Every finding on record at Haven of Camp Verde

Based on staff interviews, clinical record review, facility documentation, and facility's policy and procedure, the facility failed to ensure physician's orders were followed for one out of three sampled residents (Resident #17) related to blood glucose management. The deficient practice could result in residents not receiving treatment as ordered, placing them at risk for potential harm.Findings include:Resident #17 was initially admitted on [DATE], with diagnoses that included Type 1 Diabetes, Tinea Unguium, Hypo-osmolality, and Hyponatremia. An alert chart progress note dated April 04, 2026, revealed that the resident is alert and oriented times 4. A care plan initiated dated April 04, 2026 revealed a focus area noting that Resident #17 had Diabetes Mellitus (dm). The goal is for the resident to have no diabetes-related complications through the review date. Intervention included diabetes medication as ordered by the doctor, and monitor/document for side effects and effectiveness. The intervention further revealed that the resident was dependent on insulin for management of his diabetes.The physician's orders dated April 2026 revealed following orders:- Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML(Insulin Aspart)Inject 3 units subcutaneously with meals for type 1 diabetes; Start date 04/04/2026- Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 100 - 150 = 2 units; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = Call MD Call MD, subcutaneously before meals for diabetes; Start date 04/04/2026 - Accucheck: Notify MD if < 65 or > 400 before meals and at bedtime for dm ; start date 04/06/2026 The Medication Administration Record (MAR) for April 2026 revealed the following blood sugar levels:- April 06, 2026 (PM/HS Shift): Blood Glucose was 406 mg/dl. - April 08, 2026 (NOON Shift): Blood Glucose was 401 mg/dl.- April 09, 2026 (NOON Shift): Blood Glucose was 478 mg/dl - April 09, 2026 (PM/HS Shift): Blood Glucose was 47 mg/dlHowever, the clinical record revealed no documentation that the provider was notified of any of the above-listed blood glucose result, as required by the physician's orders. The April 2026 MAR revealed the resident did not receive the scheduled 1800 dose of Insulin Aspart FlexPen on April 5, 2026.The clinical record revealed no documentation pertaining to why the medication was not administered. The April 2026 MAR further revealed the resident did not receive the ordered sliding-scale insulin, and no blood glucose result was documented on April 5, 2026 for Evening Shift. The clinical record had no documentation pertaining to why the medication was not administered. An interview was conducted on June 29, 2026, at 12:00 pm with Certified Nursing Assistant (CNA/#45), who stated that it is important to obtain the resident's complete set of vital signs because certain medications require the resident's vital signs to meet specific parameters before administering the medication. The CNA then stated they will take the resident's vitals sheet and provide it to the nurse to document on the resident's chart. The CNA also stated that documenting the resident's vital signs is important to maintain an accurate record and to monitor for any changes in condition.An interview was conducted on June 29, 2026, at 12:24 PM with Registered Nurse (RN/Staff #75), who stated that she follows the physician's orders by reviewing the order, verifying that the insulin pen matches the order, and cleaning the injection site before administration. She also stated that the assessment for change of condition would include: time of event, observation, vital signs, blood sugar levels, documentation of contracting provider, follow-up, and outcome of the intervention. She further stated that it is important to recognize and respond to a change of condition in a timely manner because it could result in residents falling and hurting themselves and, in the worst-case scenario, death. Staff #75 stated that if a resident's blood sugar is below 65 mg/dL and greater than 400 mg/dL, she would contact the provider prior to administering the insulin, and if blood glucose is under 65 she would provide the resident with juice. She then stated that she would document on the MAR for medication administration. She stated that it is important to notify the provider for a change in condition because adjustments can be made to keep the resident safe. She then stated it is important to follow the physician's orders because if they don't, they are basically practicing without a license, and it is the law. An interview was conducted on June 29, 2026, with a Licensed Practical Nurse (LPN/Staff #78), who stated that when following the physician's order, he would verify the resident's name, confirm whether a sliding scale was in place, and administer the appropriate amount based on the sliding scale. He then stated that if provider orders were not followed, it could be catastrophic. He further stated that it was important to follow the physician's orders to maintain the resident's health and safety.An interview was conducted on June 29, 2026, at 2:46 pm with the Director of Nursing (DON/Staff#33). The DON reviewed the April 2026 MAR and confirmed that the ordered sliding scale Insulin Aspart FlexPen was not administered on April 5, 2026. The DON further confirmed there was no documentation explaining why the medication was not administered. The DON also confirmed the physician's order required staff to notify the physician of blood glucose readings below 65 mg/dL or above 400 mg/dL before meals and at bedtime. The DON reviewed April 2026 MAR and confirmed blood glucose readings of 406 mg/dL on April 6, 401 mg/dL on April 8, and 478 mg/dL on April 9, with no documentation that the provider was notified. The DON further confirmed that the scheduled 1800 dose of insulin Aspart FlexPen, 3 units subcutaneously with meals, was not administered on April 5, 2026, and there was no documentation explaining why the medication was not administered. The DON stated that failure to follow the physician's orders does not meet the facility's expectations and could result in potential harm to the resident. The DON further stated that staff are expected to follow physician's orders because failure to do so is equivalent to practicing outside their scope of authority, as staff do not have the authority to change, dismiss, or write physician's orders.A policy titled Orders/ Receiving/Transcribing: Medication and Treatment Orders revealed Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in the state

Based on review of facility documentation and policy, and staff interviews, the facility failed to ensure that daily staff postings were posted accurately regarding actual number of licensed and unlicensed staff that worked each shift and actual hours worked by licensed and unlicensed staff for 17 out of 17 days reviewed. The census was 43. The deficient practice could result in residents, visitors, and facility staff not being informed of accurate and current staffing information. Findings include: Review of 17 randomly selected daily staff postings and corresponding punch details revealed the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Aides (CNAs) that worked each shift and the hours worked by staff were not updated on the daily staff postings to include the actual number of staff that worked each shift and the actual hours worked by staff. The daily staff posting dated October 26, 2024, revealed a census of 44 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours:- 40 RN hours,- 16 LPN hours, and- 64 CNA hoursReview of the punch details requested for that day revealed:- 23.75 RN hours,- 30.87 LPN hours, and- 69.36 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated November 2, 2024, revealed a census of 48 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours:- 32 RN hours,- 0 LPN hours, and- 88 CNA hoursReview of the punch details requested for that day revealed:- 31.65 RN hours,- 8.38 LPN hours, and- 71.46 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated November 30, 2024, revealed a census of 47 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 24 RN hours,- 24 LPN hours, and- 56 CNA hoursReview of the punch details requested for that day revealed:- 23.99 RN hours,- 33.4 LPN hours, and- 47.43 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated December 14, 2024, revealed a census of 44 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 32 RN hours,- 24 LPN hours, and- 72 CNA hoursReview of the punch details requested for that day revealed:- 34.71 RN hours,- 18.55 LPN hours, and- 75.33 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated December 28, 2024, revealed a census of 47 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 32 RN hours,- 8 LPN hours, and- 88 CNA hoursReview of the punch details requested for that day revealed:- 32.69 RN hours,- 8.1 LPN hours, and- 69.12 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated April 5, 2025, revealed a census of 41 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 24 RN hours,- 16 LPN hours, and- 72 CNA hours Review of the punch details requested for that day revealed:- 32.22 RN hours,- 0 LPN hours, and- 73.67 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated April 19, 2025, revealed a census of 45 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 16 RN hours,- 24 LPN hours, and- 72 CNA hoursReview of the punch details requested for that day revealed:- 16.8 RN hours,- 23.85 LPN hours, and- 72.15 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated May 17, 2025, revealed a census of 48 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 16 RN hours,- 24 LPN hours, and- 72 CNA hoursReview of the punch details requested for that day revealed:- 24.11 RN hours,- 24.21 LPN hours, and- 83.07 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated May 25, 2025, revealed a census of 48 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 16 RN hours,- 32 LPN hours, and- 64 CNA hoursReview of the punch details requested for that day revealed:- 17.85 RN hours,- 24.12 LPN hours, and- 79.53 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated June 7, 2025, revealed a census of 50 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 24 RN hours,- 24 LPN hours, and- 64 CNA hoursReview of the punch details requested for that day revealed:- 26.17 RN hours,- 25.4 LPN hours, and- 71.55 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated June 22, 2025, revealed a census of 48 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 16 RN hours,- 32 LPN hours, and- 64 CNA hoursReview of the punch details requested for that day revealed:- 18.7 RN hours,- 32.55 LPN hours, and- 65.24 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated July 5, 2025, revealed a census of 50 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 24 RN hours,- 24 LPN hours, and- 72 CNA hoursReview of the punch details requested for that day revealed:- 24.63 RN hours,- 17.48 LPN hours, and- 79.94 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated July 19, 2025, revealed a census of 50 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 32 RN hours,- 24 LPN hours, and- 80 CNA hoursReview of the punch details requested for that day revealed:- 24.32 RN hours,- 29.42 LPN hours, and- 98.88 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated August 16, 2025, revealed a census of 48 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 24 RN hours,- 16 LPN hours, and- 80 CNA hoursReview of the punch details requested for that day revealed:- 28.78 RN hours,- 8.45 LPN hours, and- 81.58 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated August 23, 2025, revealed a census of 50 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 16 RN hours,- 24 LPN hours, and- 96 CNA hoursReview of the punch details requested for that day revealed:- 16.78 RN hours,- 24.29 LPN hours, and- 88.71 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated September 13, 2025, revealed a census of 51 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 32 RN hours,- 16 LPN hours, and- 80 CNA hoursReview of the punch details requested for that day revealed:- 33 RN hours,- 15.03 LPN hours, and- 73.82 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. The daily staff posting dated September 21, 2025, revealed a census of 50 residents with no evidence of the actual number of nurses and CNAs that worked each shift or the actual number of hours worked by all licensed staff and CNAs each day. The daily staff posting included the following scheduled hours worked:- 24 RN hours,- 16 LPN hours, and- 80 CNA hoursReview of the punch details requested for that day revealed:- 35.88 RN hours,- 16.57 LPN hours, and- 78.3 CNA hoursThe daily staff posting included a column to include the actual hours worked by staff, but was left blank. An interview was conducted on May 28, 2026, at 12:59 PM, with the staffing coordinator (Staff #64). Staff #64 stated he was responsible for creating the staff schedule, he was not responsible for the daily staff posting. Staff #64 further stated that he provided the staff schedule to the receptionist, who would fill in the number of staff and hours scheduled to work. Staff #63 stated that he was not aware if the daily postings were updated; they would be updated by the receptionist. An interview was conducted on May 28, 2026 at 1:15 PM with the receptionist (Staff #39). Staff #39 stated she had been in the position for six years and had been trained by the receptionist before her. She further stated that she had not been trained to update the daily staff posting throughout the day. Staff #39 further stated the process for completing the daily staff posting involved checking the staff schedule, inputting the numbers based on what was provided, and posting the information on the nursing unit. Staff #39 stated she had never been informed of the need to update the daily staff posting to include the actual number of staff that worked and the actual number of hours worked by staff. An interview was conducted on May 28, 2026 at 1:22 PM, with the Director of Nursing (DON/ Staff #86). Staff #86 stated that she is not responsible for overseeing any part of the daily staff posting. She further stated she was not aware of who would update the daily staff posting with the actual hours worked, but that this information should be updated. Staff #86 stated that the risk of not updating the daily staff posting to include the actual number of staff and hours worked included not being properly staffed to meet the needs of the residents in the building. She stated that, as the DON, she used the daily staff posting to ensure there were an appropriate number of nurses and CNAs, and that she may not be able to accurately assess the need of more staff if the actual hours are not updated. Staff #86 reviewed a daily staff posting and the corresponding punch details for April 5, 2025, and stated that, according to the information provided, there may not have been enough staff on that day to meet the needs of the residents. An interview was conducted on May 28, 2026 at 2:31 PM, with the executive director (Staff #84). Staff #84 stated she was unaware of the need for the actual number of staff and hours worked to be updated on the daily staff posting. She further stated she had never seen an updated daily staff posting, did not see any risk associated with not updating the daily staff posting to include the actual number of staff and hours worked. The facility policy, Administrative Policies: Staffing, Sufficient and Competent Nursing, revised January 2024, revealed that the direct care daily staffing numbers are to be posted in the facility for every shift. Review of the policy further revealed that any staffing concerns are to be directed to the director of nursing services or a designee. Review of Federal regulation CFR S483.35(g)(1)(iii) revealed the facility must post the total and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, and certified nurse aides.

Based on observation, interview, and record review, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for two of the four sampled residents. The deficient practice could result in injury to residents. Findings Include:About Resident #77:Resident #77 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbance; anxiety; type 2 diabetes mellitus with diabetic neuropathy and foot ulcer; alcohol abuse; and acquired absence of another left toe.An admission Minimum Data Set (MDS) assessment completed on January 13, 2023, indicated that Resident #77 had a Brief Interview for Mental Status (BIMS) score of 12, reflecting moderate cognitive impairment.Review of a Progress Note (Alert Note) dated January 16, 2023, at 1:22 p.m., documented that Resident #77 remained at risk for elopement. The note indicated that a functioning Wander Guard was in place and that staff continued to closely monitor the resident due to ongoing exit-seeking behaviors.A subsequent Progress Note (Health Status Note) dated January 18, 2023, at 1:24 p.m., documented that Resident #77 continued to exhibit exit-seeking behaviors. The Wander Guard remained in place and operational, and staff were providing frequent redirection. The resident's son had been notified of the resident's behaviors and noncompliance.According to a Progress Note (Alert Charting) dated January 24, 2023, Resident #77 was discovered missing from the facility and was later found on the side of Route 260 across from a gas station. The note documented that the resident was wearing a Wander Guard; however, no alarm sounded when the resident exited the facility. The resident was located by a Certified Nursing Assistant (CNA). Upon return to the facility, a head-to-toe assessment was completed and revealed no new injuries. The resident's family and facility administration were notified of the incident and the resident's continued exit-seeking behaviors.A skin assessment for Resident # 77 completed on January 29, 2023, revealed no new injuries related to the elopement incident were noted.Resident's (#77) care plan related to wandering and exit-seeking behaviors following the elopement incident was updated.The care plan interventions included administering medications as ordered, anticipating and addressing the resident's needs, implementing interventions necessary to protect the resident and others, and approaching the resident in a calm manner while redirecting and diverting attention to alternative locations as needed.Resident # 71 Resident #71 was re-admitted to the facility on [DATE], with diagnoses including Insomnia, encounter for palliative care, alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease(, chronic kidney disease, stage 3, unspecified urinary incontinence, history of falling.An admission Minimum Data Set (MDS) assessment completed on May 31, 2023, indicated that Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment.According to the Elopement Risk Evaluation completed in April,2023 the resident was identified as being at risk for elopement, with a score of 12. The resident's care plan (#71) addresses exit-seeking behaviors and includes orders for a Wander Guard. Interventions include notifying the family, responsible party, physician, and social services of any changes in the resident's condition, as well as monitoring and observing for changes in behavior. Review of a Progress Note (Alert Charting) dated May 29, 2023, at 1:13 p.m., documented that at approximately 3:32 p.m., a community member contacted the facility to report seeing a tall, thin, confused woman walking along Salt Mine Road and believed she might be a resident of the facility. Staff immediately checked to determine whether any residents were missing and discovered that Resident # 71 was not present on the unit. Facility staff conducted a search of the building and surrounding grounds and dispatched a staff member to drive along Salt Mine Road. Resident # 71 was located at approximately 3:32 p.m. and returned to the facility. Upon the return, the Unit Manager and the nurse completed a comprehensive assessment and skin check. No injuries or skin impairments were identified. The resident's (#71) temperature was 98.8 F, mucous membranes were moist and pink, and skin turgor was noted to be normal. The resident's Wander Guard was observed to be in place and functioning on her ankle. Hospice services were notified of the incident and indicated they would contact the resident's family. The Unit Manager and Administrator were also notified.Resident's (#71) care plan related to wandering and exit-seeking behaviors following the elopement incident was updated The care plan interventions included administering medications as ordered, anticipating and addressing the resident's needs.A skin assessment completed for Resident # 71 on May 29, 2023, revealed no new injuries related to the elopement incident were noted.An interview was conducted on May 28, 2026, at 10:16 a.m. with a Registered Nurse (RN/Staff #74). The RN (Staff # 74) stated that residents at risk for wandering or elopement are identified through information received from hospitals or prior facilities, admission assessments, or observed exit-seeking behaviors. Assessments are typically completed within 24 hours of admission, and residents identified as at risk should be care planned with appropriate interventions, such as a Wander Guard, implemented based on behavior. The RN confirmed that a physician's order is required prior to using a Wander Guard and that staff are educated regarding residents identified as being at risk. The RN further explained that Wander Guards only activate alarms at the facility's front entrance and do not alert at other exits, and that all staff share responsibility for monitoring residents and facility exits. The RN (Staff # 74) also stated that if a resident at risk for wandering leaves the facility unsupervised, the potential consequences may range from minor injury to serious harm, including being struck by a vehicle or death, emphasizing that wandering and elopement risks are taken seriously due to the significant safety concerns involved. Regarding Resident #71, the RN (Staff # 74) recalled that the resident was very confused, ambulatory, and exhibited wandering behaviors. The RN stated that Resident #71 typically wore a Wander Guard during respite stays and believed the resident had been identified as a wandering risk, with interventions that included placement near the nurses' station and supervision during meals. The RN (Staff # 74) was unable to recall Resident #77 or provide information regarding his wandering risk status or related interventions.An interview was conducted on May 28, 2026, at 9:15 AM with the Director of Nursing (DON/Staff #86), who stated that residents are assessed for wandering and elopement risk upon admission, with the results documented in both the resident's physical chart and PointClickCare (PCC). Residents identified as high risk for elopement require a physician's order and consent from the resident or their Power of Attorney (POA) before a Wander Guard can be applied. These residents are also added to a wander-risk binder maintained at the front desk. Staff are informed of residents who are at risk for wandering and are provided photographs to assist with identification and monitoring. Wander Guards are typically used for residents identified as high risk through assessment or those demonstrating repeated exit-seeking behaviors. The DON (Staff #86) confirmed that a physician's order is required prior to applying a Wander Guard and acknowledged that applying one without an order is not accepted. The DON (Staff #86) further stated that Wander Guards activate alarms only at the front entrance, while two rear exits near the kitchen are not connected to the Wander Guard alarm system. The facility has approximately eight exits, and all staff members share responsibility for monitoring wandering-risk residents and facility exits. The DON (Staff #86) further stated that if a resident at risk for wandering leaves the facility unsupervised, potential consequences include the possibility of injury or harm, inability to locate the resident, and potentially death, particularly given the facility's proximity to a highway. The DON (Staff #86) further indicated that such an event would represent a failure to meet facility expectations. Residents leaving the facility without staff knowledge, particularly when identified as high risk for wandering, would be considered as an elopement.The DON (Staff #86) further stated that she was not working at the facility at the time of the incidents.The DON (Staff #86) reviewed the records for Residents #71 and #77 and acknowledged that an elopement occurred at the facility. The DON (Staff #86) further stated that this did not reflect good practice. An interview was conducted on May 28, 2026, at 1:55 PM with the executive director (ED / Staff #84) who stated that residents at risk for elopement or wandering are identified through assessments and communicated to all staff. Monitoring varies based on the resident's condition, and Wander Guards may be used depending on assessment findings. The ED (Staff # 84) stated that a physician's order is required prior to application, but also indicated a Wander Guard may not be placed without an order. Wander Guards are not easily removed by residents and typically require cutting to remove. She explained that alarms activate only at the front exit, while other exits are locked and alarmed but not linked to the Wander Guard system; the facility has approximately ten exits. The ED (Staff # 84) further stated that unsupervised elopement can result in serious harm, including falls, dehydration, or being struck by a vehicle, and confirmed that a resident leaving without staff knowledge while at risk for wandering is considered elopement. A review of the facility policy titled N007 - Behavior/Mood/Cognition: Wandering and Elopements, revised January 1, 2024, indicates that the facility is responsible for identifying residents at risk for unsafe wandering and implementing measures to prevent harm while maintaining the least restrictive environment possible for each resident.

Based on interviews, clinical record review, and review of facility policies and procedures, the facility failed to protect the rights of one (#75) of eleven sampled residents by failing to ensure the resident was free from abuse by another resident (#74). The census was 43 residents. The deficient practice resulted in resident-to-resident sexual abuse and had the potential to result in ongoing abuse and further harm to other residents.Findings include:Resident #75 (alleged victim) was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, hyperosmolality and hypernatremia, acute kidney failure, morbid obesity due to excess calories, obstructive sleep apnea, essential hypertension, hyperlipidemia, and benign prostatic hyperplasia without lower urinary tract symptoms.A care plan focus for Resident #75, initiated [DATE], revealed that Resident #75 was at risk for an activities of daily living (ADL) self-care performance deficit. Interventions included encouraging the resident to use the call light for assistance.Resident #75's Medicare 5-Day Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS further revealed that Resident #75 required the assistance of two staff members for dressing, personal hygiene, and toilet use and utilized a wheelchair for mobility.Resident #74 (alleged perpetrator) was readmitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, dysphagia, cognitive communication deficit, major depressive disorder, anxiety disorder, and insomnia.Resident #74's admission MDS, dated [DATE], revealed a BIMS score of 14, indicating that the resident was cognitively intact. The MDS further indicated that Resident #74 displayed no behaviors directed toward others and exhibited no evidence of psychosis during the assessment period.A census review for Residents #74 and #75 revealed that the residents began sharing a semi-private room on [DATE].Regarding the [DATE] incident:On [DATE], at 9:30 p.m., an alert progress note was entered into the clinical record for Resident #75. The note indicated that a Licensed Practical Nurse (LPN), Staff #105, entered the room to attend to the needs of Resident #75. Staff #105 documented observing Resident #74 inappropriately touching Resident #75's genital area. Staff #105 shouted for Resident #74 to remove his hands from Resident #75. The note further indicated that Resident #75 was asked whether Resident #74 had been touching him inappropriately, and he responded, yes. The note indicated that Resident #74 was transferred to another room and a report was provided to facility management.On [DATE], a skin assessment was entered into the clinical record for Resident #75, indicating that no new skin issues or injuries were noted.On [DATE], at 9:46 p.m., an alert charting progress note was entered into the clinical record for Resident #74. The note indicated that Staff #105 entered the room shared by Residents #74 and #75 and observed Resident #74 inappropriately touching his roommate in the genital area. Staff #105 documented that she shouted for Resident #74 to stop. Resident #74 stopped and appeared confused and unaware of what had occurred. Resident #74 was immediately moved to a private room, and the appropriate parties were notified.On [DATE], at 11:15 p.m., a progress note was entered into the clinical record for Resident #75. The note documented that at 9:15 p.m., Resident #75 was found unresponsive, without a pulse or respirations. Emergency medical services were contacted, and cardiopulmonary resuscitation (CPR) was initiated. Resident #75 was pronounced deceased at 9:43 p.m.On [DATE], at 3:07 p.m., an alert charting progress note was entered into the clinical record for Resident #74. The note revealed that a urine specimen had been sent to the laboratory and that an order for Macrobid had been initiated due to symptoms consistent with a urinary tract infection (UTI).Review of the facility's 5-Day Investigation Report, dated [DATE], indicated that the allegation of resident-to-resident abuse was substantiated. An interview conducted with a facility [NAME] (Staff #107), who witnessed the incident, revealed that on [DATE], he entered the room shared by Residents #74 and #75 in response to a call light. He observed Resident #74 attempting to get into his wheelchair and was concerned regarding the amount of medication the resident had received. Staff #107 reported that he went to retrieve the nurse and returned to the room with her. Upon returning, he observed Resident #74 seated in his wheelchair next to Resident #75's bed and touching Resident #75 underneath the blanket. Staff #107 further stated that the room was dark, limiting his ability to observe all details of the incident.The investigation also included an interview with Staff #105. Staff #105 stated that she entered the room with Staff #107 to assess concerns involving Resident #74. Upon entering the room, she observed Resident #74's hand inside Resident #75's brief. She instructed Resident #74 to stop, and Resident #74 appeared confused and unaware of what had occurred. Staff #105 stated that Resident #74 was subsequently relocated to a private room.Interviews were conducted with Resident #75, who stated that he did not ask Resident #74 to touch him and did not want to be touched. Resident #75 further stated that he was too embarrassed to tell his wife and requested that staff notify her on his behalf. Resident #74 was also interviewed and stated that he had no recollection of the event.On [DATE], at 6:57 a.m., a psychiatric progress note was entered into the clinical record for Resident #74. The note indicated that Resident #74 stated he was being framed and had done nothing wrong. He further stated that he knew what was happening and was being used as an experiment. The note also documented that Resident #74 tested positive for a urinary tract infection.On [DATE], at 8:26 p.m., a behavior progress note was entered into the clinical record for Resident #74. The note indicated that a Certified Nursing Assistant (CNA) reported that Resident #74 slapped her buttocks during the evening shift.On [DATE], at 11:20 a.m., an alert progress note was entered into the clinical record for Resident #74. The note indicated that the resident was transferred to the emergency department for evaluation and treatment of altered mental status.On [DATE], at 6:49 a.m., an infection progress note indicated that Resident #74 had returned to the facility and continued oral antibiotic treatment for a urinary tract infection.On [DATE], at 8:40 a.m., an alert charting progress note indicated that on [DATE], a student instructor at the facility reported that Resident #74 stated, he needed to get out of here so he could molest more people.Review of the care plan for Resident #74 revealed a focus initiated on [DATE]. The focus identified an alteration in neurological status related to sexual behaviors. Interventions included providing care in pairs when rendering resident care.Attempts were made to interview Resident #74 by telephone on [DATE]. No return call was received.Requests were made for contact information for former facility employee Staff #105; however, no contact information was available.On [DATE], at 12:29 p.m., an interview was conducted with the Director of Nursing (DON), Staff #86. Staff #86 stated that one resident touching another resident inappropriately would meet the definition of abuse and would not meet her expectations for resident safety and care.On [DATE], at 12:53 p.m., an interview was conducted with the facility Administrator, Staff #84. Staff #84 stated that the incident involving Residents #74 and #75 on [DATE], constituted abuse and could result in physical harm and emotional distress to the victim. Staff #84 further stated that such abuse would not meet her expectations for the facility.Review of the facility policy titled, Resident Rights/Dignity: Abuse and Neglect - Clinical Protocol, effective [DATE], defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy further defined sexual abuse as non-consensual sexual contact of any type with a resident.

Based on observation, interview, and record review, the facility failed to ensure that care and treatment were provided in accordance with physician orders for 1 of 4 sampled residents. This deficient practice resulted in the implementation of resident safety interventions without physician authorization. Findings Include:Resident #77 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbance; anxiety; type 2 diabetes mellitus with diabetic neuropathy and foot ulcer; alcohol abuse; and acquired absence of another left toe.An admission Minimum Data Set (MDS) assessment completed on January 13, 2023, indicated that Resident #77 had a Brief Interview for Mental Status (BIMS) score of 12, reflecting moderate cognitive impairment.Review of a Progress Note (Alert Note) dated January 16, 2023, at 1:22 p.m., documented that Resident #77 remained at risk for elopement. The note indicated that a functioning Wander Guard was in place and that staff continued to closely monitor the resident due to ongoing exit-seeking behaviors.A subsequent Progress Note (Health Status Note) dated January 18, 2023, at 1:24 p.m., documented that Resident #77 continued to exhibit exit-seeking behaviors. The Wander Guard remained in place and operational, and staff were providing frequent redirection. The resident's son had been notified of the resident's behaviors and noncompliance.According to a Progress Note (Alert Charting) dated January 24, 2023, Resident #77 was discovered missing from the facility and was later found on the side of Route 260 across from a gas station. The note documented that the resident was wearing a Wander Guard; however, no alarm sounded when the resident exited the facility. The resident was located by a Certified Nursing Assistant (CNA). Upon return to the facility, a head-to-toe assessment was completed and revealed no new injuries. The resident's family and facility administration were notified of the incident and the resident's continued exit-seeking behaviors.A skin assessment for Resident # 77 completed on January 29, 2023, revealed no new injuries related to the elopement incident were noted.Resident's (#77) care plan related to wandering and exit-seeking behaviors following the elopement incident was updated.The care plan interventions included administering medications as ordered, anticipating and addressing the resident's needs, implementing interventions necessary to protect the resident and others, and approaching the resident in a calm manner while redirecting and diverting attention to alternative locations as needed.Review of the clinical record indicated that Resident #77 did not have a hospital order or physician order for a Wander Guard prior to the incident. The physician order authorizing the Wander Guard was subsequently obtained and entered on January 25, 2023. An interview was conducted on May 28, 2026, at 10:16 a.m. with a Registered Nurse (RN, Staff #74). The RN stated that residents at risk for wandering or elopement are identified through information obtained from hospitals or previous facilities, admission assessments, and observations of exit-seeking behaviors. The RN further stated that assessments are generally completed within 24 hours of admission, and residents that are determined to be at risk should have appropriate interventions included in their care plan, such as the use of a Wander Guard when indicated. The RN confirmed that a physician's order must be obtained before a Wander Guard is applied and that staff receive education regarding residents identified as being at risk for wandering or elopement. An interview was conducted on May 28, 2026, at 9:15 a.m. with the Director of Nursing (DON, Staff #86). The DON stated that residents are assessed for wandering and elopement risk upon admission, and the assessment results are documented in both the resident's medical record and PointClickCare (PCC). Residents identified as being at high risk for elopement must have a physician's order and consent from the resident or the resident's Power of Attorney (POA) before a Wander Guard is applied. The DON (Staff #86) further stated that these residents are included in a wander-risk binder maintained at the front desk, and staff are notified of residents at risk for wandering through communication and the use of resident photographs to assist with identification and monitoring. The DON (Staff #86) stated that Wander Guards are typically used for residents who have been assessed as being at high risk for elopement or who demonstrate recurrent exit-seeking behaviors. The DON confirmed that a physician's order must be obtained prior to the application of a Wander Guard and acknowledged that the use of a Wander Guard without a physician's order was not in accordance with facility policy and expectations. An interview was conducted on May 28, 2026, at 1:55 PM with the executive director (ED / Staff #84) who stated that residents at risk for elopement or wandering are identified through assessments and communicated to all staff. Monitoring varies based on the resident's condition, and Wander Guards may be used depending on assessment findings. The ED (Staff # 84) stated that a physician's order is required prior to application, but also indicated a Wander Guard may not be placed without an order and acknowledged that the use of a Wander Guard without a physician's order was not in accordance with facility policy and expectations. A review of the facility policy titled G002 - Orders/Receiving/Transcribing: Medication Orders, revised January 1, 2024, revealed that the facility is responsible for ensuring that all physician orders are accurately received, transcribed, communicated, and implemented as prescribed.

Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure one (#8) out of the three sample residents received activities of daily living (ADL) care as per facility policy. The deficient practice could result in resident's hygiene needs not being met, skin breakdown, and psychosocial harm.Findings include-Resident #8 was admitted to the facility on [DATE], with diagnosis that included fracture of right femur, type 2 diabetes mellitus with hyperglycemia, muscle weakness, and osteoarthritis on right knee.Orders dated January 16, 2026, revealed a complete skin check weekly.A care plan initiated on January 17, 2026, revealed that the Resident #8 is at risk for functional self-care deficits and mobility. The interventions included Resident #8 required skin inspection during routine cares and per bath schedule, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The care plan further revealed that the resident is at risk for skin impairment related to red coccyx, reg thigh rash present during admission. The interventions included administer treatments as ordered and monitor for effectiveness.A quarterly MDS (minimum data set) dated January 21, 2026, revealed that the resident was a BIMS (brief interview for mental status) score of 08 which indicated moderately impaired cognition.Review of the weekly skin check and wound assessment revealed that 1 skin assessment was done on January 16, 2026. However, there was no evidence that weekly skin assessment was done from January 17 through February 11, 2026.A facility document titled, shower schedule, included that Resident #8 was to be provided shower two times a week during evening shift.Review of shower documents included:-One shower was provided on January 30, 2026 and February 7, 2026.-No evidence of showers was provided from January 16 through January 29, February 1 through February 6, and February 8 through February 11, 2026. An interview was conducted on February 17, 2026, at 11:56 a.m., with a licensed practical nurse (LPN, staff # 58) who worked at the facility for about one month and assisted residents with medication administration, vitals, wound care, and daily skilled evaluation. The LPN then stated that she is aware of Resident #8 who needed assistance with activity of daily living (ADLs) including toileting, transferring, and bathing. The LPN then stated that on February 10, 2026, Resident #8 had a change of condition where she was less communicative to staff and refused care including ADLs, vitals. LPN then reviewed the Resident #8 electronic health record and stated that the resident skin was assessed on January 16, 2026, with a red area on coccyx, rash on thigh, and scab on right knee. LPN then stated that on January 30, 2026, the document titled braden scale revealed skin occasionally moist. Then on February 9, 2026 document titled braden scale for predicting pressure ulcer evaluation revealed that Resident #8 revealed skin occasionally moist, activity chairfast, and mobility slightly limited. However, she did not find any document regarding redness in coccyx region nor any documentation regarding weekly skin assessment after January 16, 2026. LPN then stated that she came to know on February 16, 2026, from Interim director of nursing (DON #79) that LPN's are supposed to do weekly skin assessment. The LPN then stated that DON follow up with nurses regarding resident's skin assessment and shower at least once a week. She stated that the risk if a resident's skin was not assessed weekly then there would be a chance of the resident getting skin injury, tear, or opening. LPN further stated that all residents in the facility get shower twice a week by CNAs (certified nursing assistant) and nurses follow up on any skin condition during showers, review signed shower sheets and notify any skin issue to the provider and the DON (director of nursing). The LPN then review physical copy of shower sheets and stated she could not find Resident #8'shower sheets and that may be DON pulled out Resident#8's binder from the sheet.An interview was conducted on February 17, 2026, at 1:34 p.m., with a certified nursing assistant (CNA staff # 26) who stated that she had worked at the facility for about 7 months and assisted residents with activities of daily living (ADLs) including transferring, bathing, dressing, and oral care. The CNA then stated initially after admission CNA provided ADLs care to resident #8 but after a couple weeks, the resident refused all cares including transferring from bed to wheelchair, toileting, repositioning, and started hitting to staffs. The CNA then stated that Resident #8's change in condition may be due to family, who stopped visiting her at the facility as they lived far away from the facility and Resident #8 did no longer want to stay at the facility. The CNA then stated that during Resident #8's stay, her vitals were normal and she was not aware of any change in Resident#8's conditions or medications. The CNA further stated that Resident #8 was scheduled for showers every Tuesday and Friday and could ask for Sunday if she preferred. The CNA then stated that she did not provide any shower to Resident #8. However, during resident's shower, skin was assessed, and any skin condition or refusal of shower would be charted on the shower sheet and floor nurses would review and sign off on the shower sheets. The CNA further stated that the risk if resident were not provided shower or skin were not assessed then there would be a chance of skin breakdown, irritation and foul smell from resident.An interview was conducted on February 17, 2026, at 2:19 p.m., with the DON (staff # 79) who worked at the facility as interim DON until a new DON is hired. Staff #79 then stated that the Resident #8 was admitted to the facility for therapy due to facture on right femur. The DON then stated that Resident #8 was on maximum assistance for bed mobility and moderate to maximum assistance for sit to stand. The DON further stated that there was a change in condition (COC) for Resident #8 from February 7 through February 9, where Resident refused all ADLs care including transferring, toileting and vitals. She stated that the provider was notified and Resident #8's therapy was put on hold. The DON then stated that Resident was not on any psychotropic medication and the only medication would cause COC may be gabapentin and tramadol that could make her sleepy. The DON also stated that Resident #8 had redness on the coccyx region during admission and on her last shower on February 7, 2026, there was no redness on coccyx found. The DON then reviewed the Resident #8 clinical record and stated that the resident had an order dated January 16, 2026, for a complete weekly skin check and there was only one skin assessment done on January 16, 2026. However, no skin assessments were done after January 16, 2026. Staff #79 then stated that the previous DON (staff # 90) usually followed up with floor nurses on all resident skin assessment every day as resident's name identified. The DON further stated that the risk if skin was not assessed for resident weekly would be a chance of skin breakdown. The DON further stated that all resident was scheduled to receive shower at least twice a week by CNAs and nurses signed out the shower sheet. The DON (staff #90) then follow-up on shower sheet. The DON further stated that if shower was not provided as per schedule then there would be a risk for resident's skin breakdown.Review of the facility policy titled Personal Care: Activities of Daily Living (ADL), revised on January 1, 2024, revealed that appropriate care and services will be provided for the residents and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Review of the facility policy titled Bathing and Showers, dated 2022, revealed that the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy further revealed that upon admission shower schedule will be decided with resident, observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-grey area of skin over a pressure point, blisters, or skin breakdown.

Based on clinical record review, staff interviews, facility policy and procedure and police report, the facility failed to ensure life-saving measures including cardiopulmonary resuscitation (CPR) were provided according to the advance directives for one resident (#10) who was found unresponsive. The deficient practice resulted in the resident not receiving life-saving measures and death.Findings include:Resident #10 was admitted to the facility on [DATE], with diagnoses of pneumonia due to pseudomonas, other acute osteomyelitis, bacteremia, autistic disorder, bipolar disorder, mood disorder, epilepsy, need for assistance with personal care, and unspecified lack of expected normal physiological development in childhood.An Alert Charting note dated January 22, 2026 revealed Resident #10 arrived to the facility at 1:50 p.m. and was on contact isolation precautions; and that, fall mats were placed on the floor next to the resident's bed for safety.The history & physical note dated January 23, 2026 included that code status and advanced care planning was done and discussed with resident or surrogate; and, reviewed advanced directives at initial visit.A Nursing admission Evaluation dated January 23, 2026, revealed Resident #10 admitted to the facility on [DATE], at 3:50 p.m. from a short-term hospital, with medication orders present on admission that included anticonvulsant, psychotropic, antianxiety, and sedative/hypnotic medications. The discharge plan included that the resident expected to be discharged to the community. Further, the evaluation revealed that the resident did not have an active infection requiring isolation.An Advance Directive signed January 23, 2026 included Resident #10 wanted CPR if his breathing and heart stopped, nutrition by tube feeding, intravenous fluids, pain medication for comfort, antibiotic therapy, and life or death blood transfusions.The fall risk evaluation dated January 23, 2026 included a score of 18 indicating resident was a high risk for fall.An Occupational Therapy (OT) Daily Note dated January 23, 2026, revealed the resident may not be appropriate for the facility due to need for 1 on 1 care; and that, the resident demonstrated aggressive outbursts when desiring something (snacks, boombox). The note included that the resident had a fall out of bed shortly after the OT evaluation and demonstrated significantly decreased ability to follow safety advice and instruction to wait for help when standing.An Alert Charting note dated January 23, 2026, stated that Resident #10 was agitated and frequently calling and yelling out. The documentation noted that he would quiet down when staff responded to see what he needed, but would begin calling out again afterward.A Late Entry Social Services Progress Note dated January 23, 2026 revealed Social Services consulted with the psychiatric nurse practitioner and the Director of Nursing (DON / Staff #66) regarding the resident's current psychiatric and behavioral presentation. The note revealed it was determined that the resident required transfer to a behavioral health facility, as the level of psychiatric and behavioral care required exceeded the capabilities of the facility. This progress note was created on January 24, 2026.A social services progress note dated January 23, 2026, revealed the resident's family agreed to transfer the resident to a behavioral unit; and that, social services was working with a facility to coordinate appropriate transfer of Resident #10.An alert charting note dated January 25, 2026, at 2:30 a.m. revealed that Resident #10 had a witnessed seizure for about 50 seconds; had the following vital signs: blood pressure (BP) was 160/86, heart rate was 63, respiratory rate was 18, temperature was 97.7 degrees, and O2 saturation was 97%; and, was placed on neurological checks. Per the documentation, the nurse notified the DON (Director of Nursing) and attempted to notify the on-call provider but was unsuccessful. The documentation also included another provider who was not the on-call provider was informed; and, this provider discontinued the resident's short-acting benzodiazepine medication, ordered long-acting sedative-hypnotic and instructed to send the resident out to the hospital if the resident had another seizure.A physician order dated January 26, 2026, and entered at 9:24 a.m., revealed the resident was full code and indicated for CPR.An alert charting note signed by the DON (Staff #66) and dated January 26, 2026, at 12:27 p.m., revealed the DON came to assist Resident #10 who was on the floor. According to the documentation, after the DON entered the room, Resident #10 was found leaning slightly against the bed, and was partially on the floor mat placed for his protection. Further, the note included the resident appeared to be deceased ; and that, the DON checked for the resident's pulse 3 times, and attempted CPR until a staff member reported to the DON that police were at the facility. The documentation included that a second nurse attempted to listen for a heartbeat as the police officer arrived in the room.There was no evidence found that CPR was initiated or an AED (automated external defibrillator) was used on Resident #10.An e-MAR (medication administration) note dated January 26, 2026, at 5:50 p.m., revealed the resident was deceased .A death in facility MDS (minimum data set) assessment dated [DATE] revealed Resident #10 was coded as deceased .A facility self-report submitted to the State Agency (SA) on January 26, 2026 revealed that on January 26, 2026, Resident #10 had medication pass completed around 7:00 a.m., received breakfast at 8:30 a.m., and was checked on at 9:30 a.m. The documentation included that at 11:30 a.m. on January 26, 2026, a CNA (certified nurse assistant) found Resident #10 on the fall mat; and the nurse was called to the room. It also included the nurse assessed the resident and attempted three times to find a pulse; and, the resident appeared deceased . According to the documentation, CPR was initiated, 911 was called, and a second nurse was brought in until the police arrived.Review of the transcript of the 911 call initiated by the facility staff on January 26, 2026 included the facility staff reporting that it was a medical emergency and the resident was not responsive and not breathing. The 911 operator asked the reporting facility staff whether CPR was initiated, the staff responded that she was going into the room. The 911 operator asked the reporting staff again if someone is doing CPR and the reporting staff responded No and that the resident was deceased .The Marshal Office (police) incident report dated January 26, 2026, revealed Resident #10 was found unconscious and not breathing at the facility, and was first reported on January 26, 2026, at 11:35 a.m. The report revealed officers were enroute to the scene when they were advised approximately 2 minutes later that the resident was dead. Responding units arrived on scene at approximately 11:39 a.m., and were directed to the resident's room. Upon arrival, officers identified Resident #10 lying on his back, face up, unresponsive, and with his eyes open. The report revealed deputies arrived and checked for a pulse, felt no pulse, and observed Resident #10 was cold to the touch, and the time of death was called at approximately 11:39 a.m. According to the report, the position of Resident #10 position on the floor was unusual, that his head and shoulders were raised above the floor, and his right elbow was up.Continued review of the report revealed that the RN (registered nurse) assigned to Resident #10 for the day was the DON (Staff #66) who reported that Resident #10 was last rounded on at approximately 9:30 a.m. and the resident was known to be well at that time. The DON reported that a CNA (Staff #40) notified her that Resident #10 was on the floor in his room and needed help. The report revealed that the DON said that it was normal to find Resident #10 on the floor inside his room, outside of his bed; and that, when she entered Resident #10's room, she found him seated on the floor, leaning to his left, and against the bed, and was laying half on and half off of a gray fall mat on the floor. The report revealed that the DON stated they identified that (Resident #10) had passed away and did not initiate CPR. The police report also revealed that the CNA (Staff #40) who was assigned to Resident #10 reported that Resident #10's door was closed, so she knocked on the door, and opened the door to find Resident #10 on the floor, with only his legs visible. The report revealed the CNA (Staff #40) reported that she called other medical staff for help, and entered the room and ended up on the opposite side of the bed from Resident #10, and could not see his positioning. Further, the CNA (Staff #40) stated she could not see if the gray fall mat was on the floor underneath Resident #10.The police report included that the scene was investigated and Resident #10 was laying on the ground, slightly turned to his left side, eyes open, staring toward the ceiling. The report revealed Resident #10's skin was cold to the touch, but rigor mortis had not yet set in. The documentation included that Resident #10 had a small laceration on the posterior side of his head, with blood having dripped off of his head, onto the floor, and was dry upon arrival. A gray fall mat was leaning against the wall in the northwest corner of the room, behind a bedside table, empty food tray, and pile of laundry. The pile of laundry was sitting across the rolling wheels of the table, inconsistent with having been moved recently. According to the report, this was interesting as the table would have had to have been moved to access the gray (fall mat). An additional blue fall mat was located on the wall of the south side center portion of the room, but appeared to have been unused recently as it was clean and, in a position, as if it was being stored there.Further review of the police report showed that Resident #10's bed appeared freshly made, suggesting he may not have fallen from it. The report also noted conflicting statements from the DON. In one statement to police, she said CPR was not initiated. In another statement, she said she began life-saving measures but believed the resident was beyond help and did not move him to a flat position on the floor because police and EMS were already present. The report also included that the DON reported that while she was initiating lifesaving measures, staff may have changed and straightened the bed linens.Review of the clinical record revealed no evidence or documentation of any laceration on the posterior side of the head of Resident #10 at the time of the incident.A State Agency Bureau of Vital Records Human Remains Release Form dated January 26, 2026, included that the deceased person was Resident #10, and the time of death was 11:38 a.m.A phone interview was conducted with a licensed practical nurse (LPN / Staff #2) on February 11, 2026, at 11:08 a.m. The LPN stated that he was familiar with Resident #10, who would yell out when he wanted items such as ice cream or when he wanted his television channel changed. He also reported that he had been informed through verbal report that the resident had a history of crawling out of bed. The LPN stated that he was the nurse assigned to Resident #10 on January 25, 2026, at approximately 2:30 a.m., when the resident had a seizure. He stated that he attempted to contact the on-call provider but was unsuccessful. The LPN said that he was able to notify the DON and another provider, who was not the resident's on-call provider, regarding the seizure; and that, the resident's provider eventually contacted him after his shift had ended.A phone interview was conducted with a certified nursing assistant (CNA /Staff #31) on February 11, 2026, at 11:20 a.m. The CNA stated that she was working on Resident #10's unit on the morning of January 26, 2026. She stated that she checked on Resident #10 early in the morning before breakfast, and the resident appeared fine. The CNA stated she was not involved with finding Resident #10 unresponsive. She said that another CNA, Staff #40, who also served as the facility's staff scheduler, found the resident on the floor in his room. The CNA stated that after Staff #40 entered the room and discovered the resident, the DON entered shortly afterward. She indicated that she was not aware of what happened next but later learned that Resident #10 had expired.An interview was conducted on February 11, 2026, at 11:29 a.m. with the staff scheduler/CNA (Staff #40) who stated that she never worked with Resident #10, except on January 26, 2026, the day that he expired. She stated that at approximately noon on January 26, 2026 when she had attempted to deliver the resident his lunch tray to his room. She stated that the resident's door was closed, so she knocked and opened it. Upon entering, she observed the resident's feet on the floor but could not see the rest of his body. She stated that she believed he had fallen. Staff #40 reported that her hands were full with the meal tray, so she stepped back into the hallway and called for the DON (Staff #66), who was nearby. She stated that she then returned the meal tray to the cart. At that time, the DON entered the resident's room and instructed someone to get the registered nurse (RN, Staff #17). Staff #40 stated that when the RN arrived, the RN briefly left to retrieve a stethoscope, returned to the room, and assessed the resident. She reported that the RN then informed her and the DON that Resident #10 was gone. Staff #40 stated that the DON instructed her to get the corporate clinical resource nurse (Staff #83), who was on the other side of the building. She reported that she went to the conference room to notify the corporate nurse and then returned to the resident's room. Staff #40 stated that the DON and another nurse were in the room beside the resident. She further stated that no one was performing CPR and that she did not observe anyone provide CPR at any time during the incident. She reported that after several minutes, approximately four police officers arrived at the resident's room.In an interview conducted on February 11, 2026, at approximately 12:00 p.m., the registered nurse (RN), Staff #17, stated that she was working on January 26, 2026, when a CNA informed her that the DON needed her in Resident #10's room. The RN stated that when she entered the room, she believed the resident was expired because his eyes were open, he was looking at nothing, and he was unresponsive. She reported that no one was performing CPR and that the DON was present in the room beside the resident. The RN stated that she left briefly to retrieve her stethoscope, then returned to assess the resident. She reported that she listened to the resident's heart, lungs, and abdomen and did not hear any sounds. Based on her assessment, she believed the resident was deceased . The RN stated that she was aware emergency medical services (EMS) had been called but did not know who contacted 911. She reported that she then returned to her unit, and within several minutes, she observed officers from the marshal's office (police) walking down the hall toward the resident's room.During an interview with the DON (Staff #66) conducted on February 11, 2026, at 12:58 p.m., the DON stated that if a resident with full code status becomes unresponsive, staff were expected to remain with the resident, call out for someone to contact 911, check for a pulse, and initiate life-saving measures, including CPR. The DON stated that on January 26, 2026, she was assisting on the unit when, at approximately 11:30 a.m., a CNA (Staff #40) informed her that Resident #10 was on the floor. She reported that upon entering the room, Resident #10 was seated on his buttocks on the fall mat, with his legs extended in front of him, his shoulders were leaning against the bedframe, and his head was upright but slightly tilted to the left. She stated that the resident was not breathing, was unresponsive, and had his eyes open. The DON said that she checked for a pulse and was unable to detect one. She stated that she called out for someone to dial 911 but did not know who made the call. She said she was unsure whether the resident exhibited rigor mortis. The DON stated that she attempted to move the resident into a flat position on the floor. She described the resident as feeling slightly stiff but noted it was difficult to determine due to his larger size and her smaller frame, which made repositioning him challenging. The DON stated that she initiated CPR and continued performing CPR without stopping, except to check for a pulse, until police arrived and instructed her to stop. She reported that she was the only staff member who provided CPR but could not recall exactly how long CPR was performed.An interview was conducted with a corporate clinical resource nurse (Staff #83) on February 11, 2026, at 1:34 p.m. She stated that on January 26, 2026, she was in the facility's conference room for a meeting when a CNA informed her that the DON needed her in Resident #10's room. She stated that upon entering the room, Resident #10 was seated on his bottom on the floor, with his shoulders leaning against the bedframe, and appeared deceased . She noted that the resident's back was not flat on the floor, making it impossible to perform CPR in that position. She said the DON was kneeling beside the resident and stated that the resident was gone. The corporate clinical resource nurse stated that she then left the room and went to the nurses' station just outside the resident's room to locate the resident's code status and advance directive documents. She said that while she was at the nurses' station, EMS personnel arrived at the resident's room. She stated that after the incident, she confirmed with the DON that Resident #10 was full code status. The DON reportedly said she performed a sternal rub, checked the resident's pulse, found none, and attempted two CPR compressions but stopped because the chest was mushy. The corporate clinical resource nurse told the DON that for a full code resident, CPR should not be stopped until instructed by a physician or EMS. She further stated that she did not know the exact timeline from when Resident #10 was found to when EMS arrived. She also noted that while the facility had an automated external defibrillator (AED), no staff brought it to the room to attempt lifesaving measures on January 26, 2026. She emphasized that failure to provide CPR or other lifesaving measures for a full code resident could result in harm or death and stated that an unresponsive resident could be in cardiac arrest, in which case staff could use an AED as a lifesaving measure.Review of the facility policy titled Emergency/First Aid: Emergency Procedure - Cardiopulmonary Resuscitation, dated January 1, 2024, revealed personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms (arrhythmias). Cardiac arrest occurs soon after symptoms appear. It is a leading cause of death among adults. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden cardiac arrest (SCA). Typically, heart attacks are less sudden than SCA. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis).The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Chest compressions included to push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; allow full chest recoil after each compression; and, minimize interruptions in chest compressions. Tilt head back and lift chin to clear airway. After 30 chest compressions provide 2 breaths via ambu-bag or manually (with CPR shield). All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. When the AED arrives, assess for need and follow AED protocol as indicated. Continue with CPR/BLS until emergency medical personnel arrive.The facility policy titled End of Life Care: Death of Resident, Documenting, dated January 1, 2024, revealed a resident may be declared dead by a licensed physician or registered nurse with physician authorization in accordance with state law. All information pertaining to a resident's death (i.e., date, time of death, the name and title of the individual pronouncing the resident dead, etc.) must be recorded on the nurses' notes. The attending physician must record the cause of death in the progress notes, and must complete and file a death certificate with the appropriate agency within twenty-four (24) hours of the resident's death or as may be prescribed by state law.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#2) following an allegation of abuse. The deficient practice could lead to care team members not being aware of a resident's status, and lead to missed or delayed treatment. Findings include: -Resident #2 was admitted to the facility March 28, 2025, and re-admitted to the facility on [DATE], with diagnoses that included cognitive communication deficit, pressure ulcer of sacrum, laceration of right foot with foreign body, and unspecified dementia. A facility self-report submitted to the State Agency, dated May 6, 2025, revealed on May 6, 2025, at approximately 2:45 PM, Resident #2 was calling to the clinical staff in the hall for help. Resident #2's roommate, Resident #4, was bothered by the volume and moved his body closer to Resident #2 from the other side of the room. Resident #4 moved his arm in the direction of Resident #2, and Resident #4's hand made contact with Resident #2's chest and top of head. The CNA intervened and separated the residents. However, the clinical record revealed no evidence of a description of a resident to resident incident on May 6, 2025, any evidence of monitoring or that the resident was placed on alert charting, notification of the incident to the medical provider, and assessment for injury following the incident. An interview was conducted on May 13, 2025, at 9:28 AM with Resident #4, who stated that there was a disagreement between himself and his former roommate. Resident #4 stated that Resident #2 was yelling, and was nosey. Resident #4 stated that Resident #2 kept yelling, and I told him to press the red button, and that staff will come. Resident #4 stated that there was physical interaction that occurred and that I'm the one that did it and that he pushed Resident #2 in the head. Resident #4 stated I was mad, and I kind of lost my mind. Resident #4 then demonstrated the motion of pushing his hand out in front of him. Resident #4 stated I pushed him in the head. I didn't slap or hit, just pushed. An interview was conducted on May 13, 2025, at 9:43 AM with Resident #2, who stated that this was his second room at the facility and that he thought that he remembered getting into a disagreement with his roommate. Resident #2 stated that he made a statement that his roommate did not agree with, and that his roommate yelled at him and threw something at him, and he may have pushed him, but he could not recall specifically. A telephonic interview was attempted on May 13, 2025, at 11:13 AM with a Registered Nurse (RN / Staff #30). A voicemail was left for a return phone call. The staff did not return the phone call. An interview was conducted on May 13, 2025, at 11:25 AM, with a CNA (Staff #20) who stated she was aware of the incident between Resident #2 and #4. Staff #20 stated that it was about 2:45 PM, and she was on the floor and heard yelling. She stated she made her way over to the room, and heard Resident #4 moving toward Resident #2. Staff #20 stated she looked into the residents' room, and that is when she saw Resident #4 swing out and then swing down with his hand and strike Resident #2, once with a backhanded motion that struck Resident #2 on the chin, and once in a downward motion that hit Resident #2 on top of the head. Staff #20 stated it was aggressive in nature, he hit him. Staff #20 stated that she made sure Resident #2 was ok, then redirected Resident #4 out of the room, and then told the nurse, the Administrator, and the charge nurse right away. An interview was conducted with the DON (Staff #16) on May 13, 2025, at 1:58 PM. The DON stated that residents are assessed following allegations of abuse by completing a head to toe assessment to ensure there are no injuries. Additionally, the DON stated that notifications of the allegation of abuse are made to the administrator, the medical provider, and the resident's family as indicated. The DON stated that the initiation of 15-minute checks to monitor the resident was missed this time. The DON stated that these assessments and notifications are documented in the risk management and progress notes in the resident's record, and that the facility maintains an accurate medical record for residents to ensure something is not missed. Review of the facility policy titled Documentation: Charting and Documentation, effective January 1, 2024, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the facility abuse policy was implemented for a resident (#2) with an allegation of abuse. The deficient practice could lead to physical or psychosocial harm of a resident. Finidngs include: -Resident #2 was admitted to the facility March 28, 2025, and re-admitted to the facility on [DATE], with diagnoses that included cognitive communication deficit, pressure ulcer of sacrum, laceration of right foot with foreign body, and unspecified dementia. The clinical record review revealed no evidence of a description of a resident to resident incident on May 6, 2025, any monitoring or that the resident was placed on alert charting, notification of the incident to the medical provider, and any assessment for injury following the incident. -Resident #4 was admitted to the facility on [DATE], with diagnoses that included alcohol dependence, alcoholic cirrhosis of liver, nontraumatic subdural hemorrhage, type 2 diabetes mellitus, osteomyelitis of vertebra of lumbar region, acute pancreatitis, and other toxic metabolic encephalopathy. A facility self-report submitted to the State Agency, dated May 6, 2025, revealed on May 6, 2025, at approximately 2:45 PM, Resident #2 was calling to the clinical staff in the hall for help. Resident #2's roommate, Resident #4, was bothered by the volume and moved his body closer to Resident #2 from the other side of the room. Resident #4 moved his arm in the direction of Resident #2, and Resident #4's hand made contact with Resident #2's chest and top of head. The CNA intervened and separated the residents. An interview was conducted on May 13, 2025, at 9:28 AM with Resident #4, who stated that there was a disagreement between himself and his former roommate. Resident #4 stated that Resident #2 was yelling, and was nosey. Resident #4 stated that Resident #2 kept yelling, and I told him to press the red button, and that staff will come. Resident #4 stated that there was physical interaction that occurred and that I'm the one that did it and that he pushed Resident #2 in the head. Resident #4 stated I was mad, and I kind of lost my mind. Resident #4 then demonstrated the motion of pushing his hand out in front of him. Resident #4 stated I pushed him in the head. I didn't slap or hit, just pushed. An interview was conducted on May 13, 2025, at 9:43 AM with Resident #2, who stated that this was his second room at the facility and that he thought that he remembered getting into a disagreement with his roommate. Resident #2 stated that he made a statement that his roommate did not agree with, and that his roommate yelled at him and threw something at him, and he may have pushed him, but he could not recall specifically. A telephonic interview was attempted on May 13, 2025, at 11:13 AM with a Registered Nurse (RN / Staff #30). A voicemail was left for a return phone call. The staff did not return the phone call. An interview was conducted on May 13, 2025, at 11:25 AM, with a CNA (Staff #20) who stated she was aware of the incident between Resident #2 and #4. Staff #20 stated that it was about 2:45 PM, and she was on the floor and heard yelling. She stated she made her way over to the room, and heard Resident #4 moving toward Resident #2. Staff #20 stated she looked into the residents' room, and that is when she saw Resident #4 swing out and then swing down with his hand and strike Resident #2, once with a backhanded motion that struck Resident #2 on the chin, and once in a downward motion that hit Resident #2 on top of the head. Staff #20 stated it was aggressive in nature, he hit him. Staff #20 stated that she made sure Resident #2 was ok, then redirected Resident #4 out of the room, and then told the nurse, the Administrator, and the charge nurse right away. An interview was conducted on May 13, 2025, at 1:35 PM with the Administrator (Staff #66). The Administrator stated that his understanding of abuse is when someone has the intent to harm another individual, including intended actions of hitting someone and willfully harming them. The Administrator stated that the facility's policy if there is an allegation of abuse is to separate the residents and ensure they feel safe, perform skin checks, complete an investigation, and to report the incident to authorities as required by law within 2 hours. The Administrator stated that he completed the facility's 5-day Investigation Report for the incident. The Administrator stated he was notified immediately from the CNA of the incident and that staff interviewed both residents and that Resident #2 was on his call light and asking staff for help, and Resident #4 was concerned with Resident #2's volume, so he moved over closer to Resident #2. The Administrator stated that the CNA witnessed Resident #4 touch or make contact with Resident #2, and we conducted an investigation. The Administrator stated that Resident #4 was going over to help Resident #2 and brushed him unintentionally on Resident #2's cheek and head. The Administrator stated that Staff #20 witnessed the incident and saw Resident 4 make soft contact with Resident #2, and that it was not aggressive and was not intentional. The Administrator stated that the facility did not substantiate the incident as abuse due to lack of evidence. An interview was conducted with the DON (Staff #16) on May 13, 2025, at 1:58 PM. The DON stated that her understanding of abuse is any threat to life or harm, and could be verbal, physical or sexual. The DON stated that she was passing medication on the hall when the CNA approached her and stated there was an incident, and that Resident #4 and Resident #2 had been separated. Resident #2 was in the recliner and Resident #4 was in the room. The CNA had told the floor nurse (Staff #30) who was assessing the residents. The DON stated she then talked to Resident #2 who stated something hit him on the head. The DON stated she realized then after talking with Resident #2 that he was not cognitively intact. The DON stated that herself and the Administrator talked to the CNA (Staff #20) who stated she saw Resident #4 swing his arm and hit Resident #2 on the chest or the cheek and then again directly on top of the head. The DON stated that swinging arms at another person could be considered abuse. Review of the facility policy titled Abuse Policy, dated 2022, revealed that if abuse is witnessed or suspected, reporting and investigation will take place in the following manner. The Executive Director (ED) will be notified. The DON will notify the following: Physician, Responsible Party, and [NAME] President of Clinical Operations. The ED will begin investigation immediately and complete within 5 working days. Interviews may also include the alleged perpetrator, witnesses, and staff members as applicable. The resident suspected of being abused will be monitored and placed on alert charting.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a baseline care plan was developed to meet the needs of one resident (#2). The deficient practice could lead to care team members not being aware of a resident's medical conditions and/or plan of care to address the resident's individual needs. Findings include: Resident #2 was admitted to the facility March 28, 2025, and re-admitted to the facility on [DATE], with diagnoses that included cognitive communication deficit, pressure ulcer of sacrum, laceration of right foot with foreign body, and unspecified dementia. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. There was no evidence of a baseline care plan to address the resident's impaired cognition. An interview was conducted with the DON (Staff #16) on May 13, 2025, at 1:58 PM. The DON stated that residents are assessed for risk of having behaviors that are abusive or could contribute to an abusive situation by monitoring behaviors. Additionally, the DON stated aggression is manifested very differently with impaired cognition, and that impaired cognition and dementia are always risk factors for abuse. The DON stated that impaired cognition and dementia are items that should be care planned to ensure that all staff are aware and updated with changes. Review of the facility policy titled Assessments/Care Planning: Care Plans - Baseline, effective January 1, 2024, revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#2) to be free from physical abuse by another resident (#4). The deficient practice could lead to physical or psychosocial harm of a resident. Findings include: -Resident #2 was admitted to the facility March 28, 2025, and re-admitted to the facility on [DATE], with diagnoses that included cognitive communication deficit, pressure ulcer of sacrum, laceration of right foot with foreign body, and unspecified dementia. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. The clinical record review revealed no evidence of a description of a resident to resident incident on May 6, 2025, notification of the incident to the medical provider, and any assessment for injury following the incident. -Resident #4 was admitted to the facility on [DATE], with diagnoses that included alcohol dependence, alcoholic cirrhosis of liver, nontraumatic subdural hemorrhage, type 2 diabetes mellitus, osteomyelitis of vertebra of lumbar region, acute pancreatitis, and other toxic metabolic encephalopathy. A quarterly MDS assessment dated [DATE], revealed the resident had a BIMS score of 4, indicating severe cognitive impairment. A BIMS assessment completed May 6, 2025, revealed a score of 14, indicating the resident was cognitively intact. A Late Entry Progress Note created May 9, 2025, effective May 6, 2025, by the Director of Nursing (DON / Staff #16) revealed while helping on the medication cart, the DON was notified by a Certified Nursing Assistant (CNA) that there had been an incident between residents. The CNA and another CNA heard raised voices and immediately responded to the room. The CNA advised that she seen Resident #4 moving his arm but did not see Resident #4 make contact with Resident #2, and advised there was no contact. The CNA advised that the residents had been separated, and both were in safe areas being monitored by staff. The administrator was notified and an investigation was started. The writer assessed both residents and found no signs of injury, no alteration in skin, and both denied injury at the time. A facility self-report submitted to the State Agency, dated May 6, 2025, revealed on May 6, 2025, at approximately 2:45 PM, Resident #2 was calling to the clinical staff in the hall for help. Resident #2's roommate, Resident #4, was bothered by the volume and moved his body closer to Resident #2 from the other side of the room. Resident #4 moved his arm in the direction of Resident #2, and Resident #4's hand made contact with Resident #2's chest and top of head. The CNA intervened and separated the residents. The residents were made safe and were being checked routinely. Both residents were assessed, and no injuries or signs of physical contact were noted on either resident, and the residents have been placed in separate rooms to prevent further interaction. At this time, both residents are doing well with no lingering effects. A full investigation will be completed in the appropriate time frame. A facility Reportable Event Record/Report (5-day Investigation Report) dated May 12, 2025, revealed on May 6, 2025, at approximately 2:45 PM, Resident #2 was calling to the clinical staff in the hall for help. The roommate, Resident #4, was concerned by the volume and walked across the room to Resident #2 from the other side of the room. Resident #4 moved his arm in the direction of Resident #2 in an attempt to get his attention and his hand made contact with Resident #2's chest and top of head. The CNA intervened and separated the residents. This is the first time these residents were involved in an occurrence. A witness statement dated May 13, 2025, and signed by the Administrator (Staff #66) revealed see attached. There was no evidence of any other attached documents of any witness statements. An interview was conducted on May 13, 2025, at 9:28 AM with Resident #4, who stated that there was a disagreement between himself and his former roommate. Resident #4 stated that Resident #2 was yelling, and was nosey. Resident #4 stated that Resident #2 kept yelling, and I told him to press the red button, and that staff will come. Resident #4 stated that there was physical interaction that occurred and that I'm the one that did it and that he pushed Resident #2 in the head. Resident #4 stated I was mad, and I kind of lost my mind. Resident #4 then demonstrated the motion of pushing his hand out in front of him. Resident #4 stated I pushed him in the head. I didn't slap or hit, just pushed. An interview was conducted on May 13, 2025, at 9:43 AM with Resident #2, who stated that this was his second room at the facility and that he thought that he remembered getting into a disagreement with his roommate. Resident #2 stated that he made a statement that his roommate did not agree with, and that his roommate yelled at him and threw something at him, and he may have pushed him, but he could not recall specifically. A telephonic interview was attempted on May 13, 2025, at 11:13 AM with a Registered Nurse (RN / Staff #30). A voicemail was left for a return phone call. The staff did not return the phone call. An interview was conducted on May 13, 2025, at 11:25 AM, with a CNA (Staff #20) who stated she was aware of the incident between Resident #2 and #4. Staff #20 stated that it was about 2:45 PM, and she was on the floor and heard yelling. She stated she made her way over to the room, and heard Resident #4 moving toward Resident #2. Staff #20 stated she looked into the residents' room, and that is when she saw Resident #4 swing out and then swing down with his hand and strike Resident #2, once with a backhanded motion that struck Resident #2 on the chin, and once in a downward motion that hit Resident #2 on top of the head. Staff #20 stated it was aggressive in nature, he hit him. Staff #20 stated that she made sure Resident #2 was ok, then redirected Resident #4 out of the room, and then told the nurse, the Administrator, and the charge nurse right away. An interview was conducted on May 13, 2025, at 11:35 AM, with a Licensed Practical Nurse (LPN / Staff #51) who stated that she was aware of an altercation that occurred between Residents #4 and #2. Staff #51 stated that she had arrived for the next shift, and had heard that the incident had already occurred, but was not aware of the details. An interview was conducted on May 13, 2025, at 1:35 PM with the Administrator (Staff #66). The Administrator stated that his understanding of abuse is when someone has the intent to harm another individual, including intended actions of hitting someone and willfully harming them. The Administrator stated that the facility's policy if there is an allegation of abuse is to separate the residents and ensure they feel safe, perform skin checks, complete an investigation, and to report the incident to authorities as required by law within 2 hours. The Administrator stated that he completed the facility's 5-day Investigation Report for the incident. The Administrator stated he was notified immediately from the CNA of the incident and that staff interviewed both residents and that Resident #2 was on his call light and asking staff for help, and Resident #4 was concerned with Resident #2's volume, so he moved over closer to Resident #2. The Administrator stated that the CNA witnessed Resident #4 touch or make contact with Resident #2, and we conducted an investigation. The Administrator stated that Resident #4 was going over to help Resident #2 and brushed him unintentionally on Resident #2's cheek and head. The Administrator stated that Staff #20 witnessed the incident and saw Resident 4 make soft contact with Resident #2, and that it was not aggressive and was not intentional. The Administrator stated that the facility did not substantiate the incident as abuse due to lack of evidence. An interview was conducted with the DON (Staff #16) on May 13, 2025, at 1:58 PM. The DON stated that her understanding of abuse is any threat to life or harm, and could be verbal, physical or sexual. The DON stated that she was passing medication on the hall when the CNA approached her and stated there was an incident, and that Resident #4 and Resident #2 had been separated. Resident #2 was in the recliner and Resident #4 was in the room. The CNA had told the floor nurse (Staff #30) who was assessing the residents. The DON stated she then talked to Resident #2 who stated something hit him on the head. The DON stated she realized then after talking with Resident #2 that he was not cognitively intact. The DON stated that herself and the Administrator talked to the CNA (Staff #20) who stated she saw Resident #4 swing his arm and hit Resident #2 on the chest or the cheek and then again directly on top of the head. The DON stated that swinging arms at another person could be considered abuse. Review of the facility policy titled Abuse Policy, dated 2022, revealed the facility strives to prevent the abuse of all their residents. By definition, abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. If abuse is witnessed or suspected, or an injury of unknown origin is identified, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.

Based on clinical record review, facility documentation, interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#3) received showering assistance per facility policy and resident preference. The deficient practice could have a potential to cause a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings Include: Resident #3 was readmitted into the facility on [DATE], with diagnoses of pulmonary hypertension, chronic obstructive pulmonary disease, acute on chronic congestive heart failure, and unspecified dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) assessment score was 12, indicating the resident had moderately impaired cognition. A Social Service Progress Note dated November 4, 2024, revealed Resident #3 was upset that she had gone 3 weeks without a shower; and that, the resident was unhappy with the current care plan for bed bath. According to the documentation, the resident relations manager spoke with the hospice nurse who will change the resident's care plan; and, the certified nursing assistants (CNAs) were to assist the hospice nurse to shower the resident moving forward. Review of the facility's care plan dated May 16, 2024, revealed the resident was at risk for functional self-care deficits and/or functional mobility limitations. The interventions included to encourage the resident to use the call light, to encourage to discuss feelings about self-care deficits, to encourage the resident to participate to the fullest extent possible, and to praise all efforts at self-care. The care plan revealed no evidence of specifically addressing the resident's showering preference. A facility CNA bathing task logs for August through December 2024 revealed that bathing was documented as provided on the following dates: -September 4; -September 18; -October 19; -November 21; -December 14; and, -December 20. Further review of the CNA bathing task log revealed there were no documented showers for August 2024. Review of the shower sheets for August through December 2024 revealed that the resident received showers on the following dates: -August 5, 8 and 12; -September 18; -November 21; and, -December 14. Further review of the shower sheets revealed that there were no shower sheets completed by the facility staff or hospice staff in October 2024. The CNA bathing task log for January through March 5, 2025 revealed that bathing occurred on the following dates: -January 1; -January 30; -February 6; -February 13; and, -February 27. Further review of the CNA bathing task log revealed there were no documented showers from March 1 through 5, 2025. The shower sheets completed by staff for January through March 5, 2025 included the resident received showers on the following dates: -January 1; -January 30; -February 13; and, -February 27. There were no shower sheets documented as completed from March 1 through 5, 2025. Further review of the clinical record revealed no evidence that the resident received showers other than the dates that were documented in the CNA bathing task log and shower sheets from August 2024 through March 5, 2025. An interview was conducted on March 5, 2025, at 3:14 p.m. with Resident #3 who stated that she does not get showers as often as she would like; and that, she was supposed to get showers twice a week. In an interview with the Director of Nursing (DON/staff #5) conducted on March 6, 2025 at 9:00 a.m., the DON stated that residents bathing and showering was very important because it relates to the quality of care provided; and, to ensure the skin integrity and cleanliness were maintained and for the comfort of a resident. The DON stated that it was the facility's policy to offer bathing or showers twice weekly; and that, the residents have a right to refuse the bathing. The DON stated that if the showers were refused by the resident, refusal is documented on the shower sheets. The DON also stated that the hospice company were obligated to provide care to the resident at least twice a week and this included providing showers. The DON said that the facility has some responsibility for ensuring those showers are provided to the residents. Regarding resident #3, the DON stated that December 2024, the facility CNAs reported that Resident #3 was not receiving showers and there were no hospice aides coming to care for the resident. The DON further stated that she informed the hospice company and the DON was told that it was taken care of, so no further investigation occurred. An interview was conducted on March 6, 2025, at 9:47 a.m. with the vice president of clinical operations (VP/Staff #17) who stated that it was her understanding that the facility CNAs brought a concern to the DON (staff #5) sometime around November or December 2024. She stated that the hospice company was not coming to the facility to provide care, including showers, for Resident #3. Further, the VP stated that it was ultimately the facility's responsibility to ensure that care was being provided to the resident. In an interview with a certified medication assistant (CMA/staff #51) conducted on March 6, 2025, at 9:59 a.m., the CMA stated that resident #3 reported that hospice staff were not coming to the facility to provide care. The CMA stated that he could not remember when this occurred. An interview was conducted on March 6, 2025, at 10:55 a.m. with a hospice aide (staff #25) who stated that Resident #3 was scheduled for once a week visits by the hospice company; and that, if a shower was given, the hospice aide would complete the shower sheet. A telephonic interview was conducted with hospice patient care manager (staff #33) on March 6, 2025, at 11:14 a.m. The hospice patient care manager stated that Resident #3 was scheduled for once a week hospice visit. The hospice patient care manager reviewed the actual visits completed by hospice staff including aides and nurses and stated that the resident was seen by hospice staff on October 4, 7, 22, November 2, 16, 17, 22, December 4, 10, 20 and 27, 2024; and, January 3, 10, and 30, 2025. Further, the hospice patient care manager stated that in January, the facility called with concern that Resident #3's showers not being provided. The hospice patient care manager stated that the hospice staff who was providing care to Resident #3 no longer works for the hospice company. A telephonic interview was conducted on March 6, 2025, at 11:30 a.m. with the hospice executive director (hospice ED/staff #49) who stated that Resident #3 preferred to be showered instead of receiving bed baths; and that, because of safety concerns, Resident #3 required two staff members to safely assist her out of bed into the shower. The hospice ED stated that the hospice company often can only send one staff member, and required the facility to provide a staff member to help assist the resident out of bed to the shower. However, the hospice ED said that at times the facility had not been able to provide another person to assist the hospice aide to bring Resident #3 to the shower; and, this issue had been communicated to the facility in the past. Further, the hospice ED stated that Resident #3 was scheduled for once a week hospice visits since September 2024; and, it was her expectation that hospice aides document if a shower or bath did or did not occur. In another interview with the DON (staff #5) conducted on March 6, 2025 at 11:56 a.m., the DON stated that she was not sure how many times a week hospice was scheduled to provide care for Resident #3. A review of the clinical record was conducted with the DON who stated that she could not locate in the record any indication of how many times a week hospice was to visit Resident #3. The DON stated that it was the hospice company's responsibility for providing Resident #3's personal daily care. Further, the DON stated that she was not sure whether it was hospice or the facility's responsibility to ensure Resident #3 received personal care. The facility policy on Bathing and Showers, dated 2022, revealed a purpose to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Upon admit, shower schedule will be decided upon with resident. The following information should be recorded in the resident's record: the date and time shower/bath were performed, skin observations, if the resident refused the tub/shower, and how the bath/shower were tolerated. Notify supervisor if the resident refuses bath/shower. Review of the facility policy titled Personal Care: Activities of Daily Living (ADL), Supporting, dated January 1, 2024, revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). The facility policy titled, End of Life Care; Hospice Program, dated January 1, 2024, revealed the facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.

Based on observations, clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure professional standards of quality were met regarding accurate documentation for two of two sampled residents (#10, #20). The deficient practice could result in residents' clinical record not being accurate and complete. Findings include: -Regarding Resident #10 Resident #10 was admitted to the facility on [DATE] with diagnoses of biliary acute pancreatitis without necrosis or infection. The physician order dated June 27, 2024 prescribed to give Creon Oral Capsule Delayed Release Particles ( Pancrelipase (Lipase-Protease-Amylase)) three capsules by mouth three times a day for chronic pancreatitis. Review of the quarterly Minimum Data Sheet (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. A progress note dated January 27, 2025 documented that Creaon Oral Capsule was unavailable. Two progress notes dated January 28, 2025 documented Creon Oral Capsule as Medication pending delivery. A subsequent progress note dated January 28, 2025 also documented that Creon Oral Capsule was Not available. Awaiting delivery from the pharmacy. Review of the January 2025 Medication Administration Record (MAR) indicated that the Creon Oral Capsule was administered on January 29 for the a.m. and noon dose. However, review of a progress note dated January 29, 2025 revealed that the medication was on order. Furthermore, during an interview with the resident conducted on January 29, 2025 at 10:22 am., he stated that he has not received his Creon Oral Capsule medication for the last 4 days. An interview with a Registered Nurse (RN/staff #22) was conducted on January 30, 2025 at 12:32 p.m. She confirmed that Creon had not been administered for 3 days as documented in the MAR. Staff #22 stated that she called the pharmacy for a re-order. An interview was conducted on January 20, 2025 at 2:40 pm with the Clinical Resource (staff #100). She stated that the expectation is that medication administration documentation is accurate. The Clinical Resource said that a risk of inaccurate medication administration documentation is improper resident monitoring. The January 2025 MAR was reviewed with the Clinical Resource (staff #100) on January 20, 2025 at approximately 2:40 p.m. She looked at the January 29, 2025 twice for AM and noon shifts and it has been out since Monday (January 27, 2025). She stated the facility does not document administration until all meds have been administered. She stated the documentation of resident #10 ' s Creon Oral Capsule medication did not meet their expectations. She stated occasionally the Nurse Practitioner(staff #19) will order a couple of doses, and to their knowledge the medications were not ordered. 51965 -Regarding Resident #20: Resident # 20, was admitted on [DATE], with diagnoses including hypertensive heart disease, dementia and peripheral vascular disease. A physician order, dated January 30, 2024, prescribed Artificial Tears eye drops, two drops in each eye, four times daily. A January 2025 Medication Administration Record (MAR) revealed that two drops of Artificial Tears were administered on January 29, 2025, despite a medication administration observation that the CMA administered one drop of artificial tears in each eye. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no evidence of a completed assessment for mental status. During a medication administration observation conducted on January 29, 2025, at 7:15 a.m., with a Certified Medication Technician (CMA/staff #5) of Resident #20 ' s medication, the CMA was observed to administer one drop of Artificial Tears into both eyes. However, the physician order was written to administer two drops of artificial tears into each eye. An interview was conducted on January 29, 2025 at 12:21 p.m. with the Director of Nursing (DON / staff #19), who stated that her expectation is that medications are administered as ordered by the provider. She further stated that the CMA (staff #5) had not followed the facility policy regarding medication administration. She also stated that the risk could result in incomplete treatment. An interview was conducted on January 30, 2025 at 12:54 p.m. with the DON (staff #19), with the Clinical Support Registered Nurse (RN-CS / staff #700), and Administrator (staff #800) present. The DON and RN-CS reviewed the clinical record and stated that documentation on the January 2025 MAR revealed that 2 drops of artificial tears had been administered in each eye. The DON also stated that staff are expected to follow physician ' s orders as written and that the risk could result in incomplete treatment. A review of the facility's policy titled, Documentation: Charting and Documentation dated January 01, 2024 revealed the facility is to maintain medical records on each resident that are complete and accurately documented. A review of a facility policy titled, Medications: Administering Oral Medications, revealed that the procedure is to provide for the safe administration of oral medications by verification of provider ' s orders, checking for expiration dates and verifying dose prior to administration.

Based on observation, staff interviews, and policy review, the facility failed to ensure infection control standards were maintained during medication administration, regarding equipment sanitizing and hand hygiene. The deficient practice could result in cross contamination and the spread of infections to others. Findings include: -Regarding equipment sanitization A medication administration observation was conducted on January 29, 2025, at 7:15 a.m., with a Certified Medication Technician (CMA/staff #5), who was observed using a glucometer to perform a blood glucose test, as well as a blood pressure cuff on a resident. When the tests were completed, the CMA/staff #5 was not observed to sanitize the glucometer or the blood pressure cuff after use, and returned the items back to the medication cart for storage. An interview was conducted on January 29, 2025 at 12:21 p.m. with the Director of Nursing (DON/staff # 19) who stated that she expected staff to follow the infection control policies at all times, including equipment sanitizing. She further stated that the CMA (staff # 5) had not followed the facility policy regarding equipment sanitization during the medication pass. -Regarding hand hygiene A medication administration observation was conducted on January 29, 2025, at 7:15 a.m.with a CMA (staff # 5) who was observed to enter and exit 3 rooms when administering medications without sanitizing his hands before or after each resident. Additionally, CMA/staff #5 was observed to collect a blood sample at the bedside and did not perform hand hygiene before or after applying gloves. The CMA was observed picking up a highlighter and a fall risk sign from the floor and did not wash his hands after picking up the items. An interview was conducted was conducted on January 29, 2025 at 8:40 a.m. with a CMA (staff # 5). Staff #5 who stated I guess I am not a germaphobe, when asked about the facility infection control and hand hygiene policies. Further interview was conducted on January 29, 2025 at 12:21 p.m. with the Director of Nursing (DON/staff # 19) who stated that she expected staff to follow the infection control policies at all times, regarding hand hygiene. She further stated that the CMA (staff # 5) had not followed the facility policy regarding hand hygiene. She also stated that the risk to the residents could result in cross contamination and infection to/from other residents. A review of the facility's policy titled, Medication: Administration Oral Medication, revealed that medications are administered in a safe manner consistent with good infection control and standards of practice, as demonstrated by handwashing before and after medication administration, verifying correct dose and correct resident and checking expiration dates. A review of the facility's policy titled, Infection Control: Handwashing/Hand Hygiene, revealed that hand hygiene is the primary means to prevent the spread of infection. This includes using soap and water or alcohol based hand sanitizer, all personnel are trained upon hire and regularly in-serviced on importance of hand hygiene and healthcare associated infections. A review of the facility's policy titled, Infection Control: Cleaning and Disinfection of Resident Care Items and Equipment, revealed resident care items will be cleaned and disinfected according to current CDC recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen standard. The policy states that reusable durable medical equipment (DME) is cleaned and disinfected before reused by another resident.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for one resident (#10), as ordered by the physician. The deficient practice could result in residents not receiving the necessary treatment and services they need. Findings include: Resident #10 was admitted on [DATE], with diagnoses of biliary acute pancreatitis without necrosis or infection. A physician's order dated June 27, 2024 prescribed to give Creon Oral Capsule Delayed Release Particles ( Pancrelipase (Lipase-Protease-Amylase)) three capsules by mouth three times a day for chronic pancreatitis. A January 2025 MAR (Medication Administration Record) revealed that Creon Oral Capsule was coded as 9 meaning Other/See Nurse Notes and had not been administered on : - January 12: evening - January 13: evening - January 14: evening - January 27: evening - January 29: morning,noon,evening A progress note dated January 12, 2025 revealed that Creon Oral Capsule medication was on order, with no evidence that the physician had been notified that the medication had not been administered. A progress note dated January 13, 2025 revealed that the Creon Oral Capsule was unavailable. An additional progress note dated January 14, 2024 revealed that Creon Oral Capsule was unavailable. The note further indicated that Meds ordered and awaiting delivery from pharmacy. A quarterly Minimum Data Sheet (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the January 2025 MAR revealed there was no evidence that Creon had been administered as ordered. Review of progress note for January 15, 2025 revealed no evidence of why the medication had not been administered and that the physician had been notified. A progress note dated January 27, 2025 indicated that Creaon Oral Capsule was unavailable, and two progress notes dated January 28, 2025 revealed that Creon Oral Capsule as Medication pending delivery. A subsequent progress note dated January 28, 2025 also revealed that Creon Oral Capsule was Not available. Awaiting delivery from the pharmacy. Further review of the January 2025 MAR indicated that the medication was administered on January 29 at am and noon doses. A progress note dated January 29, 2025 revealed that the medication was on order. Further review of the resident ' s clinical record revealed no evidence that the provider was notified about the medication Creon Oral Capsule being unavailable. Additionally, there was no evidence that the provider was aware that the resident had not received the medication on multiple occasions due to the medication being unavailable. There was no evidence that indicated a discussion with the provider what needed to be done while the medication was unavailable. Additionally, there was no evidence in the clinical record that the facility attempted to follow-up with the pharmacy regarding the status of the medication. An interview with Resident #10 was conducted on January 29, 2025 at 10:22 am, who stated that he had not received the Creon for the last 4 days. He stated that staff had informed him that the pharmacy did not have it, therefore that is why there has been a delay. An interview was conducted with a RN (Registered Nurse/staff #22) on January 30, 2025 at 12:32 p.m, who stated that Creon had not been administered for 3 days as documented on the MAR. The RN also stated that the pharmacy was called for a re-order. An interview was conducted with Director of Nursing (DON/staff #19) and Clinical Resource (staff #100) was conducted on January 30, 2025 at 2:41 p.m. The DON stated that she expected orders to be followed as written and if the medication is unavailable, she expected that the Nurse Practitioner (NP staff #19) would be contacted for further instructions. The DON further stated that the facility has had difficulties acquiring Creon from the pharmacy. The Clinical Resource (staff #100) stated that the nurse should contact the pharmacy and order medication a week before running out. The DON also stated that when there is only one day's worth of medication left, the DON, a nurse or charge nurse should call the pharmacy to follow-up. The DON confirmed that she was informed that the resident had not received the medication for three days. The DON further stated she talked to the NP on January 30, 2025 for an alternative pharmacy option.The DON reviewed the residents clinical record and stated that the progress notes did not indicate that the provider was notified regarding the medication not being available.The DON stated that conversations were held with the pharmacy and not the provider before January 30, 2025 and that did not meet her expectations. The DON further stated that the risk of not administering Creon as ordered could result in the resident experiencing abdominal discomfort. Review of a policy titled, Administering Oral Medication, included that the purpose of the procedure is to provide guidelines for safe administration of oral medications.To follow medication administration guidelines, and report other information in accordance with facility policy and professional standards of practice. Review of a facility ' s policy titled Documentation: Charting and documentation, revealed the facility is to maintain medical records on each resident that are complete and accurate.

Based on observations, staff interviews, and policy review, the facility failed to ensure that food items in the kitchen storage room were properly covered, labeled and dated. The deficient practice could result in food contamination and pest infestation which could result in sickness and potential food poisoning among the residents. Findings include: On January 28, 2025 at 10:00 am during an initial kitchen observation conducted with the with a [NAME] (staff #16) in the kitchen storage room, three plastic bins containing sugar, flour and powdered sugar were observed to be uncovered. There was no evidence of a dated label as to when the products were opened. A partial bag of macaroni noodles was also observed on a shelf that was opened, with no dated label. An interview was immediately conducted on January 28, at 10: 30 a.m with the [NAME] (staff #16) who stated that the dry food bins of flour, sugar and powdered sugar should have been covered and labeled with the date they were opened. The [NAME] stated that the risks of not covering the items could result in food contamination. The [NAME] further stated that not properly labeling, dating and covering foods items did not meet the facility's expectation. An interview conducted on January 29, 2025 at 9:19 a.m with the Kitchen Manager (staff #27) and the [NAME] (staff #16). The [NAME] confirmed the findings observed during the initial observation the previous day, regarding the opened macaroni bag and the uncovered, unlabeled bins that contained flour, sugar and powdered sugar. The kitchen manager stated that he preferred to place the open macaroni in a sealed plastic container and labeled with the date that it was first opened. The kitchen manager also stated that the bins that contained flour, sugar and powdered sugar should have been covered, and labeled with the date they were opened. The kitchen manager stated that these findings did not meet the facility's expectations and that the risks of leaving the bins open and not dated could result in the use of outdated food in cooking, pest infestation, and food contamination. The facility's policy titled, Food Storage and Date Marking, indicated that plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. The policy indicated that all containers must be legible and accurately labeled, if the product is not easily identifiable. The policy also specified that food items must be dated as it is placed on the shelves in the food storage room.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that medications were administered as ordered by physician for two residents ( #20, # 26) as observed during medication administration. The deficient practice could result in medications not being available to meet resident needs. Findings Include: -Regarding Resident #20: Resident #20, was admitted on [DATE], with diagnoses including hypertensive heart disease, dementia, and peripheral vascular disease, had inconsistencies in their eye drop administration documentation. A physician's order, dated January 30, 2024, prescribed Artificial Tears eye drops, two drops in each eye, four times daily. A January 2025 Medication Administration Record (MAR) revealed that two drops of Artificial Tears had been administered on January 29, 2025. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no evidence of a completed assessment for mental status. During a medication administration observation conducted on January 29, 2025, at 7:15 a.m., with a Certified Medication Technician (CMA/staff #5), the CMA administered one drop of Artificial Tears into each of Resident #20 ' s eyes. An interview was conducted on January 30, 2025 at 12:54 p.m. with the DON (staff #19), with the Clinical Support Registered Nurse (RN-CS / staff #700), and Administrator (staff #800) present. The DON and RN-CS reviewed the clinical record and stated that documentation on the January 2025 MAR revealed that 2 drops of artificial tears had been administered in each eye. The DON also stated that staff are expected to follow physician ' s orders as written and that the risk could result in incomplete treatment. -Regarding Resident #26: Resident #26 was admitted on [DATE], with diagnoses including [NAME] syndrome, dehydration, bilateral cataracts, hordeolum externum, right eye, eyelid dry eye syndrome of bilateral lacrimal glands. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A physician ' s order, dated January 5, 2024, prescribed PreserVision AREDS Oral Tablet (Multiple Vitamins w/ Minerals), give 2 tablets by mouth in the morning. A January 2025 MAR revealed no evidence that PreserVision AREDS tablets were administered as ordered on January 28 and January 29, 2025. Review of progress notes dated January 28. 2025 revealed no evidence that the provider had been notified that the PreserVision AREDS tablets had not been administered per orders. A progress note dated January 29, 2025 revealed that PreserVision AREDS tablets were not available. Further revealed no evidence the provider had been notified that the medication had not been administered as ordered. Further medication administration observation conducted on January 29, 2025, 8:20 a.m. with the CMA (Staff #5) of Resident #26 ' s medication preparation. During medication administration the resident stated that the eye vitamins were missing, and the CMA #5 advised the resident that they are currently out, but that they have been ordered. The CMA did not administer PreserVision AREDS tablets as ordered. An interview was immediately conducted with CMA (Staff #5) on January 29. 2025 at 8:20 a.m., who stated that the PreserVision AREDS tablets had not been administered because the medication had been out of stock since January 28, 2025. An interview was conducted on January 29, 2025 at 12:21 p.m. with the Director of Nursing (DON / staff #19), who stated that her expectation is that medications are administered as ordered by the provider. She further stated that the CMA (staff #5) had not followed the facilities policy regarding medication administration. She also stated that the risk could result in incomplete treatment. An interview was conducted on January 30, 2025 at 12:54 p.m. with the DON (staff #19), with the Clinical Support Registered Nurse (RN-CS / staff #700), and Administrator (staff #800) present. The DON stated that she expected medications to be administered as ordered. The DON further stated that she had not been informed that Resident # 26 ' s the medication was PreserVision AREDS tablets were not available and that more needed to be ordered/purchased. The DON reviewed the clinical record and stated there was no evidence that the provider had been notified regarding the PreserVision AREDS tablets, however she noted that there was a progress note dated January 29, 2025 that the medication was out of stock. The DON stated that the missed doses of the medication could affect the resident ' s eye site. A review of a facility policy titled, Medications: Administering Oral Medications, revealed that the procedure is to provide for the safe administration of oral medications by verification of provider ' s orders, checking for expiration dates and verifying dose prior to administration.

Based on observations, facility documentation, staff interviews and facility policy, the facility failed to submit accurate staffing information base on payroll data in a uniform format to CMS (Centers for Medicare & Medicaid Services). Findings include: A review of the [NAME] PBJ Staffing Data Report that was run on November 30, 2023 revealed that the facility was triggered for excessively low weekend staffing for the following: Fiscal year, quarter four (July 1st-September, 30) 2022 Fiscal year, quarter one (October 1st - December 31st) 2023 Fiscal year, quarter two (January 1st - March 31st) 2023 Fiscal year quarter three (April 1st - June 30th) 2023 During the review of the sampled staff postings for November and December 2023 with the Regional Support Nurse, (staff #666) and the Regional [NAME] President (staff #484), it was revealed that the facility was not accurately reporting hours to CMS and staff were missing hours in their pay period related to a possible software issue.

Based on observations, facility documentation, staff interviews and facility policy, the facility failed to ensure there was sufficient nursing staff on a 24-hour basis based on staffing schedule, postings and in accordance with the facility assessment (completed 8/31/23, Updated 10/12/23). Findings include: On December 5, 2023 a review of the facility assessment was conducted and revealed that there should be two licensed nurses per shift. There should be four CNA's (Certified Nursing Aide) for day shift, three CNA's for second shift and two CNA's on night shift. A review of the staff postings compared to punch details revealed that the facility to follow the facility assessment for staffing. For the sampled dates in November 2023, the facility failed to have two licensed nurses on night shift for;November 15, 16, 17, 22, and 29. Additionally the facility failed to have two CNA's on night shift for; November 2, 2023. For the sampled dates in December 2023, the facility failed to have two licensed nurses on night shift for; December 1, 3, and 4. Additionally the facility failed to have two CNA's on night shift for; December 1 and 2, 2023. Of the 11 sampled days for November and December 2023, there were eight shifts that had only one licensed nurse and 3 shifts with only one CNA. On December 7, 2023 at approximately 9:52 AM, an interview was conducted with staff #152, DON (Director of Nursing), Staff #152 stated that on night shift the expectation is that there should be two CNA's scheduled and the CMA (Certified Medication Assistant) is not considered a to be in the count as a CNA. Staff #152 stated that the CMA works 6:00pm to 6:00am three days a week and that there are times that the schedule will reflect one licensed nurse, one CMA and two CNA's on night shift.

Based on review of facility documentation, staff interviews and policy review, the facility failed to ensure that the nurse staffing information was accurately posted on a daily basis, which included the actual hours worked by licensed and unlicensed nursing staff. Findings include: A review of the sampled daily staff postings for November and December of 2023, revealed they did not contain the total actual hours worked by licensed and unlicensed staff. During an interview that was conducted with the Administrator, (staff #555) on December 7, 2023 at approximately 11:21 AM, it was noted that the actual hours worked were not on the daily staff postings. Staff #555 stated that she will be updating the postings sheet to reflect actual hours worked in the future. Review of the facility Staffing Policy effective revealed that the Daily Posted Staffing Schedule must include the total number and the actual number of hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides.

Based on observations, clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to ensure adequate supervision and assistance was provided to one resident (#1) resulting in a fall with injury. The deficient practice resulted in the resident sustaining a fracture to the right hip. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, muscle weakness, difficulty in walking, other reduced mobility, and need for assistance with personal care. The ADL (activities of daily living) care plan dated September 25, 2021 included the resident had Self Care Performance deficit. The goal was that the resident would maintain the current level of function. Interventions included the resident required staff participation to use the toilet, personal hygiene, bed mobility and bathing; required extensive 1 staff participation with transfers; and, to encourage to use call light to call for assistance. The admission MDS (Minimum Data Set) assessment dated [DATE] included the resident had a BIMS (Brief Interview for Mental Status) score of 1 indicating severe cognitive impairment. Active diagnoses included dementia and [CONDITION(S)]. The assessment included the resident required extensive assistance with one-person physical assist with transfers, toilet use; and, required supervision with bed mobility and locomotion on unit. Review of the clinical record from October 1 through December 31, 2021 revealed the resident had the following fall incidents: -October 1, 2021 - found on the floor next to the bed; and that, the resident reported she was trying to catch a plane. No injuries noted. -October 3, 2021 - found lying on the floor, on her right side, parallel to the bed; and, reported to staff she was trying to get up to go to the cabinet when she fell . No injuries noted; -October 5, 2021 - Found on the floor next to the bed and the resident unable to describe what happened and there were no injuries. -October 15, 2021 - slid herself out of the wheelchair to sit on the floor, was unable to give description of the fall and there were no injuries noted. -October 30, 2021 - Found on the floor in her room and reported that she crawled out of bed because she had lots of things to do. There were no injuries noted; -November 1, 2021 - Crawled out of bed to sit on the fall mat with no injuries and denied hitting or bumping her head. There was no other documentation related to this incident found in the clinical record and the facility documentation; -December 24, 2021- Found on the floor in front of her wheelchair; and, sustained a small bump to the base of her head on the right; and, -December 29, 2021- Found laying on her back just inside the door with her wheelchair beside her; and reported to staff that she was trying to get up, fell and hit her head. According to the documentation in the clinical record, the predisposing factors for these falls included confusion, impaired memory, incontinence, and weakness and [CONDITION(S)]. A review of the current comprehensive care plan revealed each time a fall had occurred, the care plan was revised to include new interventions such as the following: -Protective mat next to bed; -Ensuring call light was within reach; -Anticipate and meet needs; -Call for assistance; -Bed against the wall; -Prompt response to all requests for assistance; -Wearing appropriate footwear; -Bed in low position; -Following Falling Leaf Program; -Checking the resident every 2-3 hours and as required for incontinence; and, -Dycem (non-slip mat) in the wheelchair. Continued review of the clinical record from October 1 through December 31, 2021 revealed documentation that the resident was confused, anxious, attempted to self-transfer, had history of skootching out of bed, frequently moves about within the bed but without meaningful purpose, and slid out of the wheelchair or crawled out of bed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included the resident was assessed to have short- and long-term memory problems, had severely impaired cognitive skills for daily decision making and was always incontinent of urine and bowel. The assessment included the resident required extensive assistance with 2-person for toilet use; and, was not steady and only able to stabilize with human assistance for moving from a seated to standing position and for moving on and off the toilet. Further, the assessment included the resident had two or more falls with no injury and one fall with injury that is not major since the prior assessment. An electronic medication administration record (eMAR) note dated January 5, 2022 revealed the resident remained totally confused always, bed was lowered to the floor, as usual, for the night; and that, the resident had scooted off on the fall mat again and was crawling to try to reach her wheelchair. A Physician note dated January 7, 2022 included the resident had dementia with behavioral disturbance. Plan was to continue to monitor for safety and redirect behavior as needed. An incident report dated January 13, 2022 revealed the CNA (Certified Nursing Assistant) helped the resident into the restroom and stepped out into the room to grab a pull up when the resident fell off the toilet while trying to stand up. The report included the resident was disoriented, unable to describe what happened and was wearing the appropriate footwear. Predisposing factors included incontinence and impaired memory. The documentation also revealed the resident was assisted to the wheelchair and neuro check was started. Further, it included resident had a fracture to the right iliac crest, An alert charting note dated January 13, 2022 included the resident had a non-injury fall; and that, the resident reported she needed to go to the restroom. The documentation also included a CNA assisted her to the restroom, went to grab a clean pull up and upon re-entering the bathroom, resident had fallen. There were no injuries noted but the resident complained of pain to the right knee. A radiology report dated January 14, 2022 revealed acute right hip fracture. The fall care plan was revised on January 14, 2022 to include an intervention to post a Call Don't Fall sign in the bathroom. The alert charting note dated January 15, 2022 included that an X-ray was obtained and resident presented with fracture of indeterminate age to the right hip which contradicted the radiology report. An incident report dated January 17, 2022 revealed the resident was found lying on her right side on the floor next to the bed. Per the report, the resident described that she was trying to get up. Predisposing factors included confusion, gait imbalance, impaired memory and that, the resident was a wanderer. According to the report, there were no new injuries noted at the time. Despite documentation of multiple repeated falls and interventions such as the protective mat at bedside, Falling Leaf Program and the Call don't fall sign, during an observation conducted on January 25, 2022 at 10:45 a.m., there were no signs or identification posted on the doorway to the resident's room indicating the resident was a fall risk. The resident was lying on her bed that was against the wall and was in low position with a bedside table placed over the resident. However, there was no floor mat next to the resident's bed. Observation of the resident's bathroom also revealed there were no signs posted inside and outside of the bathroom to instruct and remind the resident to call for help to avoid falling. An interview with resident #1 was conducted immediately following the observation. Resident #1 was alert to self only, was unable to state where she was, the date, time and was unable to answer questions about her falls. During the interview, the staffing coordinator (staff #11) walked into the room and posted a Call Don't Fall sign in the resident's bathroom. An interview was conducted on January 25, 2022 at 10:50 a.m. with a staffing coordinator (staff #11) who stated she was instructed by the Director of Nursing (DON/staff #44) to post the Call Don't Fall sign in the resident's bathroom. Staff #11 further stated she did not know why the sign was needed to be placed at that time; and that, she was just instructed to do so. In an interview conducted with the Administrator on January 25, 2022 at 11:02 a.m., the administrator stated the DON told her the Call Don't Fall sign was posted in resident's bathroom but the resident took it off the wall. However, the administrator said she did not know when the resident had pulled the sign down. An interview was conducted on January 25, 2022 at 11:15 a.m. with a Certified Nurse Assistant (CNA/staff #20) who stated the green leaf magnets on the door frame indicate a resident is a fall risk. Staff #20 stated there are no leaf magnets on the door for resident #1's room because resident #1 was not a fall risk. An interview was conducted on January 25, 2022 at 12:04 p.m. with a Registered Nurse (RN/staff #31) who stated that residents identified as a fall risk are placed on the falling Leaf program; and a green leaf magnet is placed on the door to alert staff that the resident is a fall risk. Staff #31 stated the staff know that residents identified as a fall risk need help getting out of bed with the bed placed in a low position, and sometimes, fall mats are also placed. Staff #31 stated a care plan is also developed to alert staff of the care needs of the resident. Further, staff #31 stated resident #1 is not cognitively intact enough to follow directions; which is why the resident was a fall risk and her bed is kept in the low position at all times. In another interview conducted with the CNA (staff #20) on January 25, 2022 at 12:17 p.m., staff #20 stated resident #1 follows commands to a certain extent and believes the current year was 1928. She stated she never received a report that resident #1 was a fall risk. Staff #20 also stated the resident was pretty steady when being assisted, stands really well and she had no reason to believe the resident was a fall risk. An interview was conducted on January 25, 2022 at 12:30 p.m. with another CNA (staff #40) who stated that when a resident is on fall interventions, a green leaf magnet is posted on the door frame and a sign to call for help is posted in the bathroom. Staff #40 stated the resident who is in the falling leaf program cannot be left resident alone in the bathroom. Regarding resident #1, the CNA stated he cared for the resident for many weeks; and that, resident #1 is an absolute fall risk because the resident is not cognitively intact and cannot sit still and/or sit up by herself. Staff #40 stated that since the fall on January 13, 2022 the resident had increased pain levels, decreased desire to move and, does not move or rotate in bed like before because of the hip fracture. During an interview conducted on January 25, 2022 at 1:11 p.m. with the Director of Nursing (DON/staff #44), she stated residents identified as a fall risk are placed on the falling leaf program and a care plan is developed. The DON stated the falling leaf program includes removing obstacles in the room, frequent rounding, a green leaf magnet on the door to alert staff, proper non-slip footwear, call light within reach, fall mat on the floor for those that could not transfer, bed placed in a low position, and a call don't fall sign in the bathroom or the room. The DON said she does not know why green leaf magnets were not on the door frame of resident #1's room. Further, she stated the green leaf magnets should have been placed on the resident's room door. Regarding resident #1, the DON stated the resident was identified on admission as a fall risk and fall interventions including signs/postings were put in place. However, the DON said the resident does not like signs on the walls so the removes them all the time. Regarding the fall incident on January 13, 2022, she said the CNA (staff #3) left the resident alone in the bathroom to grab a brief and when the CNA returned the resident was found on the floor. The DON stated resident #1 should not have been left unattended because the resident #1 was impulsive and does not follow commands at times. The facility Fall Prevention Program included that the facility developed a culture of safety for residents to thrive. The Falling Leaf Program was designed to assist the facility staff in this development. Residents will be identified as candidates for the program if they had an actual fall or whom scored as a high fall risk. The residents on the program will have generic protocols initiated including a falling leaf magnet identifier on the door frame, comprehensive care plan in place with individualized interventions, and a monthly review by the fall committee. The facility policy on Dementia-Clinical Protocol included that direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes and therapeutic and recreational activities will be supervised and supported throughout the day. The facility policy on Safety and Supervision of Residents revealed that it is their policy to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Per the policy, resident-oriented approach to safety addresses safety and accident hazards for individual residents. Implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to all relevant staff; and, ensuring that interventions are implemented. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#292) was free from neglect, by staff performing an unsafe transfer causing a fall, which resulted in psychological harm to the resident. The facility also failed to ensure 4 out of 5 sampled residents (#'s 3, 16, 244 and 292) were free from abuse. The deficient practice resulted in one resident being fearful of falling, causing psychological distress and anxious behaviors, which resulted in an overall decline. The deficient practice also resulted in four residents being subjected to abuse. Findings include: -Resident #292 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 27, (YEAR). Regarding an incident of neglect: Review of the baseline care plan-admission evaluation dated (MONTH) 11, (YEAR) under the section for ADL's (activities of daily living), revealed that resident #292 was alert and oriented x 4 and was totally dependent on two staff with transfers. The documentation included the resident had severe impairment with movement to bilateral legs and hips. Review of the ADL care plan dated (MONTH) 13, (YEAR), revealed the resident had an ADL self-care performance deficit, related to deconditioning. One of the interventions included that staff participation was required for transfers. However, the care plan did not specify how many staff were required for transfers or if mechanical lifts should be used. According to the Physical Therapy Evaluation and Plan of Treatment dated (MONTH) 14, (YEAR), the resident was totally dependent with bed mobility and transfers and required maximum assistance. A nurses note dated (MONTH) 16, (YEAR), revealed the resident was a Hoyer lift for transfers and was totally dependent on two+ persons for assistance. Review of a psych progress note dated (MONTH) 22, (YEAR), revealed resident denies any feelings of anxiety and reports that she feels very stable on her current psychiatric medications, which included duloxetine (anti-depressant) and [MEDICATION NAME] (for [MEDICAL CONDITION]). The progress note also stated that staff report no agitation/anxiety symptoms and no aggression or bizarre behaviors since admission. According to a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR), the resident scored a 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Per the MDS, the resident required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use, and was totally dependent on two persons with transfers. The MDS also noted that the resident did not have any behaviors. A physical therapy note dated (MONTH) 4, (YEAR), revealed the resident started therapy and had needed 100% assistance, but now has improved to 20 % assistance. The note included that for bed mobility and sit to stand, the resident was a moderate assist of two persons with a front wheel walker. A nurses note dated (MONTH) 5, (YEAR) included the resident required extensive assistance of two staff members for transfers, secondary to generalized weakness and size, and utilizes a mechanical lift as needed. Review of the nurse's notes from (MONTH) 11, (YEAR) to (MONTH) 6, (YEAR), revealed no documentation that the resident experienced any fearfulness, any anxiety type behaviors or ADL decline. Review of clinical record revealed that resident #292 did not have any falls, since admission. A nurses note dated (MONTH) 6, (YEAR) revealed that a CNA (certified nursing assistant/staff #18) transferred the resident alone by herself from the bed to the wheelchair, with the help of a walker. While attempting to sit into the wheelchair, the resident slid to the floor on her knees. The note included that two staff members (CNA #18 and nurse #56) with the help of a sit/stand Hoyer lift assisted the resident from the floor to the wheelchair. The resident had no injuries except for a right hip old superficial blister, which had popped and a dressing was applied. A IDT review note dated (MONTH) 7, (YEAR), revealed a non-injury fall related to weakness during transfer and resident placed on alert charting. Review of the nurses progress notes from (MONTH) 7, (YEAR) through Discharge (September 27, (YEAR)) revealed the following: September 7: Resident did not want to get out of bed this shift and also refused therapy this a.m. September 8: Resident hitting CNA's during brief changes, refusing to help transfer self, demonstrates anxious behaviors when receiving ADL assistance and yelling from the room. September 9: Resident did not get out of bed this shift or the evening shift. September 10: Resident demonstrates anxious behaviors when receiving ADL assistance. Resident non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning, getting out of bed and physical and occupational therapy. September 11 and 12: Resident demonstrates anxious behaviors when receiving ADL assistance; refusing care such as toileting, repositioning and getting out of bed. September 15: An incident note by the nurse included that around 9 p.m., the resident became afraid and scared that she was going to fall during a brief change. The resident remained upset and asked the nurse to call the doctor for something to calm the nerves. The nurse obtained an order for [REDACTED]. September 17: Resident demonstrates anxious behaviors when receiving ADL assistance, non-compliant with transfer and repositioning. Patient refusing care such as toileting, repositioning, getting out of bed and refusing physical and occupational therapy. September 18: Resident still refusing to get out of bed and non-compliant with most ADL's. Refusing PT/OT. Nurse Practitioner (NP) notified regarding resident's statements of anxiousness and fearful thoughts of falling out of bed. September 19: Resident requesting PRN [MEDICATION NAME] due to anxiousness, agitation and fear of falling out of bed. Demonstrates anxious behaviors when receiving ADL assistance and non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning and getting out of bed. [MEDICATION NAME] given as needed. September 20: Resident refused to get out of bed this shift, refused to take a shower and multiple attempts made to encourage out of bed activities. The majority of all meals were served in her room per resident's request. September 21: Resident demonstrates anxious behaviors when receiving ADL assistance, non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning and getting out of bed, [MEDICATION NAME] as needed. September 22: Demonstrates anxious behaviors when receiving ADL assistance, non-compliant with transfers and repositioning. Refusing care such as toileting, repositioning, getting out of bed and PT/OT. [MEDICATION NAME] given as needed. September 24: Resident is alert and oriented, remained in bed all day per her request. Non-compliant with ADL's and PT/OT. September 25: Resident refusing brief changes with CNA's. Went in and spoke with resident and offered [MEDICATION NAME], which previously had been effective with fear of falling during brief changes. The resident continued to refuse. The night shift note stated the resident also feels like she is going to fall when rolled from back to side. Non-compliant with most ADL's, PT and OT. (MONTH) 26: Resident alert and oriented x 2 confused and anxious. Resident feels like she is going to fall when rolled from back to side. Non-compliant with most ADL's, PT and OT. Review of the therapy treatment notes from (MONTH) 6, (YEAR) to Discharge (September 27, (YEAR)) revealed the following: September 6, 7 and 10: Resident refused multiple attempts to participate in therapy in the therapy room or in the room. September 11: Resident is a Hoyer, tolerated sitting in wheelchair for lunch. Refused to go to the gym. Resident making very minimal progress at this time. Resident requires motivation and encouragement to participate. Resident fearful of falling, resistive with staff with rolling and changing brief. Resident was reassured she is safe and was not going to fall. September 12: Resident refused therapy services, refused to get out of bed. September 17: Making very minimal progress at this time due to lack of participation and missed visits. Resident requesting pain medications and [MEDICATION NAME]. She stated that she would like to follow up with her psychiatrist, as she is fearful of falling when being changed and is afraid that she will fall out of bed. Resisting care with CNA's. September 18: Straight leg raising was attempted during therapy but unable to complete. September 19, 20, 21 and 22: Resident making minimal progress, unmotivated and has fear of falling. Refused multiple attempts to participate in therapy and getting out of bed. September 24: Therapy discharge summary included resident has steadily declined. Refuses to get out of bed due to lack of motivation, effort. Resident is being discharged at this time from therapy. Review of the resident's care plans dated (MONTH) 17, (YEAR), revealed the resident uses anti-anxiety medication ([MEDICATION NAME]) related to an anxiety disorder. A goal included the resident will have decreased episodes of signs and symptoms of anxiety. Interventions included to give anti-anxiety medications as ordered, monitor side effects and track target behaviors of statements of anxiousness. A psych eval progress note dated (MONTH) 19, (YEAR) revealed staff reports that last week resident had a fall and it appears to have resulted in worsening depression and anxiety. The resident has anxiety symptoms of excessive worry/anxiety and being fearful. The recommendation was to continue [MEDICATION NAME] 0.5 mg every 12 hrs as needed for anxiety, as evidence by agitation and fearfulness. Further review of the clinical record revealed the resident was discharged on (MONTH) 27, (YEAR). The facility was unable to provide any evidence that the incident regarding a fall due to an unsafe transfer, which resulted in the resident experiencing psychological distress and overall decline was identified as neglect. In addition, there was no evidence that the incident was thoroughly investigated. An interview with a CNA (staff #18) was conducted on (MONTH) 26, 2019 at 11:47 a.m. She stated when the resident fell , she was transferring the resident with the help of a gait belt and walker. She said the resident slid out of the wheelchair and sat straight down on her knees. Staff #18 stated that she was told by therapy the day before that the resident was going to be an extensive assist of one person for transfers, instead of two. An interview was conducted on (MONTH) 26, 2019 at 12:05 p.m. with a licensed practical nurse (LPN/staff #56), who worked the day shift on (MONTH) 6, (YEAR) when the resident fell . She stated that she was going into the resident's room to give her medications and when she entered the room, the resident was on her knees on the floor in front of the wheelchair. She said the CNA was in the room and had tried to transfer the resident. Staff #56 stated that she asks therapy every day for any changes with the resident's ability and type of assistance needed with transfers, and then documents it in a progress note. She stated if she documented the resident needs two person extensive assistance, it means that she clarified this with therapy, prior to documenting it. An interview with a physical therapy assistant (PTA/staff #58) was conducted on (MONTH) 26, 2019 at 12:58 p.m. At this time, the therapy notes were reviewed with staff #58, who stated the resident was a two person transfer at the time of the fall. She said that since the resident was transferred from the bed to a standing position, it would require two persons. She stated the resident was making good progress, until the fall on (MONTH) 6, (YEAR). An interview with a registered nurse (RN/staff #83) was conducted on (MONTH) 26, 2019 at 4:10 p.m. Staff #83 stated that she usually works the night shift and that the resident was a two person Hoyer lift for transfers at all times. An interview with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director(ED/staff #10) was conducted on (MONTH) 28, 2019 at 8:52 a.m. Staff #36 stated that staff should care plan the number of staff assistance which is needed for transfers in the care plan within 24 hours of admit, because the care plan also transfers to the kardex where the CNA's look to find out how much help a resident needs with transfers. She stated that it would be neglect if staff were not following the care plan or therapy orders for transfers. Staff #36 said she would expect the CNA's to follow what therapy recommends for transfers. She stated if therapy makes any changes in the transfer status, she expects them to document it in their notes. At this time, the fall documentation was reviewed with staff #36. She stated that during an IDT meeting (which included the Director of Nusing (DON), ADON, the Care Coordinator and therapy), it was not identified that the fall was an unsafe transfer. Staff #36 said that since they did not identify the incident as neglect, they did not report or investigate the incident. Staff #10 stated that he remembers the resident and that after the fall, the resident was scared to leave the room or get out of bed. According to the Lifting Machine policy, the use of a mechanical lift for resident transfers will be conducted with the assistance of at least two nursing assistants to safely move a resident. Types of mechanical lifts include sit to stand lifts. Regarding an allegation of abuse for resident #292: Review of a facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3-6 a.m., a CNA (staff #85) witnessed another CNA (staff #86) telling resident #292 to shut up and threaten to drop the resident if she did not stop swinging her arms around, while changing the resident's brief. Staff #85 reported the resident was reaching her arms out, because she was afraid of falling and wanted help. Staff #85 reported that staff #86 told the resident that if she hits her, I will drop you. The investigation included a written interview with staff #86 who said that on (MONTH) 27, (YEAR), she yelled at resident #292 because the resident was afraid of falling and she needed to calm down. Staff #86 stated that she told the resident that she might drop her if she did not calm down or if she hit her. The investigation report also included an interview with resident #292's roommate who stated that on (MONTH) 27, (YEAR), she heard resident #292 yelling because she was scared that she was going to fall out of bed. The roommate stated that she heard one of the staff tell the resident to shut-up or be quiet. The roommate stated that she was upset and did not like what was happening. -Resident #16 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 14, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 14, which indicated the resident had intact cognition. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) during the night shift between 3:00 a.m. and 6:00 a.m., a CNA (staff #85) witnessed another CNA (staff #86) swearing and handling resident #16 rough, when changing the resident's brief. The report included that staff #85 had asked staff #86 to help her change the resident's brief. Staff #85 reported that while changing the resident's brief, staff #86 said that she did not know why the resident waits so long to pee, while grabbing and yanking the resident towards her. Per the report, staff #86 also hurriedly turned the resident on her side, so she could change the resident's sheets. Staff #85 reported that she thought staff #86 intended to be mean and that staff #86 had been frustrated all night. The resident reported that she was awakened by staff and that staff #86 was saying damn it or God damn it because her bed was wet. The resident said that staff #86 shoved her hard to the side while changing her sheets and that she knew staff #86 was mad, because her bed sheets were wet. The investigation also included a written interview with staff #86 who stated that she was swearing while in the resident's room, because she was frustrated. Staff #86 reported that she said crap and may have said sh Staff #86 said that she could see how the resident may have thought that she was swearing at her and that she did not mean to shove and push the resident onto her side and back at medium speed, while changing the resident's sheets. An interview was conducted with resident #16 on (MONTH) 27, 2019 at 2:29 p.m., who stated that staff #86 came into her room on (MONTH) 27, (YEAR) and shoved her so hard that she hit the bedrail. The resident stated that she was not hurt, but she was humiliated. She said staff #86 was angry and swearing because her bed was wet. She also stated that another CNA (staff #85) was present, but did not say anything. An interview was conducted on (MONTH) 28, 2019 at 8:52 a.m., with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10). The ADON said that their policy includes that abuse can be physical, mental, verbal or emotional. -Resident #244 was admitted on (MONTH) 24, (YEAR) and readmitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 4, (YEAR). The admission MDS assessment dated (MONTH) 31, (YEAR) revealed a BIMS score of 3, which indicated the resident had severe impaired cognition. According to the resident's care plans, the resident did not exhibit any physical or verbal aggression towards others. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3 a.m. - 6 a.m., staff #85 asked staff #86 to help her change resident #244's brief. Staff #85 was having difficulty because resident #244 pulled her pants up and said that she was cold. Staff #86 told staff #85 that she was going to show her a trick. Staff #86 then proceeded to pull the resident's pants down, tore open the brief, forced the resident to roll over, and pried the resident's legs apart. Staff #85 stated that she felt that staff #86 forced the resident to roll over. Staff #85 reported that staff #86 told the resident to open her legs and then told staff #85, I kind of forced her to open her legs. The resident then said that she wanted to be left alone. Staff #85 said she believed that staff #86 was trying to be mean, had been frustrated all night and forced resident #244 to open her legs. The investigation also included an interview with resident #244, but she was unable to remember anything that occurred on (MONTH) 27. -Resident #3 was readmitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 18, (YEAR), revealed a BIMS score of 6, which indicated the resident had severe cognitive impairment. Review of the facility's investigation report revealed that on (MONTH) 27, (YEAR) on the night shift between 3:00 a.m. and 6:00 a.m., staff #85 reported that she and staff #86 woke resident #3 up to change his brief. Staff #85 said the resident was having trouble standing up, so staff #86 told the resident Fine, you don't get changed tonight and left the room. The investigation report included a written interview with staff #86, who reported that she yelled at the resident to get him to stand up. She stated that she was frustrated, because the resident was not helping her change his brief. The report included that staff #86 stated that she cannot control the volume or tone of her voice. Further review of the investigative findings regarding the allegations of abuse for resident #3, #16, #244 and #292, revealed they all occurred on the night shift on (MONTH) 27, (YEAR) sometime between 3 a.m. - 6 a.m. and involved staff #86. The documentation also included the following: Staff #86 was physically more forceful than needed when providing care, raised her voice and used profanity. Staff #86 was perceived by staff and residents as being angry and frustrated. Staff #86 was involuntary terminated. An interview was conducted on (MONTH) 28, 2019 at 8:52 a.m. with the Assistant Director of Nursing (ADON/staff #36) and the Executive Director (ED/staff #10). Staff #36 said that their policy includes that abuse can be physical, mental, verbal or emotional. She said that during new hire orientation, staff receive abuse training and that their first priority is to protect the residents. Staff #10 stated that the incidents of suspected abuse (for resident #3, #16, #244 and #292) occurred on the night shift on (MONTH) 27, (YEAR) between 3 a.m. - 6 a.m. He said abuse training is provided throughout the year and they have had several trainings on abuse in the past 6 months. Review of the Resident Rights policy revised (MONTH) (YEAR), revealed that employees shall treat all residents with kindness, respect and dignity. Residents have the right to be free from abuse and neglect. Review of the facility's Abuse policy dated (MONTH) (YEAR) revealed the facility strives to prevent the abuse of all residents. The objective is to provide a safe haven for residents through preventative measures which protect residents right to be free from abuse and neglect. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial well-being. Instances of abuse cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, mental abuse and neglect. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. If abuse/neglect is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse/neglect.

Based on closed clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to notify one resident's (#42) physician/practitioner in a timely manner regarding consistent refusals of medications and treatments. The deficient practice resulted in a delay of treatment and subsequent emergency transport to the hospital. Findings include: Resident #42 was admitted to the facility on (MONTH) 24, 2019, with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated (MONTH) 24, 2019 revealed the resident was admitted from the hospital and oxygen saturations (sats) were 91%. The resident was assessed to be alert, oriented, able to communicate her needs and required two person extensive assistance for all activities of daily living (ADL). The assessment also included the resident had wheezing and was on oxygen at 2 liters per minute. Review of the physician admission orders [REDACTED] -Breo Ellipta (corticosteroid) 100-250 micrograms (mcg) one puff, inhale one time daily for [MEDICAL CONDITION]. -[MEDICATION NAME] solution ([MEDICATION NAME][MEDICATION NAME]) 0.25 mg inhale only via nebulizer three times a day for [MEDICAL CONDITION]. -Oxygen at (0-5) liters per minute to keep sats above 89% and check every shift. -Apixaban (an anticoagulant) 2.5 mg two times daily. -[MEDICATION NAME] (antibiotic) 300 mg every 12 hours for a urinary tract infection. -[MEDICATION NAME] (antidepressant) 75 mg one daily for [MEDICAL CONDITION]. -[MEDICATION NAME] (multivitamin) 2000 units once daily as a supplement. -[MEDICATION NAME] suspension (nasal decongestant) one spray in each nostril once daily for allergies [REDACTED].>-[MEDICATION NAME] Aerosol (corticosteroid) 250/50 mcg one puff inhale orally two times daily for [MEDICAL CONDITION]. -[MEDICATION NAME] (anticonvulsant) 400 mg three times daily. -[MEDICATION NAME] (diuretic) 20 mg once daily for [MEDICAL CONDITION] and hypertension. -[MEDICATION NAME] (respiratory [MEDICATION NAME]) 600 mg every 12 hours for congestion. -Magnesium Chloride 64 mg two times daily as a supplement. A Nurse Practitioner (NP) note dated (MONTH) 25, 2019 revealed a detailed plan to treat the [MEDICAL CONDITION] which included the following: supplemental oxygen as needed to keep oxygen sats more than 90%, chest x-ray as clinically indicated, small volume equalizer ( SVN), monitor breathing and aggressive incentive spirometry. Also included was that the resident would undergo aggressive therapies and all disciplines to evaluate and treat as indicated. Progress would be reviewed weekly with the entire interdisciplinary team and all facets of care would be reviewed on an ongoing basis by the NP and medical director. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. However, on (MONTH) 27, 28, and 29, the documentation showed that the resident refused the bedtime dose of [MEDICATION NAME]. Review of the resident's care plans dated (MONTH) 29, 2019 revealed a problem related to [MEDICAL CONDITION]. The goal was for the resident to display daily optimal breathing patterns. Interventions included to give the aerosol or [MEDICATION NAME] as ordered and document any side effects and/or effectiveness. Another care plan identified the resident had a mood problem related to a [DIAGNOSES REDACTED]. The goal was that the resident would have an improved and happier mood state. Interventions were to administer medications as ordered and monitor for effectiveness/side effects and behavioral health consults as needed. The care plan did not include any interventions related to the resident's refusal of medications. Review of an internal document provided by facility staff who identified this form as an informal communication system between the nursing staff and the physicians/medical providers. This form included documentation dated (MONTH) 30, 2019 that resident #42 was not eating, drinking or taking medications. Although there were sections for additional information such as new orders, the only documentation for resident #42 was a signature by the prescriber to indicate the communication note had been seen. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 31, 2019 revealed the resident scored a 12 on the brief interview for mental status, which indicated mild cognitive impairment. The MDS included the resident required extensive assistance of two staff with ADLs, was on oxygen therapy and that the resident did not display any behavioral symptoms, such as rejecting or refusing care and services. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A nursing note dated (MONTH) 2, 2019 documented the resident refused all of the medications and that education was given to the resident about the importance of the medication and being compliant. Further documented was the nurse went through every medication with the resident and explained what it was for and the resident still refused. Continued review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the clinical record revealed no evidence that the resident refused the physician ordered oxygen. Review of the internal document communication form between physicians/providers and nursing staff revealed an entry dated (MONTH) 7, 2019. Although the resident continued to consistently refuse scheduled medications, the entry on the form made no mention of this. There was no documentation to indicate the physician had knowledge of the resident's refusal of multiple medications. Review of the MAR from (MONTH) 8-16, 2019 revealed documentation that the resident refused all doses of prescribed medications. Further review of the clinical record for this time period revealed no documentation that the physician/NP was notified of the resident's ongoing refusal of medications. In addition, there were no corresponding physician/NP notes from (MONTH) 8-16, 2019. A nursing note dated (MONTH) 16, 2019 documented the resident continued to refuse all medications and that education was given. Review of the internal document communication form between physicians/providers and nursing staff revealed an entry dated (MONTH) 17, 2019 regarding resident #42. Although the resident continued to consistently refuse all scheduled medications, the entry on the form made no mention of this. There was no documentation to indicate the physician/NP had knowledge of the resident's continued refusal of multiple medications. Review of the [MEDICAL CONDITION] medication review form dated (MONTH) 18, 2019 revealed the following staff had been in attendance to review the [MEDICATION NAME] (antidepressant) medication: the physician, consulting pharmacist, Director of Nursing and the Assistant Director of Nursing. Further documented was the resident's target behaviors of a sad mood had increased. Although there was discussion of the resident's depression and increased symptoms, there was no documentation regarding the resident's ongoing refusal of the [MEDICATION NAME]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A nursing note dated (MONTH) 20, 2019 included the resident continued to refuse medications and was given helpful advice regarding her health status. Review of the internal document communication form between physicians/providers and nursing staff revealed an entry dated (MONTH) 23, 2019 regarding resident #42. Although the resident continued to refuse scheduled medications, the entry on the form made no mention of this. Also, there was no documentation to indicate the physician/NP had knowledge of the resident's refusal of multiple medications. A monthly nursing summary dated (MONTH) 23, 2019 documented the resident now had a mental/behavioral status that included delusions related to being in a nursing home. However, there was no further documentation of the resident's delusions and no evidence that the physician/NP were notified. In the respiratory section, there was documentation that the resident used oxygen and lung sounds were diminished. A statement included that the resident refuses to get out of bed, eat or take medications. Continued review of the internal document communication form revealed an entry dated (MONTH) 25, 2019. The documentation included the resident had refused all medications. However, there was no evidence of a signature on the form to indicate the physician/NP had reviewed this entry. Review of the nursing notes through (MONTH) 25, 2019 revealed no evidence that the physician/NP had been notified, despite multiple entries of the resident's consistent refusals of medications. According to the MAR from (MONTH) 20-27, 2019, the resident continued to refuse medications. The MAR indicated [REDACTED]. Further review of the resident's care plans revealed no evidence that the care plans were revised since the initial date of (MONTH) 29, 2019, to reflect the resident's ongoing refusal of medications. In addition, there was no plan or interventions to address the resident's refusal of medications. A nursing note dated (MONTH) 27, 2019 with an entry time of 9:20 p.m., revealed the resident had a change of condition. The note included the resident refused all medications except one medication to help with nausea. After the resident had been administered the medication, she vomited within five minutes. Per the note, the resident had been refusing to wear her oxygen, even though she stated that she was having problems breathing. Staff assisted the resident in placing the nasal cannula back on and made sure the oxygen was set at 2 liters per minute. Staff left the room and when they returned the oxygen was again off of the resident. However, there was no documentation the physician/NP had been notified of the resident's change of condition and ongoing refusal of medications. Nursing notes dated (MONTH) 28, 2019 documented the following: 12:36 a.m: Resident able to sleep. 10:18 a.m: Resident refused ALL medications. 10:10 a.m: Change of condition summary: B/P = 130/92, pulse = 29-36, oxygen saturation 58-92% and oxygen was increased to 5 liters per minute. The family was notified and came to the facility to be with the resident. The resident initially refused to be evaluated at the hospital, however, upon a lot of encouragement from staff and family she agreed to be transported. Vital signs: B/P = 129/82, oxygen saturation at 56% and the resident refused the oxygen mask and oxygen via nasal cannula was in place. An order was obtained for transport to the hospital for acute care evaluation. A discharge assessment dated (MONTH) 2, (YEAR) documented the resident was transferred to the hospital on (MONTH) 28, 2019 via ambulance. The documentation included that vital signs were very poor and oxygen saturation levels were at 50-83%. Measures taken to stabilize resident prior to transfer was to increase the oxygen and elevate the head of bed. An interview was conducted with a Registered Nurse (Acting Director of Nursing/staff #36) on (MONTH) 28, 2019 at 2:15 p.m. Staff #36 stated the nursing staff use the informal communication system form, as a means to communicate and notify the medical provider. Staff stated the physician should have been notified that resident #42 had refused her medications on so many occasions. Staff #36 stated she thought she remembered that she had told the physician of the resident's refusals and was told the resident had the right to refuse. She stated she made an error in not having documentation to support this. She said physician notification for medication refusals would be considered a standard of nursing practice. An interview was conducted with a Licensed Practical Nurse (staff #64) on (MONTH) 28, 2019 at 2:36 p.m. Staff #64 stated if a resident refuses medications the physician has to be notified as some medications are more important than others, like breathing medications and treatments for a resident with [MEDICAL CONDITION]. Staff #64 stated she world notify the physician before the end of her shift and certainly if the resident kept on refusing the medications. An interview was conducted with a RN (staff #14) on (MONTH) 28, 2019 at 3:18 p.m. Staff #14 stated if a resident refused a medication, she would document and certainly notify the physician if the resident refused three or more times. Staff #14 stated physician notification would depend on the medical status of the resident and the severity of the symptoms. According to a facility policy regarding a resident change of condition the following was included: Our facility shall promptly notify the resident, the attending physician, and representative of changes in the resident's medical/mental status. The nurse will notify the resident's physician or physician on call when there is a significant change in the resident's mental and physical condition, and when there is refusal of medications on two or more consecutive times. A significant change of condition is a major decline that 1) Will not normally resolve itself without staff intervention by implementing standard clinical interventions. 2) Impacts more than one area of the resident's health status. 3) Requires interdisciplinary review and/or revision to the care plan. 4) Ultimately is based on judgement of the clinical staff. According to a facility policy regarding medication administration the following was included: Medications are administered in accordance with good nursing guidelines and practices. Medications are administered in accordance with the written orders of the prescriber. If a dose of regularly scheduled medication is refused the space provided on the front of the MAR indicated [REDACTED]. If two or more doses of a vital medication is refused, the physician is notified.

Based on closed clinical record review, facility and hospital documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to one resident (#245), who was at risk for aspiration. Findings include: Resident #245 was initially admitted on (MONTH) 1, (YEAR) and readmitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a Swallowing Ability and Function Evaluation dated (MONTH) 18, (YEAR), revealed the resident had mild to moderate dysphagia, experienced coughing after swallowing and had no teeth. Review of a hospital Modified [MEDICATION NAME] Swallow report dated (MONTH) 4, (YEAR) revealed the resident presented with moderate diffuse lingual residue, after swallows of thin, nectar-thick and puree consistencies. The report included that solids were not tried, due to poor dentition. Resident presents with tongue base and posterior pharyngeal wall weakness, as well as delayed swallowing initiation, which results in tongue base and pharyngeal residue with all consistencies. No penetration or aspiration occurred during this study. The report recommendations including the following: -mechanical soft-ground with thin liquids -small bites and sips -the patient should be monitored during meals to ensure she takes small bites and sips -the resident should be out of of bed and fully upright for all oral medications, and meds should be crushed and presented in puree form -aspiration precautions and for daily swallowing exercise regimen. The physician orders [REDACTED]. The order also included that the resident must be out of bed in chair, supervised and to take slow bites when eating meals or snacks, due to inhalation of solids and liquids. Another physician's orders [REDACTED]. Review of the ST evaluation and treatment notes dated (MONTH) 8, (YEAR), indicated the resident was referred to ST, due to exacerbation of cognitive impairment and risk for aspiration and [MEDICAL CONDITION]. The notes included for ST to assess/evaluate least restrictive oral intake and analyze the oral/pharyngeal function, improve cognitive-linguistic skills and develop and instruct in compensatory strategies. A nutritional care plan dated (MONTH) 8, (YEAR) indicated the resident had decreased intake related to aspiration. The approaches included that staff were to explain and reinforce the importance of maintaining the diet orders, encourage compliance, and staff were to serve the diet as ordered. Further review of the resident's care plans including the nutritional care plan revealed that none of the care plans addressed the resident's aspiration risk and difficulty with swallowing. The care plans also did not include that the resident required supervision with eating and must be out of bed in a chair, and for the resident to take slow bites when eating meals or snacks. A physician's orders [REDACTED]. Review of a nurses note dated (MONTH) 9, (YEAR) revealed that ST was teaching swallowing/chewing techniques and was waiting for endoscopy to be done. Review of the nurses notes dated (MONTH) 10, (YEAR) at 9:00 a.m., revealed the resident had a choking episode in the dining room during breakfast. A certified nursing assistant (CNA), yelled out to a Licensed Practical Nurse (LPN) that resident #245 was choking. The notes indicated that the resident was turning blue. Abdominal chest thrusts were initiated and the nurse removed a piece of toast the size of a golf ball. The resident was then able to cough and breath, and her color returned to normal. The physician was notified and ordered a pureed diet, nectar thick liquids and a ST evaluation. The notes further included that ST evaluated the resident that same day. According to the Speech Therapy treatment note dated (MONTH) 10, (YEAR), the resident required the [MEDICATION NAME] maneuver today. The note included the resident's diet and liquid texture were assessed with [REDACTED]. Instructions included alternating liquids/solids to increase pharyngeal clearance and to use small controlled sips and small bites. Review of the physician orders [REDACTED]. Review of a nurses notes dated (MONTH) 10, (YEAR) at 8:40 p.m., revealed the resident must be closely supervised during meal times and hydration times. Further review of the resident's care plans revealed they were not revised to reflect that the resident had a choking episode, nor of the need to provide supervision with eating or any additional interventions. An annual Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), included a Brief Interview for Mental Status (BIMS) score of 10, which indicated that the resident had moderate cognitive impairment. The MDS indicated the resident was wheelchair bound and required limited assistance of one staff for eating. The MDS also included that the resident had swallowing disorders of coughing or choking during meals or when swallowing medications. Per the MDS, the resident had no natural teeth and was receiving a mechanically altered diet. Nursing notes dated (MONTH) 14, (YEAR) included that the resident chokes easily and requires constant supervision with eating. Physician orders [REDACTED]. The order also included the following: must be in dining room for meals, assisted dining for cues to sip water/juice to clear oral residue every couple of bites, small bites and thorough chew related to pneumonitis, due to inhalation of other solids and liquids. Review of the nurses notes dated (MONTH) 26, (YEAR) at 11:10 p.m., revealed that the resident's diet was upgraded from a puree diet to a regular mechanical soft diet, with ground meat. The nurses notes also indicated that the resident continues to need supervision with eating, due to a history of choking. Continued review of the resident's care plans revealed they were still not revised to reflect that the resident was at risk for aspiration and choking, and required supervision with eating. Review of the nurses notes and the facility's investigative documentation dated (MONTH) 10, (YEAR), revealed the resident took a donut from the activity room, and then took it with her to the dining room and proceeded to eat the donut. Per the documentation, No staff was in dining room yet as it was not lunch time .This nurse arrived in dining room and found patient with her head upright and leaning back slightly gasping and unable to breath or cough A hospice nurse (who was not employed by the facility) was in the dining room and performed two [MEDICATION NAME] maneuvers and then went to get help. A LPN (licensed practicable nurse/staff #37) came to the dining room and also performed the [MEDICATION NAME] maneuver. The resident became unconscious and emergency procedures continued, including manual ventilation with oxygen, until emergency responders arrived. The resident was then transported to the hospital. Review of the hospital emergency room (ER) physician notes dated (MONTH) 10, (YEAR) revealed PT CHOKED ON A DONUT, [MEDICATION NAME] DIDN'T WORK, EMS ARRIVED AND INTUBATED W/GOOD CAPNOGRAPHY AND PT WENT INTO [MEDICAL CONDITION] ON WAY HERE. The resident had a right side pneumothorax and a chest tube was inserted. The resident was transferred to the intensive care unit. On (MONTH) 30, (YEAR) at 2:06 p.m., an interview was conducted with the Director of Nursing (DON/staff #51). The DON stated the resident was in the activity room, when the donut was given to her by activity staff (staff #7). The DON stated the resident was supposed to be supervised, when having snacks or meals. The DON further stated the activity staff were unaware that the resident had wrapped the donut into a napkin. An interview was conducted on (MONTH) 31, (YEAR) at 8:26 a.m., with the activity assistant (staff #7). Staff #7 stated that the resident was in the activity room for a church activity and at the end of the church service, she passed out donuts. Staff #7 said she asked the resident if she wanted her donut cut up into smaller pieces. She stated the resident told her that she wanted to take the donut to the dining room for lunch. She said the resident then propelled herself out of the activity room to the dining room. Staff #7 stated that later she was taking other residents to the dining room and she saw resident #245 sitting at table next to another resident, and the donut was still wrapped in the napkin. She said that sometimes the resident would wrap food up and take it out of the activity room, but nothing happened. Staff #7 stated that on the day of the incident, she gave the resident a donut and she was aware that the resident wrapped the donut in a napkin and took it to the dining room. She stated that during activities she watched the resident eat. Staff #7 stated that once the residents were in the dining room, the CNA's were responsible for supervising the residents with eating. On (MONTH) 31, (YEAR) at 11:39 a.m., an interview was conducted with the speech language pathologist/clinical fell owship (staff #66). Staff #66 stated that she saw resident #245 for cognition and swallowing problems. Staff #66 stated that the resident needed supervision with eating at all times, as she was a high risk for aspiration. She stated that having food without supervision would be putting the resident at high risk for choking. She said the resident should not have been allowed to take the donut with her. Staff #66 further stated that the resident needed supervision, as she had a tendency of eating at a fast rate, needed to be cued, and needed to be reminded to tuck her chin in, as that helped her swallow better. Staff #66 stated that she upgraded the resident's diet on (MONTH) 26, (YEAR), but the resident still needed to be cued and supervised with eating. On (MONTH) 31, (YEAR) at 12:46 p.m., an interview was conducted with a CNA (staff #6). Staff #6 stated that resident #245 was able to feed herself, but needed to be supervised, as she had a tendency to eat too fast. Staff #6 stated that they did not let her have food in her room, as she was a high choking risk. Staff #6 stated the resident was always monitored while eating in activities, and usually activity staff would make sure she did not take anything out of the activity room. An interview was conducted on (MONTH) 31, (YEAR) at 1:33 p.m. with a LPN (staff #37), who was the resident's nurse on the day of the incident on (MONTH) 10. Staff #37 stated the resident could feed herself, but needed to be supervised and that staff had to stay with her to make sure she took small bites. Staff #37 stated the resident would not finish chewing, and would take another bite. Staff #37 stated that as far as she knew, the activities staff were aware of the diet restrictions for every resident. She stated that she was in the hallway when the incident occurred, and then helped perform the [MEDICATION NAME] maneuver. On (MONTH) 1, (YEAR) at 8:53 a.m., an interview was conducted with the Unit Manager (registered nurse/staff #32). Staff #32 stated the resident was to be supervised while eating. She said the resident was not allowed to bring food out of the activity room, because of her swallowing deficits. Staff #32 stated that this was not uncommon for her to carry things around. She said the care plan should have included this and that the resident needed supervision with eating. Staff #32 stated that the resident's diet restrictions, the level of supervision and that the resident should not carry food on her, were all communicated to activity staff in care conferences and on the unit. An interview was conducted on (MONTH) 1, (YEAR) at 9:15 a.m., with the Nurse Practitioner (NP/staff #64). The NP stated that the resident was to be supervised while eating meals and snacks, secondary to dysphasia. The NP stated that supervision with eating would include eating snacks and any other kind of eating. Staff #64 stated that the resident could not have food anywhere without supervision for her safety, as she did not fully understand the risks. An interview was conducted on (MONTH) 1, (YEAR) at 3:01 p.m., with the hospice RN (staff #67). Staff #67 stated that she was in the dining room talking to another resident, when someone shouted choking. Staff #67 stated that she went over to the table where the resident was parked in her wheelchair and performed the [MEDICATION NAME] maneuver. Staff #67 stated the resident was still alert, but dusky and then went to the office next door to the dining room to tell staff that someone was choking. She said that she then ran back into the dining room and performed the [MEDICATION NAME] maneuver again, and then staff #37 came and helped. She further stated that when the resident choked, there were no staff in the dining room, so she had to go out of the dining room to get help.