Every finding on record at Harmony House Health Care Center

Based on record review, interviews, policy review, the facility failed to ensure specialized respiratory care was safely provided by qualified personnel for 4 of 4 residents on mechanical ventilation (a life-support treatment that uses a machine to move air in and out of your lungs when you cannot breathe adequately on your own). The facility utilized floor staff to work in the respiratory therapy department and allowed a Licensed Practical Nurse (LPN) to function as the sole licensed nurse onsite without a Registered Nurse (RN) or Respiratory Therapist (RT) present in the building (Resident #1, #5, #6, and #11). The facility reported a census of 51 residents. Findings include:The facility provided an undated document titled Residents with Vents (Ventilators) that revealed four residents at the facility required mechanical ventilation (life-support breathing treatment). The list included Resident #1, Resident #5, Resident #6, and Resident #11. Review of the facility's May June Respiratory and Nursing schedule revealed on [DATE] from 6:00 PM to 6:00 AM, [DATE] from 6:00 PM to 6:00 AM, and [DATE] from 10:00 PM to 6:00 AM, Staff E, a Licensed Practical Nurse (LPN), worked as the only licensed nurse onsite. 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of [DATE]. Resident #1 achieved a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 depended on staff for toileting and bathing, didn't get out of bed, and needed supervision or touching assistance with rolling in bed. Resident #1 had diagnoses of diabetes (high blood sugar), malnutrition (poor nutrition), depression, psychotic disorder (severe mental condition), anxiety, respiratory failure (breathing failure), dependence on respirator status, and myotonic muscular dystrophy (progressive muscle weakness). Resident #1 didn't complete any restorative nursing programs in the past seven days. 2. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of [DATE]. Resident #5 had short-term and long-term memory problems and severely impaired cognitive daily decision-making skills. Resident #5 depended on staff for all activities of daily living (ADLs) and couldn't stand or walk. Resident #5 required a feeding tube, a tracheostomy (breathing tube), and an invasive mechanical ventilator (breathing machine). 3. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed an admission date of [DATE]. Resident #6 had short-term and long-term memory problems and severely impaired cognitive daily decision-making skills. Resident #6 depended on staff for all ADLs and couldn't stand or walk. Resident #6 required a feeding tube, a tracheostomy, and an invasive mechanical ventilator. 4. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of [DATE]. Resident #11 achieved a BIMS score of 13, indicating intact cognition. Resident #11 needed supervision or touching assistance with transfers and walking. Resident #11 had diagnoses of anxiety, respiratory failure, and dependent on respirator status. On [DATE] at 1:56 PM, Staff D, an Agency Licensed Practical Nurse, stated the facility pulled LPNs to do respiratory care. Staff E worked as a Respiratory Therapist (RT), and the facility had no Registered Nurses (RN) on duty and no RT in the building. Staff E worked by herself and quit. It happened maybe three to four weeks ago. On [DATE] at 2:50 PM, Staff F, the Human Resources (HR) Coordinator, informed that Staff E worked three days as an RT. Staff E worked as the RT on [DATE], [DATE], and [DATE]. She worked as the only one in the role those days. On [DATE], [DATE], [DATE], [DATE], and [DATE], the facility had Staff H, an RN, working. On [DATE] at 1:21 PM, Staff K, a Respiratory Therapist, stated an RT program requires a two-year degree with five semesters and four months of clinical experience. She expressed that an RN couldn't manage a vent; they could do a breathing treatment, but they couldn't manage anything with the vent. An LPN couldn't do it because it requires a lot of school. Really bad things could happen if no RT worked onsite because staff cannot mess with the vents and it's risky. Staff would have to bag (manually pump air into) the resident and do Cardiopulmonary Resuscitation (CPR) until the ambulance arrived. The facility had no RT onsite a couple of times that she heard of, and it's too risky. If a trach fell out, they'd take the patient off the vent and start bagging through the trach until the ambulance arrived. If they still couldn't get a good oxygen saturation (blood oxygen level), staff would have to cover the stoma (surgical neck opening) and go by mouth to figure out if the airway remained clear. It requires a lot of critical thinking. On [DATE] at 3:13 PM, the Director of Nursing (DON) stated typically one RT covers the facility and works from 6:00 AM to 6:00 PM. The facility experienced turnover in that department and utilized floor staff to work in the RT department. The nurses completed competencies and took a quiz before they could do the RT role, and preferably the respiratory therapist should go over it with them. She honestly didn't know offhand what nurses completed training in that role. Usually they worked as the RT during the day. She personally did it during the day, and she did it this past Saturday. The RT completes all trach care, breathing treatments, inner cannula (inner tube) changes, vent checks, and vent alarm checks. They have four residents on ventilators. Staff M and Staff P, both RTs, trained the DON, and a corporate nurse consultant provided the competencies to go over. The first time a nurse worked as an RT occurred probably in December on Christmas, and involved her. On [DATE] at 11:10 AM, Staff M stated they had to adjust vent settings for the residents, including changing the mode, tidal volume (breath volume), and respiratory rate (breathing speed). She changed the mode for Resident #5. She didn't feel like an RN or LPN could work in the facility alone without an RT onsite. She voiced her concern because they had nurses working the floor. She felt concerned with the trachs if they fell out. Management instructed staff to just bag the resident, and that's not going to save them. She also found tubing that a nurse rotating as an RT took off. She felt staff didn't have enough knowledge to safely care for the residents. Nothing really bad happened but it could. Staff don't have in-depth diagnostic training or the training besides just suctioning. RTs know how to look for leaks because they're drilled in school since this is intensive care. If a trach falls out, that's their main airway, and if a blockage occurred, she questioned how staff bagged them. She didn't think a resident would last very long. If a mucus plug occurred, they probably needed deep suctioning. RTs can take care of that pretty fast, and she didn't feel sure if nurses knew how to look or do that. Resident #11 dropped to the 70s when she got sick, and depending on her situation, she might need a different mode. It acted pretty fast. She thought the nurses might know how to assess to give an as-needed Albuterol (bronchodilator) (breathing medicine) treatment, but they cannot wait four hours and have to override that for an asthmatic exacerbation (asthma attack). If low levels occurred, staff must critically think to try and do everything in-house. Sometimes they'll try many things and then change the trach as a last resort. She completed some of the training with the nurses, but they didn't really pay attention. She had to train them and tell them to focus on her because they kept going back to nursing. On [DATE] at 12:57 PM, the Nurse Practitioner (NP) stated she wasn't very familiar with regulations and the nurses they have working are knowledgeable. She preferred an RT be on duty in case something happened to cause a distraction. It caused more concern if only an LPN worked on duty. On [DATE] at 1:36 PM, Staff O, a Nurse Practitioner, stated it concerned her if no RT remained in the building. On [DATE] at 3:11 PM, the Administrator stated she received education and instruction that LPNs will no longer work as RTs. They're piecing together RN training to ensure they have proper training to work as RTs. The Medication Administration policy dated as an undated document instructed that the corporation doesn't have a policy for medication administration but follows the national standard of the 5 rights of administration. The Professional Nurse Coverage policy dated as an undated document instructed that the corporation doesn't have a professional nurse coverage policy but follows professional standards of nursing delegation. The Vent Check Competency policy dated [DATE] instructed only the Respiratory Therapist adjusted settings. Nurses who completed training in RT received direction to call 911 if vent settings required changes and an RT didn't work in the facility.

Based on record review and interview, the facility failed to ensure residents with contractures (shortened muscles) received necessary restorative nursing care to maintain or improve functional potential. Specifically, management canceled passive range of motion (PROM), active range of motion (AROM), and walking programs for Resident #2, Resident #6, Resident #7, Resident #8, and Resident #10 without documenting a clinical rationale in the progress notes. The facility lacked trained or dedicated staff to deliver restorative care interventions. The facility reported a census of 51 residents.Findings include:Review of an undated list titled Contractures identified eight residents currently living in the facility with contractures (shortened muscles). The list included Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #10. 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] listed Resident #2 sometimes understood others and sometimes could make others understand them. The MDS assessment showed a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview couldn't be completed. The Staff Assessment for Mental Status listed Resident #2 possessed short- and long-term memory problems, with severely impaired cognitive skills for daily decision making. Resident #2 exhibited a functional limitation in range of motion impairments to both sides of the body on the upper and lower extremities. Resident #2 required total assistance from staff with personal hygiene. Diagnoses included contracture (permanent muscle tightening) of the right elbow, unspecified lack of coordination, hemiplegia (one-sided paralysis) or hemiparesis (one-sided weakness), and other dystonia (involuntary muscle contractions). Resident #2 received Occupational Therapy (OT) and Physical Therapy (PT) for 15 minutes a day on one or more days in the last 7 days. The Restorative Nursing Programs section indicated Resident #2 didn't receive restorative care for at least 15 minutes in the look-back period. The Care Plan Focus revised 6/22/26 indicated Resident #2 carried a risk for alteration in skin integrity (skin breakdown) due to contractures and limited physical mobility. The interventions directed the following: monitor skin to bilateral upper extremities (both arms) before applying resting hand splints (supportive hand braces); use prevention/positioning devices as needed; utilize a rolled-up washcloth in palms of hands until new splints arrive; and utilize a rolled-up washcloth between the right shoulder and neck. On 6/22/26 at 2:18 PM Resident #2 Representative stated Resident #2 previously lived at a different facility and could feed himself, but he no longer maintained that ability because his muscles completely contracted. The Encounter Note dated 3/10/26 at 12:00 AM reflected Resident #2 received PT and OT for 7 days under a restoration care plan. The Encounter Note dated 3/17/26 at 12:00 AM identified Resident #2 had contractures that kept his neck and arm tight to his body with contractures at the elbow and wrist. The staff reported he had redness and moisture in those areas, specifically the right neck, right antecubital fossa (inner elbow crease), and right axilla (armpit). Resident #2 experienced chronic issues with drooling and excessive sweating. The note indicated staff discussed no specific changes or interventions. The Communication - with Physician dated 3/17/26 at 10:03 AM documented the Primary Care Provider (PCP) gave new orders to apply Calmoseptine (healing ointment) to the right neck and axilla twice a day until resolved, then use Vaseline (petroleum jelly) to areas of moisture to protect the skin. Resident #2's Task Description listed a task to apply rolled wash towels for grip while in the wheelchair and remove them while in bed. The task required staff to replace the towels daily or sooner if soiled. The description instructed staff to apply a cervical cushion (neck pillow) or towel roll on the right side of the neck in the morning, remove it at lunch, reapply it at 2:30 PM, and remove it at dinner. The Task Description listed the following tasks as resolved:Neck pillowRestorative Active Assistive Range of Motion (AAROM): aquatics program twice a week5/8/26: Restorative Passive Range of Motion (PROM): cervical, upper extremities, and lower extremitiesUpper extremity splints Resident #2's March 2026 Documentation Survey Report v2 listed the following interventions and tasks: restorative PROM: cervical, upper extremities, and lower extremities. Documentation indicated Resident #2 refused restorative care on 3/18/26. The location for documentation remained blank for the following dates: 5/4/26, 5/11/26, 5/23/26, and 5/30/26. For the splint or brace (upper extremities, neck) task, the documentation lacked entries for the following times and dates:8:00 AM: 3/1/26, 3/5/26, 3/26/26, 3/11/26 - 3/13/26, 3/17/26, 3/20/26, 3/22/26, 3/24/26, 3/26/26, 3/29/26, and 3/31/2612:00 PM: 3/1/26, 3/5/26, 3/26/26, 3/10/26 - 3/13/26, 3/17/26, 3/20/26, 3/22/26 - 3/24/26, 3/26/26, and 3/31/262:30 PM: 3/6/26, 3/9/26, 3/10/26, and 3/28/266:00 PM: 3/6/26, 3/9/26, 3/10/26, and 3/28/26 Resident #2's May 2026 Documentation Survey Report v2 listed the following interventions and tasks: restorative PROM: cervical, upper extremities, and lower extremities. The location for documentation included x's indicating the tasks did not fall due for the month except on 5/4/26 and 5/6/26. On 5/4/26, the documentation reflected Resident #2 refused to do restorative care, and 5/6/26 remained blank. For the splint or brace (upper extremities, neck) task, the documentation lacked entries for the following times and dates:8:00 AM: 5/6/26 and 5/25/2612:00 PM: 5/6/26 and 5/25/262:30 PM: 5/3/26, 5/4/26, and 5/23/266:00 PM: 5/3/26, 5/4/26, and 5/23/26 Resident #2's June 2026 Documentation Survey Report v2 printed 6/29/26 listed the following interventions and tasks: apply rolled wash towels for grip while in the wheelchair; remove the towel while in bed; replace daily or sooner if soiled; and apply a cervical cushion or towel roll on the right side of the neck in the morning, remove at lunch, reapply it at 2:30 PM, and remove at dinner. The location for documentation remained blank on the following times and dates:2:30 PM: 6/2/26, 6/9/26, and 6/24/268:00 PM: 6/2/26, 6/9/26, 6/16/26, 6/24/26, and 6/27/26 Resident #2's June 2026 Treatment Administration Record (TAR) listed the following orders:6/6/26: Apply bilateral resting hand splints while up in the wheelchair every day and evening shift. The facility discontinued the order on 6/22/26. The record lacked documentation on 6/19/26 for the 6:00 AM - 2:00 PM shift and 6/20/26 for the 2:00 PM - 10:00 PM shift.6/6/26: Remove bilateral resting hand splints while in bed (wipe off splints and hands after removing) every day and evening shift. The facility discontinued the order on 6/22/26. The record lacked documentation on 6/19/26 for the 6:00 AM - 2:00 PM shift and 6/20/26 for the 2:00 PM - 10:00 PM shift.6/23/26: Apply rolled up washcloth into bilateral palms when out of bed (cleanse hands and inspect prior to application) every day and evening shifts for contractures. The record lacked documentation on 6/27/26 for the 6:00 AM - 2:00 PM shift.6/23/26: Apply rolled up washcloth between the right shoulder and neck when out of bed (cleanse neck and inspect prior to application) every day and evening shifts for contractures. The record lacked documentation on 6/27/26 for the 6:00 AM - 2:00 PM shift.6/23/26: Remove rolled up washcloth into bilateral palms when out of bed (inspect palms after removing) every day and evening shifts for contractures. The record lacked documentation on 6/27/26 for the 6:00 AM - 2:00 PM shift.6/23/26: Apply rolled up washcloth between the right shoulder and neck when out of bed (inspect neck after removing) every day and evening shifts for contractures. The record lacked documentation on 6/27/26 for the 6:00 AM - 2:00 PM shift. The Orders - Administration Note dated 6/4/26 at 1:43 PM reflected Resident #2 received an order for betadine swabs to the small open area midline right collarbone area until resolved for skin healing for 5 days. The Encounter Note dated 6/5/26 at 12:00 AM identified the provider saw Resident #2 due to a new area of skin breakdown on the right clavicle (collarbone)/right neck. The provider considered the area pressure-related and described it as resembling moisture-associated skin damage (MASD) (moisture skin damage). The section for skin/breast reflected MASD and a stage 2 pressure ulcer. The section related to skin listed a stage 2 pressure injury over the right clavicle/right neck region measuring 2 centimeters (cm) x 2 cm. The wound bed appeared pink and dry, consistent with MASD. The General Progress Note dated 6/5/26 at 11:42 AM indicated the PCP gave new orders to clean Resident #2's wound on the right side of his neck, apply Xeroform dressing (medicated gauze) to the wound, cover it with 2x2 gauze and tape, and place an ABD pad (absorbent pad) to keep it dry every day until healed. The General Progress Note dated 6/9/26 at 2:40 PM reflected the Administrator (facility manager) notified the Dietitian (nutrition manager) of the pressure ulcer to Resident #2's right clavicle. The Dietitian planned to review Resident #2's information for recommendations. The General Progress Note dated 6/11/26 at 1:15 PM described Resident #2's wound on his neck as healing well. The wound measured 1.75 x 1.75, and staff noted scant serous drainage (clear fluid) on the dressing. The General Progress Note dated 6/15/26 at 8:50 PM indicated the Administrator talked to the doctor and Nurse Practitioner (NP). The doctor reported neither provider believed his wound related to pressure, but rather resulted from moisture from sweat and drooling. The providers classified the area as MASD at the time. The Encounter Note dated 6/16/26 at 12:00 AM listed Resident #2 possessed an area that the provider described as a stage 2 pressure ulcer. The provider described the area as very moist and associated the moisture with Resident #2 keeping his head tilted toward the area. The order for Calmoseptine and Mepilex (foam dressing) kept the area too moist. Resident #2 had contractures to his right wrist and right ankle. The section related to skin listed an open, very moist pressure ulcer (stage 2) over the right clavicle/right neck region. The plan listed a referral to dermatology (skin specialty) per his mother's request to the facility for neck redness. The Order Note dated 6/17/26 at 3:38 AM indicated the NP gave an order to discontinue Calmoseptine to the neck area, apply xeroform to the right clavicle area twice a day, and cover it with a 2x2 gauze and tape. The order directed staff not to use Mepilex because it kept the area too moist. On 6/24/26 at 1:56 PM Staff D, an Agency Licensed Practical Nurse (LPN), stated Resident #2 has never spoken to her. She stated he previously had a skin issue on the right side of his neck, but the condition improved. On 6/25/26 at 11:40 AM Staff I, a Certified Nursing Assistant (CNA), stated Resident #2 becomes stiff frequently and develops yeast infections she thinks, which required a medical topical powder that she applied to his hands. She noted that sometimes when the weather became very hot, staff placed a washcloth in his hand, but they didn't do this every day. She stated she previously applied baby powder, but staff informed her today about the medical topical powder when she asked for the shampoo. She stated she doesn't believe a consistent restorative nursing program exists for Resident #2, but believes Resident #2 would benefit from one. On 6/25/26 at 12:04 PM Staff J stated Resident #2 is stiff when he gets up in the morning, and his morning routine includes a brace on his right arm and a collar on his neck. She stated she has observed staff perform range of motion exercises with Resident #2 only once while shaving him, and she has never completed any range of motion programs with him. On 6/29/26 at 11:48 AM Staff L, a Certified Occupational Therapy Assistant (COTA), stated that she is currently working with him in therapy. She revealed if staff do not apply braces routinely, a resident's contractures can worsen or remain unchanged. She stated he recently got a new brace and that even when she removes Resident #2's braces now, his hands return immediately to a contracted position due to his brain injury. Staff L stated Resident #2's fingers are severely contracted, and when she attempts to apply the braces, he signals that his wrist hurts by blinking his eyes. She stated therapy ordered resting hand splints made of soft plastic, but because they lacked adaptability, staff used rolled washcloths to absorb sweat. She noted she recently ordered a different pair with adaptable metal braces that can be adjusted. Staff L stated Resident #2's muscles pull down severely, and his neck requires a rolled towel to stay contracted as it is, rather than trying to stretch it. She stated she does passive range of motion exercises with him. Staff L completed an Occupational Therapy Discharge Summary for services from 9/19/25 to 12/4/25. Staff L revealed she didn't recommend passive or active range of motion programs because the facility lacked staff to perform them, though she believed Resident #2 would benefit from one. Staff L stated she didn't believe the facility had a restorative program since July 2025. She noted staff just started washing clothes last week and it could've resulted from a miscommunication since she didn't see staff use them prior. On 6/29/26 at 12:57 PM Staff N stated a restorative program would work well for Resident #2, noting she ordered therapy for multiple residents and Resident #2's Representative becomes upset because he doesn't receive a restorative program. On 6/29/26 at 2:17 PM Resident #2's family member stated the family brought Resident #2 to the facility specifically for water therapy because it contained a pool, but he no longer gets into the water. She stated she visited every week and felt the staff didn't know how to care for him, noting they didn't place anything in his hands to keep them open or perform exercises to make him stronger. Resident #2's family member stated his speaking ability has declined significantly, though he can say yes, no, good night, I love you, goodbye, and thank you. She noted he raised his arm to signal yes and frowned without moving his arm to signal no. She stated the facility lacked the necessary help to assist him into the pool, causing him to decline physically, and expressed that only a handful of staff members truly care. On 6/29/26 at 3:11 PM the Administrator stated she worked at the facility for 4 weeks. Regarding Resident #2's discontinued aquatic pool program, she stated she is looking into obtaining a lifeguard and setting up a training course to restart the program. Regarding Resident #2's restorative program, the Administrator stated she is unsure if management will hire someone for the role or train CNAs, noting they need to review all residents to determine who requires a program. She noted an individual informed her on 6/23/26 at 2:48 PM that the restorative program discontinued for Resident #2 because he saw therapy starting in May, and the aquatics program discontinued for everyone as they currently don't have a lifeguard to run the program. 2. Resident #5's Minimum Data Set (MDS) dated [DATE] documented an admission date of 12/10/24. Resident #5 experienced short-term and long-term memory problems alongside severely impaired cognitive daily decision-making skills. Resident #5 possessed functional limitations in range of motion (ROM; joint movement) on both sides of the upper and lower extremities. Resident #5 depended on staff for all activities of daily living (ADL; everyday tasks) and couldn't stand or walk. Resident #5 required a feeding tube, a tracheostomy (breathing tube), and an invasive mechanical ventilator (breathing machine). Resident #5 didn't complete a restorative program for at least 15 minutes a day over the past seven days. Review of Resident #5's Diagnosis Report dated 6/30/26 revealed current diagnoses with an onset date of 12/10/24, which included spastic quadriplegic cerebral palsy (stiff limbs), dependence on a respirator (ventilator), and spina bifida (spine defect). Review of Resident #5's tasks in the Electronic Health Record (EHR) on 6/30/26 revealed Resident #5 didn't have a restorative program in place and hadn't since admission to the facility. 3. Resident #6's Minimum Data Set (MDS) dated [DATE] revealed an admission date of 3/13/25. Resident #6 had short-term and long-term memory problems and severely impaired cognitive daily decision-making skills. Resident #6 experienced functional limitations in ROM on both sides of the upper and lower extremities. Resident #6 depended on staff for all ADLs and couldn't stand or walk. Resident #6 required a feeding tube, a tracheostomy, and an invasive mechanical ventilator. Resident #6 didn't complete a restorative program for at least 15 minutes a day over the past seven days. Review of Resident #6's Diagnosis Report dated 6/30/26 revealed current diagnoses with an onset date of 3/13/25, including spastic quadriplegic cerebral palsy and dependence on a respirator. Review of Resident #6's tasks in the EHR on 6/30/26 revealed Resident #6 didn't have a restorative program in place at this time. Review of Resident #6's task history revealed a passive range of motion (PROM; assisted movement) program to both upper extremities that management canceled on 5/12/26. Review of Resident #6's progress notes for May 2026 lacked documentation explaining the rationale for why the facility canceled the restorative program. 4. Resident #7's Minimum Data Set (MDS) dated [DATE] documented an admission date of 1/29/25. The MDS revealed a BIMS score of 12, indicating moderately impaired cognition. Resident #7 had limited upper and lower functional extremity ROM on one side. Resident #7 required substantial to maximal assistance with transfers and standing, couldn't walk, but moved in a wheelchair independently. Resident #7 didn't complete a restorative program for at least 15 minutes a day over the past seven days. Review of Resident #7's admission Record dated 6/30/26 revealed diagnoses of spastic quadriplegic cerebral palsy, mild intellectual disabilities, hemiplegia (one-sided paralysis) affecting the left nondominant side, and a contracture (shortened muscle) of the left shoulder. Review of Resident #7's tasks in the EHR on 6/30/26 revealed Resident #7 didn't have a restorative program in place at this time. Review of Resident #7's task history revealed a walking restorative program as tolerated and an active range of motion (AROM; unassisted movement) program for grip strength for 15 minutes a day as tolerated that management canceled on 5/8/26. Review of Resident #7's progress notes for May 2026 lacked documentation explaining the rationale for why the facility canceled the restorative program. 5. Resident #8's Minimum Data Set (MDS) dated [DATE] documented an admission date of 5/26/15. Resident #8 had short-term and long-term memory problems and severely impaired cognitive daily decision-making skills. Resident #8 experienced functional limitations in ROM on both sides of the upper and lower extremities. Resident #8 depended on staff for all ADLs and couldn't stand or walk. Resident #8 required a feeding tube and a tracheostomy. Resident #8 didn't complete a restorative program for at least 15 minutes a day over the past seven days. Review of Resident #8's Diagnosis Report dated 6/30/26 revealed a current diagnosis with an onset date of 7/22/25 for a contracture of another specified joint. Review of Resident #8's tasks in the EHR on 6/30/26 revealed Resident #8 didn't have a restorative program in place at this time. Review of Resident #8's task history revealed a PROM restorative program for the upper and lower extremities scheduled twice a week that management canceled on 5/13/26. Review of Resident #8's progress notes for May 2026 lacked documentation explaining the rationale for why the facility canceled the restorative program. 6. Resident #10's Minimum Data Set (MDS) dated [DATE] documented an admission date of 2/6/18. The MDS revealed a BIMS score of 15, indicating intact cognition. Resident #10 had functional limitations in ROM in both lower extremities. Resident #10 depended on staff for all ADLs except upper body dressing and couldn't walk. Resident #10 didn't complete a restorative program for at least 15 minutes a day over the past seven days. Review of Resident #10's Diagnosis Report dated 6/30/26 revealed current diagnoses with an onset date of 2/6/18, including an intracranial injury (brain injury) with loss of consciousness of unspecified duration, chronic pain due to trauma, spastic diplegic cerebral palsy (paralytic stiffness), and quadriplegia (four-limb paralysis). Review of Resident #10's task history revealed an assisted AROM aquatic program that management canceled on 8/11/25 and a PROM restorative program scheduled twice a week that management canceled on 5/19/26. Review of Resident #10's progress notes for August 2025 and May 2026 lacked documentation explaining the rationale for why the facility canceled the restorative programs. On 6/23/26 at 2:48 PM the Administrator stated the facility discontinued the aquatics program for everyone because they currently didn't have a lifeguard to run the program. On 6/24/16 at 1:39 PM Staff B, Certified Nursing Assistant (CNA), stated CNAs didn't have time to do restorative care and didn't do any ROM. Staff B noted the facility used to have a restorative program where she performed ROM, walking, and the bicycle. Staff B stated when the outside management company took over, they stopped the restorative program, and now only a contracted therapy company performed it. Staff B indicated management knew about the issue and blamed the new company. On 6/24/16 at 1:44 PM Staff C, CNA, stated she gave Resident #4 showers and performed stretches with Resident #4 in the morning, but she didn't do anything restorative for other residents. On 6/24/16 at 2:14 PM Staff F, Human Resources (HR) Coordinator, stated he'd never heard of a restorative aide or staff, and he didn't staff an aide for that role. Staff F noted he'd worked at the facility for six months. On 6/25/16 at 11:40 AM Staff I, CNA, stated she didn't know if anyone performed a restorative program. Staff I didn't think they maintained a consistent, routine restorative program. Staff I noted Resident #2's roommates walked to the dining room, and another resident had a walking program but refused it. Staff I stated Resident #4 asked for ROM, but she couldn't think of any other restorative programs. On 6/25/16 at 12:04 PM Staff J, CNA, stated she saw Physical Therapy (PT) and Occupational Therapy (OT) staff working with residents, but she only witnessed staff performing restorative care with Resident #4 because Resident #4 requested it. On 6/29/16 at 11:48 AM Staff L, Certified Occupational Therapy Assistant (COTA), stated the facility didn't use the pool because they lacked a lifeguard on duty. Staff L noted the facility maintained a restorative care program in the past, but not currently. Staff L revealed she worked for a contracted therapy company rather than the facility, and she had to add a few residents on Medicaid to her caseload. Staff L believed a restorative program would've prevented those residents from needing therapy again. Staff L stated all long-term residents at the facility would benefit from a restorative program, and the process grew harder as they aged. Staff L indicated restorative care would help every resident. Staff L explained that if a resident had a clinically diagnosed contracture, they'd likely develop another one, so a restorative program could potentially prevent it. Staff L revealed she didn't include recommendations for PROM or AROM programs on her discharge summaries because the facility lacked staff to implement them, though she believed residents would benefit from them. Staff L stated she didn't believe the facility maintained a restorative program since July 2025 for any residents in the building. On 6/29/16 at 12:57 PM the Nurse Practitioner (NP) stated a restorative program would help many residents; however, the facility didn't provide it. The NP didn't know why the facility lacked the program. The NP noted she ordered therapy for multiple residents and believed a restorative program would work very well for them. On 6/29/16 at 3:11 PM the Administrator stated she looked into hiring a lifeguard and finding a train-the-trainer lifeguard course to restart the pool program. Regarding the restorative program, the Administrator didn't know if they'd assign someone to the role or train the CNAs. The Administrator noted they needed to evaluate every resident to determine who required specific programs. The Nursing Rehabilitation/Restorative Care Policy dated May 2025 directed the facility to incorporate restorative programs assisting a resident to maintain or improve physical functioning based upon completing a comprehensive assessment. The policy instructed that candidates for restorative nursing care required appropriate assessment, care planning, and progress evaluation. It defined rehabilitation or restorative care as nursing interventions promoting a resident's maximum functional potential. The policy required care plans to contain measurable objectives and interventions, and required a licensed nurse to conduct periodic evaluations in the clinical record. It further mandated that nursing assistants received training in techniques promoting resident function under nursing staff supervision. Exercise groups couldn't exceed four residents per caregiver, and activities required a total practice time of at least 15 minutes over a 24-hour period. The undated Facility Assessment revealed the General Staff Guidelines directed the facility required restorative care 5-7 days per week.

Based on interview, record review, and policy review, the facility failed to provide sufficient nursing staff to respond to call lights in a timely manner for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51 residents. Findings include: Review of the Employee Warning Notice for Staff R, Certified Nursing Assistant (CNA), dated 5/8/26 revealed that on 6/6/26 the facility failed to answer Resident #1's call light within 15 minutes, with one instance lasting 54 minutes and another lasting 16 minutes. The form revealed the incident violated policy and procedure. Review of the Employee Warning Notice for Staff S, CNA, dated 6/16/26 revealed that on 6/12/26 Resident #1's call light remained on for 30 minutes. The form revealed the delay violated policy and procedure. On 6/22/26 at 11:48 AM Resident #1 stated that staff responded to call lights poorly at all times of the day, and responses took up to an hour. On 6/22/26 at 1:20 PM Resident #1 Representative, Power of Attorney (POA), stated that when they first arrived at the facility, call lights took two to two and a half hours to answer. Resident #1 Representative noted that although responses improved, times still pushed over 15 minutes. Staff entered the room and shut off the lights to look good, but the Respiratory Therapist (RT) didn't arrive for up to 45 minutes to help Resident #1. On 6/24/26 at 1:25 PM Staff A, Licensed Practical Nurse (LPN), stated that residents didn't complain about call lights. On 6/24/26 at 1:39 PM Staff B, CNA, stated she tried to answer call lights timely, but she couldn't stop in the middle of a task. She noted staff used a phone to alert them of call lights, and she experienced issues with it daily. She expressed a need for a lock on the device so staff couldn't shut off the sound as it should chime. She stated some staff acted lazy, including both nurses and CNAs, and they sometimes didn't have enough time in the day to take care of residents properly. On 6/24/26 at 1:44 PM Staff C, CNA, stated staff used an app on a phone for call lights. She felt her workload felt tolerable and she could answer call lights in 15 minutes, though the facility ran a little short of staff on Fridays sometimes. On 6/24/26 at 1:56 PM Staff D, LPN, stated that most days brought enough time to get work done, but it depended on the situation and staffing. On 6/24/26 at 2:14 PM Staff F, Human Resources (HR) Coordinator, stated he became aware of Resident #1's delayed call light on 6/24/26. He typed a written warning for the involved CNA but hadn't caught her to deliver it yet. He didn't have concerns with the call light system and ensured all sound audios remained on. On 6/25/26 at 11:40 AM Staff I, CNA, stated that if they didn't have any call-ins, they maintained perfect staffing. Most days they could answer call lights within 15 minutes, depending on the day and resident needs. She noted that CNAs shouldn't answer call lights alone, and it would help if others pitched in. On 6/25/26 at 12:04 PM Staff J, CNA, stated she didn't think they had enough staff to get everything done. She noted they could answer call lights within 15 minutes if everyone pitched in, and stated they needed five CNAs and a shower aid. She revealed Resident #1 put her call light on a lot, but it just involved little things. On 6/25/26 at 1:21 PM Staff K, RT, stated the workload felt heavy because they had many tracheostomies (artificial airways) that required suctioning. It took around 8 minutes to suction a resident on average, but it could be more. She confirmed she had to suction Resident #1 a lot. On 6/29/26 at 11:10 AM Staff M, RT, stated the shift could become busy, and some residents wanted frequent suctioning. On 6/29/26 at 3:11 PM Administrator stated that upon hire, staff received orientation on the call light system and how to use it. She brought it up during an all-staff in-service meeting when a major trend appeared, and they reviewed the 15-minute response time standard. The Call Light Policy dated September 2023 directed a prompt response to a resident's call for assistance. The policy instructed the facility ensured the call system remained in proper working order. It required staff to answer call lights in a timely, prompt, and courteous manner, knocking before entry and introducing themselves. When answering a call light, staff needed to respond to the request. If they couldn't provide immediate assistance and no emergency existed, staff could turn off the light and inform the resident that a staff member would return shortly.

Based on clinical record review, family, and staff interviews, the facility failed to provide consistent showers to 1 of 3 residents reviewed (Resident #2). The facility reported a census of 51 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #2 couldn't complete the interview. Staff noted Resident #2 experienced severe impairment with decisions regarding tasks of daily life and had short-term and long-term memory problems. The MDS assessment revealed Resident #2 had upper extremity (arm) and lower extremity (leg) impairment to both sides and used a wheelchair. The MDS assessment revealed Resident #2 depended on staff for toileting, dressing, bathing, transfers, and rolling in bed, and didn't walk or stand. Resident #2 had diagnoses of traumatic brain injury (TBI; brain damage from an external force), anxiety, depression, contracture (permanent muscle tightening), and dysphagia (swallowing difficulty) following a cerebral infarction (stroke). Resident #2 didn't complete a restorative nursing program in the previous 7 days. The Care Plan Focus revised 10/28/24 indicated Resident #2 required assistance with Activities of Daily Living (ADLs) related to TBI and limited mobility. The interventions directed that Resident #2 required total assistance from 1 to 2 staff members to complete baths. Review of Resident #2's March 2026 Documentation Survey Report Version 2 lacked documentation to indicate he received a shower on 3/5/26, 3/6/26, 3/10/26, 3/12/26, 3/13/26, 3/17/26, and 3/28/26. Resident #2's April 2026 Documentation Survey Report Version 2 lacked documentation to indicate he received a shower on 4/25/26. Resident #2's May 2026 Documentation Survey Report Version 2 lacked documentation to indicate he received a shower on 5/3/26 and 5/23/26, and staff documented no on 5/24/26. On 6/22/26 at 2:18 PM, Resident #2 Representative stated during a facility visit on 6/1/26, Resident #2 appeared absolutely filthy. Resident #2 Representative stated Resident #2 had an order for a medicated shampoo for dandruff but possessed approximately an inch of thick white buildup over the back of Resident #2's head and in Resident #2's beard, noting this hadn't happened for the first time. Resident #2 Representative stated she walked up and down the halls to find a staff member, and a Certified Nursing Assistant (CNA) stated she'd locate the Head Nurse. When asked to check the last recorded bath, this nurse didn't know how to look in the chart because CNAs tracked the baths. Resident #2 Representative located a different nurse who believed Resident #2 received a shower the previous day, but Resident #2 Representative disputed this due to a severe odor and had staff smell Resident #2. The nurses agreed Resident #2 smelled poorly. On 6/22/26 at 4:38 PM, the Director of Nursing (DON) stated staff completed all scheduled showers. DON informed that management tried to assign a designated shower assistant, but if that became impossible, the staff remained responsible for their own showers on their assigned hallways. On 6/25/26 at 11:40 AM, Staff I, a CNA, stated Resident #2 can be rough to get up in the morning. Staff I stated the ordered medicated shampoo isn't always available, which requires staff to order it. Staff I stated Resident #2 received a shower today, but staff couldn't locate the medicated shampoo, so she used Head and Shoulders shampoo and scrubbed Resident #2's scalp thoroughly instead. Staff I stated that when she began working at the facility at the end of May 2026, Resident #2 possessed a significant amount of white dandruff and a red, itchy area on the right side of Resident #2's scalp. Staff I noted Resident #2 becomes stiff frequently and develops what she thinks are yeast infections, which required a medical topical powder that she applied to Resident #2's hands. Staff I noted that sometimes when the weather became very hot, staff placed a washcloth in Resident #2's hand, but they didn't do this every day. Staff I stated she previously applied baby powder, but staff informed her today about the medical topical powder when she asked for the shampoo. On 6/29/26 at 2:17 PM, Resident #2's family member stated Resident #2 didn't receive proper cleaning and routinely had food on Resident #2's face. The Hygiene - Bathing / Shower policy dated March 2024 instructed that the purpose includes cleaning the skin, promoting cleanliness, and preventing infection.

Based on record review, interviews, and policy review the facility failed to ensure 1 of 3 resident received necessary care and services in accordance with professional standards of practice, her comprehensive assessment, and her plan of care (Resident #1). Specifically, staff failed to administer ordered respiratory treatments by omitting or allowing the refusal of tracheostomy (breathing tube) cares on six occasions in May 2026, and failed to provide ordered nutrition by failing to administer her full tube feeding regimen on 13 separate days in May 2026. The facility reported a census of 51 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 entered the facility on 1/4/26. The MDS assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 depended on staff for toileting and bathing, didn't get out of bed, and required supervision and physical assistance with rolling in bed. Resident #1 had diagnoses of diabetes, malnutrition (poor nutrition), depression, psychotic disorder (mental illness), anxiety, respiratory failure (lung failure), dependence on a respirator (ventilator) status, tracheostomy (breathing tube), and myotonic muscular dystrophy (genetic muscle wasting). The May 2026 Treatment Administration Record (TAR) showed that tracheostomy cares required completion twice daily in the morning and evening and as needed. Resident #1 refused care on 5/7/26 at AM, 5/11/26 at AM, 5/17/26 at PM, and 5/25/26 at AM. Staff omitted documentation regarding whether completion occurred on 5/27/26 at AM and 5/30/26 at AM. The May 2026 Medication Administration Record (MAR) documented an order for scheduled feedings four times a day. The Electronic Health Record (EHR) showed an order to offer feedings five times a day at AM, AM, Lunch, mid-afternoon (MA), and bedtime (HS) starting on 4/16/26. For the month of May 2026, Resident #1 didn't receive the order as scheduled, and documentation showed refusals. Resident #1 received only three feedings on 5/1/26, 5/2/26, 5/4/26, 5/5/26, 5/7/26, 5/11/26, 5/14/26, 5/18/26, 5/22/26, 5/24/26, 5/30/26, and 5/31/26, and received only two feedings on 5/8/26. The Progress Notes for Resident #1 showed a lack of documentation regarding alternative feeding options for May 2026. The Progress Notes only contained the notes listed below, with nothing recorded for the other dates staff missed feedings. The Nutrition and Dietary Note dated 5/13/26 at 7:32 PM indicated the current tube feeding regimen might not adequately meet estimated nutrition needs due to frequent refusals of feedings. Significant weight loss and pressure areas remained concerns. The note recommended continued encouragement and education regarding the importance of nutrition for weight maintenance and wound healing. The note recommended nursing documentation of tube feeding acceptance percentages and intake trends. The note also suggested a review of the feeding schedule and method for improved tolerance and acceptance, and directed staff to monitor weights, skin integrity, hydration status, and overall nutritional status closely. The note recommended Zinc and concentrated liquid medical foods and protein supplements 30 milliliters (ml) twice daily via tube for increased protein. The Nutrition and Dietary Note dated 5/18/26 at 10:27 AM indicated Resident #1's weight increased three pounds over the past week to 118.6 pounds, which staff intended and viewed as favorable. Resident #1 remained nothing by mouth (NPO) with all nutrition provided via enteral (tube) feeding of Jevity 1.5 at 240 ml bolus four times daily with a 50 ml water flush before and after each feeding. The current feeding regimen continued to meet estimated nutritional needs when fully administered. Resident #1 continued to refuse feedings at times, which might impact the consistency of nutrient delivery. The note instructed staff to encourage acceptance of feedings and monitor weights, tolerance, hydration status, and skin integrity, and referred to the recommendations dated 5/13/26 regarding additional supplementation to support skin integrity. The Orders and Administration Note dated 5/18/26 at 4:57 PM documented that staff held an enteral feed order due to a stomach residual of 100 ml. The Orders and General Note from eRecord dated 5/18/26 at 9:19 PM documented that staff held the mid-afternoon feeding due to a residual of 100 ml. Resident #1 reported feeling full. Resident #1's residual at 8:00 PM totaled 40 ml, so staff administered the feeding and medications. Staff elevated the head of the bed, and family remained at the bedside. Resident #1 denied any complaints or needs. The Orders and Administration Note dated 5/24/26 at 7:15 AM documented an enteral feed order four times a day related to gastrostomy (surgical stomach opening) status for Jevity 1.5 240 ml bolus four times per day, with a 50 ml water flush before and after. Resident #1 stated, Later, and refused the feeding. The Orders and Administration Note dated 5/26/26 at 8:34 PM documented that Resident #1 refused her last feeding. Her husband remained at the bedside and knew about the refusal. On 6/22/26 at 1:20 PM Resident #1 Representative/Power of Attorney (POA) stated staff didn't complete scheduled tracheostomy cares twice a day as required. Resident #1 Representative/POA stated Resident #1 didn't like to wake up early and'd consistently accept all feedings, but staff scheduled them differently than how her day went. Resident #1 Representative/POA further stated that after a care conference, the facility then worked to change her schedule of feedings to start later at 10:30 AM to allow her to sleep in. On 6/23/26 at 7:00 PM Resident #1 and Resident #1 Representative/POA stated Resident #1 didn't receive her 2:30 PM feeding until 5:00 PM because a new nurse didn't arrive at the scheduled time. They denied any complaints at this time, and noted some good nurses worked at the facility, including traveling staff. On 6/25/26 at 11:40 AM Staff I, Certified Nursing Assistant (CNA), stated she cared for Resident #1 and described her as a sweet lady. Staff I stated she didn't know of any late feedings for Resident #1 because she didn't handle that task, but she hoped they didn't occur. On 6/25/26 at 12:04 PM Staff J, CNA, stated Resident #1 refused a lot of interventions, and staff had to encourage her to get changed. Staff J stated Resident #1 refused her tube feedings frequently. On 6/25/26 at 1:21 PM Staff K, Respiratory Therapist (RT), stated Resident #1 only wanted her tracheostomy inner cannula (inner tube) changed once a day and never accepted albuterol (breathing medication) treatments. Staff K stated Resident #1 had thick, yellow secretions and required suctioning of her mouth and tracheostomy 5 to 10 times a day. Staff K stated she always offered and reattempted the treatments, but Resident #1 declined. Staff K noted the open times to change the inner cannula occurred between 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM rather than a specific time, and she usually performed it around 2:00 PM. On 6/29/26 at 11:10 AM Staff M, RT, stated Resident #1 had orders to receive tracheostomy cares twice a day, but Resident #1 told her that the agency RT didn't even come in once to perform them. On 6/29/26 at 1:36 PM Staff O, Nurse Practitioner (NP), stated Resident #1 refused almost 50 percent of her feedings and had a diagnosis of failure to thrive (progressive decline in vitality). Staff O stated Resident #1 refused at least one if not two feedings daily, didn't want hospice care, and didn't support her own nutritional needs. Staff O expressed concern regarding staff not cleaning Resident #1's tracheostomy twice a day, stating that it definitely should be done along with monitoring her settings and keeping a close eye on her. The Enteral Tubes: Intermittent/Continuous (Pump) Feedings policy dated June 2024 instructed staff on feeding protocols but lacked instructions regarding resident choice, accommodation of preferences, and the management of dietary refusals. Specifically, the policy failed to direct staff on the necessary protocols to follow when a resident declines a feeding, requests an alternative schedule to match personal routines, or reports clinical intolerance such as feeling full. It omitted requirements for staff to offer alternative feeding options, provide nutritional substitutes, or notify the physician and dietitian when consistent refusals impact a resident's nutritional status.

Based on observations, staff interviews and policy review the facility failed to maintain a sanitary kitchen; failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. The facility reported a census of 50 residents. Findings include:On 5/12/26 from 8:34 AM to 9:00 AM, a continuous observation revealed Staff A, Cook, licked the thumb of her hand at 8:34 AM and proceeded to serve food without performing hand hygiene. Staff A picked up bacon with her hands and placed it on a plate when serving residents. At 8:38 AM, Staff A touched her food-soiled apron with her hands, picked up bacon with her hands, and didn't use the tongs on the steam table.On 5/12/26 at 9:05 AM, a walkthrough of the kitchen revealed the floor in the dry storage area had dried leaves, dried liquid, and food particles on it. A box of soups sat on the floor. In the refrigerator, a liquid eggs box and a sliced ham box of food were stored on the floor. In the kitchen, the flour and sugar bins were covered in flour and food particles.On 5/13/26 at 9:06 AM, an interview with Staff A revealed she'd been an employee for 5 years. Staff A reported staff are to use tongs to serve bacon. She acknowledged she served the bacon with her hands and licked her thumb.On 5/13/26 at 9:20 AM, during a second walkthrough of the kitchen the Administrator reported staff are to use tongs when handling bacon. Throughout the walkthrough, she acknowledged the floors in the dry storage areas remained dirty with dried food particles, dried liquids, and leaves. The boxes of food supplies still on the floor should've been stored up off the floor. The undated General Food Preparation and Handling policy instructed staff to store food items properly as soon as possible, with the exception of dry goods which should be stored by the end of the shift, and food will be prepared and served with clean utensils.The Food Brought In From Outside Source/Safe Food Handling policy revised January 2024 directed cross-contamination can occur when harmful substances, chemicals, or disease-causing microorganisms are transferred to food by hands.

Based on observation, record review, staff interviews, the facility failed to implement standard infection control practices and Enhanced Barrier Precautions (EBP) (involves the use of gowns and gloves during high-contact resident care activities for residents known to be colonized, infected and at increased risk of Multidrug Resistant Organisms (MDRO) (bacteria that are resistant to three or more families of antibiotics) for 3 of 3 residents (Resident #15, Resident #24 and Resident #4). The facility also failed to review their infection policy yearly. The facility reported a census of 50 residents. Findings include:1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] documented he had severe cognitive impairment. The MDS included diagnoses of chronic respiratory failure (long-term inability of the lungs to clear carbon dioxide and provide oxygen) and a resistance to unspecified antibiotics. The MDS documented he's dependent, meaning a helper does all of the effort, the resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity, for toileting, personal hygiene, and bed mobility. The MDS documented he had multiple pressure ulcers (bedsores).On 5/12/26 from 1:00 PM to 2:10 PM, a continuous observation showed Staff C, Agency Registered Nurse (RN), performed wound care on Resident #15. Staff C verified the treatments. Staff D, Certified Nurse's Aide (CNA), came to assist her with Resident #15's wound care. Both donned a gown, gloves, and mask. The treatment supplies sat in the room on a tray table. The first areas Staff C did were the left heel and right ankle where she painted betadine on the areas and let them dry. Staff C did the right hip next. Staff C cleansed the side with wound wash and gauze. The old dressing was already off due to a shower. The wound wash was in a bottle, and throughout the cleaning process of the hip wound, Staff C sprayed gauze with the wound wash, wiped the wound, and then threw away the gauze. With the same gloved hand that just cleaned the wound, Staff C pulled out gauze from the bulk package of gauze, sprayed wound wash on the gauze, and continued to clean the area. Staff C repeated this process 3 times. Staff C set the bottle of wound wash on the bed without a barrier with each gauze cleaning. Staff C then took gauze out and took the Dakin's solution (wound care solution), opened the bottle, and poured it on the gauze, all with the same gloves she used to cleanse the wound. Staff C took the gauze and applied it to the wound bed. She repeated the process again with the Dakin's solution. Staff C then took the ABD pad (highly absorbent dressing) and put it over the wound area and secured it with tape. Staff C removed her gloves, performed hand hygiene, and applied new gloves. At 1:12 PM, when Staff C went to start the wound on the coccyx (tailbone), Resident #15 had a bowel movement. Staff D began cleaning him using the same wipe multiple times and didn't always wipe from front to back. Staff D handed Staff C a pillow which Staff C touched with the same gloves she just cleaned Resident #15 with. Resident #15's catheter fell to the floor, which wasn't in a protective bag, and Staff C then picked up the catheter and placed it on the clean bedding on the bed that they just changed due to feces on other sheets. Once they cleaned Resident #15 on that side, they rolled him back to his left side, laying him on the clean sheets with dried feces noted on the bandage to the left hip to pull the clean sheets through, which Staff C applied with the same gloves she used to clean Resident #15 with. Staff C and Staff D removed their gloves, performed hand hygiene, and applied new gloves. Staff C removed the dressing to the left hip area, removed her gloves, and then performed hand hygiene. Staff C applied new gloves and took gauze from the bulk pack, then sprayed it with wound cleaner, placed the bottle on the bedding, and then cleansed the wound. Staff C repeated this process 3 times while wearing the same gloves and touching the wound cleaner bottle and bulk gauze, and cleansing the wound with the same gloved hands. Staff C removed her gloves and applied new gloves. Staff C then took gauze out of the bulk package, applied Dakin's solution, and put it on the wound bed. She grabbed another gauze out and repeated the same process. She took an ABD pad, covered the wound, and secured it with tape. She then removed her gloves. At 1:40 PM, Staff C applied new gloves, removed the dressing from the sacral (lower spine) area, and removed her gloves. Staff C applied new gloves, took gauze from the bulk package, sprayed it with wound cleaner from the bottle, and set the bottle on the bed. She then washed the wound bed. Staff C repeated this process 3 times with the same gloves and touched the bulk package with her gloved hands each time. Staff C removed her gloves, performed hand hygiene, and applied new gloves. She then took gauze from a bulk package, applied Dakin's solution to the gauze, and applied it to the wound bed. Staff C repeated this process 3 times. She applied an ABD pad and secured it with tape. At 1:55 PM, Staff C removed the dressing to the right scapular (shoulder blade) area and then removed her gloves. Staff C applied new gloves, took gauze from the bulk package, sprayed it with wound cleaner from the bottle, and set the bottle on the bed without a barrier. She then washed the wound bed. Staff C repeated this process 3 times with the same gloves and touched the bulk package with her gloved hands each time. Staff C then took gauze from a bulk package, applied Dakin's solution to the gauze, and applied it to the wound bed. Staff C repeated this process 2 times. She applied an ABD pad and secured it with tape.On 5/12/26 at 2:20 PM, an interview with the Assistant Director of Nursing (ADON) who was in the room during the dressing changes revealed she acknowledged the concerns with staff not always performing hand hygiene between glove changes, touching the supplies with dirty gloves, not always changing gloves between the clean and dirty processes, and using a wipe multiple times for incontinence care. The ADON reported staff should've used the wipe just once and wiped front to back.2. Resident #24's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included a diagnosis of a stage 4 pressure ulcer, which means full-thickness tissue loss with exposed muscle, fascia (connective tissue), tendon, or bone.On 5/13/26 at 2:45 PM, an observation showed Staff G, Agency Licensed Practical Nurse (LPN), performed wound treatments on Resident #24. Staff G donned a gown and gloves. Staff G had her supplies on a bedside table. Staff G pulled bandage scissors out of her scrub pocket and set them on the barrier on the bedside table. Staff G didn't clean the scissors prior to using them. Staff G removed the bandage to the right foot and removed her gloves. Staff G applied new gloves she pulled out from a bulk package, took some gauze, and dampened it with wound cleanser. Staff G used the dampened gauze to cleanse the wound bed. Staff G removed her gloves and applied new gloves. Staff G then took more gauze from the package, dampened it with Vashe (wound cleansing solution), and applied it to the wound bed. Staff G wrapped the foot with gauze wrap and secured it with tape. Staff G removed her gloves and applied new gloves. Staff G then removed the upper dressing on the right upper hip, removed her gloves, and applied new gloves. Staff G pulled some gauze out from a bulk package and dampened it with Vashe. She used the dampened gauze to cleanse the wound bed. She removed her gloves and applied new gloves. Staff G applied Calmoseptine (moisture barrier ointment) to the skin around the wound using a cotton swab. Staff G then took more gauze from the package, dampened it with Dakin's solution, and applied it to the wound bed. Staff G covered it with an ABD pad and secured it with tape. Staff G performed the same process with the buttock wound. At 3:12 PM, Staff G then moved to the right upper thigh wound vac treatment. Staff G applied new gloves, removed the old wound dressing, and removed her gloves. Staff G applied new gloves, pulled gauze out of the bulk package, dampened it with Dakin's solution, and cleansed the wound bed. Staff G grabbed more gauze and patted it dry. Staff G then removed her gloves and applied new gloves. Staff G picked up the scissors and cut the black foam to size for the wound. Staff G placed the foam in the wound bed, covered it with a single-lumen suction bell (a cup-shaped device with tubing used to connect to the wound vac), and secured it with an adhesive drape, which is a clear film dressing. She then connected the tubing to the wound vac and turned the machine on. Throughout the process, Staff G didn't perform any hand hygiene between glove changes, and didn't clean the scissors prior to use.On 5/13/26 at 3:22 PM, an interview with the ADON revealed Staff G should've performed hand hygiene with each glove change and should've cleaned the scissors prior to using them.3. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS documented he's dependent for toileting. The MDS included a diagnosis of respiratory failure and dependent on a respirator (ventilator) status.On 5/14/26 at 10:42 AM, an observation showed Staff F, CNA, and Staff E, CNA, checked and changed Resident #4. Staff F wore a gown and gloves. Staff E wore a gloves and a gown but didn't have his arms in the armholes and only wore it around his neck. Staff E set up supplies with a barrier underneath. Staff E used the wipe only once and wiped from front to back. Staff E changed his gloves from dirty to clean and performed hand hygiene between. Once Resident #4 was clean, Staff E removed the gown and gloves and washed his hands.On 5/14/26 at 10:56 AM, an interview with Staff E acknowledged he forgot to put his arms in the gown so he didn't wear it correctly.The Hand Hygiene policy revised October 2023 directed staff to perform hand hygiene using an alcohol-based hand rub before and after doing a dressing change and with glove changes during dressing changes.The Enhanced Barrier Precautions policy revised March 2024 directed staff to use enhanced barrier precautions in conjunction with standard precautions for residents with medical devices such as a ventilator.

Based on observations, interviews, and policy review the facility failed to ensure cold food items were maintained at or below 40 degrees Fahrenheit (4 degrees Celsius) and served immediately to prevent potential bacterial growth. Specifically, a half-gallon of milk sat out at room temperature without an ice bath for at least eight minutes, reaching a temperature of 53 degrees Fahrenheit before Staff B, Certified Nurse's Aide (CNA), poured and served a glass of it to a resident. Additionally, the facility left breakfast trays exposed to the open air on a dining room half wall before serving to a resident. One resident, Resident #13 who received one of the meals reported the breakfast was cold as usual. The facility reported a census of 50 residents.Findings include:On 5/12/26 from 8:40 AM to 9:00 AM, Staff A, Cook, dished up four plates for room trays and sat them on the half wall in the dining room in front of the steam table. The trays consisted of foam plates, and Staff A used another foam plate to cover them, which left the sides of the food exposed to open air. Next to the plates sat a half-gallon of milk, not in an ice bath or anything else to maintain its temperature. Staff A then told a nurse to call for staff to come get the room trays. At 8:47 AM, Staff B, Certified Nurse's Aide (CNA), came and poured a glass of milk from the half-gallon of milk sitting next to the tray tables. Staff B then took the milk with one of the plates dished up to a resident's room. At 8:48 AM, Staff A took the temperature of the half-gallon of milk sitting out. The temperature registered 53 degrees, and Staff A reported the milk shouldn't have been used.On 5/12/26 at 8:50 AM, an interview with Staff A revealed the temperature of milk should be below 45 degrees.On 5/12/26 at 9:10 AM, an observation of the last room tray being delivered showed the last room tray was taken to Resident #13's room.On 5/12/26 at 9:15 AM, an interview with Resident #13 revealed the breakfast was cold, but it usually is, so it wasn't the best.On 5/13/26 at 9:06 AM, an interview with Staff A reported for room trays, she's to let the CNAs know they're ready to serve, dish the meal, and then put it up on the half wall. She reported the CNAs will then get the drinks and deliver the trays, which should be delivered right away. She reported the milk is to be on ice to keep its temperature. On 5/13/26 at 9:20 AM, the Administrator reported the temperature of the milk wasn't at the correct temperature and the staff shouldn't have served the milk.The Food Brought In From Outside Source/Safe Food Handling policy revised January 2024 directed cold items should be 40 degrees Fahrenheit (4 degrees Celsius) or below.

Based staff interview, clinical record review, and facility policy review, the facility failed to maintain a resident's nutritional status for 1 of 5 residents reviewed (Resident #4). As evidenced by a significant, unexplained weight loss from 130 pounds on 1/05/26 to 119.5 pounds on 3/25/26. The facility failed to consistently follow the Care Plan intervention to notify the physician and dietitian of significant weight change. Furthermore, the facility did not follow its own policy for Notification for Change in Condition by failing to consult with the resident's physician and notify the Dietitian of a significant change in status (weight loss) and the significant alteration of treatment (reduction of enteral feedings from five times to two times per day) without a documented physician's order or indication. The Registered Dietitian denied receiving report of the resident's frequent refusal of tube feedings throughout February 2026 and the subsequent decrease in feedings, indicating a breakdown in communication and a failure to implement necessary nutritional interventions in a timely manner. The facility reported a census of 42 residents.Findings include:Resident #4's Minimum Data Set (MDS) assessment, dated 2/16/26, identified they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of myotonic muscular dystrophy (a type of muscle-wasting disease that causes prolonged muscle contractions), diabetes mellitus, and malnutrition (not getting enough nutrients, or too much of the wrong ones). The MDS indicated Resident #4 required tube feedings while a resident at the facility. The Care Plan Focus initiated 1/5/26, reflected Resident #4 had the potential/actual risk for altered nutrition status related to a nothing by mouth (NPO) diet. The goal indicated Resident #4 would maintain weight with no significant changes. The Interventions dated 1/5/26 directed the following:Provide diet as ordered - NPO. Monitor weights. Notify the physician and Dietitian of significant weight change. The Care Plan Focus initiated 1/16/26 identified Resident #4 had tube feedings related to gastrostomy status (a feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, or medications directly). The goal indicated Resident #4 would tolerate the tube feedings and remain free of complications. The Intervention dated 1/29/26 instructed Resident #4 may refuse feedings. The Nutrition Assessment, completed by the Dietitian, dated 1/13/26, reflected Resident #4's had a diet of NPO and enteral feeding (feeding through a tube into the stomach or small intestine) provided all of their nutrition. The Dietitian made a recommendation to increase his nutritional solution amount from 240 milliliters (mL) 5 times per day to 250 mL 5 times per day and increase water flushes, before and after feedings, from 30 mL to 60 mL, due to Resident #4 being below her estimated needs. Resident #4's February 2026 Medication Administration Record (MAR) included the following orders:1/16/26: Enteral feedings 250 milliliters (mL), five times a day, (total of 1,250 mL nutritional solution per day) related to gastrostomy status, with 50 mL water before and after feedings. The facility discontinued the order on 2/25/26. The MAR indicated between the dates of 2/1/26 and 2/25/26, Resident #4 refused the following scheduled tube feedings times: 6:00 AM tube feeding: refused 1 time. 10:00 AM tube feeding: refused 15 times.2:00 PM tube feeding: refused 2 times. 6:00 PM tube feeding: refused 15 times. 10:00 PM tube feeding: refused 17 times. 2/26/26: Enteral feedings 300 mL, two times a day (total of 600 mL nutritional solution per day), related to gastrostomy status, with 50 mL water before and after feedings. The facility discontinued the order on 3/4/26. Resident #4's March 2026 MAR included an order started 3/5/26 for enteral feedings 300 mL, two times a day (total of 600 mL nutritional solution per day), related to gastrostomy status, with 50 mL water before and after feedings. Resident #4's Electronic Health Records (EHR) revealed the following recorded weights:On 1/5/26, Resident #4 weighed 130 pounds. On 1/10/26, Resident #4 weighed 130 pounds. On 2/19/26, Resident #4 weighed 121.1 pounds. During an electronic mail (Email) correspondence, on 3/25/26 at 1:06 PM, upon request for Resident #4's most recent weight, the Director of Nursing (DON) reported that Resident #4's weighed 119.5 pounds on 3/25/26. During an interview on 3/25/26 at 1:07 PM, the Registered Dietitian (RD) reported visiting the facility on 3/24/26 and made a recommendation to return Resident #4's tube feedings back to 5 times per day. The Dietitian denied receiving a report from the facility that Resident #4 refused multiple feedings throughout February 2026. Additionally, they denied receiving notification from the facility that they reduced the feedings to twice per day on 2/26/26. The Dietitian stated she couldn't find an order or indication from physician to decrease the number of Resident #4's feedings. The Dietitian reported the weight entered into Resident #4's EHR on 3/25/26 showed a significant weight loss. The Dietitian stated she planned to contact the DON and recommend to check Resident #4's weights weekly. During an interview on 3/25/26 at 4:00 PM, the DON reported they expected the nurses to notify physician and Dietitian of resident's refusal of tube feedings if it happened more than 2 times. The DON reported she didn't know why Resident #4's feedings decreased to twice per day and couldn't find documentation to indicate the reason for the decrease. Review of the facility policy titled, Notification for Change in Condition, revised June 2023, directed the facility to provide care to residents and provide notification of resident changes in status. The section titled Procedures, instructed the following: The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); Additionally, the policy instructed, per federal guidance, the need to alter treatment significantly meant a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before).

Based on resident and staff interviews, clinical record review, facility Grievance Log review, call light log review and facility policy review, the facility failed to answer call lights in a timely manner to meet resident needs for 3 of 3 residents (Resident #4, #9, and #11) reviewed for call lights. The facility failed to answer residents' calls for assistance in a timely manner, with logged wait times for multiple residents frequently exceeding acceptable limits (greater than 15 minutes), sometimes lasting over an hour and a half. The failure persisted despite residents reporting concerns through interviews and the facility's own grievance logs and after staff were reportedly re-educated on the importance of responding to call lights and carrying communication devices. Furthermore, staff, including the Director of Nursing, failed to respond to a prolonged audible alarm indicating an issue with a resident's essential feeding tube pump, and the facility did not have a written policy to ensure timely call light response. The facility reported a census of 42 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment, dated 2/16/26, identified they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of myotonic muscular dystrophy (a type of muscle-wasting disease that causes prolonged muscle contractions), diabetes mellitus, and malnutrition (not getting enough nutrients, or too much of the wrong ones). The Care Plan Focus initiated 1/5/26 indicated Resident #4 required assistance with activities of daily living (ADLs) and had a risk for falls. The Intervention instructed the staff to keep Resident #4's call light within reach. During an interview on 3/16/26 at 2:20 PM, Resident #4 reported it took up to 2 hours for someone to answer her call light. During an interview on 3/24/26 at 2:25 PM, Staff J, Certified Nursing Assistant (CNA), stated while they worked the overnight shift on 3/21/26, she noticed Resident #4's call light on for over an hour. Staff J added no one reported it to the nurse on duty, because the nurse stated she was going to quit. Review of the Call Light Log System on 3/25/26 at 11:30 AM, with the Human Resources (HR) Director present, revealed the following call light wait times for Resident #4:On 3/20/26, the call light pressed at 10:42 AM and answered after 46 minutes, 29 seconds.On 3/20/26, the call light pressed at 11:25 PM and answered after 27 minutes, 1 second.On 3/21/26, the call light pressed at 9:57 AM and answered after 37 minutes, 53 seconds.On 3/21/26, the call light pressed at 1:59 AM and answered after 1 hour, 21 minutes, 10 seconds.On 3/22/26, the call light pressed at 9:57 AM and answered after 37 minutes, 53 secondsOn 3/22/26, the call light pressed at 3:30 PM and answered after 18 minutes, 37 seconds.On 3/22/26, the call light pressed at 5:59 PM and answered after 19 minutes, 34 seconds. 2. Resident #9's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #9 as dependent on staff assistance for toileting hygiene, bed mobility, and transferring. The MDS included diagnoses of type 2 diabetes mellitus, anxiety disorder, depression, chronic respiratory failure with hypoxia (low oxygen saturation), and asthma. The Care Plan Focus initiated 10/30/25, reflected Resident #9 required assistance with ADLs and had a risk for falls. The Intervention directed the staff to keep Resident #9's call light within reach. Review of the facility provided Grievance Logs, revealed a concern reported by Resident #9 on 1/27/26. Resident #9 reported the staff refused to lay her down. The staff went into her room, turned off the call light and left. She had her call light on for over an hour. The Grievance Log indicated the facility re-educated the staff on call lights, carrying the iPod and walkies. Additionally, the facility educated to lay down Resident #9. The Grievance Log dated 1/27/26 lacked a date of concern resolution. Review of the Call Light Log System on 3/25/26 at 11:30 AM, with the HR Director present, revealed the following call light wait times for Resident #9, in part:On 3/20/26, the call light pressed at 3:16 PM and answered after 33 minutes, 36 seconds.On 3/20/26, the call light pressed at 7:04 PM and answered after 56 minutes, 51 seconds.On 3/20/26, the call light pressed at 9:51 PM and answered after 32 minutes, 59 seconds.On 3/21/26, the call light pressed at 6:03 PM and answered after 31 minutes, 59 seconds.On 3/22/26, the call light pressed at 2:03 AM and answered after 1 hour, 47 minutes, 53 seconds.On 3/22/26, the call light pressed at 12:33 PM and answered after 20 minutes, 38 seconds.On 3/22/26, the call light pressed at 9:07 PM and answered after 29 minutes, 37 seconds.On 3/22/26, the call light pressed at 9:39 PM and answered after 33 minutes, 19 seconds. 3. Resident #11's MDS Assessment, dated 12/31/25, identified a BIMS score of 15, indicating intact cognition. The MDS listed Resident #11 as able to transfer and ambulate independently. The MDS included diagnoses of diabetes mellitus, arthritis, anxiety disorder, depression, post traumatic stress disorder (PTSD), asthma, and unspecified intellectual disabilities. The Care Plan Focus initiated 10/3/25, reflected Resident #11 had a risk for falls with occasional bladder incontinence related to inability to make it to the bathroom quickly. The Intervention instructed the staff to keep Resident #11's call light within reach. Review of the facility provided Grievance Logs, revealed a concern reported by Resident #11 on 2/11/26. Resident #11's reported on 2/11/26 from 1:00 AM to 3:00 AM, she had her call light on and no one answered. Reported she had her roommate press her call light because Resident #11 didn't have hers in reach. The Grievance Log indicated the facility provided staff re-education on call lights and they had no further complaints. The Grievance Log dated 2/11/26 listed the concern resolved on 2/14/26. Review of the Call Light Log System on 3/25/26 at 11:30 AM, with the HR Director present, revealed the following call light wait times for Resident #9:On 2/11/26, the call light pressed at 3:13 AM and answered after 51 minutes, 7 seconds.On 2/11/26, the call light pressed at 8:03 AM and answered after 36 minutes, 59 seconds. 4. Resident #3's Minimum Data Set (MDS) assessment, dated 2/27/26, identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of paraplegia (impairment of motor and sensory function in lower body), seizure disorder, coronary artery disease (CAD), respiratory failure, and malnutrition. Resident #3 required a feeding tube for 51% or more of total daily calorie intake and 501 mL or more of total daily fluid intake. During a continuous observation on 3/18/26 between the times of 8:09 AM and 9:05 AM:At 8:09 AM: Resident #3 appeared sleeping in bed with a tube feeding pump on a pole placed next to his bed. The feeding tube pump's digital screen flashed yellow and made a continuous beeping alarm that could be heard from the hallway. The feeding tube pump's digital screen indicated a cassette error.At 8:12 AM, observed a housekeeping staff present in the hallway outside of Resident #3's room. They didn't respond to the alarm.At 8:25 AM a male staff member exited an office at the end of the hall, walked past Resident #3's room. They didn't respond to the alarm. Then at 8:33 AM the same staff member walked past the room again and returned to the office.At 9:04 AM, witnessed the Director of Nursing (DON) present in the hallway near Resident #3's room. The DON went into another resident's room and didn't respond to the alarm in Resident #3's room.At 9:05 AM Staff K, Licensed Practical Nurse (LPN), stood at a medication cart, located at the other end of the hallway, and didn't respond to the alarm. The Surveyor reported to Staff K they heard alarm in Resident #3's room. Staff K proceeded to Resident #3's room and checked Resident #3's feeding tube pump. Staff K stated that the alarm occurred when the tubing for tube feeding got occluded causing a pause in the resident's tube feeding. During an interview on 3/25/26 at 4:00 PM, the DON revealed they expected call lights to be answered as soon as possible. The DON confirmed residents have complained about call light wait times and they re-educated staff about promptly answering call lights. The DON confirmed that 1 hour and 47 minutes was too long for a call light to be unanswered and stated clearly more call light audits needed done. The facility couldn't provide a policy related to call light timeliness.

Based on observations, clinical record review, staff interview and facility policy review the facility failed to provide tube feeding care per the physician's orders for 2 out of 5 residents reviewed (Residents #1 and #10). The facility failed to ensure to administer and document medically necessary nutritional feedings, water flushes, and g-tube (a feeding tube that goes through the skin directly into the stomach) residual checks as ordered for Resident #1. Additionally, the facility failed to ensure staff followed physician's orders for the required water flush amounts before and after medication administration via tube feeding for Resident #10, providing unverified standard amounts, and lacked a clear policy to guide staff on proper tube feeding medication procedures. The facility reported a census of 42 residents. Finding include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS included diagnoses of traumatic hemorrhage cerebrum (life threatening brain bleed caused by physical injury), seizure disorder, Dysarthria (a motor speech disorder characterized by weak, damaged, or paralyzed speech muscles (lips, tongue, vocal cords, diaphragm), leading to slurred, slow, or difficult-to-understand speech) and Anarthria (the severe, total loss of the ability to articulate speech due to brain damage or neurological disorders, preventing control of muscles for speaking while often leaving language comprehension intact. Often considered an extreme form of dysarthria, it results from lesions impacting motor pathways, causing complete muteness). The MDS showed Resident #1 required a tube feeding for nutrition. The Care Plan for Resident#1 revised on 11/14/2025 identified a focus on gastrostomy tube (G-tube) feeding related to dysphagia (difficulty swallowing, often caused by neurological conditions) and risk for dehydration. The Care Plan directed provide enteral nutrition (tube feed) as ordered NPO (nothing by mouth). Resident #1's January 2026 Medication Administration Record (MAR) directed the following orders: Enteral feed (providing liquid nutrition through a tube directly into the stomach or small intestine) Fibersource HN 375 milliliters (ml) four times a day for nutritional supplement.The MAR revealed the facility failed to document the feeding provided to Resident #1 on: 1/6/26 at hour of sleep (HS), 1/10/26 at lunch, 1/16/26 at HS, 1/18/26 at lunch, 1/21/26 at lunch and HS, and 1/25/26 at lunch.The MAR dated 1/2026 directed enteral feed order four times a day flush G-tube with 150 ml of water with feedings.Water flush of 150 ml with each feed The facility failed to document on:1/6/26 at HS, 1/10/26 at lunch, 1/16/26 at HS, 1/18/26 at lunch, 1/21/26 at lunch and HS, and on 1/25/26 at lunch.Check placement of g-tube with residual (5-20ml) prior to every medication pass or feeding every shift for medication and nutrition via tube.The facility staff failed to document completion of the checking the residual on: 1/1/26 on the overnight shift, 1/16/26 on evening shift, and 1/21/26 on the evening shift. Enteral feed order every shift 60 ml of water before and after medications.The MAR showed the facility failed to document the completion of administered water before and after medication on: 1/1/26 on the overnight shift, 1/16/26 on evening shift, and 1/21/26 on the evening shift. Resident #1's February 2026 MAR directed the following orders:Enteral feed order Fibersource HN 375 four times a day for nutritional supplement ml four times a day.The MAR revealed the facility failed to document the feeding provided to Resident #1 on 2/8/26 at PM, and 2/25/26 at mid afternoon.Enteral feed order four times a day flush G-tube with 150 ml of water with feedings.The MAR showed the facility failed to document the flush completed on: 2/8/26 at hs, 2/11/26 at mid afternoon and 2/25/26 at mid afternoon. On 3/23/26 at 3:40 PM the Medical Director reported he knew Resident #1 missed a few feedings. He confirmed he expected the staff to follow the providers' orders as written. On 3/25/26 at 9:57 AM Staff D, Licensed Practical Nurse (LPN), reported she knew Resident#1 failed to get a few of his feedings. On 3/25/26 at 2:09 PM Staff F, MDS Coordinator, reported she knew about Resident #1's missed feedings. Staff F reported she talked to the Director of Nursing (DON) about the gaps on the MARs and the DON directed her to follow up on the gaps. The MDS Coordinator reported she failed to have time for that. The MDS Coordinator said if it's not documented it's not done. She reported the facility failed to complete audits. 2. Resident #10's MDS assessment dated [DATE], identified a BIMS showed a score of 14, indicating intact cognition. The MDS included diagnoses of stroke, heart failure, high blood pressure, and diabetes mellitus. The MDS reflected Resident #10 required tube feedings for nutrition. The Care Plan dated 12/31/25 identified Resident #10 had a risk for dehydration related to dependence on tube feeding for hydration. The Care Plan directed flush the feeding tube as ordered. Resident #10's March 2026 MAR failed to direct the amount of water to flush the feeding tube before and after medication administration. On 3/25/26 at 8:35 AM, observed Staff I, Registered Nurse (RN), set up for medication administration and asked the DON if she could check the amount of water needed for flushing medication before and after. The DON left the room, when she returned the DON told Staff I she needed to flush the tube feeding line with 60 cubic centimeter (cc) of water before and after the medication. Staff I flushed the tube with 60 cc of water, then administered some of the medications. Staff I reported she felt some resistance during the administration, the DON took over and started to flush the tube. The DON administered 30 cc flush and Staff I flushed the other 30 cc of water. On 3/25/26 at 10:37 AM the Assistant Director of Nursing (ADON) reported she failed to see the order for Resident #10's water flush amount before and after medication. On 3/25/26 at 10:50 AM Staff I confirmed the DON told her she needed to flush with 60 cc water before and after Resident #10's medication administration. Staff I opened the MAR and reported she didn't see the water flush on the MAR. On 3/25/26 at 10:53 AM the DON reported she said the 60 cc for the water flush because that's the standard amount. On 3/25/26 at 3:15 PM the Director of Nursing (DON) confirmed nursing 101 that if a task or action is not documented, it is not done. She acknowledged the gaps on the MAR for Resident#1. The DON reported the facility followed the six rights for medication administration and lacked a policy directed the staff how to administer medication. The facility provided a policy titled Enteral Tubes: Intermittent/Continuous (pump) Feedings dated June 2024 directed to verify physician's orders for formula, rate, and frequency.

Based on observation, resident and staff interview, clinical record review, and facility policy review, the facility failed to communicate to Residents #3, #4, and #12 in a dignified manner and ensure communication between staff, within hearing distance of Resident #3, was conducted in a dignified manner for 3 of 4 residents (R#3, R#4, and R#12) reviewed for resident rights. The facility reported a census of 42 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment, dated 2/27/26, identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of paraplegia (impairment of motor and sensory function in lower body), seizure disorder, respiratory failure, and malnutrition. The Care Plan Focus, dated 3/3/26, indicated Resident #3 had a psychosocial well-being complication and a mood state disturbance related to diagnoses of major depressive disorder (MDD), antisocial personality disorder, and post traumatic stress disorder (PTSD). The Interventions dated 3/3/26 directed the following:Assist Resident #3 to process feelings and find positive outcomes. Encourage Resident #3 to verbalize feelings, perceptions and fears.Provide assistance and support to identify causative factors contributing to issues with psychosocial well-being.Encourage Resident #3 to communicate feelings.Acknowledge and validate Resident #3's concerns. Collaborate with Resident #3 to address complaints. During an interview on 3/19/26 at 2:30 PM, Resident #3 reported an incident occurred when Staff G, Respiratory Therapist (RT) suctioned his tracheostomy tube (surgical procedure creating an opening in the neck to provide a direct, stable airway). Staff G told him she would put some saline down his tube before suctioning, but had put the saline in his tracheostomy tube, while he was talking, causing him to choke, cough and gag. Resident #3 reported Staff G poured a lot of saline down his tracheostomy tube and stated it seemed Staff G wanted to shut him up. Resident #3 stated he told Staff G she was going to drown him. Resident #3 stated when Staff G suctioned his tracheostomy tube it felt rough. Resident #3 reported when Staff G left his room he could hear her talking to another female staff member in the hallway outside of his room. He heard Staff G say, he said she was going to drown him, in a mocking tone. Resident #3 reported Staff G played it off and made light of it. During an interview on 3/18/26 at 5:00 PM, Staff H, RT, recalled Resident #3 reported an incident on 2/22/26 involving Staff G. Staff H stated Resident #3 told her when Staff G left his room and went into the hallway outside his room, he could hear her laughing with another staff member about his reported concern. Review of a facility provided document titled, Statement, dated 2/22/26, recorded an interview with Resident #3 about how he asked Staff G for moist toothette and she talked over him saying why it was a bad idea to have a moist toothette. She asked if he wanted suctioned. The first pass she warned him she would try saline, he stated she poured the saline down and sucked hard while he was talking. He stated the second pass she did not warn him about saline, he felt every time he would start to talk, she would start to suction. He felt as though she was trying to get him to shut up. He added Staff G left the room and laughed in the hallway. During an interview on 3/24/26 at 3:47 PM, Staff G confirmed they worked with Resident #3 on 2/22/26 in the early morning. They suctioned his tracheostomy tube per Resident #3's request at approximately 5:00 AM. Staff G stated Resident #3 had very dry secretions and she told him she would use saline to loosen the secretions. He didn't object. Staff G reported she squirted saline down the tube just before the second pass of suction. Staff G reported Resident #3 started yelling that she tried to drown him. Resident #3 told Staff G, she took his voice. Staff G recalled Resident #3 said he was trying to talk when she put the saline down. She recalled she responded, he didn't say anything to her when she put the saline in. Staff G reported she instructed Resident #3 to take a few breaths and stated the more she tried to talk to him, the more agitated he got. When she left Resident #3's room, Staff A, Licensed Practical Nurse (LPN), was coming down the hallway. Staff G told Staff A she wouldn't go back into Resident #3's room without someone with her because he accused her of trying to drown him. Staff G confirmed having a conversation with Staff A in the hallway outside of Resident #3's room. During an interview on 3/25/26 at 10:45 AM, Staff A confirmed they worked on 2/22/26 in the early morning with Resident #3 and Staff G. Staff A recalled at approximately 5:00 AM, as she walked down the hallway near Resident #3's room, Staff G had come out of Resident #3's room. Staff G told Staff A she wouldn't go in his room because he's accused her of trying to kill him. Staff A recalled Resident #3 started banging on the wall and screaming. Staff A reported she entered Resident #3's room and asked him to not bang on the wall. Resident #3 stopped and didn't report any concerns to her. The Health Status Note, dated 2/22/26 at 5:15 AM, documented by Staff A reflected as they walked down the hall to answer a call light, Staff G came out of Resident #3's room. They said they were done because he just accused her of trying to drown him. At that point Resident #3 started to bang on the wall. Staff A went and told him he needed to stop banging on the wall because he was waking up the other residents. He didn't voice any other concerns at that time. 2. Resident #4's MDS assessment dated [DATE] identified they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of myotonic muscular dystrophy (a type of muscle disease that causes prolonged muscle contractions and general muscle weakness), chronic respiratory failure with hypoxia (low oxygenation to the tissues), anxiety disorder, and MDD. The Care Plan Focus initiated 1/5/26, indicated Resident #4 used psychotropic medication related to a psychotic disorder for targeted behavior of delusions, disorganized speech, speech that doesn't make sense or is off-topic, highly disorganized or unusual body movements, and negative symptoms like showing less emotion, not being able to feel pleasure, and difficulty starting or finishing planned activities. The Care Plan lacked identification of impaired communication and lacked an intervention related to Resident #4's use of a communication board to assist with their ability to communicate. During an interview on 3/19/26 at 1:30 PM, when asked if they had any concerns with Staff G, Resident #4 nodded their head, yes, and spelled out rude on her communication board. During an interview on 3/24/26 at 2:25 PM, Staff J, Certified Nursing Assistant (CNA), reported they witnessed on an unknown date, Staff G entering Resident #4's room and responding what do you want? As they were just in there. Staff J recalled Staff G's had a rude tone during the interaction and had made Resident #4 cry. 3. Resident #12's MDS assessment, dated 2/26/26, identified a BIMS score of 4, indicating severe cognitive impairment. The MDS included diagnoses of traumatic brain injury, seizure disorder, and depression. The Care Plan Focus revised 9/15/25, reflected Resident #12 had impaired cognitive function and thought processes related to traumatic brain injury. The interventions instructed staff to allow Resident #12 time to respond and process tasks as he gets frustrated easily when he can't get the words out he wants to say. If this happened, he would cuss and yell. During an observation on 3/17/26 at 8:18 AM, Resident #12 sat outside the shower room in his wheelchair, waiting for a staff member to return and assist him with a bath. Resident #12 made a loud exhaling noise and a staff member standing nearby at a medication cart repeated the sound he made and said to Resident #12, life is so tough isn't it, it's so terrible. Resident #12 did not respond. During an interview on 3/24/26 at 5:00 PM, the Administrator explained they expected the staff to treat all residents with dignity and respect. They added laughing or talking about a resident within hearing distance is never okay. Review of the facility policy, titled Residents Rights - Dignity and Respect, revised April 2024 directed to treat all residents with dignity and respect while maintaining and enhancing his or her self-esteem and self-worth. Residents have the right to considerate and respectful care, which includes being treated with honesty and dignity and having their individual needs reasonably accommodated. This right is upheld unless accommodating those needs would endanger the health, safety, or rights of the resident or other individuals within the facility, as outlined in the Procedure.

Based on staff interviews, clinical record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse. The facility omitted written witness statements and documentation of additional residents' interviews from the investigation. The facility reported a census of 42 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of paraplegia (impairment of motor and sensory function in lower body), seizure disorder, respiratory failure, and malnutrition. Review of the Care Plan, dated 3/3/26, revealed Focus areas for Resident #3 having psychosocial well-being complication and a mood state disturbance related to diagnoses of Major Depressive Disorder (MDD), antisocial personality disorder, and Post Traumatic Stress Disorder (PTSD). The Interventions dated 3/3/26 directed the following:Assist Resident #3 to process feelings and find positive outcomes. Encourage Resident #3 to verbalize feelings, perceptions and fears. Provide assistance and support to identify causative factors contributing to issues with psychosocial well-being. Encourage Resident #3 to communicate their feelings. Listen to concerns and assure Resident #3 that concerns are validated. Work cooperatively with Resident #3 to resolve complaints. The facility's investigation of their self-reported incident, submitted to the State Agency on 2/26/26, related to Resident #3's allegation of physical abuse against a staff member, revealed the following: The heading titled, Conclusion, documented: After completing Resident #3 and staff interviews, Resident #3s report feeling safe with Staff G, Respiratory Therapist (RT), while she is working. Resident #3s deny ever feeling like Staff G was physically rough with them in any way. Resident #3s deny having any care without the care being explained first. Staff report that they feel strongly that Staff G is competent in her skills. Staff deny ever witnessing that Staff G completes any cares or tasks without first explaining herself to the Resident #3. After completing staff and Resident #3 interviews, it is concluded that there is no evidence to support the allegation against Staff G. The heading titled, Action Plan, documented: Resident #3 was assessed by the facility Administrator and no injuries were observed. Staff G was suspended from job duties until the investigation is concluded. The primary care provider was notified, and no new orders were given.Staff G's competencies will be reviewed to ensure her skills meet professional standards and uphold Resident #3s' rights, with a continued emphasis on providing compassionate and professional care.The Investigation included the following Statements dated 2/22/26:Staff F, MDS Coordinator, interviewed Resident #3.Staff F interviewed Staff H. The document lacked Staff H's signature to acknowledge their statement.The DON interviewed Staff G. The document lacked Staff G signature to acknowledge their statement. On 3/19/26 at 3:01 PM, upon request for documentation of any additional residents and/or staff interviewed, as documented in the facility's investigation of a self-reported incident under the heading, Conclusion, the DON provided a list of 3 residents and 3 staff names. During an interview on 3/18/26 at 5:00 PM, Staff H, confirmed they worked 2/22/26 with Resident #3. Resident #3 made an allegation of abuse to her against Staff G. Staff H immediately notified the Administrator and Staff F, the nurse on-call, of the abuse allegation. Staff H stated she wrote her witness statement, then sat with Resident #3 to help him write his statement with Staff D, Licensed Practical Nurse (LPN), present in the room. Staff H reported Staff F came into the facility and took the statements she wrote. During an interview on 3/24/26 at 3:47 PM, Staff G, confirmed they worked Resident #3 in the early morning of 2/22/26. Staff G stated the DON contacted her on 2/23/26 about the alleged incident. She didn't receive any other contact from the facility following the conversation on 2/23/26. During an interview on 3/25/26 at 1:55 PM, Staff F, confirmed Staff H notified them on 2/22/26 regarding an allegation of abuse made by Resident #3 against Staff G. Staff F reported she came into the facility and spoke to Staff H, Staff D, and Resident #3 about the allegation. Staff F stated she reviewed Staff H's written statement and used it to write a statement for Staff H and Resident #3. Review of Staff G's Employee File, included a document titled, One-On-One Inservice Record, dated 3/2/26, signed by DON. The document indicated the DON discussed with Staff G about explaining what she is doing with a Resident #3, prior to completing task/care. The document lacked Staff G's signature. The document included Staff G gave verbal understanding via phone. Review of the facility policy titled, Patient Protection Guidelines Abuse Preventions, Reporting, and Investigation, revised September 2025, indicated the 7 Key Components of an Abuse Prevention System as screening, training, prevention, identification, investigation, protection, reporting/response. The section related to Investigation instructed according to the Centers of Medicare and Medicaid Services (CMS), the facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the facility conducts a timely, thorough, and objective investigation of the consideration of the indicators of possible abuse. The administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident. The facility evaluates, processes, and measures compliance against established indicators derived from policies and procedures and industry standards.

Based on staff interview, clinical record review, facility grievance form review, and facility policy review, the facility failed to provide supervision of Resident #6 while outside smoking on 1/4/26. In addition the facility failed to complete smoking or elopement assessments for 1 of 6 residents (Resident #6) reviewed for inadequate staff supervision. The facility did not consistently follow its own safety procedures for Resident #6, identified as a dependent smoker with a risk of wandering. The facility failed to complete the required annual updates to the resident's smoking and elopement risk assessments after 2024. A nurse left the resident unattended outside while smoking, which violated the Care Plan requiring supervision due to the resident's inability to smoke safely. The facility documented addressing the incident with staff education and discipline but could not produce evidence the follow-up occurred, nor documented the incident in the resident's medical records as required. The facility failed to maintain safety monitoring and internal accountability for a resident who required close supervision. The facility reported a census of 42 residents. Findings include: Resident #6's Minimum Data Set (MDS) assessment, dated 1/20/26, identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of traumatic brain damage (TBI), aphasia (inability or impaired ability to understand or produce speech, as a result of brain disease or damage), and seizure disorder. The Care Plan Focus initiated 10/21/24, indicated Resident #6 used tobacco. The goal indicated Resident #6 would adhere to the smoking policy. The Interventions dated 10/21/24 directed the following:Complete a smoking evaluation as needed. Inform resident and/or responsible party of the smoking policy. Dependent smoker: Staff to assist Resident #6 to the designated smoking areas at designated smoking times. Dependent smoker: Staff to supervise while smoking. Independent smoker: Must keep smoking accessories secured when not in use (via lockbox or in control of facility staff). Independent smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas). The Smoking assessment dated [DATE], reflected Resident #6 had cognitive loss and couldn't light a cigarette safely. Resident #6's Electronic Health Records (EHR), lacked additional Smoking Assessments completed after 10/21/24. The Elopement Risk Assessment, dated 10/21/24, revealed a score of 9, indicating they had risk to wander. Resident #6's EHR, lacked additional Elopement Risk Assessments completed after 10/21/24. Review of the facility provided Grievance Logs, revealed a concern reported to the facility Administrator, on 1/5/26, regarding Resident #6. On 1/5/26, the Administrator and Director of Nursing (DON) learned on 1/4/26, a nurse took Resident #6 outside to smoke, lit their cigarette, and then returned inside, leaving them unattended. A signed, typed document from the Administrator accompanied the concern. According to the Grievance Log, the facility resolved the issue by 1/8/26, after staff education and disciplinary action. When requested, the facility couldn't produce the completed staff education and discipline as indicated in the Grievance Log dated 1/5/26. Resident #6's EHRs lacked documentation related to the reported concern on 1/4/26. During an interview, on 3/25/26 at 4:00 PM, the DON stated the facility completed Smoking Assessments and Elopement Risk Assessments on residents at admission and annually. The DON reported the facility did a verbal education with an agency nurse related to leaving Resident #6 outside unsupervised to smoke. The DON stated the staff need to document a progress note or incident report related to any occurrence outside of the resident's plan of care. The Smoking Policy revised January 2024, instructed to establish and maintain safe resident smoking practices. Determine if a resident is an independent or dependent smoker prior to the resident exercising the privilege to smoke. Facilities, at their discretion, may choose to not allow smoking on their premises, may allow smoking only when the resident requires no supervision to smoke, or may offer smoking times and supervised smoking only. The section Guidelines Smoking Facilities, instructed the following:The facility would require residents determined to be a dependent smoker wear a protective smoking vest or apron if needed. They will be supervised while smoking and be assisted during designated smoking times. The facility would update the Care Plan for smokers to include, but not limited to, assistance required if needed, safety interventions or protective equipment needed if indicated, storage of materials. Care Plans will be reviewed and revised as necessary.

Based on observations, clinical record review, staff interviews and facility policy review the facility failed identify a change in condition that required physician notification for 2 of 4 residents reviewed (Residents #3 and #5). The facility failed to provide necessary care for two residents. When Resident #5's CAT scan on 2/18/26 diagnosed a pulmonary embolism (PE). The facility delayed treatment until 2/20/26, despite a call from his Guardian and a staff assessment noting a low pulse ox. The Medical Director expected immediate provider notification. When Resident #3, had two episodes of unresponsiveness and dizziness on 2/28/26, and a dangerously low blood pressure (60/40) on 3/1/26. The facility delayed nursing documentation, assessment, and physician notification until 3/2/26. The facility reported a census of 42 residents. Findings included:1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate problems with thinking and memory. The MDS included diagnoses of atrial fibrillation (irregular heart beat), mild intellectually disabled, and need for assistance with personal care. The Care Plan Focus dated 4/29/25 identified Resident #5 required assistance with activities of daily living (ADL's) related to weakness and decreased strength. The Interventions directed the following: Resident #5 dependent on 1 or 2 staff for grooming, dressing, and bed mobility. Resident #5 dependent on 2 staff with a full-body mechanical lift to transfer. The Progress Notes dated 2/18/26 at 7:30 AM indicated facility staff transported Resident #5 to an appointment for a CAT scan (a special kind of X-ray that takes pictures of the inside of your body). The Progress Notes dated 2/18/26 at 12:59 PM documented Resident #5 returned from the CAT scan, but the nurses' station couldn't print the paperwork. The staff would make a follow-up call in a few days to check for any faxed dictation. The Progress Notes dated 2/18/26 at 3:10 PM, Staff B, Registered Nurse (RN) documented Resident #5's Guardian contacted the facility regarding possible abnormal blood clot results in the lungs. The Guardian asked for an update on the resident's condition. Staff B assessed Resident #5's vitals, noting only his low pulse ox (oxygen in blood). Staff B placed Resident #5 on oxygen, and his pulse ox returned to the normal range (90-100%). Resident #5 denied troubles breathing or pain issues. A Certified Nurse Aide (CNA) entered the room, assisted Resident #5 into the wheelchair for transfer to the dining room. The staff didn't note any incident or concerns at the time. The Progress Note dated 2/18/26 at 3:15 PM Staff B, updated Resident #5's Responsible Party. The Progress Note dated 2/20/26 at 11:17 AM indicated Staff F, MDS Coordinator, received a call from a provider with CT scan results showed lung pulmonary embolism (LPE, a serious, life-threatening condition where a blood clot, usually from the leg, travels to the lungs and blocks an artery). The provider gave an order to send Resident #5 to the emergency department (ED). The Progress Note dated 2/20/26 at 6:48 PM reflected Resident #5 returned to the facility on anticoagulant (blood thinners) medication. The After Visit Summary dated 2/20/26 listed a diagnosis of pulmonary embolism. On 3/23/26 at 3:45 PM the Medical Director reported he expected the facility to notify the provider as soon as they knew of the PE in Resident #5's lung. He confirmed Resident #5 had a delay in treatment. On 3/24/26 at 6:07 PM Staff B reported he assessed Resident #5 after Resident #5's Representative called about the concern with blood clots. Staff B said Resident #5 seemed stable with no complaints. Staff B explained he talked to the Director of Nursing (DON) and she told him he needed to wait for the documentation of the PE or a call from the provider to validate the PE. On 3/25/26 at 2:14 PM, Staff F reported it took 2 days for the facility to get an order for the treatment for Resident #5's PE took. Staff F said the hospital called and left a message for the DON on her voicemail (VM). Staff F reported the DON failed to check her VM on a regular basis. On 3/25/26 at 3:20 PM the DON reported Resident #5 CAT scan identified a PE. She explained they called her with the results of the CAT scan and she notified the provider who ordered to send Resident #5 to the ED. The DON said she thought it all happened in one day. The DON denied she knew Staff B got a phone call from Resident #5's Representative about the PE on 2/18/26. The DON reported she expected the staff to notify the provider of a change in conditions. 2. Resident #3's Minimum Data Set (MDS) assessment, dated 2/27/26, identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of paraplegia (impairment of motor and sensory function in lower body), seizure disorder, coronary artery disease (CAD), respiratory failure, and malnutrition. The Respiratory Therapy Notes, dated 2/28/26, revealed the following entries documented by Staff H, Respiratory Therapist (RT): On 2/28/26 at 8:03 AM: Staff H assisted the CNA transfer Resident #3 from the bed to a wheelchair. During the transfer, Resident #3 reported feeling dizzy, then exhibited a fixed gaze (looking forward without blinking) and became unresponsive to verbal stimuli. He stayed in that state for approximately eight minutes after they laid Resident #3 in a wheelchair. During that time, Resident #3's respirations measured 12-14 breaths per minute. (Note: Resident #3 is known to sleep with their eyes open.). As Resident #3 began to recover, they experienced uncontrolled arm swinging. Following this, Resident #3 became responsive to verbal cues, stated they were thirsty, and returned to their normal state. On 2/28/26 at 5:00 PM: Staff H helped transfer Resident #3 from the bed to the wheelchair as the CNAs and nurse remained in the room. They transferred Resident #3 using a full-body mechanical lift and full-body sling. Just above the wheelchair, Resident #3 displayed the same blank stare he had that morning, but this time it lasted over 15 minutes. Staff H tried to get a pulse oximeter reading but failed. Resident #3's breathing slowed to 7-8 breaths per minute. Resident #3's lips turned grayish. Staff H administered 10 Liters (L) of oxygen and attempted to suction them with no response. Staff H performed a sternum rub; but Resident #3 did not respond. Staff H lifted Resident #3's eyelid and saw no pupil response; his pupils resembled pin dots. In a split second, Resident #3 moved his jaw and awoke. When Staff H said Resident #3's name, he responded that he felt thirsty. He stated he felt dizzy, but otherwise okay and hungry. The nursing staff knew about the incident due to their presence at the time. Resident #3's Electronic Health Records (EHR), lacked nursing documentation, assessment, or physician notification of the two unresponsive episodes occurring on 2/28/26. The Respiratory Therapy Notes, dated 3/1/26, documented by Staff H identified the following: On 3/1/26 at 12:31 PM: Staff H talked with the DON about Resident #3's episodes of going unresponsive. They both agreed to track Resident #3's blood pressure when the episodes happened and documenting when they took place. On 3/1/26 at 3:31 PM: Staff H notified the nurse that Resident #3 reported to them that he had low blood pressure and took medication to raise his blood pressure at the other facility. Staff H had Resident #3 try to sit up in bed at an angle of 70 degrees. After 20 minutes, Resident #3 got dizzy, he said would pass out and needed lowered. Staff H lowered the bed to the 30-degree angle, and Resident #3 described that as better. After 10 minutes, Resident #3 had Staff H lower the bed again to 20 degrees due to still feeling dizzy and felt like he would pass out. Staff H notified the nurse about the incident. On 3/1/26 at 4:36 PM: Resident #3's blood pressure was recorded as 60/40 (significantly lower than the average of 120/80) after he became lightheaded at a 30-degree angle and was then positioned at a 20-degree angle. Resident #3's Electronic Health Records (EHR), lacked nursing documentation, assessment, or physician notification of Resident #3's episodes of dizziness or the blood pressure of 60/40 noted on 3/1/26. The Communication - with Physician Note, dated 3/2/26 at 12:34 PM documented by the DON indicated staff called regarding apneic (not breathing) spells and hypotension (low blood pressure) with position changes. His vital signs measured a blood pressure of 115/58, 91 heart beats per minute, 8 respirations per minute, 94% oxygen saturation on room air. When Resident #3 minimally responded to verbal stimuli and his face appeared pale, the staff elevated the feet of his chair above his heart to promote blood flow. The received a new order to send Resident #3 to the ED for further evaluation. The staff called 911 for transport to the ED. The Order Note labeled Late Entry, dated 3/2/26 at 12:40 PM documented by DON identified the facility received a new order to increase Midodrine (medication used to treat severe orthostatic hypotension or drop in blood pressure upon sitting or standing) to 5 milligrams (mg) three times a day (from 2.5 mg three times a day). Resident #3 out at hospital. The Health Status Note, dated 3/2/26 at 7:49 PM, reflected Resident #3 returned from the ED via ambulance with no new orders and to follow up with their provider as soon as possible for a visit in 2 days. The Care Plan, initiated 2/20/26, lacked identification or interventions related to Resident #3's episodes of orthostatic hypotension and unresponsive episodes during changes in position. During an interview on 3/18/26 at 5:00 PM, Staff H reported that the RT staff would notify nursing staff of any changes in a resident's condition and nursing would communicate with the provider to obtain any new orders. During an interview on 3/25/26 at 4:00 PM, the DON reported they expected nursing staff to notify the physician of low blood pressures and anything outside of a resident's normal condition. The Notification for Change in Condition policy, revised June 2023, directed the facility to provide care to residents and provide notification of resident changes in status. The Procedure section listed the following: The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or A decision to transfer or discharge the resident from the facility. Additionally, the policy instructed, per federal guidance, physicians need notification if a resident experiences symptoms such as chest pain, loss of consciousness, or other signs or symptoms of heart attack or stroke.

Based on staff interview, clinical record review, facility Grievance log review, and facility policy review, the facility failed to bath residents at least once per week for 2 of 3 resident (Resident #2 and Resident #4) reviewed for resident's rights. The facility reported a census of 42 residents. Findings include:1. Resident #2's Minimum Data Set (MDS) assessment, dated 1/8/26, identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of respiratory failure, heart failure, morbid (severe) obesity with hypoventilation (condition where breathing is too shallow to meet the resident's needs), and methicillin resistant staphylococcus aurorus (MRSA) infection (an infection that certain antibiotics don't work to treat). The MDS indicated Resident #2 required a partial to moderate amount of staff assistance with bathing. The Care Plan, initiated 1/2/26, revealed a Focus area for Resident #2 required assistance with Activities of Daily Living (ADLs) with an intervention that instructed to assist Resident #2 with a bath or shower per schedule. The facility provided Grievance Logs, revealed a concern reported by Resident #2 on 2/16/26, which documented they weren't getting showers. Resident #2 told staff she had not received one in a week. The Grievance Log indicated the facility changed the showers to second shift and discussed Resident #2 refused showers. The Grievance Log dated 2/16/26 indicated they resolved the concern on 2/18/26. Resident #2's Electronic Health Records (EHR) revealed bath/showers documentation for the month of February, 2026, listed they only refused to take a shower on 2/2/26 and only received a shower on 2/16/26. 2. Resident #4's Minimum Data Set (MDS) assessment, dated 2/16/26, identified they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of myotonic muscular dystrophy (a type of muscle-wasting disease that causes prolonged muscle contractions), diabetes mellitus, and malnutrition (not getting enough nutrients, or too much of the wrong ones). The Care Plan Focus initiated 1/5/26, indicated Resident #4 required assistance with activities of daily living (ADLs). The Interventions directed the following:1/5/26: Assist Resident #4 with a shower or bath per schedule. Date initiated: 1/5/26. 3/24/26: Resident #4 preferred to take bed baths versus showers. Staff will still offer Resident #4 a shower. Resident #4's EHR, revealed bath/shower documentation for the month of February, 2026, the staff documented Resident #4 only received a shower on 2/28/26. They left 2/2/26, 2/4/26, and 2/9/26 blank. Resident #4 refused to shower on 2/7/26, 2/11/26, 2/18/26, 2/21/26, and 2/23/26. The staff documented Resident #4 didn't receive a shower on 2/14/26, 2/16/26, or 2/25/26.During an interview on 3/23/26 at 10:00 AM, Staff L, Certified Medication Assistant (CMA), stated since the facility implemented a decreased staff to resident ratio, the residents haven't received showers. During an interview on 3/24/26 at 2:25 PM, Staff J, Certified Nursing Assistant (CNA), reported a resident told her that he didn't get a shower for 2 weeks, between being hospitalized and returning to the facility. When he asked another CNA for a shower, she claimed she would do it, but never returned to help him. During an interview on 3/25/26 at 1:55 PM, Staff F, MDS Coordinator, reported being disappointed with the lack of care going on at the facility. She added she believed it had to do with not having enough staff due to the strict staffing numbers implemented by the facility. Staff F stated residents told her they hadn't got a shower in a week. She suggested to facility leadership to use a bath aide to assist with completing showers, but they told her to delegate the bathing task. During an interview on 3/25/26 at 4:00 PM, the Director of Nursing (DON), stated completing resident baths/showers needed room for improvement. The DON revealed they expected residents to receive a bath or shower two times a week. The DON stated they had enough staff to complete baths between nurses, medication aides, and CNAs. The facility policy titled, Hygiene - Bathing/Shower, dated March 2024, instructed to cleanse skin, promote cleanliness, and prevent infection. The policy instructed staff to document in the EHR when they completed a bath or shower.

Based on staff interview, facility narcotic logs, clinical record review, and facility policy review, the facility failed to correctly transcribe physician orders for two controlled substances morphine sulfate concentrate oral solution (opioid narcotic used to treat severe pain) and lorazepam concentrate oral solution (benzodiazepine, which acts as a central nervous system depressant, used to treat anxiety disorders, insomnia, and seizures) which resulted in Resident #3 receiving an 8 times greater dose of morphine than ordered on 3/8/26 at 1:11 AM, followed by administration of naloxone (Narcan- nasal spray to rapidly reverse an overdose of opioid medications) on 3/8/26 at 1:45 AM, as well as, a 2 times greater dosage of Lorazepam than ordered, administered 8 times between the dates of 3/7/26 and 3/10/26 for 1 of 6 residents (Resident #3) reviewed for medication administration. Findings include: Resident #3's Minimum Data Set (MDS) assessment, dated 2/27/26, identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of paraplegia (impairment of motor and sensory function in lower body), seizure disorder, respiratory failure, malnutrition, and cachexia (severe involuntary loss of weight, muscle and fat caused by chronic diseases). Resident #3's hospice admission orders, dated 3/6/26, noted by the facility on 3/7/26, revealed the following written physician orders: Morphine Sulfate concentrate 20 milligrams (mg) per milliliter (mL), with instructions to give 0.25 mL (5 mg) by mouth/sublingual every 2 hours as needed for pain or shortness of breath. Lorazepam concentrate 2 mg per 1 mL (2mg/mL), with instructions to give 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. Review of Resident #3's Electronic Health Records (EHR), listed the created and discontinued dates for the following medication orders:Morphine Sulfate (concentrate) oral solution 100mg/5mL directed the following instructions:3/7/26: Give 2 mL by mouth every 2 hours as needed for pain or shortness of breath, was created on 3/7/26, and discontinued on 3/8/26 at 1:39 AM. 3/8/26: Give 0.25 mL by mouth every 2 hours as needed for pain or shortness of breath. Lorazepam oral concentrate 2mg/mL directed the following instructions:3/7/26: Give 0.5 mL by mouth every 2 hours as needed for anxiety or restlessness. The facility discontinued the order on 3/10/26 with the note, clarified with hospice. The Health Status Note labeled Late Entry electronically signed entry by Staff A, Registered Nurse, dated 3/8/26 at 1:11 AM, documented they gave Resident #3 morphine concentrate 100mg/5mL, 2 mL at 1:11 AM for a pain level 8, indicating severe pain. The note order indicated they updated the order to reflect the correct dose. The Health Status Note labeled Late Entry electronically signed entry by Staff A, dated 3/8/26 at 1:45 AM, documented: they gave Resident #3 Narcan at that time for prophylaxis (preventive treatment for disease). Staff A went into Resident #3's room and explained the plan. Staff A told Resident #3, they planned to give them Narcan because they gave him too much morphine. Resident #3 asked if they were going to wash all the morphine out of him. Staff A responded yes, that's what Narcan is for. Resident #3 threw his hands in the air. He acted asymptomatic (showing no symptoms of disease), and showed no signs or symptoms of respiratory distress at the time of administration. Staff A administered one dose of Narcan. The Encounter note, dated 3/10/26, revealed Resident #3 had an acute care visit with Provider for follow up after a medication error over the weekend that required naloxone (Narcan) administration. The note documented Resident #3 admitted to hospice on 3/6/26 with orders for comfort medications including morphine concentrate 100mg/5mL, 0.25 mL every 2 hours as needed and lorazepam concentrate 2mg/mL, 0.25 mL every 2 hours as needed. Due to a transcription error, the Medication Administration Record (MAR) listed morphine as 2 mL every 2 hours as needed. During the incident, the patient received morphine 0.25 mL, but there was concern that 2 mL could have been administered. Additionally, the patient received lorazepam 1 mg every 2 hours instead of the intended 0.5 mg tablet every 2 hours for restlessness. The staff notified the DON and on-call Provider and administered naloxone as a precaution. Resident #3 did not experience any adverse effects from the medication error, appeared pain-free, and rested comfortably since the incident. Resident #3's March 2026 MAR included the following orders:Morphine Sulfate (concentrate) oral solution 100mg/5mL. Give 2 mL by mouth every 2 hours as needed for pain or shortness of breath. Start date: 3/7/26 at 11:30 AM. Discontinue date: 3/8/26 at 1:39 AM. Medication administration, documented by Staff A, on 3/8/26 at 1:11 AM. Lorazepam oral concentrate 2mg/mL. Give 0.5 mL by mouth every 2 hours as needed for anxiety or restlessness. Start date: 3/7/26 at 11:30 AM. Discontinue date: 3/10/26 at 4:29 PM.Medication administrations, documented by various staff, on 3/7/26 at 2:19 PM, 3/8/26 at 1:11 AM, 3/8/26 at 9:09 AM, 3/8/26 1:30 PM, 3/8/26 at 4:27 PM, 3/9/26 7:15 AM, 3/9/26 at 3:45 PM, and 3/10/26 at 5:26 AM.Naloxone (Narcan) nasal liquid 4mg/.1mL. Give one spray in alternating nostrils, one time only, for opioid overdose for one day. Start date: 3/8/26 at 1:45 AM. Medication administration, documented by Staff A, on 3/8/26 at 1:45 AM. Review of the facility document used to log and track the disposition of controlled substances for Resident #3's morphine sulfate, revealed the following logged entries:On 3/7/26 at 11:30 AM, the current balance of morphine solution 30 mL, the amount dispensed 0.25 mL and the remaining amount 29.75 mL. On 3/7/26 at 2:00 PM, the current balance of morphine solution 29.5 mL, the amount dispensed 0.25 mL, and the remaining amount 29.5 mL. On 3/8/26 at 1:12 AM, the current balance of morphine solution 29.5 mL, the amount dispensed 2 mL, and the remaining amount 27.5 mL. The facility couldn't locate a controlled substance log for Resident #3's lorazepam solution. The Incident Report Note, electronically signed by Staff A, dated 3/10/26 at 2:55 PM, documented a nurse and an orientee changed a colostomy and urostomy for Resident #3 who then asked for pain medication. The MAR and order tab incorrectly showed an order for 2 mL of morphine sulfate every two hours as needed. The staff gave Resident #3 the morphine sulfate and lorazepam. However, when the nurse went to sign out the narcotic book, they immediately discovered the book stated the correct order of only 0.25 mL of morphine sulfate. This meant Resident #3 received a significantly higher dose than ordered. The nurse promptly informed the Nurse Manager, who instructed her to call Resident #3's doctor. Resident #3 didn't appear to be in pain prior to receiving the medication. The note listed his vital signs as blood pressure 68/58 (a typical person usually measures 120/80), temperature 97.7, heart rate of 59, respirations of 19, and an oxygen level of 96% on room air. The Incident Report note, electronically signed by Director of Nursing (DON), dated 3/10/26 at 4:31 PM, documented Resident #3 received lorazepam concentrate 2 mg/mL, 0.5 mL every 2 hours as needed for anxiety or restlessness. The facility notified Resident #3, hospice, and provider of the incident. The Care Plan Focus revised 3/9/26, identified Resident #3 received the opioid medication, morphine. The goal indicated Resident #3 would remain free of complications related to use of opioid medication. The Interventions instructed staff to monitor for medication side effects such as: feelings of euphoria, dry mouth, headache, flushing, mental fog, constipation, drowsiness, itching, respiratory depression, lethargy, addiction, irregular heart beat, depression, and severe abdominal pain. The Care Plan Focus revised on 3/4/26, reflected Resident #3 complained of pain, described as chronic, related to paraplegia (paralysis that affects the lower half of the body, including both legs) and pressure wounds. The Intervention directed to administer pain medication per physician orders. During an interview on 3/25/26 at 10:45 AM, Staff A confirmed they worked on 3/8/26 and that Resident #3 needed morphine for pain. Staff A checked Resident #3's doctor's orders and medication record, both listed a 2 mL dose of morphine. However, Staff A admitted they didn't check the controlled substance log before preparing and giving the medication. Although Staff A questioned the 2 mL dose as being too high because Resident #3 recently started hospice and was very thin, she couldn't find the original hospice orders to check. Staff A and a nurse in training gave the 2 mL dose. When Staff A returned to the nurse's station to sign out the medication in the controlled substance log, she discovered a medication error: Resident #3's received only 0.25 mL for their last dose. Immediately after realizing the mistake, Staff A called the Nurse Manager and the on-call doctor, informed Resident #3, and documented the event. Staff A gave Resident #3 Narcan (naloxone) nasal spray as instructed. They watched Resident #3 closely all night and he didn't show any harmful side effects. During an interview on 3/25/26 at 1:55 PM, Staff F, the MDS Coordinator, confirmed that she entered the orders for Resident #3's morphine and lorazepam into the electronic health record (EHR) on 3/7/26. She explained that another nurse received the orders on 3/6/26, but hadn't transcribed them. Staff F stated she felt pressured to enter the orders quickly because she also worked as a floor nurse that day and didn't have another nurse available to double-check her work. Staff F reported she gave Resident #3 the prescribed 0.25 mL dose of morphine and 0.5 mL of lorazepam, though they later determined the lorazepam dose to be incorrect. She also noted that a controlled substance log should be used to record the dispensing of both morphine and lorazepam. During an interview on 3/25/26 at 4:00 PM, the Director of Nursing (DON) revealed they expected the nurses to administer medications as ordered by the provider and double check orders with another nurse to ensure accuracy. On 3/25/26 at 4:59 PM the Administrator denied having policies and procedures for medication administration. They stated the facility followed the industry standard of following the 6 rights of medication administration: the right patient, dose, medication, route, time, and documentation.

Based on observations, clinical record review, staff interview, and facility policy review the facility failed to administer medications as ordered for 3 out of 6 residents reviewed (Residents #1, #4, and #8). The facility reported a census of 42 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS included diagnoses of traumatic hemorrhage cerebrum (life threatening brain bleed caused by physical injury), seizure disorder, Dysarthria (a motor speech disorder characterized by weak, damaged, or paralyzed speech muscles (lips, tongue, vocal cords, diaphragm), leading to slurred, slow, or difficult-to-understand speech) and Anarthria (the severe, total loss of the ability to articulate speech due to brain damage or neurological disorders, preventing control of muscles for speaking while often leaving language comprehension intact. Often considered an extreme form of dysarthria, it results from lesions impacting motor pathways, causing complete muteness). The MDS showed Resident #1 required a tube feeding for nutrition. The Care Plan dated 12/16/24 identified Resident #1 had a risk for altered neurological status related to a seizure disorder. The Interventions directed to give medications as ordered. Resident #1's January 2026 Medication Administration Record (MAR) included the following orders: Famotidine (reduces stomach acid) 20 mg two times a day. The MAR lacked documentation to indicate Resident #1 received famotidine on: 1/6/26, 1/16/26, and on 1/21/26 at bedtime (HS). Keppra (prevent seizures) 250 milligrams (mg) via peg tube two times a day for convulsions. The MAR lacked documentation to indicate Resident #1 received Keppra on 1/21/26 Baclofen (muscle relaxant) 20 mg via feeding tube four times a day for muscle spasms. The MAR lacked documentation to indicate Resident #1 received Baclofen on: 1/6/26 at HS, 1/10/26 at lunch, 1/16/26 at HS, 1/18/26 at lunch, 1/21/26 at lunch and HS, 1/25/26 at lunch. The Incident Report Medication Event dated 1/22/26 at 22:33 PM reflected staff found Resident #1 failed to get medications (Baclofen 20 mg Keppra 250 mg) for the PM shift on 1/21/26. The Progress Note dated 1/26/26 at 1:12 AM reflected no adverse effects from the medication omission on 1/21/26. Resident #1's February 2026 MAR included the following orders: Keppra 250 mg via peg tube two times a day for convulsions. The MAR lacked documentation to indicate Resident #1 received Keppra on 2/25/26 mid afternoon. Famotidine 20 mg two times a day. The MAR lacked documentation to indicate Resident #1 received famotidine on 2/8/26 at HS. Baclofen 20 mg via G-tube four times a day. The MAR lacked documentation to indicate Resident #1 received Baclofen on 2/8/26 at HS and 2/25/26 in the afternoon. The Medication Event - Missing Medication dated 2/20/26 at 4:00 PM reflected Resident #1 failed to get Baclofen 20 mg and Keppra 250 mg in the afternoon and Baclofen 20 mg at bedtime. 2. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] Cognitive assessment indicated Resident #8 rarely or never understood, with short and long term memory problems. Resident #8 had severely impaired daily decision making skills. The MDS included diagnoses of traumatic brain injury (TBI), traumatic brain dysfunction, and quadriplegia (paralysis that affects all four limbs, both the arms and the legs). The Care Plan dated 12/2/24 directed to give Resident #8 medications as ordered. Resident #8's March 2026 MAR lacked documentation to show the facility provided ipratropium-albuterol solution 0.5-2.5 3 MG/3 milliliter (Ml)1 vial via trach four times a day related to tracheostomy status. The Progress Note dated 2/4/26 at 11:02 PM reflected when the evening shift administered medication and they found the AM (morning) glycopyrrolate (reduces stomach acid) tab 1 mg and AM Baclofen 10 mg and 5 mg dose still in the medication card. The note indicated the agency staff failed to give the medication. The Incident Report - Medication Event dated 2/6/26 identified when the facility attempted to contact Resident #8's Representative, they got their voicemail. The facility left a message to call the facility to update missed medication. On 3/23/26 at 5:00 PM Staff K, Licensed Practical Nurse (LPN), reported found medications not given on the day shift by other nurses. Staff K said she did the incident report and let the doctor know. On 3/25/26 at 2:09 PM Staff F, MDS Coordinator, reported she knew Resident #1 missed their medications. On 3/25/26 at 3:15 PM the Director of Nursing (DON) agreed that, as is basic in nursing, if you don't write it down, it didn't happen. She acknowledged the gaps on Resident #1's MAR. The DON reported the facility followed the 6 rights for medication administration and lacked a policy directing the staff how to administer medication. 3. Resident #4's Minimum Data Set (MDS) assessment, dated 2/16/26, identified they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of myotonic muscular dystrophy (a type of muscle-wasting disease that causes prolonged muscle contractions), diabetes mellitus, and malnutrition (not getting enough nutrients, or too much of the wrong ones). The Care Plan dated 1/5/26 directed to administer Resident #4's medications as ordered. Resident #4's February 2026's MAR indicated they received all bedtime medications on 2/19/26 and 2/20/26. The Health Status Note, dated 2/21/26 at 3:28 PM, documented as the staff got Resident #4's medications ready that morning, they noticed they still had medications in the card for the evening and bedtime on 2/19/26. The medications included Midodrine (a medication used to raise blood pressure) 2.5 milligrams (mg), Eliquis (a blood thinner) 2.5 mg, escitalopram (a common medication for depression and anxiety) 10 mg, and quetiapine (an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder) 50 mg. The facility notified the husband of the missed medications while he visited the facility. The nurse on-call and physician still needed notified. The Incident Report titled, Medication Event/Missing Medication, dated 2/20/26, reflected the facility notified the physician, responsible party, and on-call nurse of the incident. The Incident Report included a handwritten note indicating the nurse no longer picked up shifts at the facility.

Based on staff interview, facility document review, and facility policy review, the facility failed to keep record of the distribution for controlled substance Lorazepam (medication used to treat anxiety, insomnia, and seizures) for 1 of 6 residents (Resident #3) reviewed for medication administration. The facility reported a census 42 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment, dated 2/27/26, identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of paraplegia (impairment of motor and sensory function in lower body), seizure disorder, respiratory failure, and malnutrition. The Care Plan included the following Focuses:Resident #3 had a mood state disturbance related to diagnoses of major depressive disorder, antisocial personality disorder, and post traumatic stress disorder (PTSD).Resident #3 had a history of substance overuse that may impact psychosocial functioning. The Interventions instructed the following:3/4/26: Administer medications as ordered. 3/4/26: Remain non-judgmental and be alert to changes in behavior such as restlessness or increased tension. 3/3/26: Initiate increased monitoring and supervision of Resident # 3 as needed. 3/3/26: Medication review with pharmacy per facility protocol. Resident #3's hospice admission orders, dated 3/6/26, noted by the facility on 3/7/26, revealed a written physician's order for lorazepam concentrate 2 milligrams (mg) per 1 milliliter (mL) (2mg/mL). The instructions directed to give 0.25 mL (0.5 mg) by mouth/sublingual (under the tongue) every 2 hours as needed for anxiety or restlessness. Resident #3's March 2026 Medication Administration Record (MAR) included an order dated 3/7/26 at 11:30 AM to give lorazepam oral concentrate 2 mg/mL 0.5 mL by mouth every 2 hours as needed for anxiety or restlessness. The facility discontinued the order on 3/10/26 at 4:29 PM. The MAR included the following Medication administrations, documented by various staff:On 3/7/26 at 2:19 PM, 3/8/26 at 1:11 AM, 3/8/26 at 9:09 AM, 3/8/26 1:30 PM, 3/8/26 at 4:27 PM, 3/9/26 7:15 AM, 3/9/26 at 3:45 PM, and 3/10/26 at 5:26 AM. The facility couldn't locate a controlled substance log (a document used to log and track the disposition of controlled substances) for Resident #3's lorazepam solution. The Incident Report note, electronically signed by Director of Nursing (DON), dated 3/10/26 at 4:31 PM, documented Resident #3 received lorazepam concentrate 2 mg/mL, 0.5 mL every 2 hours as needed for anxiety or restlessness. The facility notified Resident #3, hospice, and provider of the incident. During an interview on 3/25/26 at 1:55 PM, Staff F, MDS Coordinator, confirmed she transcribed Resident #3's order for lorazepam into the EHR on 3/7/26. Staff F reported being in a rush to enter the orders due to working as the floor nurse that day and didn't have another nurse to double check the orders. Staff F stated she gave Resident #3 0.5 mL of lorazepam on 3/7/26, later identified as an incorrect dosage. Staff F reported they should use a controlled substance log to document distribution of lorazepam. During an interview on 3/25/26 at 4:00 PM, the Director of Nursing (DON) revealed they expected the nurses to administer medications as ordered by the provider and double check orders with another nurse to ensure accuracy. The DON reported they expected a controlled substance log to be initiated and completed with each administration of lorazepam. On 3/25/26 at 4:59 PM the Administrator denied having policies and procedures for medication administration. They stated the facility followed the industry standard of following the 6 rights of medication administration: the right patient, dose, medication, route, time, and documentation.

Based on observations, record review, resident, and staff interviews, the facility failed to report an allegation of abuse to the Administrator, as well as the State Survey Agency within the mandated timeframe (2 hours). This resulted in a failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to report an allegation of abuse prevented an investigation into the incident, as a result, the harm continued to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. The facility staff removed the Immediate Jeopardy on 8/6/25 through the following actions:The facility completed staff education on 8/5/25 regarding the reporting of allegations and suspicions of abuse, and injury of unknown source. The facility would use the abuse policy and guidelines for training and education of the reporting requirements. The education and training would include the chain of command, how to access administrative staff, and the on-call numbers. The staff unavailable that day to receive the education, would receive the education prior to clocking into their next shift. The Staff would validate understanding by verbally reiterating the process, actions, and steps to take when an allegation is made.The facility interviewed alert and oriented residents. In addition, the facility conducted body audits of residents with a Brief Interview for Mental Status (BIMS) score lower than 13, to rule out any additional unknown allegations of abuse. The scope lowered from J to D at the time of survey after ensuring the facility implemented education and their policy and procedure. The facility reported a census of 49 residents. Findings include:Resident #51's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview For Mental Status (BIMS) score of 9, indicating a moderate cognitive impairment. The MDS indicated Resident #51 didn't exhibit the behavior of rejecting care. Resident #51 required maximal assistance for lying to sitting on the side of the bed. The MDS listed Resident #51 as dependent on staff for all transfers. Resident #51 was unable to walk 10 feet. The MDS included diagnoses of chronic obstructive pulmonary disease, mild intellectual disabilities, cognitive communication deficit, abnormalities of gait, and mobility.The Care Plan Focuses with a target date of 7/7/25 reflected Resident #51 had:The tendency to refuse medications and showers. The Interventions directed the following: Staff to approach or speak in a calm manner.Assure the resident that concerns are validated and staff are willing to address legitimate concerns.Encourage to participate in care activities and respect the resident's rights to make his own lifestyle choice. A risk for falls. The Interventions directed the following:Staff provide assistance of 2 staff with the standing mechanical lift for all transfers to the wheelchairPlace the call light within reachOrient to surroundings Consult with therapy as needed.Used anticoagulant (blood thinner) medication. The Interventions directed the staff to monitor for signs and symptoms of bleeding to include bruising.A document titled Therapy Recommendation from Physical/Occupational Therapy (PT/OT) to Nursing dated 6/18/25 directed staff to use the standing mechanical lift for all transfers. The document directed staff to direct Resident #51 to explain before completing task to hold hands, assist or guide the patient's arm to safely grip the handle. Resident #51 required time to set up in the standing mechanical lift. During an interview on 7/28/25 at 4:02 PM, Resident #51 reported the staff pulled him from his bed. He added it happened day and night and received bruises to his forearms. Resident #51 stated he had thin skin and could bruise when touched. Resident #51 stated he reported it to staff because being pulled from bed wasn't good for him. Resident #51 pointed out several bruises to both of his forearms about the size of half dollar coins. Resident #51 stated, he reported this one.The Progress Notes lacked documentation of Resident #51's dark purple bruises. In addition, the progress notes lacked documentation of notification to the nursing staff, administration, his family, or physician for Resident #51's bruises.During an interview on 8/4/25 at 1:42 PM, Staff O, Certified Nursing Assistant (CNA), stated Resident #51 blamed her and a coworker for the bruises to his arms. Staff O stated she received direction to get Resident #51 up to the wheelchair with a gait belt, then stand him and pivot (turn) him.During an interview on 7/30/25 at 3:04 PM, Staff B, CNA, stated she never had a problem with Resident #51 and didn't hear him say someone pulled him out of bed or hurt him. Staff B stated they noticed the bruising on his arms. Staff B stated if a CNA noted bruises on a resident, they chart it in the electronic health record (EHR) then they tell the nurse. Staff B stated the nurses did a good job assessing a concern right away when staff report a change in a resident's condition. She explained no staff reported how Resident #51 received the bruising.During an interview on 7/30/2025 at 3:31 PM, Staff J, CNA stated she noticed Resident #51 had bruising on his arms but didn't know how he got them.During an interview on 7/30/25 at 3:44 PM, Staff M, CNA, stated on 7/28/25, 2-10 shift, Resident #51 reported that a staff person came into his room and grabbed him too hard by the arm to get him out of the bed. Staff M stated Resident #51 had dark bruises on his arms. Staff M stated they reported the incident to the nurse, but they couldn't recall the time, but claimed to reported it to the nurse that evening. On 7/30/25 at 4:00 PM, notified the facility Administer about how Resident #51's claimed the staff pulled him out of bed by his arms. In addition, he informed the staff of the incident as it hurt his arms, and he had visible bruising to both wrists and forearms. The Administrator stated no one informed her about the claim.The Incident Report Note dated 7/31/25 at 11:52 AM reflected Resident #51 had bruising and a skin tear to his left posterior (back of) forearm. His range of motion remained at baseline, and Resident #51 denied pain. Resident #51 required staff assistance for activities of daily living (ADL). Resident #51 received Eliquis 2 times a day for atrial fibrillation (abnormal heart rhythm) which increased the risk for bruising.During an interview on 7/31/25 at 1:31 PM Staff I, Infection Preventionist, described Resident #51 as not cooperative. Staff I stated Staff H, MDS Coordinator, assisted her with the skin sheet and the initial measurements. They asked Resident #51 how the injuries occurred. Staff I stated the skin sheets included the bruises Resident #51 sustained when he fell, but they healed them on 7/16/25. Staff I stated he didn't have any other bruising. Staff I couldn't say how Resident #51's bruises occurred, and she didn't ask him. She thought they happened from his fall. Staff I reported Resident #51 didn't act delusional but would get agitated. Staff I stated she didn't know Resident #51 claimed the staff hurt him recently and denied the staff reporting it to her. Staff I stated Resident #51 may have resisted care. During an interview on 7/31/25 at 1:50 PM, Staff H stated Resident #51 always had some reddish discoloration of his arms. Staff H stated on 6/27/25 he assessed dark purple bruises and a week later it faded and yellowed. Staff H stated he heard in the past Resident #51 made a claim of people being mean to him. Staff H stated he didn't know about Resident #51's recent claim of being pulled from the bed and new bruises. Staff H stated if Resident #51 reported abuse, he would complete an assessment of Resident #51's body for injuries, call the DON, and law enforcement.During an interview on 8/4/25 at 12:49 PM, Staff S, Advanced Registered Nurse Practitioner (ARNP), stated they didn't know about Resident #51's new bruising to his arms. Staff S described Resident #51 as very clear when he explained how he fell over his shoes the previous month when he hit his arm and head. Resident #51 could explain what happened to his arms. Staff S stated she would absolutely expect someone to follow-up on Resident #51's claim that someone hurt him and caused the bruising to his arms. During an interview on 8/5/25 at 10:43 AM, Staff P, Registered Nurse (RN), said she worked the evening of 7/28/25. She reported a CNA didn't approach her and she couldn't remember what staff worked that night. Staff P claimed she didn't know Resident #51 reported to staff that someone grabbed him and pulled him from bed. Staff P described Resident #51 as an assist of 1 staff for care and transfers but, she didn't see him get transferred.During an interview on 8/5/25 at 11:03 AM, Staff T, Licensed Practical Nurse (LPN), stated she didn't know Resident #51 reported to a CNA claiming someone hurt his arm. Staff T stated she visualized the bruises to Resident #51's arms. Staff T stated she didn't report the bruises because someone told her the nurses inform the skin nurse about bruises or skin injuries and then that nurse would follow-up with the assessments. Staff T stated she failed to inform the skin nurse, being new to this facility.During an interview on 8/5/25 at 11:12 AM, Staff R, CNA, stated she visualized bruises on his arms recently and reported the findings to the female nurse on duty.The document Patient Protection Guidelines: Abuse Prevention, Reporting, and Investigation revised May 2025:The facility staff are required to notify the charge nurse and Abuse Coordinator immediately.Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, exploitation, or mistreatment. The Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern.All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections, Appeals and Licensing (DIAL) and any other required state agency if applicable (law enforcement). Reports of abuse or if the incident resulted in bodily injury, the facility should report immediately and no later than two (2) hours.

Based on observations, record review, resident, and staff interviews, the facility failed to conduct a thorough investigation of an allegation of abuse, resulting in failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to investigate the allegation of abuse resulted in further harm to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. The facility staff removed the Immediate Jeopardy on 8/6/25 through the following actions:The facility completed education on 8/5/25 with the Abuse Coordinator regarding reporting allegations and suspicions of abuse as above. The staff would receive education to separate an alleged staff perpetrator immediately per the Abuse policy and guidelines. The facility would commence investigations immediately. The staff unavailable that day to receive the education would receive the education prior to their next scheduled shift. The facility interviewed alert and oriented residents. In addition, the facility conducted body audits of residents with a Brief Interview for Mental Status (BIMS) score lower than 13, to rule out any additional unknown allegations of abuse.The facility re-educated the nursing staff on the care Kardex and reapproach the identified resident to prevent additional occurrences.The facility re-interviewed the nursing staff who worked with the identified resident from 7/28/25-8/5/25 and the investigation continued. The facility suspended 2 staff members pending the Department of Inspection, Appeals and Licensing (DIAL) investigation. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. The facility reported a census of 49 residents. Findings include:Resident #51's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview For Mental Status (BIMS) score of 9, indicating a moderate cognitive impairment. The MDS indicated Resident #51 didn't exhibit the behavior of rejecting care. Resident #51 required maximal assistance for lying to sitting on the side of the bed. The MDS listed Resident #51 as dependent on staff for all transfers. Resident #51 was unable to walk 10 feet. The MDS included diagnoses of chronic obstructive pulmonary disease, mild intellectual disabilities, cognitive communication deficit, abnormalities of gait, and mobility.The Care Plan Focuses with a target date of 7/7/25 reflected Resident #51 had:The tendency to refuse medications and showers. The Interventions directed the following: Staff to approach or speak in a calm manner.Assure the resident that concerns are validated and staff are willing to address legitimate concerns.Encourage to participate in care activities and respect the resident's rights to make his own lifestyle choice.A risk for falls. The Interventions directed the following: Staff provide assistance of 2 staff with the standing mechanical lift for all transfers to the wheelchairPlace the call light within reachOrient to surroundingsConsult with therapy as needed.Used anticoagulant (blood thinner) medication. The Interventions directed the staff to monitor for signs and symptoms of bleeding to include bruising.A document titled Therapy Recommendation from Physical/Occupational Therapy (PT/OT) to Nursing dated 6/18/25 directed staff to use the standing mechanical lift for all transfers. The document directed staff to direct Resident #51 to explain before completing task to hold hands, assist or guide the patient's arm to safely grip the handle. Resident #51 required time to set up in the standing mechanical lift. During an interview on 7/28/25 at 4:02 PM, Resident #51 reported the staff pulled him from his bed. He added it happened day and night and received bruises to his forearms. Resident #51 stated he had thin skin and could bruise when touched. Resident #51 stated he reported it to staff because being pulled from bed wasn't good for him. Resident #51 pointed out several bruises to both of his forearms about the size of half dollar coins. Resident #51 stated, he reported this one.During an interview on 7/30/25 at 3:44 PM, Staff M, CNA, stated on 7/28/25, 2-10 shift, Resident #51 reported that a staff person came into his room and grabbed him too hard by the arm to get him out of the bed. Staff M stated Resident #51 had dark bruises on his arms. Staff M stated they reported the incident to the nurse, but they couldn't recall the time but claimed to report it to the nurse that evening. On 7/30/25 at 4:00 PM, notified the facility Administer about how Resident #51's claimed the staff pulled him out of bed by his arms. In addition, he informed the staff of the incident as it hurt his arms, and he had visible bruising to both wrists and forearms. The Administrator stated no one informed her about the claim.A document TimeLine of Investigation dated 7/30/25 for Resident #51 reflected the following:At 6:00 PM, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and Staff U, Regional Nurse Consultant, completed an interview and assessment with Resident #51.They completed measurements of areas to his right hands, left hands, and arms completed. They determined the prior left elbow skin tear healed when assessed at 2:00 PM that day. The skin assessment revealed the following: Left lateral elbow maroon (reddish purple coloring) bruising 4 cm x 2.5 cm.The back o0f right-hand light purple/maroon bruising 9 cm x 4.5 cmThe right posterior forearm light purple/maroon 15 cm x 8 cmThe left posterior forearm skin tear 0.5 cm x 2 cm - edge of skin flap is scabbed. The back of left-hand maroon and yellow bruising 5.5 cm x 9.5 cmThe left posterior forearm bruising maroon and yellow 17 cm x 9 cmResident #51's range of motion to left arm moved at his baseline and he denied pain.Resident #51 reported he bumped his right arm getting out of bed.During the interview with Resident #51 stated 2 young black staff members assisted him from bed and grabbed his left arm. He explained it happened in the day time. He told the ADON he wanted to tell her, but just hadn't yet.The staff conducted a review of Resident #51's July 2025 behavioral documentation, the nursing schedule, and compiled a staff interview list based on his behavior and interview.The facility completed the initial self-report.They spoke with the Police Department and received a case number.The staff reported Resident #51 refused to transfer with the standing mechanical lift. They placed an order for a PT and OT evaluation.They initiated the staff interviews.They interviewed all staff who worked with Resident #51 on 7/29/25 - 7/30/25.The staff didn't report any injury or incidents to his arms to account for the bruising on 7/30/25 at 6:00 PM.The Root Cause Analysis revealed: Resident #51 had no evidence of staff-inflicted injury to his arms.Resident #51 recently experienced significant mobility and cognitive decline.Resident #51 used an anticoagulant medication, making him prone to bruising easily.The bruises likely resulted from self-injury while attempting to get out of bed without assistance.The progress notes lacked documentation for falls or attempted transfers that resulted in a self-injury from 6/5/25 through 7/30/25.The Incident Report Note dated 7/31/25 at 11:52 AM reflected Resident #51 had bruising and a skin tear to his left posterior (back of) forearm. His range of motion remained at baseline, and Resident #51 denied pain. Resident #51 required staff assistance for activities of daily living (ADL). Resident #51 received Eliquis 2 times a day for atrial fibrillation (abnormal heart rhythm) which increased the risk for bruising.During an interview on 7/31/25 at 1:31 PM Staff I, Infection Preventionist, described Resident #51 as not cooperative. Staff I stated Staff H, MDS Coordinator, assisted her with the skin sheet and the initial measurements. They asked Resident #51 how the injuries occurred. Staff I stated the skin sheets included the bruises Resident #51 sustained when he fell, but they healed them on 7/16/25. Staff I stated he didn't have any other bruising. Staff I couldn't say how Resident #51's bruises occurred, and she didn't ask him. She thought they happened from his fall. Staff I reported Resident #51 didn't act delusional but would get agitated. Staff I stated she didn't know Resident #51 claimed the staff hurt him recently and denied the staff reporting it to her. Staff I stated Resident #51 may have resisted care.During an interview on 7/31/25 at 1:50 PM, Staff H, Registered Nurse (RN) MDS Coordinator, stated Resident #51 always had some reddish discoloration of his arms. Staff H stated on 6/27/25 he assessed dark purple bruises and a week later it faded and yellowed. Staff H stated he heard in the past Resident #51 made a claim of people being mean to him. Staff H stated he didn't know about Resident #51's recent claim of being pulled from the bed and had new bruises. Staff H stated if Resident #51 reported abuse, he would complete an assessment of Resident #51's body for injuries, call the DON, and law enforcement. During an interview on 8/4/25 at 12:49 PM, Staff S, ARNP, stated they didn't know about Resident #51's new bruising to his arms. Staff S described Resident #51 as very clear when he explained how he fell over his shoes the previous month when he hit his arm and head. Resident #51 could explain what happened to his arms. Staff S stated she would absolutely expect someone to follow-up on Resident #51's claim that someone hurt him and caused the bruising to his arms. During an interview on 8/4/25 at 1:42 PM, Staff O, Certified Nursing Assistant (CNA), stated Resident #51 blamed her and a coworker for the bruises to his arms. Staff O stated Resident #51 didn't have bruises the morning of 7/28/25. When she returned to work the morning of 7/30/25, the night shift reported finding bruises to both forearms. Staff O stated she received direction to get Resident #51 up to the wheelchair with a gait belt, then stand him and pivot (turn) him. Staff O stated Resident #51 refused to allow her to transfer him that day (8/4/25) to take him to lunch. Staff O stated she offered 3 times and notified the nurse of his refusal. Staff O claimed she didn't know if someone delivered food to Resident #51.During an interview on 8/5/25 at 10:08 AM Staff A, CNA, stated Resident #51 didn't usually speak to her except to say no he didn't want to get up or no he didn't want to eat. Staff A stated when Resident #51 told her no, she reported it to the nurse who directed her to get him up. Staff A explained the other CNAs directed to her use the standing mechanical lift when she transferred Resident #51. She reported she got him up with the assistance of 2 staff, one on each side. Once he stood up, he grabbed the wheelchair. Staff A stated she used the gait belt and would place her other hand under his arm.During an interview on 8/5/25 at 10:43 AM, Staff P, RN, said she worked the evening of 7/28/25. She reported a CNA didn't approach her and she couldn't remember what staff worked that night. Staff P described Resident #51 as an assist of 1 staff for care and transfers but, she didn't see him get transferred. During an interview on 8/5/25 at 11:03 AM, Staff T, Licensed Practical Nurse (LPN), stated she didn't know Resident #51 reported to a CNA claiming someone hurt his arm. Staff T stated she visualized the bruises to Resident #51's arms. Staff T stated she didn't report the bruises because someone told her the nurses inform the skin nurse about bruises or skin injuries and then that nurse would follow-up with the assessments. Staff T stated she failed to inform the skin nurse, being new to this facility.During an interview on 8/5/25 at 11:12 AM, Staff R, CNA, stated the facility hired her and trained her in March 2025. Staff R reported they needed assistance from 2 staff to transfer Resident #51 with a gait belt to stand and pivot (turn) to a wheelchair. Staff R stated Resident #51 reached out to grab her hand or arm. Staff R stated she visualized bruises on his arms recently and reported the findings to the female nurse on duty. Staff R stated she followed directions on a paper at the nurses' station that listed the resident's hall, room number. The list also contained how the resident transferred, ate, the briefs they wore, and if they wore hearing aids. The facility provided the document to staff as direction on how to transfer the residents. During a follow up interview on 8/5/25 at 2:28 PM, when questioned if Resident #51 feared the staff who transferred him to the wheelchair who caused the bruising he reported to the surveyor, Resident #51 responded yes. When asked if he would be comfortable with the staff to continue providing his care, Resident #51 responded well and clinched his teeth put his arms across his body and shook back and forth in his bed and stated, they did it again and I told them not to but they did it again. When asked if he someone pulled him by his arms again, he nodded and stated, they did it again.The document Patient Protection Guidelines: Abuse Prevention, Reporting, and Investigation revised May 2025:Any allegation requires an investigation.The facility staff are required to notify the charge nurse and Abuse Coordinator immediately. According to the CMS, the facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, exploitation, or mistreatment. The Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. Upon receiving a report of an allegation of resident abuse, neglect, exploitation, injuries of unknown origin or misappropriation, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process.

Based on observations, interviews, and record review the facility failed to ensure communication devices were utilized for 2 out of 3 residents reviewed (Resident #1 and Resident #2). Resident #1 had a communication device that used a button he controlled with his head to select words and phrases on a computer. The communication device could be used when it was not on his wheelchair(w/c). The nursing staff were not educated on how to use the communication device nor did they know they could use the communication device, therefore Resident #1 was communicating with the staff by answering yes or no questions only, limiting his ability to communicate his wants and needs to his full potential. Resident #2 had a picture board with pictures of items that she would/could frequently request. Staff interviewed did not know about a picture board for Resident #2 and stated they had not used the picture board with Resident #2. The picture board could not be found in this resident's room. The facility reported a census of 40 residents. Findings include: 1. Minimum Data Set/s (MDS/s) for Resident #1 dated 9/5/22, 12/1/22, 3/2/23, and 6/1/23 all had a Brief Interview of Mental Status score of 15 out of 15, which indicated intact cognition. The MDS dated [DATE], had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. It documented that this resident was able to complete the BIMS. The Census sheet for Resident #1 documented that this resident admitted to the facility on [DATE]. It documented that the facility stopped billing on 12/28/23. The Medical Diagnoses Page for this resident showed his diagnoses included spastic quadriplegic cerebral palsy dated 8/29/22, epilepsy dated 8/29/22, and major depressive disorder, recurrent severe without psychotic features dated 3/30/23. A Care Plan directed that Resident #1 had been admitted to skilled level of care and that Speech Therapy would be working with Resident #1 with personalizing and making adjustments to his communication device. It was canceled on 9/20/22 but had a target date of 12/26/23. This Care Plan directed that the PASRR (Pre-Admission Screening and Resident Review) had identified that Resident #1 could benefit from rehabilitative services with a target date of 12/26/23 and a cancel date of 12/28/23. It directed that assistance with assistive technology be overseen by the facility Social Worker. This intervention had a start date of 8/29/22 and was resolved on 12/11/23. On 1/23/24 at 10:45 a.m., Staff A, Speech Therapist (ST), stated they have two companies that provide communication devices and services for the device, repairs, tech support, and that kind of thing. This ST stated they had three residents with communication devices and now the facility had two residents that had communication devices. Staff A stated that 1 resident, Resident #1, discharged closer to his family. She stated that the facility did have some technical issues with the switch Resident #1 used. Staff A stated Resident #1 used a head switch in his head support on his w/c. She stated Resident #1's communication device would show him phrases or words and he would make selection with the head switch. Staff A stated Resident #1 was able to use the communication device when he was in bed too. She stated that staff knew how to help him with that. Staff A stated she did not know of any concerns from him that he was unable to use the device. Staff A stated it worked via blue tooth. She stated that occasionally they would have to reboot the device so it would pair with the blue tooth. She stated Resident #1 used the device often. He could answer yes/no questions-by nodding or shaking his head. She stated that she often would see Resident #1 using the device in bed as well as in his w/c. On 1/23/24 at 12:24 p.m., Staff B, Certified Nurse Aide (CNA), stated that Resident #1 used his communication device when he first got to the facility before his chair broke. Staff B stated they could meet his needs as Resident #1 would tell them yes or no. Staff B stated that this resident preferred to stay in bed. Staff B stated she did not see him use his communication device in bed. She stated he always communicated with them by head gestures yes or no. On 1/23/24 at 12:30 p.m., Staff A, ST stated that Resident #1 was proficient with his communication device so she did not have him on their caseload. On 1/23/24 at 12:35 p.m., Staff C, CNA, stated that Resident #1 only used his communication device for the first year that he came but then after that she didn't see it. She stated the reason he wasn't using it had something to do with the chair. She said the communication device was impossible to use in bed. He had to be in the chair to use it. She stated he would communicate with staff by answering yes/no questions. Staff C stated that when his chair was working he used the communication device all of the time. Staff C added that Resident #1 really liked to use it. Staff C stated she would say that Resident #1 was upset that he couldn't use the communication device anymore but he never told Staff C that but he really only could answer yes or no questions. After his chair broke, they did fix it but he needed a piece for the communication device. He never did get the part on the w/c and discharged without being able to use his communication device again. Staff C said that it was a good year that he went without the communication device. On 1/23/24 at 12: 45 p.m., Staff D, CNA stated that she had only worked at the facility for a month. She stated that she noticed Resident #1 moved out of the facility. She stated that Resident #1 did not use a communication device. On 1/23/24 at 12:50 p.m., Staff A stated that she definitely had seen Resident #1 using his communication device in bed. She said there should be documentation regarding Resident #1 using the communication device in bed. She stated that Resident #1 had a stand as well that they could put the computer on. Staff A stated that it was used mostly with his family when they visited. On 1/23/24 at 1:00 p.m., Staff A stated that Staff E, Speech Restorative Aide was the one who would use the communication device to meet with Resident #1. Staff E no longer worked at this facility. On 1/23/24 at 1:45 p.m., Staff F, CNA stated that Resident #1 used the communication device until his w/c broke. He was not able to use it in bed or in a geri chair (a padded reclining chair on wheels). She stated he communicated with yes or no answers. On 1/23/24 at 2:40 p.m., the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), Staff G, Social Worker (SW), Staff H, Nurse Manager, and Staff I Nurse Manager/MDS Coordinator came in to talk about Resident #1's communication device. Staff G stated Resident #1 was unable to answer the MDS questions without the device, so that is why she was unable to have him answer the BIMS questions on the most recent MDS's. The group stated that he was able to use the device in a geri-chair but it took at least 2 staff to help hold him up right as he was so spastic. They had to replace many buttons (used to choose words or phrases that he could see on his computer). The w/c he came with had zip ties, shoe strings, and duct tape all over it. They finally were able to replace his w/c but did not get the right parts to hook the communication device back on to it. Staff H stated that he opted not to get up in the geri chair very often because he hurt when he sat in it. He would get up for meetings and it would take several of them to assist him with working the communication device. She stated he couldn't use it in bed because of the spasms. Staff H stated that Resident #1 took bed baths because he refused the shower chair. He couldn't activate his call light because of his spasms. The SW and DON pointed out that they still gave him the call light and would always answer it if it did go off. They stated he would yell out if he needed something. He was very verbal. It sounded somewhat like a loud guttural sound and he would sometimes do this when he saw staff walking by. When asked about the speech restorative person using the device in bed or on the stand-almost daily they stated they didn't know anything about that. They would have to verify that with her. Stated they had replaced many buttons for him and many wires as he would have a spasm and knock the wire out that connected the communication device to his computer. They at one point switched it to Blue Tooth but then there were issues with the 2 devices syncing. A timeline was requested of chair breaking down and communication device issues. On 1/23/24 3:20 p.m., the LNHA stated for a timeline on the communication device, it's difficult because it was always hit or miss. Something would go wrong and they would try to fix it. She stated her IT (Information Technology) guy had worked on it a few times as well. The communication device was made for the wheelchair and was old. The IT staff tried to adapt the communication device to be used off of the w/c and it was difficult to do. When asked about wasn't there another way to administer the MDS when a resident has communication difficulties, the Administrator stated that the SW had checked with corporate office to see how she was to code his MDS. The administrator said that the IT person would not have made notes on what he tried to help with. The manufacturer would have made the repairs needed. The IT staff would have just tried to make things work in the meantime. She will look for any documentation from the company that serviced the communication device. On 1/23/24 at 3:35, the LNHA brought in SW notes stating the notes show somewhat of a timeline for repairs with his communication device and wheelchair. She stated she understands the concerns and is trying to figure out the best way to get the information. On 1/23/24 4:05 p.m., Resident #1's Current Caregiver stated that Resident #1 had an attorney and that was how he was able to get a new w/c and how he was able to go to a different care providing service. She stated that Resident #1 had been failing for about 9 months. She stated he now has a new wheelchair and his doctor had put in an order for his headrest to be revamped so the communication device would work. On 1/23/24 at 4:08 p.m., a Facetime call was placed to Resident #1 with his current caregiver holding the phone. Resident #1 did not have a communication device and they are in the process of getting one. He can answer yes or no questions. Resident #1: nodded emphatically yes to feeling emotionally distraught related to not being able to use his communication device to communicate with the staff while at the facility He nodded yes to the staff not using the communication device to talk with him while in bed. He nodded yes to using the communication device while in a geri chair and nodded yes to it taking more than one staff to assist with this at times. He nodded yes to the facility assisting with this for meetings with his case worker. He nodded yes emphatically to feeling depressed regarding not using his communication device. He nodded yes to not wanting to get up for showers. This resident shook his head no when asked if he didn't want to get up out of bed and into a geri chair. He nodded yes when asked if he refused to get up sometimes but that didn't mean he didn't want to get up all the time. He nodded yes to the speech restorative aide/Staff E using the communication device with him while he was in bed. He nodded yes to enjoying those moments when he could use his device to communicate He nodded yes to having a stand that the communication device could be placed. He nodded yes to his family using this device when they would visit him at the facility. On 1/23/24 at 5:15 p.m., Staff E, stated Resident #1 used his communication device pretty much all of his life, or at least some kind of communication device. She stated he could answer yes or no questions without the device. She thought she talked with Resident #1 at least twice a week. When asked how long she had been meeting with him, she stated pretty much two times a week for the whole time he had been at the facility. She never saw any of the CNAs using the communication device to talk with him. She said Resident #1 would have preferred using his device instead of answering yes or no questions with staff. She stated that Resident #1 was really proficient at using the device and again stated he had been using a device for pretty much all of his life. She stated she did not take notes on their visits as he was not on a speech program. She stated that she stopped in twice a week just to check in on him. On 1/24/24 at 11:30 a.m., the DON and LNHA asked what was needed. Shared that the concern is that the ability was there to use the communication device and it wasn't being used. Staff E used it twice a week pretty much since he arrived at the facility to communicate with this resident. When asked about the family using the device when they came, the DON stated that yes the family did use the communication device. The DON stated the facility would set that up for the family. On 1/24/24 at 11:46 a.m., Staff J, Program Coordinator/CNA/CMA(Certified Medication Aide), stated that Resident #1 could say yes or no. She stated he could say other words too. Once you get to know him you can understand him if you ask him things. Staff J then said she guessed you would have to ask yes or no questions. She stated that she had never saw him use his communication device in bed. She stated the facility got the tri pod and she had tried to set it up. She stated that she thought Staff E worked with him using the tri pod. Staff J stated that when he was in the chair the communication device worked really well. Staff J did not know how he would use the communication device while lying in bed anyway. She said she didn't know how it would work out. She stated the CNAs would basically go in and ask Resident #1 if he wanted the TV or something on and he would answer yes or no. Staff J stated that if Resident #1 seemed upset, they could figure out what he needed. She said he would make noise if he needed something and they would assist him. She stated they would ask him a couple of questions and within those couple questions we could figure out what he needed. He would use the communication device all the time when the chair was working. He was very funny and very intelligent. Staff J stated that when they got him up he was uncomfortable with getting up in the geri chair (not his wheelchair) and would want to lay right back down. Staff J stated during Covid isolation it was really awful, residents were so lonely. Staff J stated she didn't know if he felt that way. She stated understanding that he wasn't using a communication device with the staff and that took away the ability to tell them more. She stated he did use the device easily when it was on his w/c. Staff J stated she could see how that might have impacted him. Staff J stated that most of the time he had a smile on his face and when she left the room, he seemed content. Staff J stated she wouldn't be able to say if he was feeling otherwise. Staff J stated she could put herself in his shoes, and if it were her, she would want to be able to use the device so she could communicate her feelings. On 1/24/24 at 1:15 p.m., the SW was asked if she had done all MDS's prior to the one done in 8/2023 with Resident #1 using his communication device. She stated she only used the communication device on the admission/initial MDS and was not able to use it after that. She did not know how she did the MDS's without the device and could not find documentation on how she completed it. She would keep looking for documentation. She stated that Resident #1 was a very intelligent young man and that he had no signs of decline in his cognitive status. The SW was not aware that his communication device could have been used. She stated that she called the office regarding how to do his MDS in August of 2023 and they directed her to document the staff response questions for the MDS and not document as his answers. A SW progress note dated 9/6/22 at 1:16 p.m., documented that Resident #1's Disability Attorney called to check on Resident #1. She inquired about his transition to the facility and how he was doing. SW informed Attorney about a couple of Resident #1's statements; This is the best place for me medically but not mentally, and l am too smart for this place. Resident #1 has asked his Dad if he will be here forever. On 09/02/2022 Resident #1's Mom and Grandmother came to visit him and the SW informed the family of these same statements. Mom stated that it may be possible for him to take online classes but she would consult one of his sisters, who is a professor. The SW shared this information with the Attorney because she believed that his mental state of mind can play a factor in his health. Attorney stated that she will periodically call and check on Resident #1. A SW note dated 9/7/22 at 3:27 p.m., documented the Disability Attorney called the facility at 1 :37 PM for a Zoom Call that was supposed to happen at 1 :30 PM. This resident was in bed at the time. Case Manager joined the call about 15-20 minutes later. Once the resident was in his chair, the head rest was off centered so he was not able to use his communication device to speak with the Attorney. Multiple people were in and out of the room to try to adjust his headrest; Nurse Manager, a Med Aide, two CNAs, Environmental Supervisor, the Occupational Therapist (OT), and the SW. It was very noticeable today that the headrest was positioned different. Attorney expressed her concern about this resident not being able to communicate to staff but SW assured the Attorney that the resident had been able to communicate to staff, it seems the problem did not arise until today. The best conclusion was for the Case Manager to contact the individual who used to adjust this resident's chair for possible repairs. Staff will need to be educated on the functions of Resident #1's device, and other functions of his chair. Attorney stated that she will call the facility at another time to discuss the repairs of the headrest and also to reschedule the Zoom call that she initially called for. The Zoom call was supposed to be private (no staff assistance). A SW note dated 9/21/22 at 3:00 p.m., documented that a service man came to the facility to assess the Resident's chair. He stated that the headrest was very loose and needed tightening. It appeared that he tightened the headrest and exited the building in a quick manner. SW noticed the difference in the headrest but Resident was in bed in order to try out adjustments. OT was out on a home visit when he arrived to the facility. A SW Note dated 11/10/22 at 2:23 p.m., documented that this resident's uncle came to the facility today for a visit. SW introduced herself to the uncle and told him where he could find SW office if he needed anything. The uncle came to the SW office to ask if Resident #1 had his communication device at this facility. SW went to Resident #1's room and noticed that his Device was sitting on the sink countertop. SW found the wire to his device tucked under his wheelchair broken into two pieces ([NAME] wires). The uncle put the wires back together and put black tape on them. SW plugged in device as it was dead. Resident #1 was then able to communicate with his uncle. This resident also wanted his wheel chair adjusted but the wheelchair was dead. A CNA came to show SW and the uncle how to charge the chair and she also adjusted a brace on the chair. SW was very surprised that there was not a note about Resident #1's communication device being disabled. SW spoke with Resident #1 on Tuesday and the communication device was working properly. SW will talk with therapy to clarify if the facility would have to order a new wire or if IT can do it. SW will notify Nurse Manager of these issues and continue to follow progress. A SW note dated 11/25/22 at 4:10 p.m., documented the Nurse Manager, IT, and SW are aware of Resident #1's issues with his communication device. We are working hard to resolve this issue as soon as possible. Family and Administrator has been notified. SW will continue to follow. A SW note dated 12/1/22 at 10:32 a.m., documented Resident #1 was in his room in his chair when SW approached him to conduct the MDS assessment. Resident #1 had a BIMS score of 15 and a PHQ-9 score of 04. This resident indicates that he has little interest or pleasure doing things 7-14 days within the last two weeks. He also expressed feeling down or depressed around the same frequency. Recently, this resident has been having issues with his communication device, which could play a role with how he feels. After consulting with the device tech support, they are confident that he needs a new head switch to operate the device. A speech pathologist will be consulted to support the next steps with fixing this ongoing issue. SW will continue to follow until the device has been serviced and then this resident can be reevaluated to see if his mood has changed. A SW Note dated 6/12/23 at 10:59 a.m., documented that Resident #1 had a meeting today with his Disability Right's lawyer and Disability Rights Advocate. His lawyer came to the facility to obtain consents from Resident #1 to work on the case of his wheel chair being repaired. Resident #1 has been waiting for months to get parts for his chair and more recently, was denied to pay for parts because it is the facility's responsibility according to the Provider's Manual. His lawyer is trying to see how she can fight this situation . SW will continue to follow. A SW Note dated 08/31/23 at 9:51 a.m., documented that the SW conducted the Staff MDS assessment with CNA. Resident #1 is usually able to respond to interview questions himself, but he is not able to use his device due to ongoing wheel chair repairs. SW will re-conduct assessment after Resident #1 is able to use his device again. There are not any cognitive changes that staff are aware of at this time. Resident #1's attorney is working hard to hold insurance accountable for wheelchair repairs. The team is working hard as well to help find placement out in the community for this resident. SW will continue to follow progress. A SW Note dated 11/28/23 at 12:24 p.m., documented SW conducted the Staff MDS assessment with a CNA. Upon conclusion of the interview, Staff believes that this resident may have felt down two times within the last couple of weeks due to the holidays and wanting to be with the new host-home within the community. Staff also indicates that this resident's short and long term memory is ok. Staff believes that this resident is aware of the current season and is aware of staff names and faces. Overall, Resident #1 appears to be cognitive to time, place, and people around him. There were no changes to code status at this time and the goal for him to return to the community is currently active. A Nursing Note dated 5/5/23 at 10:19 p.m., documented that the nurse (Staff H) would like to have speech therapy do an evaluation with resident to take a look at his communication device to see if they can write up steps for staff on how to set it up properly for him to use. A Doctor's Order dated 5/9/23, directed a speech evaluation be done for communication device directions for staff. On 1/24/24 at 2:45 p.m., the DON and LNHA stated they were not aware of an order regarding Speech Therapy providing education to staff on how to use Resident #1's communication device. They acknowledged the concern regarding Resident #1's communication device was not being utilized by the staff for ease of communication. They acknowledged the concern that this could have impacted his mental health and his well-being. 2. A MDS dated [DATE], documented that diagnoses for Resident #2 included cerebral palsy and intellectual disabilities. The BIMS was answered by staff and indicated that this resident's cognition was severely impaired. A Care Plan directed staff that sometimes Resident #2 has problems communicating related to being non-verbal. Resident #2 would maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, through the review date. The target date was 2/6/24. On 1/23/24 at 10:45 a.m., Staff A stated that Resident #2 had low tech picture pages that staff can use to communicate with her. There was a picture of suctioning on it for Resident #2 let staff know that she would like to be suctioned as Resident #2 requests this often. On 1/23/24 at 12:24 p.m., Staff B stated Resident #2 smiles when the answer is yes. Her aunt has told us she doesn't like to lie down. When we check and change her she makes a face like she is going to cry until she gets back up. Staff B stated they can tell what she wants/needs because of her smiling or a dissatisfied facial expression. She likes to be up out of her room and out here in the dining room. Following the above interview, the Licensed Nursing Home Administrator went into the resident room and was unable to locate the low tech picture pages. On 1/23/24 at 12:35 p.m., Staff C stated that Resident #2 communicates by moving her head yes or no. We know what she wants with cares as she can communicate that to us. Staff C stated she had not seen a picture board/pages that they were to use with her. On 1/23/24 at 12: 45 p.m., Staff D stated that Resident #2 sometimes would look down for yes or move head side to side for no. On 1/24/24 at 11:46 a.m., Staff J stated that she had never seen Resident #2 use a picture board/pages. On 1/24/24 at 1:30 p.m., Staff A stated the picture boards were kept on Resident #2's bedside table. Staff A stated she looked for them as she was just asked about them and could not find them. Staff A stated that Resident #2 was packed up as she was going to move out of state but now she was not going to move. When told that the staff were unaware that there was a communication board with pictures on it, she stated they should have known. This Speech Therapist stated the communication aides were left in sight so that staff could use them. She stated they were on the bed side table. On 1/24/24 at 2:45 p.m., the DON and LNHA acknowledged the concern that Resident #2 had a picture board to aide in communication. They acknowledged that staff reported not knowing about the picture board. The administrator stated they are unable to locate the picture board. An undated Enhancing and Maintaining Quality of Life policy, directed the following to staff: The facility will care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. The facility will provide reasonable accommodations of residents' individual needs and preferences related to their care and environment, directed toward assisting the resident to maintain and/or achieve their highest practicable level of functioning, promoting dignity and well-being, except when the health or safety of the individual or other residents would be endangered The facility will provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Based on observation, clinical record review, interviews, and facility policy review the facility failed to ensure one (1) of five (5) residents received adequate supervision to protect against hazards in the environment, (Resident #5). Resident interview, record review and staff interviews revealed Resident #5 required assistance of two staff with a mechanical stand lift for transfer. On 8/15/22, one nursing staff person assisted Resident #5 to transfer without a gait belt. The resident lost balance and fell to the floor, required transfer to the local emergency room (ER) where determined resident had sustained a lower left leg fracture. The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 8/12/22 for Resident #5 documented a score of 13 of 15 on Brief Interview for Mental Status (BIMS) test which indicated intact cognitition. The resident had diagnoses that included dependence on respirator, [CONDITION(S)], [CONDITION(S)] and required extensive assistance of two staff for bed mobility and transfer. The resident had no falls since reentry. A Nursing Care Plan with a target date of 5/26/22 identified a focus area: ADL (Activities of Daily Living) need assistance with ADL's related to history of stroke, [CONDITION(S)], and weakness with a goal to participate in cares and make needs known, and directed the following interventions: Transfer with assist of 2 and pivot disc. A facility memo dated 6/21/22 from Occupational Therapy (OT) to Nursing regarding transfers for Resident #5 directed the following: Discontinue use of pivot disc, transfer with EZ stand (mechanical lift stand) and assist of two for all tranfers, and hoyer lift may be utilized at the nurse's discretion. A Fall Risk assessment dated [DATE] documented a score of 14 which indicated a moderate risk of falls. A facility Incident Report documented a witnessed fall on 8/15/22 at 1:52 p.m. The report documented Resident #5 was transferred from wheelchair to bed when lost balance and fell . The report documented in error the resident was transferred by 2 staff. Resident complained of severe pain to left lower extremity, unable to bear weight. Facility provider assessed. An Emergency Department Discharge Instructions dated 8/15/22 at 7:13 p.m. for Resident #5 doucmented a diagnosis of closed fracture of epiphyseal plate of proximal tibia (shin bone) and a fall from standing. An X-ray Report dated 8/15/22 at 4:57 p.m. documented a probable nondisplaced transverse fracture of the proximal left tibial region. In an interview on 9/28/22 at 12:20 p.m. Resident #5 was observed to have an immobilizer brace on the left leg. Resident #5 stated that a nurse had transferred her as a one person and she fell and broke her leg. Resident #5 denied that she had alerted the caregiver at the time of transfer that she required a lift stand. Resident #5 stated they usually use a lift with two staff. In an interview on 9/29/22 at 1:00 p.m., Staff A, Certified Nursing Assistant (CNA) stated on 8/15/22 Resident #5 had requested to return to bed from her wheelchair. Staff A positioned her wheelchair next to the bed and lifted under the residents arms. Staff A confirmed she had not used a gait belt. During transfer Resident #5 slumped to the floor but she still had ahold of resident under her arms. Recalled that Resident #5 complained of pain right away. Stated that she had not checked the care plan, was new at the facility and had been oriented by staff who had not used a lift to transfer Resident #5. Confirmed that she had been informed after the incident that Resident #5 was a two person lift stand transfer and had been counseled to always follow the care plan and/or PT(physical therapy)/nursing recommendations. In an interview on 9/29/22 at 1:25 p.m., Staff B, Licensed Practical Nurse (LPN) stated she had been called to Resident #5's room after she had fallen. Recalled that she was surprised right away when she entered the room and there wasn't a lift in the room. Confirmed that there were two CNA's in the room when she entered so she had assumed that the resident had been transferred by both staff, became aware later that only Staff A had transferred Resident #5. Stated in house nurse manager had confirmed transfer was directed to be a mechanical stand lift with two staff assistance. Confirmed no gait belt on resident. Responded the expectation a gait belt should be used for all assisted transfers. In an interview on 9/29/22 at 1:25 p.m. the Director of Nursing confirmed the expectation for resident transfers was to follow the care plan and PT/Nursing directives. Additionally would expect staff to use a gait belt for all staff assisted transfers and ambulation. Review of a Facility Verbal Counseling dated as signed on 8/15/22 revealed Staff A failed to exercise safety measures and adhere to safety precautions. Cited [NAME] A transferred Resident #5 as a stand pivot transfer without a gait belt. Resident ended up on the floor. Going forward expected to transfer all residents as care planned or per PT/Nursing recommendations. Clarified Resident #5 was to be transferred via ez-stand with assist of 2 staff. Review of a facility policy titled, Tansfer/Gait Belts/Ambulation and Use of Safety Straps/Belts last reviewed on 11/08 directed gait belts will be used on residents who require assistance with transfers and/or ambultions when mechanical liftin devices are not used.

Based on clinical record review, staff and resident interviews and observations the facility staff failed to assess a resident's right hip bruise and pain which delayed the resident in receiving treatment for 4 days for 1 of 6 open sampled residents (Resident #1). The facility reported a census of 56 residents. Findings include: According to Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The resident could not participate in his mental status examination which indicated severe cognitive ability. Resident #1 had total dependence on 2 staff for transfers, dressing, hygiene, extensive assistance of 1 staff for nutrition and had impairment on both upper and lower extremities. The resident did not walk and had total dependence on staff to meet all his activities of daily living. The care plan dated 8/22/19 directed the staff to monitor Resident #1 for side effects related to the use of anitplatelet (blood thinner) medications and to monitor for side effects which include low blood pressure, abdominal pain, constipation, bruising and rash. The care plan informed the staff Resident #1 may experience pain related to [MEDICAL CONDITION] changes and decreased mobility and indicated the resident may show signs of pain which included yelling and screaming, facial grimace and grabbing at his painful extremity. Review of the late entry progress note dated 8/8/19 revealed Staff A-LPN charted Resident #1 had bruising to his right femur extending to the knee and the guardian notified. During an interview with Staff A-LPN on 11/18/19 at 1:22 p.m., Staff A stated she did notice bruises to the resident's right thigh extending from the hip to about mid thigh. She described the bruise as purple in the center and yellowish/green area around the purple colored area. The bruise went into the resident's groin area, around the front of the groin and into the right hip area. Staff A indicated the RN completed a head to toe assessment the evening before and she assumed the RN took care of all of the paper work and reporting of the bruise. Staff A stated she did not see a skin sheet in regards to the resident's bruise. Staff A stated she failed to chart the bruise on 8/8/19 but charted it on 8/12/19 as directed by the Director of Nurses on 8/12/19. Staff A reviewed the progress notes for Resident #1 from 8/8-8/12/19 and indicated it looks like no one assessed or documented anything about the bruises to the resident's right groin, hip and thigh during that time frame. Review of a written statement dated 8/16/19, Staff A-LPN stated on the early morning of 8/8/19 she went into the residents room to administer medication and noticed the presence of a Foley catheter. Staff A pulled back the covers and noticed bruising to the resident's inner thigh. She indicated she assumed the previous evening nurse already addressed the bruises as per facility policy. On 8/8/19 Staff C-C.N.A called LPN into the room and reported the resident had swelling to the right knee, LPN informed Staff C that she was aware and as the resident returned from the hospital with it. The statement indicated on 8/8/19 Staff D-C.N.A called Staff A into Resident #1's room and reported the bruises. On 8/10/19 Staff E-C.N.A reported swelling to the resident's right knee. On 8/11/19 Staff D-C.N.A came to Staff A and reported how easy it is now to turn the resident as his leg is not so contracted anymore. Staff A and Staff D assessed the resident, Staff A stated she noted while rolling the resident she placed her hand on the resident's right hip and noted the feeling of moving bones. Staff A directed the aide to keep the resident comfortable and will request an intervention when the physician comes to the facility in the morning. Review of the progress notes dated 8/12/19 at 8:15 a.m. completed by Staff B-RN revealed the resident had noted increased pain with cares and with movement of the right side. Resident is noted to have continued bruising to the groin, right hip and inner thigh to the knee. Staff B notified the provider and received an order for [REDACTED]. The progress notes indicated at 10:11 a.m. the technician completed the ordered x-ray and at 10:51 a.m. the staff contacted emergency transport for transfer to a local hospital for fracture of right hip. During an interview with Staff B-RN on 11/18/19 at 2:30 p.m. she stated in (MONTH) 2019 she worked as the unit manager where Resident #1 resided. Staff B indicated on 8/12/19 Staff A LPN showed the bruises on Resident #1 to Staff B. Staff B indicated this is the first time she had knowledge of the bruises. Staff B reviewed the progress notes dated from 8/8-8/12 and stated it appears the staff failed to document the resident's bruises. Staff B revealed the staff failed to complete skin sheets for the right hip/groin bruises, failed to contact the physician regarding the bruises. Staff B stated the facility began an investigation to identify the cause of the bruise on 8/12/19. During an interview with Staff C-C.N.A on 11/19/19 at 11:08 a.m., Staff C stated she worked with Resident #1, on the day shift on 8/8 and 8/10/19. Staff C stated on 8/8/19 she saw a purple/yellowish bruise on the resident's thigh, describing the bruise as very large. Staff C indicated she reported the bruising to Staff A-LPN. Staff C stated on 8/8 and 8/10 when rolling the resident to do cares, the resident would yell out in pain. Staff C reported on 8/10/19 when getting the resident up in the Hoyer lift the resident seemed fine but when rolling him for cares he appeared to be in pain. Staff C stated she rolled the resident at least every 2 hours to complete cares. During an interview with Staff D-C.N.A on 11/18/19 at 3:35 p.m. Staff D reported seeing the bruising on Resident #1 on 8/8, she indicated she could tell there was something wrong with the resident's right leg. Staff D described the bruise into the groin area, right hip and right leg . Staff D reported the bruise to Staff A on 8/8/19. On 8/11/19 Staff D again reported the bruising to Staff A and reported an additional observation. She reported to Staff A on 8/11/19 that Resident #1's right leg seemed floppy and described the area as not contracted anymore. Staff A assessed the resident and told Staff D the nurses know about it. Staff A asked C.N.A to get Resident #1 up out of bed on the weekend but she refused to do so reporting the resident had bruising and was having right hip/leg pain. During an interview with Staff E-LPN on 11/18/19 at 3:17 p.m., Staff [NAME] stated she worked the evenings of 8/7, 8/8, 8/9 and 8/10, she reported she had no knowledge of the bruises to Resident #1's right hip/groin area. During an interview with Staff F-LPN on 11/18/19 at 3:30 p.m. shared she worked the night shift on 8/7 and 8/8/19, the staff failed to report any bruises to Resident #1's right hip/groin area during that time frame. Review of an undated written statement from Staff H-C.N.A, Staff H stated Resident #1 had abnormal vocalizations on the day after returning from the hospital (8/8), she reported the resident more vocal than usual like he had pain. Staff H reported this observation to the day nurse-Staff A-LPN. During an interview with Staff G-D.O.N. on 11/18/19 at 3:098 p.m., Staff G acknowledge the staff failed to make out skin sheets for the bruise to Resident #1's right groin, hip, thigh area, failed to document in the progress notes until 8/12/19, failed to notify the physician of the bruises. Staff G stated Staff A received re-education on the need to check and make sure a bruise is documented and not assume that it was already done. Also re-educated Staff A that she should have called the physician on Sunday, 8/11/19 to report the loose hip and symptoms of pain. Review of a non-pressure skin condition record dated 8/12/19, the form revealed the staff first noted a bruise to the resident's right groin, right hip and inner knee. The staff described the whole right groin black/blue with [MEDICAL CONDITION] and [MEDICAL CONDITION] noted to the right hip extending to the right knee area. During an interview with Resident #1's primary care Advanced Registered Nurse Practice (ARNP) on 11/18/19 at 2: 52 p.m. , ARNP indicated the resident returned from a local hospital about 3pm on 8/7/19. The staff called her to alert of the resident's return but failed to mention anything about bruising to the right hip/groin area. On 8/10/19 an ARNP from their practice visited the resident at the facility, the resident up in his wheelchair, fully clothed. The staff failed to report bruises to right groin/hip area. The ARNP indicated when she visualized the bruises on 8/12/19 the bruise to the right groin/hip/thigh area were significant, describing the bruise as extensive over the right groin and anterior hip. The resident had a history of [REDACTED]. During a visit to the facility on [DATE], ARNP indicated the staff reported the resident yelled out in pain. ARNP felt it should have been reported to her on 8/8/19 when discovered so the bruise could have been evaluated and followed. On 8/12/19 when ARNP became aware x-rays were ordered, resident found with [MEDICAL CONDITION] and sent to local emergency room for evaluation and treatment. Review of a portable x-ray report dated 8/12/19 revealed x-ray completed of Resident #1's right hip/groin area and right knee. The resident had a comminuted and displaced proximal femur fracture. During a family interview on 11/19/19 at 9:43 a.m., the guardian for Resident #1 revealed they did not know about the resident's bruises until his transfer to the local emergency roiagnom on [DATE]. The guardian reported taking a picture of the bruise on 8/12/19 at 7:00 p.m She reported the photo was of the resident's right femur just prior to surgery. The guardian provided a photo of the resident's bruises to the right hip/groin/thigh area. Review of a non-pressure skin condition assessment and documentation policy dated (MONTH) 2012. The policy directs staff that non-pressure skin impairments should be assessed upon onset; the results documented; and the status of the skin condition monitored weekly until resolved. Some examples of non-pressure skin impairments may be skin tears, abrasion, bruises,[MEDICAL CONDITION] excoriated skin conditions due to moisture, etc. The results of the assessment should be documented on the non-pressure skin condition report.

Based on clinical record review, staff, and family interviews and observations the facility failed to provide a safe environment for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 59 residents. Findings include: Review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was admitted to the facility on [DATE]. According to the MDS Resident #1 ' s Brief Interview for Mental Status (BIMS) score of 7 indicated severe cognitive impairment. Resident #1 required limited assistance of 1 staff with transfers and personal hygiene, required extensive assistance of 1 person for walking in the facility and total dependence of 1 person for locomotion off the unit. The MDS indicated Resident #1 could only transfer with staff assistance as he/she was not stable. Resident #1 utilized a wheelchair and walker to ambulate. Review of Resident #1's undated Care Plan, revealed a risk for falls related to his/her traumatic brain injury. The Care Plan directed the staff to apply a personal bed and chair alarm to alert the staff of Resident #1 ' s attempts to transfer independently, to wear a wander-guard to alert staff if Resident #1attempts to leave the building unattended. The care plan indicated on 1/26/15 placed a wander-guard on Resident #'1s wheelchair. Review of an Elopement Risk assessment dated [DATE] revealed Resident #1 had a cumulative elopement risk score of 10 but failed to indicate if they were at risk for elopements. Review of the Interdisciplinary Progress Notes dated 1/23/15 at 10:00 p.m. indicated a staff member came in from taking out the garbage and reported a lady in a wheelchair outside the building attempting to get into a car. The staff located Resident #1 outside in the parking lot with a car door open attempting to get inside the car. Staff members returned Resident #1 back into the building and warmed him/her up. The staff attached a wander guard bracelet to Resident #1's wheelchair as the resident had the ability to remove the wander-guard independently and hide it. The notes stated staff located Resident #1's wander-guard bracelet in his/her dresser buried under the clothes after the elopement. Review of a Follow-up for Incident form dated 1/23/15 indicated staff found Resident #1 outside of the building and the staff are to monitor Resident #1 for cold exposure and bruises. According to the Follow-up for incident sheet, checks occurred for 72 hours. However the document failed to contain any form of assessment, vital signs or notations regarding whether Resident #1 suffered from cold exposure or developed bruises as Review of the incident report dated 1/23/15 but lacking a time of incident revealed Resident #1 was found outside of the building in the parking lot. Staff teaching completed and the wander-guard was moved to the wheelchair. According to the incident report the physician signed acknowledgment of the incident on 1/24/15. The incident report lacked any documentation of vital signs or assessment done at the time of the incident. During an interview with Staff A-Dietary Aide on 2/23/15 at 12:43 p.m., Staff A stated she went outside at approximately 7:45 p.m. on 1/23/15 to take out the kitchen garbage. Staff A went out the main entrance, walked south on the side walk by the STEPS (Hall A) entrance and didn't see anyone by the door. Staff A walked down to the dumpster and saw a person asking for help to get into a car in the south parking lot. The person attempting to get into the car sat in a wheelchair and was crying, stating he/she wanted to go home. The person did not have a coat on, short sleeve shirt with arms uncovered. Staff A ran back into the building and informed the nurses on STEPS/Hall A that a resident was in the parking lot. During an interview with Staff B Licensed Practical Nurse (LPN) on 2/23/15 at 1:00 p.m. Staff B stated she heard the STEP door alarm come over the pager at 8:20 p.m. on 1/23/15. Staff B asked Staff C-Certified Nursing Assistant (C.N.A.) to check the door. Staff C informed Staff B she observed a dietary staff member taking out the garbage. Staff B stated a dietary staff member entered the building through the STEP unit door and reported she saw a person outside trying to get into a car. During an interview with Staff C C.N.A. on 2/19/15 at 2:00 p.m., Staff C stated she worked the evening shift on 1/23/15 on Hall A/STEP unit. Staff C stated Staff B asked them to respond to the sounding STEPS door alarm. At the time Staff C responded to the door alarm she saw Staff A taking out the garbage and assumed Staff A was responsible for setting off the door alarm. Staff C turned off the door alarm without going outside to investigate the reason for the sounding alarm. Staff C does not know what time this event occurred. Staff C continued to perform resident cares and upon returning to the nurse ' s station she saw Resident #1 sitting in the wheelchair draped with blankets. Staff C stated she looked for Resident #1's wander-guard and according to Staff C located Resident#1 ' s wander-guard in the dresser drawer beneath clothing. Staff C stated she was re-educated on answering the door alarms. According to Staff C, staff members are to visualize the reason the door alarm sounded. Staff C stated Resident #1 was able to move independently in a wheelchair in the facility. Staff C stated Resident #1 will sometimes go into other resident rooms. Staff C stated Resident #1 had a cloth band for his/her wander-guard but now has a plastic band on their wrist plus an additional wander-guard placed on Resident #1 ' s wheelchair. During an interview with Staff D-LPN on 2/25/15 at 10:30 a.m., Staff D stated she worked on the STEP unit/Hall A with Staff B on 1/23/15, evening shift. Staff D stated Staff A entered the unit and said there was a person in parking lot trying to get into a car. Staff D stated the nurses are the only staff members to carry pagers that sound when a door alarm is activated. The door alarms do not sound audibly for all to hear only comes over the nurse pagers. Staff D ran outside and found Resident #1 in his/her wheelchair attempting to get into the back seat of a car sitting in the south staff parking lot. Staff D stated she did not hear the wander-guard alarm sound any time and stated after the administration watched the video of the event it was determined Resident #1 appeared to enter the posted code to de-activate the alarm and exited the building. Staff D stated the door alarm activated when Staff A ran back into the building to alert staff of Resident #1's whereabouts. Staff D stated when the alarm activates and until silenced anyone can go out of the door, the alarm will just keep sounding. Staff D stated when Resident #1 was returned to the facility Resident #1 was cold and shivering. The staff stated Resident #1 ambulated freely about the unit via his/her wheelchair. During an interview with Resident #1's spouse on 2/19/15 at 1:15 p.m., the spouse indicated he/she received a call from the facility late evening of 1/23/15 alerting them of Resident #1 ' s elopement from the facility. The facility reported Resident #1 was trying to get into a car. According to the facility report to Resident #1 ' s spouse, he/she was cold but didn't fall. During an interview with Staff E-Administrator on 2/191/5 at 11:00 a.m. and 2:20 p.m. revealed Staff E acknowledged the facility has a wander-guard alarm system installed on the STEP/Hall A exit door. Staff E stated at the time of the elopement the facility exit door code was posted by the door. Staff E confirmed the facility front door will have a wander-guard placed the following week. Review of a STAFF EDUCATION sheets dated 1/23/15 informed the staff Resident #1 has a wander-guard on his/her wheelchair now due to taking it off. Review of STAFF EDUCATION form dated 1/26/15 directed the staff when a door alarm goes off, a staff member must respond to the door and look outside to determine why the alarm went off, do not just re-set keypad and nursing must carry door alarm with them at all times. The STAFF EDUCATION sheets dated 1/27/15 revealed Resident #1was placed on 15 minute safety checks for a week and staff members are directed to document the checks. Observation on 2/19/15 at 11:28 a.m. revealed a Wander-guard alarm system and door alarm on the STEP/Hall A exit door without the exit code posted. Observation of the front exit door revealed no Wander-guard system and a posted code by the key pad for the door alarm. Staff E stated the facility recently decided to place a Wander-guard system on the front door but are currently waiting for parts to enable it to function. At the time of Resident #1's elopement the key pad code for the STEPS exit door had been posted by the key pad, it has since been changed and removed. During an interview with Staff F-Maintenance Supervisor on 2/24/15 at 9:00 a.m. Staff F stated the Wander-guard alarms are audible to all staff but the exit doors go to a pager the nurses carry to alert them the door alarm has been activated. During an interview with Staff E-Administrator on 2/23/15, Staff E stated they were not sure if they could get a copy of the video for the 1/23/15 elopement of Resident #1 but could provide a written summary they wrote after watching the video. Staff E stated they watched the video and record the times. Review of the time line revealed Resident #1 approached the exit door of STEP unit at 20.06.55 and exited the door at 20.07.49. The video next revealed Staff A ran into the building at 20.22.13 and the resident returned to the building with staff at 20.24.29. The video indicated Resident #1 left and remained out of the building for approximately 15 minutes without staff knowledge. Review of the Vision Link Data (door alarm) for 1/23/15 revealed the STEP/Hall A exit door alarmed a the following times: a. On 1/23/15 at 4:05 p.m. and staff responded in 41 seconds. b. On 1/23/15 at 5:34 p.m. and staff responded in 23 minutes and 58 seconds. c. On 1/23/15 at 6:54 p.m. and staff responded in 11 minutes and 52 seconds. d. On 1/23/15 at 7:34 p.m. and staff responded in 13 minutes and 39 seconds. During an interview with Staff E- Administrator on 2/24/15 at 10:00 a.m., Staff E stated a response time greater than 13 minutes is not an acceptable amount of time for staff members to answer the door alarm. A pager/door alarm check on 2/24/15 at 1:40 p.m. with the Director of Nursing (DON)revealed the following information: a. At 1:50 p.m. the DON activated the Wander-guard and door alarm at the STEP/Hall A exit door the nurse pager revealed a time of 11:09 p.m. b. At 1:53 p.m. the D.O.N. activated the front door alarm and the pager time revealed 11:12 p.m. Interview on 2/24/15 at 1:40 p.m. with the DON stated the times listed on the nurse ' s pagers regarding the door alarms are incorrect. The pager time resets each time the batteries are changed and acknowledged the times did not coincide with the actual time. The DON stated the only accurate time is on the alarm computer print out forms. During an interview on 2/23/15 at 11:05 a.m. with the State Climatologist, indicated the temperature and conditions on 1/23/15 at approximately 8:30 p.m. as follows-temperature 32 degrees with wind chill of 26 degrees, clear sky with winds from west at 6 miles per hour. Note: At the time of the complaint/incident investigation the findings of the investigation revealed an immediate and serious jeopardy with a scope of " J " identified. By 1/27/15 the facility had removed the sign next to the exit door with the exit code visible to all. The facility implemented 15 minute checks for Resident #1. The facility provided staff education regarding the use of a Wander-guard alarm system and the placement of the wander-guard alert bracelet placement on Resident #1 ' s wheelchair to prevent independent removal. The facility implemented education to staff regarding the expanded expectations regarding response to alarms to include checking outside for residents and the potential cause of the alarm. The alarms are checked to make sure they are operating correctly every shift. On 1/28/15 the facility changed the exit door alarm codes and door alarm audits by staff members each shift are completed. The facility implemented additional stop signs placed by the exits on 1/30/15 to remind Resident #1 and others not to exit out the doors. On 2/25/15 the facility implemented training for the staff members on how to properly change the date and time when batteries are changed in the pagers. So the grid level for the deficiency was lowered to a " D " . As of the 3/3/15 exit the facility had failed to assure compliance with policies in determining the whereabouts of residents when staff members are unaware of the location of any wandering residents.