 and Psychologist #1 since Resident #7's admission to the facility in November 2024. An initial psychiatric evaluation by APRN #1 on 11/11/24 identified that Resident #7 had a history of suicide with an attempt to shoot his/herself and 2 suicide attempts by intentional overdose, most recently 8 years ago. The note further identified Resident #7 had a history of homicidal ideation and reported to APRN #1 that he/she had a history of physical violence against random strangers that included pushing people into traffic and pistol-whipping people. The evaluation also identified that Resident #7 had a longstanding history of cocaine dependence with chronic heavy use as well as consistent illicit substance use for several years. The treatment plan included a verbal contract with Resident #7 to notify someone if he/she had violent thoughts or might act aggressively, and to start talk therapy and substance abuse support. An initial psychotherapy assessment by Psychologist #1 on 11/19/24 identified Resident #7 has a history of drug use since his/her teen years and a history of active crack cocaine use. Resident #7 also identified that he/she had a history of violence and could still be triggered. The treatment plan included therapy visits 4x monthly with interventions including substance abuse counseling, relapse prevention, psychosocial education, and cognitive behavioral therapy.Review of the clinical record failed to identify a care plan in place that referenced or addressed Resident #7's history of suicidal ideation, suicide attempts, homicidal ideation, harm directed behaviors towards strangers, or long-standing history of cocaine and illicit substance use following Resident #7's initial psychiatric and psychotherapy evaluations in 11/2024. Further review of the clinical record also failed to identify that Resident #7's care plan had been revised with interventions following the positive Level II PASARR on 11/26/25 which also identified Resident #7's history related to these issues. Interview with RN #9 (MDS Coordinator) on 1/30/26 at 7:50 AM identified she was responsible to update the resident's plan of care with positive Level II PASARR findings. RN #9 identified she was not aware that Resident #7 had a Level II PASARR and this was an oversight on her part but that the PASARR should be reviewed by the social worker, psychiatric APRN, physician or PA, and any other providers involved in the resident care as well as the recommendations being added to the resident's care plan. RN #9 identified the providers, and social work would be responsible for addressing the actual crisis intervention and safety planning. RN #9 further identified that while she was aware of Resident #7's history of mental illness, she was not aware of any previous history related to substance abuse disorder, suicidal ideation or attempts, or homicidal ideation, and that the care plan should have reflected the need for treatment and interventions related to those issues. Interview with SW #1 on 1/30/26 at 8:50 AM identified she was aware of Resident #7's positive Level II PASARR but was not aware of any of the recommendations that were provided to the facility, including the need for crisis intervention and a safety plan. SW #1 identified that these should have been put into place, but that Resident #7 had never exhibited any behaviors of self-harm or attempted to harm any other residents. While SW #1 identified that Resident #7 had not exhibited behaviors, she identified when she was with Resident #7, she made sure to keep her guard up due to the resident's history. Interview with APRN #1 on 1/30/26 at 9:45 AM identified she was aware that Resident #7 had a history of suicide attempts and harming others. APRN #1 identified that she had an informal verbal safety plan with Resident #7 and that the resident agreed to notify her if he/she had any thoughts of self-harm. APRN #1 identified that she always completed verbal safety planning with her residents, but no formal planning was developed or documented, and APRN #1 failed to identify that she addressed or developed any crisis intervention planning. APRN #1 identified she was not aware that Resident #7 had a positive Level II PASARR and had not completed any review of the PASARR or the recommendations. Interview with Psychologist #1 on 1/30/26 at 10 AM identified that Resident #7 had reported multiple incidents with Resident #6 that included verbal altercations and attempts to intimidate before and after the incidents in 9/2025 but was unable to provide specific information. Psychologist #1 identified that Resident #6 had a long psychiatric history that included paranoia and fear of others. Psychologist #1 identified that due to his/her history, Resident #7 had avoidant behaviors with others due to fear that he/she might be harmed, and further identified Resident #7 had a history of physical aggression and was triggered when he/she was in fear or worried for his/her safety. Psychologist #1 identified she was not aware that Resident #7 had a positive Level II PASARR and had not completed any review of the PASARR or the recommendations that were outlined in the report. Psychologist #1 also identified she did not have any formal safety plan or interventions in place, but that she saw Resident #7 frequently and Resident #7 knew to contact her if he/she felt the urge to harm self or others. Psychologist #1 identified she did not know how to develop or add a formal safety plan for Resident #7 and identified she had never done so for any of her patients and would have to research this further. Although attempted, an interview with Resident #7 was not obtained. Although requested, the facility failed to provide a policy related to PASARR recommendations.Although requested, the facility failed to provide a policy related to behavior monitoring.The facility policy on care plan that a comprehensive and individualized plan of care would be developed for each resident and would guide the resident's caregivers to assist in achieving or maintaining the resident's highest practicable level of wellbeing. The policy further directed that the care plan was developed by the interdisciplinary team, which included the social worker, and that the care plan was developed in collaboration with the resident's physician/provider. The policy further directed the care plan was updated at least quarterly and as necessary to reflect any changes in the resident's status.

Based on review of the clinical record, facility policies, and interviews for 1 of 3 residents (Resident #63) reviewed for pressure ulcers, the facility failed to ensure the care plan was reflective of interventions to address pressure ulcers including a Deep Tissue Injury (DTI) and for 1 of 3 resident (Resident #38) reviewed for nutrition, the facility failed to ensure the care plan was reflective of interventions related to congestive heart failure (CHF). The findings include: Resident #38 was admitted to the facility in January 2026 with diagnoses that included bilateral humerus fractures, atrial fibrillation, and chronic diastolic congestive heart failure. The physician's orders dated 1/15/26 directed Congestive Heart Failure protocol as follows. Check oxygen saturation every shift. Obtain daily weights at 6:30 AM and notify the MD/APRN of weight gain of 3 lbs. or more in one day or 5 lbs. in a week. Monitor edema to the abdomen, legs, ankles, and feet every shift. Monitor fatigue every shift. Monitor for shortness of breath and cough every shift. Monitor lung sounds every shift. The admission MDS dated [DATE] identified Resident #38 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and was dependent on facility staff to assist with eating, bathing, and toileting. Review of the care plan failed to identify the congestive heart failure diagnoses or interventions to address such. Review of the clinical record and interview with RN #9 (MDS Coordinator) on 1/30/26 at 7:50 AM identified she was responsible to update the resident's baseline care plan upon admission and with the admission MDS assessment. RN #9 identified the care plan should have included a history of CHF and that the CHF protocol had been ordered. RN #9 identified that she was unsure what happened as it appeared that the diagnosis and interventions were not added due to an oversight, and she would address the issue. The facility policy on care plan that a comprehensive and individualized plan of care would be developed for each resident and would guide the resident's caregivers to assist in achieving or maintaining the resident's highest practicable level of wellbeing. The policy further directed that the care plan was developed by the interdisciplinary team, which included the social worker, and that the care plan was developed in collaboration with the resident's physician/provider. The policy further directed the care plan was updated at least quarterly and as necessary to reflect any changes in the resident's status. 2. Resident #63 was admitted to the facility in January 2026 with diagnoses that included difficulty in walking and protein-calorie malnutrition. The Nursing admission assessment dated [DATE] identified Resident #63 complained of tenderness to heels; the skin was intact, will off load. The care plan dated 1/16/26 identified Resident #63 was at risk for impaired skin related to decreased mobility, with interventions that included preventative treatments per MD orders, staff to encourage and assist with positioning, and completing weekly skin audits. The physician's admission note dated 1/16/26 identified Resident #63 had reported ongoing burning to his/her bilateral heels; Lidocaine 4% topical patch to both heels, every 12 hours was ordered. The admission MDS dated [DATE] identified Resident #63 had intact cognition, required substantial/maximal assistance with rolling left to right, lying to sitting and sitting to standing, had no unhealed pressure ulcers, and was at risk for pressure ulcers/injury The nurse's note dated 1/22/26 at 5:52 PM identified Resident #63 was alert and oriented, scheduled Tylenol was given for foot pain. Pain, redness (looks ruptured) blisters were noted on both heels. Both heels elevated with pillow to relieve pressure. A physician's order dated 1/22/26 directed for offloading Bolster BLE (bilateral lower extremities) when in bed, check for placement every shift. The Skin Grid dated 1/23/26 identified Resident #63 had a right suspected deep tissue injury measuring 1.2cm x 1.2cm, slight red/maroon area, fluctuant, the peri wound was intact, no odor or drainage noted, wound pain reported with pressure. Current treatment to offload heels and refer to the wound specialist. The physician's progress note dated 1/23/26 identified Resident #63 reported that he/she continued to have bilateral heel pain worse with ambulation, no different from baseline. The physical exam identified a small fluid-filled blister to the right heel and no blister to the left heel, but bogginess was appreciated and was tender to palpation. Bogginess and blisters were concerning for pressure injury, wound care was following. Plan to continue offloading heels at rest, follow-up with wound care, and continue with as needed Acetaminophen and Gabapentin. A physician's order dated 1/24/26 directed to apply skin prep spray to the right heel followed by Opti-foam dressing every 2 days and as needed. The care plan with a revision date of 1/27/26 failed to identify interventions following the identification of the deep tissue injury (DTI) to the right heel. Interview with the Wound Nurse (RN #1) on 1/28/26 at 9:35 AM identified that typically it would be the MDS staff that would develop and update care plans for DTIs following morning report. Interview with the DNS on 1/30/26 at 10:41 identified that Resident #63's care plan should have been updated to reflect the DTI that was identified on 1/22/26. The DNS indicated that it was the responsibility of the nursing supervisor that admitted the resident to initiate a baseline care plan and the MDS Coordinator would follow up and develop the comprehensive care plan. Clinical record review with the MDS Coordinator (RN # 9) on 1/30/26 at 10:49 AM failed to identify that a comprehensive care plan was put into place following the identification of the DTI to the right heel, on 1/22/26. Interview with RN # 9 on 1/30/26 at 10:49 AM identified that a care plan should be in place for Resident #63's DTI. RN #9 identified that there were 2 MDS coordinators, and both attended morning report where status changes and resident conditions would be discussed and information would be learned to update the resident's care plan. RN #9 indicated that she could not recall if Resident #63's DTI had been discussed during morning report. RN #9 identified that Resident #63's care plan would be updated to reflect his/her DTI. The facility's Care Plan policy directs a comprehensive and individualized plan of care will be developed for each patient/resident. The care plan will guide caregivers to assist patients/residents to achieve or maintain their highest practical level of well-being. The care plan will include a statement of the problem; reasonable and measurable goals, interventions to achieve these goals and disciplines responsible for carrying out the interventions. CNA assignment sheets will be updated as needed to reflect changes made to the patient/resident's plan of care. The facility's Protocols for Pressure Injuries policy directs for the highest quality of wound care for patients with pressure ulcers and defines a deep tissue injury as a purple or maroon localized discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy and warmer or cooler compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin. Evolution may include a thin blister over dark wound. The wound may further evolve and be covered with thin eschar, evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Prevention and interventions include updating the care plan in CNA report sheets with interventions.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #2) reviewed for death, the facility failed to utilize a hard surface (backboard) beneath the resident while performing cardiopulmonary resuscitation (CPR) according to the American Heart Association current guidelines. The findings include:Resident #2 was admitted to the facility in 6/2025 with diagnoses that included malignant neoplasm of glottis (region of the larynx or voice box containing vocal cords) and history of acute and chronic respiratory failure with a tracheostomy placement.The quarterly MDS dated [DATE] identified Resident #2 was cognitively intact, independent with bed mobility, transfers and ambulation without assistance and received tracheostomy care.The care plan dated [DATE] identified Resident #2 had a potential for altered respiratory status secondary to having a tracheostomy (trach) and history of respiratory failure. Interventions included monitoring respiratory status and reporting changes to the physician. Advance directives specified a full code status, meaning CPR would be initiated for life saving measures if necessary.A physician's order dated [DATE] directed to complete trach care every shift by cleaning the non-disposable inner cannula, around stoma (opening) and under flange of the trach with sterile water and change the 4x4 drainage sponge, suction trach once every shift and as needed and provide cool mist aerosol via air compressor at 2 liters/min via trach mask every evening shift. The physician's order also directed full code status.Facility video surveillance dated [DATE] at 6:13 AM identified NA #6 enter Resident #2's room with a weight scale and vital sign machine and later exit.Nurse's note dated [DATE] at 6:15 AM identified Acetaminophen 800 mg was administered via g-tube for pain level of 2.Nurses note dated [DATE] at 6:55 AM identified follow up pain assessment was effective post administration of Acetaminophen.Facility video surveillance dated [DATE] at 8:11 AM identified LPN #4 retrieving the emergency cart and oxygen tank. A backboard was not visualized on top of or attached to the cart.Nurse's note dated [DATE] at 11:55 AM identified at 8:12 AM, Resident #2 was found unresponsive in the recliner chair in his/her room. A medical alert was paged overhead. Resident #2 was transferred into bed by staff and CPR was initiated. Emergency medical services (EMS) were dispatched. High flow oxygen was delivered via Ambu bag (aides in delivery of breaths and oxygen), and an automated external defibrillator or AED was applied (used for treatment when in cardiac arrest by delivering an electric shock to restore normal heart rhythm). No shock was advised. At 8:28 AM EMS arrived and assumed CPR with intermittent suctioning via the trach and orally. Interosseous (in the bone marrow) fluids 0.9% normal saline were initiated, five rounds of epinephrine and one round of bicarbonate (medications that aid in restarting the heart) total were administered. A LUCAS device (automated CPR machine designed to deliver consistent chest compressions during CPR) was applied at 8:41 AM. Resident #2 was intubated (mechanically creates an open airway) at 8:49 AM. EMS contacted the hospital physician, CPR was discontinued and the resident was pronounced at 8:58 AM. Next of kin was notified, postmortem care provided, and the body was subsequently released to the funeral home at 11:15 AM.The death certificated dated [DATE] at 8:58 AM identified the cause of death as mucous plugging, tracheostomy and laryngeal cancer and manner of death as natural.Observation of the emergency carts on [DATE] at 9:00 AM on the second and third floors identified the CPR backboards (used to provide a firm surface during CPR) were was not attached to the emergency cart and instead next to the emergency cart leaning up against the wall.Interview with RN #1 on [DATE] at 9:54 AM identified she was working the 7:00 AM to 3:00 PM shift on [DATE] in her role as the infection preventionist when she heard a medical alert paged overhead indicating a medical emergency. RN #1 responded to the area where she observed Resident #2 sitting in a recliner in his/her room unresponsive. RN #1 indicated she assisted in transferring Resident #2 directly onto the bed cover but did not participate in delivering CPR. RN #1 further identified she did not see a backboard in use at any time and when asked about the backboard she indicated she would have to refer to the facility policies for its indication.Interview with LPN #5 on [DATE] at 10:23 AM identified she was the assigned nurse 7:00 AM to 3:00 PM shift on [DATE]. LPN #5 indicated she had seen Resident #2 sitting upright in a recliner in his/her room when she arrived at the unit at 7:30 AM but was unable to determine if Resident #2 was awake and responsive. LPN #5 was informed in report by the off going nurse that trach care had been provided during the 11:00 PM to 7:00 AM shift without complications. At 8:12 AM, LPN #4 was alerted by NA #3 that Resident #2 was 'slumped' in the chair and staff were unable to obtain vital signs. LPN #5 went to Resident #2's room, found him/her unresponsive, checked for a carotid pulse and determined it was absent. LPN #5 remained with Resident #2 and instructed NA #3 to call a medical emergency. Staff responded immediately. Resident #2 was subsequently transferred directly onto the bed and CPR was initiated. LPN #5 further identified a backboard was not used during CPR and she would need to 'circle back' to discuss its rationale.An interview with the Administration on [DATE] at 10:30 AM identified a post incident debriefing and review of the incident was not completed to evaluate whether effective CPR was delivered as there was no indication to do so.Interview with MD #2 on [DATE] at 11:15 AM identified on [DATE], she had arrived at 8:05 AM and a short time later she heard a medical emergency announcement overhead. MD #2 responded to Resident #2's room where she observed the resident sitting unresponsive in a recliner pale and pulseless. Staff transferred Resident #2 onto the bed and initiated CPR. MD #2 provided direction and continued to oversee all activities related to the timing and compression intervals of CPR including performing a cycle herself until EMS arrived and assumed care. MD #2 did observe there was no backboard in use and inquired about its absence and was told someone was getting it. MD #2 indicated that although lack of a hard surface likely did not affect the outcome as Resident #2 was pale, only slightly warm and compressions appeared effective, staff should have utilized a backboard during CPR, and she should have followed up on its status when one did not arrive.Interview with OT #1 on [DATE] at 11:43 AM identified she was working during the 7:00 AM to 3:00 PM shift on [DATE] when she heard a medical emergency announced. OT #1 went to Resident #2's room where she observed him/her to be unresponsive in the chair. OT #1 assisted staff in transferring Resident #2 directly onto the bed without the benefit of a backboard. Additionally, she delivered a cycle of CPR and could not recall being present when MD #2 requested a backboard. OT #1 further identified she would need to refer to facility policy to discuss a backboard's indication for use.Interview with RN #7 on [DATE] at 2:34 PM identified she was working during the 7:00 AM to 3:00 PM shift on [DATE] when she heard a medical emergency announced. Upon arrival, nursing staff were already present in Resident #2's room and the emergency cart had been brought to the area. RN #7 did not observe a backboard attached to the cart or in use. RN #7 assisted in transferring Resident #2 directly onto the bed but did not participate in delivering CPR. RN #7 indicated she observed the bed rise and fall during chest compressions, and the compressions themselves appeared ineffective. EMS subsequently arrived and assumed care. RN #7 further identified that although she was aware the use of a backboard was essential to delivering effective chest compressions, she did not make efforts to initiate its use during the transfer, prioritizing placement of the resident safely on the bed before initiating CPR.Interview with LPN #4 on [DATE] at 3:13 PM identified she worked [DATE] to [DATE] but was not assigned nurse. LPN #4 was on the unit when the medical emergency was announced and brought the emergency cart and oxygen to Resident #2's room, without a backboard. LPN #4 further identified that although she was aware a backboard or hard surface should be used during CPR, she was unable to explain the rationale for its use.Interview with LPN #6 on [DATE] at 6:35 AM identified she worked as the assigned nurse during overnight [DATE] to [DATE] from 11:00 PM to 7:00 AM. LPN #6 indicated she provided routine care and suctioning for Resident #2 during the shift and administered Tylenol for mild discomfort with effect. It was routine for Resident #2 to elect to remain in his/her recliner during the overnight hours and commonly request Tylenol for generalized pain and there was nothing unusual noted during care. LPN #6 also responded when the medical emergency was announced and assisted in transferring Resident #2 back to bed, without a backboard. LPN #6 indicated the backboard should be attached to the emergency cart and used prior to initiating CPR but was unable to explain what occurred in this case and why it was not used.Interview and facility documentation review with the facility certified CPR instructor for the American Heart Association (AHA) on [DATE] at 9:52 AM identified he was responsible for basic life support certifications to the facility staff including CPR. The CPR instructor identified that a resident must be placed on a hard surface during CPR in a clinical setting to deliver effective chest compressions to profuse the heart, brain and other body organs. Without a hard surface chest compression would be less effective.A subsequent interview with MD #2 on [DATE] at 10:14 AM confirmed she was told by RN #1 that the backboard was being retrieved by RN #2. MD #2 did not follow up with administration to provide a debriefing related to the absence of a backboard as it slipped her mind and she was involved with other post incident tasks.Interview with RN #2 on [DATE] 10:58 AM identified she was the assigned unit manager on [DATE] when she heard a medical emergency announced. RN #2 arrived at Resident #2's room and nursing staff were already present, and the emergency cart was nearby. RN #2 did not assist transferring Resident #2 to bed but assisted by clearing the room of furniture and delivering oxygenation during CPR. RN #2 also delivered a two-minute cycle of CPR but did not notice if the compressions were rising and falling with the bed. Additionally, although aware of the need for a hard surface, RN #2 was not thinking about using a backboard and did not recall being asked to acquire one.Interview with NA #3 on [DATE] at 11:19 AM identified she was the assigned aide working 7:00 AM to 3:00 PM on [DATE]. NA #3 had not received report from the night shift aide, NA #6, from the preceding shift and had not seen Resident #2 previously. NA #3 indicated at approximately 8:15 AM she knocked and entered Resident #2's room where she found him/her unresponsive and leaning to the side. NA #3 indicated the skin was pale and felt cold to the touch. NA #3 immediately summoned housekeeping staff to call for help while she remained with Resident #2. Nursing staff arrived immediately, and NA #3 left the area.Interview and policy review with the DNS on [DATE] at 12:05 PM identified she would defer to the facility policies when discussing the need for a hard surface during CPR. However, noted the requirement for a hard surface was not included in the current the policy.A subsequent interview and facility documentation review with the Administrator on [DATE] at 12:05 PM identified that while her independent research indicated a hard surface was preferred but not regulatory, she did not disagree with AHA standard of practice of a hard surface during CPR as crucial for effective profusion.Subsequent to survey inquiry, the facility policy was revised to include the requirement of a hard surface before initiating CPR, backboards on all units were secured on the emergency cart and new emergency carts were ordered.A review of the facility policy for Cardiopulmonary Resuscitation directed CPR to be instituted in cases of cardiac/pulmonary arrest to sustain or support a residents cardiac/pulmonary function until advanced life support is available. In the event of cardiac arrest, CPR is initiated immediately, supervisor pages STAT (immediately) three times and CPR was to continue until life-support systems are available and operable.American Heart Association current guidelines for CPR directs that performing CPR on a hard surface is crucial for effective resuscitation. A hard surface allows for better compression depth and reduces rescuer fatigue. When CPR is performed on compliant surfaces like mattresses, the quality of compressions can be compromised, leading to less effective resuscitation.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #38) reviewed for nutrition, the facility failed to ensure that daily weights were obtained and documented per the physician's order. The findings include:Resident #38 was admitted to the facility in January 2026 with diagnoses that included bilateral humerus fractures, atrial fibrillation, and chronic diastolic congestive heart failure. The physician's order dated 1/15/26 directed to obtain daily weights at 6:30 AM and notify the MD/APRN of weight gain of 3 lbs. or more in one day or 5 lbs. in a week.The admission MDS dated [DATE] identified Resident #38 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and was dependent on facility staff to assist with eating, bathing, and toileting.Review of the care plan failed to identify interventions related to congestive heart failure or the need for daily weights. Review of the clinical record failed to identify daily weights had been obtained on the following dates: 1/17, 1/18, 1/19, 1/20, 1/22, 1/25 and 1/28/26. Further, the clinical record failed to identify why the weights were not obtained on those dates.Interview with RN #3 (Unit Manager for Resident #38's unit) on 1/30/26 at 12:05 PM identified she was aware of the issue regarding the missing weight documentation for Resident #38. RN #3 identified that for the first few days following admission, it was difficult to obtain the weights because Resident #38 had bilateral humerus fractures with pain on movement. RN #3 identified that after the first 3-4 days, Resident #38 was able to tolerate more movement and at that point the weights should have been done daily. RN #3 identified that if the nursing staff were unable to obtain the weights, the rationale should have been documented in the clinical record, and the provider should have been made aware. Although requested, the facility failed to provide a policy on accurate documentation in the clinical record.The facility policy on weighing residents directed that the purpose of the policy was to monitor residents for weight loss or gains and that weights would be recorded in the electronic medical record.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #11) reviewed for range of motion, the facility failed to ensure an adaptive device for limited mobility of the right hand was applied according to physician's orders. The findings include.Resident #11 was admitted to the facility in 10/2024 with diagnoses that included cerebral infarction and disorders of the automatic nervous system.The quarterly MDS dated [DATE] identified Resident #11 was severely cognitively impaired, had limited range of motion in the upper and lower extremities and required two person assist for bed mobility, transfers, and dressing.The care plan dated 1/3/26 identified Resident #11 required ADL assistance related to decreased mobility with cognitive deficits. Interventions included providing supportive care, assistance with mobility as needed and PT/OT referral, evaluation and treatment as ordered.A physician's order dated 1/4/26 (original date 4/11/25) directed a right C-grip hand splint to be applied every day shift after morning care for up to four hours.The schedule for the assistive device posted on the inside of Resident #11's closet with images directed the right-hand device to be applied after morning care for up to four hours. Staff were to make sure straps were not tight, follow numbers when applying, check skin for breakdown and notify the supervisor for any questions.The nurse aide care card did not include the C-grip schedule for application/removal or corresponding care. Observation on 1/27/26 at 12:15 PM identified Resident #11 was up and dressed sitting in his/her wheelchair without the benefit of the prescribed right-hand C-grip.Interview with NA #2 on 1/27/26 at 12:15 PM identified Resident #2 was able to make needs known, was originally resistive to wanting to get changed earlier in the day but later was agreeable without any refusals.Observation on 1/28/26 at 11:30 AM identified Resident #11 was still in bed. The right hand was not visualized.A subsequent observation on 1/28/26 at 1:46 PM identified Resident #11 was up in his/her chair and dressed without the benefit of the C-grip to the right hand.An interview with NA #2 on 1/28/26 at 1:46 PM identified Resident #11 did not experience any complications or refusals during morning care. NA #2 indicated that while direction for use of the C-grip was not on the nurse aide card, she was aware the device was to be applied after morning care as directions were posted on the inside of Resident #2's closet. NA #2 further identified she did not routinely apply the C-grip when assigned, was unsure who was responsible for its placement, would not know where to find the C-grip, was never formally in-serviced and had not reported any of these concerns to the charge nurse. Interview with RN #2 on 1/29/26 at 207 PM identified she worked as unit manager during the day shift. RN #2 indicated rehabilitation staff were responsible for entering orders into the system regarding use of any adaptive device. The assigned charge nurse was then responsible for transcribing the orders and placing information on the nurse aide care card. Nurse aides were responsible for the application of the adaptive device and nursing staff were responsible for ensuring its application and skin check were completed during the shift.Interview and clinical record review with OTR #1 on 1/29/26 at 2: 23 PM identified Resident #11 had a right-hand splint that was to be applied during the day up to four hours as tolerated and was trialed before assigning care to nursing staff. On 6/18/25, supervisory nursing staff were educated on the program and demonstrated good understanding. Instructions for use were documented in the clinical record and in Resident #2's room.Review of the nursing staff in-service for the application and care of Resident #2's C-grip did not include NA #2.Interview and clinical record review with the DNS on 1/29/26 at 2:34 PM identified she would expect nurse aide staff to apply the C-grip in accordance with physician orders and to notify the nurse for any refusal or inability to locate.Interview with LPN #5 on 1/30/26 at 2:40 PM identified she was the assigned nurse on 1/29/26 during the 7:00 AM to 3:00 PM shift. LPN #5 indicated that although aware nursing staff were responsible for overseeing the placement of the C-grip and to perform a skin check, she did not do so on 1/29/26 as no concerns related to the assistive device were reported.A review of the facility policy for splints directed that residents are issued splints to improve range of motion or prevent further contracture, prevent skin breakdown and maintain/improve hygiene. Rehabilitation staff may trial new splints to ensure tolerance, comfort and function. Rehabilitation staff will in-service nursing staff as needed regarding purpose, donning and doffing, wear schedule and care. Rehabilitation staff may provide written instructions and photographs. Physician orders will be obtained for the wear schedule. Orders will be transcribed to the resident care plan and nurse aide assignment sheet. Nursing will refer any splinting issues back to the therapy department as needed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #8) reviewed for antibiotic use, the facility failed to ensure the resident with an indwelling medical device and chronic wound was placed on Enhanced Barrier Precautions (EBP), and for the only sampled resident (Resident #16) reviewed for dialysis, the facility failed to ensure a resident with an indwelling medical device was placed on EBP.1. Resident #8 was admitted to the facility on 12/2025 with diagnoses that included a non-pressure chronic ulcer of the left and right heel and left and right midfoot with bone involvement.A physician's order dated 12/26/25 directed to change the dressing to the right foot wound daily, every shift, and to change the wound vac (125 mmHg) dressing to the left foot every Monday, Wednesday, and Friday. The physician's orders identified that Resident #8 had a single lumen Peripherally Inserted Central Catheter (PICC) to the right upper chest with an order that directed for transparent dressing changes: 24-hours post insertion or admission, then weekly and as needed. The physician's order failed to direct EBP. The admission MDS dated [DATE] identified Resident #8 had intact cognition, required substantial/maximal assistance with toileting hygiene, showering/bathing, and lower body dressing, required partial/moderate assistance with upper body dressing and personal hygiene, had a foot infection, required surgical wound care and the application of foot dressings, was receiving an antibiotic, and had intravenous (IV) access. The care plan dated 1/7/26 identified Resident #8 had an alteration in skin integrity related to: surgical incision to the bilateral feet, with interventions that included dressing changes as ordered and wound vacuum (a negative pressure wound therapy device used for treatment of acute, chronic, and surgical wounds) if appropriate, and Resident #8 had an IV Hickman line (a central line used for long-term direct access to the blood stream), with interventions that included administering medications and fluids per the MD order, changing the dressing and IV site per the policy and as needed, and flushing per policy. The care plan failed to identify EBP was included as a care plan focus or intervention. The Internal Medicine progress note dated 1/28/26 identified Resident #8 underwent bilateral foot debridement on 6/5/25 and was closely followed in the outpatient setting with frequent debridement to the chronic heel wounds; a left calcaneal biopsy was completed on 11/26/25 and showed evidence of acute osteomyelitis. On 12/8/25 Resident #8 was sent to the ED with necrotic heel wounds and increasing purulent drainage coming from the right foot. On 12/8/25 Resident #8 started on Vancomycin/Zosyn (antibiotics), and then on 12/9/25, he/she was taken to the OR for right foot incision and drainage. Podiatry took Resident #8 to the OR on 12/18/25, status post left partial calcanectomy, right foot with excisional debridement of nonviable soft tissue with application of biological grafts to bilateral heel wounds and negative pressure wound-VAC therapy-open. Resident #8 was discharged to short term rehab on IV Unasyn and Vanco. Interview with LPN #7 on 1/30/26 at 6:45 AM identified that she was not aware of Resident #8 being placed on EBP or if he/she met the criteria for EBP, and she was not aware of any residents on her 4th floor assignment requiring EBP. Interview with RN #10 on 1/30/26 at 10:08 AM identified that she was not aware of Resident #8 being placed on EBP and she was not sure if he/she met the criteria for EBP. 2. Resident #16 was admitted to the facility on 01/2026 with diagnoses that included end-stage renal disease and dependance on renal dialysis.A physician's order dated 1/19/26 directed to change transparent dressing: resident has a permacath to right upper chest wall, check dressing integrity and date of the last dressing change every shift. The admission MDS dated [DATE] identified Resident #16 had intact cognition, required substantial/maximal assistance with toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene, and was receiving hemodialysis. The care plan dated 2/2/26 identified Resident #16 had an arteriovenous (AV) fistula to the left arm related to dialysis (right AV fistula not used), with interventions that included monitoring the chest venous port side every shift and as needed for signs and symptoms of infection and bleeding. Interview with RN #1 on 1/27/26 at 10:14 AM identified that Resident #16's AV fistula was not in use due to an evacuation of a hematoma, and he/she was dialyzed through a permacath. Interview with LPN #8 on 1/30/26 at 6:46 AM identified that she was not aware of Resident #16 being placed on EBP or if he/she met the criteria for EBP, and she was not aware of any residents on the 4th floor that required EBP since she began working at the facility, a little less than a year ago. Interview with RN #8 on 1/30/26 at 8:10 AM identified that Resident #16 was not on EBP and was not sure if he/she had met the criteria for EBP. Review of the facility's EBP education documentation with the Infection Control Preventionist (RN #1) and the ADNS (covering staff development) on 1/30/26 at 9:15 AM, identified education was provided to all nursing staff on the topic of EBP from October 2025 through December 2025, including the criteria for implementing EBP, which includes residents with chronic wounds and indwelling medical devices. Interview with RN #1 on 1/30/26 at 10:02 AM identified that due to the high turnover of admissions and discharges and her interpretation of the CDC's EBP FAQ sheet, which identified that the CDC did not recommend implementation of Enhanced Barrier Precautions (EBP) in other healthcare settings aside from nursing homes, and since the facility's long term care residents resided only on the 3rd floor, she did not place the residents residing on the short term rehab floors (2nd and 4th floors) on EBP, when applicable. RN #1 indicated that the facility was a licensed chronic and convalescent nursing home, and residents requiring transmission-based precautions (TBP) were not limited to the 3rd floor and could be placed in rooms on the 2nd and 4th floors, with TBP in place. RN #1 identified that Resident #8 should be on EBP due his/her PICC line (an indwelling medical device), and Resident #16 should also be on EBP due to his/her dialysis permcath (an indwelling medical device). RN #1 identified that she would place Residents #8 and #16 on EBP, as well as any residents on the short-term rehab floors meeting the EBP criteria and would initiate reeducation on EBP for all nursing staff, therapy, and housekeeping. Interview with the DNS on 1/30/26 at 10:38 AM identified that Residents #8 and 16 should have been placed on EBP due to their indwelling medical devices. The DNS indicated that Residents #8 and #16 were at the facility for short term rehab, not long-term care, and due to the fluidity of resident status changes and the volume of turnover due to admissions and discharges, residents on the short-term rehab floors had not been placed on EBP. The DNS indicated that the plan moving forward would be to implement EBP, when appropriate, on the short-term rehab floors, as well. The facility's Enhanced Barrier Precautions policy directs that EBP will be used for all patients with infection or colonization with a novel or targeted MDRO when contact precautions do not apply on long term care units/long term care patients, and EBP will also be used for patients with wounds or indwelling medical devices regardless of MDRO colonization status, if on units with patients that require transmission based precautions. Staff will don appropriate PPE for these patients prior to high contact care activities. These patients do not always require a private room and this does not require restrictions for movement throughout facility or participation in activities within the facility's policy. High contact patient care activities are defined as follows: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device: central line, urinary catheter, feeding tube, tracheostomy, ventilator, and wound care: any opening requiring a dressing slash major chronic wounds (pressure injuries, diabetic ulcers, on healed surgical wounds, and chronic venous stasis ulcers).

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for the plan of care , the facility failed to ensure a comprehensive care plan with appropriate interventions was implemented for a resident at risk for bruising. The findings include: Resident #1 had diagnoses that included Waldenstrom macroglobulinemia, myeloproliferative disease ( blood disorders) , lymphoplasmacytic lymphoma (a type of cancer), anemia, amyloidosis, post-traumatic stress disorder, delirium, and depressive disorder. Review of the nursing admission assessment dated [DATE] completed by RN #6 identified Resident #1 had a fading bruise to the left side of forehead, bruising to both arms, and dark purple discoloration to the peri area extending to the inner buttocks. The care plan dated 10/19/24 identified Resident #1 at risk for impaired skin integrity related to decreased mobility and incontinence. Interventions directed preventative treatments per MD orders, weekly skin audit, and monitor for skin changes and report as needed. Review of MD #5's note dated 10/22/24 identified Resident #1 is noted with small non-palpable purpura in the crease between h/her inner thigh line and extensive ecchymosis to the coccyx and buttocks. MD #5 indicated the purpura, and ecchymosis is of unknown etiology questioning if related to Resident #1's diagnosis of amyloidosis and possible trauma related to a wick used in the hospital. MD #5 indicated he was also questioning if Zanubrutinib (Brukinsa) (antineoplastic medication used to treat certain cancers) is contributing to above. Review of MD #2's note dated 10/23/24 at 12:09 P.M. identified Resident #1's had acute kidney injury and anemia had suspected volume depletion but now worsening questioning possibly from Zanubrutinib. MD #2 indicated she spoke with MD #6 (oncologist) who recommends holding Zanubrutinib for now. MD #2 indicated she there is a question if Zanubrutinib (Brukinsa) is the cause of Resident #1's perianal ecchymosis noted yesterday. The admission MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of ten (10) indicative of moderately impaired cognition, was frequently incontinent of bowel and bladder, was dependent with transfers, and required substantial assistance with ADLs and bed mobility. In addition, Resident #1 is taking an antiplatelet medication. The physician's order dated 11/11/24 directed to admininster Brukinsa (antineoplastic medication used to treat certain cancers) 160 milligrams twice per day. Review of APRN #1's note dated 11/21/24 at 1:01 P.M. identified Resident #1 was seen for an evaluation of h/her left hip bruise. APRN #1 identified Resident #1's left thigh hyperemia appears to be superficial rupture of the capillaries and of note Resident #1's Brukinsa was recently resumed which may also increase the risk for bruising. Interview with APRN #1 on 12/5/24 at 11:35 A.M. identified on 11/20/24 Resident #1 had used the commode over the toliet and from Resident #1's left thigh resting against the frame of the commode Resident #1 developed a large bruise. APRN #1 identified Resident #1 was at risk for increased bruising related to h/her diagnoses and the side effects related the medication Brukinsa that include bruising. Interview with the DNS on 12/5/24 at 2:00 P.M. identified Resident #1 was at increased risk for bruising due to multiple diagnoses that cause bruising and the side effects related to the use Brukinsa medication. The DNS identified there should have been a comprehensive care plan in place for Resident #1 that identified the resident was at increased risk of bruising with appropriate interventions. The DNS indicated it is her expectations when a resident is identified at risk a care plan is developed, and interventions are implemented. Review of facility care plan policy dated 1/3/2024 identified a comprehensive care plan based on identified needs, strengths and preferences of the resident will be developed no later than 7 days after completion of the admission MDS. The care plan will include a statement of the problem; reasonable and measurable goals; interventions to achieve these goals and discipline responsible for carrying out the interventions.

Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure the charge nurse was notified when it was identified that the resident had purple discoloration to the groin and upper inner thighs. The findings include: Resident #1 had diagnoses that included Waldenstrom macroglobulinemia (a blood disorder), myeloproliferative disease (a blood disease), lymphoplasmacytic lymphoma (a type of cancer), amyloidosis, ( a systemic diease) post-traumatic stress disorder, delirium, and depressive disorder. The admission MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of ten (10) indicative of moderately impaired cognition, was frequently incontinent of bowel and bladder, was dependent with transfers, and required substantial assistance with ADLs and bed mobility. The physician's order dated 11/11/24 directed to administer Brukinsa (antineoplastic medication used to treat certain cancers) 160 milligrams twice per day. The care plan dated 11/20/24 identified Resident #1 has a large bruise to the left outer thigh with interventions that direct to monitor skin for changes and report as needed. Interview and clinical record review with the DNS on 12/5/24 at 2:00 P.M. that the resident was sent to the hospital for abnormal bloodwork, while at the hospital there was bruising noted to the vaginal area and the hospital had called to report the finding to the facility, and she started an investigation. The investgation identified that NA #1 noted on 11/28/24 that she observed purple discoloration to Resident #1's groin and upper inner thighs, however, NA #1 did not report the change in condition to the charge nurse. The DNS identified NA #1 should have reported Resident #1's change in condition to the charge nurse on 11/28/24. The DNS indicated it is her expectation that when a resident has any change in condition the nurse aide reports it immediately to the charge nurse. The DNS identified on 12/2/24 she initiated staff education to ensure nurse aides report changes in condition to the nurses immediately. An interview with NA #1 on 12/5/24 at 10:20 A.M. identified while providing care to Resident #1 on 11/28/24 during the 7:00 A.M. to 3:00 P.M. shift NA #1 noted Resident #1's groin and upper inner thighs had purple discoloration. NA #1 identified although on 11/24/24 when she last cared for Resident #1, she did not observe any purple discoloration to Resident #1's groin and upper inner thighs NA #1 did not report the change in condition to the nurse on 11/28/24. NA #1 indicated she thought the nurse already knew. Review of the facility's Inservice education dated 12/2/24 identified staff were provided with education that was titled: When staff notice bruising or open areas on residents' the nurse aides need to report it to the nurses right away. Review of facility change in condition policy dated 1/3/2024 identified; in part, all significant changes in resident's condition will be reported to the physician and family.

Based on facility documentation review, and interviews, the facility failed to ensure a certified Infection Preventionist was employed by the facility. The findings include Review of RN #4 (Infection Control Nurse) certification documentation on 4/8/24 at 9:30 AM identified a certificate of achievement from Infection Control Training dated 4/4/22 and the course topics included: Introduction, Transmission, Prevention and Control, Hand Hygiene, Personal Protective Equipment, Environmental Controls, Sharps and Injection Safety, Occupational Health and Safety, Sepsis, Final Exam. The course was 4 hours long, and the certification expires after 2 years. RN #4 also identified she took also took several courses in the CDC/Infection Control Training site which was is 19 hours long and consists of 23 modules, however RN#4 did not complete the final exam associated with the CDC/Infection Control Training and as a result did not have a certificate of completion. The courses were taken June 2022. Interview and Infection Control curriculum review with RN #4 on 4/9/24 at 9:40 AM identified RN #4 completed many modules however 2 remained outstanding and she had never taken the test to secure a certificate of completion. Interview with the Administrator and DNS on 4/9/24 at 10:40 identified they were not aware the CDC course and final test were not completed. The DNS identified RN #4 was the only nurse certified for infection control since her hire date of June 2022. Subsequent to surveyor inquiry, RN #4 completed the 2 remaining modules, took the test and presented a certificate certifying completion of the CDC Infection Prevention Course and exam dated 4/9/24. The policy for the Infection Prevention and Control Program state the qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist job description which states the qualifications include the ability to demonstrate and to maintain the standards of care rendered in accordance with the State Agency, governing body of the facility and the State and Federal agencies.

Based on review of the clinical record, review of facility documentation and interviews for 3 of 3 residents (Resident #53, #58, and #70) reviewed for advanced directive, the facility failed to ensure the advanced directive form was completed. The findings include: 1. Resident #53 was readmitted to the facility on [DATE] with diagnoses which included dementia, end stage renal disease, and anxiety. The hospital discharge summary dated [DATE] did not identify a code status for Resident #53. A nurses' note dated [DATE] at 10:09 PM identified Resident #53 was admitted to the facility and was alert and oriented times 3. The resident representative was called identified he/she wanted Resident #53 to be a full code. The facility consent form for the administration or withdrawal of cardiopulmonary resuscitation (CPR) identified on [DATE] that 1 nurse had signed a telephone verbal consent from the resident's representative as a full code. The witness line was blank. Review of the nurse's notes dated [DATE]-[DATE] did not reflect that Resident #53 was asked about his/her wishes for the code status. A physician progress note dated [DATE] did not identify a code status. The APRN progress note dated [DATE] did not identify a code status. The quarterly MDS assessment dated [DATE] identified Resident #53 had intact cognition and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The care plan dated [DATE] identified advanced directives. Interventions included Resident #53 was a full code and to review advanced directives quarterly with the resident and/or family. Interview with the DNS on [DATE] at 6:50 AM identified the code status must be discussed on every admission and readmission with the resident or resident's representative that day or within the first 24 hours. The DNS indicated that if a resident had a BIMS of ,d+[DATE] that resident could sign the advanced directives themselves but if not cognitively intact then the charge nurse was responsible to call the resident representative. The DNS indicated that if the charge nurse calls a resident representative that 2 nurses or 1 nurse and 1 social worker must be present to discuss and receive the advanced directive wishes and the 2 staff must sign the advanced directive form. The DNS indicated if the charge nurse was not able to reach the resident representative that her expectation was there would be a nurses note to reflect that there was a call attempting to get the advance directives. The DNS indicated that if by the day after admission the charge nurse did not get in touch with the resident representative, the social worker would attempt to call and document the call. The DNS indicated if there was a telephone verbal consent for the code status she did not expect that the next time the resident representative visited or at the next quarterly care conference that the resident representative would sign the form. Interview with the ADNS on [DATE] at 7:10 AM indicated that a resident with a BIMS of 15 was able to make their own decisions. The ADNS indicated that Resident #53 had a conservator of person who was the resident representative. The ADNS indicated that on readmission or admission the charge nurse was responsible to get the advanced directives right away. The ADNS indicated if the charge nurse had to call a resident representative to get a code status 2 nurses must hear the resident representative's wishes for the code status on the phone and sign the document. After review of the clinical record, the ADNS indicated there was not a physician's order for the code status and the advance directive form for Resident #53 was only signed by one nurse and there was not any witness. The ADNS indicated there must be 2 nurse's signatures and did not know why it was not done correctly. 2. Resident #58 was readmitted to the facility on [DATE] with diagnoses which included a stroke, anxiety, and diabetes. The nurses note dated [DATE] at 11:00 PM identified Resident #58 was admitted from hospital and was alert and confused. Resident representative was called and requested Resident #58 be a full code. The facility consent form for the administration or withdrawal of cardiopulmonary resuscitation (CPR) form identified on [DATE] that 1 nurse had signed a telephone verbal consent from the resident's representative as a full code. The witness line was blank. A physician's order dated [DATE] directed Resident #58 was a full code. The quarterly MDS assessment dated [DATE] identified Resident #58 had moderately impaired cognition and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The care plan dated [DATE] identified advanced directives. Interventions included Resident #58 was a full code and to review advanced directives quarterly with the resident and/or family. Interview with the ADNS on [DATE] at 7:15 AM indicated that Resident #58 had a responsible party. After clinical record review, the ADNS indicated that the charge nurse had called the resident representative and received a verbal consent from the resident representative but did not have a witness. The ADNS indicated she would have expected a second person to witness and sign the form. 3. Resident #70 was admitted to the facility on [DATE] with diagnoses which included heart failure, schizophrenia, and diabetes. The hospital discharge summary dated [DATE] identified Resident #70 was a full code per the W-10 to the hospital but was not discussed with resident or resident representative. A physician's order dated [DATE] directed full code. The care plan dated [DATE] identified advanced directives. Interventions included Resident #70 was a full code and to review advanced directives quarterly with the resident and/or family. The nurse's note dated [DATE] at 9:44 PM identified Resident #70 was admitted to the facility and had a BIMS of 3 (BIMS of 3 means severely impaired cognition). Called the conservator and left a message. Review of the progress notes dated [DATE]- [DATE] did not identify any staff had attempted to speak with the conservator regarding the code status. Interview with the ADNS on [DATE] at 7:20 AM identified the administration or withdrawal of cardiopulmonary resuscitation (CPR) form was blank in Resident #70's chart. The ADNS indicated that Resident #70 was admitted from the hospital as a full code on [DATE] and the facility had not spoken with Resident #70's conservator. The ADNS indicated the conservator had visited but did not recall when. The ADNS indicated the charge nurse should have discussed the advanced directives when he/she had visited and documented the conversation. The ADNS indicated the code status should have been obtained within the first day or two following admission to the facility. Interview with the SW #1 on [DATE] at 7:30 AM indicated if a resident was admitted and is not cognitively intact nursing will inform her if they were unable to reach the residents representative. SW #1 indicated she will attempt to call and if she needs to, she will fax, scan, or email the residents representative regarding the advanced directives requesting they sign the form and send it back to the facility. SW #1 indicated that she should document any attempts to call someone but doesn't always document. SW #1 indicated the advanced directive should have been received by the resident or resident representative within ,d+[DATE] hours of the admission or readmission. SW #1 indicated that a resident is a full code until the resident or resident representative signs the advance directive form. SW #1 indicated that Resident 53's representative does come into the facility to visit and could sign the advanced directive form. SW #1 indicated that Resident #58, she did not see any social worker notes identifying social services got involved with the code status. SW #1 indicated that Resident #70, she had seen the resident representative and handed the advanced directive form to him/her but thought nursing would have followed up to get the form back. Review of the facility Advanced Directive and Physician Order Form Policy identified all residents upon admission to the facility will be asked their advanced directives. The advanced directive and physician order form will be completed. The physician order for code status will be transcribed by the nurse into the electronic medical record.

Based on review of the clinical records ,review of facility documentation, and interviews for 3 of 5 residents (Resident #1, 18 and 71), reviewed for hospitalization , the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when the residents were transferred to the hospital. The findings include. 1a. Resident #1 was admitted to the facility in February 2024 with diagnoses which included chronic kidney disease, myocardial infarction, and atherosclerotic heart disease. The nurse's note dated 2/17/24 at 1:48 PM identified Resident #1 was transferred to the hospital. The nurse's note dated 2/29/24 at 2:41 PM identified Resident #1 was readmitted to the facility. Review of the Action Summary dated 2/1/24 - 2/29/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #1 was transferred to the hospital on 2/17/24. b. The nurse's note dated 3/16/24 at 6:22 AM identified Resident #1 was transferred to the hospital. The nurse's note dated 3/28/24 at 3:39 AM identified Resident #1 was readmitted to the facility. Review of the Action Summary dated 3/1/24 - 3/31/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #1 was transferred to the hospital on 3/16/24. 2a. Resident #18 was admitted to the facility in September 2020 with diagnoses which included congestive heart failure, atrial fibrillation, and chronic kidney disease. The nurse's note dated 3/15/24 at 10:55 AM identified Resident #18 was transferred to the hospital. The nurse's note dated 3/20/24 at 8:47 PM identified Resident #18 was readmitted to the facility. Review of the Action Summary dated 3/1/24 - 3/31/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #18 was transferred to the hospital on 3/15/24. b. The nurse's note dated 3/28/24 at 12:13 PM identified Resident #18 was transferred to the hospital. The nurse's note dated 4/2/24 at 11:28 PM identified Resident #18 was readmitted to the facility. Review of the Action Summary dated 3/1/24 - 3/31/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #18 was transferred to the hospital on 3/28/24. 3. Resident #71 was admitted to the facility in November 2023 with diagnoses that included Wegener's granulomatosis, epilepsy, and chronic pain syndrome. The nurse's note dated 11/17/23 at 6:14 PM identified Resident #71 was transferred to the hospital. The nurse's note dated 12/27/23 at 11:01 PM identified Resident #71 was readmitted to the facility. Review of the Action Summary dated 11/1/23 - 11/30/23 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #71 was transferred to the hospital on 11/17/23. Interview with the Administrator on 4/8/24 at 9:00 AM identified she was not aware of the Action Summary was being sent out monthly but was not aware it was being sent incorrectly. Interview with the DNS on 4/8/24 at 9:10 AM identified SW #1 and the medical record staff were responsible for sending the Action Summary to the Office of the State Long-Term Care Ombudsman. Interview with the medical record staff on 4/8/24 at 10:39 AM identified she uploads the discharges to the hospital to the Office of the State Long-Term Care Ombudsman the first week of each month. The medical record person indicated she was not aware she was sending the incorrect Action Summary. Subsequent to surveyor inquiry SW #1 send the correction for the Action Summary dated 1/1/23 - 12/31/23 and 1/1/24 - 3/31/24 to the Office of the State Long-Term Care Ombudsman. Although requested, a facility policy was not provided.

Based on review of the clinical record, review of facility documentation, and interviews for 2 of 4 residents (Resident #40, Resident #37) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall resulting in a fracture and the facility failed to ensure appropriate observation and monitoring was conducted for a resident with multiple recurrent falls.The findings include: 1. Resident #40 was admitted to the facility with diagnoses which included schizophrenia, emphysema, bilateral lower extremity neuropathy, and multiple malignant neoplasms. The quarterly MDS assessment dated [DATE] identified intact cognition and required supervision with transfers, bed mobility, walking in room and corridor, dressing, toilet use, and personal hygiene. The care plan dated 3/23/23 identified Resident #40 was at risk for falls related to cancer diagnosis and anticipated decline in functional status with a progressive terminal disease. Interventions included to cue for safety awareness, keep environment safe, and remind to call for assistance. The Occupational Therapy Discharge Summary dated 3/23/23 identified Resident #40 was contact guard assistance with rolling walker or holding the tube feeding pole and assistance with peroneal hygiene for thoroughness. Resident #40 was discharged with recommendations of continue with independent ambulation and participation with activities of daily living. The Physical Therapy Discharge Summary dated 3/24/23 identified ambulation with rolling walker minimal assist of 1 sidestepping. Discharge recommendations continue ambulation with or without feeding tube pole for support and moderate independent mobility ad lib on nursing unit. The reportable event dated 4/29/23 at 2:55 PM indicated Resident #40 had an unwitnessed fall in the shower. Resident #40 indicated that he/she slipped and fell while in the shower on his/her left arm. Resident #40 complained of pain in left shoulder, had increased swelling, tenderness to touch, and was unable to move the left upper extremity. The physician was notified and directed the resident be transferred to the emergency room for an evaluation. The care plan dated 4/30/23 identified at risk for falls. Intervention directed to assist resident in the shower to prevent falls in the shower. The reportable event summary written by the DNS dated 5/3/23 identified Resident #40 had an unwitnessed fall in the shower. The emergency room x-ray report indicated an acute mildly displaced fracture at the proximal humerus. Resident #40 had reported he/she was in the shower and lost his/her balance and slipped and fell on to the left arm. Resident #40 had gotten him/herself up off the shower floor and ambulated to his/her room and notified the nurse of the fall and requested pain medication. Left cuff and collar sling in place and Resident #40 now is non weight bearing to the left upper extremity. Resident #40 is to follow up with orthopedics within 2 weeks. Interview and clinical record review with the DNS on 4/8/24 at 10:27 AM indicated Resident #40 was independent with ambulation and the nursing assistant should help set Resident #40 up in the shower but was expected to stay in shower room with resident for safety in case the resident would fall because the floor gets wet from the water, or the shower chair could move when attempting to sit on it or get up. Interview and clinical record review with OT #1 on 4/8/24 at 10:45 AM indicated that she had worked with Resident #40 and discharged him/her on 3/23/23. OT #1 indicated Resident #40 could ambulate independently but was not evaluated if he/she could shower independently. OT #1 indicated that she would be responsible to evaluate a resident to see if the resident was safe to shower independently. OT #1 indicated her expectation was that when Resident #40 gets a shower that a nursing assistant stay with Resident #40. Interview with NA #3 on 4/9/24 at 10:30 AM indicated when she is assigned to Resident #40, she will bring him/her washcloths and towels and Resident #40 will ambulate to the shower room. NA #3 indicated after Resident #40 is set up she will leave him/her alone in the shower. NA #3 indicated when Resident #40 is done with the shower Resident #40 will ambulate independently back to his/her room pushing the IV/feeding tube pole. NA #3 indicated that all the nursing assistants just knew that Resident #40 was independent in the shower. NA #3 indicated she does not recall if it was on the nursing assistant care card for Resident #40 to shower alone NA #3 indicated she did not ask the nurse if it was okay to leave Resident #40 alone in the shower. NA #3 indicated on the day that Resident #40 had fallen and had to go to the emergency room she did not recall if she had escorted him/her that day to the shower prior to going on her break. NA #3 did recall she was at break at the time of the fall. Interview with APRN #1 on 4/9/24 at 12:47 PM indicated that for a resident to be independent and left alone in a shower that therapy would have to conduct an evaluation and clear the resident as independent in the shower. The facility was unable to provide documentation that Resident #40 was assessed by therapy to independently shower alone and have a physicians order to allow Resident #40 to shower alone. Although attempted, an interview with LPN #3and RN #3 were not obtained. 46040 2. Resident # 37 was admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, and dementia. The admission MDS assessment dated [DATE] identified Resident # 37 had severely impaired cognition, was always continent of bowel and bladder, required extensive assistance from staff with bathing and moderate assistance with toileting and transfers. The MDS further identified Resident #37 had a history of falls in the month prior to admission to the facility and had at least one following admission to the facility. The care plan dated 11/11/23 identified Resident #37 was at risk for falls due to functional decline and a history of repeated falls. Interventions included offering frequent toileting, always use nonskid socks, and keep resident in sight. A facility accident and incident (A&I) report dated 11/25/23 at 11:45 PM identified Resident #37 had an unwitnessed fall. The report identified that Resident #37 was found on the bathroom floor after self-transferring to the bathroom. Interventions identified that Resident #37 required a 1:1 sitter. Review of the clinical record failed to identify any documentation related to 1:1 monitoring observations of Resident #37 after the 11/25/23 unwitnessed fall. A facility A&I report dated 11/26/23 at 12:50 PM identified Resident #37 had an unwitnessed fall attempting to get up from a chair and fell to the floor on his/her right arm. Interventions included a X-ray of the right arm and that Resident required a 1:1 sitter. The care plan dated 11/26/23 identified Resident # 37 was at risk for falls due to functional decline and a history of repeated falls and included a new intervention of a need for a 1:1 sitter. Review of the clinical record failed to identify any documentation related to 1:1 monitoring observations of Resident #37 after the 11/26/23 unwitnessed fall. An APRN note dated 11/27/23 by APRN #1 identified that Resident #37's right arm x ray did not show any acute fracture, but that Resident #37 had a + Covid test and had been started on Paxlovid (a medication for Covid 19). The note further identified Resident #37 had a 1:1 sitter for safety interventions. Review of the clinical record identified multiple nursing notes which noted Resident #37 was on 1:1 monitoring due to repeated falls. The clinical record failed to identify any documentation related to 1:1 monitoring observations by any nursing staff at the facility conducted on Resident #37 from 11/27-12/7/23. A nurse's note dated 12/7/23 at 12:49 AM identified Resident #37 had a 1:1 sitter for safety. A facility A&I report dated 12/7/23 at 7:30 AM identified Resident #37 had an unwitnessed fall and was found sitting on the floor next to his/her bed. The interventions included continuing with a 1:1 sitter. Review of working daily staffing roster included with the A&I report failed to identify that any staff member was assigned to monitor Resident #37 at any time from 7:00 AM-11:00PM. Review of the clinical record failed to identify any documentation related to neurological monitoring completed following Resident #37's unwitnessed fall on 12/7/23. Review of the clinical record identified that Resident #37's monitoring was changed from 1:1 to every 30 minute checks on 1/4/24 and identified that Resident #37 had every 30 minute monitoring completed and documented on the form Every half hour checks for safety and care needs. Further review of the clinical record identified one additional monitoring form completed for Resident #37 dated 1/6/24. The clinical record failed to identify any additional documentation related to every 30 minute observations or monitoring completed for Resident #37 from 1/7-1/17/24. The nurse's note dated 1/17/24 at 12:56 AM identified Resident #37 was on every 30 minute checks. A facility A&I report dated 1/17/24 at 10:00 AM identified Resident #37 had an unwitnessed fall. The A&I report identified that staff were providing care to the resident at approximately 10:00 AM and identified a bruised area to Resident #37's left shoulder and left outer eye. The report identified Resident #37 indicated he/she fell last night while attempting to use the bathroom. Interventions included an X-ray of the left shoulder and every 15 minute checks of the resident. The X ray report dated 1/18/24 identified Resident #37 had no acute changes to the left shoulder. Review of the clinical record failed to identify any documentation related to every 15 minute observations or monitoring completed following Resident #37's unwitnessed fall on 1/17/24. The clinical record also failed to identify every 15 minute observations or monitoring were completed on 1/18/24 and 1/19/24. Review of the clinical record identified documentation related to every 15 minutes and observation checks completed on Resident #37 beginning on 1/20/24. The documentation reviewed identified multiple days and timeframe's when no observations or monitoring were documented and included: 1/22/24: 7 AM-2:45 PM and 6 PM-10:45 PM 1/23/24: 7 AM-10:45 PM 1/24/24: 7:45 PM-9 PM 1/27/24: 9 AM-10:45 PM 1/29/24: 8 PM-10:45 PM 1/30/24: 7 AM-2:45 PM 1/31/24: 3 PM-10:45 PM 2/1/24: No documentation for this date 2/4-2/5/24: No documentation for these dates A facility A&I report dated 2/7/24 at 10:05 PM identified Resident #37 had an unwitnessed fall. The report identified that Resident #37 was found on the floor to the left side of his/her bed and no apparent injuries were identified. Interventions included continuing every 15 minute checks. Review of the clinical record identified documentation related to every 15 minute monitoring and observation checks were continued and completed on Resident #37 following the fall on 2/7/24. The documentation reviewed failed to identify any observations or monitoring were documented or completed for the following dates/times: 2/9/24: 7 AM-2:45 PM 2/10/24: 3 PM-10:45 PM 2/11/24: 3 PM-10:45 PM 2/12/24: 7 AM-2:45 PM 2/13/24: 7 AM-2:45 PM 2/14/24: 7 AM-10:45 PM 2/16/24: 7 AM-2:45 PM 2/18/24: 7 AM-2:45 PM 2/19/24: 3 PM-10:45 PM 2/25/24: 7 AM-10:45 PM 2/26/24: 7 AM-10:45 PM 2/27/24: 7 AM-2:45 PM 2/28/24: 7 AM-2:45 PM and 8 PM-10:45 PM A facility A&I report dated 2/29/24 at 2:30 AM identified Resident #37 had a witnessed fall by facility staff. The report identified Resident #37 was witnessed trying to place shoes on and after standing upright slid to the floor. The report further identified while the resident initially had no apparent injuries, at 5:15 AM, the resident was observed to have a small hematoma to the right temple. Interventions included to continue 15 minute checks. Review of the clinical record identified documentation related to every 15 minutes and observation checks were continued and completed on Resident #37 following the fall on 2/29/24. The documentation reviewed failed to identify any observations or monitoring were documented or completed for the following dates/times: 2/29/24: 12:45PM-2:45 PM 3/2/24: 7 AM-2:45 PM and 7:15 PM-10:45 PM 3/3/24: 7 AM-2:45 PM 3/4-3/5/24: No documentation for these dates 3/6/24: 7 AM-2:45 PM 3/9/24: 3 PM-10:45 PM 3/10/24: 3 PM-10:45 PM 3/12/24: 7 AM-2:45 PM 3/13/24: 7 AM-2:45 PM 3/15/24: 2:15 PM-10:45 PM A facility A&I report dated 3/16/24 at 9:30 AM identified Resident #37 had an unwitnessed fall. The report identified that Resident #37 slid off his/her bed and hit his/her buttocks on the floor. Resident #37 reported he/she was attempting to walk to the bathroom. Interventions included continuing every 15 minute checks. Further review of the clinical record failed identify any documentation related to every 15 minute monitoring and observation checks were completed on 3/16/24 from 7 AM -2:45 PM. Review of the clinical record failed to identify any documentation related to neurological monitoring was completed following Resident #37's unwitnessed fall on 3/16/24. Review of the clinical record identified documentation related to every 15 minute monitoring and observation checks were continued and completed on Resident #37 following the fall on 3/16/24. The documentation reviewed failed to identify any observations or monitoring were documented or completed on 3/17/24 or 3/18/24. A facility A&I report dated 3/19/24 at 12:15 AM identified Resident #37 had an unwitnessed fall. The report identified Resident # 37 was found sitting on the floor next to his/her bed with no apparent injuries. Interventions included continuing every 15 minute checks and offer toileting when resident was awake. Review of the clinical record identified documentation related to every 15 minute monitoring and observation checks were continued and completed on Resident #37 following the fall on 3/19/24. The documentation reviewed failed to identify any observations or monitoring were documented or completed on 3/21/24 beginning at 3 PM. A facility A&I report dated 3/21/24 at 3:15 PM identified Resident #37 had an unwitnessed fall. The report identified Resident #37 was found sitting on the floor in his/her room with his/her back against a chair. Resident #37 reported that he/she had returned from the bathroom and attempted to sit in the chair but slid to the floor. Interventions included a 1:1 sitter. Review of the clinical record failed to identify any documentation related to neurological monitoring was completed following Resident #37's unwitnessed fall on 3/21/24. Review of the clinical record failed to identify documentation related to 1:1 observation and monitoring were initiated and completed on Resident #37 following the fall on 3/21/24 from 3:00 PM-10:45 PM. Further review of the clinical record identified that every 15 minute were done in place of 1:1 monitoring beginning 3/22/24 at 11 PM. The documentation reviewed failed to identify any observations or monitoring, including every 15 minute checks or 1:1 monitoring, were documented or completed for the following dates/times: 3/22/24: 7:15 PM-10:45 PM 3/23/24: 7 AM-10:45 PM 3/24/24: no documentation for this date 3/25/24: 7 AM-10:45 PM 3/26/24: 7 AM-10:45 PM 3/27-3/28/24: no documentation for these dates 3/29/24: 12:30 PM-10:45 PM 3/30/24: no documentation related to monitoring or observations. Review of the monitoring form identified sitter/1:1 written at the 11 PM, 7 AM, and 3 PM time slots with a line and arrow drawn down the row of the respective subsequent 15-minute times with no additional documentation. 4/1-4/3/24: no documentation for these dates 4/4/24: Review of the monitoring form identified sitter/1:1 written at the 11 PM time slots with a line and arrow drawn down the row. 7 AM-2:45 identified 15 minute checks were completed. The documentation also identified a line and arrow and 1:1 sitter written in at the 3PM timeslot with an arrow to 9:15 PM. No additional line or note was identified from 9:30 PM-10:45 PM. 4/5/24: Review of the monitoring form identified sitter written at the 11 PM time slot with a line and arrow drawn down the row. 7 AM-10:00 AM identified 15 minute checks were completed and at 10:15 AM sitter was written into the time slot with a line and arrow drawn to 2:45 PM. No documentation was identified from 3 PM-10:45 PM. 4/6/24: no documentation related to monitoring or observations. Review of the monitoring form identified sitter/1:1 written at the 11 PM and 3 PM time slots with a line and arrow drawn down the row. No documentation was identified from 7 AM-2:45 PM. A daily nursing roster report dated 4/7/24 provided to the survey team upon entrance to the facility identified Resident #37 was on every 15 minute checks. Observation on 4/7/24 at 7:46 AM identified Resident #37 sleeping in bed in his/her room. During this observation, no staff member was identified in the room. During this observation, NA #1 was observed assisting another resident in the same hallway as Resident #37. Review of the clinical record identified Resident #37 was on 1:1 monitoring as a nursing measure on 4/7/24. Review of the daily staffing sheet for 4/7/24 identified NA #1 was assigned as the sitter for Resident #37's unit. Observation on 4/8/24 at 8:45 AM identified NA #1 in Resident #37's room. NA #1 was assisting Resident #299, Resident #37's roommate, with dressing. NA #1 was observed with her back turned to Resident #37, who was seated across the room in a chair. Interview on 4/8/24 at 10:00 AM with RN # 2 (unit manager) and LPN #3, who was assigned to care for Resident #37, identified that Resident #37 had a nursing intervention in place for 1:1 monitoring and that providers at the facility did not place monitoring orders for residents. RN #2 identified that a sitter was listed on the daily nursing schedule to be assigned to residents who required 1:1 monitoring, but due to staffing issues, 1:1 monitoring could not always be provided. RN #2 identified that depending on staffing, monitoring for Resident #37 would fluctuate between 1:1 monitoring, every 15-minute checks, every 30 minute checks, or every hours. LPN #3 identified there was always a staff member checking in on Resident #37, even if it was not 1:1 and that when the sitter assigned to care for Resident #37 would go on break or lunch, that Resident #37 would not have a sitter assigned to cover this time, rather, staff would just go in and do frequent checks on the resident. RN #2 identified that Resident #299 had recently been put on 1:1 monitoring due to a recent fall, and that he/she was moved to the same room as Resident #37 to allow for one sitter to be assigned to both residents. RN #2 identified that the facility did not have the staffing for each resident to have a staff member assigned individually and that the staff member assigned to complete 1:1 monitoring for more than one resident was expected to also complete any ADL assistance, including assistance with toileting, daily care, personal hygiene, and transfers. Observation and interview with NA #1 on 4/8/24 at 1:15 PM identified that she was the primary day shift staff member assigned to complete 1:1 monitoring for Resident #37. NA #1 identified that while the schedule would identify her assignment as a sitter for Resident #37, this often changed due to short staffing due to call outs. NA #1 identified that she had been assigned to care for both Resident #37 and Resident #299 as a 1:1 and that any staff member in the facility would be assigned to care for both residents as a 1:1, and that would include all care that would be provided to both residents during the shift. NA #1 also identified that when she was assigned to care for Resident #37, she was also responsible to document her observations on the form for every 15 minute checks. NA #1 identified that prior to 4/8/24, she had not been assigned to complete any 1:1 monitoring or care for Resident #39 for over a week due to staffing and assignment changes, and had not been assigned to care for or provide monitoring for Resident #37 on 4/7/24. During this observation, NA #1 was observed sitting with both Resident #37 and #299 in the unit's resident dining room. Interview with the DNS on 4/8/24 at 2:24 PM identified that the facility policy did not require that frequent monitoring, whether it be hourly, every 30 minute, 15 minute, or 1:1 continuous monitoring, have a physician's order. The DNS identified that the facility would decide on the level of monitoring needed on a case by case basis and that the facility policy for residents with a history of falls allowed for purposeful rounding, which required staff to check on residents hourly, and that level of monitoring would change depending on the resident's needs. The DNS identified that if a resident was deemed to need 1:1 monitoring, this would have been determined based on her discussing the resident at the weekly risk management meeting with APRN #1. The DNS identified that she was aware of Resident #37's history of repeated falls and that he/she had been on 1:1 monitoring from 11/26/23-1/3/24, then changed to every 30 minute checks from 1/4-2/6/24, then every 15 minute checks from 2/7-3/20/24, and was currently on 1:1 monitoring. The DNS identified that 1:1 monitoring in the facility was to be conducted with one staff member and one resident, and that the assignment be 1 person to 1 person. The DNS also identified that neurological monitoring should be initiated and completed over 72 hours for any resident who was a poor historian and had an unwitnessed fall. The DNS identified that she reviewed the facility A&I reports as part of the risk meetings for the residents and that she was unsure why the documentation related to the neurological assessments for 12/7/23, 3/16/24, or 3/21/24 but that they should have been completed. The DNS identified she was not aware that the staff had adjusted Resident #37's monitoring based on staffing issues, or at times the monitoring intervention in place was not being carried out at all due to staffing issues. The DNS identified she did review Resident #37's case and history of falls weekly at-risk management but did not review staffing or the monitoring sheets to determine if that may be part of Resident #37's issue with repeated falls. The DNS identified that she would re-educate the staff on 1:1 monitoring and that Resident #37 should have only have one staff member assigned to him/her exclusively if he/she required 1:1 monitoring. The DNS was not able to explain how Resident #37 continued to have multiple falls while on enhanced monitoring. Interview with APRN #1 on 4/9/24 at 12:45 PM identified that she was aware of Resident #37's history of repeated falls and that he/she often required either 15 minute checks or 1:1 monitoring. APRN #1 identified that the monitoring was not a provider directed order in the resident's chart, but a nursing intervention, but that the level of monitoring was determined based on the resident's risk and discussion between her and the DNS, and at times also Resident #37's physician. APRN #1 identified that she was not aware that the monitoring put in place was altered based on the nursing staffing levels and was not being done at times, and identified staffing has been an issue everywhere. APRN #1 identified that her expectation would be that the monitoring level discussed with the DNS, whether it be every 15 minutes or continuous 1:1 monitoring, be carried out to ensure the resident's safety. The facility policy on falls directed that residents at risk for falls would have fall prevention and precautions implemented as appropriate and that all falls would be reviewed during at risk meetings, monthly, and as needed to identify trends and any common causes. The policy further directed that interventions would be utilized for patients that were fall risks, including purposeful rounding and at times may require a 1:1 sitter. The policy identified that as part of the fall prevention program, the facility staff would complete purposeful rounding, which included rounding on all residents of the facility hourly to determine if the residents required any assistance or needed any items (tissues, something to eat/drink, etc) to help with fall prevention. The facility policy on neurological checks directed neurological checks should be completed on any resident with an unwitnessed fall who was unable to accurately verbalize if he/she hit his/her head. The policy further directed that for unwitnessed falls, check would be initiated and completed every 15 minutes for 2 hours, every 30 minutes for 2 hours, every hour for 4 hours, every 8 hours for 16 hours, and every shift for 3 days and should include date and time of the assessment, level of consciousness, vital signs, and pupil response.

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #17) reviewed for nutrition, the facility failed to ensure the dietitian had followed up on weight loss. The findings include: Resident #17 was admitted to the facility with a diagnosis which included Alzheimer's disease, dementia, dysphagia, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition and required set up with meals. Resident #17's height was 70 inches, weighed of 236 lbs. and did not have a weight gain or loss. Resident #17 was on a therapeutic diet. The care plan dated 12/13/23 identified nutrition and dehydration risk with a weight gain this quarter ending on 12/13/23. Interventions included to provide diet as ordered. The dietitian quarterly progress note dated 12/13/2023 at 9:36 AM identified Resident #17's diet was no added salt and no concentrated sweets. On 12/11/23 residents' weight was 235.9 lbs. Resident continues to feed him/herself and oral intake is consistently documented at 75-100%, with no problems chewing or swallowing. Resident has diagnosis of dementia and new goal is for weight maintenance. A review of the clinical record failed to identify Resident #17 usual and/or ideal body weight. The care plan was revised on 12/13/23 to identify at risk for nutrition and dehydration related to dysphasia. Interventions included providing diet as ordered and Resident #17 will maintain weight of 236 lbs. plus or minus 5 lbs through next review. The Weight Summary Form identified Resident weight on 12/25/2023 at 8:55 PM was 239 lbs. A physician's order dated 1/3/24 directed to provide shower, body audit, and weight every Monday 3:00 PM -11:00 PM shift. The dietitian progress note dated 1/3/2024 at 12:03 PM identified Resident #17 was scheduled for a significant change due to a left ankle fracture. There is no change in residents' nutritional status related to this change. Care plan remains as outlined. The Weight Summary Form dated 1/8/24 identified Resident #17's weight was 224 lbs., a weight loss from 12/25/23 of 15 lbs. which represented a 6.3 % weight loss. Additionally, had an 11.8 lbs. representing a 5% weight loss from 12/11/23, and had an 18.6 lbs. weight loss representing a 7.7% weight loss since 10/9/23. Weight Summary Form dated 1/10/24 identified Resident #17's weight was 221.9 lbs., identified it was a 14 lb. and 6% weight loss since 12/11/23 and 18.6 lb. and 7.7% weight loss since 10/23/23. Weight Summary Form dated 1/23/24 identified Resident #17's weight was 220.6 lbs. identified it was an 18.4 lbs. and 7.7% weight loss since 12/25/23. Weight Summary Form dated 2/12/24 identified Resident #17's weight was 219.5 lbs. identified it was a 19.5 lbs. and 8.2% weight loss since 12/25/23. Interview and clinical record review with the Dietitian on 4/8/24 at 12:00 PM, failed to provide documentation that she had assessed Resident #17 after the noted weight loss on 1/8, 1/10, 1/23, and 2/12/24 and brought it to the weekly meeting with the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise. The Dietitian had assessed Resident #17 on 12/13/23 and then did not see Resident #17 until 3/8/24. Review of the facility Nutritional Care of Residents for Weight Loss and Gain Policy identified to assist in maintaining each resident as closely as possible to their ideal body weight. All residents will be assessed by the dietitian and the dietitian will define the ideal body weight for individual residents. When there is an unexplained weight loss or gain, nursing will reweigh the resident to check for accuracy of the weight. If there is a 5% weight loss in a month or a 10% weight loss in 6 months, the charge nurse shall notify the physician, the dietitian and the residents care plan will be updated with the new interventions to prevent any further unwanted weight loss. If there is a significant unplanned weight loss or gain the dietitian will assess the resident and will make appropriate recommendations to address the loss or gain. Review of the dietitian job description identified she was responsible for assessing resident's dietary needs through interviews, assessments, and collaboration with other team members.

Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #37) reviewed for accidents, the facility failed to ensure adequate nursing staff was available to provide close monitoring for a resident with multiple falls per facility policy. The findings include: Resident # 37 was admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, and dementia. The admission MDS assessment dated [DATE] identified Resident # 37 had severely impaired cognition, was always continent of bowel and bladder, required substantial assistance from staff with bathing and moderate assistance with toileting and transfers. The MDS further identified Resident #37 had a history of falls in the month prior to admission to the facility and had at least one following admission to the facility. The care plan dated 11/26/23 identified Resident # 37 was at risk for falls due to functional decline and a history of repeated falls and included a new intervention of a need for a 1:1 sitter. Review of the clinical record and facility accident/incident reports identified Resident #37 had a total of 12 falls at the facility between 11/2/23-3/21/24. A daily nursing roster report dated 4/7/24 provided to the survey team upon entrance to the facility identified Resident #37 was on every 15 minute checks. Review of the clinical record identified Resident #37 was on 1:1 monitoring as a nursing measure on 4/7/24 Review of the daily staffing sheet for 4/7/24 identified NA #1 was assigned as the sitter for Resident #37's unit. Observation on 4/7/24 at 7:46 AM identified Resident #37 sleeping in bed in his/her room. During this observation, no staff member was identified in the room. During this observation, NA #1 was observed assisting another resident in the same hallway as Resident #37. Observation on 4/8/24 at 8:45 AM identified NA #1 in Resident #37's room. NA #1 was assisting Resident #299, Resident #37's roommate, with dressing. NA #1 was observed with her back turned to Resident #37, who was seated across the room in a chair. Interview on 4/8/24 at 10:00 AM with RN # 2 (unit manager) and LPN #3, who was assigned to care for Resident #37, identified Resident #37 had a nursing intervention in place for 1:1 monitoring and that providers at the facility did not place monitoring orders for residents. RN #2 identified that a sitter was listed on the daily nursing schedule to be assigned to residents who required 1:1 monitoring, but due to staffing issues, 1:1 monitoring could not always be provided. RN #2 identified that depending on staffing, monitoring for Resident #37 would fluctuate between 1:1 monitoring, every 15-minute checks, every 30 minute checks, or every hour checks. LPN #3 identified there was always a staff member checking in on Resident #37, even if it was not 1:1 and that when the sitter assigned to care for Resident #37 would go on break or lunch, that Resident #37 would not have a sitter assigned to cover this time, rather, staff would just go in and do frequent checks on the resident. RN #2 identified that Resident #299 had recently been put on 1:1 monitoring due to a recent fall, and that he/she was moved to the same room as Resident #37 to allow for one sitter to be assigned to both residents. RN #2 identified that the facility did not have the staffing for each resident to have a staff member assigned individually and that the staff member assigned to complete 1:1 monitoring for more than one resident was expected to also complete any ADL assistance, including assistance with toileting, daily care, personal hygiene, and transfers. Observation and interview with NA #1 on 4/8/24 at 1:15 PM identified that she was the primary day shift staff member assigned to complete 1:1 monitoring for Resident #37. NA #1 identified that while the schedule would identify her assignment as a sitter for Resident #37, this often changed due to short staffing due to call outs. NA #1 identified that she had been assigned to care for both Resident #37 and Resident #299 as a 1:1 and that any staff member in the facility would be assigned to care for both residents as a 1:1, and that would include all care that would be provided to both residents during the shift. NA #1 also identified that when she was assigned to care for Resident #37, she was also responsible to document her observations on the form for every 15 minute checks. NA #1 identified that prior to 4/8/24, she had not been assigned to complete any 1:1 monitoring or care for Resident #37 for over a week due to staffing and assignment changes, and had not been assigned to care for or provide monitoring for Resident #37 on 4/7/24. During this observation, NA #1 was observed sitting with both Resident #37 and #299 in the unit's resident dining room. Interview with the DNS on 4/8/24 at 2:24 PM identified that the facility policy did not require that frequent monitoring, whether it be hourly, every 30 minute, 15 minute, or 1:1 continuous monitoring, have a physician's order. The DNS identified that the facility would decide on the level of monitoring needed on a case by case basis and that the facility policy for residents with a history of falls allowed for purposeful rounding, which required staff to check on residents hourly, and that level of monitoring would change depending on the resident's needs. The DNS identified that she was aware of Resident #37's history of repeated falls with current 1:1 monitoring. The DNS identified that 1:1 monitoring in the facility was to be conducted with one staff member and one resident, and that the assignment be 1 person to 1 resident. The DNS identified she was not aware that the staff had adjusted Resident #37's monitoring based on staffing issues, or at times the monitoring intervention in place was not being carried out at all due to staffing issues. The DNS identified she did review Resident #37's case and history of falls weekly at-risk management meeting but did not review staffing or the monitoring sheets to determine if that may be part of Resident #37's issue with repeated falls. The DNS identified that she would re-educate the staff on 1:1 monitoring, and that Resident #37 should have only have one staff member assigned to him/her exclusively if he/she required 1:1 monitoring. Interview with APRN #1 on 4/9/24 at 12:45 PM identified that she was aware of Resident #37's history of repeated falls and that he/she often required either 15 minute checks or 1:1 monitoring. APRN #1 identified that the monitoring was not a provider directed order in the resident's chart, but a nursing intervention, but that the level of monitoring was determined based on the resident's risk and discussion between her and the DNS, and at times also Resident #37's physician. APRN #1 identified that she was not aware that the monitoring put in place was altered based on the nursing staffing levels and was not being done at times and identified staffing has been an issue everywhere. APRN #1 identified that her expectation would be that the monitoring level discussed with the DNS, whether it be every 15 minutes or continuous 1:1 monitoring, be carried out to ensure the resident's safety. The facility policy on falls directed that residents at risk for falls would have fall prevention and precautions implemented as appropriate and that all falls would be reviewed during at risk meetings, monthly, and as needed to identify trends and any common causes. The policy further directed that interventions would be utilized for patients that were fall risks, including purposeful rounding and at times may require a 1:1 sitter. The policy identified that as part of the fall prevention program, the facility staff would complete purposeful rounding, which included rounding on all residents of the facility hourly to determine if the residents required any assistance or needed any items (tissues, something to eat/drink, etc) to help with fall prevention.

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 5 residents (Resident #16) reviewed for unnecessary medications, the facility failed monitor targeted behaviors for antipsychotics use. The findings include: Resident #16 was admitted to the facility with diagnoses which included bipolar disorder, dementia, depressive episodes, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #16 had intact cognition, did not display physical or verbal behaviors towards others, no hallucinations or delusions, no rejection of care or wandering. Resident #16 receives antipsychotics and antidepressants in the last 7 days. The care plan dated 2/7/24 identified daily use of psychotropic medication related to bipolar disorder with anxiety and depression. Interventions included to administer medications as ordered, monitor for side effects including movement disorder, discomfort, hypotension, gait disturbance, constipation or cognitive/behavioral impairment, and physician to consider dose reduction when clinically appropriate. The psychiatric APRN progress note dated 2/15/24 indicated Resident #16 was on Zoloft and Zyprexa daily and Trazodone (start date unknown) twice a day as needed for 30 days. Resident #16 chooses to stay in bed and self-isolate at baseline. Resident #16 and staff deny any concerns for adverse reactions for psychotropic medications. A physician's order dated 2/21/24 directed to document on behavior monitoring flow sheet every shift. Olanzapine Oral Tablet 5 MG (Zyprexa an antipsychotic) give 5 mg by mouth at bedtime for depression, Sertraline HCl Oral Tablet (Zoloft an antidepressant) give 100 mg by mouth one time a day for depression. Additionally, Trazadone 25 mg (a sedative, original order dated 12/29/23) twice a day as needed for 60 days and then re-evaluate. The psychiatric APRN progress note dated 2/26/24 indicated to monitor behaviors of concern: disorganized behaviors, delusions, and restlessness. Resident #16 is currently hypomanic. The physician progress note dated 3/4/24 indicated Resident #16 was seen to help with dealing with grief of losing roommate. Resident #16 does not present an active delusion process. The progress note did not reflect the rationale to continue the use Trazadone 25mg as needed for 60 days. A physician's order dated 3/4/24 directed to give Trazodone HCl Oral Tablet (Trazodone HCl) give 25 mg by mouth twice a day as needed for anxiety/sleep for 60 Days and have APRN re-evaluate Trazodone order in 6o days. Interview with the DNS on 4/7/24 at 2:30 PM indicted that the licensed nurses must document every shift for targeted behaviors for Resident #16 on antipsychotic medication which id located in the electronic health record. Interview and clinical record review with the DNS on 4/8/24 at 1:30 PM indicated that the behavior flow sheets that were provided contained the signatures of the nursing assistants and some from the nurses. Review of the flow sheets with the DNS indicated that for example on 3/11/24 the day and evening shift it was the nurse that documented but on 11-7 it was only the nursing assistant that signed off on the behaviors. The DNS indicated that the behaviors for Resident #16 was a computerized template and not targeted behaviors for Resident #16 specifically. The DNS indicated that it was supposed to be individualized for the behaviors that the resident exhibits. The psychiatric APRN progress note dated 4/9/24 indicated behaviors of concern to monitor for Resident #16 were delusions, hallucinations, paranoid, and restlessness. Review of the 3/1/24-4/8/24 identified the licensed nurses were signing off every shift on the physician order that they would document behaviors on the behavior monitoring flow sheet every shift. Review of the March 2023 behavior monitoring flow sheet there were 50 behaviors listed. The DNS and the Administrator identified Licensed nursing staff signed off on 60 shifts out of 93 opportunities for monitoring behaviors and the nursing assistants documented on 31 shifts. There were 2 days on the 11:00 PM -7:00 AM shifts missing signatures on 3/13/24 and 3/24/24. Review of the 4/1/24-4/8/24 behavior monitoring flow sheet the DNS and the Administrator identified the Licensed nursing staff signed off on 15 shifts out of 24 opportunities for monitoring behaviors and the nursing assistants documented on 7 shifts. There was 1 shift missing documentation on 4/1/24 on the 11:00 PM -7:00 AM shift. Review of the facility Antipsychotic Drug Use Indications Policy identified the facility was to utilize antipsychotic drugs to treat specific indications as endorsed by the Pharmacy and Therapeutics Committee. Antipsychotic drugs should not be used unless the clinical record documentation shows the resident has one or more of the following specific conditions as Schizophrenia, Schizoaffective disorder, Psychotic mood disorder, acute psychotic episodes, Tourette's disorder, Huntington's disease, and organic mental syndrome (including dementia) with associated psychotic and/or agitated features as defined as specific behaviors such as specific quantitative (number of episodes) and objectivity such as hitting, biting, kicking, scratching, documented by the facility which causes the resident to actually interfere with staff's ability to provide care and continuously crying out, screaming, yelling, pacing if these behaviors cause impairment in functional capacity and if they are quantitative and psychotic symptoms such as hallucinations, paranoia, and delusions exhibited as specific behaviors. All anti-psychotic and psychotropic medications that are ordered as needed are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on review of the clinical record, review of facility documentation, and interviews for 1 sampled resident (Resident #145) reviewed for medication error, the facility failed to ensure a laboratory test was obtained per physician's order for a resident receiving an anticoagulant medication which resulted in a significant medication error as the anticoagulant medication was not administered for 13 days. The findings include: Resident #145 was admitted to the facility in January 2023 with diagnoses which included prosthetic heart valve, endocarditis, atherosclerotic heart disease, and congestive heart failure. The admission MDS assessment dated [DATE] identified Resident #145 had severely impaired cognition and required extensive assistance with personal hygiene. The January 2023 care plan dated identified Resident #145 was at risk for abnormal bleeding related to use of anticoagulation status-post Surgical Aortic Valve Replacement (SAVR). Interventions included administering anticoagulant as ordered, schedule laboratory tests as ordered by the physician to monitor coagulation factors and report abnormal results to the physician. A physician's order dated 2/1/23 directed to administer Coumadin (anticoagulant medication) 4mg at bedtime until 2/2/23. The nurse's note dated 2/2/23 at 4:32 PM identified laboratory test INR (International Normalized Ratio) (blood test that tells how long it takes for blood to clot) result was 2.1. APRN was notified with a new order for Coumadin 4mg at bedtime was obtained and to . check laboratory test INR on 2/7/23. Review of the Medication Administration Record (MAR) dated 2/1/23 - 2/28/23 identified Resident #145 received Coumadin 4mg at bedtime on 2/1/23 through 2/6/23. The MAR failed to reflect documentation that Coumadin was given on 2/7/23 through 2/19/23 (total of 13 days without Coumadin). Coumadin 5mg at bedtime was then restarted on 2/20/23. Review of the MAR dated 2/1/23 - 2/28/23 identified LPN #2 signed on 2/7/23 that laboratory test INR was obtained. A review of Resident #145's clinical record failed to reflect documentation that a laboratory test INR was obtained on 2/7/23. Review of the nurse's note and nursing assessment dated [DATE] through 2/28/23 failed to reflect documentation of Resident #145 had a laboratory test for INR on 2/7/23 and missed 13 days of Coumadin therapy. Review of the protime and INR lab results report dated 2/20/23 identified prothrombin time 11.6 and INR 1.10 (therapeutic range: 2.0 - 3.0). A physician's order dated 2/20/23 direct to administer Coumadin 5mg at bedtime until 2/23/23. Check laboratory test INR on 2/23/23. The reportable event report dated 2/24/23 at 10:30 AM identified Resident #145 did not receive Coumadin for 13 days. Resident #145 laboratory test INR result was 1.10 on 2/20/23 when the discovered missed Coumadin doses was noted. Per the cardiologist, Resident #145 therapeutic range was 2.0 - 3.0. Resident #145 was restarted on Coumadin. The cardiologist, MD #1, and the Administrator were made aware of the medication error. Resident #145 was alert and confused. Laboratory test INR ordered, and Coumadin dose was changed based off the INR result. The interview and clinical record review with LPN #2 on 4/8/24 at 2:57 PM identified she was responsible for obtaining the INR on 2/7/23 at the beginning of the shift 7:00 AM - 3:00 PM shift. LPN #2 indicated she tried to do the INR twice and could not get a reading from the INR machine. LPN #2 indicated she notified RN #2 who informed her that INR was going to be done by the laboratory. LPN #2 indicated she did not follow up to see if the INR was done. Interview with APRN #1 on 4/9/24 at 12:29 PM identified she was aware of the issue the same day the error was discovered. APRN #1 indicated the facility notified her Resident #145 INR was not obtained on 2/7/23 as ordered and the Resident #145 did not receive Coumadin from 2/6/23 to 2/20/23. APRN #1 indicated on 2/20/23 she ordered labs and Coumadin 5mg at bedtime. APRN #1 indicated the nursing staff should have followed the physician's order and make sure the INR was done on 2/7/23. APRN #1 indicated there were no adverse effects or clinical changes to Resident #145. Although attempted, an interview with MD #2 (cardiologist) was not obtained. Review of the facility INR (International Normalized Ratio) (blood test that tells you how long it takes for your blood to clot) Testing policy identified to assess blood coagulation level. Licensed nursing staff will perform this procedure per physician's order. Review of the facility drug administration guidelines policy identified to provide a standard administration time for medication at the facility. All nurses will follow the five guidelines to ensure safe drug administration include the right resident/patient, the right drug, the right dose, the right route, and the right time/frequency.

Based on observation, facility documentation, facility policy and interviews, the facility failed to ensure the glucometer was sanitized after use and hand hygiene performed per policy and professional standards of care. The findings include: Resident #245 was admitted to the facility on [DATE] with diagnosis which included Type 2 Diabetes, muscle weakness, and congestive heart failure. The nursing assessment dated [DATE] identified Resident #245 was alert, forgetful, and confused and oriented to person and place. The care plan for Resident #245 dated 4/1/24 identified a focus on both nutrition and hydration with interventions that included to provide diet as ordered, and labs as ordered. The physician's orders dated 4/1/24 identified Resident #245's blood sugar should be monitored before meals and at bedtime, and to administer Lispro (insulin) via a sliding scale based upon blood sugar level. Observation on 4/7/24 at 7:45AM identified LPN #1 obtaining a blood sugar level for Resident #245. LPN #1 obtained a blood sugar of 187 mg/dl, exited the room wearing gloves and placed the glucometer on top of the medication cart. LPN #1 removed her gloves, discarded the lancet used to obtain the blood sugar in the appropriate container and performed hand hygiene, repositioned the glucometer with her recently sanitized left hand, entered the blood sugar into the computer and proceeded to open an alcohol swab to clean the top of the bottle of Lispro (insulin) to administer 2 units as ordered for administration without the benefit of hand hygiene. The surveyor stopped the administration prior to the insulin syringe being inserted for the insulin draw to inquire about hand hygiene. LPN #2 indicated she did not perform hand hygiene after touching the glucometer. LPN # 1 proceeded to go to the room across the hall to Resident #7 and # 246. She identified both were due for blood sugar monitoring prior to breakfast. LPN #1 inserted the glucometer strip into the glucometer and proceeded with unopened alcohol swabs and a lancet to enter the room. The Surveyor asked that she stop and inquired of her knowledge of facility policy for glucometer cleaning. She identified she did not know. LPN #1 returned to the cart stating she asked a coworker who advised her to use the Sani-Purple wipes which have a noted dwell time of 2 minutes. LPN #1 wiped the unit with the Sani-Purple wipe as she claims she was instructed to do and immediately proceeded to insert the lancet. The surveyor inquired about adequate dwell time to which LPN #1 was uncertain. LPN #1 called the supervisor, RN #1, who identified the policy to clean glucometer and perform hand hygiene are on the cart and proceeded share the policies with LPN #1. RN #1 advised LPN #1 that she should have napkins to position the glucometer on after wiping for the dwell time, and RN #1 secured napkins from another cart and instructed LPN #1 on the proper cleaning. LPN #1 cleaned the glucometer as instructed and noted per policy the dwell time is an additional 2 minutes for a total of 4 minutes before the glucometer is considered sanitized for subsequent use. Interview with RN #4 and the ADNS/Staff Development 4/9/24 at 9:30AM identified agency staff are briefed on facility policy upon initial entrance into the facility. The overview generally takes 1 hour to complete. She identified LPN #1 was educated on glucometer cleaning and the policy is also visible on all medication carts should there be a question. Interview with the DNS on 4/9/24 at 10:40AM identified all licensed agency staffing receive an overview of policies and procedures including glucometer cleaning upon entrance into the facility. LPN #1 should have followed the policy for glucometer cleaning to ensure the safety of the residents. Subsequent to surveyor inquiry, the facility initiated an inservice on Glucometer Disinfecting which states Staff should follow facility policy and steps for cleaning and disinfecting the glucometer before and after each use. The instructions for glucometer use located on the med carts included 28 steps with a dwell time of 2 minutes for the Purple Cap Wipes PDI and a bleach wipe dwell time of 4 minutes. The manufacturer's recommendations for this glucometer suggest the use of a germicidal bleach wipe, and a dwell time for 1 minute and allow to air dry for an additional minute for a total of 2 minutes. The policy for cleaning and disinfecting the glucometer includes after securing the blood sugar, disinfecting the glucometer (Sani-wipes or Purple Cap Wipes PDI-dwell time 2 minutes) after each use.